The anergy panel: An ineffective tool to validate tuberculin skin testing

Many veterans enrolled in Veterans Affairs (VA) health care systems also receive care through other health care systems. Both VA and non-VA health care use must therefore be considered when conducting research in this population. This study characterized dual-care utilization in veterans with rheumatoid arthritis (RA) and explored associations with RA disease activity. Through a questionnaire mailed to RA patients at 3 VA sites, veterans reported medical services by non-VA primary care and subspecialty providers, comorbidities, non-VA medications, and hospitalizations. Disease Activity Score in 28 joints (DAS28) and Multidimensional Health Assessment Questionnaire (MD-HAQ) scores were recorded during VA clinic visits, and respondent groups were compared. Of the 510 participants surveyed, 318 (62%) responded. Respondents were older (ages 69 versus 66 years; P = 0.006), more likely nonsmokers (80% versus 67%; P = 0.001), and had lower disease activity (DAS28 3.3 versus 3.8; P < 0.001, MD-HAQ 0.8 versus 0.9; P = 0.01) than nonrespondents (n = 192 [38%]). The respondents with a non-VA provider (n = 130 [41%]) were older (71 versus 68 years; P = 0.001) and had more education (14 versus 13 years; P = 0.021) than nondual-care users. Only 6% of respondents reported having a non-VA rheumatologist, with 2% receiving a non-VA prescribed biologic agent or disease-modifying antirheumatic drug. In this study, VA beneficiaries with RA had lower dual-care utilization than previously reported for the general VA population, with few patients receiving dual rheumatology care or non-VA RA medications. This survey suggests that most US veterans with RA who access VA care use the VA as their primary source of arthritis care.

Venous thromboembolism (VTE), especially pulmonary embolism (PE) and lower extremity deep vein thrombosis (LE-DVT), is a serious and potentially preventable complication for patients with cancer undergoing systemic therapy. Using retrospective data from patients diagnosed with incident cancer from 2011-2020, we derived a parsimonious risk assessment model (RAM) using least absolute shrinkage and selection operator regression from the Harris Health System (HHS, n = 9,769) and externally validated it using the Veterans Affairs (VA) health care system (n = 79,517). Bootstrapped c statistics and calibration curves were used to assess external model discrimination and fit. Dichotomized risk strata using integer scores were created and compared against the Khorana score (KS). Incident VTE and PE/LE-DVT at 6 months occurred in 590 (6.2%) and 437 (4.6%) patients in HHS and 4,027 (5.1%) and 3,331 (4.2%) patients in the VA health care system. Assessed at the time of systemic therapy initiation, the new RAM included components of the KS with the modified cancer subtype, cancer staging, systemic therapy class, history of VTE, history of paralysis/immobility, recent hospitalization, and Asian/Pacific Islander race. The c statistic was 0.71 in HHS and 0.68 in the VA health care system (compared with 0.65 and 0.60, respectively, for KS). Furthermore, the new RAM appropriately reclassified 28% of patients and increased the proportion of VTEs in the high-risk group from 37% to 68% in the validation data set. The novel RAM stratified patients with cancer into a high-risk group with 8%-10% cumulative incidence of VTE and 7% PE/LE-DVT at 6 months (v 3% and 2%, respectively, in the low-risk group). The model had improved performance over the original KS and doubled the number of VTE events in the high-risk stratum. We encourage additional external validation from prospective studies.[Media: see text].

Racial/Ethnic Differences in Influenza Vaccination in the Veterans Affairs Healthcare System

Objective: To examine hospitalisation rates and resource utilisation following initiation of risperidone long-acting therapy (RLAT) among US veterans with schizophrenia.Methods: Encounter data were analysed from the Ohio Veterans Affairs (VA) Healthcare System. Adult patients (schizophrenia or schizoaffective disorder) with ≥1 medical or hospital visits with a diagnosis code of 295.xx, continuous enrolment from January 2003 through January 2006, and ≥4 injections of RLAT were selected. Analyses compared psychiatric-related resource utilisation pre- and post-exposure to RLAT; each patient served as his/her own control. The pre-exposure and post-exposure periods defined were equal in duration (e.g., a 6-month post-exposure period was matched with a 6-month pre-exposure period). Descriptive and comparative analyses (paired t tests, McNemar's test) were performed.Results: Patients (n=106) were 51.9 years old (±10.2), male (93%), white (73%) and received on average 14 RLAT doses (±9.7; range, 4–47 injections) over 309 days (±196; range, 42–737 days). Most experienced a psychiatric-related hospitalisation prior to initiation; less than half experienced hospitalisation after initiation (75% vs. 42%; p<0.001). Relative to pre-initiation, fewer psychiatric-related hospitalisations (mean [SD] change, –0.8 [2.0]; p<0.001), shorter length of stay (–25 [63.6] days; p<0.001), fewer inpatient days/month (–3.1 [7.2] days) and one (2.8) additional outpatient visit/month (p<0.001) occurred post-initiation.Limitations: The absence of a control group in this pre-/post comparison may have resulted in exposure to a regression to the mean effect. Also, this study evaluated only one cohort of patients in a VA healthcare setting.Conclusions: VA patients with schizophrenia and schizoaffective disorder treated with RLAT experienced fewer hospitalisations and psychiatric-related inpatient days following RLAT initiation. Further studies utilising a control group and in non-VA populations are warranted.

Military veterans experiencing relationship or family difficulties are able to access family services (i.e., couple and family therapy) through the Veterans Affairs (VA) Health Care System. Although family services have historically been provided face-to-face (F2F), the COVID-19 pandemic necessitated a sudden shift to the provision of care via telemental health, which includes videoconferencing (TMH-V) or audio-only phone appointments. This study demonstrated an unprecedented 16-fold increase in the number of TMH-V appointments for family services in VA during the first 9 months of the pandemic. The present study also examined demographic, mental health, and military variables associated with TMH-V utilization before and during the pandemic using a large national VA data set of 13,344 veterans who were referred to couple or family therapy from October 2017 through December 2020. Logistic regression was used to evaluate predictors of having any appointments via TMH-V before and during COVID-19, respectively, as well as predictors of having 50% or more of family service appointments via TMH-V versus phone versus face-to-face appointments during the COVID-19 era. Pre-COVID predictors of TMH-V utilization were limited to obsessive-compulsive disorder diagnosis and history of psychiatric hospitalization, suggesting that TMH-V usage was largely related to clinical indications. In the COVID-19 era, older and rural veterans were less likely to attend appointments via TMH-V than younger and suburban/urban veterans, while Hispanic veterans were more likely to do so than non-Hispanic veterans. The findings from the present study may aid efforts to ensure equity in access to care among veterans in the VA Health Care System. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The recently published article by Riviere et al,1 in which the authors investigated the survival of African American (AA) and non-Hispanic white (NHW) patients with prostate cancer (PCa) in the Veterans Affairs (VA) health care system, was of great interest to us. It is well documented that the racial disparity in PCa is among the largest in all cancer diagnoses,2 with AA men presenting at a younger age, with more advanced disease, and with increased mortality compared with white men.3 It commonly is accepted that genetic and/or biologic factors play a significant role in the racial differences observed in PCa outcomes, yet there is growing evidence that access-related variables may play an increasingly important role.4 Using the VA health care system, Riviere et al1 were able to evaluate PCa outcomes in an equal-access system and add to the growing literature of access-related variables contributing to the racial disparities noted with regard to PCa outcomes. Their study1 had some interesting outcomes that warrant discussion. First, Riviere et al found that AA men had a significantly lower 10-year prostate cancer–specific morality (PCSM) rate compared with NHW men.1 This was confirmed further in multivariable competing risk analysis after controlling for factors such as age, body mass index, smoking history, stage of disease, clinical T and M classifications, log-transformed prostate-specific antigen (PSA) level, and other variables.1 It is interesting to note that although Riviere et al found that AA men present at a younger age and with a higher PSA level, they were slightly less likely to present with Gleason score 8 to 10 disease, a clinical T classification of ≥3, or distant metastatic disease.1 The study by Riviere et al1 has provided strong evidence against some of the common adages found in the PCa literature. First, AA men did not have significantly higher PCa mortality rates compared with NHW men in the equal-access VA health care system. This result is supported by the recent study by Dess et al,4 who found that after controlling for nonbiological differences such as access to care and standardized treatment, black race was not associated with inferior stage-to-stage PCSM. This large analysis of 306,100 patients included 5 VA hospitals, and within this VA subgroup, the PCSM of AA men was found to be similar to that of NHW men.4 Although Riviere et al1 did find that AA men presented at a younger age and with a higher PSA level compared with NHW men, they did not present with higher grade disease compared with NHW men. This provides evidence that previous studies linking AA race with more aggressive disease at the time of presentation may be a result of access-related variables instead of genetic and/or biologic causes. The paradigm of understanding the racial differences in PCa outcomes is beginning to shift toward investigating the depth to which these health care disparities run. Multiparametric magnetic resonance imaging–ultrasound fusion biopsy is increasingly being used for the evaluation of men with clinical suspicion of PCa because it has been found to increase the detection of clinically significant cancer while decreasing the detection of clinically insignificant cancer compared with the standard 12-core systematic biopsy.5 Our recently published analysis found that biopsy-naive AA men were significantly less likely to receive multiparametric magnetic resonance imaging–ultrasound fusion biopsy compared with white men, thereby providing some evidence of the true depth at which the racial disparities in PCa exist, even extending to how it initially is diagnosed.6 Although it is unclear whether the improved PCSM among AA men noted in the study by Riviere et al1 was due to equal access to health care or factors such as more aggressive PCa screening, similar treatment choices, or consistent follow-up, it provides compelling evidence that equal access to health care may help to reduce the racial disparities noted among PCa outcomes. We are hoping that further studies exploring equitable access and quality of health care can help to better explain the racial differences observed in PCa outcomes. No specific funding was disclosed. The authors made no disclosures.

Use of the electronic record in the Home-Based Primary Care (HBPC) programs of the Department of Veterans Affairs (VA) Health Care System is described. The VA electronic record is a complete computerized system for a patient's record. The use of this system provides instant information on the health status of each patient referred to and managed by home care.

Older adults often require specialized health care expertise, but the effects of geriatrics-focused models of primary care have not been fully evaluated. To compare the effects of geriatrics-focused primary care vs traditional primary care for older patients in the Veterans Affairs (VA) health care system. In this cohort study, geriatrics-focused primary care and traditional primary care patient dyads matched on variables associated with geriatrics-focused primary care entry and outcomes were enrolled from VA medical centers with operational geriatrics-focused primary care clinics serving 500 or more patients annually in fiscal year 2016. Across 57 eligible sites, patients 65 years or older who transferred their care to geriatrics-focused primary care within the previous 12 months (exposure period) (n = 291) and their matched traditional primary care controls (n = 277) were enrolled. Study recruitment occurred from March 22, 2018, through December 11, 2019, with patient outcomes data collection completed June 24, 2021. Data were analyzed from June 2023 to January 2024. At least 2 geriatrics-focused primary care visits during the exposure period. Geriatrics-focused primary care involves interprofessional teams of clinicians with geriatrics expertise to provide comprehensive primary care for older veterans with complex needs. The primary outcome was home time (days not in a hospital unit, short-term nursing facility, inpatient rehabilitation, or an emergency visit) within 18 months of the exposure period. Secondary outcomes were completion of advance directives, assessments (falls, incontinence, and function), and medication quality (potentially inappropriate medications, Anticholinergic Drug Scale score). Patients were surveyed over 18 months about care experiences using Patient Perceptions of Integrated Care subscales, and Patient-Reported Outcomes Measurement System self-reported health and well-being measures. A total of 568 patients were enrolled (mean [SD] age, 80.5 [7.0] years; 558 [98.2%] male), including 291 in the geriatrics-focused primary care and 277 matched in the traditional primary care groups; most baseline variables were comparable between the 2 groups. Geriatrics-focused primary care was not associated with more home time (rate ratio, 0.97; 95% CI, 0.62-1.51) over 18 months. Geriatrics-focused primary care was associated with higher odds of assessment for falls (odds ratio [OR], 2.86; 95% CI, 1.62-5.04), incontinence (OR, 2.73; 95% CI, 1.69-4.42), and function (OR, 4.05; 95% CI, 2.39-6.85) at 18 months. Geriatrics-focused primary care was not associated with advance directive completion, medication quality, or self-reported health and well-being. In this cohort study, geriatrics-focused primary care did not increase time at home or other measures of self-reported health and well-being or integration of care within the first 18 months after care transition. However, increases in some process measures important for quality of care were observed, suggesting that further studies are needed to evaluate outcomes over a longer time frame.

To assess the prostate-specific antigen (PSA) threshold value that optimally predicts future risk of prostate cancer (overall and by race) for a dispersed US population. This was a retrospective analysis of men in the Veterans Affairs (VA) Health Care System database. Men≥40years with a baseline PSA≤4.0ng/mL, not receiving 5-alpha reductase inhibitors, and without a prostate cancer diagnosis prior to baseline PSA date were included and followed for 4years. Patients diagnosed with prostate cancer within 6months of baseline were excluded. The optimal PSA threshold value for future 4-year prostate cancer risk was determined by maximizing Youden's index. The eligible population for the final analysis included 41,250 Caucasian (n=24,518; 59.4%) and African American (n=16,732; 40.6%) patients. The 4-year prostate cancer rate was 3.08% overall, and race-specific rates were 3.02 and 3.17% for Caucasian and African American men, respectively. Mean time to prostate cancer diagnosis was 2.01years across all patients. Race-specific PSA thresholds that optimally predicted future prostate cancer were 2.5ng/mL [area under the curve (AUC)=80.3%] in Caucasians and a 1.9ng/mL (AUC=85.4%) in African Americans; across all patients, a 2.4ng/mL threshold was optimal (AUC=82.5%). In the VA population, a relatively low PSA threshold of ~2.5ng/mL was optimal in predicting prostate cancer within 4years overall and for Caucasian men, but an even lower threshold of 1.9ng/mL was applicable for African American men.

Background The presence of latent tuberculosis is routinely assessed by tuberculin skin test (TST), which detects a cell mediated immune response to the injected tuberculin purified protein derivative (PPD). Although TST has been in use for over a century, its limitations include poor specificity (i.e. numerous false positive results), the need to examine the site 48-72 hours after injection and the subjective interpretation of results (i.e. estimation of the diameter of induration). Recently, an in vitro assay has been investigated as an alternative to overcome limitations posed by TST. This assay, also known as gamma interferon release assay (GIRA) detects the release of gamma interferon from sensitized lymphocytes upon exposure to mycobacterium TB antigen coated tubes.

Traditional risk prediction and risk adjustment models have focused on clinical characteristics, but accounting for social determinants of health (SDOH) and complex health conditions could improve understanding of sepsis outcomes and our ability to predict outcomes, treat patients, and assess quality of care. To evaluate the impact of SDOH and health scales in sepsis mortality risk prediction and hospital performance assessment. Observational cohort study. One hundred twenty-nine hospitals in the nationwide Veterans Affairs (VA) Healthcare System between 2017 and 2021. Veterans admitted through emergency departments with community-acquired sepsis. Individual- and community-level SDOH (race, housing instability, marital status, Area Deprivation Index [ADI], and rural residence) and two health scales (the Care Assessment Need [CAN] score and Claims-Based Frailty Index [CFI]). The primary outcome was 90-day mortality from emergency department arrival; secondary outcomes included 30-day mortality and in-hospital mortality. Among 144,889 patients admitted to the hospital with community-acquired sepsis, 139,080 were men (96.0%), median (IQR) age was 71 (64-77) years, and median (IQR) ADI was 60 (38-81). Multivariable regression models had good calibration and discrimination across models that adjusted for different sets of variables (e.g., AUROC, 0.782; Brier score, 1.33; and standardized mortality rate, 1.00). Risk-adjusted hospital performance was similar across all models. Among 129 VA hospitals, three hospitals shifted from the lowest or highest quintile of performance when comparing models that excluded SDOH to models that adjusted for all variables. Models that adjusted for ADI reported odds ratios (CI) of 1.00 (1.00-1.00), indicating that ADI does not significantly predict sepsis mortality in this cohort of patients. In patients with community-acquired sepsis, adjusting for community SDOH variables such as ADI did not improve 90-day sepsis mortality predictions in mortality models and did not substantively alter hospital performance within the VA Healthcare System. Understanding the role of SDOH in risk prediction and risk adjustment models is vital because it could prevent hospitals from being negatively evaluated for treating less advantaged patients. However, we found that in VA hospitals, the potential impact of SDOH on 90-day sepsis mortality was minimal.

“Won’t Get Fooled Again” (by Tuberculosis)

Comparison of Interferon-Gamma Release Assay Versus Tuberculin Skin Test for Tuberculosis Screening in Inflammatory Bowel Disease

1. Rosalind S. Abernathy, MD* 1. 2. *Associate Professor of Pediatrics, University of Arkansas for Medical Sciences; Pediatric Consultant, Tuberculosis, Arkansas State Department of Health, Little Rock, AR. 1. The majority of tuberculosis cases in children are from high-risk populations, that is, African-Americans, Hispanics, immigrants, and those living in poverty and in the inner cities. 2. The only acceptable tuberculin skin test is the intradermal Mantoux test with purified protein derivative (PPD), and three levels of positivity now are accepted. Children exposed to active disease who have findings suggestive of tuberculosis or who have human immunodeficiency virus (HIV) infection are positive at 5 to 9 mm; other high-risk groups are positive at 10 mm. 3. Diagnosis of childhood tuberculosis depends on a high index of suspicion coupled with suggestive epidemiologic data, tuberculin skin test results, and chest radiographic findings. Cultures are not routinely positive, and results are available only after treatment must be started. 4. Treatment is a uniform 6-month course of isoniazid, rifampin, and pyrazinamide for 2 months followed by 4 months of isoniazid and rifampin daily or twice weekly. Additional drugs are needed in cases of drug resistance. 5. Chemoprophylaxis for all children who have a positive tuberculin reaction will prevent future disease. Despite the availability of effective antituberculosis drugs since 1952, tuberculosis remains an important cause of morbidity, mortality, and health care cost in the United States. Tuberculosis case rates declined at a rate of 6% annually for more than 20 years until 1985 when they leveled off (Fig. 1⇓). Factors responsible for this include human immunodeficiency virus (HIV) infection; immigration of individuals from countries where tuberculosis rates are 10 to 30 times that of the United States; transmission of disease in hospitals, homeless shelters, and prisons; and poverty, overcrowded living, and poor access to medical care. While all this was occurring, funds for tuberculosis control by public health programs declined. Fortunately, the number of cases reported annually has decreased by 8.7% in the past 2 years, probably …

Chronic conditions are among the most common causes of death and disability in the United States. Patients with such conditions receive disproportionate amounts of health care services and therefore cost more per capita than the average patient. This study assesses the prevalence among the Department of Veterans Affairs (VA) health care users and VA expenditures (costs) of 29 common chronic conditions. The authors used regression to identify the marginal impact of these conditions on total, inpatient, outpatient, and pharmacy costs. Excluding costs of contracted medical services at non-VA facilities, total VA health care expenditures in fiscal year 1999 (FY1999) were $14.3 billion. Among the 3.4 million VA patients in FY1999, 72 percent had 1 or more of the 29 chronic conditions, and these patients accounted for 96 percent of the total costs ($13.7 billion). In addition, 35 percent (1.2 million) of VA health care users had 3 or more of the 29 chronic conditions. These individuals accounted for 73 percent of the total cost. Overall, VA health care users have more chronic diseases than the general population.