Publications
Department of Medicine faculty members published more than 3,600 peer-reviewed articles in 2024.
2020
BACKGROUND
Concerns over timely access and waiting times for appointments in the Veterans Health Administration (VHA) spurred the push towards greater privatization. In 2014, VHA increased the provision of care from community providers through the Veterans' Choice Program (Choice).
OBJECTIVES
We examined the characteristics of patients and practices more likely to use Choice care and whether using Choice care affected patients' attrition from VHA primary care.
STUDY DESIGN
We conducted a longitudinal study of VHA primary care users in the fiscal year 2015 and their attrition 2 years later. In the multivariate analysis, we examined whether attrition from VHA primary care was related to prior use of Choice care.
SUBJECTS
A total of 1.4 million nonelderly patients diagnosed with chronic conditions.
MEASURES
Choice outpatient care utilization was measured in the baseline year. Attrition was measured as not receiving any VHA primary care in 2 subsequent years.
RESULTS
In our cohort, 93,710 (7%) patients used some Choice outpatient care, and these patients were more likely to be female, White or Hispanic, to have more primary care utilization at baseline, and to have long driving distances to VHA care. Practices which sent more patients out for Choice care had lower mean scores for patient-centered medical home implementation and longer mean waiting times for appointments. In the adjusted analysis, the probability of attrition was significantly lower (-0.009) among patients who used Choice outpatient care (0.036) versus patients who did not (0.044) (P<0.001).
CONCLUSION
The use of community outpatient providers in the Choice program was associated with less attrition from VHA primary care.
View on PubMed2020
2020
2020
2020
2020
BACKGROUND/OBJECTIVES
Chronic kidney disease (CKD) is associated with frailty. Fibroblast growth factor 23 (FGF23) is elevated in CKD and associated with frailty among non-CKD older adults and individuals with human immunodeficiency virus. Whether FGF23 is associated with frailty and falls in CKD is unknown.
DESIGN
Cross-sectional and longitudinal observational study.
SETTING
Systolic Blood Pressure Intervention Trial (SPRINT), a randomized trial evaluating standard (systolic blood pressure [SBP] <140 mm Hg) versus intensive (SBP <120 mm Hg) blood pressure lowering on cardiovascular and cognitive outcomes among older adults without diabetes mellitus.
PARTICIPANTS
A total of 2,376 participants with CKD (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m).
MEASUREMENTS
The exposure variable was intact FGF23. We used multinomial logistic regression to determine the cross-sectional association of intact FGF23 with frailty and Cox proportional hazards analysis to determine the longitudinal association with incident falls. Models were adjusted for demographics, comorbidities, randomization group, antihypertensives, eGFR, mineral metabolism markers, and frailty.
RESULTS
After adjustment, the odds ratio for prevalent frailty versus non-frailty per twofold higher FGF23 was 1.34 (95% confidence interval [CI] = 1.01-1.77). FGF23 levels in the highest quartile versus the lowest quartile demonstrated more than a twofold increased fall risk (hazard ratio [HR] = 2.32; 95% CI = 1.26-4.26), and the HR per twofold higher FGF23 was 1.99 (95% CI = 1.48-2.68).
CONCLUSION
Among SPRINT participants with CKD, FGF23 was associated with prevalent frailty and falls.
View on PubMed2020
2020