Faculty Bibliography

Background/Purpose: Osteoarthritis (OA) and gout are each associated with increased cardiovascular disease (CVD), but their relative impacts on CV risk are not known. We compared rates of CVD among patients with OA (OA-only), gout (gout-only), or both (gout+OA). Methods: We used ICD-9 codes to identify male patients from within our VA health care system with OA-only, goutonly, or gout+OA, and an active medical record between August 2007 and August 2008. For each group, we collected baseline demographics and CVD risk factors. The primary outcome was a composite index (CV4) consisting of any diagnosis of myocardial infarction (MI), angina, coronary bypass surgery (CABG), and/or coronary artery disease (CAD). Secondary outcomes included individual diagnoses within the CV4, congestive heart failure (CHF) and death. Logistic regression was used to compare the associations of OA-only, gout-only, and gout+OA with CV outcomes, adjusting for traditional CV risk factors: age, race, hypertension (HTN), diabetes mellitus, hyperlipidemia (HLD), chronic kidney disease (CKD), and smoking. Results: 1280 gout subjects met inclusion criteria (983 gout-only, 297 gout+OA), along with 1231 OA-only subjects. Gout subjects, with or without OA, had more CVD risk factors at baseline, including HTN, HLD and CKD vs. OA-only. In an unadjusted model, a diagnosis of gout increased the risk for CV4, CAD, angina, CABG, CHF, and death compared to a diagnosis of OA-only. In a fully adjusted model, gout-only subjects continued to have increased risk for all outcomes except MI and death compared to OA-only subjects, while gout+OA subjects exhibited increased risk for angina and CHF (Table 1). Gout+OA did not impart additional risk over gout-only for any outcome except CABG. Conclusion: Our data suggest that gout is associated with higher risk of CVD compared with OA, that at least some of this increased risk may be independent of traditional risk factors, and that OA does not impart additive CVD risk to patients who also have gout. (Table Presented)

BACKGROUND: As primary care practices evolve into medical homes, there is an increasing need for effective models to shift from visit-based to population-based strategies for care. However, most medical teams lack tools and training to manage panels of patients. As part of a study comparing different approaches to panel management at the Manhattan and Brooklyn campuses of the VA New York Harbor Healthcare System, we created a toolkit of strategies that non-clinician panel management assistants (PMAs) can use to enhance panel-wide outcomes in smoking cessation and hypertension. METHODS: We created the toolkit using: 1) literature review and consultation with outside experts, 2) key informant interviews with staff identified using snowball sampling, 3) pilot testing for feasibility and acceptability, and 4) further revision based on a survey of primary care providers and nurses. These steps resulted in progressively refined strategies for the PMAs to support the primary care team. RESULTS: Literature review and expert consultation resulted in an extensive list of potentially useful strategies. Key informant interviews and staff surveys identified several areas of need for assistance, including help to manage the most challenging patients, providing care outside of the visit, connecting patients with existing resources, and providing additional patient education. The strategies identified were then grouped into 5 areas -- continuous connection to care, education and connection to clinical resources, targeted behavior change counseling, adherence support, and patients with special needs. CONCLUSIONS: Although panel management is a central aspect of patient-centered medical homes, providers and health care systems have little guidance or evidence as to how teams should accomplish this objective. We created a toolkit to help PMAs support the clinical care team for patients with hypertension or tobacco use. This toolkit development process could readily be adapted to other behaviors or conditions. Trial registration: NCT01677533 (www.clinicaltrials.gov).

Although injection drug use (IDU) and blood transfusions prior to 1992 are well-accepted risk factors for hepatitis C virus (HCV) infection, many prior studies that have evaluated tattooing as a risk factor for HCV infection did not control for a history of IDU or transfusion prior to 1992. In this large, multicenter case-control study we analyzed demographic and HCV risk factor exposure history data from 3,871 patients, including 1,930 with chronic HCV infection (HCV RNA positive) and 1,941 HCV negative (HCV antibody negative) controls. Crude and fully adjusted odds ratios of tattoo exposure by multivariate logistic regression in HCV infected versus controls were determined. As expected, injection drug use (65.9% vs. 17.8%, p < 0.001), blood transfusions prior to 1992 (22.3% vs. 11.1%, p < 0.001), and history of having one or more tattoos (OR = 3.81; 95% CI 3.23 - 4.49, p<0.001) were more common in HCV-infected patients than in control subjects. After excluding all patients with a history of ever injecting drugs and those who had a blood transfusion prior to 1992, a total of 1,886 subjects remained for analysis (465 HCV positive and 1,421 controls). Among these individuals without traditional risk factors, HCV positive patients remained significantly more likely to have a history of one or more tattoos after adjustment for age, sex, and race/ethnicity (OR = 5.17; 95% CI 3.75 - 7.11, p<0.001). Conclusion: Tattooing is associated with HCV infection, even among those without traditional HCV risk factors such as injection drug use and blood transfusion prior to 1992. (HEPATOLOGY 2013.).

Background: Although vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV) is recommended for all patients with chronic hepatitis C virus (HCV) infection, physician vaccination practices are suboptimal. Since training for family medicine (FM) and internal medicine (IM) physicians differ, we hypothesised that there are differences in knowledge, attitudes and barriers regarding vaccination against HAV and HBV in patients with chronic HCV between these two groups. Methods: A two-page questionnaire was mailed to 3000 primary care (FM and IM) physicians randomly selected from the AMA Physician Masterfile in 2005. The survey included questions about physician demographics, knowledge and attitudes regarding vaccination. Results: Among the 3000 physicians surveyed, 1209 (42.2%) returned completed surveys. There were no differences between respondents and non-respondents with regard to age, gender, geographic location or specialty. More FM than IM physicians stated that HCV+ patients should not be vaccinated against HAV (23.7% vs. 11.8%, p < 0.001) or HBV (21.9% vs. 10.6%, p < 0.001). FM physicians were also less likely than IM physicians to usually/always test HCV+ patients for immunity against HAV (33.9% vs. 48.6%, p < 0.001) or against HBV (50.8% vs. 68.0%, p < 0.001). There were numerous barriers to HAV and HBV vaccination identified. The median number of barriers was 3 for FM physicians and 2 for IM physicians (p < 0.001). Conclusions: Despite recommendations to vaccinate against HAV and HBV in patients with chronic HCV infection, physicians often do not test or vaccinate susceptible individuals. Interventions are needed to overcome the barriers identified and improve vaccination rates.