Your cart is empty
Showing 1 - 25 of 51 matches in All departments
Lung cancer is the leading cause of cancer death in both men and women in the United States, and male Veterans seeking care at VA hospitals have a much higher age-specific incidence of lung cancer than males in the general population. The personal and economic significance of lung cancer has led to a vast research endeavor to try and identify new and more effective treatments. Until recently, all therapies for advanced NSCLC were based on their cytotoxic properties. In the last few years, several novel agents aimed at specific molecular targets have been developed. This review was requested to evaluate the current evidence on the effectiveness and cost-effectiveness of treatments for advanced lung cancer. Most patients with lung cancer are diagnosed when the cancer is already advanced (stage III or IV), and they are no longer candidates for surgical resection. Small cell lung cancer and nonsmall cell lung cancer (NSCLC) are treated as different diseases in terms of therapy. In the last few years, several novel agents aimed at specific molecular targets have been developed. This review was requested to evaluate the current evidence on the effectiveness and cost-effectiveness of treatments for advanced NSCLC. The key questions were: Key Question #1. For patients with metastatic non-small cell lung cancer (NSCLC) what is the comparative effectiveness of the different recommended (e.g. NCCN guidelines) first line chemotherapy regimens? Key Question #2. For patients with metastatic NSCLC what is the comparative effectiveness of the different recommended (e.g. NCCN guidelines) second line chemotherapy regimens? Key Question #3. For patients with metastatic NSCLC what is the benefit of maintenance therapy following first line chemotherapy regimens compared with no maintenance therapy? Key Question #4. What is the relative cost and cost-effectiveness of the different approaches in Key Questions 1-3?
There is great potential to improve health outcomes for Veterans and other patients with chronic genotype 1 (GT1) Hepatitis C (HCV) infections through the use of newly-available triple combination therapies that include directly acting antivirals (DAA) along with recently developed patient genotyping (IL-28B) which is predictive of HCV treatment response. Chronic GT1 HCV infections have been historically difficult to treat, with low cure rates on standard two drug therapy (Pegylated Interferon + Ribavirin), high rates of side-effects and treatment discontinuation, and low rates of uptake. Recently, FDA approved two DAAs (boceprevir and telaprevir). Used in combination with standard two drug therapy as triple therapy, these DAAs show higher rates of sustained viral response, though they are also more costly and have more severe side-effect profiles. IL-28B genotyping can help to identify patients least likely to respond to standard therapy and hence who stand to benefit the most from triple therapy and for whom, therefore, the increased risks of side-effects may be most justified. We addressed four related questions: Key Question #1: What are the current usage patterns of directly acting antivirals and of IL-28B patient genotyping in the VA health system? And how do these patterns differ by VISN? Key Question #2: What will be the health impacts of using either of two available directly acting antivirals combined with pegylated interferon and ribavirin (triple therapy)? Key Question #3: How will be the magnitudes of the health impacts measured in Key Question #2 change if IL-28B patient genotyping is used to offer triple therapy to those less likely to benefit from two-drug pegylated interferon + ribavirin? Key Question #4: What will be the cost and resource use patterns when using either triple therapy or IL-28B-guided triple therapy? We used analysis of observational data and decision analysis to answer these questions over a 5 year time horizon, all in comparison to health outcomes and costs if standard two-drug treatment were continued without adoption of either of the new technologies. Importantly, these results are appropriate for short-term budgeting and planning considerations but are not appropriate for formal cost-effectiveness analyses as they do not represent the full costs and benefits experienced over a life time.
Although the Surgeon General's recent report on osteoporosis stated that, "Strong bones (are) essential to overall health and quality of life," it warned that, "The bone health status of Americans... is in jeopardy." Traditionally, osteoporosis was viewed as a disease of women, but it has become clear that osteoporotic fractures result in substantial morbidity, mortality, and costs in men. A 60-year old man has a 25% lifetime risk of sustaining an osteoporotic fracture. The consequences of this fracture can be severe as the one-year mortality rate in men after hip fracture is twice that of women. With the aging of the population, rates of osteoporosis in men are expected to increase nearly 50% in the next 15 years and hip fractures rates are projected to double or triple by 2040. Furthermore, annual U.S. direct medical costs for osteoporosis exceed $17 billion and are expected to increase rapidly with an aging population. The percentage of costs directly attributable to men or veterans is unclear, although 25% of hip fractures, the fracture type associated with greatest costs due to hospitalization and long-term care, occur in men. This large and growing clinical and cost burden, combined with an environment of increasingly limited health care resources, strongly underlies the need to develop rational, evidence-based osteoporosis management strategies to obtain maximum benefit for every health care dollar spent. Despite the substantial advances in our understanding of osteoporosis over the last decade, there are no consensus guidelines on the assessment and management of male osteoporosis. Although osteoporosis management strategies have been evaluated in women, much less work has been done in this area in men. Lack of research in this area has led to considerable uncertainty regarding optimal osteoporosis strategies in men and Veterans. The VA Office of Quality and Performance and the U.S. Preventive Services Task Force offer no clinical practice guidelines on the management of osteoporosis in men. This review is being performed as part of the Evidence Synthesis Project, an HSR&D-organized initiative to provide VA policymakers with high quality evidence reviews. The purpose of this review is to analyze the literature in order to answer three key questions: 1) What is the epidemiology and what are the key risk factors for male osteoporosis?; 2) Are there any validated screening tools for osteoporosis in men (beyond DXA-assessed central bone density)?; and 3) What is the evidence regarding bone mineral density and fracture risk? Although 25% of men over the age of 60 will sustain osteoporotic fractures during their lifetime, data suggest that male osteoporosis is underdiganosed and undertreated. In order to help inform decisions about whether the Veterans Health Administration should develop screening guidelines for male osteoporosis, summaries of what is known about 1) the epidemiology of male osteoporosis, and 2) the validity of tools to screen and diagnose male osteoporosis are needed. The Key Questions were: Key Question 1. What are the prevalence of and risk factors for osteopenia, osteoporosis and osteoporotic fractures among men in general and among male Veterans specifically? Key Question 2. Are there any validated tools (outside of central bone density) to screen for osteoporosis in men? Key Question 3. What values of BMD determined by Dual energy X-ray Absorptiometry (DXA) (and by different DXA techniques) have been used to diagnose osteopenia and osteoporosis; and what is the evidence regarding the relationship between differing definitions and the development of osteoporotic fractures?
According to the World Health Organization, at least 180 million people worldwide suffer from diabetes. Though prevalent throughout the world, diabetes is more common (especially type 2) in more developed countries like the United States. The National Diabetes Information Clearinghouse estimates that diabetes costs $132 billion in the United States alone every year. Given these estimates along with the projection that the worldwide incidence of diabetes will double in the next 20 years, 1 intensified research into better management of this chronic disease is paramount. Tighter control of blood glucose is advocated as a means to reduce microvascular and macrovascular complications. VA has performance measures assessing the proportion of patients meeting certain A1c goals, currently 7% and 9%. Theoretically, self-monitoring of blood glucose (SMBG) can improve compliance with recommendations on diet and exercise and medication regimens. The American Diabetes Association has recommended that the optimal frequency of SMBG for patients with type 2 diabetes should be adequate to facilitate reaching glucose goals. This hypothesis is based on the expectation that life style changes are facilitated by SMBG. Under these conditions, we should expect an improvement of glycemic control SMBG may decrease patient management costs, and because of the high prevalence of type 2 diabetes, efforts to establish the efficacy of SMBG in type 2 diabetes mellitus are of greater relevance. Methods to achieve improved glycemic control, and therefore a higher proportion of patients meeting target A1c levels, include diet, exercise, and medication. However, evidence supporting the use of SMBG for diabetics not requiring insulin is not as clear. The purpose of this review is to analyze the literature to answer four key questions given to us by VA: 1) Is regular self-monitoring of blood glucose effective in achieving target A1c levels for patients with type 2 diabetes?; 2) Is regular self-monitoring of blood glucose effective in maintaining target A1c levels for patients with type 2 diabetes?; 3) Does regular self-monitoring of blood glucose reduce the frequency of hypoglycemia in patients with type 2 diabetes?; 4) Is there evidence that different frequencies of testing result in differences in improvements in A1c?
Access to healthcare has been identified as a critical issue, both by the Department of Veterans Affairs (VA) and the larger medical community. Access has been broadly defined as "the timely use of personal health services to achieve the best health outcomes" and has been hypothesized to have three discrete steps: 1) gaining entry into the system, 2) getting access to sites of care where patients can receive needed services, and 3) finding providers who meet the needs of the patient and with whom a productive working relationship can form. Historically, VA has focused on the first two steps (getting access to the system and sites of care) and has adopted Demakis's conceptualization of access as an individual's ability to obtain the healthcare they need within an appropriate time frame. Recently, researchers within the VA have begun to develop an updated conceptualization of access which takes into account the impact of new technology on access and places a greater focus on outcomes beyond increased access. Specifically, while the definition of access remains limited to the ability to connect with needed care, the reconceptualization acknowledges post-access outcomes such as satisfaction, symptom levels, and functioning. As such, we sought to conduct a review of the literature that would clarify the current state of the knowledge regarding the link between access to healthcare (both objective and perceived access) and system-level (e.g., utilization, satisfaction with care) and patient-level (quality of life, symptoms, mortality) outcomes. Further, the VA has continued its commitment to improving access for Veterans, and has implemented several programs designed to improve access to care for all veterans. Examples include the establishment of clinics located in areas distant from VA facilities (Community-Based Outpatient Clinics or CBOCs), mobile clinics, and increased use of telecommunications (telephone, internet, or videoconferencing). As such, we also examined the efficacy of interventions designed to improve access, with a focus on access, system-level, and patient-level outcomes. The Key Questions addressed in this review are: KEY QUESTION #1: What is the evidence that variation in veterans' ability to obtain needed health care (i.e., access) contributes to variation in system level (e.g., utilization, satisfaction) or patient level (e.g., quality of life, functional ability, mortality) outcomes? KEY QUESTION #1A: Does the effect of access on system and/or patient level outcomes differ by patient (e.g., demographics, overall health, illness severity), treatment (e.g., mental health, physical health), or setting (e.g., rural, urban, community, VA) characteristics? KEY QUESTION #2: What interventions have been successful in improving access for patient populations with reduced health care access? KEY QUESTION #2A: Have interventions that have improved health care access led to improvements in system level and patient level outcomes?
Ethical integrity in the conduct of health care research is essential for maintaining the public trust and support of such activities. Institutional Review Boards (IRBs) play a critical role in maintaining the ethical integrity of research by reviewing research protocols to ensure, among other things, that research participants receive safe and ethical treatment and provide informed consent, and that the potential for a conflict of interest is minimized. The purpose of this review was to catalog the literature on issues pertaining to IRBs, to identify the issue with the greatest number of published studies which might inform VA policy, and to assess the evidence regarding that issue, which were conflict of interest policies and the activities of the IRB. Without research, health care cannot advance in a scientific fashion. But by definition, research that involves human participants necessitates that some aspects of their care are no longer being provided solely for their health benefit: research is meant to inform the care of future patients. Therefore, care provided as part of a research protocol always involves a risk of harm. Sometimes it is a direct health risk, as in the case of a new treatment of hoped-for-but-as-yet-unproven benefit with the potential for certain adverse events; or it may be less obvious, such as the risk of disclosure of sensitive information. The ethical management of risk is a primary focus of maintaining integrity in research. The goal of this review was to describe the evidence regarding areas of interest in the ethical conduct of research, with a particular focus on the IRB and quality improvement initiatives. Further discussions resulted in the following key questions: Key Question #1. What has been published regarding the IRB, and each of the following issues: Quality improvement initiatives as research, Conflict of interest, Studies requiring approval of multiple IRBs, Genetic issues. Key Question #2. What is the actual evidence regarding the issue with the largest literature which may inform VA policy?
Hyperglycemia is a common finding among medical and surgical inpatients with and without known diabetes, and is associated with poor outcomes across a variety of inpatient subpopulations. The relationship between hyperglycemia and inpatient outcomes may be weaker in patients with diabetes than in patients without diabetes. Hyperglycemia may be a marker of severe, acute illness, one of many physiological derangements associated with an abundance of counter-regulatory hormones, insulin resistance, and suppression of anabolic pathways. On the other hand, many investigators believe that hyperglycemia itself may worsen outcomes by contributing to inflammation, oxidative stress, poor immune function, and endothelial dysfunction. Interventions to control hyperglycemia in inpatients have largely centered on the use of adjustable insulin infusions to lower blood glucose. An early trial in myocardial infarction patients found that lowering blood glucose using intensive insulin therapy (IIT) reduced long-term mortality, though it remains unclear whether the inpatient or outpatient components of the intervention were responsible for the benefit. An influential single-center observational study of cardiac surgery patients reported reduced wound infection and mortality rates after the introduction of an intensive care unit IIT protocol. Subsequently a single-center trial in critically ill surgical patients suggested a mortality benefit from IIT used to achieve normoglycemia. These findings have fueled widespread interest in inpatient glycemic control strategies, and organizations have called for strict glycemic control strategies to be implemented in a variety of intensive care unit settings. More recently, new trials have been completed that may help clarify the balance of benefits and harms of widespread IIT implementation in intensive care units. We conducted a systematic review of trials and a critical appraisal of frequently cited observational studies to identify strengths of-and gaps in-the evidence supporting broad use of IIT to achieve glycemic control in inpatients. The objectives of this review are to address the following questions: 1. Does the use of intensive insulin therapy (IIT) to achieve tight glycemic control compared to less tight glycemic control improve final health outcomes in the following patients? patients in the surgical intensive care unit, patients in the medical intensive care unit, patients in the perioperative setting, acute myocardial infarction patients, acute stroke patients, general surgical ward patients, general medicine ward patients.2. What are the harms of strict glycemic control in the above subpopulations? 3. What are the most effective and safest means of lowering blood glucose in the above subpopulations?
Non-professional caregivers are an important source of physical, emotional and other support to ill or injured Veterans. With an increasing number of Veterans who require care and assistance for traumatic brain injuries (TBI), physical impairments, or other debilitating disorders such as posttraumatic stress (PTSD) and dementia, there is a greater growing demand for spouses, parents or other family members and friends to assume the role of caregiver. Electronic health applications and tools are increasingly available and have the potential to facilitate caregiving outside of traditional healthcare settings, especially in the context of the rising use of smartphones and mobile technologies. Lessons learned from prior consumer health information technology (CHIT) interventions could help inform the development of health-related mobile applications. CHIT applications are defined as electronic tools or technologies intended for use by consumers, by patients or family members, that interact directly with users for the management of their health or healthcare, and in which data, information, or other recommendations are tailored and/or individualized; the system may or may not link to a health professional or health system services. The Veterans Health Administration (VA) is currently developing mobile applications intended for use by seriously injured post-9/11 Veterans and their family caregivers enrolled in the Comprehensive Assistance for Family Caregivers program. This report was requested on behalf of the VA offices that are developing these mobile tools. The objectives of this report are the following: 1) to identify studies of CHIT applications that aim to support the needs of caregivers; 2) examine the usage and effects of CHIT applications on caregiver burden outcomes, and patient outcomes, clinical process measures, and healthcare utilization of interest; 3) discuss parallels that can be drawn from pediatric literature, and 4) identify gaps in the literature. The key questions addressed by this systematic review are as follows: Key Question #1. How does the use of consumer health information technologies (CHIT) by nonprofessional caregivers of adult patients with chronic illnesses or disability, or by such patients who rely on a non-professional caregiver, affect outcomes for caregivers, patients, clinical process measures, and healthcare utilization? Key Question #2. What lessons can be learned from studies evaluating consumer health information technologies that specifically target the parents/caregivers of children? Key Question #3. What are the major gaps in the consumer health information technology literature serving non-professional caregivers of adult patients with regards to technology development, availability, and/or evaluation?
Racial and ethnic disparities are widespread in the US health care system. A 2007 report from the Portland Evidence-based Synthesis Program (ESP) similarly found disparities were prevalent in a variety of clinical arenas within Department of Veterans Affairs (VA). The report identified several promising avenues for future interventions designed to reduce racial and ethnic disparities. The extent to which such intervention research has been conducted in VA populations is unclear, though our review of published studies suggests disparities intervention research in the VA may be lagging behind research of interventions conducted outside of the VA setting. Furthermore, the approach to disparities interventions may be quite varied, and this may further complicate the development of an organized research agenda within the VA. Identifying challenges to conducting intervention research remain critical steps to informing future VA disparities intervention efforts to reduce disparities and improve health outcomes for minority Veterans. The objectives of this review are to describe the state of disparities intervention research within the VA, glean lessons from systematic reviews of intervention research not limited to VA settings, and develop an organizing framework to describe studies in this field of research. This report is also intended to inform future disparities intervention research in the VA, as well as VA policies and programs to reduce disparities. To accomplish these objectives, we will answer the following key questions: Key Question #1. What is the state of research on interventions to reduce race/ethnic disparities or to improve health and health care in minority populations within VA health care settings? Key Question #2. What are the results of interventions (within and outside the VA) to reduce race/ethnic disparities or to improve health and health care in minority populations?
Benign prostatic hyperplasia (BPH) causes urinary hesitancy and intermittency, weak urine stream, nocturia, frequency, urgency, and the sensation of incomplete bladder emptying. These symptoms, collectively called "lower urinary tract symptoms," or LUTS, can significantly reduce quality of life. Approximately 50% of men who have BPH develop moderate to severe symptoms. BPH is the 4th most commonly diagnosed disease among patients 50 years of age or older, after coronary disease and hyperlipidemia; hypertension; and type 2 diabetes. Among men over 50 years the prevalence of diagnosed BPH in the community is 13.5%. Reducing symptoms is the main reason to treat BPH. Men with no symptoms or mild symptoms (AUA Symptom Index SI] score of less than 7 points), and those who tolerate moderate symptoms well, may be managed without pharmacotherapy ("watchful waiting"). Medical treatments include alpha-1-selective adrenergic receptor (a-1-AR) antagonists, and 5-alpha-reductase inhibitors (5-aRIs). Several reasons to choose one treatment instead of another have been suggested. A clinician may consider several factors in choosing a treatment: expeditious relief of the presenting symptoms and quality of life; quality of life related to adverse effects of medications such as sexual dysfunction, dizziness, and asthenia; preventing or delaying progression (especially acute urinary retention) in the long-term; the risk of developing cancer; the effect of treatment on hypertension, diabetes, post-traumatic stress disorder, and other conditions common among veterans. This report addresses the following questions about treatment for BPH: 1. For patients with BPH, what are the comparative benefits, harms, and efficacy of combination therapy with a 5-alpha-reductase inhibitor plus an alpha blocker versus either treatment alone? 2. What are the comparative efficacy and harms of alpha-1-adrenergic antagonists? 3. Are there subgroups of patients based on demographics (age, racial groups), other medications, or co-morbidities for which one treatment is more effective or associated with fewer adverse events?
Poor pain management in surgical settings is known to be associated with slower recovery, greater morbidity, longer lengths of stay, lower patient satisfaction, and higher costs of care, suggesting that optimal pain care in these settings is of utmost importance in promoting acute illness management, recovery, and adaptation. VA/DoD Clinical Practice Guidelines have been developed for the management of acute post-operative pain, although the basis for many of the recommendations was by expert consensus rather than empirical evidence. The prevalence of pain on the inpatient medical ward is lower than that of a surgical service, but is still substantial. In one hospital survey, 43% of medical ward patients experienced pain, and 12% reported unbearable pain. There are currently no pain relevant performance measures in place that can support efforts to enhance pain care in these settings, and research on pain management in nonsurgical, nonmalignant acute pain is sparse. The Key Questions were: 1. For inpatients who have acute pain, how do differences in timing and frequency of assessment, severity of pain, and follow-up of pain affect choice of treatment, clinical outcomes, and safety? 2. How do the timing and route of administration of pain interventions compare in effectiveness, adverse effects, and safety in these inpatient care settings? 3. For inpatients with impaired self-report due to any of several factors, including delirium or confusion, pre-existing severe dementia, closed head injury, stroke, and psychosis, how do differences in assessment and management of acute pain affect clinical outcomes or safety? 4. For inpatients with dependencies on tobacco, alcohol, stimulant, marijuana, or opioids, how do differences in assessment and management of acute pain affect clinical outcomes or safety? How do the assessment and management of acute pain differ between patients on prexisting opioid therapy and patients with opiate addiction?
Long term anticoagulation with Vitamin K antagonists (e.g. warfarin) has been shown to reduce major thromboembolic complications in patients with many common chronic conditions, including atrial fibrillation, history of deep vein thrombosis and pulmonary embolism, and mechanical heart valves. However, Vitamin K antagonists have a very narrow therapeutic window requiring frequent laboratory monitoring to ensure that patients are neither excessively anti-coagulated, which increases the risk for bleeding, or under anti-coagulated, which increases the risk for thromboembolism. Laboratory monitoring consists of measuring the blood's tendency to clot with a test known as the International Normalized Ratio (INR), usually performed every 4-6 weeks. Dosage adjustments are then based on these results. Since management of long term oral anticoagulation requires frequent testing and dose adjustment, anticoagulation clinics (ACC) have been developed to streamline and standardize this care. Typically run by specially trained nurses or pharmacists, these clinics provide intense patient education, provide timely follow-up of INR results, use algorithms for dose adjustments, and are easily accessible to patients between visits. More recently, portable devices have become available that are able to accurately measure the INR with a drop of capillary blood. This means that patients can now test themselves at home and either call in the result to their provider who suggests dosage adjustments (known as patient self testing, PST) or adjust their dose of medication themselves (known as patient self management, PSM). As a leader in safety and quality, the Department of Veterans Affairs (VA) is interested in assuring that veterans on long-term anticoagulation receive state-of-the-art care that maximizes efficacy and minimizes complications. Towards that end, this review was commissioned by the VA's Evidence-based Synthesis Program, in conjunction with the Office of Quality and Performance. The final key questions are: 1. For management of long-term outpatient anticoagulation in adults, are specialized anticoagulation clinics (ACC) more effective and safer than care in non-specialized clinics (e.g., primary care clinics, physician offices)? 1a. Which components of a specialized anticoagulation clinic are associated with effectiveness/safety? 2. Is Patient Self Testing (PST), either alone or in combination with Patient Self Management (PSM), more effective and safer than standard care delivered in either ACCs or non-specialized clinics? 3. What are the risk factors for serious bleeding in patients on chronic anticoagulant therapy?
The Department of Veterans Affairs (VA) "Open Government Plan" outlines the agency's commitment to transparency, and defines transparency as both increasing access to public information and enabling better engagement and advocacy on behalf of Veterans. Key elements of the transparency initiative involve public presentation of health system and facility data about quality of care and safety. Examples include the VA Hospital Compare website, which provides outcomes and process data for selected diagnoses and the ASPIRE dashboard, which reports quality and safety goals for all VA hospitals. There are many reasons to make quality and safety information available to the public. One of the key goals of public reporting is to improve the quality of services. Theories and experience suggest multiple pathways from public reporting to health services improvement and ultimately to better patient outcomes. In a situation where patients and families have a choice among health care providers (systems or facilities), quality information makes it possible for patients to select providers based on performance. Public reporting also "levels the playing field" by making the knowledge about quality more accessible to patients. Without public reporting this information may only be known by providers. In turn, concern about loss of market share may motivate providers to improve processes and strive to improve outcomes. Publicly available data may also give provider organizations direct incentives to improve care. Report cards, rankings, and websites about quality allow organizations to compare their performance to that of their peers, but also make providers aware that others can make these comparisons as well. Concern about reputation can itself be a powerful motivator for change. Patient advocates, policy makers, and the media can also use publicly reported data to identify high and low performing organizations, track change over time, and promote high quality care. VA is committed to making its publicly reported performance data as accessible and useful as possible. This review and synthesis seeks to identify the key lessons for VA drawn from available research on public reporting that could be applied to future VA transparency efforts. The Key Questions were: 1. What is the most effective way of displaying quality and service information so that it is understandable? 2. How do patients prefer to receive or access this information? 3. What is the evidence that patients or their families use publicly reported quality and safety information to make informed health care decisions? 4. What is the evidence that public reporting of quality and safety information leads to improved quality of safety?
An increasing body of literature attempts to describe and validate hospital readmission risk prediction tools. Interest in such models has grown for two reasons. First, transitional care interventions may reduce readmissions among chronically ill adults. Readmission risk assessment could be used to help target the delivery of these resource-intensive interventions to the patients at greatest risk. Ideally, models designed for this purpose would provide clinically relevant stratification of readmission risk and give information early enough during the hospitalization to trigger a transitional care intervention, many of which involve discharge planning and begin well before hospital discharge. Second, there is interest in using readmission rates as a quality metric. Recently, the Centers for Medicare & Medicaid Services (CMS) began using readmission rate as a publicly reported metric, with plans to lower reimbursement to hospitals with excess risk-standardized readmission rates. Valid risk adjustment methods are required for calculation of risk-standardized readmission rates which could, in turn, be used for hospital comparison, public reporting, and reimbursement determinations. Models designed for these purposes should have good predictive ability; be deployable in large populations; use reliable data that can be easily obtained; and use variables that are clinically related to, and validated in, the populations in which use is intended. This systematic review was performed to synthesize the available literature on validated readmission risk prediction models, describe their performance, and assess their suitability for clinical or administrative use.
It remains unclear where the Veterans Health Administration (VA) finds itself in the spectrum of care currently available in the United States. The quality of care provided by the VA has been subject to debate since, and well before, the VA's system transformation starting in the mid-90s. Media and entertainment vehicles have, rightly or wrongly, not infrequently portrayed VA care in less than optimal light, although there have been notable exceptions1. Regardless of media views, the VA has established itself as an innovative healthcare system, including implementation of its advanced electronic medical record, with broad clinical and educational missions. The immediate objective of this project is to conduct a systematic literature review of the published literature comparing the quality of medical and surgical care provided by the VA to relevant non-VA healthcare facilities and systems. The Key Question was: Compare and contrast studies that assess VA and non-VA quality of care for surgical, nonsurgical and other medical conditions.
Prevalence of type 2 diabetes is increasing at an alarming pace, fueled by the rising rates of overweight and obesity in many populations. A recent study estimated that the number of people with diabetes increased worldwide from 153 million in 1980 to 347 million in 2008. This study estimated that from 1980 to 2008, the age standardized prevalence of diabetes in the United States increased from 6% to 12% in men and from 5% to 9% in women. In the VA, prevalence of diabetes is higher than in the general population and increasing over time. Miller et al. reported estimated rates of diabetes in VA of 17% in fiscal year (FY) 1998, 19% in FY99 and 20% in FY00. More recently, it was estimated that nearly 25% of veterans receiving care in the VA have diabetes. Although people with diabetes have a substantially increased risk of cardiovascular disease (CVD), three large well designed recent clinical trials testing intensive versus conventional glucose control strategies (ACCORD, ADVANCE and VA-DT), have found that intensive glucose control does not reduce the risk of CVD death or all-cause mortality although it reduces the risk of microvascular complications (nephropathy, retinopathy and neuropathy) and possibly non-fatal myocardial infarction. Intensive glucose control also increases the risk of hypoglycemic episodes. Several recent meta-analyses that included these large "intensive versus conventional control" trials have concluded that intensive control is associated with a 2-2.5 fold increased risk of severe hypoglycemia. However, these reviews included only randomized controlled trials; we are unaware of a comprehensive systematic review examining incidence of and risk factors for severe hypoglycemia in adults with type 2 diabetes in both real-world and clinical trial settings. Despite the increased risk of hypoglycemia with intensive glycemic control, influential national guidelines support an aggressive approach for patients with type 2 diabetes, recommending a target hemoglobin A1c level (HbA1c) of less than 7. This recommendation implies that the benefits of tight control outweigh the risks even though the balance between these benefits and harms is not actually known. In particular, the effects of hypoglycemia on outcomes besides CVD events and all-cause mortality have not, to our knowledge, been rigorously evaluated. The VA/DoD guidelines recommend a more nuanced approach: target HbA1c levels are based on life expectancy and severity of microvascular complications. A level of less than 7% is recommended only for those with no microvascular complications and a life expectancy of greater than 10 years. We conducted the current review to provide broader insight into the incidence of, the risk factors for, and the clinical impact of severe hypoglycemia in adults with type 2 diabetes treated with glucose lowering medications. The key questions were as follows: In adults with type 2 diabetes treated with one or more hypoglycemic agents: Key Question #1: What is the incidence of severe hypoglycemia in adults with type 2 diabetes on one or more hypoglycemic agents? Key Question #2: What are the risk factors for severe hypoglycemia in adults with type 2 diabetes on one or more hypoglycemic agents (e.g., demographics, co-morbidities, diabetes treatment regimen, other medication use, goal and achieved HbA1c)? Key Question #3: What is the effect of severe hypoglycemia on other outcomes in adults with type 2 diabetes on one or more hypoglycemic agents (e.g., quality of life, mortality, morbidity, utilization)?
Regular physical activity has many positive health benefits, including protection against chronic disease, improved physical and mental health and cognitive function, and better health-related related quality of life. Moreover, lack of physical activity is associated with higher health care costs and utilization. The current U.S. guidelines recommend that adult Americans (1) engage in at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity each week (or an equivalent mix of moderate- and vigorous-intensity aerobic activity) and (2) perform strengthening activities that target all major muscle groups on at least 2 days a week. However, many Americans do not get the recommended levels of physical activity. More Veterans are sufficiently active than non-Veterans. However, Veterans who use Veterans Affairs (VA) health care are more likely to be physically inactive (22.6% vs. 14.9%) and are less likely to meet physical activity recommendations (42.6% vs. 46.7%) compared with Veterans who do not use VA health care. Multiple personal, social, and environmental factors influence a person's participation in physical activity. Consequently, multiple internal and external barriers to obtaining regular physical activity exist. Internal barriers include a lack of time and motivation, health problems, and emotional difficulties. External barriers involve weather; cultural issues; safety concerns; limited access to facilities, equipment, and transportation; and monetary expenses such as those associated with attending a fitness center. The perceived cost of engaging in physical activity is a significant barrier that increases the likelihood of sedentary behaviors and decreases the likelihood of participation in vigorous physical activity. Thus, reducing the cost of being physically active through providing full or partial memberships to fitness centers may be a viable option to increase physical activity and the positive health outcomes associated with such activity. Given that most Americans (84%) have access to some form of health insurance, health plan promotion of and coverage for fitness center memberships has the potential to address multiple barriers to physical activity (e.g., cost, access) and extend fitness center access to many Americans. The effects of physical activity on health care utilization and costs, various health outcomes, and general well-being are well established. However, the evidence base on health plan-sponsored benefits-specifically involving fitness center memberships-that support these outcomes has not been synthesized. Our objective in this evidence synthesis was to summarize the results of diverse studies of health plan-sponsored fitness center memberships in an effort to understand how these benefits affect physical activity, clinical outcomes, health care costs and utilization, retention of plan members, and member satisfaction. The final key questions (KQs) were: KQ 1. What are the effects of policy/benefits packages that include vouchers, rebates, premium reductions, or other economic incentives to encourage physical activity through fitness center memberships on: (a) Physical activity participation rates among plan members? (b) Health outcomes demonstrated to be improved by physical activity (i.e., weight, pain, glucose, blood pressure, health-related quality of life)? (c) Overall health care costs and health care utilization? KQ 2. What are the effects of policy/benefits packages that include vouchers, rebates, premium reductions, or other economic incentives to encourage physical activity through fitness center memberships on satisfaction with the health plan and retention of members in the health plan? KQ 3. Do the effects of policy/benefits packages to encourage physical activity vary by specific characteristics of the package (premium vs. lump sum) or age, sex, and physical illness of participants?
As internet access and the use of mobile devices becomes more widely available, and as it is increasingly used by patients to access health information, many healthcare systems are capitalizing on this trend by offering patients electronic methods to communicate with providers and to learn about their health and medical problems. Some organizations or practices have developed stand-alone systems that allow for secure messaging between patients and their providers. Others, particularly those with existing electronic health record systems (EHRs), are developing companion applications specifically designed for patients that give patients access to email communication, access to their medical records and to test reports, and access to educational information on preventive care or disease-specific care. Much of this development is based on a perception that this is something that patients desire; and, that these systems will enhance patient satisfaction, improve care or make it more efficient. As the Veterans Health Administration (VHA) expands the capabilities of its personal health record system, My HealtheVet (MHV), and places greater emphasis on encouraging its use, it is interested in understanding how best to prioritize different functionalities and which of them will provide the greatest benefits to Veterans. This systematic review was designed to evaluate the literature surrounding secure messaging systems and electronic applications that give patients access to their own medical records, specifically investigating the evidence that these systems improve health outcomes, patient satisfaction, healthcare utilization and efficiency, and adherence. Additionally, the review examined studies that evaluated attitudes, particularly regarding patients having online access to their own medical information; and specific patient characteristics associated with use of personal health record systems. The review distinguished between electronic systems that were "tethered" or tied to existing healthcare institution systems similar to how MHV is tethered to VHA's EHR, versus those that were "stand-alone." The key questions were: Key Question #1. What is the association between secure messaging and health outcomes, patient satisfaction, adherence, efficiency or utilization, or automated email? Key Question #2. What is the association between patient access to their own medical record and health outcomes, patient satisfaction, adherence, efficiency or utilization, and attitudes about access?
Current clinical guidelines for depression address depression treatment for patients detected in primary care; VA/DOD depression guidelines; and NICE guidelines. Research to date indicates that, under usual care conditions, less than half of primary care patients found to have major depression complete minimally adequate medications or psychotherapy. A variety of organizational changes aimed at improving care for depression in primary care have been tested. Yet evidence-based guidance for healthcare organizations and their primary care practices about which organizational changes are necessary for achieving improved depression outcomes is lacking. The purpose of this review is to establish a basis for organizational guidelines or best practices for achieving improved depression care. The collaborative care model for depression has been extensively studied, and found to be both effective and cost-effective in prior meta-analysis. Collaborative care models are organizational interventions designed to remedy known deficits in current depression care. These multifaceted models are loosely defined as involving collaboration between providers from different specialties to provide appropriate, timely depression care or as involving two of three types of professionals (a case manager, a primary care clinician, and a mental health specialist) working collaboratively within primary care. Thus, while all applications of this model are similar in focusing on supporting effective management of primary care patients detected outside of a mental health specialty setting, the specific features of the model vary from study to study. These variations make it difficult for care settings to know what features of the models tested and found to be effective in randomized trials of collaborative care are essential for achieving the expected effects. Collaborative care definitions like these have been directed primarily at staffing (e.g., the presence of case manager or mental health specialist). Current theories of chronic illness care, however, postulate that key additional organizational changes are required to achieve consistent, sustainable improvement. When the multiple facets of collaborative care models are considered, most can be considered specific applications of the general, across-disease chronic illness care model. This review focuses on high quality depression care randomized trials that involved at least one change in the organization of care as described in the chronic illness care model. Our main research question was whether there are specific design features of collaborative care interventions that are consistently associated with greater impact on depression symptoms compared to a usual care control group. We also aimed to explore additional outcomes including patient satisfaction and functioning. In addition, we asked whether there were specific design features of randomized trial evaluations of collaborative care that were associated with consistently greater effects. Secondarily, we aimed to assess whether any patient characteristics, such as comorbidities, were associated with differential collaborative care effects, and the degree to which model effects persisted over time. We investigated these goals based on the following research questions. 1) Primary Research Question: What is the core set of intervention features that characterize collaborative care interventions, and which additional features are most linked to enhanced outcome effects? 2) Secondary Research Question: Are there specific evaluation features among randomized trials of collaborative care that are associated with effect size differences, independently of intervention features? 3) Secondary Research Question: To what extent is collaborative care more effective than usual care for decreasing depressive symptoms among patients with comorbid mental health conditions (PTSD, dementia, anxiety, dysthymia, substance abuse) or medical conditions?
Evidence suggests that the majority of Americans will experience a traumatic event at some time during their lives and that approximately 8% will subsequently develop post-traumatic stress disorder (PTSD). PTSD is one of the most common psychiatric sequellae of traumatic experiences and is characterized by an intense emotional reaction to the traumatic event, and followed by a persistent re-experiencing of the trauma, avoidance of things associated with the trauma, numbed emotional responsiveness, and increased arousal. Rates among military Veterans returning from deployments in Iraq and Afghanistan are much higher than that found in the general population, as high as 20% by some estimates. Currently, about 400,000 Veterans enrolled in VA carry a PTSD diagnosis. Those who suffer from PTSD often have diminished functioning and a poorer quality of life as evidenced by elevated rates of suicide, hospital admissions, poverty, and unemployment. Significant medical morbidity is also common among those with PTSD and several agerelated chronic medical conditions develop earlier. Moreover, people with PTSD have higher prevalence rates of problematic health behaviors, and utilize medical care at higher rates than those without PTSD. Although there are PTSD treatments available that have demonstrated effectiveness among individuals with diagnosed PTSD, many people who have PTSD may not be diagnosed and many who are diagnosed do not pursue mental health treatment. Of those who do seek treatment, prolonged delays are common. To minimize treatment delays and to maximize population reach, VA established a screening program to identify PTSD in their patients as they present in primary care clinics. Such screening programs may be helpful because primary care providers often have difficulty identifying PTSD in their patients and PTSD is therefore frequently undertreated in the primary care setting. The premise of this type of screening program is to identify individuals needing further evaluation so as to facilitate mental health treatment engagement earlier in the course of the illness and to identify patients for treatment who might not otherwise be identified as needing mental health care. Recently, the Institute of Medicine (IOM) released a report examining the screening, diagnosis, treatment, and rehabilitation services for military Veterans and service members with PTSD in the Department of Veterans Affairs and the Department of Defense. As noted in the IOM report and elsewhere, successful screening programs utilize instruments that are simple, valid, precise, and acceptable both clinically and socially. To identify screening tools that are best suited to primary care practice and to maximize relevance to the VA population, this evidence synthesis report reviews the literature on the feasibility and diagnostic accuracy of screening tools used in a primary care setting in the United States.We addressed the following key questions: Key Question #1. What tools are used to screen for PTSD in primary care settings, and what are their characteristics (i.e., length, format/administration, response scale)? Key Question #2. What are the psychometric properties and utility of the screening tools (sensitivity, specificity, likelihood ratios, predictive values, area under curve, reliability)? Key Question #3. What information is there about the implementability (e.g., ease of administration, patient satisfaction) of PTSD screening tools in primary care clinics? Key Question #4. Do the psychometric properties and utility of each of the screening tools differ according to age, gender, race/ethnicity, substance abuse, or other comorbidities?
Polytrauma is defined in the VHA Polytrauma Rehabilitation Centers Directive as: "injury to the brain in addition to other body parts or systems resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability." The definition of polytrauma has since expanded to include concurrent injury to two or more body parts or systems that results in cognitive, physical, psychological or other psychosocial impairments. Traumatic Brain Injury (TBI) often occurs in polytrauma and in combination with other disabling conditions including amputation, auditory or visual impairments, spinal cord injury (SCI), post-traumatic stress disorder (PTSD), and other mental health conditions. Pain resulting from polytraumatic injuries poses numerous challenges during rehabilitation treatment and afterwards. Treatments typically used to reduce pain in these individuals (for example, oral opioids) have the potential to interfere with the active rehabilitation needed to restore function. Pain resulting from polytraumatic injuries poses numerous challenges during and after rehabilitation treatment. The objectives of this report are to systematically review the literature to address the assessment and management of pain in patients with polytraumatic injuries, to identify patient, clinician and systems factors associated with pain-related outcomes in these patients, and to describe current or planned research addressing the key questions in this report. The key questions were: 1. Have reliable and valid measures and assessment tools been developed to measure pain intensity and pain-related functional interference among patients with cognitive deficits due to TBI? Which measures and tools are likely to be most useful in assessing pain in polytrauma patients with cognitive deficits due to TBI? 2. A. Which treatment approaches are most likely to be effective in improving pain outcomes (pain intensity and functional interference) in polytrauma patients? B. Which pain treatment approaches are most likely to enhance overall rehabilitation efforts? 3. A. Does blast-related headache pain differ in terms of phenomenology and treatment from other types of headache pain? B.Which treatments are best for persistent blast-related headache pain? 4. What patient factors are associated with better and worse pain-related clinical outcomes among polytrauma patients? Have interventions been developed to specifically address these factors? 5. What are unique provider and system barriers to detecting and treating pain among polytrauma patients? Have interventions been developed to effectively address these barriers?
Age-related macular degeneration (AMD) is the leading cause of irreversible vision loss in the developed world. In 2004, AMD affected 1.75 million persons in the United States, a number which is expected to rise to nearly 3 million by 2020 due to the aging of the population. AMD is characterized by the appearance of involutional changes (e.g. drusen) in the structure of the central retinal pigment epithelium (RPE) leading to the loss of normal central (macular) vision. AMD can be categorized as dry (non-exudative) or wet (exudative). Dry AMD represents the great majority of AMD patients (90%) and may lead to slow visual loss over many decades, with the most severe cases developing geographic atrophy and profound loss of central vision. Dry AMD can progress to wet AMD with the development of neovascularization beneath the diseased RPE leading to hemorrhage, scarring, and the devastating loss of macular vision over a period of months. By convention, there are four categories which describe the severity of macular degeneration. Category 1 are those patients essentially free of age-related macular abnormalities, with a total drusen area less than five small drusen (63 m), and visual acuity of 20/32 or better in both eyes. Category 2 patients have mild or borderline, age-related macular features (multiple small drusen, single or nonextensive intermediate drusen (63-124 m), pigment abnormalities, or any combination of these) in one or both eyes, and visual acuity of 20/32 or better in both eyes. Category 3 patients require the absence of advanced AMD in both eyes and at least one eye with visual acuity of 20/32 or better with at least one large drusen (125 m), extensive (as measured by drusen area) intermediate drusen, or geographic atrophy (GA) that does not involve the center of the macula, or any combination of these. Category 4 patients have visual acuity of 20/32 or better and no advanced AMD in one eye, with the fellow eye having either lesions of advanced AMD, or visual acuity less than 20/32 with AMD abnormalities sufficient to explain reduced visual acuity as determined by examination of photographs. Advanced AMD is defined as having GA involving the center of the macula or features of choroidal neovascularization. Observational studies suggest that people with dietary intakes higher in various carotenoids, antioxidants and omega-3 fatty acids have a lower risk of developing AMD. This has led to several supplementation trials designed to examine the ability of nutritional supplement with carotenoids, antioxidants, or omega-3 fatty acids to prevent the progression of AMD. Our report focuses on the evidence documenting the potential benefits and harms of certain dietary supplements in patients with AMD. Recommendations to the Department of Veterans Affairs with regard to these supplements will have important implications to that patient population as well as to older U.S. adults. We conducted a systematic review of published literature to address the following key questions:1) In patients with age-related macular degeneration, do nutritional supplements containing carotenoids, antioxidants, or omega-3 fatty acids alone or in combination prevent functional visual loss? 2) In adult populations, what are the harms of carotenoid, antioxidant, and omega-3 fatty acid supplementation?
Anxiety disorders are a major public health concern associated with functional impairment and increased use of the health care system. Two of the more common anxiety disorders are generalized anxiety disorder (GAD) and panic disorder (PD), which if identified, can be treated successfully with medications or psychotherapy. GAD is characterized by at least 6 months of persistent and excessive anxiety and worry that is difficult to control and is accompanied by three of six additional symptoms: restlessness, fatigue, decreased concentration, irritability, muscle tension, and sleep disturbance. PD, on the other hand, is episodic in nature and characterized by recurrent and unexpected panic attacks-periods of intense fear or terror associated with autonomic arousal such as breathlessness, chest pain, or fear of losing control-that become a cause of persistent concern in the patient. Generalized anxiety disorder (GAD) and panic disorder (PD) are two common mental illnesses that present in primary care clinics, often with physical symptoms that can inhibit appropriate diagnosis and treatment. Recognition of these disorders by primary care physicians is much lower than the expected rates-in part due to somatic presentations but also due to the lack of routine screening that is in place for some other mental illnesses. Patients with anxiety disorders are often high utilizers of health care resources, and when their anxiety disorders are not diagnosed and treated, they can frequently undergo more expensive testing to rule out medical causes. Identification of accurate and feasible screening instruments for GAD and PD that have been validated in primary care settings have the potential to improve detection and facilitate treatment of these disorders within the primary care clinic, or to generate appropriate referral. Our report is a systematic review of the literature to evaluate the performance of self-report instruments used to diagnose GAD and PD in primary care settings. Three key questions (KQs) guided this systematic review: KQ 1. In general medical patients with somatic symptoms, what are the performance characteristics (e.g., sensitivity, specificity) of self-report questionnaires for diagnosing generalized anxiety disorder or panic disorder? KQ 2. For questionnaires evaluated in KQ 1, which measures are most feasible to use in primary care settings? Specifically, what is the reading comprehension level, time required to complete, response format, and compatibility with telephone administration? KQ 3. For questionnaires evaluated in KQ 1, do the performance characteristics vary by gender, race, age group, or setting?
Women Veterans are among the fastest growing groups of new VA health care users of the VA healthcare system, and currently reflect approximately eight percent of all U.S. Veterans. With Operation Enduring Freedom and Iraqi Freedom (OEF/OIF), women comprise a larger percentage of the military (11.3 percent) than of prior military operations. As of fiscal year 2010, 51.3 percent of female OEF/OIF Veterans had enrolled in VA health care, in sharp contrast to women from previous eras (an estimated 11 percent). Of this group, 88 percent have used VA health care more than once. To better understand the needs of this rapidly growing group, women Veterans' health research has expanded as well. Two previous systematic reviews examined the literature on women Veterans' health and health care up to 2008. In this review, we specifically explored women Veterans' post-deployment health, with two main areas of concentration: 1) post-deployment effects on reproductive health for women Veterans, and 2) post-trauma sequelae among women Veterans from the OEF/OIF cohort. In response to a growing need to understand the effects of military service on health status, this report supplements our prior review by focusing directly on the reproductive and trauma effects on women in the military or Veterans who have been deployed. The goal is to broaden the knowledge of VA policy leaders and clinicians about post-deployment health issues for women. The Key Questions were: Key Question #1: What research has been published on the effects of deployment on postdeployment reproductive outcomes? We operationalized "reproductive effects" to encompass the following: fertility issues, birth defects, menstrual effects (e.g., change in cycles, loss of cycles), urinary tract infections, sexually transmitted infections, and reproductive cancers (e.g., cervical, ovarian, etc). Key Question #2: What research has been published on post-trauma sequelae in OEF/OIF women Veterans, including: mental health problems, suicide, cardiovascular disease, risky health behaviors (including: tobacco use, hazardous alcohol use, substance abuse, suicide, homicide, assaultive behavior, and eating disorders), and other post-trauma sequelae?
Optimal care of chronic illness requires both high-quality care (i.e., excellent clinical outcomes) and ready access to care. However, health care systems struggle with providing access and quality simultaneously-and to achieve both these objectives while simultaneously maintaining staff job satisfaction is a formidable undertaking. Although Veterans Affairs (VA) has made large strides in delivering quality care over the past two decades, quality gaps remain, both gaps in technical quality (e.g., still only 70 to 75% of patients have appropriate blood pressure control) and gaps in timeliness of services. Group medical visits offer the promise of improving the effectiveness, timeliness, and efficiency of health care. Additionally, because clinicians may prefer to work in collaborative, multidisciplinary settings, group medical visits also have the potential to improve staff satisfaction. Group medical visits are defined as multiple patients seen together while in the same clinical setting. A subset of group clinics-referred to as shared medical appointments (SMAs)-is defined by groups of patients meeting over time for comprehensive care, usually involving a practitioner with prescribing privileges, for a defining chronic condition or health care state. SMAs often use educational and/or self-management enhancement strategies, paired with medication management, in an effort to achieve improved disease outcomes. SMAs have been scientifically studied in an array of primary care settings over the last 10 to 15 years. However, there has been great variability among these studies. In particular, the settings of these studies have been heterogeneous; different chronic health care states have been assessed; and the impact on clinical, cost, and utilization outcomes has been variable. Most important, there has been significant variation in the SMA intervention itself-in particular, which types of clinical, educational, and self-efficacy approaches are included in the specific SMA under evaluation. This uncertainty regarding the optimal design and impact of SMAs led the VA to commission this evidence synthesis report. Our objective in this evidence synthesis was to summarize the results of the diverse studies of SMAs in an effort to understand their impact on staff satisfaction, patient experience, and clinical outcomes along with effects on health care utilization. A second objective was to determine whether the impact of SMA visits varies by clinical condition or specific components of the intervention. This review was commissioned by the VA Evidence-based Synthesis Program. The topic was nominated after a topic refinement process that included a preliminary review of published peer reviewed literature, consultation with internal partners and investigators, and consultation with key stakeholders. We further developed and refined the key questions based on a preliminary review of published peer-reviewed literature in consultation with VA experts. The final key questions were: Key Question 1. For adults with chronic medical conditions, do shared medical appointments (SMAs) compared with usual care improve the following: Patient and staff experience?; Treatment adherence?; Quality measures such as (a) process of care measures utilized by VA, National Quality Forum, or National Committee for Quality Assurance and (b) biophysical markers (laboratory or physiological markers of health status such as HbA1c and blood pressure)?; Symptom severity and functional status?; Utilization of medical resources or health care costs? Key Question 2. For adults with chronic medical conditions, do the effects of SMAs vary by patient characteristics such as specific chronic medical conditions and severity of disease? Key Question 3. Is the intensity of the intervention or the components used by SMAs associated with intervention effects?
You may like...
Funko Mystery Mini Box - Avengers End…
Philips Avent Natural Trainer Cup 150ml
R195 Discovery Miles 1 950
Simply Child Hot Air Balloon Mobile…
R390 Discovery Miles 3 900
Halle Berry, Daniel Craig DVD
Canon CL-513 Tri-Colour Ink Cartridge
R602 Discovery Miles 6 020
Kingsons Valentine Series Shoulder Bag…
Cobra Adventure AM-645 2-Way Radios…
Lord You Are Good
Rebecca Malope CD R109 Discovery Miles 1 090
Mellerware Hercules 1000W Non-Stick Dry…
Nadine Gordimer Paperback (2)