Academic Appointments

  • Associate Professor (Research), Surgery

Administrative Appointments

  • Associate Professor, Department of Surgery (2016 - Present)

Honors & Awards

  • Presidential Early Career Award in Science and Engineering (PECASE), The National Science and Technology Council (NSTC) (2008)
  • Health System Impact Award, Department of Veterans Affairs, Health Services Research and Development (2014)

Professional Education

  • Post-Doctoral Fellow, Department of Veterans Affairs, Health Services Research (2004)
  • MS, Stanford University, Statistics (2001)
  • PhD, Stanford University, Counseling Psychology (2003)

Research & Scholarship

Current Research and Scholarly Interests

Quality Measurement, Predictive Modeling, Implementation Science,


All Publications

  • Predictive Validity of Outpatient Follow-up After Detoxification as a Quality Measure. Journal of addiction medicine Schmidt, E. M., Gupta, S., Bowe, T., Ellerbe, L. S., Phelps, T. E., Finney, J. W., Humphreys, K., Trafton, J., Vanneman, M. E., Harris, A. H. 2017; 11 (3): 205-210


    Care coordination for substance use disorder (SUD) treatment is a persistent challenge. Timely outpatient follow-up after detoxification from alcohol and opiates is associated with improved outcomes, leading some care systems to attempt to measure and incentivize this practice. This study evaluated the predictive validity of a 7-day outpatient follow-up after detoxification quality measure used by the Veterans Health Administration (VHA).A national sample of patients who received detoxification from alcohol or opiates (N = 25,354) was identified in VHA administrative data. Propensity score-weighted mixed-effects regressions modeled associations between receiving an outpatient follow-up visit within 7 days of completing detoxification and patient outcomes, controlling for facility-level performance and clustering of patients within facilities.Baseline differences between patients who did (39.6%) and did not (60.4%) receive the follow-up visit were reduced or eliminated with propensity score weighting. Meeting the quality measure was associated with significantly more outpatient treatment for SUD (b = 1.07 visits) and other mental health conditions (b = 0.58 visits), and higher inpatient utilization for SUD (b = 0.75 admissions) and other mental health conditions (b = 0.76 admissions). Notably, meeting the quality measure was associated with 53.3% lower odds of 2-year mortality (P < 0.001 for all).These findings support the predictive validity of 7-day follow-up after detoxification as a care coordination measure. Well-coordinated care may be associated with higher outpatient and inpatient utilization, and such engagement in care may be protective against mortality in people who receive detoxification from alcohol or opiates.

    View details for DOI 10.1097/ADM.0000000000000298

    View details for PubMedID 28282324

  • Postdeployment Behavioral Health Screens and Linkage to the Veterans Health Administration for Army Reserve Component Members. Psychiatric services Vanneman, M. E., Harris, A. H., Chen, C., Adams, R. S., Williams, T. V., Larson, M. J. 2017: appips201600259-?


    Approximately three to six months after returning from deployment, military service members complete the Post-Deployment Health Reassessment (PDHRA), which includes screens for alcohol misuse, depression, and posttraumatic stress disorder (PTSD). To determine whether Army Reserve Component (RC) members (Army National Guard and Army Reserve) with positive screening scores on the PDHRA receive needed care, the investigators examined the association between positive scores and enrollment and utilization of care ("linkage") in the Veterans Health Administration (VHA), as well as rescreening scores, diagnosis, and behavioral treatment in VHA.Mixed-effects regression models were used to predict linkage to VHA within six months after RC members (N=73,164) completed the PDHRA, with alcohol misuse, depression, and PTSD screen scores as key independent variables. Regression models were stratified by gender and National Guard versus Reserve status. Among those who linked to VHA (N=25,168), screening scores and subsequent diagnosis and treatment in VHA were also examined.Army RC members with positive PTSD and depression screening scores were more likely than those with negative screens to link to VHA, and most (54%-84%) received VHA treatment once diagnosed. Positive screens for alcohol misuse were associated with linkage to VHA for men but not for women, and treatment rates for alcohol use disorders were relatively low (0%-25%) for both men and women diagnosed as having an alcohol use disorder.The finding that Army RC members with greater indications of behavioral health problems linked to VHA is encouraging. However, more outreach and treatment engagement strategies could be directed to those with alcohol use disorder, particularly women.

    View details for DOI 10.1176/

    View details for PubMedID 28412888

  • Revision Hip Arthroplasty Using a Modular, Cementless Femoral Stem: Intermediate-Term Follow-Up JOURNAL OF ARTHROPLASTY Sivananthan, S., Lim, C., Narkbunnam, R., Sox-Harris, A., Huddleston, J. I., Goodman, S. B. 2017; 32 (4): 1245-1249
  • Weight Gain After Primary Total Knee Arthroplasty Is Associated With Accelerated Time to Revision for Aseptic Loosening. journal of arthroplasty Lim, C. T., Goodman, S. B., Huddleston, J. I., Harris, A. H., Bhowmick, S., Maloney, W. J., Amanatullah, D. F. 2017


    Obesity is a major health problem worldwide and is associated with complications after total knee arthroplasty (TKA). It remains unknown whether a change in body mass index (BMI) after primary TKA affects the reasons for revision TKA or the time to revision TKA.A total of 160 primary TKAs referred to an academic tertiary center for revision TKA were retrospectively stratified according to change in BMI from the time of their primary TKA to revision TKA. The association between change in BMI and time to revision was also analyzed according to indication for revision of TKA using Pearson's chi-square test.The mean change in BMI from primary to revision TKA was 0.82 ± 3.5 kg/m(2). Maintaining a stable weight after primary TKA was protective against late revision TKA for any reason (P = .004). Patients who failed to reduce their BMI were revised for aseptic loosening earlier, at less than 5 years (P = .020), whereas those who reduced their BMI were revised later, at over 10 years (P = .004).Maintaining weight after primary TKA is protective against later revision TKA for any reason but failure to reduce weight after primary TKA is a risk factor for early revision TKA for aseptic loosening and osteolysis. Orthopedic surgeons should recommend against weight gain after primary TKA to reduce the risk of an earlier revision TKA in the event that a revision TKA is indicated.

    View details for DOI 10.1016/j.arth.2017.02.026

    View details for PubMedID 28318864

  • Iraq and Afghanistan Veterans' Use of Veterans Health Administration and Purchased Care Before and After Veterans Choice Program Implementation. Medical care Vanneman, M. E., Harris, A. H., Asch, S. M., Scott, W. J., Murrell, S. S., Wagner, T. H. 2017


    The veterans choice program (VCP), enacted by Congress after concerns surfaced about access, enables veterans to receive care outside Veterans Health Administration (VHA) facilities. Veterans who face long wait times, large driving distances, or particular hardships are eligible for VCP. Prior purchased care programs were comparatively limited in scope.We sought to describe utilization of VHA-provided and purchased outpatient care by veterans eligible for VCP before and after VCP implementation. We focused on veterans recently eligible for VHA as they are of particular policy relevance and might have less established care patterns.We identified all Iraq and Afghanistan veterans who were eligible for VCP in 2015. We tabulated their use of VHA and purchased outpatient care for 3 years before (FY2012-2014) and 1 year after VCP implementation (FY2015).Our study population consisted of 214,449 Iraq and Afghanistan veterans who were eligible for VCP due to wait-time, distance, or hardship issues.In the first year of the program, 3821 (2%) of these Iraq and Afghanistan veterans used non-VHA services through VCP. Per capita VHA utilization tended to decline slightly after VCP implementation, but these changes varied by type of outpatient care.There was low uptake of VCP services in the first year of the program. Data from additional years are needed to better understand the impact of this policy.

    View details for DOI 10.1097/MLR.0000000000000678

    View details for PubMedID 28146036

  • Racial/ethnic differences in initiation of and engagement with addictions treatment among patients with alcohol use disorders in the veterans health administration. Journal of substance abuse treatment Bensley, K. M., Harris, A. H., Gupta, S., Rubinsky, A. D., Jones-Webb, R., Glass, J. E., Williams, E. C. 2017; 73: 27–34


    Specialty addictions treatment can improve outcomes for patients with alcohol use disorders (AUD). Thus, initiation of and engagement with specialty addictions treatment are considered quality care for patients with AUD. Previous studies have demonstrated racial/ethnic differences in alcohol-related care but whether differences exist in initiation of and engagement with specialty addictions treatment among patients with clinically recognized alcohol use disorders is unknown. We investigated racial/ethnic variation in initiation of and engagement with specialty addictions treatment in a national sample of Black, Hispanic, and White patients with clinically recognized alcohol use disorders (AUD) from the US Veterans Health Administration (VA).National VA data were extracted for all Black, Hispanic, and White patients with a diagnosed AUD during fiscal year 2012. Mixed effects regression models estimated the odds of two measures of initiation (an initial visit within 180days of diagnosis; and initiation defined consistent with Healthcare Effectiveness Data and Information Set (HEDIS) as a documented visit ≤14days after index visit or inpatient admission), and three established measures of treatment engagement (≥3 visits within first month after initiation; ≥2 visits in each of the first 3months after initiation; and ≥2 visits within 30days of HEDIS initiation) for Black and Hispanic relative to White patients after adjustment for facility- and patient-level characteristics.Among 302,406 patients with AUD, 30% (90,879) initiated treatment within 180days of diagnosis (38% Black, 32% Hispanic, and 27% White). Black patients were more likely to initiate treatment than Whites for both measures of initiation [odds ratio (OR) for initiation: 1.4, 95% confidence interval (CI) 1.4-1.4; OR for HEDIS initiation: 1.1, 95% CI: 1.1-1.1]. Hispanic patients were more likely than White patients to initiate treatment within 180days (OR: 1.2, 95% CI 1.2-1.3) but HEDIS initiation did not differ between Hispanic and White patients. Engagement results varied depending on the measure but was more likely for Black patients relative to White for all measures (OR for engagement in first month: 1.1, 95% CI: 1.0-1.1; OR for engagement in first three months: 1.2, 95% CI: 1.1-1.2; OR for HEDIS measure: 1.1, 95% CI: 1.0-1.1), and did not differ between Hispanic and White patients.After accounting for facility- and patient-level characteristics, Black and Hispanic patients with AUD were more likely than Whites to initiate specialty addictions treatment, and Black patients were more likely than Whites to engage. Research is needed to understand underlying mechanisms and whether differences in initiation of and engagement with care influence health outcomes.

    View details for DOI 10.1016/j.jsat.2016.11.001

    View details for PubMedID 28017181

  • VA residential substance use disorder treatment program providers' perceptions of facilitators and barriers to performance on pre-admission processes. Addiction science & clinical practice Ellerbe, L. S., Manfredi, L., Gupta, S., Phelps, T. E., Bowe, T. R., Rubinsky, A. D., Burden, J. L., Harris, A. H. 2017; 12 (1): 10


    In the U.S. Department of Veterans Affairs (VA), residential treatment programs are an important part of the continuum of care for patients with a substance use disorder (SUD). However, a limited number of program-specific measures to identify quality gaps in SUD residential programs exist. This study aimed to: (1) Develop metrics for two pre-admission processes: Wait Time and Engagement While Waiting, and (2) Interview program management and staff about program structures and processes that may contribute to performance on these metrics. The first aim sought to supplement the VA's existing facility-level performance metrics with SUD program-level metrics in order to identify high-value targets for quality improvement. The second aim recognized that not all key processes are reflected in the administrative data, and even when they are, new insight may be gained from viewing these data in the context of day-to-day clinical practice.VA administrative data from fiscal year 2012 were used to calculate pre-admission metrics for 97 programs (63 SUD Residential Rehabilitation Treatment Programs (SUD RRTPs); 34 Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs) with a SUD track). Interviews were then conducted with management and front-line staff to learn what factors may have contributed to high or low performance, relative to the national average for their program type. We hypothesized that speaking directly to residential program staff may reveal innovative practices, areas for improvement, and factors that may explain system-wide variability in performance.Average wait time for admission was 16 days (SUD RRTPs: 17 days; MH RRTPs with a SUD track: 11 days), with 60% of Veterans waiting longer than 7 days. For these Veterans, engagement while waiting occurred in an average of 54% of the waiting weeks (range 3-100% across programs). Fifty-nine interviews representing 44 programs revealed factors perceived to potentially impact performance in these domains. Efficient screening processes, effective patient flow, and available beds were perceived to facilitate shorter wait times, while lack of beds, poor staffing levels, and lengths of stay of existing patients were thought to lengthen wait times. Accessible outpatient services, strong patient outreach, and strong encouragement of pre-admission outpatient treatment emerged as facilitators of engagement while waiting; poor staffing levels, socioeconomic barriers, and low patient motivation were viewed as barriers.Metrics for pre-admission processes can be helpful for monitoring residential SUD treatment programs. Interviewing program management and staff about drivers of performance metrics can play a complementary role by identifying innovative and other strong practices, as well as high-value targets for quality improvement. Key facilitators of high-performing facilities may offer programs with lower performance useful strategies to improve specific pre-admission processes.

    View details for DOI 10.1186/s13722-017-0075-z

    View details for PubMedID 28372579

  • Cost-Minimization Analysis of Open and Endoscopic Carpal Tunnel Release. journal of bone and joint surgery. American volume Zhang, S., Vora, M., Harris, A. H., Baker, L., Curtin, C., Kamal, R. N. 2016; 98 (23): 1970-1977


    Carpal tunnel release is the most common upper-limb surgical procedure performed annually in the U.S. There are 2 surgical methods of carpal tunnel release: open or endoscopic. Currently, there is no clear clinical or economic evidence supporting the use of one procedure over the other. We completed a cost-minimization analysis of open and endoscopic carpal tunnel release, testing the null hypothesis that there is no difference between the procedures in terms of cost.We conducted a retrospective review using a private-payer and Medicare Advantage database composed of 16 million patient records from 2007 to 2014. The cohort consisted of records with an ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis of carpal tunnel syndrome and a CPT (Current Procedural Terminology) code for carpal tunnel release. Payer fees were used to define cost. We also assessed other associated costs of care, including those of electrodiagnostic studies and occupational therapy. Bivariate comparisons were performed using the chi-square test and the Student t test.Data showed that 86% of the patients underwent open carpal tunnel release. Reimbursement fees for endoscopic release were significantly higher than for open release. Facility fees were responsible for most of the difference between the procedures in reimbursement: facility fees averaged $1,884 for endoscopic release compared with $1,080 for open release (p < 0.0001). Endoscopic release also demonstrated significantly higher physician fees than open release (an average of $555 compared with $428; p < 0.0001). Occupational therapy fees associated with endoscopic release were less than those associated with open release (an average of $237 per session compared with $272; p = 0.07). The total average annual reimbursement per patient for endoscopic release (facility, surgeon, and occupational therapy fees) was significantly higher than for open release ($2,602 compared with $1,751; p < 0.0001).Our data showed that the total average fees per patient for endoscopic release were significantly higher than those for open release, although there currently is no strong evidence supporting better clinical outcomes of either technique.Value-based health-care models that favor delivering high-quality care and improving patient health, while also minimizing costs, may favor open carpal tunnel release.

    View details for PubMedID 27926678

  • The effect of foot landing position on biomechanical risk factors associated with anterior cruciate ligament injury. Journal of experimental orthopaedics Tran, A. A., Gatewood, C., Harris, A. H., Thompson, J. A., Dragoo, J. L. 2016; 3 (1): 13-?


    Identification of biomechanical risk factors associated with anterior cruciate ligament (ACL) injury can facilitate injury prevention. The purpose of this study is to investigate the effects of three foot landing positions, "toe-in", "toe-out" and "neutral", on biomechanical risk factors for ACL injury in males and females. The authors hypothesize that 1) relative to neutral, the toe-in position increases the biomechanical risk factors for ACL injury, 2) the toe-out position decreases these biomechanical risk factors, and 3) compared to males, females demonstrate greater changes in lower extremity biomechanics with changes in foot landing position.Motion capture data on ten male and ten female volunteers aged 20-30 years (26.4 ± 2.50) were collected during double-leg jump landing activities. Subjects were asked to land on force plates and target one of three pre-templated foot landing positions: 0° ("neutral"), 30° internal rotation ("toe-in"), and 30° external rotation ("toe-out") along the axis of the anatomical sagittal plane. A mixed-effects ANOVA and pairwise Tukey post-hoc comparison were used to detect differences in kinematic and kinetic variables associated with biomechanical risk factors of ACL injury between the three foot landing positions.Relative to neutral, landing in the toe-in position increased peak hip adduction, knee internal rotation angles and moments (p < 0.01), and peak knee abduction angle (p < 0.001). Landing in the toe-in position also decreased peak hip flexion angle (p < 0.001) and knee flexion angle (p = 0.023). Landing in the toe-out position decreased peak hip adduction, knee abduction, and knee internal rotation angles (all p < 0.001). Male sex was associated with a smaller increase in hip adduction moment (p = 0.043) and knee internal rotation moment (p = 0.032) with toe-in landing position compared with female sex.Toe-in landing position exacerbates biomechanical risk factors associated with ACL injury, while toe-out landing position decreases these factors.

    View details for DOI 10.1186/s40634-016-0049-1

    View details for PubMedID 27315816

  • Revision Hip Arthroplasty Using a Modular, Cementless Femoral Stem: Intermediate-Term Follow-Up. journal of arthroplasty Sivananthan, S., Lim, C., Narkbunnam, R., Sox-Harris, A., Huddleston, J. I., Goodman, S. B. 2016


    Modular femoral stem provides flexibility in femoral reconstruction, ensuring improved "fit and fill". However, there are risks of junction failure and corrosion, as well as cost concerns in the use of modular femoral stems.We reviewed prospectively-gathered clinical and radiographic data on revision total hip arthroplasties (THAs) performed from 2001-2007 using modular, cementless femoral component performed by the 2 senior authors. Patients with a minimum follow-up of 7 years were included in this study.Sixty-four patients (68 hips) with a median age of 68 ± 14 years (range 40-92 years) at revision THA were included. The median follow-up was 11.0 ± 1.8 years (range 7-14). Harris hip score, femoral stem subsidence, and stem osseointegration were recorded. The Harris hip score improved from an average of 38.1-80.1 (P < .01). Five hips had one or more dislocations. Seven patients underwent reoperations, 3 of which did not involve the stem. Four stems required revision because of infection, recurrent dislocation, or suboptimal implant position. Survival rates for any reasons and revision for femoral stems were 90% and 94%, respectively, at the most recent follow-up. Four stems subsided more than 5 mm, but established stable osseointegration thereafter. Seven nonloose stems (10.2%) demonstrated radiolucent lines in Gruen zones 1 and 7. No complications regarding the modular junction were encountered.Modular, cementless, extensively porous-coated femoral components have demonstrated intermediate-term clinical and radiographic success. Initial distal intramedullary fixation ensures stability, and proximal modularity further maximizes fit and fill.

    View details for DOI 10.1016/j.arth.2016.10.033

    View details for PubMedID 27923596

  • Response to Dr Fiscella: Transparency and Debate are Essential to Improve Guidelines and Measures. Journal of addiction medicine Harris, A. H., Chen, C., Weisner, C. M., Chalk, M., Capoccia, V., Thomas, C. P. 2016; 10 (6): 453-454

    View details for PubMedID 27787293

  • An RCT of Effects of Telephone Care Management on Treatment Adherence and Clinical Outcomes Among Veterans With PTSD. Psychiatric services Rosen, C. S., Azevedo, K. J., Tiet, Q. Q., Greene, C. J., Wood, A. E., Calhoun, P., Bowe, T., Capehart, B. P., Crawford, E. F., Greenbaum, M. A., Harris, A. H., Hertzberg, M., Lindley, S. E., Smith, B. N., Schnurr, P. P. 2016: appips201600069-?


    This study assessed whether adding telephone care management to usual outpatient mental health care improved treatment attendance, medication compliance, and clinical outcomes of veterans with posttraumatic stress disorder (PTSD).In a multisite randomized controlled trial, 358 veterans were assigned to either usual outpatient mental health treatment (N=165) or usual care plus twice-a-month telephone care management (TCM) and support in the first three months of treatment (N=193). Treatment utilization and medication refills were determined from U.S. Department of Veterans Affairs administrative data. PTSD, depression, quality of life, aggressive behavior, and substance use were assessed with self-report questionnaires at intake, four months, and 12 months.Telephone care managers reached 95% of TCM participants (N=182), completing an average 5.1 of 6.0 planned telephone calls. During the three-month intervention period, TCM participants completed 43% more mental health visits (M±SD=5.9±6.8) than did those in usual care (4.1±4.2) (incident rate ratio=1.36, χ(2)=6.56, df=1, p<.01). Treatment visits in the nine-month follow-up period and medication refills did not differ by condition. Only 9% of participants were scheduled to receive evidence-based psychotherapy. Slopes of improvement in PTSD, depression, alcohol misuse, drug problems, aggressive behavior, and quality of life did not differ by condition or treatment attendance.TCM improved PTSD patients' treatment attendance but not their outcomes. TCM can enhance treatment engagement, but outcomes depend on the effectiveness of the treatments that patients receive.

    View details for PubMedID 27745535

  • Path From Predictive Analytics to Improved Patient Outcomes: A Framework to Guide Use, Implementation, and Evaluation of Accurate Surgical Predictive Models. Annals of surgery Harris, A. H. 2016: -?

    View details for PubMedID 27735825

  • Are Early Career Orthopaedic Trauma Surgeons Performing Less Complex Trauma Surgery? JOURNAL OF ORTHOPAEDIC TRAUMA Gire, J. D., Gardner, M. J., Harris, A. H., Bishop, J. A. 2016; 30 (10): 525-529
  • Predictors of Army National Guard and Reserve Members' Use of Veteran Health Administration Health Care After Demobilizing From OEF/OIF Deployment. Military medicine Harris, A. H., Chen, C., Mohr, B. A., Adams, R. S., Williams, T. V., Larson, M. J. 2016; 181 (10): 1392-?

    View details for PubMedID 27753586

  • Beyond the threshold HEALTH ECONOMICS POLICY AND LAW Harris, A. H. 2016; 11 (4): 433-438

    View details for DOI 10.1017/S1744133116000050

    View details for Web of Science ID 000385355800006

    View details for PubMedID 27040001

  • Evaluation of Contemporary Trends in Femoral Neck Fracture Management Reveals Discrepancies in Treatment. Geriatric orthopaedic surgery & rehabilitation Bishop, J., Yang, A., Githens, M., Sox, A. H. 2016; 7 (3): 135-141


    Recent evidence supports total hip arthroplasty (THA) as compared to hemiarthroplasty (HA) for the management of displaced femoral neck fractures in a significant subset of elderly patients. The purpose of this study was to examine trends in femoral neck fracture management over the last 12 years.Using the National Inpatient Sample database, we identified patients treated for femoral neck fractures between 1998 and 2010 with THA, HA, or internal fixation (IF). We examined treatment trends and demographic variables including patient age, gender, socioeconomic status, and payer and hospital characteristics.We identified 362 127 femoral neck fracture patients treated between 1998 and 2010. Overall, there were statistically significant increases in rates of THA and HA, whereas rates of IF decreased. Total hip arthroplasty varied based on patient age, with significant increases occurring in age-groups 0 to 49 years, 50 to 59 years, 60 to 69 years, and 70 to 79 years. Utilization of THA varied significantly based on socioeconomic status and race. Patient sex, urban versus rural hospital location, and teaching versus nonteaching hospital status were not related to rates of THA.Rates of THA for femoral neck fractures increased between 1998 and 2010 in patients younger than 80 years, suggesting that surgeons are responding to clinical evidence supporting THA for the treatment of elderly femoral neck fractures. This is the first study to demonstrate this change and expose disparities in practice patterns over time in response to this evidence in the United States. Further research is indicated to explore the effect of socioeconomic status and race on femoral neck fracture management.

    View details for DOI 10.1177/2151458516658328

    View details for PubMedID 27551571

    View details for PubMedCentralID PMC4976740

  • Predictive validity of a quality measure for intensive substance use disorder treatment. Substance abuse Schmidt, E. M., Gupta, S., Bowe, T., Ellerbe, L. S., Phelps, T. E., Finney, J. W., Asch, S. M., Humphreys, K., Trafton, J., Vanneman, M., Harris, A. H. 2016: 1-7


    Measures of substance use disorder (SUD) treatment quality are essential tools for performance improvement. The Veterans Health Administration (VHA) developed a measure of access to and engagement in intensive outpatient programs (IOPs) for SUD. However, predictive validity, or associations between this measure and treatment outcomes, has not been examined.Data on veterans with SUD came from 3 samples: the Outcomes Monitoring Project (N = 5436), a national evaluation of VHA mental health services (N = 339,887), and patients receiving detoxification services (N = 23,572). Propensity score-weighted mixed-effects regressions modeled associations between receiving at least 1 week of IOP treatment and patient outcomes, controlling for facility-level performance and a random effect for facility.Propensity score weighting reduced or eliminated observable baseline differences between patient groups. Patients who accessed IOPs versus those who did not reported significantly reduced alcohol- and drug-related symptom severity, with significantly fewer past-month days drinking alcohol (b = 1.83, P < .001) and fewer past-month days intoxicated (b = 1.55, P < .001). Patients who received IOP after detoxification services had higher 6-month utilization of SUD outpatient visits (b = 2.09, P < .001), more subsequent detoxification episodes (b = 0.25, P < .001), and lower odds of 2-year mortality (odds ratio [OR] = 0.68, 95% confidence interval [CI]: 0.61-0.75; P < .001).Receiving at least 1 week of SUD treatment in an IOP was associated with higher follow-up utilization, improved health outcomes, and reduced mortality. These associations lend support to the predictive validity of VHA's IOP quality measure. Future research should focus on measure feasibility and validity outside of VHA, and whether predictive validity is maintained once this quality measure is tied to performance incentives.

    View details for PubMedID 27435754

  • Quality and Value in an Evolving Health Care Landscape. journal of hand surgery Kamal, R. N. 2016; 41 (7): 794-799


    Demonstrating and improving value of care continues to be increasingly important in hand surgery. To prepare for emerging models that transition payment from volume to value, hand surgeons will benefit from a clear understanding of quality, cost, and value. National organizations and both public and private payers increasingly advocate for patient-reported outcome measures for pay for reporting and pay for performance initiatives. These are intended to incentivize providers and health systems to improve patient-centered care while minimizing costs. Appreciating the limitations to using patient-reported outcomes in hand surgery can ensure hand surgery is appropriately assessed in novel payment models.

    View details for DOI 10.1016/j.jhsa.2016.05.016

    View details for PubMedID 27374791

  • Stated and Revealed Preferences for Funding New High-Cost Cancer Drugs: A Critical Review of the Evidence from Patients, the Public and Payers PATIENT-PATIENT CENTERED OUTCOMES RESEARCH MacLeod, T. E., Harris, A. H., Mahal, A. 2016; 9 (3): 201-222


    The growing focus on patient-centred care has encouraged the inclusion of patient and public input into payer drug reimbursement decisions. Yet, little is known about patient/public priorities for funding high-cost medicines, and how they compare to payer priorities applied in public funding decisions for new cancer drugs.The aim was to identify and compare the funding preferences of cancer patients and the general public against the criteria used by payers making cancer drug funding decisions.A thorough review of the empirical, peer-reviewed English literature was conducted. Information sources were PubMed, EMBASE, MEDLINE, Web of Science, Business Source Complete, and EconLit. Eligible studies (1) assessed the cancer drug funding preferences of patients, the general public or payers, (2) had pre-defined measures of funding preference, and (3) had outcomes with attributes or measures of 'value'. The quality of included studies was evaluated using a health technology assessment-based assessment tool, followed by extraction of general study characteristics and funding preferences, which were categorized using an established WHO-based framework.Twenty-five preference studies were retrieved (11 quantitative, seven qualitative, seven mixed-methods). Most studies were published from 2005 onward, with the oldest dating back to 1997. Two studies evaluated both patient and public perspectives, giving 27 total funding perspectives (41 % payer, 33 % public, 26 % patients). Of 41 identified funding criteria, payers consider the most (35), the general public considers fewer (23), and patients consider the fewest (12). We identify four unique patient criteria: financial protection, access to medical information, autonomy in treatment decision making, and the 'value of hope'. Sixteen countries/jurisdictions were represented.Our results suggest that (1) payers prioritize efficiency (health gains per dollar), while citizens (patients and the general public) prioritize equity (equal access to cancer medicines independent of cost or effectiveness), (2) citizens prioritize few criteria relevant to payers, and (3) citizens prioritize several criteria not considered by payers. This can explain why payer and citizen priorities clash when new cancer medicines are denied public funding.

    View details for DOI 10.1007/s40271-015-0139-7

    View details for Web of Science ID 000375678900003

    View details for PubMedID 26370257

  • Enhancing access to alcohol use disorder pharmacotherapy and treatment in primary care settings: ADaPT-PC IMPLEMENTATION SCIENCE Hagedorn, H. J., Brown, R., Dawes, M., Dieperink, E., Myrick, D. H., Oliva, E. M., Wagner, T. H., Wisdom, J. P., Harris, A. H. 2016; 11


    Only 7.8 % of individuals meeting diagnostic criteria for alcohol use disorder (AUD) receive treatment in a given year. Most individuals with AUDs are identified in primary care (PC) settings and referred to substance use disorders (SUD) clinics; however, only a minority of those referred attend treatment services. Safe and effective pharmacological treatments for AUD exist, but they are rarely prescribed by PC providers. The objective of this study is to refine, implement, and evaluate an intervention to integrate pharmacological AUD treatment options into PC settings. This paper provides a detailed description of the intervention design and the evaluation components.Three large Veterans Health Administration (VHA) facilities are participating in the intervention. The intervention targets stakeholder groups with tailored strategies based on implementation theory and prior research identifying barriers to implementation of AUD pharmacotherapy. Local SUD providers and primary care mental health integration (PCMHI) providers are trained to serve as local implementation/clinical champions and receive external facilitation. PC providers receive access to consultation from local and national clinical champions, educational materials, and a dashboard of patients with AUD on their caseloads for case identification. Veterans with AUD diagnoses receive educational information in the mail just prior to a scheduled PC visit. Effectiveness of the intervention will be evaluated through an interrupted time series with matched controls to monitor change in facility level AUD pharmacotherapy prescribing rates. Following Stetler's four-phase formative evaluation (FE) strategy, FE methods include (1) developmental FE (pre-implementation interviews with champions, PC providers, and Veterans), (2) implementation-focused FE (tracking attendance at facilitation meetings, academic detailing efforts by local champions, and patient dashboard utilization), (3) progress-focused FE (tracking rates of AUD pharmacotherapy prescribing and rates of referral to PCMHI and SUD specialty care), and (4) interpretive FE (post-implementation interviews with champions and PC providers). Analysis of FE data will be guided by the Consolidated Framework for Implementation Research (CFIR).If demonstrated to be successful, this implementation strategy will provide a replicable, feasible, and relative low-cost method for integrating AUD treatment services into PC settings, thereby increasing access to AUD treatment.

    View details for DOI 10.1186/s13012-016-0431-5

    View details for Web of Science ID 000376091500001

    View details for PubMedID 27164835

  • Specifying and Pilot Testing Quality Measures for the American Society of Addiction Medicine's Standards of Care JOURNAL OF ADDICTION MEDICINE Harris, A. H., Weisner, C. M., Chalk, M., Capoccia, V., Chen, C., Thomas, C. P. 2016; 10 (3): 148-155


    In 2013, the American Society of Addiction Medicine (ASAM) approved its Standards of Care for the Addiction Specialist Physician. Subsequently, an ASAM Performance Measures Panel identified and prioritized the standards to be operationalized into performance measures. The goal of this study is to describe the process of operationalizing 3 of these standards into quality measures, and to present the initial measure specifications and results of pilot testing these measures in a large health care system. By presenting the process rather than just the end results, we hope to shed light on the measure development process to educate, and also to stimulate debate about the decisions that were made.Each measure was decomposed into major concepts. Then each concept was operationalized using commonly available administrative data sources. Alternative specifications examined and sensitivity analyses were conducted to inform decisions that balanced accuracy, clinical nuance, and simplicity. Using data from the US Veterans Health Administration (VHA), overall performance and variation in performance across 119 VHA facilities were calculated.Three measures were operationalized and pilot tested: pharmacotherapy for alcohol use disorder, pharmacotherapy for opioid use disorder, and timely follow-up after medically managed withdrawal (aka detoxification). Each measure was calculable with available data, and showed ample room for improvement (no ceiling effects) and wide facility-level variability.Next steps include conducting feasibility and pilot testing in other health care systems and other contexts such as standalone addiction treatment programs, and also to study the specification and predictive validity of these measures.

    View details for DOI 10.1097/ADM.0000000000000203

    View details for Web of Science ID 000380839400005

    View details for PubMedID 26933875

  • Are Improvements in Measured Performance Driven by Better Treatment or "Denominator Management"? JOURNAL OF GENERAL INTERNAL MEDICINE Harris, A. H., Chen, C., Rubinsky, A. D., Hoggatt, K. J., Neuman, M., Vanneman, M. E. 2016; 31: 21-27


    Process measures of healthcare quality are usually formulated as the number of patients who receive evidence-based treatment (numerator) divided by the number of patients in the target population (denominator). When the systems being evaluated can influence which patients are included in the denominator, it is reasonable to wonder if improvements in measured quality are driven by expanding numerators or contracting denominators.In 2003, the US Department of Veteran Affairs (VA) based executive compensation in part on performance on a substance use disorder (SUD) continuity-of-care quality measure. The first goal of this study was to evaluate if implementing the measure in this way resulted in expected improvements in measured performance. The second goal was to examine if the proportion of patients with SUD who qualified for the denominator contracted after the quality measure was implemented, and to describe the facility-level variation in and correlates of denominator contraction or expansion.Using 40 quarters of data straddling the implementation of the performance measure, an interrupted time series design was used to evaluate changes in two outcomes.All veterans with an SUD diagnosis in all VA facilities from fiscal year 2000 to 2009.The two outcomes were 1) measured performance-patients retained/patients qualified and 2) denominator prevalence-patients qualified/patients with SUD program contact.Measured performance improved over time (P < 0.001). Notably, the proportion of patients with SUD program contact who qualified for the denominator decreased more rapidly after the measure was implemented (p = 0.02). Facilities with higher pre-implementation denominator prevalence had steeper declines in denominator prevalence after implementation (p < 0.001).These results should motivate the development of measures that are less vulnerable to denominator management, and also the exploration of "shadow measures" to monitor and reduce undesirable denominator management.

    View details for DOI 10.1007/s11606-015-3558-1

    View details for Web of Science ID 000373159900006

  • Veterans' Service Utilization Patterns After Alcohol and Opioid Detoxification in VHA Care PSYCHIATRIC SERVICES Timko, C., Gupta, S., Schultz, N., Harris, A. H. 2016; 67 (4): 460-464


    This study aimed to examine detoxification-related service utilization in the Veterans Health Administration (VHA).VHA data for 266,908 patients were used to examine rates and predictors of receiving detoxification, attending post-detoxification appointments, and entering specialty treatment. Multilevel, mixed-effects logistic regressions were used to examine associations between patient and facility characteristics and service utilization.Nationally, 8.0% of VHA patients with alcohol or opiate dependence received detoxification in fiscal year 2013 (facility range=.1%-20.4%); 43.1% of detoxified patients received follow-up (11.1%-76.4%), and 49.9% entered specialty treatment (13.0%-77.2%). In adjusted analyses, detoxification was more likely among male, younger, white, and homeless patients with documented alcohol or opiate disorders and comorbid general medical conditions but without previous addiction treatment. Detoxification was also more likely in facilities with fewer vacant addiction therapist positions. Follow-up and specialty treatments were more likely among younger, healthier homeless patients with previous addiction treatment and a documented alcohol use disorder.Detoxification-related service utilization was highly variable across the VHA. Interventions are needed to optimize use.

    View details for DOI 10.1176/

    View details for Web of Science ID 000377778300021

    View details for PubMedID 26766752

  • Excellent Patient Care Processes in Poor Hospitals? Why Hospital-Level and Patient-Level Care Quality-Outcome Relationships Can Differ. Journal of general internal medicine Finney, J. W., Humphreys, K., Kivlahan, D. R., Harris, A. H. 2016; 31: 74-77


    Studies finding weak or nonexistent relationships between hospital performance on providing recommended care and hospital-level clinical outcomes raise questions about the value and validity of process of care performance measures. Such findings may cause clinicians to question the effectiveness of the care process presumably captured by the performance measure. However, one cannot infer from hospital-level results whether patients who received the specified care had comparable, worse or superior outcomes relative to patients not receiving that care. To make such an inference has been labeled the "ecological fallacy," an error that is well known among epidemiologists and sociologists, but less so among health care researchers and policy makers. We discuss such inappropriate inferences in the health care performance measurement field and illustrate how and why process measure-outcome relationships can differ at the patient and hospital levels. We also offer recommendations for appropriate multilevel analyses to evaluate process measure-outcome relationships at the patient and hospital levels and for a more effective role for performance measure bodies and research funding organizations in encouraging such multilevel analyses.

    View details for DOI 10.1007/s11606-015-3564-3

    View details for PubMedID 26951280

  • Receipt of pharmacotherapy for opioid use disorder by justice-involved U.S. Veterans Health Administration patients. Drug and alcohol dependence Finlay, A. K., Harris, A. H., Rosenthal, J., Blue-Howells, J., Clark, S., McGuire, J., Timko, C., Frayne, S. M., Smelson, D., Oliva, E., Binswanger, I. 2016; 160: 222-226


    Pharmacotherapy - methadone, buprenorphine, or naltrexone - is an evidence-based treatment for opioid use disorder, but little is known about receipt of these medications among veterans involved in the justice system. The current study examines receipt of pharmacotherapy for opioid use disorder among veterans with a history of justice involvement at U.S. Veterans Health Administration (VHA) facilities compared to veterans with no justice involvement.Using national VHA clinical and pharmacy records, we conducted a retrospective cohort study of veterans with an opioid use disorder diagnosis in fiscal year 2012. Using a mixed-effects logistic regression model, we examined receipt of pharmacotherapy in the 1-year period following diagnosis as a function of justice involvement, adjusting for patient and facility characteristics.The 1-year rate of receipt for pharmacotherapy for opioid use disorder was 27% for prison-involved veterans, 34% for jail/court-involved veterans, and 33% for veterans not justice-involved. Compared to veterans not justice-involved, those prison-involved had 0.75 lower adjusted odds (95% confidence interval [CI]: 0.65-0.87) of receiving pharmacotherapy whereas jail/court-involved veterans did not have significantly different adjusted odds.Targeted efforts to improve receipt of pharmacotherapy for opioid use disorder among veterans exiting prison is needed as they have lower odds of receiving these medications.

    View details for DOI 10.1016/j.drugalcdep.2016.01.013

    View details for PubMedID 26832998

  • Racial/Ethnic Differences in the Prevalence of Clinically Recognized Alcohol Use Disorders Among Patients from the US Veterans Health Administration ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH Williams, E. C., Gupta, S., Rubinsky, A. D., Jones-Webb, R., Bensley, K. M., Young, J. P., Hagedorn, H., Gifford, E., Harris, A. H. 2016; 40 (2): 359-366


    Alcohol use disorders (AUDs) are common and have worse consequences for racial/ethnic minority groups than whites. AUDs are often underrecognized in clinical settings, but it is unknown whether the prevalence of clinically recognized AUD varies across racial/ethnic groups. We describe the overall and age- and gender-stratified prevalence of clinically documented AUD across 3 racial/ethnic groups in a national sample of Veterans Health Administration (VA) patients.Data from VA's National Patient Care Database identified all patients who used VA care in Fiscal Year 2012 and were documented as black, Hispanic, or white race/ethnicity. The prevalence of clinically recognized AUD based on ICD-9 diagnoses was compared across racial/ethnic groups overall and within gender and age groups using chi-square tests of independence.Among 4,666,403 eligible patients, 810,902 (17.4%) were black, 302,331 (6.5%) were Hispanic, and 3,553,170 (76.1%) were white. The prevalence of clinically recognized AUD was 6.5% overall, and 9.8% (95% CI 9.8 to 9.9) among black, 7.1% (95% CI 7.0 to 7.2) among Hispanic, and 5.7% (95% CI 5.6 to 5.7) among white patients (p < 0.001). This pattern generally held for men, regardless of age group, with the exception of those 18 to 29 years old, for whom no difference was observed across race/ethnicity. Among women, the prevalence of AUD was generally lowest among Hispanic and highest among black patients, with the exception of those 30 to 44 years old, for whom the highest prevalence was among whites.In contrast to findings from the general population, the prevalence of clinically recognized AUD among VA patients is generally highest among black men and women and lowest among white men and Hispanic women. This is the first study to describe the prevalence of clinically recognized AUD across racial/ethnic groups in a large healthcare system. Future research comparing estimates to diagnoses based on structured gold-standard assessments is needed to understand whether AUDs are under- or overidentified.

    View details for DOI 10.1111/acer.12950

    View details for Web of Science ID 000369998900014

    View details for PubMedID 26842254

  • Arthroscopy for Knee Osteoarthritis Has Not Decreased After a Clinical Trial CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Adelani, M. A., Harris, A. H., Bowe, T. R., Giori, N. J. 2016; 474 (2): 489-494
  • The primitive state of quality measures in addiction treatment and their application ADDICTION Harris, A. H. 2016; 111 (2): 195-196


    Developing quality measures in addiction treatment and implementing them is easy. Developing ones that are valid, interpretable, that motivate real improvements in quality and do not have adverse unintended consequences is very difficult. One serious, but mostly unacknowledged, threat to the validity of quality measures is poor estimates of the true prevalence of substance use disorder in a target population, leading to errors in estimates of treatment coverage.

    View details for DOI 10.1111/add.13096

    View details for Web of Science ID 000368940500001

    View details for PubMedID 26395364

  • Multifaceted academic detailing program to increase pharmacotherapy for alcohol use disorder: interrupted time series evaluation of effectiveness. Addiction science & clinical practice Harris, A. H., Bowe, T., Hagedorn, H., Nevedal, A., Finlay, A. K., Gidwani, R., Rosen, C., Kay, C., Christopher, M. 2016; 11 (1): 15-?


    Active consideration of effective medications to treat alcohol use disorder (AUD) is a consensus standard of care, yet knowledge and use of these medications are very low across diverse settings. This study evaluated the overall effectiveness a multifaceted academic detailing program to address this persistent quality problem in the US Veterans Health Administration (VHA), as well as the context and process factors that explained variation in effectiveness across sites.An interrupted time series design, analyzed with mixed-effects segmented logistic regression, was used to evaluate changes in level and rate of change in the monthly percent of patients with a clinically documented AUD who received naltrexone, acamprosate, disulfiram, or topiramate. Using data from a 20 month post-implementation period, intervention sites (n = 37) were compared to their own 16 month pre-implementation performance and separately to the rest of VHA.From immediately pre-intervention to the end of the observation period, the percent of patients in the intervention sites with AUD who received medication increased over 3.4 % in absolute terms and 68 % in relative terms (i.e., 4.9-8.3 %). This change was significant compared to the pre-implementation period in the intervention sites and secular trends in control sites. Sites with lower pre-implementation adoption, more person hours of detailing, but fewer people detailed, had larger immediate increases in medication receipt after implementation. The average number of detailing encounters per person was associated with steeper increases in slope over time.This study found empirical support for a multifaceted quality improvement strategy aimed at increasing access to and utilization of pharmacotherapy for AUD. Future studies should focus on determining how to enhance the programs effects, especially in non-responsive locations.

    View details for DOI 10.1186/s13722-016-0063-8

    View details for PubMedID 27633982

  • Implementing Effective Substance Abuse Treatments in General Medical Settings: Mapping the Research Terrain. Journal of substance abuse treatment Ducharme, L. J., Chandler, R. K., Harris, A. H. 2016; 60: 110-118


    The National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Drug Abuse (NIDA), and Veterans Health Administration (VHA) share an interest in promoting high quality, rigorous health services research to improve the availability and utilization of evidence-based treatment for substance use disorders (SUD). Recent and continuing changes in the healthcare policy and funding environments prioritize the integration of evidence-based substance abuse treatments into primary care and general medical settings. This area is a prime candidate for implementation research. Recent and ongoing implementation projects funded by these agencies are reviewed. Research in five areas is highlighted: screening and brief intervention for risky drinking; screening and brief intervention for tobacco use; uptake of FDA-approved addiction pharmacotherapies; safe opioid prescribing; and disease management. Gaps in the portfolios, and priorities for future research, are described.

    View details for DOI 10.1016/j.jsat.2015.06.020

    View details for PubMedID 26233697

  • Are Early Career Orthopaedic Trauma Surgeons Performing Less Complex Trauma Surgery? Journal of orthopaedic trauma Gire, J. D., Gardner, M. J., Harris, A. H., Bishop, J. A. 2016; 30 (10): 525–29


    There has recently been an increase in the number of fellowship trained orthopaedic trauma surgeons, raising concerns that the surgical experience of early career surgeons may be diluted. We sought to evaluate the change in complex trauma case volume of orthopaedic trauma surgeons sitting for Part II of the American Board of Orthopaedic Surgeons certification examination.The case log data from all surgeons taking Part II of the American Board of Orthopaedic Surgeons examination over a 13-year period (2003-2015) was evaluated. Any surgeon who examined in the trauma subspecialty was included. We defined pelvis, acetabulum, and periarticular fracture surgeries as complex trauma procedures and evaluated changes in case volume over time.We included 468 candidates who examined as trauma subspecialists and performed 90,261 procedures. The number of candidates testing in trauma per year ranged from 15 to 65 and increased significantly over time [β = 4.05 (0.37), P < 0.0001]. Their case volume was stable over time [β = -1.7 (1.1), P = 0.16]. The number of acetabulum fracture surgeries performed decreased significantly over time from a mean of 10.1 cases in 2003 to 5.2 cases in 2015 [β = -0.34 (0.08), P = 0.0015]. There was no significant change in the number of pelvic fracture surgeries [β = -0.1 (0.1), P = 0.285]. There was a trend toward less periarticular fracture surgeries [β = -0.3 (0.1), P = 0.072].Although pelvic ring and periarticular fracture case volume have remained stable, early career surgeons have experienced a significant decrease in acetabular fracture case volume. The implications of this decreased surgical experience warrant careful consideration as the orthopaedic trauma workforce evolves.

    View details for DOI 10.1097/BOT.0000000000000653

    View details for PubMedID 27668503

  • Use of Veterans Health Administration Mental Health and Substance Use Disorder Treatment After Exiting Prison: The Health Care for Reentry Veterans Program. Administration and policy in mental health Finlay, A. K., Stimmel, M., Blue-Howells, J., Rosenthal, J., McGuire, J., Binswanger, I., Smelson, D., Harris, A. H., Frayne, S. M., Bowe, T., Timko, C. 2015: -?


    The Veterans Health Administration (VA) Health Care for Reentry Veterans (HCRV) program links veterans exiting prison with treatment. Among veterans served by HCRV, national VA clinical data were used to describe contact with VA health care, and mental health and substance use disorder diagnoses and treatment use. Of veterans seen for an HCRV outreach visit, 56 % had contact with VA health care. Prevalence of mental health disorders was 57 %; of whom 77 % entered mental health treatment within a month of diagnosis. Prevalence of substance use disorders was 49 %; of whom 37 % entered substance use disorder treatment within a month of diagnosis. For veterans exiting prison, increasing access to VA health care, especially for rural veterans, and for substance use disorder treatment, are important quality improvement targets.

    View details for PubMedID 26687114

  • Possible Alternatives to Diagnosis-Based Denominators for Addiction Treatment Quality Measures JOURNAL OF SUBSTANCE ABUSE TREATMENT Harris, A. H., Rubinsky, A. D., Hoggatt, K. J. 2015; 58: 62-66


    Consumers of healthcare quality measures are often unaware of how measured performance may be driven by diagnosing practices rather than the provision of high quality care. Reliance on quality metrics that depend on documented diagnoses can therefore subvert comparisons between clinicians, facilities or systems. In this study, three versions of an alcohol use disorder (AUD) treatment quality measure were calculated: method 1--the usual denominator including all diagnosed patients; method 2--a "population-based" denominator including the entire facility census; and method 3-an epidemiologically-derived denominator comprising the expected prevalence of AUD based on case-mix characteristics and geographic region. Performance rankings under the three specifications were calculated. Changes in percentile rank of up to 30-45% were observed between methods. Therefore, much of the observed between-facility differences on diagnosis-based quality measures may reflect variation in the propensity to diagnose rather than real differences in performance. Stakeholders must decide which of the validity threats produced by these different methods is least worrisome.

    View details for DOI 10.1016/j.jsat2015.06.004

    View details for Web of Science ID 000362312000008

    View details for PubMedID 26251046

  • Which Fixation Device is Preferred for Surgical Treatment of Intertrochanteric Hip Fractures in the United States? A Survey of Orthopaedic Surgeons. Clinical orthopaedics and related research Niu, E., Yang, A., Harris, A. H., Bishop, J. 2015; 473 (11): 3647-3655

    View details for DOI 10.1007/s11999-015-4469-5

    View details for PubMedID 26208608

  • Army Active Duty Members' Linkage to Veterans Health Administration Services After Deployments to Iraq or Afghanistan and Following Separation MILITARY MEDICINE Vanneman, M. E., Harris, A. H., Chen, C., Mohr, B. A., Adams, R. S., Williams, T. V., Larson, M. J. 2015; 180 (10): 1052-1058


    This study described the rate and predictors of Operation Enduring Freedom/Operation Iraqi Freedom active duty Army members' enrollment in and use of Veterans Health Administration (VHA) services (linkage), as well as variation in linkage rates by VHA facility. We used a multivariate mixed effect regression model to predict linkage to VHA, and also calculated linkage rates in the catchment areas of each facility (n = 158). The sample included 151,122 active duty members who deployed to Iraq or Afghanistan and then separated from the Army between fiscal years 2008 and 2012. Approximately 48% of the active duty members separating utilized VHA as an enrollee within one year. There was significant variation in linkage rates by VHA facilities (31-72%). The most notable variables associated with greater linkage included probable serious injury during index deployment (odds ratio = 1.81), separation because of disability (odds ratio = 2.86), and various measures of receipt of VHA care before and after separation. Information about the individual characteristics that predict greater or lesser linkage to VHA services can be used to improve delivery of health care services at VHA as well as outreach efforts to active duty Army members.

    View details for DOI 10.7205/MILMED-D-14-00682

    View details for Web of Science ID 000364632900016

    View details for PubMedID 26444467

  • Comparative utilization of pharmacotherapy for alcohol use disorder and other psychiatric disorders among US Veterans Health Administration patients with dual diagnoses JOURNAL OF PSYCHIATRIC RESEARCH Rubinsky, A. D., Chen, C., Batki, S. L., Williams, E. C., Harris, A. H. 2015; 69: 150-157


    Patients with alcohol use disorder (AUD) and another co-occurring psychiatric disorder are a vulnerable population with high symptom severity. Such patients may benefit from a full arsenal of treatment options including pharmacotherapy. Receipt of AUD pharmacotherapy is generally very low despite recommendations that it be made available to every patient with AUD, including those with co-occurring disorders. Little is known about pharmacotherapy rates for AUD compared to other psychiatric disorders among patients with dual diagnoses. This study compared rates of pharmacotherapy for AUD to those for non-substance use psychiatric disorders and tobacco use disorder among patients with dual diagnoses in the U.S. Veterans Affairs (VA) healthcare system. VA data were used to identify patients with AUD and another psychiatric disorder in fiscal year 2012, and to estimate the proportion receiving pharmacotherapy for AUD and for each comorbid condition. Among subsets of patients with AUD and co-occurring schizophrenic, bipolar, posttraumatic stress or major depressive disorder, receipt of medications for AUD ranged from 7% to 11%, whereas receipt of medications for the comorbid disorder ranged from 69% to 82%. Among patients with AUD and co-occurring tobacco use disorder, 6% received medication for their AUD and 34% for their tobacco use disorder. Among patients with dual diagnoses, rates of pharmacotherapy for AUD were far lower than those for the comorbid disorders and contrary to evidence that medications for AUD are effective. Additional system-wide implementation efforts to identify and address patient- and provider-level barriers are needed to increase AUD pharmacotherapy in this high-need population.

    View details for DOI 10.1016/j.jpsychires.2015.07.016

    View details for Web of Science ID 000361927800022

    View details for PubMedID 26343607

  • Cancer Prevalence among a Cross-sectional Survey of Female Orthopedic, Urology, and Plastic Surgeons in the United States. Women's health issues : official publication of the Jacobs Institute of Women's Health Chou, L. B., Lerner, L. B., Harris, A. H., Brandon, A. J., Girod, S., Butler, L. M. 2015; 25 (5): 476-481


    Exposure to ionizing radiation from fluoroscopy performed during surgery, although low and within established limits, remains a health concern among surgeons. Estimates of breast cancer prevalence among women across surgery specialties with different patterns of fluoroscopy use are needed to evaluate this concern.Female U.S. surgeons in urology, plastics, and orthopedics were identified using national directories and mailed surveys to collect information on occupational and medical history, including cancer diagnoses. Standardized prevalence ratios (SPRs) and 95% CIs were calculated by dividing the observed number of cancers among female surgeons in each specialty by the expected number, based on the gender-specific, age-specific, and race-specific cancer prevalence statistics in the general U.S.Standard fluoroscopy use more than once per week was common among urologists (54%) and orthopedists (37%); the same frequency of mini fluoroscopy use was only common among orthopedics (31%) and hardly ever used by urologists. Plastic surgeons reported very infrequent use of any fluoroscopy. For orthopedic surgeons, a significantly greater than expected prevalence of any cancer (SPR, 1.85; 95% CI, 1.19-2.76) and breast cancer (SPR, 2.90; 95% CI, 1.66-4.71) were observed. There was no difference between the observed and expected prevalence of any cancer or breast cancer for urology or plastics.Using the first available cancer prevalence data comparing female surgeons across three specialties, we report that orthopedic surgeons have a greater than expected prevalence of cancer that may or may not be owing to occupational exposure to ionizing radiation.

    View details for DOI 10.1016/j.whi.2015.05.005

    View details for PubMedID 26265543

  • Recommendations for the Design and Analysis of Treatment Trials for Alcohol Use Disorders ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH Witkiewitz, K., Finney, J. W., Harris, A. H., Kivlahan, D. R., Kranzler, H. R. 2015; 39 (9): 1557-1570


    Over the past 60 years, the view that "alcoholism" is a disease for which the only acceptable goal of treatment is abstinence has given way to the recognition that alcohol use disorders (AUDs) occur on a continuum of severity, for which a variety of treatment options are appropriate. However, because the available treatments for AUDs are not effective for everyone, more research is needed to develop novel and more efficacious treatments to address the range of AUD severity in diverse populations. Here we offer recommendations for the design and analysis of alcohol treatment trials, with a specific focus on the careful conduct of randomized clinical trials of medications and nonpharmacological interventions for AUDs.This paper provides a narrative review of the quality of published clinical trials and recommendations for the optimal design and analysis of treatment trials for AUDs.Despite considerable improvements in the design of alcohol clinical trials over the past 2 decades, many studies of AUD treatments have used faulty design features and statistical methods that are known to produce biased estimates of treatment efficacy.The published statistical and methodological literatures provide clear guidance on methods to improve clinical trial design and analysis. Consistent use of state-of-the-art design features and analytic approaches will enhance the internal and external validity of treatment trials for AUDs across the spectrum of severity. The ultimate result of this attention to methodological rigor is that better treatment options will be identified for patients with an AUD.

    View details for DOI 10.1111/acer.12800

    View details for Web of Science ID 000360824300002

    View details for PubMedID 26250333

  • Guidelines for the Reporting of Treatment Trials for Alcohol Use Disorders ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH Witkiewitz, K., Finney, J. W., Harris, A. H., Kivlahan, D. R., Kranzler, H. R. 2015; 39 (9): 1571-1581


    The primary goals in conducting clinical trials of treatments for alcohol use disorders (AUDs) are to identify efficacious treatments and determine which treatments are most efficacious for which patients. Accurate reporting of study design features and results is imperative to enable readers of research reports to evaluate to what extent a study has achieved these goals. Guidance on quality of clinical trial reporting has evolved substantially over the past 2 decades, primarily through the publication and widespread adoption of the Consolidated Standards of Reporting Trials statement. However, there is room to improve the adoption of those standards in reporting the design and findings of treatment trials for AUD.This paper provides a narrative review of guidance on reporting quality in AUD treatment trials.Despite improvements in the reporting of results of treatment trials for AUD over the past 2 decades, many published reports provide insufficient information on design or methods.The reporting of alcohol treatment trial design, analysis, and results requires improvement in 4 primary areas: (i) trial registration, (ii) procedures for recruitment and retention, (iii) procedures for randomization and intervention design considerations, and (iv) statistical methods used to assess treatment efficacy. Improvements in these areas and the adoption of reporting standards by authors, reviewers, and editors are critical to an accurate assessment of the reliability and validity of treatment effects. Continued developments in this area are needed to move AUD treatment research forward via systematic reviews and meta-analyses that maximize the utility of completed studies.

    View details for DOI 10.1111/acer.12797

    View details for Web of Science ID 000360824300003

    View details for PubMedID 26259958

  • High Incidence of Infraspinatus Muscle Atrophy in Elite Professional Female Tennis Players AMERICAN JOURNAL OF SPORTS MEDICINE Young, S. W., Dakic, J., Stroia, K., Nguyen, M. L., Harris, A. H., Safran, M. R. 2015; 43 (8): 1989-1993


    Isolated infraspinatus muscle atrophy is common in overhead athletes, who place significant and repetitive stresses across their dominant shoulders. Studies on volleyball and baseball players report infraspinatus atrophy in 4% to 34% of players; however, the prevalence of infraspinatus atrophy in professional tennis players has not been reported.To investigate the incidence of isolated infraspinatus atrophy in professional tennis players and to identify any correlations with other physical examination findings, ranking performance, and concurrent shoulder injuries.Cross-sectional study; Level of evidence, 3.A total of 125 professional female tennis players underwent a comprehensive preparticipation physical health status examination. Two orthopaedic surgeons examined the shoulders of all players and obtained digital goniometric measurements of range of motion (ROM). Infraspinatus atrophy was defined as loss of soft tissue bulk in the infraspinatus scapula fossa (and increased prominence of dorsal scapular bony anatomy) of the dominant shoulder with clear asymmetry when compared with the contralateral side. Correlations were examined between infraspinatus atrophy and concurrent shoulder disorders, clinical examination findings, ROM, glenohumeral internal rotation deficit, singles tennis ranking, and age.There were 65 players (52%) with evidence of infraspinatus atrophy in their dominant shoulders. No wasting was noted in the nondominant shoulder of any player. No statistically significant differences were seen in mean age, left- or right-hand dominance, height, weight, or body mass index for players with or without atrophy. Of the 77 players ranked in the top 100, 58% had clinical infraspinatus atrophy, compared with 40% of players ranked outside the top 100. No associations were found with static physical examination findings (scapular dyskinesis, ROM glenohumeral internal rotation deficit, postural abnormalities), concurrent shoulder disorders, or compromised performance when measured by singles ranking.This study reports a high level of clinical infraspinatus atrophy in the dominant shoulder of elite female tennis players. Infraspinatus atrophy was associated with a higher performance ranking, and no functional deficits or associations with concurrent shoulder disorders were found. Team physicians can be reassured that infraspinatus atrophy is a common finding in high-performing tennis players and, if asymptomatic, does not appear to significantly compromise performance.

    View details for DOI 10.1177/0363546515588177

    View details for Web of Science ID 000358892400026

    View details for PubMedID 26078449

  • Examining the Specification Validity of the HEDIS Quality Measures for Substance Use Disorders JOURNAL OF SUBSTANCE ABUSE TREATMENT Harris, A. H., Ellerbe, L., Phelps, T. E., Finney, J. W., Bowe, T., Gupta, S., Asch, S. M., Humphreys, K., Trafton, J. 2015; 53: 16-21


    Accurate operationalization is a major challenge in developing quality measures for substance use disorder treatment. Specification validity is a term used to describe whether a quality measure is operationalized such that it captures the intended care processes and patients. This study assessed the specification validity of the 2009 Healthcare Effectiveness Data and Information Set (HEDIS®) substance use disorder initiation and engagement measures by examining whether encounters assumed to include relevant treatment have corroborating evidence in the clinical progress notes. The positive predictive values were excellent (>90%) for residential and outpatient records selected from addiction treatment programs but more modest for records generated in non-addiction settings, and were highly variable across facilities. Stakeholders using these measures to compare care quality should be mindful of the clinical composition of the data and determine if similar validation work has been conducted on the systems being evaluated.

    View details for DOI 10.1016/j.jsat.2015.01.002

    View details for Web of Science ID 000354505900003

    View details for PubMedID 25736624

  • What ecologic analyses cannot tell us about medical marijuana legalization and opioid pain medication mortality. JAMA internal medicine Finney, J. W., Humphreys, K., Harris, A. H. 2015; 175 (4): 655-656

    View details for DOI 10.1001/jamainternmed.2014.8006

    View details for PubMedID 25844747

  • Sex Differences in Mental Health and Substance Use Disorders and Treatment Entry Among Justice-involved Veterans in the Veterans Health Administration. Medical care Finlay, A. K., Binswanger, I. A., Smelson, D., Sawh, L., McGuire, J., Rosenthal, J., Blue-Howells, J., Timko, C., Blodgett, J. C., Harris, A. H., Asch, S. M., Frayne, S. 2015; 53 (4): S105-11


    Over half of veterans in the criminal justice system have mental health or substance use disorders. However, there is a critical lack of information about female veterans in the criminal justice system and how diagnosis prevalence and treatment entry differ by sex.To document prevalence of mental health and substance use disorder diagnoses and treatment entry rates among female veterans compared with male veterans in the justice system.Retrospective cohort study using national Veterans Health Administration clinical/administrative data from veterans seen by Veterans Justice Outreach Specialists in fiscal years 2010-2012.A total of 1535 females and 30,478 male veterans were included.Demographic characteristics (eg, sex, age, residence, homeless status), mental health disorders (eg, depression, post-traumatic stress disorder), substance use disorders (eg, alcohol and opioid use disorders), and treatment entry (eg, outpatient, residential, pharmacotherapy).Among female veterans, prevalence of mental health and substance use disorders was 88% and 58%, respectively, compared with 76% and 72% among male veterans. Women had higher odds of being diagnosed with a mental health disorder [adjusted odds ratio (AOR)=1.98; 95% confidence interval (CI), 1.68-2.34] and lower odds of being diagnosed with a substance use disorder (AOR=0.50; 95% CI, 0.45-0.56) compared with men. Women had lower odds of entering mental health residential treatment (AOR=0.69; 95% CI, 0.57-0.83).Female veterans involved in the justice system have a high burden of mental health disorders (88%) and more than half have substance use disorders (58%). Entry to mental health residential treatment for women is an important quality improvement target.

    View details for DOI 10.1097/MLR.0000000000000271

    View details for PubMedID 25767963

  • State-level relationships cannot tell us anything about individuals. American journal of public health Harris, A. H., Humphreys, K., Finney, J. W. 2015; 105 (4)

    View details for DOI 10.2105/AJPH.2015.302604

    View details for PubMedID 25713959

  • Predictive validity of two process-of-care quality measures for residential substance use disorder treatment. Addiction science & clinical practice Harris, A. H., Gupta, S., Bowe, T., Ellerbe, L. S., Phelps, T. E., Rubinsky, A. D., Finney, J. W., Asch, S. M., Humphreys, K., Trafton, J. 2015; 10: 22-?


    In order to monitor and ultimately improve the quality of addiction treatment, professional societies, health care systems, and addiction treatment programs must establish clinical practice standards and then operationalize these standards into reliable, valid, and feasible quality measures. Before being implemented, quality measures should undergo tests of validity, including predictive validity. Predictive validity refers to the association between process-of-care quality measures and subsequent patient outcomes. This study evaluated the predictive validity of two process quality measures of residential substance use disorder (SUD) treatment.Washington Circle (WC) Continuity of Care quality measure is the proportion of patients having an outpatient SUD treatment encounter within 14 days after discharge from residential SUD treatment. The Early Discharge measure is the proportion of patients admitted to residential SUD treatment who discharged within 1 week of admission. The predictive validity of these process measures was evaluated in US Veterans Health Administration patients for whom utilization-based outcome and 2-year mortality data were available. Propensity score-weighted, mixed effects regression adjusted for pre-index imbalances between patients who did and did not meet the measures' criteria and clustering of patients within facilities.For the WC Continuity of Care measure, 76 % of 10,064 patients had a follow-up visit within 14 days of discharge. In propensity score-weighted models, patients who had a follow-up visit had a lower 2-year mortality rate [odds ratio (OR) = 0.77, p = 0.008], but no difference in subsequent detoxification episodes relative to patients without a follow-up visit. For the Early Discharge measure, 9.6 % of 10,176 discharged early and had significantly higher 2-year mortality (OR = 1.49, p < 0.001) and more subsequent detoxification episodes.These two measures of residential SUD treatment quality have strong associations with 2-year mortality and the Early Discharge measure is also associated with more subsequent detoxification episodes. These results provide initial support for the predictive validity of residential SUD treatment quality measures and represent the first time that any SUD quality measure has been shown to predict subsequent mortality.

    View details for DOI 10.1186/s13722-015-0042-5

    View details for PubMedID 26520402

    View details for PubMedCentralID PMC4672518

  • Extended Release Naltrexone for Alcohol Use Disorders: Quasi-Experimental Effects on Mortality and Subsequent Detoxification Episodes ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH Harris, A. H., Bowe, T., Del Re, A. C., Finlay, A. K., Oliva, E., Myrick, H. L., Rubinsky, A. D. 2015; 39 (1): 79-83


    Utilization of extended release naltrexone (XRN) for alcohol use disorders (AUDs) in the U.S. Veterans Health Administration (VHA) has been limited, perhaps due to high cost, lack of established superiority over less expensive alternatives including oral naltrexone, and related formulary restrictions. Despite these barriers, pockets of higher utilization exist in VHA, allowing for the quasi-experimental examination of the effects of XRN on 1-year mortality and number of subsequent detoxification episodes among patients with high rates of psychiatric comorbidities and previous psychosocial and pharmacological addiction treatment.Using propensity score-weighted mixed-effects logistic regression, 1-year mortality was compared between patients with AUDs who received XRN in fiscal year 2010 (n = 387) and a random sample of patients with AUDs who did not receive XRN (n = 3,759). Among the subgroup of patients who had at least 1 detoxification episode in the previous year, 1-year mortality and number of subsequent detoxification episodes were compared between those who did and did not receive XRN.Overall, 1-year mortality for the patients receiving XRN was significantly lower than for the comparison group who did not receive XRN (odds ratio [OR] = 0.30; p < 0.001). Among patients with a detoxification episode in the previous year, those receiving XRN had, on average, 0.80 fewer subsequent detoxification episodes (p < 0.001) and significantly lower mortality (OR = 0.78, p < 0.001) in the postindex year.Among patients with AUDs, those receiving XRN had lower 1-year mortality and fewer detoxifications compared to similar patients not receiving XRN. These results, although observational, support the use of XRN, especially among patients with high rates of psychiatric comorbidities and previous addiction treatment who are still struggling with AUDs and/or facing a period of vulnerability to relapse.

    View details for DOI 10.1111/acer.12597

    View details for Web of Science ID 000348719100010

    View details for PubMedID 25623408

  • If pharmacotherapies for alcohol use disorders are effective, why are they underutilised? Evidence-based medicine Oliva, E. M., Harris, A. H. 2014; 19 (6): 230-231

    View details for DOI 10.1136/ebmed-2014-110050

    View details for PubMedID 25147300

  • Hip Range of Motion and Association With Injury in Female Professional Tennis Players AMERICAN JOURNAL OF SPORTS MEDICINE Young, S. W., Dakic, J., Stroia, K., Nguyen, M. L., Harris, A. H., Safran, M. R. 2014; 42 (11): 2654-2658


    Adequate hip range of motion is required for the transfer of energy from the lower to the upper extremity along the kinetic chain. Repetitive rotational stresses in the lower extremities during tennis may lead to sport-specific range of motion adaptations, which may increase the risk of injury to other joints along the kinetic chain.To assess whether such range of motion adaptations occur in the hip, and if so, to identify whether they are associated with injury.Cross-sectional study; Level of evidence, 3.A total of 125 female professional tennis players, the majority of whom were ranked in the top 200 World Tennis Association singles rankings, underwent a comprehensive preparticipation physical health status examination. Hip range of motion was assessed using a digital inclinometer and side-to-side differences in rotational parameters calculated, and associations with previous injuries were identified.A history of an abdominal strain was reported by 10% of players, and there was an association between abdominal strains and the presence of hip flexion contractures (odds ratio, 6.1; P = .006). Hip flexion contractures were bilateral in 85% of those found, affected only the nondominant side in 9%, and affected only the dominant side in 6%. We were unable to identify any specific side-to-side rotational adaptations in the dominant or nondominant hips, and no association between loss of hip range of motion and shoulder, lower back, hip, knee, or ankle injuries was found.We report an association in female professional tennis players between abdominal strains and flexion contractures of the hip with iliopsoas tightness. We did not find evidence of specific hip adaptations in rotational range of motion. If hip flexion contractures are found on clinical examination, a stretching program may be indicated. Further studies are required to assess whether such a program can reduce the risk of abdominal injury.

    View details for DOI 10.1177/0363546514548852

    View details for Web of Science ID 000344658000018

    View details for PubMedID 25214532

  • Antiobesity Medication Use Across the Veterans Health Administration: Patient-Level Predictors of Receipt OBESITY Del Re, A. C., Frayne, S. M., Harris, A. H. 2014; 22 (9): 1968-1972


    Pharmacotherapy is an effective adjunct to behavioral interventions to treat obesity; although it is unclear how often medications are integrated into obesity treatment plans and for which patients in the Veterans Health Administration (VHA).A retrospective cohort study was conducted that examined variation in and predictors of antiobesity medication receipt (orlistat) among > 2 million obese Veterans within 140 facilities nationwide.One-percent of all obese patients using VHA services filled a prescription for orlistat. Veterans were more likely to be treated with orlistat if they had a higher BMI, were female, unmarried, younger, a minority, had home instability, prescribed obesogenic psychiatric medications, had a psychiatric or obesity-related comorbidity, and used MOVE! weight management services. Among those who likely met the criteria for use, 2.5% had at least one orlistat prescription. Facility-level prescription rates varied from 0 to 1% of all obese patients in a VA facility receiving a prescription and 0 to 21% among those who met the criteria for use.Consistent with guidelines recommending that obesity pharmacotherapy be prescribed in conjunction with behavioral therapy, the strongest predictor of receiving orlistat was being enrolled in the MOVE! weight-loss management program.

    View details for DOI 10.1002/oby.20810

    View details for Web of Science ID 000341578000008

    View details for PubMedID 24931332

  • Predictors of Army National Guard and Reserve Members' Use of Veteran Health Administration Health Care After Demobilizing From OEF/OIF Deployment MILITARY MEDICINE Harris, A. H., Chen, C., Mohr, B. A., Adams, R. S., Williams, T. V., Larson, M. J. 2014; 179 (10): 1090-1098


    This study described rates and predictors of Army National Guard and Army Reserve members' enrollment in and utilization of Veteran Health Administration (VHA) services in the 365 days following demobilization from an index deployment. We also explored regional and VHA facility variation in serving eligible members in their catchment areas. The sample included 125,434 Army National Guard and 48,423 Army Reserve members who demobilized after a deployment ending between FY 2008 and FY 2011. Demographic, geographic, deployment, and Military Health System eligibility were derived from Defense Enrollment Eligibility Reporting System and "Contingency Tracking System" data. The VHA National Patient Care Databases were used to ascertain VHA utilization and status (e.g., enrollee, TRICARE). Logistic regression models were used to evaluate predictors of VHA utilization as an enrollee in the year following demobilization. Of the study members demobilizing during the observation period, 56.9% of Army National Guard members and 45.7% of Army Reserve members utilized VHA as an enrollee within 12 months. Demographic, regional, health coverage, and deployment-related factors were associated with VHA enrollment and utilization, and significant variation by VHA facility was found. These findings can be useful in the design of specific outreach efforts to improve linkage from the Military Health System to the VHA.

    View details for DOI 10.7205/MILMED-D-13-00521

    View details for Web of Science ID 000349098300008

    View details for PubMedID 25269126

  • Perceptions of behavioral health care among veterans with substance use disorders: Results from a national evaluation of mental health services in the Veterans Health Administration JOURNAL OF SUBSTANCE ABUSE TREATMENT Blonigen, D. M., Bui, L., Harris, A. H., Hepner, K. A., Kivlahan, D. R. 2014; 47 (2): 122-129


    Understanding patients' perceptions of care is essential for health care systems. We examined predictors of perceptions of behavioral health care (satisfaction with care, helpfulness of care, and perceived improvement) among veterans with substance use disorders (SUD; n = 1,581) who participated in a phone survey as part of a national evaluation of mental health services in the U.S. Veterans Health Administration. In multivariate analyses, SUD specialty care utilization and higher mental health functioning were associated positively with all perceptions of care, and comorbid schizophrenia, bipolar, and PTSD were associated positively with multiple perceptions of care. Perceived helpfulness of care was associated with receipt of SUD specialty care in the prior 12 months (adjusted OR = 1.77, p<.001). Controlling for patient characteristics, satisfaction with care exhibited strong associations with perceptions of staff as supportive and empathic, whereas perceived improvement was strongly linked to the perception that staff helped patients develop goals beyond symptom management. Survey responses that account for variation in SUD patients' perceptions of care could inform and guide quality improvement efforts with this population.

    View details for DOI 10.1016/j.jsat.2014.03.005

    View details for Web of Science ID 000338480700002

    View details for PubMedID 24848543

  • Many diabetic total joint arthroplasty candidates are unable to achieve a preoperative hemoglobin A1c goal of 7% or less. journal of bone and joint surgery. American volume Giori, N. J., Ellerbe, L. S., Bowe, T., Gupta, S., Harris, A. H. 2014; 96 (6): 500-504


    Patients with poorly controlled diabetes have an elevated risk of complications and death following total joint arthroplasty. Some centers set a threshold hemoglobin A1c (HbA1c) value above which surgery is delayed pending better glycemic control. The purpose of this study was to examine how many diabetic patients scheduled for primary total joint arthroplasty underwent a delay because of an HbA1c value of >7.0%, how many subsequently achieved this goal, and how much time was necessary to achieve this goal.The study involved a retrospective chart review at one Veterans Affairs medical center. Patients with an HbA1c of >7.0% were referred to their primary care provider for better diabetic control. Unless reduction of the HbA1c to ≤7.0% was deemed medically inadvisable, surgery proceeded only after the patient returned with an HbA1c of ≤7.0%.A total of 404 diabetic patients were scheduled for total joint arthroplasty. In fifty-nine cases, the surgery was delayed because of an HbA1c of >7.0%. Thirty-five of these patients were able to reduce the HbA1c level to ≤7.0% after a median of 141 days (range, seven to 1043 days), and twenty-four failed to achieve this goal. If an HbA1c goal of ≤8.0% had been used, the surgery would have been delayed in thirty cases, and twenty-one of these patients would have subsequently achieved the goal.When establishing a goal designed to reduce perioperative risks, there should be an expectation that the goal is achievable. Overall, an HbA1c of ≤7.0% was achieved by 380 of the 404 diabetic patients (94%; 95% confidence interval [CI], 91% to 96%), but it was achieved by only thirty-five (59%; 95% CI, 46% to 72%) of the fifty-nine patients presenting with an HbA1c of >7.0%. An HbA1c of 8.0% was achieved by 395 (98%; 95% CI, 96% to 99%) of the diabetic patients and by twenty-one (70%; 95% CI, 50% to 85%) of the thirty patients presenting with an HbA1c of >8.0%. Achieving an HbA1c value of ≤7.0% may not be possible for certain diabetic patients, and such a requirement may risk access to total joint arthroplasty treatment.

    View details for DOI 10.2106/JBJS.L.01631

    View details for PubMedID 24647507

  • Component alignment during total knee arthroplasty with use of standard or custom instrumentation: a randomized clinical trial using computed tomography for postoperative alignment measurement. journal of bone and joint surgery. American volume Woolson, S. T., Harris, A. H., Wagner, D. W., Giori, N. J. 2014; 96 (5): 366-372


    Patient-specific femoral and tibial cutting blocks produced with use of data from preoperative computed tomography (CT) or magnetic resonance imaging (MRI) scans have been employed recently to optimize component alignment in total knee arthroplasty. We report the results of a randomized controlled trial in which CT scans were used to compare postoperative component alignment between patients treated with custom instruments and those managed with traditional instruments.The in-hospital data and early clinical outcomes, including Knee Society scores, were determined in a randomized clinical trial of forty-seven patients who had undergone a total of forty-eight primary total knee arthroplasties with patient-specific instruments (twenty-two knees) or standard instruments (twenty-six knees). Orientation of the implants was compared by using three-dimensional CT data.No significant differences were found between the study and control groups with respect to any clinical outcome after a minimum of six months of follow-up. The patient-specific tibial cutting block was abandoned in favor of a standard external alignment jig in seven of the twenty-two study knees because of possible malalignment. A detailed analysis of intent-to-treat and per-protocol groups of study and control knees did not show any significant improvement in component alignment, including femoral component rotation in the axial plane, in the patients treated with the custom instruments. The percentage of outliers-defined as less than -3° or more than 3° from the correct orientation of the tibial slope-was significantly higher in the group treated with use of patient-specific blocks than it was in the control group, in both the intent-to-treat (32% versus 8%, p = 0.032) and the per-protocol (47% versus 6%, p = 0.0008) analysis.There were no significant improvements in clinical outcomes or knee component alignment in patients treated with patient-specific cutting blocks as compared with those treated with standard instruments. The group treated with patient-specific cutting blocks had a significantly higher prevalence of malalignment in terms of tibial component slope than the knees treated with standard instruments.Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.2106/JBJS.L.01722

    View details for PubMedID 24599197

  • Incidence and Risk Factors for Turf Toe Injuries in Intercollegiate Football: Data From the National Collegiate Athletic Association Injury Surveillance System FOOT & ANKLE INTERNATIONAL George, E., Harris, A. H., Dragoo, J. L., Hunt, K. J. 2014; 35 (2): 108-115


    Turf toe is the general term for a sprain of the first metatarsophalangeal (MTP) joint complex. Previously attributed to shoe design and artificial turf, the incidence of turf toe injury has been thought to decline with the advent of newer turf designs. However, the current incidence and epidemiology remain unknown as the majority of the literature consists of small series and addresses diagnosis and treatment rather than epidemiology and prevention.We examined data from the NCAA's Injury Surveillance System (ISS) for 5 football seasons (2004-2005 through 2008-2009), including all preseason, regular season, and postseason practice and competition data. The incidence, epidemiology, and risk factors for turf toe injury, defined as injury to the connective tissue of the first MTP joint, plantar plate complex, and/or sesamoid fracture, were determined.The overall incidence of turf toe injuries in NCAA football players was 0.062 per 1000 athlete-exposures (A-Es; 95% CI 0.052, 0.072). Athletes were nearly 14 times more likely to sustain the injury during games compared to practice, with a mean days lost due to injury of 10.1 (7.9, 12.4). Fewer than 2% of turf toe injuries required operative intervention. There was a significantly higher injury rate on third-generation artificial surfaces compared to natural grass (0.087 per 1000 A-E [0.067, 0.11] vs 0.047 per 1000 A-E [0.036, 0.059]). The majority of injuries occurred as a result of contact with the playing surface (35.4%) or contact with another player (32.7%), and running backs and quarterbacks were the most common positions to suffer turf toe injury.Our data suggest a significantly higher incidence of turf toe injuries during games, a greater susceptibility among running backs and quarterbacks, and a significant contribution of playing surface to risk of injury. Though turf toe injuries may be less common that previously reported in elite football players, these injuries warrant appropriate acute and long-term management to prevent long-term dysfunction.Level IV, case series.

    View details for DOI 10.1177/1071100713514038

    View details for Web of Science ID 000339327300003

    View details for PubMedID 24334272

  • Biomechanical analysis of three tennis serve types using a markerless system. British journal of sports medicine Abrams, G. D., Harris, A. H., Andriacchi, T. P., Safran, M. R. 2014; 48 (4): 339-342


    PURPOSE: The tennis serve is commonly associated with musculoskeletal injury. Advanced players are able to hit multiple serve types with different types of spin. No investigation has characterised the kinematics of all three serve types for the upper extremity and back. METHODS: Seven NCAA Division I male tennis players performed three successful flat, kick and slice serves. Serves were recorded using an eight camera markerless motion capture system. Laser scanning was utilised to accurately collect body dimensions and data were computed using inverse kinematic methods. RESULTS: There was no significant difference in maximum back extension angle for the flat, kick or slice serves. The kick serve had a higher force magnitude at the back than the flat and slice as well as larger posteriorly directed shoulder forces. The flat serve had significantly greater maximum shoulder internal rotation velocity versus the slice serve. Force and torque magnitudes at the elbow and wrist were not significantly different between the serves. CONCLUSIONS: The kick serve places higher physical demands on the back and shoulder while the slice serve demonstrated lower overall kinetic forces. This information may have injury prevention and rehabilitation implications.

    View details for DOI 10.1136/bjsports-2012-091371

    View details for PubMedID 22936411

  • Prevalence of abnormal patellofemoral congruence in elite american football players and association with quadriceps isokinetic testing. The journal of knee surgery Brown, C. A., Carragee, C., Sox-Harris, A., Merchant, A. C., McAdams, T. R. 2014; 27 (1): 47-52


    Abnormal patellofemoral joint alignment has been discussed as a potential risk factor for patellofemoral disorders and can impact the longevity of any elite athlete's career. The prevalence of abnormal patellofemoral congruence in elite American football athletes is similar to the general population and does not have a relationship with quadriceps isokinetic testing. A total of 125 athletes (220 knees) from the 2011 National Football League (NFL) Combine database who had radiographic and isokinetic studies were reviewed. Congruence angles (CA) and lateral patellofemoral angles (LPA) were calculated on a Merchant radiographic view. Isokinetic testing was used to determine quadriceps-to-hamstring strength (Q/H) ratio and side-to-side deficits. The relationships between abnormal CA and LPA with Q/H ratios, side-to-side deficits, and body mass index (BMI) were examined in separate logistic regression models. A Chi-square test was used to examine the association between CA and player position. Of all, 26.8% of the knees (95% CI: 21.1-33.2%) had an abnormal CA. Knees with normal CA (n = 161) did not significantly differ from those with an abnormal CA (n = 59) in Q/H ratios (mean: 0.699 vs. 0.728, p = 0.19) or side-to-side quadriceps deficits (mean: 4.0 vs. 1.24, p = 0.45). For each point increase in BMI, the odds ratio (OR) of abnormal congruence increased by 11.4% (p = 0.002). Of all the knees, 4.1% (95% CI: 1.9-7.6%) had an abnormal LPA, and this was not associated with Q/H ratios (p = 0.13). For each point increase in BMI, the odds of abnormal LPA increased by 16% (p = 0.036). CA abnormality had much higher odds of having an abnormal LPA (OR: 5.96, p = 0.014). We found that abnormal patellofemoral radiographic alignment in elite American football players is relatively common and there was no association with isokinetic testing.

    View details for DOI 10.1055/s-0033-1348406

    View details for PubMedID 23925950

  • Inhibition of Chondrocyte and Synovial Cell Death After Exposure to Commonly Used Anesthetics Chondrocyte Apoptosis After Anesthetics AMERICAN JOURNAL OF SPORTS MEDICINE Rao, A. J., Johnston, T. R., Harris, A. H., Smith, R. L., Costouros, J. G. 2014; 42 (1): 50-58


    An intra-articular injection of local anesthetics is a common procedure for diagnostic and therapeutic purposes. It has been shown that these agents are toxic to articular cartilage and synovial tissue in a dose- and time-dependent fashion, and in some cases, they may lead to postarthroscopic glenohumeral chondrolysis (PAGCL). However, the role of apoptosis in cell death is still unclear, and the potential role of apoptosis inhibition in minimizing chondrocyte and synovial cell death has not been reported.(1) To quantify the degree of apoptotic cell death in chondrocytes and synovial cells exposed to local anesthetics, and (2) to determine whether caspase inhibition could reduce cell death.Controlled laboratory study.Human chondrocytes and synovial cells were expanded in vitro and exposed to normal saline, 0.5% bupivacaine, 0.5% ropivacaine, 1% lidocaine, or 1:1000 epinephrine for 90 minutes. Apoptosis was then detected at 1, 3, 5, and 7 days after exposure using terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick-end labeling (TUNEL) and immunohistochemistry. Apoptosis was then inhibited using the pan-caspase inhibitor z-vad-fmk. Results were normalized to normal saline controls and analyzed by generalized regression models and pairwise confidence intervals.Analysis of cumulative chondrocyte apoptosis relative to controls after anesthetic exposure demonstrated more than 60% cell death with 0.5% bupivacaine and 1:1000 epinephrine. The greatest chondroprotective effect of caspase inhibition occurred with 0.5% ropivacaine. Similarly, in synovial cells, epinephrine was also very cytotoxic; however, 1% lidocaine induced the most apoptosis. Synovial cells exposed to 0.5% ropivacaine were again most sensitive to protective caspase inhibition.Local anesthetics induce chondrocyte and synovial cell apoptosis in a time-dependent fashion, with peak apoptosis occurring 5 days after exposure. Both chondrocytes and synovial cells are most sensitive to caspase inhibition after exposure to 0.5% ropivacaine.Apoptosis inhibition may be an effective strategy in minimizing chondrocyte and synovial cell death after exposure to anesthetics. Further investigation is clinically warranted.

    View details for DOI 10.1177/0363546513507426

    View details for Web of Science ID 000329325600012

    View details for PubMedID 24166803

  • MOVE: weight management program across the veterans health administration: patient- and facility-level predictors of utilization BMC HEALTH SERVICES RESEARCH Del Re, A. C., Maciejewski, M. L., Harris, A. H. 2013; 13


    Health care systems initiating major behavioral health programs often face challenges with variable implementation and uneven patient engagement. One large health care system, Veterans Health Administration (VHA), recently initiated the MOVE!® Weight Management Program, but it is unclear if veterans most in need of MOVE!® services are accessing them. The purpose of this study was to examine patient and facility factors associated with MOVE!® utilization (defined as 1 or more visits) across all VHA facilities.Using national administrative data in a retrospective cohort study of eligible overweight (25 < = body mass index (BMI) < 30 and at least one obesity associated comorbidity) and obese (BMI > =30) VHA outpatients, we examined variation in and predictors of MOVE!® utilization in fiscal year (FY) 2010 using generalized linear mixed models.4.39% (n = 90,230) of all eligible overweight and obese patients using VHA services utilized MOVE!® services at least once in FY 2010. Facility-level MOVE! Utilization rates ranged from 0.05% to 16%. Veterans were more likely to have at least one MOVE!® visit if they had a higher BMI, were female, unmarried, younger, a minority, or had a psychiatric or obesity-related comorbidity.Although substantial variation exists across VHA facilities in MOVE!® utilization rates, Veterans most in need of obesity management services were more likely to access MOVE!®, although at a low level. However, there may still be many Veterans who might benefit but are not accessing these services. More research is needed to examine the barriers and facilitators of MOVE!® utilization, particularly in facilities with unusually high and low reach.

    View details for DOI 10.1186/1472-6963-13-511

    View details for Web of Science ID 000329372000001

    View details for PubMedID 24325730

  • A comparison of directly elicited and pre-scored preference-based measures of quality of life: the case of adhesive capsulitis QUALITY OF LIFE RESEARCH Harris, A. H., Youd, J., Buchbinder, R. 2013; 22 (10): 2963-2971


    To assess the convergent validity and comparative responsiveness in measuring the health-related quality of life associated with adhesive capsulitis of a disease-specific measure (Shoulder Pain and Disability Index), a generic quality of life measure (SF-36), a preference-based multi-attribute utility scale (assessment of quality of life), and two direct patient preference elicitation methods (willingness to pay and time trade-off).Instruments administered to all 156 participants in both arms of a randomized placebo-controlled trial of physiotherapy following arthrographic joint distension at baseline were reported at 6, 12, and 26 weeks. Convergent validity was measured using both pooled correlation between instruments and within subjects over time. Responsiveness was measured using the effect size for those with no improvement, moderate improvement, and marked improvement.With the exception of the monetary measure, all of the instruments showed a low quality of life at baseline with adhesive capsulitis (66- 87 % of perfect health) and a substantial improvement in quality of life to week 26 on recovery. The time trade-off and willingness to pay measures of patient preferences were not responsive to changes in health, but all of the other instruments were at least moderately sensitive to change and moderately correlated with one another.These findings verify the significant adverse impact of adhesive capsulitis upon quality of life found in larger studies. There was a fair degree of convergence, as measured by the correlation between the instruments but while the time trade-off mean values were quite plausible, at a mean of 87 % of full health before treatment, there was a low correlation with health profile and disease-specific measures. It may be that the time trade-off measured wider aspects of quality of life and that individuals were not prepared to trade survival for potential gains in a self-limiting condition.

    View details for DOI 10.1007/s11136-013-0415-8

    View details for Web of Science ID 000328215200034

    View details for PubMedID 23605845

  • The Challenges of Improving Statistical Practice in Alcohol Treatment Research ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH Harris, A. H., Boden, M. T., Finlay, A. K., Rubinsky, A. D. 2013; 37 (12): 1999-2001


    This commentary discusses the paper by Hallgren and Witkiewitz (2013) which evaluated 5 methods for addressing missing data in clinical trials of interventions for alcohol use disorders. The authors conclude that commonly used methods (e.g., complete case analysis, single imputation methods) can produce misleading results and that better alternatives exist (e.g., multiple imputation [MI]). The problems of using inferior approaches are well-known and well-illustrated by the analysis in this paper, which serves as an educational reminder to use more statistically justified practices.Findings of this paper are put in context of the broader statistical literature. Strategies to promote common usage of superior missing data methods are discussed.Solving the poor uptake of statistically justified missing data methods will require a multilevel diagnosis of the problem and likely a multifaceted response, perhaps including the establishment, publication, and enforcement of standards by scientific funding and regulatory agencies, scientific journals, and graduate program accreditation bodies.Little disagreement exists regarding the importance of addressing missing data in a statistically justified manner (e.g., with MI or other maximum likelihood methods). However, as with the implementation of other evidence-based practices, knowing what should be done does not alone make it happen.

    View details for DOI 10.1111/acer.12316

    View details for Web of Science ID 000327692300002

    View details for PubMedID 24299035

  • Group management of pharmacotherapy for alcohol dependence: Feasibility and impact on adoption JOURNAL OF SUBSTANCE ABUSE TREATMENT Robinson, S., Bowe, T., Harris, A. H. 2013; 45 (5): 475-477


    One of the barriers to initiating patients on medications for alcohol dependence is concern about the work involved in providing ongoing medication management. In this brief report, we describe our initial experiences with a medication management group, initially implemented to provide continued access during a staffing shortage. We describe the group structure and functioning, and provide initial analysis of the groups' impact on access and adoption of pharmacotherapy for alcohol dependence. Results of an interrupted time series analysis in one Veterans Health Administration (VHA) facility provide support for the notion that the group format is not only feasible but can actually increase access to these under-utilized medications (e.g., naltrexone and acamprosate). The number of patients receiving these medications was already increasing in this facility before the switch to group appointments, but this rate of initiation increased almost 3-fold after the onset of the groups.

    View details for DOI 10.1016/j.jsat.2013.06.009

    View details for Web of Science ID 000324900400012

    View details for PubMedID 23932227

  • Pharmacotherapy for Alcohol Dependence: Perceived Treatment Barriers and Action Strategies Among Veterans Health Administration Service Providers PSYCHOLOGICAL SERVICES Harris, A. H., Ellerbe, L., Reeder, R. N., Bowe, T., Gordon, A. J., Hagedorn, H., Oliva, E., Lembke, A., Kivlahan, D., Trafton, J. A. 2013; 10 (4): 410-419


    Although access to and consideration of pharmacological treatments for alcohol dependence are consensus standards of care, receipt of these medications by patients is generally rare and highly variable across treatment settings. The goal of the present project was to survey and interview the clinicians, managers, and pharmacists affiliated with addiction treatment programs within Veterans Health Administration (VHA) facilities to learn about their perceptions of barriers and facilitators regarding greater and more reliable consideration of pharmacological treatments for alcohol dependence. Fifty-nine participants from 19 high-adopting and 11 low-adopting facilities completed the survey (facility-level response rate = 50%) and 23 participated in a structured interview. The top 4 barriers to increased consideration and use of pharmacotherapy for alcohol dependence were consistent across high- and low-adopting facilities and included perceived low patient demand, pharmacy procedures or formulary restrictions, lack of provider skills or knowledge regarding pharmacotherapy for alcohol dependence, and lack of confidence in treatment effectiveness. Low patient demand was rated as the most important barrier for oral naltrexone and disulfiram, whereas pharmacy or formulary restrictions were rated as the most important barrier for acamprosate and extended-release naltrexone. The 4 strategies rated across low- and high-adopting facilities as most likely to facilitate consideration and use of pharmacotherapy for alcohol dependence were more education to patients about existing medications, more education to health care providers about medications, increased involvement of physicians in treatment for alcohol dependence, and more compelling research on existing medications. This knowledge provides a foundation for designing, deploying, and evaluating targeted implementation efforts.

    View details for DOI 10.1037/a0030949

    View details for Web of Science ID 000327182400007

    View details for PubMedID 23356858

  • Postoperative risks associated with alcohol screening depend on documented drinking at the time of surgery DRUG AND ALCOHOL DEPENDENCE Rubinsky, A. D., Bishop, M. J., Maynard, C., Henderson, W. G., Hawn, M. T., Harris, A. H., Beste, L. A., Tonnesen, H., Bradley, K. A. 2013; 132 (3): 521-527


    Both AUDIT-C alcohol screening scores up to a year before surgery and clinical documentation of drinking over 2 drinks per day immediately prior to surgery ("documented drinking >2d/d") are associated with increased postoperative complications and health care utilization. The purpose of this study was to evaluate whether documented drinking >2d/d contributed additional information about postoperative risk beyond past-year AUDIT-C screening results.Male Veterans Affairs (VA) patients who had a non-emergent, non-cardiac, major surgery assessed by the VA's Surgical Quality Improvement Program 10/2003-9/2006 and completed the AUDIT-C by mailed survey in the prior year were eligible for this study. Linear or logistic regression models compared 30-day postoperative complication(s), return to operating room (OR), hospital length of stay (LOS), and intensive care unit (ICU) days across eight groups defined by past-year AUDIT-C score and clinically documented drinking >2d/d, with AUDIT-C scores 1-4 and no documented drinking >2d/d as the referent, after adjusting for important covariates.Overall 8811 patients met inclusion criteria. Among patients with documented drinking >2d/d immediately prior to surgery, postoperative risk varied widely depending on past-year AUDIT-C score; scores ≥5 were associated with increased risk of complication(s), and scores ≥9 with increased hospital LOS and ICU days. Among patients without documentation of drinking >2d/d, increasing AUDIT-C scores were not associated with these outcomes.Clinical documentation of drinking >2d/d immediately prior to surgery contributed additional information about postoperative risk beyond past-year AUDIT-C score. However, among patients with documented drinking >2d/d, postoperative risk varied widely depending on the AUDIT-C score.

    View details for DOI 10.1016/j.drugalcdep.2013.03.022

    View details for Web of Science ID 000325510700018

    View details for PubMedID 23683792

  • ACL Reconstruction in Patients Aged 40 Years and Older A Systematic Review and Introduction of a New Methodology Score for ACL Studies AMERICAN JOURNAL OF SPORTS MEDICINE Brown, C. A., McAdams, T. R., Harris, A. H., Maffulli, N., Safran, M. R. 2013; 41 (9): 2181-2190


    Treatment of the anterior cruciate ligament (ACL)-deficient knee in older patients remains a core debate.To perform a systematic review of studies that assessed outcomes in patients aged 40 years and older treated with ACL reconstruction and to provide a new methodological scoring system that is directed at critical assessment of studies evaluating ACL surgical outcomes: the ACL Methodology Score (AMS).Systematic review.A comprehensive literature search was performed from 1995 to 2012 using MEDLINE, EMBASE, and Scopus. Inclusion criteria for studies were primary ACL injury, patient age of 40 years and older, and mean follow-up of at least 21 months after reconstruction. Nineteen studies met the inclusion criteria from the 371 abstracts from MEDLINE and 880 abstracts from Scopus. Clinical outcomes (International Knee Documentation Committee [IKDC], Lysholm, and Tegner activity scores), joint stability measures (Lachman test, pivot-shift test, and instrumented knee arthrometer assessment), graft type, complications, and reported chondral or meniscal injury were evaluated in this review. A new methodology scoring system was developed to be specific at critically analyzing ACL outcome studies and used to examine each study design.Nineteen studies describing 627 patients (632 knees; mean age, 49.0 years; range, 42.6-60.0 years) were included in the review. The mean time to surgery was 32.0 months (range, 2.9-88.0 months), with a mean follow-up of 40.2 months (range, 21.0-114.0 months). The IKDC, Lysholm, and Tegner scores and knee laxity assessment indicated favorable results in the studies that reported these outcomes. Patients did not demonstrate a significant difference between graft types and functional outcome scores or stability assessment. The mean AMS was 43.9 ± 7.2 (range, 33.5-57.5). The level of evidence rating did not positively correlate with the AMS, which suggests that the new AMS system may be able to detect errors in methodology or reporting that may not be taken into account by the classic level of evidence rating.Patients aged 40 years and older with an ACL injury can have satisfactory outcomes after reconstruction. However, the quality of currently available data is still limited, such that further well-designed studies are needed to determine long-term efficacy and to better inform our patients with regard to expected outcomes.

    View details for DOI 10.1177/0363546513481947

    View details for Web of Science ID 000325714200028

    View details for PubMedID 23548805

  • Hemoglobin A1C as a Marker for Surgical Risk in Diabetic Patients Undergoing Total Joint Arthroplasty. journal of arthroplasty Harris, A. H., Bowe, T. R., Gupta, S., Ellerbe, L. S., Giori, N. J. 2013; 28 (8): 25-29


    Diabetes is a risk factor for complications following total joint arthroplasty (TJA). This retrospective cohort study of 6088 diabetic patients from the Veterans Health Administration (VHA) undergoing TJA sought to determine if hemoglobin A1c, an accessible and objective lab value, has utility as a predictor of risk of complications in TJA after controlling for demographic, surgical, and medical center effects, and to evaluate the benefits and risks of alternative thresholds. Analysis of the functional relationship between hemoglobin A1c and complications revealed that the risk linearly increases through, rather than surging at, the threshold of 7%. Before delaying surgery to achieve better diabetic control, surgeons and patients should weigh the estimated risks of TJA against the potential benefits.

    View details for DOI 10.1016/j.arth.2013.03.033

    View details for PubMedID 23910511

  • Datapoints False Starts in Psychotherapy for Substance Use Disorders and PTSD in the VHA PSYCHIATRIC SERVICES Oliva, E. M., Bowe, T., Harris, A. H., Trafton, J. A. 2013; 64 (8): 722-722

    View details for Web of Science ID 000327276100006

    View details for PubMedID 23903602

  • Epidemiology of syndesmosis injuries in intercollegiate football: incidence and risk factors from National Collegiate Athletic Association injury surveillance system data from 2004-2005 to 2008-2009. Clinical journal of sport medicine Hunt, K. J., George, E., Harris, A. H., Dragoo, J. L. 2013; 23 (4): 278-282


    OBJECTIVE:: To describe the incidence and risk factors for high ankle sprains (ie, syndesmosis injuries) among National Collegiate Athletic Association (NCAA) football players. DESIGN:: Descriptive epidemiologic study. SETTING:: Data were examined from the NCAA's Injury Surveillance System (ISS) for 5 football seasons (from 2004-2005 to 2008-2009). PARTICIPANTS:: All NCAA men's football programs participating in the ISS. ASSESSMENT OF RISK FACTORS:: No additional risk factors were introduced as a result of this analysis. MAIN OUTCOME MEASURES:: For partial and complete syndesmosis injuries, outcome measures included incidence, time lost from participation, and requirement for surgical repair. RESULTS:: The overall incidence of high ankle sprains in NCAA football players was 0.24 per 1000 athlete exposures, accounting for 24.6% of all ankle sprains. Athletes were nearly 14 times more likely to sustain the injury during games compared with practice; complete syndesmosis injuries resulted in significantly greater time lost compared with partial injuries (31.3 vs 15.8 days). Less than 3% of syndesmosis injuries required surgical intervention. There was a significantly higher injury incidence on artificial surfaces compared with natural grass. The majority of injuries (75.2%) occurred during contact with another player. CONCLUSIONS:: Our data suggest a significantly higher incidence of syndesmosis injuries during games, during running plays, and to running backs and interior defensive linemen. The wide range in time lost from participation for complete syndesmosis injuries underscores the need for improved understanding of injury mechanism and classification of injury severity such that prevention, safe return to play protocols, and outcomes can be further improved.

    View details for DOI 10.1097/JSM.0b013e31827ee829

    View details for PubMedID 23339895

  • Establishing the feasibility of measuring performance in use of addiction pharmacotherapy JOURNAL OF SUBSTANCE ABUSE TREATMENT Thomas, C. P., Garnick, D. W., Horgan, C. M., Miller, K., Harris, A. H., Rosen, M. M. 2013; 45 (1): 11-18


    This paper presents the rationale and feasibility of standardized performance measures for use of pharmacotherapy in the treatment of substance use disorders (SUD), an evidence-based practice and critical component of treatment that is often underused. These measures have been developed and specified by the Washington Circle, to measure treatment of alcohol and opioid dependence with FDA-approved prescription medications for use in office-based general health and addiction specialty care. Measures were pilot tested in private health plans, the Veterans Health Administration (VHA), and Medicaid. Testing revealed that use of standardized measures using administrative data for overall use and initiation of SUD pharmacotherapy is feasible and practical. Prevalence of diagnoses and use of pharmacotherapy vary widely across health systems. Pharmacotherapy is generally used in a limited portion of those for whom it might be indicated. An important methodological point is that results are sensitive to specifications, so that standardization is critical to measuring performance across systems.

    View details for DOI 10.1016/j.jsat.2013.01.004

    View details for Web of Science ID 000318755400002

    View details for PubMedID 23490233

  • The effect of playing surface on the incidence of ACL injuries in National Collegiate Athletic Association American Football KNEE Dragoo, J. L., Braun, H. J., Harris, A. H. 2013; 20 (3): 191-195


    Artificial playing surfaces are widely used for American football practice and competition and anterior cruciate ligament (ACL) injuries are common. This study analyzed the National Collegiate Athletic Association (NCAA) Injury Surveillance System (ISS) men's football ACL injury database from 2004-2005 through 2008-2009 to determine the effect of playing surface on ACL injury in NCAA football athletes.This database was reviewed from the 2004-2005 through 2008-2009 seasons using the specific injury code, "Anterior cruciate ligament (ACL) complete tear." The injury rate was computed for competition and practice exposures. Ninety-five percent confidence intervals were calculated using assumptions of a Poisson distribution. Pair-wise, two-sample tests of equality of proportions with a continuity correction were used to estimate the associations of risk factors.There was an incidence rate of 1.73 ACL injuries per 10,000 athlete-exposures (A-Es) (95% CI 1.47-2.0) on artificial playing surfaces compared with a rate of 1.24 per 10,000 A-Es (1.05-1.45, p<0.001) on natural grass. The rate of ACL injury on artificial surfaces is 1.39 times higher than the injury rate on grass surfaces. Non-contact injuries occurred more frequently on artificial turf surfaces (44.29%) than on natural grass (36.12%).NCAA football players experience a greater number of ACL injuries when playing on artificial surfaces.

    View details for DOI 10.1016/j.knee.2012.07.006

    View details for Web of Science ID 000319533700010

    View details for PubMedID 22920310

  • Poor sleep quality as a risk factor for lapse following a cannabis quit attempt JOURNAL OF SUBSTANCE ABUSE TREATMENT Babson, K. A., Boden, M. T., Harris, A. H., Stickle, T. R., Bonn-Miller, M. O. 2013; 44 (4): 438-443


    Treatments for cannabis dependence are associated with high rates of lapse/relapse, underscoring the importance of identifying malleable risk factors that are associated with quit failure. Whereas research has demonstrated that poor sleep quality following cannabis discontinuation is related to subsequent use, there has yet to be an examination of whether poor sleep quality prior to a quit attempt results in a similar pattern of lapse. The present study addressed this gap by examining the role of pre-quit sleep quality on early lapse to cannabis use following a self-guided quit attempt, among 55 cannabis dependent military veterans. Results indicated that participants who experienced poor pre-quit sleep quality had greater risk for lapse within the first 2 days (out of 7) following their quit attempt. Findings are discussed in terms of improving treatments for individuals who report poor sleep quality prior to a cannabis quit attempt.

    View details for DOI 10.1016/j.jsat.2012.08.224

    View details for Web of Science ID 000315426300011

    View details for PubMedID 23098380

  • Trends in Opioid Agonist Therapy in the Veterans Health Administration: Is Supply Keeping up with Demand? AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE Oliva, E. M., Trafton, J. A., Harris, A. H., Gordon, A. J. 2013; 39 (2): 103-107


    Opioid agonist therapy (OAT) through addiction specialty clinic settings (clinic-based OAT) using methadone or buprenorphine or office-based settings using buprenorphine (office-based OAT) is an evidence-based treatment for opioid dependence. The low number of clinic-based OATs available to veterans (N = 53) presents a barrier to OAT access; thus, the expansion in office-based OAT has been encouraged.To examine trends in office-based OAT utilization over time and whether availability of office-based OAT improved the proportion of veterans with opioid use disorders treated with OAT.We examined Veterans Health Administration (VHA) administrative data for evidence of buprenorphine prescribing and clinic-based OAT clinic stops from October 2003 through September 2010 [fiscal years (FY) 2004-2010].The number of patients receiving buprenorphine increased from 300 at 27 facilities in FY2004 to 6147 at 118 facilities in FY2010. During this time, the number of patients diagnosed with an opioid use disorder increased by 45%; however, the proportion of opioid use disorder patients receiving OAT remained relatively stable, ranging from 25% to 27%.Office-based OAT utilization and the number of opioid use disorder veterans treated with OAT are increasing at the same rate over time, suggesting that office-based OAT is being used to meet the growing need for OAT care. Although office-based OAT is increasingly being used within the VHA and may be one way the VHA is keeping up with the demand for OAT, more research is needed to understand how to engage a greater proportion of opioid use disorder patients in treatment.

    View details for DOI 10.3109/00952990.2012.741167

    View details for Web of Science ID 000315184600007

    View details for PubMedID 23421571

  • VHA Mental Health Information System Applying Health Information Technology to Monitor and Facilitate Implementation of VHA Uniform Mental Health Services Handbook Requirements MEDICAL CARE Trafton, J. A., Greenberg, G., Harris, A. H., Tavakoli, S., Kearney, L., McCarthy, J., Blow, F., Hoff, R., Schohn, M. 2013; 51 (3): S29-S36


    To describe the design and deployment of health information technology to support implementation of mental health services policy requirements in the Veterans Health Administration (VHA).Using administrative and self-report survey data, we developed and fielded metrics regarding implementation of the requirements delineated in the VHA Uniform Mental Health Services Handbook. Finalized metrics were incorporated into 2 external facilitation-based quality improvement programs led by the VHA Mental Health Operations. To support these programs, tailored site-specific reports were generated.Metric development required close collaboration between program evaluators, policy makers and clinical leadership, and consideration of policy language and intent. Electronic reports supporting different purposes required distinct formatting and presentation features, despite their having similar general goals and using the same metrics.Health information technology can facilitate mental health policy implementation but must be integrated into a process of consensus building and close collaboration with policy makers, evaluators, and practitioners.

    View details for Web of Science ID 000337917300006

    View details for PubMedID 23407008

  • The risks of action without evidence ADDICTION Harris, A. H. 2013; 108 (1): 10-11
  • Telephone Monitoring and Support After Discharge From Residential PTSD Treatment: A Randomized Controlled Trial PSYCHIATRIC SERVICES Rosen, C. S., Tiet, Q. Q., Harris, A. H., Julian, T. F., McKay, J. R., Moore, W. M., Owen, R. R., Rogers, S., Rosito, O., Smith, D. E., Smith, M. W., Schnurr, P. P. 2013; 64 (1): 13-20


    This study assessed whether adding a telephone care management protocol to usual aftercare improved the outcomes of veterans in the year after they were discharged from residential treatment for posttraumatic stress disorder (PTSD).In a multisite randomized controlled trial, 837 veterans entering residential PTSD treatment were assigned to receive either standard outpatient aftercare (N=425) or standard aftercare plus biweekly telephone monitoring and support (N=412) for three months after discharge. Symptoms of PTSD and depression, violence, substance use, and quality of life were assessed by self-report questionnaires at intake, discharge, and four and 12 months postdischarge. Treatment utilization was determined from the Department of Veterans Affairs administrative data.Telephone case monitors reached 355 participants (86%) by phone at least once and provided an average of 4.5 of the six calls planned. Participants in the telephone care and treatment-as-usual groups showed similar outcomes on all clinical measures. Time to rehospitalization did not differ by condition. In contrast with prior studies reporting poor treatment attendance among veterans, participants in both telephone monitoring and treatment as usual completed a mental health visit an average of once every ten days in the year after discharge. Many participants had continuing problems despite high utilization of outpatient care.Telephone care management had little incremental value for patients who were already high utilizers of mental health services. Telephone care management could potentially be beneficial in settings where patients experience greater barriers to engaging with outpatient mental health care after discharge from inpatient treatment.

    View details for DOI 10.1176/

    View details for Web of Science ID 000313299500005

    View details for PubMedID 23117443

  • Rationale and Methods of the Substance Use and Psychological Injury Combat Study (SUPIC): A Longitudinal Study of Army Service Members Returning From Deployment in FY2008-2011 SUBSTANCE USE & MISUSE Larson, M. J., Adams, R. S., Mohr, B. A., Harris, A. H., Merrick, E. L., Funk, W., Hofmann, K., Wooten, N. R., Jeffery, D. D., Williams, T. V. 2013; 48 (10): 863-879


    The Substance Use and Psychological Injury Combat Study (SUPIC) will examine whether early detection and intervention for post-deployment problems among Army Active Duty and National Guard/Reservists returning from Iraq or Afghanistan are associated with improved long-term substance use and psychological outcomes. This paper describes the rationale and significance of SUPIC, and presents demographic and deployment characteristics of the study sample (N = 643,205), and self-reported alcohol use and health problems from the subsample with matched post-deployment health assessments (N = 487,600). This longitudinal study aims to provide new insight into the long-term post-deployment outcomes of Army members by combining service member data from the Military Health System and Veterans Health Administration.

    View details for DOI 10.3109/10826084.2013.794840

    View details for Web of Science ID 000322025400007

    View details for PubMedID 23869459

  • Prescription of topiramate to treat alcohol use disorders in the Veterans Health Administration. Addiction science & clinical practice Del Re, A. C., Gordon, A. J., Lembke, A., Harris, A. H. 2013; 8: 12-?


    As a quality improvement metric, the US Veterans Health Administration (VHA) monitors the proportion of patients with alcohol use disorders (AUD) who receive FDA approved medications for alcohol dependence (naltrexone, acamprosate, and disulfiram). Evidence supporting the off-label use of the antiepileptic medication topiramate to treat alcohol dependence may be as strong as these approved medications. However, little is known about the extent to which topiramate is used in clinical practice. The goal of this study was to describe and examine the overall use, facility-level variation in use, and patient -level predictors of topiramate prescription for patients with AUD in the VHA.Using national VHA administrative data in a retrospective cohort study, we examined time trends in topiramate use from fiscal years (FY) 2009-2012, and predictors of topiramate prescription in 375,777 patients identified with AUD (ICD-9-CM codes 303.9x or 305.0x) treated in 141 VHA facilities in FY 2011.Among VHA patients with AUD, rates of topiramate prescription have increased from 0.99% in FY 2009 to 1.95% in FY 2012, although substantial variation across facilities exists. Predictors of topiramate prescription were female sex, young age, alcohol dependence diagnoses, engagement in both mental health and addiction specialty care, and psychiatric comorbidity.Veterans Health Administration facilities are monitored regarding the extent to which patients with AUD are receiving FDA-approved pharmacotherapy. Not including topiramate in the metric, which is prescribed more often than acamprosate and disulfiram combined, may underestimate the extent to which VHA patients at specific facilities and overall are receiving pharmacotherapy for AUD.

    View details for DOI 10.1186/1940-0640-8-12

    View details for PubMedID 23835352

  • Optimizing lavage during knee arthroscopy: A three-dimensional MRI study JOURNAL OF MAGNETIC RESONANCE IMAGING Nord, R. M., Badowski, N., Elkins, C., Alley, M., Harris, A. H., Dragoo, J. L. 2013; 37 (1): 201-207


    To determine the best positioning and the resulting fluid flow patterns inside the knee during arthroscopy, reducing the surgical morbidity associated with the arthroscopic irrigation and debridement of a septic knee joint.Three-dimensional MRI, using an MRI-compatible human cadaveric knee arthroscopic model, generated fluid flow diagrams and velocity vector data. This was analyzed for six different arthroscopic configurations and at six different locations within the knee joint.At any one static arthroscopic position, fluid flow velocity differed at the various locations in the knee, often with statistically significantly greater flow at one location over another. In general, flow was greatest at the location at which the inflow cannula terminated and preferentially flowed directly to the outflow cannula location, neglecting spaces in the knee that were not on this direct path. Three-portal arthroscopy provided no benefit over two-portal arthroscopy.To maximize arthroscopic lavage throughout all compartments in the knee, the arthroscopist must individually enter each space in the knee. Static arthroscopy in the setting of knee sepsis may lead to inadequate flow in certain areas of the knee and may lead to treatment failure. Three-portal arthroscopy does not improve lavage efficiency.

    View details for DOI 10.1002/jmri.23787

    View details for Web of Science ID 000312720000022

    View details for PubMedID 22941502

  • The Systemic Effects of Platelet-Rich Plasma Injection AMERICAN JOURNAL OF SPORTS MEDICINE Wasterlain, A. S., Braun, H. J., Harris, A. H., Kim, H., Dragoo, J. L. 2013; 41 (1): 186-193


    Platelet-rich plasma (PRP) is an autologous blood product used to treat acute and chronic tendon, ligament, and muscle injuries in over 86,000 athletes in the United States annually. The World Anti-Doping Agency (WADA) banned intramuscular PRP injections in competitive athletes in 2010 because of concerns that it may increase performance-enhancing growth factors. The ban on PRP was removed in 2011 because of limited evidence for a systemic ergogenic effect of PRP, but the growth factors within PRP remain prohibited.To quantify the effect of PRP injection on systemic growth factors with performance-enhancing effects and to identify molecular markers to detect treated athletes.Descriptive laboratory study.Six ergogenic growth factors monitored by WADA-human growth hormone (hGH), insulin-like growth factor-1 (IGF-1), insulin-like growth factor binding protein-3 (IGFBP-3), basic fibroblast growth factor (bFGF or FGF-2), vascular endothelial growth factor (VEGF), and platelet-derived growth factor-BB (PDGF-BB)-were measured in 25 patients before (baseline) and at 0.25, 3, 24, 48, 72, and 96 hours after intratendinous leukocyte-rich PRP injection. Eating and exercise were prohibited for 3 hours before testing. Growth factors were quantified by enzyme-linked immunosorbent assay, and the change relative to each patient's baseline was calculated.Relative to serum, PRP contained significantly more bFGF (226 vs 5 pg/mL), VEGF (1426 vs 236 pg/mL), and PDGF-BB (26,285 vs 392 pg/mL), but IGF-1 and hGH were not elevated. Serum levels increased significantly for IGF-1 at 24 and 48 hours, for bFGF at 72 and 96 hours, and for VEGF at 3, 24, 48, 72, and 96 hours after PRP injection. Additionally, VEGF was increased in all 25 patients after PRP treatment.Serum IGF-1, VEGF, and bFGF levels are significantly elevated after PRP injection, supporting a possible ergogenic effect of PRP. An indirect marker for hGH doping, the product of IGFBP-3 × IGF-1, also significantly increased after PRP. Platelet-rich plasma appears to trigger an increase in circulating growth factors through activating biological pathways rather than by serving as a vehicle for the direct delivery of presynthesized growth factors. Elevated VEGF was observed in all patients after PRP, and ≥88% of patients had elevated VEGF at each time point from 3 to 96 hours after PRP, suggesting that VEGF may be a sensitive molecular marker to detect athletes recently treated with PRP.This is the first and only adequately powered study of the systemic effects of PRP. We present evidence that PRP contains and may trigger systemic increases in substances currently banned in competitive athletes. Finally, we provide evidence that VEGF could serve as a useful molecular marker to detect athletes treated with PRP.

    View details for DOI 10.1177/0363546512466383

    View details for Web of Science ID 000313008300026

    View details for PubMedID 23211708

  • Association Between Alcohol Screening Scores and Mortality in Black, Hispanic, and White Male Veterans ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH Williams, E. C., Bradley, K. A., Gupta, S., Harris, A. H. 2012; 36 (12): 2132-2140


    Scores on the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questionnaire are associated with mortality, but whether or how associations vary across race/ethnicity is unknown.Self-reported black (n = 13,068), Hispanic (n = 9,466), and white (n = 182,688) male Veterans Affairs (VA) outpatients completed the AUDIT-C via mailed survey. Logistic regression models evaluated whether race/ethnicity modified the association between AUDIT-C scores (0, 1 to 4, 5 to 8, and 9 to 12) and mortality after 24 months, adjusting for demographics, smoking, and comorbidity.Adjusted mortality rates were 0.036, 0.033, and 0.054, for black, Hispanic, and white patients with AUDIT-C scores of 1 to 4, respectively. Race/ethnicity modified the association between AUDIT-C scores and mortality (p = 0.0022). Hispanic and white patients with scores of 0, 5 to 8, and 9 to 12 had significantly increased risk of death compared to those with scores of 1 to 4; Hispanic ORs: 1.93, 95% CI 1.50 to 2.49; 1.57, 1.07 to 2.30; 1.82, 1.04 to 3.17, respectively; white ORs: 1.34, 95% CI 1.29 to 1.40; 1.12, 1.03 to 1.21; 1.81, 1.59 to 2.07, respectively. Black patients with scores of 0 and 5 to 8 had increased risk relative to scores of 1 to 4 (ORs 1.28, 1.06 to 1.56 and 1.50, 1.13 to 1.99), but there was no significant increased risk for scores of 9 to 12 (ORs 1.27, 0.77 to 2.09). Post hoc exploratory analyses suggested an interaction between smoking and AUDIT-C scores might account for some of the observed differences across race/ethnicity.Among male VA outpatients, associations between alcohol screening scores and mortality varied significantly depending on race/ethnicity. Findings could be integrated into systems with automated risk calculators to provide demographically tailored feedback regarding medical consequences of drinking.

    View details for DOI 10.1111/j.1530-0277.2012.01842.x

    View details for Web of Science ID 000312131400014

    View details for PubMedID 22676340

  • Risk of sciatic nerve traction injury during hip arthroscopy—is it the amount or duration? An intraoperative nerve monitoring study. journal of bone and joint surgery. American volume Telleria, J. J., Safran, M. R., Harris, A. H., Gardi, J. N., Glick, J. M. 2012; 94 (22): 2025-2032


    Using intraoperative nerve monitoring we prospectively studied the prevalence, pattern, and predisposing factors for sciatic nerve traction injury during hip arthroscopy.The transcranial motor (tcMEP) and/or somatosensory (SSEP) evoked potentials of seventy-six patients undergoing hip arthroscopy in the lateral position were recorded. Changes in the posterior tibial and common peroneal nerves were evaluated to assess the effects of the amount and duration of traction on nerve function. Sixteen subjects were excluded because of incomplete data. Nerve dysfunction was defined as a 50% reduction in the amplitude of SSEPs or tcMEPs or a 10% increase in the latency of the SSEPs; nerve injury was defined as a clinically apparent sensory or motor deficit. Traction time and weight were continuously monitored with use of a custom foot-plate tensiometer.Of sixty patients (thirty-one female and twenty-nine male, with a mean age of thirty-seven years [range, sixteen to sixty-one years]), thirty-five (58%) had intraoperative nerve dysfunction and four (7%) sustained a clinical nerve injury. The average maximum traction weight (and standard deviation) for patients who did and those who did not have nerve dysfunction or injury was 38.1 ± 7.8 kg (range, 22.7 to 56.7 kg) and 32.9 ± 7.9 kg (range, 22.7 to 45.4 kg), respectively. The odds of a nerve event increased 4% with every 0.45-kg (1-lb) increase in the traction amount (age/sex-adjusted; p=0.043; odds ratio, 1.04; 95% confidence interval, 1.01 to 1.08). The average total traction time for patients who did and those who did not have nerve dysfunction was 95.9 ± 41.9 minutes (range, forty-two to 240 minutes) and 82.3 ± 35.4 minutes (range, thirty-eight to 160 minutes), respectively, and an increase in traction time did not increase the odds of a nerve event (p = 0.201). Age and sex were not significant risk factors.The prevalence of nerve changes seen with monitoring of SSEPs and tcMEPs is greater than what is clinically identified. The maximum traction weight, not the total traction time, is the greatest risk factor for sciatic nerve dysfunction during hip arthroscopy. This study did not identify a discrete threshold of traction weight or traction time that increased the odds of nerve dysfunction.

    View details for PubMedID 23052834

  • Prevalence of Cannabis Use Disorder Diagnoses Among Veterans in 2002, 2008, and 2009 PSYCHOLOGICAL SERVICES Bonn-Miller, M. O., Harris, A. H., Trafton, J. A. 2012; 9 (4): 404-416


    The present investigation sought to document current rates and trends of cannabis use disorder (CUD) diagnoses among patients of the Veterans Affairs Health Care System (VA) during fiscal years 2002, 2008, and 2009. Results indicated that the prevalence of CUD diagnoses within VA has increased more than 50% (from 0.66% to 1.05%) over the past 7 years. The prevalence of patients with a CUD diagnosis but no other illicit SUD diagnosis rose 115.41% (from 0.27% to 0.58%) during the same time period. States with laws allowing for the legal use of cannabis for medicinal purposes had significantly higher rates of Cannabis-Disorder diagnoses within VA in 2002, 2008, and 2009 (p < .01). Though rates of psychiatric diagnoses, and posttraumatic stress disorder (PTSD) specifically, were higher among patients with a Cannabis-Disorder diagnosis compared with other SUD groups (p < .001), rates of specialty SUD treatment utilization among those with a Cannabis-Disorder diagnosis have decreased within VA. Results indicate that interventions to motivate treatment engagement among patients with CUD, particularly among those with co-occurring psychological problems, are needed for Veterans.

    View details for DOI 10.1037/a0027622

    View details for Web of Science ID 000311071100007

    View details for PubMedID 22564034

  • The effect of local anesthetic and corticosteroid combinations on chondrocyte viability KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Braun, H. J., Wilcox-Fogel, N., Kim, H. J., Pouliot, M. A., Harris, A. H., Dragoo, J. L. 2012; 20 (9): 1689-1695


    Local anesthetic and corticosteroid combination injections are often used in clinical practice, however research investigating the chondrotoxic properties of these combinations is minimal. The goal of this study was to evaluate the effect of single injection doses of 1% lidocaine or 0.25% bupivacaine in combination with single injection doses of dexamethasone sodium phosphate (Decadron), methylprednisolone acetate (Depo-Medrol), betamethasone sodium phosphate and betamethasone acetate (Celestone Soluspan), or triamcinolone acetonide (Kenalog) on human chondrocyte viability.All treatment conditions were delivered to human chondrocytes in vitro for the medication's respective average duration of action using a bioreactor containing a continuous infusion pump constructed to mimic joint fluid metabolism. A two-color fluorescence assay was used to evaluate cell viability. A mixed-effects regression model was used to evaluate the mean differences in cell viability between treatment groups.At 14 days, a single injection dose of 1% lidocaine or 0.25% bupivacaine in combination with betamethasone sodium phosphate and betamethasone acetate solution illustrated significant chondrotoxicity when compared with the local anesthetics alone (P < 0.01). Methylprednisolone acetate and Triamcinolone acetonide both showed significant evidence of chondrotoxicity (P = 0.013; P = 0.016, respectively) when used in combination with 1% lidocaine compared with lidocaine alone, but showed no significant chondrotoxicity in combination with 0.25% bupivacaine (P's = n.s.).Clinicians should use caution when injecting 1% lidocaine or 0.25% bupivacaine in conjunction with betamethasone sodium phosphate and betamethasone acetate solution due to its pronounced chondrotoxic effect in this study. 1% lidocaine used in combination with methylprednisolone acetate or triamcinolone acetonide also led to significant chondrotoxicity.

    View details for DOI 10.1007/s00167-011-1728-1

    View details for Web of Science ID 000307816500006

    View details for PubMedID 22037813

  • Pharmacotherapy of Alcohol Use Disorders by the Veterans Health Administration: Patterns of Receipt and Persistence PSYCHIATRIC SERVICES Harris, A. H., Oliva, E., Bowe, T., Humphreys, K. N., Kivlahan, D. R., Trafton, J. A. 2012; 63 (7): 679-685


    This study assessed changes since 2007 at Veterans Health Administration (VHA) facilities (N=129) in use of the medications approved by the U.S. Food and Drug Administration for treatment of alcohol use disorders.VHA data from fiscal years (FYs) 2008 and 2009 were used to identify patients with a diagnosis of an alcohol use disorder who received oral or extended-release naltrexone, disulfiram, or acamprosate as well as the proportion of days covered (PDC) in the 180 days after initiation and the time to first ten-day gap in possession (persistence) for each medication. Multilevel, mixed-effects logistic regression models examined the association between patient and facility characteristics and use of medications.Nationally, 3.4% of VHA patients with an alcohol use disorder received medications in FY 2009 (11,165 of 331,635 patients), up from 3.0% in FY 2007. Use of medications by patients at the facilities ranged from 0% to 12%. In fully adjusted analyses, facilities offering evening and weekend services had higher rates of medication receipt, but other facility characteristics, such as having prescribers on the addiction program's staff or using medication to treat opioid or tobacco dependence, were unrelated to medication receipt. The mean PDC of acamprosate was significantly lower than mean PDCs of the other medications (p<.05), and persistence in use of naltrexone was significantly greater than use of acamprosate and significantly less than use of disulfiram (p<.05).Use of these medications is increasing but remains variable across the VHA system. Interventions are needed to optimize initiation of and persistence in use of these medications.

    View details for DOI 10.1176/

    View details for Web of Science ID 000305931900011

    View details for PubMedID 22549276

  • Increased Breast Cancer Prevalence Among Female Orthopedic Surgeons JOURNAL OF WOMENS HEALTH Chou, L. B., Chandran, S., Harris, A. H., Tung, J., Butler, L. M. 2012; 21 (6): 683-689


    As a result of low-dose ionizing radiation exposure during clinical practice, female orthopaedic surgeons may be at increased risk for breast cancer.The 2009 American Academy of Orthopaedic Surgeons (AAOS) membership directory was used to mail a survey to all female AAOS fellows. Survey responses were collected between June 2009 and June 2010 among 505 (69.7%) of the eligible women. We calculated standardized prevalence ratios (SPRs) and 95% confidence intervals (CIs) by dividing the observed number of cancers among female orthopaedic surgeons by the expected number, based on the gender-specific, age-specific, and race-specific cancer prevalence statistics in the general U.S. population. We compared the distribution of breast cancer risk factors in our study population to that of the women in the 2007 California Health Interview Survey (CHIS, n=30,541).Twenty-four women reported a prior diagnosis of invasive cancer. Female orthopaedic surgeons had a prevalence of cancer that was 85% higher than that of the general U.S. female population (SPR 1.85, 95% CI 1.19-2.76). Orthopaedic surgeons in our study also had a statistically significant 2.9-fold higher prevalence of breast cancer compared to the general U.S. female population (SPR 2.9, 95% CI 1.66-4.71). Survey respondents had a higher prevalence of both protective and predisposing breast cancer factors compared to California women.Our findings confirm that breast cancer prevalence is elevated among female orthopaedic surgeons. Although further research is needed to determine the factors behind this population's hypothesized increased risk, taken together, our results and others suggest that the orthopaedic community consider educating current practitioners of the use of protective shielding and other modifiable breast cancer risk factors.

    View details for DOI 10.1089/jwh.2011.3342

    View details for Web of Science ID 000305575100012

    View details for PubMedID 22432467

  • Incidence and Risk Factors for Injuries to the Anterior Cruciate Ligament in National Collegiate Athletic Association Football Data From the 2004-2005 Through 2008-2009 National Collegiate Athletic Association Injury Surveillance System AMERICAN JOURNAL OF SPORTS MEDICINE Dragoo, J. L., Braun, H. J., Durham, J. L., Chen, M. R., Harris, A. H. 2012; 40 (5): 990-995


    Injuries to the anterior cruciate ligament (ACL) are common in athletic populations, particularly in athletes participating in football, soccer, and skiing.The purpose of this study was to analyze the National Collegiate Athletic Association (NCAA) Injury Surveillance System (ISS) men's football ACL injury database from the playing seasons of 2004-2005 through 2008-2009 to determine the incidence and epidemiology of complete injury to the ACL in NCAA football athletes.Descriptive epidemiology study.The NCAA ISS men's football database was reviewed from the 2004-2005 through 2008-2009 seasons using the specific injury code, "Anterior cruciate ligament (ACL) complete tear." The injury rate was computed for competition and practice exposures. Ninety-five percent confidence intervals (CIs) for the incident rates were calculated using assumptions of a Poisson distribution. Pairwise, 2-sample tests of equality of proportions with a continuity correction were used to estimate the associations of risk factors such as event type, playing surface, season segment, and football subdivision. Descriptive data were also described.The ACL injury rate during games (8.06 per 10,000 athlete-exposures [AEs] 95% CI, 6.80-9.42) was significantly greater than the rate during practice (0.8 per 10,000 AEs 95% CI, 0.68-0.93). Players were 10.09 (95% CI, 8.08-12.59) times more likely to sustain an ACL injury in competition when compared with practices. When practice exposures were analyzed separately, the injury rate was significantly greater during scrimmages (3.99 per 10,000 AEs 95% CI, 2.29-5.94) compared with regular practices (0.83 per 10,000 AEs 95% CI, 0.69-0.97) and walk-throughs (0 per 10,000 AEs 95% CI, 0-0.14). There was an incidence rate of 1.73 ACL injuries per 10,000 AEs (95% CI, 1.47-2.0) on artificial playing surfaces compared with a rate of 1.24 per 10,000 AEs (95% CI, 1.05-1.45) on natural grass. The rate of ACL injury on artificial surfaces is 1.39 (95% CI, 1.11-1.73) times higher than the injury rate on grass surfaces.Between 2004 and 2009, NCAA football players experienced a greater number of ACL injuries in games compared with practices, in scrimmages compared with regular practices, and when playing on artificial turf surfaces. This latter finding will need to be confirmed by additional studies.

    View details for DOI 10.1177/0363546512442336

    View details for Web of Science ID 000303323900006

    View details for PubMedID 22491794

  • Receipt of opioid agonist treatment in the Veterans Health Administration: Facility and patient factors DRUG AND ALCOHOL DEPENDENCE Oliva, E. M., Harris, A. H., Trafton, J. A., Gordon, A. J. 2012; 122 (3): 241-246


    Opioid agonist treatment (OAT)-through licensed clinic settings (C-OAT) using methadone or buprenorphine or office-based settings with buprenorphine (O-OAT)-is an evidence-based treatment for opioid dependence. Because of limited availability of on-site C-OAT (n=28 of 128 facilities) in the Veterans Health Administration (VHA), O-OAT use has been encouraged. This study examined OAT utilization across VHA facilities and the patient and facility factors related to variability in utilization.We examined 12 months of VHA administrative data (fiscal year [FY] 2008, October 2007 through September 2008) for evidence of OAT utilization and substance use disorder program data from an annual VHA survey. Variability in OAT utilization across facilities and patient and facility factors related to OAT utilization were examined using mixed-effects, logistic regression models.Among 128 VHA facilities, 35,240 patients were diagnosed with an opioid use disorder. Of those, 27.3% received OAT: 22.2% received C-OAT and 5.1% received O-OAT with buprenorphine. Substantial facility-level variability in proportions of patients treated with OAT was found, ranging from 0% to 66% with 44% of facilities treating <5%. Significant patient-level predictors of OAT receipt included being male, age ≥56, and without another mental health diagnosis. Significant facility-level predictors included offering any OAT services (C-OAT or O-OAT) and specialty substance abuse treatment services on weekends.In FY2008, prior to the VHA national mandate of access to buprenorphine OAT, substantial variation in the use of OAT existed, partially explained by patient- and facility-level factors. Implementation efforts should focus on increasing access to this evidence-based treatment, especially in facilities at the low end of the distribution.

    View details for DOI 10.1016/j.drugalcdep.2011.10.004

    View details for Web of Science ID 000303432200011

    View details for PubMedID 22115887

  • "Not statistically different" does not necessarily mean "the same": the important but underappreciated distinction between difference and equivalence studies. journal of bone and joint surgery. American volume Harris, A. H., Fernandes-Taylor, S., Giori, N. 2012; 94 (5)

    View details for DOI 10.2106/JBJS.K.00568

    View details for PubMedID 22398743

  • AUDIT-C Alcohol Screening Results and Postoperative Inpatient Health Care Use JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Rubinsky, A. D., Sun, H., Blough, D. K., Maynard, C., Bryson, C. L., Harris, A. H., Hawkins, E. J., Beste, L. A., Henderson, W. G., Hawn, M. T., Hughes, G., Bishop, M. J., Etzioni, R., Tonnesen, H., Kivlahan, D. R., Bradley, K. A. 2012; 214 (3): 296-U69


    Alcohol screening scores ≥5 on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) up to a year before surgery have been associated with postoperative complications, but the association with postoperative health care use is unknown. This study evaluated whether AUDIT-C scores in the year before surgery were associated with postoperative hospital length of stay, total ICU days, return to the operating room, and hospital readmission.This cohort study included male Veterans Affairs patients who completed the AUDIT-C on mailed surveys (October 2003 through September 2006) and were hospitalized for nonemergent noncardiac major operations in the following year. Postoperative health care use was evaluated across 4 AUDIT-C risk groups (scores 0, 1 to 4, 5 to 8, and 9 to 12) using linear or logistic regression models adjusted for sociodemographics, smoking status, surgical category, relative value unit, and time from AUDIT-C to surgery. Patients with AUDIT-C scores indicating low-risk drinking (scores 1 to 4) were the referent group.Adjusted analyses revealed that among eligible surgical patients (n = 5,171), those with the highest AUDIT-C scores (ie, 9 to 12) had longer postoperative hospital length of stay (5.8 [95% CI, 5.0-6.7] vs 5.0 [95% CI, 4.7-5.3] days), more ICU days (4.5 [95% CI, 3.2-5.8] vs 2.8 [95% CI, 2.6-3.1] days), and increased probability of return to the operating room (10% [95% CI, 6-13%] vs 5% [95% CI, 4-6%]) in the 30 days after surgery, but not increased hospital readmission within 30 days postdischarge, relative to the low-risk group.AUDIT-C screening results could be used to identify patients at risk for increased postoperative health care use who might benefit from preoperative alcohol interventions.

    View details for DOI 10.1016/j.jamcollsurg.2011.11.007

    View details for Web of Science ID 000301770100008

    View details for PubMedID 22244208

  • Risk of future trauma based on alcohol screening scores: a two-year prospective cohort study among US veterans. Addiction science & clinical practice Harris, A. H., Lembke, A., Henderson, P., Gupta, S., Moos, R., Bradley, K. A. 2012; 7 (1): 6-?


    Severe alcohol misuse as measured by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is associated with increased risk of future fractures and trauma-related hospitalizations. This study examined the association between AUDIT-C scores and two-year risk of any type of trauma among US Veterans Health Administration (VHA) patients and assessed whether risk varied by age or gender.Outpatients (215, 924 male and 9168 female) who returned mailed AUDIT-C questionnaires were followed for 24 months in the medical record for any International Statistical Classification of Diseases and Related Health Problems (ICD-9) code related to trauma. The two-year prevalence of trauma was examined as a function of AUDIT-C scores, with low-level drinking (AUDIT-C 1-4) as the reference group. Men and women were examined separately, and age-stratified analyses were performed.Having an AUDIT-C score of 9-12 (indicating severe alcohol misuse) was associated with increased risk for trauma. Mean (SD) ages for men and women were 68.2 (11.5) and 57.2 (15.8), respectively. Age-stratified analyses showed that, for men≤50 years, those with AUDIT-C scores≥9 had an increased risk for trauma compared with those with AUDIT-C scores in the 1-4 range (adjusted prevalence, 25.7% versus 20.8%, respectively; OR=1.24; 95% confidence interval [CI], 1.03-1.50). For men≥65 years with average comorbidity and education, those with AUDIT-C scores of 5-8 (adjusted prevalence, 7.9% versus 7.4%; OR=1.16; 95% CI, 1.02-1.31) and 9-12 (adjusted prevalence 11.1% versus 7.4%; OR=1.68; 95% CI, 1.30-2.17) were at significantly increased risk for trauma compared with men≥65 years in the reference group. Higher AUDIT-C scores were not associated with increased risk of trauma among women.Men with severe alcohol misuse (AUDIT-C 9-12) demonstrate an increased risk of trauma. Men≥65 showed an increased risk for trauma at all levels of alcohol misuse (AUDIT-C 5-8 and 9-12). These findings may be used as part of an evidence-based brief intervention for alcohol use disorders. More research is needed to understand the relationship between AUDIT-C scores and risk of trauma in women.

    View details for DOI 10.1186/1940-0640-7-6

    View details for PubMedID 22966411

  • Comparing alternative specifications of quality measures: Access to pharmacotherapy for alcohol use disorders JOURNAL OF SUBSTANCE ABUSE TREATMENT Fernandes-Taylor, S., Harris, A. H. 2012; 42 (1): 102-107


    Availability and consideration of pharmacotherapy for the treatment of alcohol use disorders (AUD) are now consensus standards for evidence-based treatment. This study compares three competing specifications of the proportion of patients with AUD receiving approved medications. We examined how altering the numerator and denominator definitions affects observed rates of pharmacotherapy use and facilities' percentile ranks. Using pharmacy and administrative data from the Veterans Health Administration (VHA), three measures of pharmacotherapy receipt were calculated for 129 VHA facilities. Difference in measure specifications alters the overall estimates of pharmacotherapy receipt but unevenly across facilities, with some experiencing no change in percentile rank and others decreasing or increasing by over a quartile. The results demonstrate that the quality measures are not interchangeable, and the choice of which version to implement is of high consequence for some facilities.

    View details for DOI 10.1016/j.jsat.2011.07.005

    View details for Web of Science ID 000297956900012

    View details for PubMedID 21839604

  • Health Economic Methods: Cost-Minimization, Cost-Effectiveness, Cost-Utility, and Cost-Benefit Evaluations CRITICAL CARE CLINICS Higgins, A. M., Harris, A. H. 2012; 28 (1): 11-?


    Health care resources are limited, and health care providers must strive to maximize health benefits to patients within available resources. This is becoming increasingly important in critical care as demand for services grows and costs associated with treatment increase. Economic evaluations enable comparisons of both the costs and effects of an intervention. There are four main types: cost-minimization, cost effectiveness,cost-utility, and cost-benefit. The costs associated with the intervention are measured in monetary units (dollars); the evaluation types differ with respect to how outcomes are measured. This article introduces the methodology for performing these economic evaluations,highlighting important aspects regarding critical care.

    View details for DOI 10.1016/j.ccc.2011.10.002

    View details for Web of Science ID 000298768000003

    View details for PubMedID 22123096

  • Too Few Patients Medicated For Alcohol Dependence HEALTH AFFAIRS Harris, A. H. 2012; 31 (1)

    View details for DOI 10.1377/hlthaff.2011.1319

    View details for Web of Science ID 000299309000037

    View details for PubMedID 22232118

  • Longer Length of Stay Is Not Associated with Better Outcomes in VHA's Substance Abuse Residential Rehabilitation Treatment Programs JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH Harris, A. H., Kivlahan, D., Barnett, P. G., Finney, J. W. 2012; 39 (1): 68-79


    Are longer stays in Veterans Health Administration (VHA) substance abuse residential rehabilitation treatment programs (SARRTPs) associated with better substance-related outcomes? To investigate, up to 50 new patients were randomly selected from each of 28 randomly selected programs (1,307 patients). The goal was to examine if patient and program average length of stay (ALOS) were associated with improvement on Addiction Severity Index (ASI) Alcohol and Drug composite scores in covariate-adjusted, multi-level regression models. Patients in programs with ALOS greater than 90 days tended to have more mental health treatment prior to the index episode and less severe substance-related symptoms, but more homelessness. At follow-up, programs longer than 90 days had the least improvement in the ASI Alcohol composite and significantly less improvement than programs with ALOSs of 15 to 30 and 31 to 45 days (both p < 0.05). Therefore, in VHA SARRTPs, ALOS greater than 90 days cannot be justified by the substance use disorder severity of the patients served or the magnitude of the clinical improvement observed.

    View details for DOI 10.1007/s11414-011-9250-2

    View details for Web of Science ID 000302999300007

    View details for PubMedID 21732222

  • Cross-Level Bias and Variations in Care JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Finney, J. W., Humphreys, K., Harris, A. H. 2011; 306 (19): 2096-2097

    View details for Web of Science ID 000297013000014

    View details for PubMedID 22089717

  • The Comparative Effectiveness of Cognitive Processing Therapy for Male Veterans Treated in a VHA Posttraumatic Stress Disorder Residential Rehabilitation Program JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Alvarez, J., McLean, C., Harris, A. H., Rosen, C. S., Ruzek, J. I., Kimerling, R. 2011; 79 (5): 590-599


    To examine the effectiveness of group cognitive processing therapy (CPT) relative to trauma-focused group treatment as usual (TAU) in the context of a Veterans Health Administration (VHA) posttraumatic stress disorder (PTSD) residential rehabilitation program.Participants were 2 cohorts of male patients in the same program treated with either CPT (n = 104) or TAU (n = 93; prior to the implementation of CPT). Cohorts were compared on changes from pre- to posttreatment using the PTSD Checklist (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993) and other measures of symptoms and functioning. Minorities represented 41% of the sample, and the mean age was 52 years (SD = 9.22). The CPT group was significantly younger and less likely to receive disability benefits for PTSD; however, these variables were not related to outcome.Analyses of covariance controlling for intake symptom levels and cohort differences revealed that CPT participants evidenced more symptom improvement at discharge than TAU participants on the PCL, F(3, 193) = 15.32, p < .001, b = 6.25, 95% CI [3.06, 9.44], and other measures. In addition, significantly more patients treated with CPT were classified as "recovered" or "improved" at discharge, χ2(1, N = 197) = 4.93, p = .032.There is still room for improvement, as substantial numbers of veterans continue to experience significant symptoms even after treatment with CPT in a residential program. However, CPT appears to produce significantly more symptom improvement than treatment conducted before the implementation of CPT. The implementation of this empirically supported treatment in VHA settings is both feasible and sustainable and is likely to improve care for male veterans with military-related PTSD.

    View details for DOI 10.1037/a0024466

    View details for Web of Science ID 000295339900003

    View details for PubMedID 21744946

  • Barriers to Use of Pharmacotherapy for Addiction Disorders and How to Overcome Them CURRENT PSYCHIATRY REPORTS Oliva, E. M., Maisel, N. C., Gordon, A. J., Harris, A. H. 2011; 13 (5): 374-381


    Substance use disorders are highly prevalent, debilitating conditions for which effective pharmacotherapies exist with a broad evidence base, yet pharmacotherapy for the treatment of addiction disorders is underutilized. The goals of this review are to describe the barriers that may contribute to poor adoption and utilization of pharmacotherapy for alcohol and opioid dependence at the system, provider, and patient level and to discuss ways to overcome those barriers. Multifaceted efforts directed at all three levels may be needed to speed pharmacotherapy adoption. More research is needed to help us better understand barriers from patients' perspectives. Strategies to promote adoption of pharmacotherapy for addiction disorders should be modified to fit the needs of the practice, system, and individual patients. Pharmacotherapy is a valuable tool in the clinical armamentarium of addiction treatment; thus, overcoming barriers to implementation may improve clinical and social outcomes.

    View details for DOI 10.1007/s11920-011-0222-2

    View details for Web of Science ID 000294504200010

    View details for PubMedID 21773951

  • Why Health Care Process Performance Measures Can Have Different Relationships to Outcomes for Patients and Hospitals: Understanding the Ecological Fallacy AMERICAN JOURNAL OF PUBLIC HEALTH Finney, J. W., Humphreys, K., Kivlahan, D. R., Harris, A. H. 2011; 101 (9): 1635-1642


    Relationships between health care process performance measures (PPMs) and outcomes can differ in magnitude and even direction for patients versus higher level units (e.g., health care facilities). Such discrepancies can arise because facility-level relationships ignore PPM-outcome relationships for patients within facilities, may have different confounders than patient-level PPM-outcome relationships, and may reflect facility effect modification of patient PPM-outcome relationships. If a patient-level PPM is related to better patient outcomes, that care process should be encouraged. However, the finding in a multilevel analysis that the proportion of patients receiving PPM care across facilities nevertheless is linked to poor hospital outcomes would suggest that interventions targeting the health care facility also are needed.

    View details for DOI 10.2105/AJPH.2011.300153

    View details for Web of Science ID 000294090500017

    View details for PubMedID 21778493

  • Alcohol Screening Scores and the Risk of New-Onset Gastrointestinal Illness or Related Hospitalization JOURNAL OF GENERAL INTERNAL MEDICINE Lembke, A., Bradley, K. A., Henderson, P., Moos, R., Harris, A. H. 2011; 26 (7): 777-782


    Excessive alcohol use is associated with a variety of negative health outcomes, including liver disease, upper gastrointestinal bleeding, and pancreatitis.To determine the 2-year risk of gastrointestinal-related hospitalization and new-onset gastrointestinal illness based on alcohol screening scores.Retrospective cohort study.Male (N = 215, 924) and female (N = 9,168) outpatients who returned mailed questionnaires and were followed for 24 months.Alcohol Use Disorder Identification Test-Consumption Questionnaire (AUDIT-C), a validated three-item alcohol screening questionnaire (0-12 points).Two-year risk of hospitalization with a gastrointestinal disorder was increased in men with AUDIT-C scores of 5-8 and 9-12 (OR 1.54, 95% CI = 1.27-1.86; and OR 3.27; 95% CI = 2.62-4.09 respectively), and women with AUDIT-C scores of 9-12 (OR 6.84, 95% CI = 1.85 - 25.37). Men with AUDIT-C scores of 5-8 and 9-12 had increased risk of new-onset liver disease (OR 1.49, 95% CI = 1.30-1.71; and OR 2.82, 95% CI = 2.38-3.34 respectively), and new-onset of upper gastrointestinal bleeding (OR 1.28, 95% CI = 1.05-1.57; and OR 2.14, 95% CI = 1.54-2.97 respectively). Two-year risk of new-onset pancreatitis in men with AUDIT -C scores 9-12 was also increased (OR 2.14; 95% CI = 1.54-2.97).Excessive alcohol use as determined by AUDIT-C is associated with 2-year increased risk of gastrointestinal-related hospitalization in men and women and new-onset liver disease, upper gastrointestinal bleeding, and pancreatitis in men. These results provide risk information that clinicians can use in evidence-based conversations with patients about their alcohol consumption.

    View details for DOI 10.1007/s11606-011-1688-7

    View details for Web of Science ID 000291701200019

    View details for PubMedID 21455813

  • The critical care costs of the influenza A/H1N1 2009 pandemic in Australia and New Zealand ANAESTHESIA AND INTENSIVE CARE Higgins, A. M., Pettilae, V., Harris, A. H., Bailey, M., Lipman, J., SEPPELT, I. M., Webb, S. A. 2011; 39 (3): 384-391


    The aim of this study was to determine the critical care and associated hospital costs for 2009 influenza A/H1N1 patients admitted to intensive care units (ICU) in Australia and New Zealand during the southern hemisphere winter All 762 patients admitted to ICUs in Australian and New Zealand between 1 June and 31 August 2009 with confirmed 2009 H1N1 influenza A were included. Costs were assigned based on ICU and hospital length-of-stay, using data from a single Australian ICU which estimated the daily cost of an ICU bed, along with published costs for a ward bed. Additional costs were assigned for allied health, overheads and extracorporeal membrane oxygenation services. The median (interquartile range) ICU and total hospital costs per patient were AU$35,942 ($10,269 to $82,152) and AU$51,294 ($22,849 to $110,340) respectively, while the mean (standard deviation) ICU and total hospital costs per patient were AU$63,298 ($78,722) and AU$85,395 ($147,457), respectively. A multivariate analysis found death was significantly associated with a reduction in the log of total costs, while the use of mechanical ventilation and ICU admission with viral pneumonitis/acute respiratory distress syndrome or secondary bacterial pneumonia were significantly associated with an increase in the log of total costs. The cost of 2009 H1N1 patients in ICU was significantly higher than the previously published costs for an average ICU admission, and the total cost of treating 2009 H1N1 patients in ICU admitted during winter 2009 was more than $65,000,000.

    View details for Web of Science ID 000291295900008

    View details for PubMedID 21675057

  • Validation of the treatment identification strategy of the HEDIS addiction quality measures: concordance with medical record review BMC HEALTH SERVICES RESEARCH Harris, A. H., Reeder, R. N., Ellerbe, L. S., Bowe, T. R. 2011; 11


    Strategies to accurately identify the occurrence of specific health care events in administrative data is central to many quality improvement and research efforts. Many health care quality measures have treatment identification strategies based on diagnosis and procedure codes - an approach that is inexpensive and feasible but usually of unknown validity. In this study, we examined if the diagnosis/procedure code combinations used in the 2006 HEDIS Initiation and Engagement quality measures to identify instances of addiction treatment have high concordance with documentation of addiction treatment in clinical progress notes.Four type of records were randomly sampled from VHA electronic medical data: (a) Outpatient records from a substance use disorder (SUD) specialty clinic with a HEDIS-qualified substance use disorder (SUD) diagnosis/CPT code combination (n = 700), (b) Outpatient records from a non-SUD setting with a HEDIS-qualified SUD diagnosis/CPT code combination (n = 592), (c) Specialty SUD Inpatient/residential records that included a SUD diagnosis (n = 700), and (d) Non-SUD specialty Inpatient/residential records that included a SUD diagnosis (n = 700). Clinical progress notes for the sampled records were extracted and two raters classified each as documenting or not documenting addiction treatment. Rates of concordance between the HEDIS addiction treatment identification strategy and the raters' judgments were calculated for each record type.Within SUD outpatient clinics and SUD inpatient specialty units, 92% and 98% of sampled records had chart evidence of addiction treatment. Of outpatient encounters with a qualifying diagnosis/procedure code combination outside of SUD clinics, 63% had chart evidence of addiction treatment. Within non-SUD specialty inpatient units, only 46% of sampled records had chart evidence of addiction treatment.For records generated in SUD specialty settings, the HEDIS strategy of identifying SUD treatment with diagnosis and procedure codes has a high concordance with chart review. The concordance rate outside of SUD specialty settings is much lower and highly variable between facilities. Therefore, some patients may be counted as meeting the 2006 HEDIS Initiation and Engagement criteria without having received the specified amount (or any) addiction treatment.

    View details for DOI 10.1186/1472-6963-11-73

    View details for Web of Science ID 000290382000001

    View details for PubMedID 21481264

  • Effects of Intermittent Hydrostatic Pressure and BMP-2 on Osteoarthritic Human Chondrocyte Metabolism In Vitro JOURNAL OF ORTHOPAEDIC RESEARCH Smith, R. L., Lindsey, D. P., Dhulipala, L., Harris, A. H., Goodman, S. B., Maloney, W. J. 2011; 29 (3): 361-368


    This study examined effects of intermittent hydrostatic pressure (IHP) and a chondrogenic growth factor, bone morphogenetic protein-2 (BMP-2), on anabolic, catabolic, and other metabolic markers in human osteoarthritic (OA) chondrocytes in vitro.Articular chondrocytes, isolated from femoral OA cartilage and maintained in high-density monolayer culture, were examined for effects of BMP-2 and IHP on gene expression of matrix-associated proteins (aggrecan, type II collagen, and SOX9) and catabolic matrix metalloproteinases (MMP-2 and MMP-3) and culture medium levels of the metabolic markers MMP-2, nitric oxide (NO), and glycosaminoglycan (GAG). The results were analyzed using a mixed linear regression model to investigate the effects of load and growth factor concentration.IHP and BMP-2 modulated OA chondrocyte metabolism in accordance with growth factor concentration independently, without evidence of synergism or antagonism. Each type of stimulus acted independently on anabolic matrix gene expression. Type II collagen and SOX9 gene expression were stimulated by both IHP and BMP-2 whereas aggrecan was increased only by BMP-2. IHP exhibited a trend to decrease MMP-2 gene expression as a catabolic marker whereas BMP-2 did not. NO production was increased by addition of BMP-2 and IHP exhibited a trend for increased levels. GAG production was increased by BMP-2.This study confirmed the hypothesis that human OA chondrocytes respond to a specific type of mechanical load, IHP, through enhanced articular cartilage macromolecule gene expression and that IHP, in combination with a chondrogenic growth factor BMP-2, additively enhanced matrix gene expression without interactive effects.

    View details for DOI 10.1002/jor.21250

    View details for Web of Science ID 000287173500009

    View details for PubMedID 20882590

  • Preoperative alcohol screening scores: association with complications in men undergoing total joint arthroplasty. journal of bone and joint surgery. American volume Harris, A. H., Reeder, R., Ellerbe, L., Bradley, K. A., Rubinsky, A. D., Giori, N. J. 2011; 93 (4): 321-327


    The risks associated with preoperative alcohol misuse by patients before undergoing total joint arthroplasty are not well known, yet alcohol misuse by surgical patients is common and has been linked to an increased risk of complications after other procedures. The purpose of this study was to evaluate the association between a patient's preoperative standardized alcohol-misuse screening score and his or her risk of complications after total joint arthroplasty.The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is an alcohol-misuse screening instrument administered annually to all patients receiving care through the Veterans Health Administration (VHA). The scores range from 0 to 12, with higher scores signifying greater and more frequent consumption. In a study of 185 male patients who had alcohol screening scores recorded in the year preceding surgery at a Palo Alto VHA facility, and who reported at least some alcohol use, we estimated the association between preoperative screening scores and the number of surgical complications in an age and comorbidity-adjusted regression analyses.Of the 185 patients reporting at least some drinking in the year before their total joint replacement, 17% (thirty-two) had an alcohol screening score suggestive of alcohol misuse; six of those thirty-two patients had one complication, four had two complications, and two had three complications. The screening scores were significantly related to the number of complications in a negative binomial regression analysis (exp[β] = 1.29, p = 0.035), which demonstrated a 29% increase in the expected number of complications with every additional point of the screening score above 1, although with wide confidence intervals for the higher scores.Complications following total joint arthroplasty were significantly related to alcohol misuse in this group of male patients treated at a VHA facility. The AUDIT-C has three simple questions that can be incorporated into a preoperative evaluation and can alert the treatment team to patients with increased postoperative risk. Preoperative screening for alcohol misuse, and perhaps preoperative counseling or referral to treatment for heavy drinkers, may be indicated for patients who are to undergo total joint arthroplasty.

    View details for DOI 10.2106/JBJS.I.01560

    View details for PubMedID 21325583

  • Alcohol Screening and Risk of Postoperative Complications in Male VA Patients Undergoing Major Non-cardiac Surgery JOURNAL OF GENERAL INTERNAL MEDICINE Bradley, K. A., Rubinsky, A. D., Sun, H., Bryson, C. L., Bishop, M. J., Blough, D. K., Henderson, W. G., Maynard, C., Hawn, M. T., Tonnesen, H., Hughes, G., Beste, L. A., Harris, A. H., Hawkins, E. J., Houston, T. K., Kivlahan, D. R. 2011; 26 (2): 162-169


    Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed.To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire-up to a year before surgery-were associated with the risk of postoperative complications.This is a cohort study.Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA's Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery.One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews.Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8-6.6%) in patients with AUDIT-C scores 1-4, to 7.9% (6.3-9.7%) in patients with AUDIT-Cs 5-8, 9.7% (6.6-14.1%) in patients with AUDIT-Cs 9-10 and 14.0% (8.9-21.3%) in patients with AUDIT-Cs 11-12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1-5.7%) in patients with AUDIT-C scores 1-4, to 6.9% (5.5-8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0-11.3%) among those with AUDIT-Cs 9-10.AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.

    View details for DOI 10.1007/s11606-010-1475-x

    View details for Web of Science ID 000287668800015

    View details for PubMedID 20878363

  • Common statistical and research design problems in manuscripts submitted to high-impact medical journals. BMC research notes Fernandes-Taylor, S., Hyun, J. K., Reeder, R. N., Harris, A. H. 2011; 4: 304-?


    To assist educators and researchers in improving the quality of medical research, we surveyed the editors and statistical reviewers of high-impact medical journals to ascertain the most frequent and critical statistical errors in submitted manuscripts.The Editors-in-Chief and statistical reviewers of the 38 medical journals with the highest impact factor in the 2007 Science Journal Citation Report and the 2007 Social Science Journal Citation Report were invited to complete an online survey about the statistical and design problems they most frequently found in manuscripts. Content analysis of the responses identified major issues. Editors and statistical reviewers (n = 25) from 20 journals responded. Respondents described problems that we classified into two, broad themes: A. statistical and sampling issues and B. inadequate reporting clarity or completeness. Problems included in the first theme were (1) inappropriate or incomplete analysis, including violations of model assumptions and analysis errors, (2) uninformed use of propensity scores, (3) failing to account for clustering in data analysis, (4) improperly addressing missing data, and (5) power/sample size concerns. Issues subsumed under the second theme were (1) Inadequate description of the methods and analysis and (2) Misstatement of results, including undue emphasis on p-values and incorrect inferences and interpretations.The scientific quality of submitted manuscripts would increase if researchers addressed these common design, analytical, and reporting issues. Improving the application and presentation of quantitative methods in scholarly manuscripts is essential to advancing medical research.

    View details for DOI 10.1186/1756-0500-4-304

    View details for PubMedID 21854631

  • Advancing performance measures for use of medications in substance abuse treatment JOURNAL OF SUBSTANCE ABUSE TREATMENT Thomas, C. P., Garnick, D. W., Horgan, C. M., McCorry, F., Gmyrek, A., Chalk, M., Gastfriend, D. R., Rinaldo, S. G., Albright, J., Capoccia, V. A., Harris, A. H., Harwood, H. J., Greenberg, P., Mark, T. L., Un, H., Oros, M., Stringer, M., Thatcher, J. 2011; 40 (1): 35-43


    Performance measures have the potential to drive high-quality health care. However, technical and policy challenges exist in developing and implementing measures to assess substance use disorder (SUD) pharmacotherapy. Of critical importance in advancing performance measures for use of SUD pharmacotherapy is the recognition that different measurement approaches may be needed in the public and private sectors and will be determined by the availability of different data collection and monitoring systems. In 2009, the Washington Circle convened a panel of nationally recognized insurers, purchasers, providers, policy makers, and researchers to address this topic. The charge of the panel was to identify opportunities and challenges in advancing use of SUD pharmacotherapy performance measures across a range of systems. This article summarizes those findings by identifying a number of critical themes related to advancing SUD pharmacotherapy performance measures, highlighting examples from the field, and recommending actions for policy makers.

    View details for DOI 10.1016/j.jsat.2010.08.005

    View details for Web of Science ID 000285371900005

    View details for PubMedID 20934836

  • Associations Between AUDIT-C and Mortality Vary by Age and Sex POPULATION HEALTH MANAGEMENT Harris, A. H., Bradley, K. A., Bowe, T., Henderson, P., Moos, R. 2010; 13 (5): 263-268


    We sought to determine the sex- and age-specific risk of mortality associated with scores on the 3-item Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) questionnaire using data from a national sample of Veterans Health Administration (VHA) patients. Men (N = 215,924) and women (N = 9168) who completed the AUDIT-C in a patient survey were followed for 24 months. AUDIT-C categories (0, 1-4, 5-8, 9-12) were evaluated as predictors of mortality in logistic regression models, adjusted for age, race, education, marital status, smoking, depression, and comorbidities. For women, AUDIT-C scores of 9-12 were associated with a significantly increased risk of death compared to the AUDIT-C 1-4 group (odds ratio [OR] 7.09; 95% confidence interval [CI] = 2.67, 18.82). For men overall, AUDIT-C scores of 5-8 and 9-12 were associated with increased risk of death compared to the AUDIT-C 1-4 group (OR 1.13, 95% CI = 1.05, 1.21, and OR 1.63, 95% CI = 1.45, 1.84, respectively) but these associations varied by age. These results provide sex- and age-tailored risk information that clinicians can use in evidence-based conversations with patients about the health-related risks of their alcohol consumption. This study adds to the growing literature establishing the AUDIT-C as a scaled marker of alcohol-related risk or "vital sign" that might facilitate the detection and management of alcohol-related risks and problems.

    View details for DOI 10.1089/pop.2009.0060

    View details for Web of Science ID 000282463400005

    View details for PubMedID 20879907

  • Rotational References for Total Knee Arthroplasty Tibial Components Change with Level of Resection CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Graw, B. P., Harris, A. H., Tripuraneni, K. R., Giori, N. J. 2010; 468 (10): 2734-2738


    Various landmarks can guide tibial component rotational alignment in routine TKA, but with the deeper tibial resection levels common in complex primary and revision TKAs, it is unknown whether these landmarks remain reliable.We asked whether three techniques for determining tibial component rotation based on local anatomic landmarks are reliable deeper tibial resection levels.The femoral transepicondylar axis was identified by three independent reviewers on MR images of knees from 24 men and 24 women and transposed at a traditional tibial resection level and at the level of the proximal, middle, and distal parts of the proximal tibiofibular joint. Three axes were drawn on axial slices at these levels: the geometric center of the tibial plateau to the medial 1/3 of the tubercle, the posterior condylar line of the tibia, and the largest mediolateral dimension of the tibia. These lines were compared with the transposed femoral epicondylar axis line.The posterior condylar line of the tibia is the least variable local landmark for tibial component positioning at deep resection levels.Assuming the normal posterior condylar line of the tibia is visible at revision, setting the tibial component at 10° external rotation with respect to the posterior condylar axis of the tibia gets the tibial component within 10° of proper rotation in 86% to 98% of patients, even to the distal part of the proximal tibiofibular joint. The experienced surgeon then can adjust this position based on cues from an assortment of other axes.

    View details for DOI 10.1007/s11999-010-1330-8

    View details for Web of Science ID 000281843200024

    View details for PubMedID 20352384

  • Effects of Tensile Strain and Fluid Flow on Osteoarthritic Human Chondrocyte Metabolism In Vitro JOURNAL OF ORTHOPAEDIC RESEARCH Mawatari, T., Lindsey, D. P., Harris, A. H., Goodman, S. B., Maloney, W. J., Smith, R. L. 2010; 28 (7): 907-913


    This study examined the hypothesis that tensile strain and fluid flow differentially influence osteoarthritic human chondrocyte metabolism. Primary high-density monolayer chondrocytes cultures were exposed to varying magnitudes of tensile strain and fluid-flow using a four-point bending system. Metabolic changes were quantified by real-time PCR measurement of aggrecan, IL-6, SOX-9, and type II collagen gene expression, and by determination of nitric oxide levels in the culture medium. A linear regression model was used to investigate the roles of strain, fluid flow, and their interaction on metabolic activity. Aggrecan, type II collagen, and SOX9 mRNA expression were negatively correlated to increases in applied strain and fluid flow. An effect of the strain on the induction of nitric oxide release and IL-6 gene expression varied by level of fluid flow (and visa versa). This interaction between strain and fluid flow was negative for nitric oxide and positive for IL-6. These results confirm that articular chondrocyte metabolism is responsive to tensile strain and fluid flow under in vitro loading conditions. Although the articular chondrocytes reacted to the mechanically applied stress, it was notable that there was a differential effect of tensile strain and fluid flow on anabolic and catabolic markers.

    View details for DOI 10.1002/jor.21085

    View details for Web of Science ID 000278654500011

    View details for PubMedID 20063382

  • Patellar Management in Revision Total Knee Arthroplasty JOURNAL OF ARTHROPLASTY Patil, N., Lee, K., Huddleston, J. I., Harris, A. H., Goodman, S. B. 2010; 25 (4): 589-593


    The management of the patella during revision total knee arthroplasty (TKA) depends on the indication for revision, the type and stability of the patellar component in place, and availability of bone stock. We prospectively compared the clinical outcome and satisfaction rates in revision TKA patients managed with patellar resurfacing (n = 13, group I) to retention of the patellar component (n = 22, group II) or patelloplasty (n = 11, group III) at a minimum follow-up of 2 years. There were no differences in the improvement of Knee Society Scores, Short-Form 36 Scores, and satisfaction rates between the groups. There were no revision surgeries for patellar component failure or patellar fractures. Satisfactory results can be achieved using a variety of methods of patellar management in revision TKA by individualizing the treatment modality depending on the clinical scenario.

    View details for DOI 10.1016/j.arth.2009.04.009

    View details for Web of Science ID 000278905300016

    View details for PubMedID 19493648

  • Aseptic versus septic revision total knee arthroplasty: Patient satisfaction, outcome and quality of life improvement KNEE Patil, N., Lee, K., Huddleston, J. I., Harris, A. H., Goodman, S. B. 2010; 17 (3): 200-203


    We prospectively compared the clinical outcomes and patient satisfaction rates of aseptic (n=30) versus septic revision TKA (n=15) at a mean follow-up of 40 months. We hypothesized that the clinical results of septic revision TKA would be inferior to aseptic revision TKA. The indication for revision in aseptic group was stiffness in 11 patients, aseptic loosening in 13, patellar loosening or maltracking in 6 patients. Patients operated for infection had better post-operative Knee Society Scores (KSS), Function Scores and SF-36 Mental Scores than aseptic group but there were no significant differences in the satisfaction rates. Patients operated for infection had more improvement in their KSS (p=0.004) and Function Scores (p=0.02) than patients revised for stiffness. Moreover, patients operated on for patellar problems had higher satisfaction rates than patients revised for stiffness (p=0.01) or aseptic loosening (p=0.01). Thus, patients undergoing septic revision TKA had better outcomes compared to those with aseptic revision TKA. However, in the aseptic group, revision TKA for stiffness was associated with the poorest outcomes. The indication for aseptic revision is an important variable when discussing treatment and outcome with patients.

    View details for DOI 10.1016/j.knee.2009.09.001

    View details for Web of Science ID 000277698100005

    View details for PubMedID 19875297

  • Pharmacotherapy of Alcohol Use Disorders in the Veterans Health Administration PSYCHIATRIC SERVICES Harris, A. H., Kivlahan, D. R., Bowe, T., Humphreys, K. N. 2010; 61 (4): 392-398


    Acamprosate, oral and long-acting injectable naltrexone, and disulfiram are approved for treatment of alcohol dependence. Their availability and consideration of their use in treatment are now standards of high-quality care. This study determined rates of medication initiation among Veterans Health Administration (VHA) patients.VHA pharmacy and administrative data were used to identify patients with alcohol use disorder diagnoses in fiscal years (FY) 2006 and 2007 and the proportion (nationally and by facility) who received each medication. Patient characteristics associated with receipt were also examined.Among more than a quarter-million patients with alcohol use disorder diagnoses, the percentage receiving any of the medications increased from 2.8% in FY 2006 to 3.0% in FY 2007. Receipt of these medications was more likely among patients who received specialty addiction care, those with alcohol dependence (compared with abuse), those younger than 55 years, and females. In the patient subgroups examined, the largest proportion to receive any of the medications was 11.6%. Across 128 VHA facilities, rates of use among patients in the sample who had received past-year specialty addiction treatment ranged from 0% to 20.5%; rates ranged from 0% to 4.3% among those with no specialty treatment. Patient preferences and medical contraindications could not be determined from the data.Findings suggest the need to better understand systemwide variation in use of these medications and their use as a rough proxy for availability and consideration of pharmacotherapy--a standard of care with strong organizational support.

    View details for Web of Science ID 000276254200011

    View details for PubMedID 20360279

  • Biomechanical Comparison of Blade Plate and Intramedullary Nail Fixation for Tibiocalcaneal Arthrodesis FOOT & ANKLE INTERNATIONAL Lee, A. T., Sundberg, E. B., Lindsey, D. P., Harris, A. H., Chou, L. B. 2010; 31 (2): 164-171


    Tibiocalcaneal arthrodesis is an uncommon salvage procedure used for complex problems of the ankle and hindfoot. A biomechanical evaluation of the fixation constructs of this procedure has not been studied previously. The purpose of this study was to compare intramedullary nail to blade plate fixation in a deformity model in fatigue endurance testing and load to failure.Nine matched pairs of fresh frozen cadaveric legs underwent talectomy followed by fixation with a blade plate and 6.5-mm fully threaded cancellous screw or an ankle arthrodesis intramedullary nail. The specimens were loaded to 270 N at a rate of 3 Hz for a total of 250,000 cycles, followed by loading to failure.Intramedullary nail fixation demonstrated greater mean stiffness throughout the fatigue endurance testing, from cycles 10 through 250,000 (blade plate versus intramedullary nail; cycle 10, 93 +/- 34 N/mm versus 117 +/- 40 N/mm (t = 2.33, p = 0.04); cycle 100, 89 +/- 34 N/mm versus 118 +/- 42 N/mm (t = 3.16, p = 0.01); cycle 1000, 86 +/- 32 N/mm versus 120 +/- 45 N/mm (t = 3.52, p = 0.01); cycle 10,000, 83 +/- 36 N/mm versus 128 +/- 50 N/mm (t = 3.80, p = 0.01); cycle 100,000, 82 +/- 34 N/mm versus 126 +/- 52 N/mm (t = 3.70, p = 0.01); cycle 250,000, 80 +/- 31 N/mm versus 125 +/- 49 N/mm (t = 4.2, p = 0.003). There was no statistically significant difference between the intramedullary nail and blade plate fixation in cycle one or in load to failure; cycle 10, blade plate 70 +/- 38 N/mm and intramedullary nail 67 +/- 20 N/mm (t = 0.60, p = 0.56); load to failure, blade plate 808 +/- 193 N, IMN 1074 +/- 290 N) (p = 0.15).Intramedullary nail fixation was biomechanically superior to blade plate and screw fixation in a tibiocalcaneal arthrodesis construct.The ankle arthrodesis intramedullary nail provides greater stiffness for fixation in tibiocalcaneal arthrodesis, which may improve healing.

    View details for DOI 10.3113/FAI.2010.0164

    View details for Web of Science ID 000274179100011

    View details for PubMedID 20132755

  • Hylamer vs Conventional Polyethylene in Primary Total Hip Arthroplasty: A Long-Term Case-Control Study of Wear Rates and Osteolysis JOURNAL OF ARTHROPLASTY Huddleston, J. I., Harris, A. H., Atienza, C. A., Woolson, S. T. 2010; 25 (2): 203-207


    The long-term results of Hylamer implants have not been reported previously. Clinical and radiographic results of a consecutive series of 43 patients (45 hips) who had primary total hip arthroplasty using Hylamer liners were compared with those of 37 patients (43 hips) who had conventional liners after 10-year follow-up. The linear wear rates for Hylamer and conventional polyethylene acetabular liners were 0.21 and 0.20 mm/y, respectively. The number of pelvic osteolytic lesions and their size detected on plain radiographs were significantly greater for Hylamer liners. Seven Hylamer hips were revised or are pending revision for osteolysis (16%) compared with 1 control hip. Close radiographic surveillance of patients who have Hylamer liners and evidence of osteolysis found on plain radiographs is warranted.

    View details for DOI 10.1016/j.arth.2009.02.006

    View details for Web of Science ID 000277580900006

    View details for PubMedID 19264443

  • Does Meeting the HEDIS Substance Abuse Treatment Engagement Criterion Predict Patient Outcomes? JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH Harris, A. H., Humphreys, K., Bowe, T., Tiet, Q., Finney, J. W. 2010; 37 (1): 25-39


    This study examines the patient-level associations between the Health Plan Employer Data and Information Set (HEDIS) substance use disorder (SUD) treatment engagement quality indicator and improvements in clinical outcomes. Administrative and survey data from 2,789 US Department of Veterans Affairs SUD patients were used to estimate the effects of meeting the HEDIS engagement criterion on improvements in Addiction Severity Index Alcohol, Drug, and Legal composite scores. Patients meeting the engagement indicator improved significantly more in all domains than patients who did not engage, and the relationship was stronger for alcohol and legal outcomes for patients seen in outpatient settings. The benefit accrued by those who engaged was statistically significant but clinically modest. These results add to the literature documenting the clinical benefits of treatment entry and engagement. Although these findings only indirectly support the use of the HEDIS engagement measure for its intended purpose-discriminating quality at the facility or system level-they confirm that the processes of care captured by the measure are associated with important patient outcomes.

    View details for DOI 10.1007/s11414-008-9142-2

    View details for Web of Science ID 000273686300003

    View details for PubMedID 18770044

  • Prevalence of cancer in female orthopaedic surgeons in the United States. journal of bone and joint surgery. American volume Chou, L. B., Cox, C. A., Tung, J. J., Harris, A. H., Brooks-Terrell, D., Sieh, W. 2010; 92 (1): 240-244

    View details for DOI 10.2106/JBJS.H.01691

    View details for PubMedID 20048119

  • Are VHA administrative location codes valid indicators of specialty substance use disorder treatment? JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT Harris, A. H., Reeder, R. N., Ellerbe, L., Bowe, T. 2010; 47 (8): 699-708


    Healthcare quality managers and researchers often need to identify specific healthcare events from administrative data. In this study, we examined whether Veterans Health Administration (VHA) clinic stop and bed section codes are reliable indicators of substance use disorder (SUD) treatment as documented in clinical progress notes. For outpatient records with a progress note, SUD clinic stop code, SUD diagnosis code, and mental health procedure code, we found chart documentation of SUD care in 92.0% of 601 records: 82.5% of 372 records with a SUD clinic stop code and SUD diagnosis code but no mental health procedure code, 21.9% of 379 records with a SUD clinic stop code and mental health procedure code but no SUD diagnosis code, and 55.3% of 318 records with a SUD clinic stop code but no SUD diagnosis or mental health procedure code. For inpatient stays with a SUD bed section code and a progress note, we found chart documentation of SUD care in 99.0% of 699 records accompanied by a SUD diagnosis but 0% of 39 records without a SUD diagnosis. These results provide validity evidence and caveats to researchers and VHA quality managers who might use SUD specialty location codes as indicators of SUD specialty care.

    View details for DOI 10.1682/JRRD.2009.07.0106

    View details for Web of Science ID 000285074300005

    View details for PubMedID 21110245

  • Developing and Validating Process Measures of Health Care Quality An Application to Alcohol Use Disorder Treatment Academy Health Annual Research Meeting Harris, A. H., Kivlahan, D. R., Bowe, T., Finney, J. W., Humphreys, K. LIPPINCOTT WILLIAMS & WILKINS. 2009: 1244–50


    Health care process quality measures usually are designed by expert panels attempting to synthesize nuanced clinical evidence and subsequently operationalized using administrative data. Many quality measures are then adopted without directly validating their presumed links with outcomes. Later efforts to validate process measures often yield negative results, leaving policy makers without a defensible means of measuring quality. This article presents an alternative strategy for developing and validating process quality measures. The development of an alcohol use disorder (AUD) treatment quality measure is used as an example.An expert panel generated a range of candidate process quality measures of AUD treatment derivable from administrative data that were then tested to determine which had the strongest associations with facility- and patient-level outcomes. Outcome and process data were from 2701 US Veterans Health Administration patients starting a new episode of care at 54 VA facilities.Several of the candidate process-of-care quality measures predicted facility- and patient-level outcomes. Having at least 3 visits during the first month of specialty AUD treatment was correlated with improvement on the Addiction Severity Index Alcohol composite at the facility level, r = 0.41 (95% Confidence Interval 0.16-0.61), and at the patient level, r = 0.07 (CI: 0.03-0.11).These "prevalidated" quality measures can now be judged for the extent they map onto the extant clinical literature and other design requirements. The development and validation strategy we describe should aid in efficiently producing quality measures in other areas of health care.

    View details for Web of Science ID 000272488100008

    View details for PubMedID 19786908

  • Common statistical and research design problems in manuscripts submitted to high-impact psychiatry journals: What editors and reviewers want authors to know JOURNAL OF PSYCHIATRIC RESEARCH Harris, A. H., Reeder, R., Hyun, J. K. 2009; 43 (15): 1231-1234


    Journal editors and statistical reviewers are often in the difficult position of catching serious problems in submitted manuscripts after the research is conducted and data have been analyzed. We sought to learn from editors and reviewers of major psychiatry journals what common statistical and design problems they most often find in submitted manuscripts and what they wished to communicate to authors regarding these issues. Our primary goal was to facilitate communication between journal editors/reviewers and researchers/authors and thereby improve the scientific and statistical quality of research and submitted manuscripts.Editors and statistical reviewers of 54 high-impact psychiatry journals were surveyed to learn what statistical or design problems they encounter most often in submitted manuscripts. Respondents completed the survey online. The authors analyzed survey text responses using content analysis procedures to identify major themes related to commonly encountered statistical or research design problems.Editors and reviewers (n=15) who handle manuscripts from 39 different high-impact psychiatry journals responded to the survey. The most commonly cited problems regarded failure to map statistical models onto research questions, improper handling of missing data, not controlling for multiple comparisons, not understanding the difference between equivalence and difference trials, and poor controls in quasi-experimental designs.The scientific quality of psychiatry research and submitted reports could be greatly improved if researchers became sensitive to, or sought consultation on frequently encountered methodological and analytic issues.

    View details for DOI 10.1016/j.jpsychires.2009.04.007

    View details for Web of Science ID 000271439900008

    View details for PubMedID 19435635

  • HEDIS Initiation and Engagement Quality Measures of Substance Use Disorder Care: Impact of Setting and Health Care Specialty POPULATION HEALTH MANAGEMENT Harris, A. H., Bowe, T., Finney, J. W., Humphreys, K. 2009; 12 (4): 191-196


    Many health care systems track the HEDIS measures of initiation and engagement in substance use disorder (SUD) care. However, the impact of setting of care (inpatient vs. outpatient) and health care specialty (SUD, psychiatric, other) on the likelihood of patients meeting the initiation and engagement criteria are unknown. If the vast majority of initiation and engagement occurs within SUD specialty clinics, then these quality measures could be used to discriminate among and incentivize SUD clinic managers. However, if these criteria are satisfied in different settings and specialties, then they should be considered characteristics of the entire facility, rather than just specialty SUD units. Using a Markov model, the probabilities of advancing to treatment initiation and engagement given initial setting and specialty of care were estimated for 320,238 SUD-diagnosed Veterans Health Affairs (VA) patients. Patients in SUD specialty units progressed more often (diagnosis to initiation, initiation to engagement) than patients in other specialties. Progression through the criteria differed for inpatients vs. outpatients. Approximately 25% of initiation and over 40% of engagement occurred outside of SUD specialty care. VA patients who have contact with SUD specialty treatment have higher rates of advancing to initiation, and from initiation to engagement, compared to SUD-diagnosed patients in psychiatric or other medical locations. Even so, a substantial portion of initiation and engagement occurs outside of SUD specialty units. Therefore, these quality measures should be considered measures of facility performance rather than measures of the quality of SUD specialty care. The usual combining of inpatient and outpatient performance on these measures into overall facility scores clouds measurement and interpretation.

    View details for DOI 10.1089/pop.2008.0028

    View details for Web of Science ID 000268811100004

    View details for PubMedID 19663621

  • Measuring the quality of substance use disorder treatment: Evaluating the validity of the Department of Veterans Affairs continuity of care performance measure JOURNAL OF SUBSTANCE ABUSE TREATMENT Harris, A. H., Humphreys, K., Bowe, T., Kivlahan, D. R., Finney, J. W. 2009; 36 (3): 294-305


    This study examined the patient- and facility-level associations between the continuity of care performance measure adopted by the Department of Veterans Affairs (VA) and improvements in self-administered Addiction Severity Index (ASI) composites and other indicators of problematic substance use. Up to 50 patients from each of a nationally representative sample of 109 VA substance use disorder (SUD) treatment programs at 73 VA facilities were assessed at intake and posttreatment. The continuity of care performance measure specifies that patients should receive at least two SUD outpatient visits in each of the three consecutive 30-day periods after they qualify as new SUD patients. In analyses adjusting for baseline characteristics, meeting the continuity of care performance measure was not associated with patient-level improvements in the ASI alcohol or drug composites, days of alcohol intoxication, or days of substance-related problems. Facility-level rates of continuity of care were negatively associated with improvements in ASI alcohol and drug composites. The continuity of care performance measure derived from prior patient-level evidence did not discriminate facility-level performance as predicted. Translating research into process-of-care quality measures requires postconstruction validation.

    View details for DOI 10.1016/j.jsat.2008.05.011

    View details for Web of Science ID 000264510000006

    View details for PubMedID 18835678

  • Performance Monitoring of Substance Use Disorder Interventions in the Veterans Health Administration AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE Humphreys, K., Harris, A. H., Kivlahan, D. R. 2009; 35 (3): 123-127


    Measuring and improving the quality of treatment for patients with substance use disorders are enduring challenges.This article describes how the Veterans Affairs health care system is using incentivized performance measures to promote more effective delivery of interventions for nicotine, illegal drug, and alcohol disorders.The monitoring and incentive system has increased the delivery of evidence-based services, including screening for alcohol use disorders.Further work remains to be done to strengthen the connection between process-based measures and longer-term patient outcomes.

    View details for DOI 10.1080/00952990802707042

    View details for Web of Science ID 000266277700002

    View details for PubMedID 19462294

  • Patients' abstinence status affects the benefits of 12-step self-help group participation on substance use disorder outcomes DRUG AND ALCOHOL DEPENDENCE McKellar, J. D., Harris, A. H., Moos, R. H. 2009; 99 (1-3): 115-122


    Studies measuring the effectiveness of 12-step self-help group attendance have yielded mixed results but none of the prior studies have accounted for the potential impact of interim abstinence status.Participants were 1683 patients with substance use disorders (SUD) from 88 community residential facilities. Self-report data were collected at baseline and 1- and 4-year follow-ups, and included measures of SUD severity, social resources, coping, and 12-step self-help group attendance. We tested the hypothesis that 12-step self-help group attendance is more effective for non-abstinent patients than for abstinent patients. We also controlled for self-selection effects by using propensity score analyses and we cross-validated our results in a second sample of patients (N=2173).Sample 1. Patients abstinent at 1-year post-treatment who attended 12-step self-help group meetings were no more likely to be abstinent at 4 years than abstinent patients who did not attend. However, for patients not abstinent at 1 year, a significant improvement in abstinence rates at 4 years emerged for those who attended 12-step self-help groups compared to those who did not (42% vs. 28.9%). A similar pattern emerged for SUD problems. There were no benefits from 12-step self-help group attendance for patients abstinent at 1 year, but non-abstinent patients who attended 12-step self-help groups had significantly fewer problems at 4 years. Sample 2. The cross-validation yielded consistent results as 12-step self-help group attendance led to higher abstinence rates and fewer SUD problems only among patients non-abstinent at interim assessment.Individual's abstinence status should be considered when evaluating the potential influence of 12-step self-help group attendance on SUD outcomes. In addition, increased clinical resources should focus on assessing patients after discharge and on improving linkage of non-abstinent patients to self-help groups.

    View details for DOI 10.1016/j.drugalcdep.2008.07.005

    View details for Web of Science ID 000262700500013

    View details for PubMedID 18778901

  • Alcohol Screening Scores Predict Risk of Subsequent Fractures SUBSTANCE USE & MISUSE Harris, A. H., Bryson, C. L., Sun, H., Blough, D., Bradley, K. A. 2009; 44 (8): 1055-1069


    The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; 0-12 points) was included on health surveys in a cohort of 32,622 general medicine outpatients from seven US Department of Veterans Affairs (VA) hospitals. Cox proportional hazards models were used to estimate the risk of fracture (mean follow-up = 1.6 years) by AUDIT-C category. After adjusting for confounders, AUDIT-C scores of 8-9 and 10-12 were associated with significantly increased risks for subsequent fractures, HR (95% CI) = 1.37 (1.03 to 1.83) and 1.79 (1.38 to 2.33) respectively. These results can be used to provide feedback to patients linking their alcohol screening scores to medical outcomes-a critical component of evidence-based brief counseling for alcohol misuse. The study's limitations are noted.

    View details for DOI 10.1080/10826080802485972

    View details for Web of Science ID 000268582500001

    View details for PubMedID 19544147

  • Subject eligibility criteria can substantially influence the results of alcohol-treatment outcome research JOURNAL OF STUDIES ON ALCOHOL AND DRUGS Humphreys, K., Harris, A. H., Weingardt, K. R. 2008; 69 (5): 757-764


    Most alcohol-treatment studies exclude some patients from participation based on particular criteria (e.g., comorbid illegal drug abuse, homelessness). The current study evaluated whether such eligibility criteria can change the outcome results a study obtains.Five widely used treatment research eligibility criteria--(1) psychiatric problems, (2) medical problems, (3) social-residential instability, (4) low motivation/noncompliance, and (5) drug problems--were applied to two samples of real-world alcohol patients whose outcomes were known. Comparing outcomes of the samples with and without the application of eligibility criteria produced estimates of bias in outcome results, as well as an assessment of change in statistical power.Medical and psychiatric eligibility criteria produced a moderate bias in outcome estimates (e.g., a 10% or less change in outcome results). In contrast, social-residential instability, low motivation/noncompliance, and drug use produced a large (e.g., up to an 18% change) to a very large (e.g., up to a 51% change) bias in outcome estimates. Sensitivity analyses showed that these biases are even larger if eligibility criteria are operationalized in a broad rather than a narrow fashion. Contrary to expectation, eligibility criteria did not produce their theoretically expected benefit of increased statistical power.Researchers who use eligibility criteria should do so judiciously and interpret outcome results in light of potential bias introduced by the ineligibility of some patients for study enrollment. Efforts to integrate findings across treatment outcome studies should also consider how conclusions might be affected by the eligibility criteria used in different research areas.

    View details for Web of Science ID 000259205200015

    View details for PubMedID 18781251

  • Treatment staff's continuity of care practices, patients' engagement in continuing care, and abstinence following outpatient substance-use disorder treatment JOURNAL OF STUDIES ON ALCOHOL AND DRUGS Schaefer, J. A., Harris, A. H., Cronkite, R. C., Turrubiartes, P. 2008; 69 (5): 747-756


    Although speculation suggests that continuity of care predicts abstinence following substance-use disorder (SUD) treatment, models examining staff's continuity of care practices and engagement in continuing care and whether they mediate or moderate the association between patient and treatment factors and abstinence are lacking. In this study, we aimed to model abstinence using combinations of independent pretreatment and treatment factors, discharge continuity of care practices, and posttreatment engagement and to identify mediators or moderators of relationships between these factors and abstinence.Staff in 18 Department of Veterans Affairs (VA) outpatient SUD programs used the Addiction Severity Index to assess 429 nonabstinent patients' alcohol and drug problems at treatment entry. Staff supplied discharge data on patients' motivation, treatment intensity and completion, and continuity of care practices. Administrative data assessed patients' continuing care engagement. A 6-month follow-up, the Addiction Severity Index assessed abstinence. Mixed-effects logistic regression models were used to examine predictors of abstinence.Abstinence occurred more when discharge plans specified at least one continuing care appointment per week, patients received continuing care appointments before discharge, and staff provided patients drug-free/sober living arrangements and with longer engagement in continuing care. SUD/psychiatric clinic use before treatment entry, treatment completion, access to transportation for continuing care appointments, and more patient motivation for continuing care also predicted abstinence. Engagement in continuing care mediated the relationship between continuity of care and abstinence and between SUD/psychiatric clinic use and abstinence.Findings suggest that continuity of care practices influence abstinence mostly through their effect on patients' engagement in continuing care.

    View details for Web of Science ID 000259205200014

    View details for PubMedID 18781250

  • Veterans affairs facility performance on Washington circle indicators and casemix-adjusted effectiveness JOURNAL OF SUBSTANCE ABUSE TREATMENT Harris, A. H., Humphreys, K., Finney, J. W. 2007; 33 (4): 333-339


    Self-administered Addiction Severity Index (ASI) data were collected on 5,723 patients who received substance abuse treatment in 1 of 110 programs located at 73 Veterans Affairs facilities. The associations between each of three Washington Circle (WC) performance indicator scores (identification, initiation, and engagement) and their casemix-adjusted facility-level improvement in ASI drug and alcohol composites 7 months after intake were estimated. Higher initiation rates were not associated with facility-level improvement in ASI alcohol composite scores but were modestly associated with greater improvements in ASI drug composite scores. Identification and engagement rates were unrelated to 7-month outcomes. WC indicators focused on the early stages of treatment may tap necessary but insufficient processes for patients with substance use disorder to achieve good posttreatment outcomes. Ideally, the WC indicators would be supplemented with other measures of treatment quality.

    View details for DOI 10.1016/j.jsat.2006.12.015

    View details for Web of Science ID 000251110700001

    View details for PubMedID 17400416

  • Consistent adherence to guidelines improves opioid dependent patients' first year outcomes JOURNAL OF BEHAVIORAL HEALTH SERVICES & RESEARCH Trafton, J. A., Humphreys, K., Harris, A. H., Oliva, E. 2007; 34 (3): 260-271


    Clinical practice guidelines for opioid substitution treatment (OST) for opioid dependence recommend that patients receive at least 60 mg daily methadone and have access to a broad array of psychosocial services. However, there is still wide variation in clinical practice in OST clinics. In real-world settings, patients could receive lower methadone doses and less psychosocial care because they require less intensive care for recovery; alternatively, barriers to delivery of guideline concordant care could limit treatment received and impair recovery. The Multisite Opioid Substitution Treatment (MOST) study examines the impact of more consistent adherence to guideline recommendations in eight Veterans Affairs OST clinics. While patients at all clinics demonstrated improvements in substance use over the first year in treatment, patients at clinics that more consistently adhered to guidelines had greater reductions in heroin and cocaine use and greater improvement in mental health. These results suggest that efforts to increase guideline adherence in OST will improve patient outcomes.

    View details for DOI 10.1007/s11414-007-9074-2

    View details for Web of Science ID 000249225600003

    View details for PubMedID 17610159

  • Influence of subject eligibility criteria on compliance with national institutes of health guidelines for inclusion of women, minorities, and children in treatment research ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH Humphreys, K., Weingardt, K. R., Harris, A. H. 2007; 31 (6): 988-995


    Many alcohol treatment outcome studies exclude some patients with particular problems, such as psychiatric disorders, noncompliance, and homelessness. Such criteria may increase the likelihood of a study being successfully conducted, but may also have the unintended consequence of reducing a study's ability to comply with National Institutes of Health guidelines for inclusion of racial minorities, women, and children in treatment research.This paper examined this issue empirically using 5 prior studies of treatment systems enrolling over 100,000 alcohol patients. Widely used eligibility criteria in the alcohol treatment field typically exclude between one-fifth to one-third of patients from enrolling in research. Under several eligibility criteria, most notably those for drug use and social/residential instability, women and African-American patients are substantially more likely to be excluded than are men and non-African-American patients, respectively.In designing treatment studies with many eligibility criteria, researchers may therefore inadvertently be thwarting their own good faith efforts to ensure that a range of vulnerable populations are able to participate in research. We analyze the implications of this dilemma for the generalizability of treatment results and for research design, and provide data that may help researchers working in different treatment systems estimate the impact of various eligibility criteria.

    View details for DOI 10.1111/j.1530-0277/2007.00391.x

    View details for Web of Science ID 000246576500009

    View details for PubMedID 17428295

  • Predictors of a suicide attempt one year after entry into substance use disorder treatment ALCOHOLISM-CLINICAL AND EXPERIMENTAL RESEARCH Ilgen, M. A., Harris, A. H., Moos, R. H., Tiet, Q. Q. 2007; 31 (4): 635-642


    The present study examined the patient intake and treatment-related risk factors associated with a suicide attempt in the 30 days before a 1-year posttreatment assessment.A national sample of 8,807 patients presenting for treatment of substance use disorders (SUDs) in the Department of Veterans Affairs healthcare system were assessed at treatment intake and follow-up. Using the MacArthur Model, the risk and protective factors for suicide attempt were identified at baseline and during treatment.At follow-up, 4% (314/8,807) of the patients reported a suicide attempt within the past 30 days. Baseline predictors of a suicide attempt before follow-up included elevated suicidal/psychiatric symptoms, more recent problematic alcohol use, and longer duration of cocaine use. Contact with the criminal justice system was a protective factor that reduced the likelihood of a future suicide attempt. Greater engagement in SUD treatment was also associated with a reduction in suicide risk.More involvement in SUD treatment reduced the likelihood of a future suicide attempt in high-risk patients. Substance use disorder treatment providers interested in reducing future suicidal behavior may want to concentrate their efforts on identifying at-risk individuals and actively engaging these patients in longer treatment episodes.

    View details for DOI 10.1111/j.1530-0277.2007.00348.x

    View details for Web of Science ID 000244976200013

    View details for PubMedID 17374043

  • Treatment setting and baseline substance use severity interact to predict patients' outcomes ADDICTION Tiet, Q. Q., Ilgen, M. A., Byrnes, H. F., Harris, A. H., Finney, J. W. 2007; 102 (3): 432-440


    This study tested the hypothesis that patients with more severe substance use disorders (SUDs) at intake respond better when treated in more structured and intensive settings (i.e. in-patient/residential versus out-patient), whereas patients with less severe SUD problems have similar outcomes regardless of treatment setting.Up to 50 new patients were selected randomly from each of a random and representative sample of 50 Department of Veterans Affairs (VA) SUD treatment programs (total n = 1917 patients), and were followed-up an average of 6.7 months later (n = 1277).Patients completed a brief self-report version of the Addiction Severity Index (ASI) at baseline and at follow-up.In mixed-model regression analyses, baseline substance use severity predicted follow-up substance use severity and there were no main effects of treatment setting. However, interaction effects were found, such that more severe patients experienced better alcohol and drug outcomes following in-patient/residential treatment versus out-patient treatment; on the other hand, patients with lower baseline ASI drug severity had better drug outcomes following out-patient treatment than in-patient treatment. Treatment setting was unrelated to alcohol outcomes in patients with less severe ASI alcohol scores.Results provide some support to the matching hypothesis that for patients who have higher levels of substance use severity at intake, treatment in in-patient/residential treatment settings is associated with better outcomes than out-patient treatment. More research needs to be conducted before in-patient/residential settings are further reduced as a part of the SUD continuum of care in the United States.

    View details for DOI 10.1111/j.1360-0443.2006.01717.x

    View details for Web of Science ID 000244098000015

    View details for PubMedID 17298651

  • Measuring performance of brief alcohol counseling in medical settings:a review of the options and lessons from the Veterans Affairs (VA) health care system. Substance abuse Bradley, K. A., Williams, E. C., Achtmeyer, C. E., Hawkins, E. J., Harris, A. H., Frey, M. S., Craig, T., Kivlahan, D. R. 2007; 28 (4): 133-149


    Brief alcohol counseling is a top US prevention priority but has not been widely implemented. The lack of an easy performance measure for brief alcohol counseling is one important barrier to implementation. The purpose of this report is to outline important issues related to measuring performance of brief alcohol counseling in health care settings. We review the strengths and limitations of several options for measuring performance of brief alcohol counseling and describe three measures of brief alcohol counseling tested in the Veterans Affairs (VA) Health Care System. We conclude that administrative data are not well-suited to measuring performance of brief alcohol counseling. Patient surveys appear to offer the optimal approach currently available for comparing performance of brief alcohol counseling across health care systems, while more options are available for measuring performance within health care systems. Further research is needed in this important area of quality improvement.

    View details for PubMedID 18077309

  • Predictors of outcome for patients with substance-use disorders five years after treatment dropout JOURNAL OF STUDIES ON ALCOHOL McKellar, J. D., Harris, A. H., Moos, R. H. 2006; 67 (5): 685-693


    Few studies focus on the outcome of patients after they drop out of substance-use disorder (SUD) treatment, and there appear to be no prior studies of the long-term outcomes of these patients. The aim of this study is to determine how well such patients do after dropping out of treatment and to identify predictors of differential outcomes.Patients in 15 residential SUD treatment programs were assessed at treatment entry and at 5-year follow-up on their frequency and severity of substance use, expectancies and beliefs about substance use, and social resources and stressors. Patients who dropped out and stayed out of treatment (n = 193) were compared with those who completed treatment (n = 3,204). Predictors of 5-year SUD problems among dropouts were identified.In general, dropouts and treatment completers did not differ significantly on their levels of SUD problems at 5 years. At baseline, patients who dropped out reported more involvement in 12-step organizations and greater cognitive impairment and more closely identified with the label "drug addict" than "alcoholic." Lower severity of SUD, lower self-efficacy, fewer positive substance- use expectancies, and less stress from social networks predicted fewer SUD problems at 5 years among dropouts.In addition to focusing on substance use, providers should address the adequacy of patients' social support and counter positive substance-use expectancies at the earliest stages of treatment before patients drop out.

    View details for Web of Science ID 000239368700005

    View details for PubMedID 16847536

  • Predictors of engagement in continuing care following residential substance use disorder treatment DRUG AND ALCOHOL DEPENDENCE Harris, A. H., McKellar, J. D., Moos, R. H., Schaefer, J. A., Cronkite, R. C. 2006; 84 (1): 93-101


    Patients in intensive SUD programs who subsequently participate in continuing care for a longer interval have better outcomes than those who participate for a shorter interval. We sought to identify patient and program factors associated with duration of engagement in SUD continuing care after residential/inpatient treatment.Patients (n=3032) at 15 geographically diverse SUD residential treatment programs provided data on demographics, symptom patterns, recovery resources, and perceptions of treatment environment. We identified patient characteristics associated with the number of consecutive months of engagement in continuing care. We then consolidated and classified risk factors into an integrated model.Being African American, having more SUD and psychiatric symptoms, more resources for recovery, and perceiving the treatment staff as being supportive were associated with longer engagement in continuing care. African Americans' engagement in continuing care was 17% longer than Caucasians'. The positive effect of being African American was partially mediated by having taken actions toward changing use, and by the presence of psychotic symptoms.These results extend previous research on the predictors of continuing care engagement after residential SUD programs. Clinicians can use information about characteristics that put patients at risk for shorter engagement in continuing care to target patients who might benefit from interventions to increase engagement in continuing care.

    View details for DOI 10.1016/j.drugalcdep.2005.12.010

    View details for Web of Science ID 000240231600010

    View details for PubMedID 16417977

  • Physical activity, exercise coping, and depression in a 10-year cohort study of depressed patients JOURNAL OF AFFECTIVE DISORDERS Harris, A. H., Cronkite, R., Moos, R. 2006; 93 (1-3): 79-85


    Epidemiological research examining the relationship between physical activity and depression has been conducted almost exclusively with community samples. We examined associations between physical activity, exercise coping, and depression in a sample of initially depressed patients, using four waves of data spanning 10 years.A cohort (n=424) of depressed adults completed measures of physical activity, exercise coping, depression, and other demographic and psychosocial constructs at baseline, 1-year, 4-years, and 10-years, with a 90% wave-to-wave retention rate. Multilevel modeling was used to analyze individual depression trajectories.More physical activity was associated with less concurrent depression, even after controlling for gender, age, medical problems, and negative life events. Physical activity counteracted the effects of medical conditions and negative life events on depression. However, physical activity was not associated with subsequent depression. The findings for exercise coping were comparable.Measures of physical activity and exercise coping encompassed a limited set of activities and did not include information about duration or intensity.Our results suggest that more physical activity is associated with reduced concurrent depression. In addition, it appears that physical activity may be especially helpful in the context of medical problems and major life stressors. Clinically, encouraging depressed patients to engage in physical activity is likely to have potential benefits with few obvious risks.

    View details for DOI 10.1016/j.jad.2006.02.013

    View details for Web of Science ID 000238773300010

    View details for PubMedID 16545873

  • Effects of a group forgiveness intervention on forgiveness, perceived stress, and trait-anger JOURNAL OF CLINICAL PSYCHOLOGY Harris, A. H., Luskin, F., Norman, S. B., Standard, S., Bruning, J., Evans, S., Thoresen, C. E. 2006; 62 (6): 715-733


    The goal of this study was to evaluate the effects of a 6-week forgiveness intervention on three outcomes: (a) offense-specific forgiveness, (b) forgiveness-likelihood in new situations, and (c) health-related psychosocial variables, such as perceived stress and trait-anger. Participants were 259 adults who had experienced a hurtful interpersonal transgression from which they still felt negative consequences. They were randomized to a forgiveness-training program or a no-treatment control group. The intervention reduced negative thoughts and feelings about the target transgression 2 to 3 times more effectively than the control condition, and it produced significantly greater increases in positive thoughts and feelings toward the transgressor. Significant treatment effects were also found for forgiveness self-efficacy, forgiveness generalized to new situations, perceived stress, and trait-anger.

    View details for DOI 10.1002/jclp.20264

    View details for Web of Science ID 000237766500009

    View details for PubMedID 16538652

  • Does expressive writing reduce health care utilization? A meta-analysis of randomized trials JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Harris, A. H. 2006; 74 (2): 243-252


    This meta-analysis examined whether writing about stressful experiences affects health care utilization (HCU) compared with writing on neutral topics or no-writing control groups. Randomized controlled trials of 30 independent samples representing 2,294 participants were located that contained sufficient information to calculate effect sizes. After omitting one study as an outlier, the effects were combined within 3 homogeneous groups: healthy samples (13 studies), samples with preexisting medical conditions (6 studies), and samples prescreened for psychological criteria (10 studies). Combined effect sizes, Hedges's g (95% confidence interval), with random effects estimation were 0.16 (0.02, 0.31), 0.21 (-0.02, 0.43), and 0.06 (-0.12, 0.24), respectively. Writing about stressful experiences reduces HCU in healthy samples but not in samples defined by medical diagnoses or exposure to stress or other psychological factors. The significance of these effects for individuals' health is unknown.

    View details for DOI 10.1037/0022-006X.74.2.243

    View details for Web of Science ID 000237667500005

    View details for PubMedID 16649869

  • Continuity of care practices and substance use disorder patients' engagement in continuing care MEDICAL CARE Schaefer, J. A., Ingudomnukul, E., Harris, A. H., Cronkite, R. C. 2005; 43 (12): 1234-1241


    Substance use disorder (SUD) patients who engage in more continuing care have better outcomes, but information on practices associated with greater patient engagement and retention in continuing care remains elusive.The objectives of this study were to determine if staff's continuity of care practices predict patients' engagement in continuing care in the 6 months after discharge from intensive SUD treatment and to determine if the impact of continuity of care practices on patients' engagement in continuing care differs for patients treated in inpatient/residential versus outpatient programs.Staff in 28 Veterans Affairs (VA) intensive SUD treatment programs with varying continuity of care practices provided data on 878 patients' alcohol and drug problems at treatment entry. At discharge, staff provided data on patients' motivation, treatment intensity, and on the continuity of care practices they used with each patient. VA administrative databases supplied data on patients' subsequent engagement in continuing care. Mixed-effects modeling was used to examine predictors of patients' engagement in care.Patients in outpatient programs who received more continuity of care engaged in continuing care significantly longer. More highly motivated outpatients, those with fewer alcohol problems at treatment entry, and patients who used VA services in the year before treatment also remained in continuing care longer. These findings did not hold for patients treated in inpatient/residential programs.Continuity of care practices predicted engagement in continuing care only for patients treated in outpatient SUD programs. More research is needed to identify effective continuity of care practices for patients treated in inpatient/residential programs.

    View details for Web of Science ID 000233711100011

    View details for PubMedID 16299435

  • Volunteering is associated with delayed mortality in older people: Analysis of the longitudinal study of aging JOURNAL OF HEALTH PSYCHOLOGY Harris, A. H., Thoresen, C. E. 2005; 10 (6): 739-752


    The Longitudinal Study of Aging (LSOA) assessed the health and social functioning of a representative sample of 7527 American community-dwelling older people (>70 years). We tested the hypothesis that frequent volunteering is associated with less mortality risk when the effects of socio-demographics, medical status, physical activity and social integration are controlled. We used Cox proportional hazards analyses to assess the unadjusted and adjusted associations between frequency of volunteering and time-to-death (96-month follow-up). Death occurred in 38.3 percent of the sample. After adjusting for covariates, frequent volunteers had significantly reduced mortality compared to non-volunteers. This association was greatest for those who frequently visited with friends or attended religious services.

    View details for DOI 10.1177/1359105305057310

    View details for Web of Science ID 000232980300001

    View details for PubMedID 16176953

  • Recent suicide attempt and the effectiveness of inpatient and outpatient substance use disorder treatment. Alcoholism, clinical and experimental research Ilgen, M. A., Tiet, Q., Finney, J. W., Harris, A. H. 2005; 29 (9): 1664-1671


    The present study investigated whether or not the effect of treatment setting (inpatient or outpatient) on 6-mo follow-up substance use varied for suicidal and non-suicidal patients. In particular, the study tested the hypothesis that treatment setting would have no differing effect for non-suicidal participants, but for suicidal participants, inpatient setting would be more closely associated with positive outcomes than the outpatient setting.A national sample of patients presenting for treatment of substance use disorders in the Veterans Administration health care system was selected to participate in the study. A total of 1,289 participants provided complete data on psychiatric and substance-related problems at baseline and 6-mo follow-up.At baseline, 4% (n=53) of the sample reported having made a suicide attempt within the past 30 days. Those who reported a suicide attempt were no more likely to have been treated in an inpatient setting than in an outpatient setting. A significant interaction between baseline suicide attempt and treatment setting was found, such that non-suicidal patients reported similar patterns of substance use when treated in inpatient or outpatient settings, but suicidal patients were significantly more likely to have better substance-related outcomes at 6-mo follow-up if they were treated in inpatient compared with outpatient settings.Suicidal patients displayed substantial improvement after substance use disorders treatment and seem particularly responsive to treatment in inpatient settings.

    View details for PubMedID 16205366

  • A randomised trial of the cost effectiveness of buprenorphine as an alternative to methadone maintenance treatment. for heroin dependence in a primary care setting PHARMACOECONOMICS Harris, A. H., Gospodarevskaya, E., Ritter, A. J. 2005; 23 (1): 77-91


    Buprenorphine offers an alternative to methadone in the treatment of heroin dependence, and has the advantage of allowing alternate-day dosing. This study is the first to examine the cost effectiveness of buprenorphine as maintenance treatment for heroin dependence in a primary care setting using economic and clinical data collected within a randomised trial.The study was a randomised, open-label, 12-month trial of 139 heroin-dependent patients in a community setting receiving individualised treatment regimens of buprenorphine or methadone. Those who were currently on a methadone program (n = 57; continuing therapy subgroup) were analysed separately from new treatment recipients (n = 82; initial therapy subgroup). The study took a broad societal perspective and included health, crime and personal costs. Data on resource use and outcomes were a combination of clinical records and self report at interview. The main outcomes were incremental cost per additional day free of heroin use and per QALY. An analysis of uncertainty calculated the likelihood of net benefits for a range of acceptable money values of outcomes. All costs were in 1999 Australian dollars (DollarA).The estimated mean number of heroin-free days did not differ significantly between those randomised to methadone (225 [95% CI 91, 266]), or buprenorphine (222 [95% CI 194, 250]) over the year of the trial. Buprenorphine was associated with an average 0.03 greater QALYs over 52 weeks (not significant). The total cost was DollarA 17,736 (95% CI -DollarA 2981, DollarA 38,364) with methadone and DollarA 11,916 (95% CI DollarA 7697, DollarA 16,135) with buprenorphine; costs excluding crime were DollarA 4513 (95% CI DollarA 3495, DollarA 5531) and DollarA 5651 (95% CI DollarA 4202, DollarA 7100). With additional heroin-free days as the outcome, and crime costs included buprenorphine has a lower cost but less heroin-free days. If crime costs are excluded buprenorphine has a higher cost and worse outcome than methadone. With additional QALYs as the outcome, the cost effectiveness of buprenorphine is DollarA 39,404 if crime is excluded, but buprenorphine is dominant if crime is included.The trial found no significant differences in costs or outcomes between methadone and buprenorphine maintenance in this particular setting. Although some of the results suggest that methadone may have a cost advantage, it is difficult to infer from the trial data that offering buprenorphine as an alternative would have a significant effect on total costs or outcomes. The point estimates of costs and outcomes suggest that buprenorphine may have an advantage in those initiating therapy. The confidence intervals were wide, however, and the likelihood of net benefits from substituting one treatment for another was close to 50%.

    View details for Web of Science ID 000226847300007

    View details for PubMedID 15693730

  • Does writing affect asthma? - A randomized trial PSYCHOSOMATIC MEDICINE Harris, A. H., Thoresen, C. E., Humphreys, K., Faul, J. 2005; 67 (1): 130-136


    Nonpharmacologic treatments for asthma may act as useful adjuncts to pharmacotherapy but should be recommended to patients only after several well-controlled studies provide evidence of efficacy. Research demonstrating that written emotional expression can improve pulmonary function in patients with asthma consists of one impressive yet unreplicated study. Our main objective was to test and extend previous research finding that written emotional expression improves pulmonary function in patients with asthma compared with writing on neutral topics.We conducted a randomized, controlled trial of outpatient asthmatics recruited from hospitals and the community. Of the 137 adult patients with asthma who were randomized, 117 began and 114 completed the study. Patients were randomly assigned to write for 20 minutes, once per week, for 3 weeks about stressful experiences (n = 41), positive experiences (n = 37), or neutral experiences (n = 36; control group). At baseline, postintervention, and 2-month follow up, patients were assessed by spirometry.The mean change from baseline to 2-month follow up in percentage of predicted forced expiratory volume in 1 second (FEV1) was 4.2% in the stress-writing group, 1.3% in the positive-writing group, and 3.0% in the control group. In forced vital capacity (FVC), there was 3.1% improvement in the stress-writing group, 3.6% in the positive-writing group, and 2.4% in the control group. These changes were not statistically or clinically significant.The present study reduces confidence in the ability of written emotional expression to benefit the disease status of asthma patients.

    View details for DOI 10.1097/01.psy.0000146345.73510.d5

    View details for Web of Science ID 000226673700019

    View details for PubMedID 15673635

  • The accuracy of abstracts in psychology journals JOURNAL OF PSYCHOLOGY Harris, A. H., Standard, S., Brunning, J. L., Casey, S. L., Goldberg, J. H., Oliver, L., Ito, K., Marshall, J. M. 2002; 136 (2): 141-148


    This article provides an empirically supported reminder of the importance of accuracy in scientific communication. The authors identify common types of inaccuracies in research abstracts and offer suggestions to improve abstract-article agreement. Abstracts accompanying 13% of a random sample of 400 research articles published in 8 American Psychological Association journals during 1997 and 1998 contained data or claims inconsistent with or missing from the body of the article. Error rates ranged from 8% to 18%, although between-journal differences were not significant. Many errors (63%) were unlikely to cause substantive misinterpretations. Unfortunately, 37% of errors found could be seriously misleading with respect to the data or claims presented in the associated article. Although deficient abstracts may be less common in psychology journals than in major medical journals (R. M. Pitkin, M. A. Branagan, & L. F. Burmeister, 1999), there is still cause for concern and need for improvement.

    View details for Web of Science ID 000176196900003

    View details for PubMedID 12081089

  • Spirituality and health: What's the evidence and what's needed? 21st Annual Meeting of the Society-of-Behavioral-Medicine Thoresen, C. E., Harris, A. H. SPRINGER. 2002: 3–13


    In this article, we familiarize readers with some recent empirical evidence about possible associations between religious and/or spiritual (RS) factors and health outcomes. In considering this evidence, we believe a healthy skepticism is in order One needs to remain open to the possibility that RS-related beliefs and behaviors may influence health, yet one needs empirical evidence based on well-controlled studies that support these claims and conclusions. We hope to introduce the dismissing critic to suggestive data that may create tempered doubt and to introduce the uncritical advocate to issues and concerns that will encourage greater modesty in the making of claims and drawing of conclusions. We comment on the following questions: Do specific RS factors influence health outcomes? What possible mechanisms might explain a relation, if one exists? Are there any implications for health professionals at this point in time? Recommendations concern the need to improve research designs and measurement strategies and to clarify conceptualizations of RSfactors. RSfactors appear to be associated with physical and overall health, but the relation appears far more complex and modest than some contend. Which specific RS factors enhance or endanger health and well-being remains unclear.

    View details for Web of Science ID 000175108100002

    View details for PubMedID 12008792

  • Psychometric properties of the life regard index-revised: A validation study of a measure of personal meaning PSYCHOLOGICAL REPORTS Harris, A. H., Standard, S. 2001; 89 (3): 759-773


    A validation study of the English version of the 28-item Life Regard Index-Revised was undertaken with a sample of 91 participants from the general population. All previous studies of the Index have examined the Dutch version. The test-retest reliabilities at 8 wk. for the total Index (r =.87), Framework (r =.82), and Fulfillment (r =.81) subscales were very high. Cronbach alphas were .92, .83, and .87, respectively. A significant restriction of range was observed at the high-meaning end of the scale. Factor analysis only weakly supported the theorized two-factor structure. A very high disattenuated correlation between the Framework and Fulfillment subscales was observed (r=.94). The Index appeared to have adequate evidence supporting its concurrent and discriminant validity when compared with measures of hopelessness, spiritual well-being, and other measures of personal meaning. A significant positive association was found between the index and the Marlowe-Crowne Social Desirability Scale (r=.38). The Index was also significantly associated with sex (women scoring higher) and marital status (divorced people scoring lower). Revisions of the English version may address the restriction of range problem by employing a 5-point rating scale, instead of the current 3-point scale, or by adding more discriminating items. Further factor-analytic studies with larger samples are needed before conclusions can be drawn regarding this scale's factor structure.

    View details for Web of Science ID 000173408800048

    View details for PubMedID 11824748

  • Incidence of critical events in professional practice: A statewide survey of psychotherapy providers PSYCHOLOGICAL REPORTS Harris, A. H. 2001; 88 (2): 387-397


    The goal was to tabulate the incidences of clients' suicide, attack by a client, and sexual contact with clients in an Alaskan sample of masters and doctoral-level psychotherapy providers (excluding psychiatrists) and to assess which, if any, demographic or professional characteristics were associated with each critical event. Results from 151 respondents (response rate 43.5%) indicated that 42.7% of providers had experienced at least one client's suicide, 28% had been physically attacked by a client, 4% reported having had sexual contact with a then current client, and 6% reported sexual contact with a former client. Areas for research are outlined, specifically the importance of using methods other than surveys and exploring variables other than standard demographic data.

    View details for Web of Science ID 000168336200012

    View details for PubMedID 11351877

  • Spiritually and religiously oriented health interventions. Journal of health psychology Harris, A. H., Thoresen, C. E., McCullough, M. E., Larson, D. B. 1999; 4 (3): 413-433


    Controlled intervention studies offer considerable promise to better understand relationships and possible mechanisms between spiritual and religious factors and health. Studies examining spiritually augmented cognitive-behavioral therapies, forgiveness interventions, different meditation approaches, 12-step fellowships, and prayer have provided some evidence, albeit modest, of efficacy in improving health under specific conditions. Researchers need to describe spiritual and religious factors more clearly and precisely, as well as demonstrate that such factors independently influence treatment efficacy. Inclusion of potential moderating and mediating variables (e.g. extent of religious commitment, intrinsic religiousness, specific religious coping strategy) in intervention designs could help explain relationships and outcomes. Using a variety of research designs (e.g. randomized clinical trials, single-subject experimental designs) and assessment methods (e.g. daily self-monitoring, ambulatory physiological measures, in-depth structured interviews) would avoid current limitations of short-term studies using only questionnaires.

    View details for DOI 10.1177/135910539900400309

    View details for PubMedID 22021607