Elevated White Blood Cell Levels and Thrombotic Events in Patients With Polycythemia Vera: A Real-World Analysis of Veterans Health Administration Data

Background Mobile health (mHealth) interventions for weight management can result in weight loss outcomes comparable to in-person treatments. However, there is little information on implementing these treatments in real-world settings. Objective This work aimed to answer two implementation research questions related to mHealth for weight management: (1) what are barriers and facilitators to mHealth adoption (initial use) and engagement (continued use)? and (2) what are patient beliefs about the appropriateness (ie, perceived fit, relevance, or compatibility) of mHealth for weight management? Methods We conducted semistructured interviews with patients with obesity at a single facility in an integrated health care system (the Veterans Health Administration). All participants had been referred to a new mHealth program, which included access to a live coach. We performed a rapid qualitative analysis of interviews to identify themes related to the adoption of, engagement with, and appropriateness of mHealth for weight management. Results We interviewed 24 veterans, seven of whom used the mHealth program. Almost all participants were ≥45 years of age and two-thirds were White. Rapid analysis identified three themes: (1) coaching both facilitates and prevents mHealth adoption and engagement by promoting accountability but leading to guilt among those not meeting goals; (2) preferences regarding the mode of treatment delivery, usability, and treatment content were barriers to mHealth appropriateness and adoption, including preferences for in-person care and a dislike of self-monitoring; and (3) a single invitation was not sufficient to facilitate adoption of a new mHealth program. Themes were unrelated to participants’ age, race, or ethnicity. Conclusions In a study assessing real-world use of mHealth in a group of middle-aged and older adults, we found that—despite free access to mHealth with a live coach—most did not complete the registration process. Our findings suggest that implementing mHealth for weight management requires more than one information session. Findings also suggest that focusing on the coaching relationship and how users’ lives and goals change over time may be an important way to facilitate engagement and improved health. Most participants thought mHealth was appropriate for weight management, with some nevertheless preferring in-person care. Therefore, the best way to guarantee equitable care will be to ensure multiple routes to achieving the same behavioral health goals. Veterans Health Administration patients have the option of using mHealth for weight management, but can also attend group weight management programs or single-session nutrition classes or access fitness facilities. Health care policy does not allow such access for most people in the United States; however, expanded access to behavioral weight management is an important long-term goal to ensure health for all.

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Hematocrit levels and thrombotic events in patients with polycythemia vera: an analysis of Veterans Health Administration data

Annals of Hematology ◽

10.1007/s00277-019-03793-w ◽

2019 ◽

Vol 98 (11) ◽

pp. 2533-2539

Author(s):

Shreekant Parasuraman ◽

Jingbo Yu ◽

Dilan Paranagama ◽

Sulena Shrestha ◽

Li Wang ◽

...

Keyword(s):

Polycythemia Vera ◽

Cox Regression ◽

Veterans Health Administration ◽

Veterans Health ◽

Health Administration ◽

Monitoring And Control ◽

The Difference ◽

And Control ◽

The Relationship

Abstract Patients with polycythemia vera (PV) have a high incidence of thrombotic events (TEs), contributing to a greater mortality risk than the general population. The relationship between hematocrit (HCT) levels and TE occurrence among patients with PV from the Veterans Health Administration (VHA) was evaluated to replicate findings of the CYTO-PV trial with a real-world patient population. This retrospective study used VHA medical record and claims data from the first claim with a PV diagnosis (index) until death, disenrollment, or end of study, collected between October 1, 2005, and September 30, 2012. Patients were aged ≥ 18 years at index, had ≥ 2 claims for PV (ICD-9-CM code, 238.4) ≥ 30 days apart during the identification period, continuous health plan enrollment from 12 months pre-index until end of study, and ≥ 3 HCT measurements per year during follow-up. This analysis focused on patients with no pre-index TE, and with all HCT values either < 45% or ≥ 45% during the follow-up period. The difference in TE risk between HCT groups was assessed using unadjusted Cox regression models based on time to first TE. Patients (N = 213) were mean (SD) age 68.9 (11.5) years, 98.6% male, and 61.5% white. TE rates for patients with HCT values < 45% versus ≥ 45% were 40.3% and 54.2%, respectively. Among patients with ≥ 1 HCT before TE, TE risk hazard ratio was 1.61 (95% CI, 1.03–2.51; P = 0.036). This analysis of the VHA population further supports effective monitoring and control of HCT levels < 45% to reduce TE risk in patients with PV.

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Cost‐effectiveness of real‐world administration of tobacco pharmacotherapy in the United States Veterans Health Administration

Addiction ◽

10.1111/add.14621 ◽

2019 ◽

Vol 114 (8) ◽

pp. 1436-1445

Author(s):

Paul G. Barnett ◽

Rosalinda V. Ignacio ◽

Hyungjin Myra Kim ◽

Mark C. Geraci ◽

Carol A. Essenmacher ◽

...

Keyword(s):

United States ◽

Cost Effectiveness ◽

Real World ◽

Veterans Health Administration ◽

The United States ◽

Veterans Health ◽

Health Administration

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Comparable Overall Survival with Rituximab-Bendamustine (R-Benda) and Rituximab-Gemcitabine-Oxaliplatin (R-GemOx) When Used As Second-Line (2L) Treatment for Diffuse Large B-Cell Lymphoma (DLBCL): A Real-World Study Using US Veterans Health Administration Data

Blood ◽

10.1182/blood-2018-99-113039 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 1711-1711 ◽

Cited By ~ 1

Author(s):

Raluca Ionescu-Ittu ◽

Aijing Shang ◽

Nancy Vander Velde ◽

Annie Guérin ◽

Yilu Lin ◽

...

Keyword(s):

Real World ◽

Research Funding ◽

Veterans Health Administration ◽

Treatment Patterns ◽

Veterans Health ◽

Health Administration ◽

Real World Data ◽

Analysis Group ◽

Kaplan Meier

Abstract Introduction: DLBCL is the most common subtype of non-Hodgkin lymphoma. R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine and prednisone) is established as the standard of care for patients (pts) with previously untreated DLBCL, but ~40% of pts will eventually relapse. For relapsed/refractory pts who are ineligible for transplant, clinical guidelines propose a broad spectrum of therapeutic options. However, little is known about treatment patterns and outcomes associated with 2L therapy in routine practice, particularly for pts less suitable for intensive therapy. Therefore, using real-world data, we evaluated 2L treatment patterns in DLBCL pts and overall survival (OS) in those pts who received 2L R-Benda or R-GemOx. We focused on these 2 treatments as they are typically used in the non-transplant setting in pts less suitable for aggressive therapy, and can typically be administered in an outpatient setting. Methods: DLBCL pts receiving care from the US Veterans Health Administration were identified through their electronic medical records and raw oncology domain. Pts diagnosed with DLBCL (and no prior other types of malignancies) between 2004-2016, with ≥1-month follow-up and who received 2L treatment were included. OS (defined as time from the start of 2L therapy until death) was analyzed in pts who received 2L R-Benda or R-GemOx using the Kaplan-Meier method. Surviving pts were censored at data cutoff (December 31, 2017). Univariate and multivariate Cox regression analyses were undertaken to assess the impact of 2L treatment (in particular, R-GemOx vs R-Benda) on OS. Results: A total of 2600 DLBCL pts were identified: 2039 received 1L and 702 received 1L and 2L therapy. Among the 702 pts treated with 2L therapy, regimens included R-ICE (n=77; 11.0%), R-CHOP (n=75; 10.7%), rituximab monotherapy (n=34; 4.8%), R-Benda (n=32; 4.6%), methotrexate (n=24; 3.4%), R-ESHAP (n=23; 3.3%), R-DHAP/R-EPOCH/R-GDP (n=18; 2.6%), rituximab plus cyclophosphamide-doxorubicin-vinblastine-vincristine (n=14; 2.0%), R-CVP (n=11; 1.6%), rituximab plus cyclophosphamide-etoposide-vincristine (n=11; 1.6%), and R-GemOx (n=10; 1.4%). Of the remaining pts, 267 (38.0%) received regimens with agent(s) included in the NCCN guidelines, while 106 (15.1%) received regimens with at least 1 agent not guideline-recommended. Baseline characteristics for pts treated with 2L R-Benda (n=32) or R-GemOx (n=10) are shown in Table 1. There was an imbalance between the 2 cohorts with regard to race, number of involved lymph nodes, B symptoms, Charlson Comorbidity Index score, and abnormal lactate dehydrogenase results. After 24 deaths in the R-Benda cohort and 7 deaths in the R-GemOx cohort, median OS was estimated at 11 and 13 months, respectively (Figure 1). Median follow-up time after start of 2L treatment was 11.3 and 11.7 months, respectively. The Kaplan-Meier curves of the 2 cohorts overlapped at multiple timepoints during follow-up. Respective 1-year OS rates (95% confidence interval [CI]) with R-Benda and R-GemOx were 50.0% (31.9%, 65.7%) and 60.0% (25.3%, 82.7%). Compared with R-Benda, R-GemOx did not significantly predict longer OS in either the univariate (hazard ratio [HR]: 0.94; 95% CI: 0.41, 2.19; p=0.893) or multivariate (HR: 1.07; 95% CI: 0.46, 2.50; p=0.873) analyses. Conclusions: This real-world study highlights the diversity of 2L treatment regimens used in DLBCL pts. There was no apparent difference in OS between R-Benda- and R-GemOx-treated pts and, with a median OS of approximately 1 year after 2L initiation with either regimen, there is clearly an unmet need in this setting. The main limitation of the study relates to the small sample size of each treatment cohort. Further research using other real-world data sources is warranted. Disclosures Ionescu-Ittu: Analysis Group, Inc.: Employment; F. Hoffman-La Roche Ltd: Consultancy, Other: I am an employee of Analysis Group, Inc., which received consulting fees from Roche for the conduct of this study. Shang:F. Hoffmann-La Roche Ltd.: Employment, Other: Ownership interests non-PLC. Guérin:F. Hoffman-La Roche Ltd: Other: I am an employee of Analysis Group, Inc., which received consulting fees from Roche for the conduct of this study; Analysis Group, Inc.: Employment. Shi:F. Hoffman-La Roche Ltd: Research Funding; Bravo4Health: Other: Ownership interests non-PLC; Genentech: Research Funding; Chiasma: Research Funding; Intuitive Surgical: Consultancy. Shi:F. Hoffman-La Roche Ltd: Other: I am an employee of Analysis Group, Inc., which received consulting fees from Roche for the conduct of this study; Analysis Group, Inc.: Employment. Qayum:F. Hoffmann-La Roche Ltd: Employment.

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Transitioning from oral risperidone or paliperidone to once-monthly paliperidone palmitate: a real-world analysis among Veterans Health Administration patients with schizophrenia who have had at least one prior hospitalization

Current Medical Research and Opinion ◽

10.1080/03007995.2019.1651129 ◽

2019 ◽

Vol 35 (12) ◽

pp. 2159-2168

Author(s):

Antoine El Khoury ◽

Charmi Patel ◽

Ahong Huang ◽

Li Wang ◽

Richa Bashyal

Keyword(s):

Real World ◽

Veterans Health Administration ◽

Paliperidone Palmitate ◽

Veterans Health ◽

Health Administration ◽

Oral Risperidone

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Adoption and Appropriateness of mHealth for Weight Management in the Real World: A Qualitative Investigation of Patient Perspectives (Preprint)

10.2196/preprints.29916 ◽

2021 ◽

Author(s):

Jessica Y Breland ◽

Khizran Agha ◽

Rakshitha Mohankumar

Keyword(s):

Health Care ◽

Weight Management ◽

Real World ◽

Health Care Policy ◽

Veterans Health Administration ◽

The United States ◽

Free Access ◽

Veterans Health ◽

Perceived Fit ◽

Health Administration

BACKGROUND Mobile health (mHealth) interventions for weight management can result in weight loss outcomes comparable to in-person treatments. However, there is little information on implementing these treatments in real-world settings. OBJECTIVE This work aimed to answer two implementation research questions related to mHealth for weight management: (1) what are barriers and facilitators to mHealth adoption (initial use) and engagement (continued use)? and (2) what are patient beliefs about the appropriateness (ie, perceived fit, relevance, or compatibility) of mHealth for weight management? METHODS We conducted semistructured interviews with patients with obesity at a single facility in an integrated health care system (the Veterans Health Administration). All participants had been referred to a new mHealth program, which included access to a live coach. We performed a rapid qualitative analysis of interviews to identify themes related to the adoption of, engagement with, and appropriateness of mHealth for weight management. RESULTS We interviewed 24 veterans, seven of whom used the mHealth program. Almost all participants were ≥45 years of age and two-thirds were White. Rapid analysis identified three themes: (1) coaching both facilitates and prevents mHealth adoption and engagement by promoting accountability but leading to guilt among those not meeting goals; (2) preferences regarding the mode of treatment delivery, usability, and treatment content were barriers to mHealth appropriateness and adoption, including preferences for in-person care and a dislike of self-monitoring; and (3) a single invitation was not sufficient to facilitate adoption of a new mHealth program. Themes were unrelated to participants’ age, race, or ethnicity. CONCLUSIONS In a study assessing real-world use of mHealth in a group of middle-aged and older adults, we found that—despite free access to mHealth with a live coach—most did not complete the registration process. Our findings suggest that implementing mHealth for weight management requires more than one information session. Findings also suggest that focusing on the coaching relationship and how users’ lives and goals change over time may be an important way to facilitate engagement and improved health. Most participants thought mHealth was appropriate for weight management, with some nevertheless preferring in-person care. Therefore, the best way to guarantee equitable care will be to ensure multiple routes to achieving the same behavioral health goals. Veterans Health Administration patients have the option of using mHealth for weight management, but can also attend group weight management programs or single-session nutrition classes or access fitness facilities. Health care policy does not allow such access for most people in the United States; however, expanded access to behavioral weight management is an important long-term goal to ensure health for all.

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Elevated White Blood Cell Levels and Thrombotic Events in Patients with Polycythemia Vera: A Real-World Analysis of Veterans Health Administration Data

Blood ◽

10.1182/blood-2018-99-118451 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 1758-1758 ◽

Cited By ~ 1

Author(s):

Shreekant Parasuraman ◽

Jingbo Yu ◽

Dilan Chamikara Paranagama ◽

Sulena Shrestha ◽

Li Wang ◽

...

Keyword(s):

Polycythemia Vera ◽

Reference Group ◽

Veterans Health Administration ◽

Veterans Health ◽

Health Administration ◽

Employment Equity ◽

Cytoreductive Treatment ◽

Equity Ownership ◽

The Mean

Abstract Introduction: Patients with polycythemia vera (PV) have poor overall survival compared with the general population, with arterial and venous thrombotic events (TEs) representing a substantial source of morbidity and mortality. A subanalysis of the Cytoreductive Therapy in Polycythemia Vera (CYTO-PV) study demonstrated a significant correlation between white blood cell (WBC) count ≥11 × 109/L and time-dependent risk of major thrombosis (hazard ratio, 3.9; 95% CI, 1.24-12.3). The objective of this analysis was to describe the association between WBC levels and occurrence of TEs among patients with PV from a large, real-world population. Methods: This was a retrospective, observational study using Veterans Health Administration claims data collected between 10/1/05, and 9/30/12. Patients with ≥2 claims for PV (ICD-9-CM code 238.4) ≥30 days apart during the identification period (10/1/06 to 9/30/07) were eligible for analysis. The earliest date for a PV claim within the identification period was designated as the index date. All patients were ≥18 years of age, had no TEs before the index date, and had continuous health plan enrollment with medical and pharmacy benefits ≥12 months pre-index. Patients were followed up until death, disenrollment, or end of study period, whichever occurred first. Patients with ≥3 WBC values per year on average during the follow-up period and, for patients with a TE, ≥1 WBC value before the TE were included in the analysis. Based on the last measurement before the TE or end of follow-up, patients were assigned to one of the following WBC categories: WBC <7.0, 7.0-8.4, 8.5-<11.0, and ≥11.0 × 109/L. A univariate Cox proportional hazards model was used to compare the risk of TEs between WBC categories using <7.0 × 109/L as the reference group. Results: A total of 1565 US veterans with PV were included in the analysis (WBC [× 109/L] <7.0, n=428 [27.3%]; 7.0-8.4, n=375 [24.0%]; 8.5-<11.0, n=284 [18.1%]; ≥11.0, n=478 [30.5%]). Patient demographics were similar across groups (Table 1). The mean Charlson Comorbidity Index and Chronic Disease Scores were similar across groups and ranged from 1.11-1.45 and 6.15-6.76, respectively. Hypertension was the most common comorbid condition among patients across all WBC categories (65.1%-71.5%). Mean follow-up times across groups ranged from 3.6 to 4.5 years. Rates of cytoreductive treatment, including phlebotomy, were similar across WBC groups and ranged from 77.3% to 78.2% (any cytoreductive treatment) and 56.9% to 65.9% (phlebotomy). The mean number of phlebotomies per patient per year was 2.6, 2.6, 4.7, and 3.0 among patients with WBC counts <7.0, 7.0-8.4, 8.5-<11.0, and ≥11.0 × 109/L, respectively. Overall, 390 patients (24.9%) experienced a TE during the study period, including 85 patients (19.9%) with WBC <7.0 × 109/L, 91 patients (24.3%) with WBC 7.0-8.4 × 109/L, 73 patients (25.7%) with WBC 8.5-<11.0 × 109/L, and 141 patients (29.5%) with WBC ≥11.0 × 109/L (Figure 1). Compared with the WBC <7.0 × 109/L reference group, the hazard ratios (95% CI) for TEs were 1.22 (0.91-1.64; P=0.1835), 1.39 (1.02-1.90; P=0.0401), and 1.81 (1.39-2.38; P<0.0001) among patients with WBC counts 7.0-8.4, 8.5-<11.0, and ≥11.0 × 109/L, respectively (Table 1). Conclusion: A significant, positive association between increased WBC counts and occurrence of TEs in patients with PV was observed in this study. Patients with WBC counts ≥8.5 × 109/L had a significantly increased risk of TE, and those with counts ≥11.0 × 109/L were at greatest risk. Effective control of WBC counts is an important component of disease management and may reduce risk of TEs in patients with PV. Disclosures Parasuraman: Incyte: Employment, Equity Ownership. Yu:Incyte Corporation: Employment, Equity Ownership. Paranagama:Incyte: Employment, Equity Ownership. Shrestha:STATinMED Research: Employment, Equity Ownership. Wang:STATinMED Research: Employment, Equity Ownership. Baser:STATinMED Research: Employment, Equity Ownership. Scherber:Gilead: Honoraria.

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Building/Campus Characteristics and Legionella in Potable Water Systems at Veterans Health Administration Facilities

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.500 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s23-s24

Author(s):

Shantini Gamage ◽

Alan Bender ◽

Loretta Simbartl ◽

Gary Roselle ◽

Stephen Kralovic ◽

...

Keyword(s):

Real World ◽

Water Samples ◽

Potable Water ◽

Veterans Health Administration ◽

Water Systems ◽

Principal Investigator ◽

Veterans Health ◽

Health Administration ◽

Water Safety ◽

Data Set

Background: When control mechanisms such as water temperature and biocide level are insufficient, Legionella, the causative bacteria of Legionnaires’ disease, can proliferate in water distribution systems in buildings. Guidance and oversight bodies are increasingly prioritizing water safety programs in healthcare facilities to limit Legionella growth. However, ensuring optimal implementation in large buildings is challenging. Much is unknown, and sometimes assumed, about whether building and campus characteristics influence Legionella growth. We used an extensive real-world environmental Legionella data set in the Veterans Health Administration (VHA) healthcare system to examine infrastructure characteristics and Legionella positivity. Methods: VHA medical facilities across the country perform quarterly potable water sampling of healthcare buildings for Legionella detection as part of a comprehensive water safety program. Results are reported to a standardized national database. We did an exploratory univariate analysis of facility-reported Legionella data from routine potable water samples taken in 2015 to 2018, in conjunction with infrastructure characteristics available in a separate national data set. This review examined the following characteristics: building height (number of floors), building age (reported construction year), and campus acreage. Results: The final data set included 201,936 water samples from 819 buildings. Buildings with 1–5 floors (n = 634) had a Legionella positivity rate of 5.3%, 6–10 floors (n = 104) had a rate of 6.4%, 11–15 floors (n = 36) had a rate of 8.1%, and 16–22 floors (n = 9) had a rate of 8.8%. All rates were significantly different from each other except 11–15 floors and 16–22 floors (P < .05, χ2). The oldest buildings (1800s) had significantly less (P < .05, χ2) Legionella positivity than those built between 1900 and 1939 and between 1940 and 1979, but they were no different than the newest buildings (Fig. 1). In newer buildings (1980–2019), all decades had buildings with Legionella positivity (Fig. 1 inset). Campus acreage varied from ~3 acres to almost 500 acres. Although significant differences were found in Legionella positivity for different campus sizes, there was no clear trend and campus acreage may not be a suitable proxy for the extent or complexity of water systems feeding buildings. Conclusions: The analysis of this large, real-world data set supports an assumption that taller buildings are more likely to be associated with Legionella detection, perhaps a result of more extensive piping. In contrast, the assumption that newer buildings are less associated with Legionella was not fully supported. These results demonstrate the variability in Legionella positivity in buildings, and they also provide evidence that can inform implementation of water safety programs.Funding: NoneDisclosures: Chetan Jinadatha, principal Investigator/Co-I: Research: NIH/NINR, AHRQ, NSF principal investigator: Research: Xenex Healthcare Services. Funds provided to institution. Inventor: Methods for organizing the disinfection of one or more items contaminated with biological agents. Owner: Department of Veterans Affairs. Licensed to Xenex Disinfection System, San Antonio, TX.

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