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

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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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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Veterans Health Administration discharge telephone follow-up and 30-day hospital readmissions

10.17077/etd.sgz0hp0q ◽

2015 ◽

Author(s):

Tyler Goss

Keyword(s):

Hospital Readmissions ◽

Veterans Health Administration ◽

Veterans Health ◽

Day Hospital ◽

Health Administration

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Vaso-Occlusive Crises and Costs of Sickle Cell Disease from a Commercial Payer's Perspective

Blood ◽

10.1182/blood-2019-124920 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3464-3464

Author(s):

George J Joseph ◽

Dominick Latremouille-Viau ◽

Vikash Kumar Sharma ◽

Patrick Gagnon-Sanschagrin ◽

Menaka Bhor ◽

...

Keyword(s):

Healthcare Costs ◽

Medical Service ◽

Cell Disease ◽

Employment Equity ◽

Consulting Services ◽

Analysis Group ◽

Equity Ownership ◽

The Mean ◽

Insured Patients

Background: Episodes of acute pain caused by vaso-occlusive crises (VOCs) are a frequent and debilitating complication associated with sickle cell disease (SCD) and represent the most common cause for emergency room (ER) visits and inpatient (IP) stays. VOCs are due to a complex pathophysiology including multicellular adhesion. The purpose of this study was to characterize VOCs and assess the costs of SCD for patients with commercial insurance using an Excel-based model. Methods: Patients with SCD aged ≥16 years were identified in the IBM Truven MarketScan commercial databases (01/01/2000-06/30/2018). The index date was randomly selected among potential calendar dates to have ≥12 months of continuous health plan enrollment before (pre-index period) and after (follow-up period) that date. Patients with Medicare Supplemental coverage or stem cell transplant (SCT) were excluded. Data were analyzed at the state level for 23 key states with the highest concentration of patients with SCD and at the national level to be incorporated into an Excel-based model. The key variables in the model were age, gender, state of residence, and SCD clinical characteristics measured during the 12-month pre-index period. The following model inputs were assessed during the subsequent 12-month follow-up period: number, type, and setting (i.e., IP, ER, or outpatient [OP]) of VOC episodes; and total all-cause and SCD-related healthcare costs. Costs were reported in 2018 USD from a payer's perspective. We defined a VOC episode requiring medical services in claims data as follows: medical service claims with a VOC-related diagnosis occurring within 3 days of each other, IP re-admission within 14 days of a previous IP stay (both with VOC-related diagnoses), or any follow-up medical services with VOC-related diagnoses in the 7 days following an initial VOC diagnosis. A complicated VOC type was defined as a VOC episode with a diagnosis of priapism, splenic sequestration, acute hepatic sequestration, or acute chest syndrome. Variables were stratified by annual number of VOCs (i.e., 0, 1, ≥2 VOCs) and medical service setting (i.e., IP, ER, or OP). Results: A total of 16,092 commercially-insured patients with SCD from all US states were included in this study: mean age was 36.7 years, and 61.4% were females. In total, 27.7% had Hb-SS, 23.4% Hb-SC, 25.8% Hb-thalassemia, and 23.1% had an unspecified SCD type. The five states that contributed the highest number of patients with SCD were New York (n=1,711; 10.6%), Texas (n=1,593; 9.9%), Florida (n=1,397; 8.7%), Georgia (n=1,382; 8.6%), and California (n=966; 6.0%). In a given year, 64.7% of patients did not have any VOC episodes, 14.0% had only 1 VOC, and 21.2% had ≥2 VOCs (10.1% had ≥4 VOCs). Among patients with ≥1 VOC, the mean number of VOC episode was 3.3 (7.3% were complicated VOCs); among those with ≥2 VOCs, this figure was 4.8 (6.9% were complicated VOCs). The model showed that VOC episodes were distributed as follows: 37.4% in an IP setting, 26.4% in an ER, and 36.2% in an OP setting (Figure 1). The mean duration of a VOC episode was 11.7 days in an IP setting, 2.3 days in an ER setting, and 1.9 days in an OP setting (Figure 2). Total annual all-cause healthcare costs for patients with 0, 1, and ≥2 VOCs were $15,747, $27,194, and $64,555, respectively (Figure 3). Total annual SCD-related healthcare costs for patients with 0, 1, and ≥2 VOCs were $8,885, $21,323, and $60,624, respectively, representing 56.4%, 78.4%, and 93.9% of total annual all-cause healthcare costs, respectively (Figure 3). Conclusions: Among commercially-insured patients with SCD in the US, over one-third of patients experienced VOCs. The model showed that the contribution of SCD-related costs to annual total healthcare costs increases with the number of VOCs per year. Disclosures Joseph: Amgen: Equity Ownership; Novartis: Employment, Equity Ownership; Pfizer: Equity Ownership; Cigna: Equity Ownership. Latremouille-Viau:Novartis: Other: I am an employee of Analysis Group, Inc., which provided paid consulting services to Novartis for the conduct of this study. Sharma:NOVARTIS HEALTHCARE PVT. LTD.: Employment. Gagnon-Sanschagrin:Novartis: Other: I am an employee of Analysis Group, Inc., which provided paid consulting services to Novartis for the conduct of this study. Bhor:Novartis: Employment, Equity Ownership. Khare:HEALTHCARE PVT. LTD.: Employment. Singh:NOVARTIS HEALTHCARE PVT. LTD.: Employment. Serra:Novartis: Other: I am an employee of Analysis Group, Inc., which provided paid consulting services to Novartis for the conduct of this study. Davidson:Novartis: Other: I am an employee of Analysis Group, Inc., which provided paid consulting services to Novartis for the conduct of this study. Guerin:Novartis: Other: I am an employee of Analysis Group, Inc., which provided paid consulting services to Novartis for the conduct of this study. Shah:GBT: Research Funding; Alexion: Speakers Bureau; Novartis: Consultancy, Research Funding, Speakers Bureau.

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Mild TBI and risk of Parkinson disease

Neurology ◽

10.1212/wnl.0000000000005522 ◽

2018 ◽

Vol 90 (20) ◽

pp. e1771-e1779 ◽

Cited By ~ 65

Author(s):

Raquel C. Gardner ◽

Amy L. Byers ◽

Deborah E. Barnes ◽

Yixia Li ◽

John Boscardin ◽

...

Keyword(s):

Brain Injury ◽

Parkinson Disease ◽

Veterans Health Administration ◽

Veterans Health ◽

Health Administration ◽

Mild Tbi ◽

Psychiatric Comorbidities ◽

Increased Risk ◽

Severe Tbi

ObjectiveOur aim was to assess risk of Parkinson disease (PD) following traumatic brain injury (TBI), including specifically mild TBI (mTBI), among care recipients in the Veterans Health Administration.MethodsIn this retrospective cohort study, we identified all patients with a TBI diagnosis in Veterans Health Administration databases from October 2002 to September 2014 and age-matched 1:1 to a random sample of patients without TBI. All patients were aged 18 years and older without PD or dementia at baseline. TBI exposure and severity were determined via detailed clinical assessments or ICD-9 codes using Department of Defense and Defense and Veterans Brain Injury Center criteria. Baseline comorbidities and incident PD more than 1 year post-TBI were identified using ICD-9 codes. Risk of PD after TBI was assessed using Cox proportional hazard models adjusted for demographics and medical/psychiatric comorbidities.ResultsAmong 325,870 patients (half with TBI; average age 47.9 ± 17.4 years; average follow-up 4.6 years), 1,462 were diagnosed with PD during follow-up. Compared to no TBI, those with TBI had higher incidence of PD (no TBI 0.31%, all-severity TBI 0.58%, mTBI 0.47%, moderate-severe TBI 0.75%). In adjusted models, all-severity TBI, mTBI, and moderate-severe TBI were associated with increased risk of PD (hazard ratio [95% confidence interval]: all-severity TBI 1.71 [1.53–1.92]; mTBI 1.56 [1.35–1.80]; moderate-severe TBI 1.83 [1.61–2.07]).ConclusionsAmong military veterans, mTBI is associated with 56% increased risk of PD, even after adjusting for demographics and medical/psychiatric comorbidities. This study highlights the importance of TBI prevention, long-term follow-up of TBI-exposed veterans, and the need to determine mechanisms and modifiable risk factors for post-TBI PD.

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Examination of potential disparities in suicide risk identification and follow‐up care within the Veterans Health Administration

Suicide and Life-Threatening Behavior ◽

10.1111/sltb.12673 ◽

2020 ◽

Vol 50 (6) ◽

pp. 1127-1139

Author(s):

Sarah P. Carter ◽

Carol A. Malte ◽

Sasha M. Rojas ◽

Eric J. Hawkins ◽

Mark A. Reger

Keyword(s):

Suicide Risk ◽

Veterans Health Administration ◽

Risk Identification ◽

Veterans Health ◽

Health Administration ◽

Follow Up Care

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Improving Perceptions of Teamwork Climate With the Veterans Health Administration Medical Team Training Program

American Journal of Medical Quality ◽

10.1177/1062860611401653 ◽

2011 ◽

Vol 26 (6) ◽

pp. 480-484 ◽

Cited By ~ 22

Author(s):

Brian T. Carney ◽

Priscilla West ◽

Julia B. Neily ◽

Peter D. Mills ◽

James P. Bagian

Keyword(s):

Veterans Health Administration ◽

Team Training ◽

Medical Team ◽

Veterans Health ◽

Health Administration ◽

Safety Attitudes ◽

Safety Attitudes Questionnaire ◽

Physician Perceptions ◽

Nonparametric Testing

There are differences between nurse and physician perceptions of teamwork. The purpose of this study was to determine whether these differences would be reduced with medical team training (MTT). The Safety Attitudes Questionnaire was administered to nurses and physicians working in the operating rooms of 101 consecutive hospitals before and at the completion of an MTT program. Responses to the 6 teamwork climate items on the Safety Attitudes Questionnaire were analyzed using nonparametric testing. At baseline, physicians had more favorable perceptions on teamwork climate items than nurses. Physicians demonstrated improvement on all 6 teamwork climate items. Nurses demonstrated improvement in perceptions on all teamwork climate items except “Nurse input is well received.” Physicians still had a more favorable perception than nurses on all 6 teamwork climate items at follow-up. Despite an improvement in perceptions by physicians and nurses, baseline nurse–physician differences persisted at completion of the Veterans Health Administration MTT Program.

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Ambulatory Medical Follow-Up in the Year After Surgery and Subsequent Survival in a National Cohort of Veterans Health Administration Surgical Patients

Journal of Cardiothoracic and Vascular Anesthesia ◽

10.1053/j.jvca.2015.12.019 ◽

2016 ◽

Vol 30 (3) ◽

pp. 671-679 ◽

Cited By ~ 2

Author(s):

Robert B. Schonberger ◽

Feng Dai ◽

Cynthia Brandt ◽

Matthew M. Burg

Keyword(s):

Veterans Health Administration ◽

Surgical Patients ◽

Veterans Health ◽

Health Administration ◽

National Cohort

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Teleoncology for Veterans: High Patient Satisfaction Coupled With Positive Financial and Environmental Impacts

JCO Oncology Practice ◽

10.1200/op.21.00317 ◽

2021 ◽

pp. OP.21.00317

Author(s):

Cindy Y. Jiang ◽

Garth W. Strohbehn ◽

Rachel M. Dedinsky ◽

Shelby M. Raupp ◽

Brittany M. Pannecouk ◽

...

Keyword(s):

Carbon Dioxide ◽

Patient Satisfaction ◽

Carbon Dioxide Emissions ◽

Financial Burden ◽

Veterans Health Administration ◽

Veterans Health ◽

Health Administration ◽

Medical Needs ◽

Strongly Agree

PURPOSE: There was rapid adoption of teleoncology care in the Veterans Health Administration during the COVID-19 pandemic. One third of 9 million Veterans Health Administration enrolled Veterans live in rural areas. Although digital solutions can expand capacity, enhance care access, and reduce financial burden, they may also exacerbate rural-urban health disparities. Careful evaluation of patients' perceptions and policy tradeoffs are necessary to optimize teleoncology postpandemic. METHODS: Patients with ≥ 1 teleoncology visit with medical, surgical, or radiation oncology between March 2020 and June 2020 were identified retrospectively. Validated, Likert-type survey assessing patient satisfaction was developed. Follow-up survey was conducted on patients with ≥ 1 teleoncology visit from August 2020 to January 2021. Travel distance, time, cost, and carbon dioxide emissions were calculated based on zip codes. RESULTS: A hundred surveys were completed (response rate, 62%). Patients overall were satisfied with teleoncology (83% Agree or Strongly Agree) but felt less satisfied than in-person visits (47% Agree or Strongly Agree). Audiovisual component improved patient perception of involvement in care, ability to self-manage health or medical needs, and comparability to in-person visits. Follow-up survey demonstrated similar satisfaction. Total travel-related savings are as follows: 86,470 miles, 84,374 minutes, $49,720 US dollars, and 35.5 metric tons of carbon dioxide. CONCLUSION: Veterans are broadly satisfied with teleoncology. Audiovisual capabilities are critical to satisfaction. This is challenging for rural populations with lack of technology access. Patients experienced financial and time savings, and society benefitted from reduced carbon emissions. Continued optimization is needed to enhance patient experience and address secondary effects.

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Incidence of Clostridioides difficile infections among young and middle-aged adults: Veterans Health Administration

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.160 ◽

2019 ◽

Vol 40 (9) ◽

pp. 997-1005 ◽

Cited By ~ 1

Author(s):

Ellyn M. Russo ◽

Jennifer Kuntz ◽

Holly Yu ◽

Jeremy Smith ◽

Ronald George Hauser ◽

...

Keyword(s):

Veterans Health Administration ◽

Health Concern ◽

Charlson Comorbidity Index Score ◽

Veterans Health ◽

Health Administration ◽

Middle Aged ◽

Clostridioides Difficile ◽

Using Data ◽

Middle Aged Adult

AbstractObjective:Clostridioides difficile infection (CDI) remains a significant public health concern, resulting in excess morbidity, mortality, and costs. Additional insight into the burden of CDI in adults aged <65 years is needed.Design/Setting:A 6-year retrospective cohort study was conducted using data extracted from United States Veterans Health Administration electronic medical records.Patients/Methods:Patients aged 18–64 years on January 1, 2011, were followed until incident CDI, death, loss-to-follow-up, or December 31, 2016. CDI was identified by a diagnosis code accompanied by metronidazole, vancomycin, or fidaxomicin therapy, or positive laboratory test. The clinical setting of CDI onset was defined according to 2017 SHEA-IDSA guidelines.Results:Of 1,073,900 patients, 10,534 had a CDI during follow-up. The overall incidence rate was 177 CDIs per 100,000 person years, rising steadily from 164 per 100,000 person years in 2011 to 189 per 100,000 person years in 2016. Those with a CDI were slightly older (55 vs 51 years) and sicker, with a higher baseline Charlson comorbidity index score (1.4 vs 0.5) than those without an infection. Nearly half (48%) of all incident CDIs were community associated, and this proportion rose from 41% in 2011 to 56% in 2016.Conclusions:The findings from this large retrospective study indicate that CDI incidence, driven primarily by increasing community-associated infection, is rising among young and middle-aged adult Veterans with high service-related disability. The increasing burden of community associated CDI in this vulnerable population warrants attention. Future studies quantifying the economic and societal burden of CDI will inform decisions surrounding prevention strategies.

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