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Research Interests: Primary Care, Clinical Trial, Implementation Science, Health Services Research, Health Administration, and 15 moreMedicine, Blood Pressure, Non Linear Dynamics, Risk factors, Randomized Trial, Implementation, Complex Adaptive System, Random Effects Model, Repeated Measures, Chronic Care Model, Clinical Data, Randomized Controlled Trial, Risk Factors, Diabetic complication, and Medical and Health Sciences
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Research Interests: Demography, Mental Health, Cardiovascular disease, Medicine, Comorbidity, and 15 moreMotivation, Humans, COPD, Female, Male, Psychological Intervention, Abstinence, Cohort, Aged, Middle Aged, Age Factors, Chronic obstructive pulmonary disease, Health surveys, Cross Sectional Studies, and Medical and Health Sciences
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Some people remain healthier throughout life than others but the underlying reasons are poorly understood. Here we hypothesize this advantage is attributable in part to optimal immune resilience (IR), defined as the capacity to preserve... more
Some people remain healthier throughout life than others but the underlying reasons are poorly understood. Here we hypothesize this advantage is attributable in part to optimal immune resilience (IR), defined as the capacity to preserve and/or rapidly restore immune functions that promote disease resistance (immunocompetence) and control inflammation in infectious diseases as well as other causes of inflammatory stress. We gauge IR levels with two distinct peripheral blood metrics that quantify the balance between (i) CD8+ and CD4+ T-cell levels and (ii) gene expression signatures tracking longevity-associated immunocompetence and mortality-associated inflammation. Profiles of IR metrics in ~48,500 individuals collectively indicate that some persons resist degradation of IR both during aging and when challenged with varied inflammatory stressors. With this resistance, preservation of optimal IR tracked (i) a lower risk of HIV acquisition, AIDS development, symptomatic influenza infe...
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Background Over 100 million Americans have chronic pain and most obtain their treatment in primary care clinics. However, evidence-based behavioral treatments targeting pain-related disability are not typically provided in these settings.... more
Background Over 100 million Americans have chronic pain and most obtain their treatment in primary care clinics. However, evidence-based behavioral treatments targeting pain-related disability are not typically provided in these settings. Therefore, this study sought to: 1) evaluate implementation of a brief evidence-based treatment, Focused Acceptance and Commitment Therapy (FACT-CP), delivered by an integrated behavioral health consultant (BHC) in primary care; and 2) preliminarily explore primary (self-reported physical disability) and secondary treatment outcomes (chronic pain acceptance and engagement in valued activities). Methods This mixed-methods pilot randomized controlled trial included twenty-six participants with non-cancer chronic pain being treated in primary care (54% women; 46% Hispanic/Latino). Active participants completed a 30-min individual FACT-CP visit followed by 3 weekly 60-min group visits and a booster visit 2 months later. An enhanced treatment as usual (...
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Service refusal, where patients actively refuse clinicians’ recommendations for additional services needed to achieve safe and full recovery after discharge, is a key but often overlooked cause of readmissions. There is a dearth of... more
Service refusal, where patients actively refuse clinicians’ recommendations for additional services needed to achieve safe and full recovery after discharge, is a key but often overlooked cause of readmissions. There is a dearth of literature on the extent of service refusal and providers’ (e.g. clinicians, nurses, social workers) observations regarding how to deal with these situations. As part of a larger, 10 VA site organizational case study of readmission, semi-structured interviews exploring causes of readmission were conducted with 21-41 staff members at each site (n=314). 41 providers identified Veteran service refusal and decision-making as causes of readmission. Providers acknowledged the need to honor patient autonomy/self-determination in decisions while at the same time worrying about potential adverse outcomes. Incongruence between Veterans’ and providers’ perceptions (especially for capacity for self-care), goals, and discharge plans was also cited as a factor in servi...
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BACKGROUND Signifying the two-compartments/one-disease paradigm, allergic rhinoconjunctivitis (ARC) and asthma (AA) are prevalent, comorbid conditions triggered by environmental factors (e.g., house dust mites (HDMs)). However, despite... more
BACKGROUND Signifying the two-compartments/one-disease paradigm, allergic rhinoconjunctivitis (ARC) and asthma (AA) are prevalent, comorbid conditions triggered by environmental factors (e.g., house dust mites (HDMs)). However, despite the ubiquity of triggers, progression to severe ARC/AA is infrequent, suggesting either resistance or adaptation. OBJECTIVE Determine if ARC/AA severity relates to maladaptive responses to disease triggers. METHODS Adults with HDM-associated ARC were challenged repetitively with HDMs in an aeroallergen challenge chamber; associated mechanistic traits were identified. RESULTS HDM challenges evoked maladaptive (persistently higher ARC symptoms), adaptive (progressive symptom reduction), and resilient (resistance to symptom induction) phenotypes. Symptom severity in the natural environment was an imprecise correlate of the phenotypes. Nasal airway traits, defined by low inflammation-effectual epithelial integrity, moderate inflammation-effectual epithelial integrity, and higher inflammation-ineffectual epithelial integrity, were hallmarks of the resilient, adaptive, and maladaptive evoked phenotypes, respectively. Highlighting a crosstalk mechanism, peripheral blood inflammatory tone calibrated these traits: ineffectual epithelial integrity correlated with CD8+ T-cells, whereas airway inflammation correlated with CD8+ T-cells and eosinophils. Hallmark peripheral blood maladaptive traits were increased NK and CD8+ cells, lower CD4+ MAIT cells, and deficiencies along the TLR-IRF-IFN antiviral pathway. Maladaptive traits tracking HDM-associated ARC also contributed to AA risk and severity models. CONCLUSIONS Repetitive challenges with HDMs revealed that maladaptation to disease triggers may underpin ARC/AA disease severity. A combinatorial therapeutic approach may involve reversal of loss-of-beneficial-function traits (ineffectual epithelial integrity, TLR-IRF-IFN deficiencies), mitigation of gain-of-adverse-function traits (inflammation), and blocking of a detrimental crosstalk between the peripheral blood and airway compartments. CLINICAL IMPLICATIONS The wide variation in allergic rhinoconjunctivitis disease severity may be underpinned by an imbalance in epithelial integrity and inflammation manifesting as maladaptation to disease triggers such as house dust mites.
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BackgroundAllergic asthma (AA) and allergic rhinoconjunctivitis (ARC) are common comorbid environmentally triggered diseases. We hypothesized that severe AA/ARC reflects a maladaptive or unrestrained response to ubiquitous... more
BackgroundAllergic asthma (AA) and allergic rhinoconjunctivitis (ARC) are common comorbid environmentally triggered diseases. We hypothesized that severe AA/ARC reflects a maladaptive or unrestrained response to ubiquitous aeroallergens.MethodsWe performed provocation studies wherein six separate cohorts of persons (total n = 217) with ARC, with or without AA, were challenged once or more with fixed concentrations of seasonal or perennial aeroallergens in an aeroallergen challenge chamber (ACC).ResultsAeroallergen challenges elicited fully or partially restrained vs. unrestrained evoked symptom responsiveness, corresponding to the resilient and adaptive vs. maladaptive AA/ARC phenotypes, respectively. The maladaptive phenotype was evoked more commonly during challenge with a non‐endemic versus endemic seasonal aeroallergen. In an AA cohort, symptom responses evoked after house dust mite (HDM) challenges vs. recorded in the natural environment were more accurate and precise predictor...
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Background The risk of severe COVID-19 varies significantly among persons of similar age and is higher in males. Age-independent, sex-biased differences in susceptibility to severe COVID-19 may be ascribable to deficits in a sexually... more
Background The risk of severe COVID-19 varies significantly among persons of similar age and is higher in males. Age-independent, sex-biased differences in susceptibility to severe COVID-19 may be ascribable to deficits in a sexually dimorphic protective attribute that we termed immunologic resilience (IR). Objective To examine whether deficits in IR that antedate or are induced by SARS-CoV-2 infection independently predict COVID-19 mortality. Methods IR levels were quantified with two novel metrics: immune health grades (IHG-I [best] to IHG-IV) to gauge CD8+ and CD4+ T-cell count equilibrium, and blood gene expression signatures. IR metrics were examined in a prospective COVID-19 cohort (n=522); primary outcome was 30-day mortality. Associations of IR metrics with outcomes in non-COVID-19 cohorts (n=13,461) provided the framework for linking pre-COVID-19 IR status to IR during COVID-19, as well as to clinical outcomes. Results IHG-I, tracking high-grade equilibrium between CD8+ and CD4+ T-cell counts, was the most common grade (73%) among healthy adults, particularly in females. SARS-CoV-2 infection associated with underrepresentation of IHG-I (21%) vs. overrepresentation (77%) of IHG-II or IHG-IV, especially in males vs. females (P<0.01). Presentation with IHG-I associated with 88% lower mortality, after controlling for age and sex; reduced risk of hospitalization and respiratory failure; lower plasma IL-6 levels; rapid clearance of nasopharyngeal SARS-CoV-2 burden; and gene expression signatures correlating with survival that signify immunocompetence and controlled inflammation. In non-COVID-19 cohorts, IR-preserving metrics associated with resistance to progressive influenza or HIV infection, as well as lower 9-year mortality in the Framingham Heart Study, especially in females. Conclusion Preservation of immunocompetence with controlled inflammation during antigenic challenges is a hallmark of IR and associates with longevity and AIDS resistance. Independent of age, a male-biased proclivity to degrade IR before and/or during SARS-CoV-2 infection predisposes to severe COVID-19. Clinical implications Biomarkers tracking immunologic resilience may have broad prognostic utility, as they associated with longevity, as well as resistance to a progressive disease course during SARS-CoV-2, influenza, or HIV infection.
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A discrete event simulation describes the screening and natural history of eye disease in patients with diabetes, using the POST simulation software. Discrete event simulation, unlike other modeling techniques, can show the interaction... more
A discrete event simulation describes the screening and natural history of eye disease in patients with diabetes, using the POST simulation software. Discrete event simulation, unlike other modeling techniques, can show the interaction between screening and the two main diabetic eye disease processes. Results show that there is a tradeoff between screening frequency, screening sensitivity and patient compliance. The extent to which screening is cost effective is not clear cut. We have little data on the cost of blindness and different views on the appropriate quality-of-life values to assume. The model can be extended to evaluate prevention and treatment for all the complications of diabetes.
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OBJECTIVE To understand Veterans', caregivers', and stakeholders' perceptions of home-based and caregiver support services and their suggestions for improvement to better align services with needs. DATA SOURCES We identified... more
OBJECTIVE To understand Veterans', caregivers', and stakeholders' perceptions of home-based and caregiver support services and their suggestions for improvement to better align services with needs. DATA SOURCES We identified Veterans and caregivers at four EDCoE sites using the VA high-need, high-risk list, representing Veterans who qualify for home-based primary care. We randomly selected Veterans and their caregivers, stratifying by age. We also identified leaders and clinicians involved in clinical service delivery. STUDY DESIGN Between February and November 2019, we conducted in-person and telephone interviews and focus groups using semi-structured questions tailored to each group, analyzing them through a rapid qualitative analysis approach and providing real-time feedback to operational partners. DATA COLLECTION Thirty-four Veterans, 24 caregivers, and 39 leaders and clinicians participated. PRINCIPAL FINDINGS Respondents identified key categories of experience that could be monitored and improved, including navigating an increasingly complex system, coordinating and communicating across services, and unmet household and financial needs. Veterans and caregivers described quality in terms of reliability, timeliness, standardization, and accountability. Summaries were created to contextualize results and to highlight gaps and opportunities for new measures and policy development. CONCLUSIONS Collaborating with Veterans, caregivers, and stakeholders enables us to understand their daily experiences and to develop meaningful approaches to evaluating services that incorporate their perspectives. Providing regular, actionable feedback to operational partners informs policy and operational initiatives, such as the scope of services and infrastructure for system navigation.
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Source Citation Saudek CD, Duckworth WC, Giobbie-Hurder A, et al., for the Department of Veterans Affairs Implantable Insulin Pump Study Group. Implantable insulin pump vs multiple-dose insulin for...
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Source Citation The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-d...
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Objective: To examine the relationship between A1c and the extent to which care delivered to patients with type 2 diabetes in primary care clinics is consistent with the Chronic Care Model (CCM), after controlling for self-care behaviors.... more
Objective: To examine the relationship between A1c and the extent to which care delivered to patients with type 2 diabetes in primary care clinics is consistent with the Chronic Care Model (CCM), after controlling for self-care behaviors. Research Design and Methods: A cross-sectional, observational study of care provided to 618 patients with type 2 diabetes across 20 small, autonomous primary care clinics in South Texas. Subjects completed an exit survey. The medical record was abstracted for A1c values. Clinicians completed the Assessment of Chronic Illness Care (ACIC) survey, a validated measure of the extent to which care delivered is consistent with the CCM. Results: There was a significant relationship between ACIC score and A1c but this relationship varied according to self-care behavior for exercise and was strongest for those who were not adherent to exercise: for every 1 point increase in ACIC, A1c was 0.144 % lower. (p<0.001) The relationship between ACIC and A1c for t...
BACKGROUND The value of secure messaging in streamlining routine patient care activities is generally agreed upon. However, the differences in how patients use secure messaging, including for communicating both routine and nonroutine... more
BACKGROUND The value of secure messaging in streamlining routine patient care activities is generally agreed upon. However, the differences in how patients use secure messaging, including for communicating both routine and nonroutine issues, and the implications of these differences in use are less well understood. OBJECTIVE The purpose of this study was to examine secure messaging use to extend current knowledge of how this tool is being used in outpatient care settings and generate new research questions to improve our understanding of the role of secure messaging in the patient-provider communication toolbox. METHODS We conducted an in-depth qualitative analysis of secure message threads in 12 US Department of Veterans Affairs outpatient clinics in south Texas. We analyzed 70 secure message threads with a total of 179 unique communications between patients and their outpatient teams for patterns in communication and secure message content. We used theories from information system...
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Source Citation Reichard P, Britz A, Carlsson P, et al. Metabolic control and complications over 3 years in patients with insulin dependent diabetes (IDDM): the Stockholm Diabetes Intervention Stud...
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Source Citation Peters AL, Davidson MB. Insulin plus a sulfonylurea agent for treating type 2 diabetes. Ann Intern Med. 1991 Jul 1;115:45-53.
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Manifestations and implications of uncertainty for tems: an analysis of routine versus non-routine, and interdependencies required for task completion). Implementation
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OBJECTIVES Identify predictors of persistence with adalimumab (ADA) among veterans and privately insured patients with inflammatory bowel disease (IBD) in the United States. STUDY DESIGN Retrospective cohort study. METHODS Patients with... more
OBJECTIVES Identify predictors of persistence with adalimumab (ADA) among veterans and privately insured patients with inflammatory bowel disease (IBD) in the United States. STUDY DESIGN Retrospective cohort study. METHODS Patients with IBD taking ADA as their first biologic were identified from the Veterans Health Administration (VHA) database from 2009 to 2013 and the Truven Health MarketScan database from 2009 to 2012 with a 12-month follow-up. Persistence was defined as continued use 1 year after initiation. Adherence was assessed by calculating a medication possession ratio, which was dichotomized as greater than 0.86 or less than or equal to 0.86. Multivariable logistic regression was used to evaluate predictors of persistence. RESULTS There were 1030 patients in the VHA population compared with 3264 patients in the privately insured (MarketScan) cohort. In MarketScan, 1800 patients (55%) remained on ADA compared with 755 (73%) in the VHA cohort. In multivariable analysis, mal...
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BackgroundThe successful implementation of interventions targeted to improve kidney health requires early identification of CKD which involves screening at-risk populations as well as recognizing CKD. We aim to determine CKD screening and... more
BackgroundThe successful implementation of interventions targeted to improve kidney health requires early identification of CKD which involves screening at-risk populations as well as recognizing CKD. We aim to determine CKD screening and recognition rates, factors associated with these rates, and evaluate the effect of CKD awareness on delivery of care.MethodsA retrospective cohort study of veterans enrolled with Veterans Integrated Service Network 17 who had hypertension (HTN) and/or diabetes (DM) and were seen at least twice in primary care clinics within 18 months. The final cohort of 270,170 patients (52% HTN, 5% DM, and 44% both) was examined for serum creatinine/eGFR, urine protein/albumin, International Classification of Diseases (ICD) codes for CKD, and nephrology referral. CKD was defined as eGFR <60 ml/min per 1.73 m2 and/or urine albumin-creatinine ratio (uACR) >30 mg/g at least twice 90 days apart. Clinical covariates, HTN control, and prescription rates of renal ...
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Research Interests: Kidney transplantation, Dialysis, Medicine, Multivariate Analysis, Humans, and 15 moreFemale, Male, Registries, Aged, Middle Aged, Proportional hazards model, Retrospective Studies, Age Factors, Chi Square Distribution, Risk Assessment, Proportional Hazards Models, Confidence Interval, Renal Dialysis, Postoperative Complications, and Medical and Health Sciences
The implementation of evidence-based practice in perioperative nursing holds promise of improving quality of care and client outcomes. Several factors within health care have precipitated an emphasis on evidence-based practice. The use of... more
The implementation of evidence-based practice in perioperative nursing holds promise of improving quality of care and client outcomes. Several factors within health care have precipitated an emphasis on evidence-based practice. The use of research results in clinical decisions is recommended as the basis of nursing practice of the future. To assist with development of evidence-based practice in nursing, basic steps of the process are presented. In addition, strategies for locating existing evidence-based practice guidelines and resources are described. Perioperative nurse researchers and practice leaders should move this issue into a top priority for the specialty.
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Twenty years ago, researchers identified the difficulties physicians have in answering the clinical questions that arise during medical care (Covell, Uman, & Manning, 1985). Fifteen years ago, the “Evidence-based medicine” movement arose... more
Twenty years ago, researchers identified the difficulties physicians have in answering the clinical questions that arise during medical care (Covell, Uman, & Manning, 1985). Fifteen years ago, the “Evidence-based medicine” movement arose (Cohen, 2001) and exhorted clinicians to use computers to look up the answers to questions as they arise during clinical care. Fortuitously for the proponents of evidence-based medicine the Internet matured in the 1990s{Hersh 1996 #3370}, epitomized by the launching of PubMed by Al Gore in June, 1997. PubMed, developed by the National Institutes of Health, provided the first free access to millions of biomedical research articles at MEDLINE. Unfortunately, the Internet has not fulfilled its potential to assist physicians in answering clinical questions. A recent study found that physicians obtain answers to only 40% of questions that arise during patient care (Ely, Osheroff, Chambliss, Ebell, & Rosenbaum, 2004); this rate is not much different than ...
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Objective The purpose of this study was to examine the effect of pain severity on activity levels and physical disability in the context of high pain acceptance. We hypothesized that pain acceptance moderates the effect of pain severity... more
Objective The purpose of this study was to examine the effect of pain severity on activity levels and physical disability in the context of high pain acceptance. We hypothesized that pain acceptance moderates the effect of pain severity on general activity and physical disability, such that at higher levels of acceptance, the deleterious effect of pain is mitigated. Methods Two hundred seven patients with chronic pain were recruited from three clinics in a large southwestern military treatment facility. Participants completed an anonymous self-report battery of standardized measures, including the Chronic Pain Acceptance Questionnaire, modified Oswestry Disability Index, and Pain Severity and General Activity subscales of the West Haven-Yale Multidimensional Pain Inventory. Results Chronic pain acceptance was found to significantly moderate relations between pain severity and general activity (b = 0.0061, t(198) = 2.75, P = 0.007, 95% confidence interval [CI] = 0.002 to 0.011) and...
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Additional file 1: Table S1. Two-day In-person POCUS Course Agenda. Table S2. Four-week Tele-ultrasound POCUS Course Agenda. Table S3. In-person Course Scanning Session Objectives. Table S4. Tele-ultrasound Course Scanning Session... more
Additional file 1: Table S1. Two-day In-person POCUS Course Agenda. Table S2. Four-week Tele-ultrasound POCUS Course Agenda. Table S3. In-person Course Scanning Session Objectives. Table S4. Tele-ultrasound Course Scanning Session Objectives. File S1. Pre- and Post-course Knowledge Test. File S2. CME Course Evaluation. File S3. Tele-ultrasound Course Evaluation. Table S5. Characteristics of Learners and Faculty. Table S6. Tele-ultrasound Course Evaluations by Learners and Faculty. Table S7. Faculty Evaluation of the Tele-ultrasound Course.
Background Lack of training is currently the most common barrier to implementation of point-of-care ultrasound (POCUS) use in clinical practice, and in-person POCUS continuing medical education (CME) courses have been paramount in... more
Background Lack of training is currently the most common barrier to implementation of point-of-care ultrasound (POCUS) use in clinical practice, and in-person POCUS continuing medical education (CME) courses have been paramount in improving this training gap. Due to travel restrictions and physical distancing requirements during the COVID-19 pandemic, most in-person POCUS training courses were cancelled. Though tele-ultrasound technology has existed for several years, use of tele-ultrasound technology to deliver hands-on training during a POCUS CME course has not been previously described. Methods We conducted a retrospective observational study comparing educational outcomes, course evaluations, and learner and faculty feedback from in-person versus tele-ultrasound POCUS courses. The same POCUS educational curriculum was delivered to learners by the two course formats. Data from the most recent pre-pandemic in-person course were compared to tele-ultrasound courses during the COVID-...
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OBJECTIVE—Improving diabetes care in the U.S. is critical because diabetes rates are increasing dramatically, particularly among minority and low-income populations. Although evidence-based practice guidelines for diabetes have been... more
OBJECTIVE—Improving diabetes care in the U.S. is critical because diabetes rates are increasing dramatically, particularly among minority and low-income populations. Although evidence-based practice guidelines for diabetes have been widely disseminated, many physicians fail to implement them. The objective of this study was to explore what happens to diabetes practice guidelines in real-world clinical settings. RESEARCH DESIGN AND METHODS—A qualitative research design was used. Open-ended semistructured interviews lasting 1–2 h were conducted with 32 key informants (physicians, certified diabetes educators, researchers, and agency personnel) selected for their knowledge of diabetes care in South Texas, an area with a high diabetes prevalence and a large proportion of minority and low-income patients. RESULTS—Health professionals stress that contextual factors are more important barriers to optimal diabetes care than physician knowledge and attitudes. Barriers exist at multiple level...
Research Interests: Poverty, Obesity, Medicine, Humans, Minority Groups, and 12 moreDiabetes mellitus, Physicians, Texas, Malpractice, Educational Status, Clinical Competence, Diabetes Care, Health Services Accessibility, Health Manpower, interprofessional relations, Medical and Health Sciences, and Physician-Patient Relations
OBJECTIVE—To describe the frequency and sequelae of diabetic renal disease in veterans who receive health care from the Veterans Administration (VA). RESEARCH DESIGN AND METHODS—Veterans with a diagnosis of diabetes, diabetic nephropathy,... more
OBJECTIVE—To describe the frequency and sequelae of diabetic renal disease in veterans who receive health care from the Veterans Administration (VA). RESEARCH DESIGN AND METHODS—Veterans with a diagnosis of diabetes, diabetic nephropathy, other kidney diseases, and end-stage renal disease (ESRD) were identified by diagnosis codes from national VA databases for FY1998. Data were obtained and analyzed for prevalence of renal disease, comorbid conditions, and 1-year mortality. RESULTS—A total of 44,671 (10.7%) of the 415,910 veterans with diabetes had a concomitant diagnosis of any renal disease. The average age was 67 years; 98% were male and 60% were white. The prevalence of diabetic nephropathy was 6.0% (n = 25,263). ESRD secondary to diabetes was present in 4.2% (17,636) of subjects. The age-standardized prevalence of diabetes and any renal disease was 72.6/1,000 persons and differed by race (white 76.1/1,000, black 103.4/1,000 persons). Diabetes-associated ESRD prevalence was high...
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OBJECTIVE— To define the test characteristics of four methods of screening for diabetic retinopathy. RESEARCH DESIGN AND METHODS— Four screening methods (an exam by an ophthalmologist through dilated pupils using direct and indirect... more
OBJECTIVE— To define the test characteristics of four methods of screening for diabetic retinopathy. RESEARCH DESIGN AND METHODS— Four screening methods (an exam by an ophthalmologist through dilated pupils using direct and indirect ophthalmoscopy, an exam by a physician's assistant through dilated pupils using direct ophthalmoscopy, a single 45° retinal photograph without pharmacological dilation, and a set of three dilated 45° retinal photographs) were compared with a reference standard of stereoscopic 30° retinal photographs of seven standard fields read by a central reading center. Sensitivity, specificity, and positive and negative likelihood ratios were calculated after dichotomizing the retinopathy levels into none and mild nonproliferative versus moderate to severe nonproliferative and proliferative. Two sites were used. All patients with diabetes in a VA hospital outpatient clinic between June 1988 and May 1989 were asked to participate. Patients with diabetes identifie...
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OBJECTIVE To assess from the perspectives of a government delivery system and patients, the cost-effectiveness of the 45-degrees retinal camera compared to the standard ophthalmologist's exam and an ophthalmic exam by a... more
OBJECTIVE To assess from the perspectives of a government delivery system and patients, the cost-effectiveness of the 45-degrees retinal camera compared to the standard ophthalmologist's exam and an ophthalmic exam by a physician's assistant or nurse practitioner technician, for detecting nonproliferative and proliferative diabetic retinopathy. RESEARCH DESIGN AND METHODS Comparison of 45-degrees fundus photographs with and without pharmacological pupil dilation taken by technicians and interpreted by experts, direct and indirect ophthalmoscopy by ophthalmologists, and direct ophthalmoscopy by technicians with seven-field stereoscopic fundus photography (reference standard). Costs were estimated from market prices and actual resource use. The study included 352 patients attending outpatient diabetes and general-medicine clinics at VA and DOD facilities. RESULTS Medical system costs per true positive were: 45-degrees photos with dilation, $295; 45-degrees photos without dilat...
Research Interests: Ophthalmology, Diabetes, Medicine, Complication, Humans, and 13 moreDiabetic Retinopathy, United States, Technique, Cost effectiveness, Ethnic Groups, Middle Aged, Cost Benefit Analysis, Diabetes Care, Socioeconomic Factors, American Diabetes Association 2017, Allied Health Personnel, mass Screening, and Medical and Health Sciences
CiteSeerX - Document Details (Isaac Councill, Lee Giles): Research article Audit and feedback and clinical practice guideline adherence: