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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 36 Research Studies DisplayedCarrel M, Clore GS, Kim S
Health care utilization among Texas Veterans Health Administration enrollees before and after Hurricane Harvey, 2016-2018.
The purpose of this study was to determine how the differential exposure to Hurricane Harvey in August 2017 was associated with changes in utilization of Veterans Health Administration health care. Findings suggested that flood disasters such as Hurricane Harvey may be associated with declines in health care utilization that differ according to flood status, race, and income strata. The patients most exposed to the disaster had the greatest delay or nonreceipt of care.
AHRQ-funded; HS027472.
Citation: Carrel M, Clore GS, Kim S .
Health care utilization among Texas Veterans Health Administration enrollees before and after Hurricane Harvey, 2016-2018.
JAMA Netw Open 2021 Dec;4(12):e2138535. doi: 10.1001/jamanetworkopen.2021.38535..
Keywords: Healthcare Utilization, Emergency Department
Ching JH, Owens DK, Trafton JA
Impact of treatment duration on mortality among Veterans with opioid use disorder in the United States Veterans Health Administration.
This study used simulation of a Veterans Health Administration cohort to identify the opioid use disorder (OUD) treatment durations necessary for the elevated mortality risks during treatment transitions balanced by reductions in mortality while receiving medication-assisted treatment (MAT) with methadone or buprenorphine. A simulated cohort of 10,000 individuals with OUD was created by using parameters obtained through calibration and published meta-analyses of studies from North America, Europe, and Australia. Methadone treatment for 4 months or longer or buprenorphine for 2 months or longer resulted in 54 and 65 fewer deaths relative to not receiving MAT for the same duration. The authors estimated shorter treatment durations necessary to achieve net mortality benefits of 2 months or longer for methadone and 1 month or longer for buprenorphine. Necessary treatment increased more with smaller mortality reductions on treatment with larger relative risks during treatment transitions.
AHRQ-funded; HS027935; HS026128.
Citation: Ching JH, Owens DK, Trafton JA .
Impact of treatment duration on mortality among Veterans with opioid use disorder in the United States Veterans Health Administration.
Addiction 2021 Dec;116(12):3494-503. doi: 10.1111/add.15574.
AHRQ-funded; HS027935; HS026128..
AHRQ-funded; HS027935; HS026128..
Keywords: Opioids, Substance Abuse, Behavioral Health, Mortality
Schuttner L, Haraldsson B, Maynard C
Factors associated with low-value cancer screenings in the Veterans Health Administration.
Most clinical practice guidelines recommend stopping cancer screenings when risks exceed benefits, yet low-value screenings persist. The Veterans Health Administration focuses on improving the value and quality of care, using a patient-centered medical home model that may affect cancer screening behavior. The objective of this study was to understand rates and factors associated with outpatient low-value cancer screenings.
AHRQ-funded; HS026369.
Citation: Schuttner L, Haraldsson B, Maynard C .
Factors associated with low-value cancer screenings in the Veterans Health Administration.
JAMA Netw Open 2021 Oct;4(10):e2130581. doi: 10.1001/jamanetworkopen.2021.30581..
Keywords: Screening, Cancer
Saffo S, Kaplan DE, Mahmud N
Impact of SGLT2 inhibitors in comparison with DPP4 inhibitors on ascites and death in veterans with cirrhosis on metformin.
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) may have favourable neurohumoral and metabolic effects in patients with chronic liver disease. However, studies examining SGLT2i in this population have been limited to patients with non-alcoholic fatty liver disease and have focused on surrogate biomarkers. The aim of this study was to evaluate whether SGLT2i could reduce the incidence of ascites and death over a period of 36 months in patients with cirrhosis and diabetes mellitus.
AHRQ-funded; HS022882; HS025164.
Citation: Saffo S, Kaplan DE, Mahmud N .
Impact of SGLT2 inhibitors in comparison with DPP4 inhibitors on ascites and death in veterans with cirrhosis on metformin.
Diabetes Obes Metab 2021 Oct;23(10):2402-08. doi: 10.1111/dom.14488..
Keywords: Diabetes
Baughman AW, Triantafylidis LK, O'Neil N
Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled nursing facility.
This study described a quality improvement (QI) approach to improve medication reconciliation in a skilled nursing facility (SNF) setting as part of the Multi-Center Medication Reconciliation Quality Improvement Study 2 (MARQUIS2). Findings showed that SNFs represent a critical setting for medication reconciliation efforts due to challenges completing the reconciliation process and the concomitant high risk of adverse drug events in this population. Initial baseline assessments effectively identified existing problems and can be used to guide targeted interventions.
AHRQ-funded; HS023757.
Citation: Baughman AW, Triantafylidis LK, O'Neil N .
Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled nursing facility.
Jt Comm J Qual Patient Saf 2021 Oct;47(10):646-53. doi: 10.1016/j.jcjq.2021.06.001..
Keywords: Medication, Quality Improvement, Quality of Care
Wayne MT, Seelye S, Molling D
Temporal trends and hospital variation in time-to-antibiotics among veterans hospitalized with sepsis.
It is unclear whether antimicrobial timing for sepsis has changed outside of performance incentive initiatives. The purpose of this study was to examine temporal trends and variation in time-to-antibiotics for sepsis in the US Department of Veterans Affairs (VA) health care system. The investigators concluded that this cohort study found that time-to-antibiotics for sepsis has declined over time. However, there remained significant variability in time-to-antibiotics not explained by patient characteristics, suggesting potential unwarranted practice variation in sepsis treatment.
AHRQ-funded; HS026725.
Citation: Wayne MT, Seelye S, Molling D .
Temporal trends and hospital variation in time-to-antibiotics among veterans hospitalized with sepsis.
JAMA Netw Open 2021 Sep 4(9):e2123950. doi: 10.1001/jamanetworkopen.2021.23950..
Keywords: Sepsis
Sico JJ, Kundu S, So-Armah K
Depression as a risk factor for incident ischemic stroke among HIV-positive veterans in the veterans aging cohort study.
Background HIV infection and depression are each associated with increased ischemic stroke risk. Whether depression is a risk factor for stroke within the HIV population is unknown. In this study the investigators examined depression as a risk factor for incident ischemic stroke among HIV-positive veterans in the veterans aging cohort study. The investigators concluded that depression is associated with an increased risk of stroke among HIV-positive people after adjusting for sociodemographic characteristics, traditional cerebrovascular risk factors, and HIV-specific factors.
AHRQ-funded; HS023464.
Citation: Sico JJ, Kundu S, So-Armah K .
Depression as a risk factor for incident ischemic stroke among HIV-positive veterans in the veterans aging cohort study.
J Am Heart Assoc 2021 Jul 6;10(13):e017637. doi: 10.1161/jaha.119.017637..
Keywords: Depression, Behavioral Health, Risk, Human Immunodeficiency Virus (HIV), Stroke, Cardiovascular Conditions
Caram MEV, Burns J, Kumbier K
Factors influencing treatment of veterans with advanced prostate cancer.
This study examined factors influencing treatment of veterans with metastatic castration-resistant prostate cancer (CRPC). Clinician and nonclinical factors associated with the first-line treatment for CPRC using data from the Veterans Health Administration was used. Almost 5000 patients who received abiraterone, enzalutamide, docetaxel, or ketoconazole from 2010 through 2017 were identified. Increasing age was associated with receipt of abiraterone or enzalutamide versus docetaxel. Greater preexisting comorbidity was associated with enzalutamide versus abiraterone. Patients with higher PSA values at the start of treatment were more likely to receive docetaxel than the other three treatments. African American men were more likely to receive ketoconazole.
AHRQ-funded; HS025707.
Citation: Caram MEV, Burns J, Kumbier K .
Factors influencing treatment of veterans with advanced prostate cancer.
Cancer 2021 Jul 1;127(13):2311-18. doi: 10.1002/cncr.33485..
Keywords: Cancer: Prostate Cancer, Cancer, Men's Health, Treatments
Rogal S, Youk A, Agbalajobi O
Medication treatment of active opioid use disorder in veterans with cirrhosis.
Although opioid use disorder (OUD) is common in patients with cirrhosis, it is unclear how medication treatment for OUD (MOUD) is used in this population. In this study, the investigators aimed to assess the factors associated with MOUD and mortality in a cohort of Veterans with cirrhosis and OUD. The investigators found that few Veterans with active OUD and cirrhosis received MOUD, and those with alcohol use disorder, schizophrenia, and previous prescriptions for opioids were least likely to receive these effective therapies.
AHRQ-funded; HS019461.
Citation: Rogal S, Youk A, Agbalajobi O .
Medication treatment of active opioid use disorder in veterans with cirrhosis.
Am J Gastroenterol 2021 Jul;116(7):1406-13. doi: 10.14309/ajg.0000000000001228..
Keywords: Opioids, Substance Abuse, Medication
Clair K, Ijadi-Maghsoodi R, Nazinyan M
Veteran perspectives on adaptations to a VA residential rehabilitation program for substance use disorders during the novel coronavirus pandemic.
This paper looks at veterans’ perspectives on adaptations made to a VA residential rehabilitation program for substance use disorders during the novel coronavirus pandemic. Adaptations to services are described within a large residential rehabilitation program for under-resourced veterans; reports veterans’ experiences; and outlines successes and challenges encountered. Data was collected from two focus groups with nine veterans in the program. The groups highlighted experiences of inconsistent communication about residential policies, interruptions to medical and addiction services, and feelings of confinement and social isolation.
AHRQ-funded; HS026407.
Citation: Clair K, Ijadi-Maghsoodi R, Nazinyan M .
Veteran perspectives on adaptations to a VA residential rehabilitation program for substance use disorders during the novel coronavirus pandemic.
Community Ment Health J 2021 Jul;57(5):801-07. doi: 10.1007/s10597-021-00810-z..
Keywords: Substance Abuse, Rehabilitation, COVID-19, Healthcare Delivery, Access to Care, Patient Experience
Spalluto LB, Lewis JA, Stolldorf D
Organizational readiness for lung cancer screening: a cross-sectional evaluation at a Veterans Affairs medical center.
Lung cancer has the highest cancer-related mortality in the United States and among Veterans. Screening of high-risk individuals with low-dose CT (LDCT) can improve survival through detection of early-stage lung cancer. Organizational factors that aid or impede implementation of this evidence-based practice in diverse populations are not well described. In this study, the investigators evaluated organizational readiness for change and change valence (belief that change is beneficial and valuable) for implementation of LDCT screening.
AHRQ-funded; HS026395.
Citation: Spalluto LB, Lewis JA, Stolldorf D .
Organizational readiness for lung cancer screening: a cross-sectional evaluation at a Veterans Affairs medical center.
J Am Coll Radiol 2021 Jun;18(6):809-19. doi: 10.1016/j.jacr.2020.12.010..
Keywords: Cancer: Lung Cancer, Cancer, Screening, Implementation, Organizational Change
Danan ER, White KM, Wilt TJ
Reactions to recommendations and evidence about prostate cancer screening among White and Black male veterans.
This study looked at differences in attitudes about recommendations and evidence on prostate cancer screening among White and Black male veterans. The authors provided a draft educational pamphlet about the benefits and harms of Prostate Specific Antigen (PSA) screening to 44 men, ages 55-81 at a midwestern VA medical center in 2013 and 2015. The groups were divided into four White and two Black focus groups. Three universal themes were low baseline familiarity with prostate cancer, surprise and resistance to the guidelines not to test routinely, and negative emotions in response to ambiguity. Discussions in the White groups highlighted the potential benefits of screening, minimized the harms, and emphasized personal choice in screening decisions. Discussions in Black groups devoted almost no time to benefits, considered harms significant, and emphasized personal and collective responsibility for cancer prevention through diet, exercise, and alternative medicine. Discussion in Black groups also emphasized the history of racism and discrimination in healthcare and medical research.
AHRQ-funded; HS026379.
Citation: Danan ER, White KM, Wilt TJ .
Reactions to recommendations and evidence about prostate cancer screening among White and Black male veterans.
Am J Mens Health 2021 May-Jun;15(3):15579883211022110. doi: 10.1177/15579883211022110..
Keywords: Cancer: Prostate Cancer, Cancer, Screening, Prevention, Racial and Ethnic Minorities, Evidence-Based Practice, Health Promotion, Education: Patient and Caregiver
Dworsky JQ, Shenoy R, Childers CP
Older veterans undergoing inpatient surgery: what is the compliance with best practice guidelines?
This study’s objective was to determine the documented compliance with best practice guidelines for optimal perioperative care for the older adult surgical patient that were created by the American College of Surgeons Quality Improvement Program and the American Geriatrics Society. The guidelines include 38 measures. A retrospective chart review was conducted on 86 older adults undergoing elective inpatient coronary artery bypass graft, prostatectomy, or colectomy over a 2-year period at a single Veterans Affairs hospital. Mean reported compliance across measures was 41% ± 4%. Of the 38 analyzed measures, 10 measures were achieved for 0 patients, and only 1 patient for 7 measures. Future work is needed to understand barriers for implementation.
AHRQ-funded; HS000046.
Citation: Dworsky JQ, Shenoy R, Childers CP .
Older veterans undergoing inpatient surgery: what is the compliance with best practice guidelines?
Surgery 2021 Feb;169(2):356-61. doi: 10.1016/j.surg.2020.08.033..
Keywords: Elderly, Surgery, Guidelines, Evidence-Based Practice, Quality Improvement, Quality of Care, Quality Measures
Donnelly JP, Wang XQ, Iwashyna TJ
Readmission and death after initial hospital discharge among patients with COVID-19 in a large multihospital system.
This study describes reasons for readmission, use of intensive care unit (ICU) interventions during readmission, and proportions of death after initial hospital discharge of COVID-19 patients from US Veterans Affairs (VA) hospitals March-June 2020.
AHRQ-funded; HS026725.
Citation: Donnelly JP, Wang XQ, Iwashyna TJ .
Readmission and death after initial hospital discharge among patients with COVID-19 in a large multihospital system.
JAMA 2021 Jan 19;325(3):304-06. doi: 10.1001/jama.2020.21465.
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Keywords: Respiratory Conditions, COVID-19, Hospital Readmissions, Hospital Discharge, Mortality, Outcomes
Lewis JA, Senft N, Chen H
Evidence-based smoking cessation treatment: a comparison by healthcare system.
The authors surveyed general medicine providers and specialists in a large academic health center (AHC) and its affiliated Veterans Health Administration (VHA) in the Mid-South in 2017 to determine the cross-sectional association of healthcare system in which the provider practiced (AHC versus VHA) with self-reported provision of evidence-based smoking cessation treatment at least once in the past 12 months. They found that VHA healthcare providers were significantly more likely to provide evidence-based smoking cessation treatment compared to AHC healthcare providers.
AHRQ-funded; HS026122.
Citation: Lewis JA, Senft N, Chen H .
Evidence-based smoking cessation treatment: a comparison by healthcare system.
BMC Health Serv Res 2021 Jan 7;21(1):33. doi: 10.1186/s12913-020-06016-5..
Keywords: Health Systems, Tobacco Use: Smoking Cessation, Tobacco Use, Evidence-Based Practice, Substance Abuse
Nelson HD, Denneson LM, Low AR
Suicide risk assessment and prevention: a systematic review focusing on veterans.
This article reviews studies of the accuracy of methods to identify individuals at increased risk of suicide and the effectiveness and adverse effects of health care interventions relevant to U.S. veteran and military populations in reducing suicide and suicide attempts. It concludes that risk assessment methods have been shown to be sensitive predictors of suicide and suicide attempts, but the frequency of false positives limits their clinical utility.
AHRQ-funded; HS019456.
Citation: Nelson HD, Denneson LM, Low AR .
Suicide risk assessment and prevention: a systematic review focusing on veterans.
Psychiatr Serv 2017 Oct;68(10):1003-15. doi: 10.1176/appi.ps.201600384.
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Keywords: Comparative Effectiveness, Behavioral Health, Prevention, Risk
Chavez LJ, Liu CF, Tefft N
The association between unhealthy alcohol use and acute care expenditures in the 30 days following hospital discharge among older Veterans Affairs patients with a medical condition.
Heavy alcohol use could predict increased risk for post-discharge acute care. This study assessed 30-day acute care utilization and expenditures for different categories of alcohol use, using VA and Medicare health care utilization data.
AHRQ-funded; HS022800.
Citation: Chavez LJ, Liu CF, Tefft N .
The association between unhealthy alcohol use and acute care expenditures in the 30 days following hospital discharge among older Veterans Affairs patients with a medical condition.
J Behav Health Serv Res 2017 Oct;44(4):602-24. doi: 10.1007/s11414-016-9529-4..
Keywords: Alcohol Use, Hospital Discharge
O'Neil ME, Callahan M, Carlson KF
Postconcussion symptoms reported by Operation Enduring Freedom/Operation Iraqi Freedom veterans with and without blast exposure, mild traumatic brain injury, and posttraumatic stress disorder.
This study examined symptom reporting related to the 10th Edition of the International Statistical Classification of Diseases (ICD-10) criteria for postconcussional syndrome (PCS) in veterans. One aim was to examine relationships among PCS symptoms by using the British Columbia Postconcussion Symptom Inventory (BC-PSI). BC-PSI factors were interpreted as cognitive, vestibular, affective, anger, and somatic. Items and factor scores were highest for veterans with blast exposure plus mTBI, and lowest for controls.
AHRQ-funded; HS022981.
Citation: O'Neil ME, Callahan M, Carlson KF .
Postconcussion symptoms reported by Operation Enduring Freedom/Operation Iraqi Freedom veterans with and without blast exposure, mild traumatic brain injury, and posttraumatic stress disorder.
J Clin Exp Neuropsychol 2017 Jun;39(5):449-58. doi: 10.1080/13803395.2016.1232699.
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Keywords: Brain Injury, Diagnostic Safety and Quality, Behavioral Health, Trauma
Mody L, Greene MT, Saint S
Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non-Veterans Affairs nursing homes.
Nursing homes provided baseline information about their infection prevention programs to assess strengths and gaps related to catheter-associated urinary tract infection (CAUTI) prevention via a needs assessment questionnaire. Among nursing homes participating in an AHRQ-funded collaborative, VA and non-VA nursing homes differed in their approach to CAUTI prevention. Best practices from both settings should be applied universally to create an optimal infection prevention program within emerging integrated healthcare systems.
AHRQ-funded; 290201000025I; HS019767; HS024385; HS018334.
Citation: Mody L, Greene MT, Saint S .
Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non-Veterans Affairs nursing homes.
Infect Control Hosp Epidemiol 2017 Mar;38(3):287-93. doi: 10.1017/ice.2016.279.
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Keywords: Catheter-Associated Urinary Tract Infection (CAUTI), Healthcare-Associated Infections (HAIs), Long-Term Care, Nursing Homes, Prevention
Brennan MB, Hess TM, Bartle B
Diabetic foot ulcer severity predicts mortality among veterans with type 2 diabetes.
Diabetic foot ulcers are associated with an increased risk of death. This study evaluated whether ulcer severity at presentation predicts mortality. It concluded that initial diabetic foot ulcer severity is a more significant predictor of subsequent mortality than coronary artery disease, peripheral arterial disease, or stroke.
AHRQ-funded; HS018542.
Citation: Brennan MB, Hess TM, Bartle B .
Diabetic foot ulcer severity predicts mortality among veterans with type 2 diabetes.
J Diabetes Complications. 2017 Mar;31(3):556-561. doi: 10.1016/j.jdiacomp.2016.11.020..
Keywords: Diabetes, Mortality, Chronic Conditions, Pressure Ulcers
Bensley KM, Harris AH, Gupta S
Racial/ethnic differences in initiation of and engagement with addictions treatment among patients with alcohol use disorders in the Veterans Health Administration.
In this study, the researchers investigated racial/ethnic variation in initiation of and engagement with specialty addictions treatment in a national sample of Black, Hispanic, and White patients with clinically recognized alcohol use disorders (AUD) from the US Veterans Health Administration (VA). The investigators found, after accounting for facility- and patient-level characteristics, Black and Hispanic patients with AUD were more likely than Whites to initiate specialty addictions treatment, and Black patients were more likely than Whites to engage.
AHRQ-funded; HS013853.
Citation: Bensley KM, Harris AH, Gupta S .
Racial/ethnic differences in initiation of and engagement with addictions treatment among patients with alcohol use disorders in the Veterans Health Administration.
J Subst Abuse Treat 2017 Feb;73:27-34. doi: 10.1016/j.jsat.2016.11.001..
Keywords: Alcohol Use, Racial and Ethnic Minorities, Substance Abuse
Musuuza JS, Roberts TJ, Carayon P
Assessing the sustainability of daily chlorhexidine bathing in the intensive care unit of a Veteran's Hospital by examining nurses' perspectives and experiences.
The objective of this project was to describe the process of daily chlorhexidine gluconate (CHG) bathing and identify the barriers and facilitators that can influence its successful adoption and sustainability in an ICU of a Veterans Administration Hospital. Patient bathing in ICUs was largely influenced by scheduling/workload and patient factors such as clinical stability, hypersensitivity to CHG, patient refusal, presence of IV lines and general hygiene.
AHRQ-funded; HS024039.
Citation: Musuuza JS, Roberts TJ, Carayon P .
Assessing the sustainability of daily chlorhexidine bathing in the intensive care unit of a Veteran's Hospital by examining nurses' perspectives and experiences.
BMC Infect Dis 2017 Jan 14;17(1):75. doi: 10.1186/s12879-017-2180-8.
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Keywords: Healthcare-Associated Infections (HAIs), Intensive Care Unit (ICU), Prevention
Storzbach D, Twamley EW, Roost MS
Compensatory cognitive training for Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans with mild traumatic brain injury.
The purpose of the study was to evaluate the efficacy of group-based compensatory cognitive training (CCT) for veterans with a history of mild traumatic brain injury. Veterans who participated in CCT reported significantly fewer cognitive and memory difficulties and greater use of cognitive strategies. They also demonstrated significant improvements on neurocognitive tests of attention, learning, and executive functioning, which were 3 of the cognitive domains targeted in CCT.
AHRQ-funded; HS022981.
Citation: Storzbach D, Twamley EW, Roost MS .
Compensatory cognitive training for Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans with mild traumatic brain injury.
J Head Trauma Rehabil 2017 Jan/Feb;32(1):16-24. doi: 10.1097/htr.0000000000000228.
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Keywords: Brain Injury, Neurological Disorders, Patient-Centered Outcomes Research, Trauma
Ahuja V, Sohn MW, Birge JR
Geographic variation in rosiglitazone use surrounding FDA warnings in the Department of Veterans Affairs.
The purpose of this study was to document variation in the use of rosiglitazone and other glucose- lowering drugs across 21 Veterans Integrated Service Networks. It found that aggregate rosiglitazone use increased monotonically from 7.7 percent, in the quarter it was added to the VA formulary, to a peak of 15.3 percent in the quarter when the FDA issued the safety alert.
AHRQ-funded; HS018542.
Citation: Ahuja V, Sohn MW, Birge JR .
Geographic variation in rosiglitazone use surrounding FDA warnings in the Department of Veterans Affairs.
J Manag Care Spec Pharm 2015 Dec;21(12):1214-34. doi: 10.18553/jmcp.2015.21.12.1214.
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Keywords: Adverse Drug Events (ADE), Medication: Safety, Medication, Practice Patterns
LaFleur J, Hoop R, Korner E
Predictors of early discontinuation of pegylated interferon for reasons other than lack of efficacy in United States veterans with chronic hepatitis C.
The researchers determined whether selected patient characteristics predicted discontinued therapy for reasons other than lack of efficcacy (non-LOE) using national databases of U.S. veterans. They found that predictors of greatest magnitude included comorbidities of myocardial infarction/congestive heart failure, renal disease, platelets 100/mm or more, Black race, albumin 3.5 mg/dl or more, sleep aid use, and poor persistence with antidepressants and antihypertensive agents.
AHRQ-funded; HS018582.
Citation: LaFleur J, Hoop R, Korner E .
Predictors of early discontinuation of pegylated interferon for reasons other than lack of efficacy in United States veterans with chronic hepatitis C.
Gastroenterol Nurs 2015 Nov-Dec;38(6):417-28. doi: 10.1097/sga.0000000000000214.
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Keywords: Chronic Conditions, Hepatitis, Medication, Patient Adherence/Compliance