Laboratory reporting of Staphylococcus aureus with reduced susceptibility to vancomycin in United States Department of Veterans Affairs facilities.
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A national survey was sent to all appropriate Veterans Health Administration (VA) medical facilities asking about the ability to test for Staphylococcus aureus with reduced susceptibility to vancomycin (SARV) (MICs >4 microg/mL). For those with this ability, a request was made for the number of patients having SARV isolated during a 1-year period. Nineteen patients from eight sites across the country had isolation of SARV. Of these, MicroScan (Dade Behring, Inc, MicroScan Division, West Sacramento, CA) technology was used for 17 patients, Vitek (Hazelwood, MO) was used for 1 of the remaining 2 patients, and E-test (AB Biiodisk North America, Inc, Piscataway, NJ) for the other. All patients with this organism had microbiology testing done onsite in the reporting VA facility's College of American Pathologists-approved laboratory. For comparison, similar data were obtained for a 1-year period 2 years prior to the current survey; seven patients from four sites were verified to have a SARV. Between the two survey periods the reported cases of SARV increased 170%, indicating a need for continued surveillance and potentially a need to initiate a collection of isolates for further analysis. (+info)
Reduction in self-monitoring of blood glucose in persons with type 2 diabetes results in cost savings and no change in glycemic control.
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OBJECTIVE: Recent Veterans Affairs (VA) guidelines recommend that persons with stable type 2 diabetes controlled on oral agents or diet therapy perform self-monitoring of blood glucose (SMBG) twice weekly. We assessed the impact of a modification of these guidelines on hemoglobin A1c (HbA1c) and monitoring cost. STUDY DESIGN: Retrospective, noncrossover clinical trial. PATIENTS AND METHODS: We instructed persons with type 2 diabetes to perform SMBG testing according to modified adapted VA guidelines. We compared patients' baseline average testing frequency and HbA1c with those obtained during a 6-month interval beginning 2 months after implementation of the modified guidelines. The impact on the cost of monitoring was calculated. RESULTS: At baseline, 913 of 1,213 SMBG users with diabetes on oral hypoglycemic agents had HbA1c tested (HbA1c = 7.83% +/- 1.34%); their frequency of SMBG was 1.36 +/- 0.95 strips per patient per day. Postimplementation, 974 of 1,278 persons with diabetes had HbA1c tested (HbA1c = 7.86% +/- 1.54%; P= .63 vs baseline); frequency of SMBG decreased by 46% to 0.74 +/- 0.50 strips per patient per day (P < .0001). At baseline, 154 of 254 SMBG users with diabetes on diet therapy had HbA1c tested (HbA1c = 6.85% +/- 0.97%); their frequency of SMBG was 1.07 +/- 0.90 strips per patient per day. Postimplementation, 177 of 282 diet-treated persons with diabetes had HbA1c tested (HbA1c = 6.78% +/- 1.20%; P = .56 vs baseline); frequency of SMBG decreased by 35% to 0.70 +/- 0.51 strips per patient per day (P < .0001). Similar findings were observed in a cohort of 421 drug-treated patients with paired HbA1c data before and after implementation, and a cohort of 50 diet-treated patients with paired HbA1c data. Linear regression analysis showed no significant impact on individuals' HbA1c with reduction in strip use. Average monthly cost savings were $8,800, or $6.37 per patient per month. CONCLUSIONS: This program decreased the frequency of SMBG in persons with type 2 diabetes, resulting in substantial cost savings without affecting glucose control. (+info)
Military and VA general dentistry training: a national resource.
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In 1999, HRSA contracted with the UCLA School of Dentistry to evaluate the postgraduate general dentistry (PDG) training programs. The purpose of this article is to compare the program characteristics of the PGD training programs sponsored by the Armed Services (military) and VA. Surveys mailed to sixty-six VA and forty-two military program directors in fall 2000 sought information regarding the infrastructure of the program, the program emphasis, resident preparation prior to entering the program, and a description of patients served and types of services provided. Of the eighty-one returned surveys (75 percent response rate), thirty were received from military program directors and fifty-one were received from VA program directors. AEGDs reported treating a higher proportion of children patients and GPRs more medically intensive, disadvantaged and HIV/AIDS patients. Over half of the directors reported increases in curriculum emphasis in implantology. The program directors reported a high level of inadequate preparation among incoming dental residents. Having a higher ratio of residents to total number of faculty predicted inadequate preparation (p=.022) although the model was weak. Although HRSA doesn't financially support federally sponsored programs, their goal of improved dental training to care for medically compromised individuals is facilitated through these programs, thus making military and VA general dentistry programs a national resource. (+info)
Cholesteryl ester transfer protein TaqI B2B2 genotype is associated with higher HDL cholesterol levels and lower risk of coronary heart disease end points in men with HDL deficiency: Veterans Affairs HDL Cholesterol Intervention Trial.
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OBJECTIVE: We have previously reported that genetic variation at the cholesteryl ester transfer protein (CETP) TaqIB locus is correlated with plasma lipid levels and coronary heart disease (CHD) risk in the Framingham Offspring Study (FOS). In FOS, the B2 allele was associated with increased levels of high density lipoprotein (HDL) cholesterol (HDL-C), decreased CETP activity, and reduced CHD risk for men having the B2B2 genotype. The present study was undertaken to further define the relationship between this polymorphism and CHD risk at the population level. METHODS AND RESULTS: We tested for associations between the CETP TaqIB genotype and plasma lipoprotein levels, response to gemfibrozil therapy, and CHD end points in 852 men participating in the Veterans Affairs HDL-C Intervention Trial (VA-HIT), a study designed to explore the potential benefits of raising HDL levels in men having established CHD with low HDL-C (< or =40 mg/dL) as their primary lipid abnormality. In VA-HIT, 13.9% of the men had the B2B2 genotype relative to 19.1% of the men in FOS (-27%, P<0.03), whereas more men in VA-HIT had the B1B1 genotype (15%, P<0.05). Similar to our finding in FOS, B2B2 men in VA-HIT had the highest mean level of HDL-C (32.6+/-4.8 mg/dL), followed by B1B2 men (32.0+/-5.3 mg/dL), and, last, by B1B1 men (30.9+/-4.9 mg/dL). Interestingly, B1B1 men, who had the least favorable plasma lipid profile at baseline, had the greatest triglyceride-lowering response to gemfibrozil (-34%, P=0.006). CETP TaqIB genotype was also associated with the risk of CHD end points in VA-HIT, with an adjusted risk ratio of 0.52 for B2B2 men (P=0.08). CONCLUSIONS: Our data demonstrate that in men with CHD and HDL deficiency, the CETP TaqI B2B2 genotype is (1) significantly reduced and (2) associated with higher levels of plasma HDL-C and lower CHD risk. Together with our earlier report, these results support the concept that increased HDL-C levels, resulting from reduced CETP activity, are associated with decreased CHD risk. (+info)
COX-2-specific inhibitors: prescribing patterns in a large managed care health system and strategies to minimize costs.
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OBJECTIVE: To determine the relative costs associated with the exclusive use of celecoxib versus rofecoxib in a large managed care system. STUDY DESIGN: A retrospective review of all calendar year 2000 prescriptions dispensed for celecoxib and rofecoxib in the Veterans Affairs (VA) system. METHODS: The primary data points included drug strength, quantity dispensed, and days supply for the prescription. The cost minimization model described in Federal Practitioner (1999;16[4]:41-44) was used to calculate the cost savings. The mean once-daily dosing rates and their 95% confidence intervals were determined by binomial data analysis. Calendar year 2001 utilization and cost projections were derived by linear regression trend analysis. RESULTS: Current VA system costs per dose are celecoxib 100 mg $0.66; celecoxib 200 mg $1.32; rofecoxib (12.5 or 25 mg) $1.32; rofecoxib 50 mg $2.14. During calendar year 2000, the VA spent $13.8 million and $4.2 million on celecoxib and rofecoxib, respectively. The percentage of once-daily or less than once-daily dosing was celecoxib 100 mg (17%), celecoxib 200 mg (67%), celecoxib overall (49%), rofecoxib 12.5 mg (86%), rofecoxib 25 mg (94%), rofecoxib 50 mg (100%), and rofecoxib overall (93%). Based on current utilization, if all celecoxib prescriptions were changed to rofecoxib, the VA would have realized annual cost savings of $2.1 million in calendar year 2000. In calendar year 2001, projected cost savings could total $5.2 million. This potential savings is largely due to the high prevalence of twice-daily celecoxib dosing. CONCLUSION: The results of the cyclooxygenase-2 cost minimization analysis provide a compelling argument for the preferred use of rofecoxib in the VA system, and potentially in other managed care systems. (+info)
The impact of ethnicity on outcomes following coronary artery bypass graft surgery in the Veterans Health Administration.
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OBJECTIVES: We evaluated the effect of African American (AA) and Hispanic American (HA) ethnicity on mortality and complications following coronary artery bypass graft (CABG) surgery in the Veterans Health Administration (VHA). BACKGROUND: Few studies have examined the impact of ethnicity on outcomes following cardiovascular procedures. METHODS: This study included all 29,333 Caucasian, 2,570 AA, and 1,525 HA patients who underwent CABG surgery at any one of the 43 VHA cardiac surgery centers from January 1995 through March 2001. We evaluated the relationship between ethnicity (AA vs. Caucasian and HA vs. Caucasian) and 30-day mortality, 6-month mortality, and 30-day complications, adjusting for a wide array of demographic, cardiac, and noncardiac variables. RESULTS: After adjustment for baseline characteristics, AA and Caucasian patients had similar 30-day (AA/Caucasian odds ratio [OR] 1.07; 95% confidence interval [CI] 0.84 to 1.35; p = 0.59) and 6-month mortality risk (AA/Caucasian OR 1.10; 95% CI 0.91 to 1.34; p = 0.31). However, among patients with low surgical risk, AA ethnicity was associated with higher mortality (OR 1.52, CI 1.10 to 2.11, p = 0.01), and AA patients were more likely to experience complications following surgery (OR 1.28; 95% CI 1.14 to 1.45; p < 0.01). In contrast, HA patients had lower 30-day (HA/Caucasian OR 0.70; 95% CI 0.49 to 0.98; p = 0.04) and 6-month mortality risk (HA/Caucasian OR 0.66; 95% CI 0.50 to 0.88; p < 0.01) than Caucasian patients. CONCLUSIONS: Ethnicity does not appear to be a strong risk factor for adverse outcomes following CABG surgery in the VHA. Future studies are needed to determine why AA patients have more complications, but ethnicity should not affect the decision to offer the operation. (+info)
Initializing the VA medication reference terminology using UMLS metathesaurus co-occurrences.
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We developed and evaluated a UMLS Metathesaurus Co-occurrence mining algorithm to connect medications and diseases they may treat. Based on 16 years of co-occurrence data, we created 977 candidate drug-disease pairs for a sample of 100 ingredients (50 commonly prescribed and 50 selected at random). Our evaluation showed that more than 80% of the candidate drug-disease pairs were rated "APPROPRIATE" by physician raters. Additionally, there was a highly significant correlation between the overall frequency of citation and the likelihood that the connection was rated "APPROPRIATE." The drug-disease pairs were used to initialize term definitions in an ongoing effort to build a medication reference terminology for the Veterans Health Administration. Co-occurrence mining is a valuable technique for initializing term definitions in a large-scale reference terminology creation project. (+info)
A semantic normal form for clinical drugs in the UMLS: early experiences with the VANDF.
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A semantic normal form (SNF) for a clinical drug, designed to represent the meaning of an expression typically seen in a practitioner's medication order, has been developed and is being created in the UMLS Metathesaurus. The long term goal is to establish a relationship for every concept in the Metathesaurus with semantic type "clinical drug" with one or more of these semantic normal forms. First steps have been taken using the Veterans Administration National Drug File (VANDF). 70% of the entries in the VANDF could be parsed algorithmically into the SNF. Next steps include parsing other drug vocabularies included in the UMLS Metathesaurus and performing human review of the parsed vocabularies. After machine parsed forms have been merged in the Metathesaurus Information Database (MID), editors will be able to edit matched SNFs for accuracy and establish relationships and relationship attributes with other clinical drug concepts. (+info)