Laurel A. Copeland Ph.D.

Cook, J. M., J. E. Zeber, V. Simiola, R. Rossom, J. F. Scherrer, A. A. Owen-Smith, B. K. Ahmedani, K. Zolfaghari and L. A. Copeland (2020). “Comparisons Between Patients Diagnosed with PTSD in Primary Care Versus Mental Health Care in Five Large Civilian Health Care Systems.” J Clin Psychol Med Settings Feb 11. [Epub ahead of print].

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Posttraumatic stress disorder (PTSD) is a serious mental health disorder that may not be adequately detected or treated in primary care (PC). The purpose of this study was to compare the clinical characteristics and health care utilization of PTSD patients diagnosed in PC versus in specialty mental health care (MHC) across five large, civilian, not-for-profit healthcare systems. Electronic claims and medical record data on patients treated during 2014 were analyzed. Treatment was considered in terms of initiation and dose (i.e., psychotherapy sessions; pharmacotherapy-prescription psychotropics). Of 5256 patients aged 15-88 with a diagnosis of PTSD, 84.4% were diagnosed by a MHC provider. Patients diagnosed by MHC providers had 4 times the rate of and more enduring psychotherapy than those diagnosed by PC providers. Receipt of psychotropics varied by provider type, with generally higher prescription fill levels for patients in MHC. Strategies to better align patient needs with access and treatment modality in PC settings are needed.

Copeland, L. A., J. E. Zeber, L. V. Thibodeaux, R. T. McIntyre, E. M. Stock and A. K. Hochhalter (2018). “Postdischarge Correlates of Health Literacy Among Medicaid Inpatients.” Popul Health Manag 21(6): 493-500.

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Health literacy may represent a target for intervention to improve hospital transitions. This study analyzed the association of health literacy with postdischarge utilization among Medicaid patients treated in an integrated health care system. Discharged inpatients covered by Medicaid (N = 112) participated in this observational study set in a single 600-bed hospital in a private, nonprofit, integrated health care system in the southwestern United States. Participants completed surveys within 15 days of discharge, self-reporting demographics, self-care behaviors, and 2 measures of health literacy (REALM-SF [Short Form of the Rapid Estimate of Adult Literacy in Medicine] and Chew [health literacy screen from Chew et al]). Electronic medical records data were incorporated to determine occurrence of 30-day/90-day postdischarge emergency visits and readmission. Half the respondents (54%) scored at the high-school grade equivalent on REALM-SF, while 46% scored adequate health literacy on the Chew. Forty percent (40%) experienced either emergency care or readmission within 90 days post discharge. Patients who were younger, female, or living with children had relatively better health literacy. Health literacy itself was not associated with readmission or postdischarge emergency care, although African American race was. Although Medicaid patients varied considerably on health literacy, this factor was not associated with adverse health care outcomes. Future work should better identify individuals requiring supportive transition services to reduce problems following hospital discharge.

Wahl, T. S., L. A. Graham, M. S. Morris, J. S. Richman, R. H. Hollis, C. E. Jones, K. M. Itani, T. H. Wagner, H. J. Mull, J. C. Whittle, G. L. Telford, A. K. Rosen, L. A. Copeland, E. A. Burns and M. T. Hawn (2018). “Association Between Preoperative Proteinuria and Postoperative Acute Kidney Injury and Readmission.” JAMA Surg 153(9): e182009. [Epub ahead of print Sep 19].

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Importance: Proteinuria indicates renal dysfunction and is a risk factor for morbidity among medical patients, but less is understood among surgical populations. There is a paucity of studies investigating how preoperative proteinuria is associated with surgical outcomes, including postoperative acute kidney injury (AKI) and readmission. Objective: To assess preoperative urine protein levels as a biomarker for adverse surgical outcomes. Design, Setting, and Participants: A retrospective, population-based study was conducted in a cohort of patients with and without known preoperative renal dysfunction undergoing elective inpatient surgery performed at 119 Veterans Affairs facilities from October 1, 2007, to September 30, 2014. Data analysis was conducted from April 4 to December 1, 2016. Preoperative dialysis, septic, cardiac, ophthalmology, transplantation, and urologic cases were excluded. Exposures: Preoperative proteinuria as assessed by urinalysis using the closest value within 6 months of surgery: negative (0 mg/dL), trace (15-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-300 mg/dL), 3+ (301-1000 mg/dL), and 4+ (>1000 mg/dL). Main Outcomes and Measures: Primary outcome was postoperative predischarge AKI and 30-day postdischarge unplanned readmission. Secondary outcomes included any 30-day postoperative outcome. Results: Of 346676 surgeries, 153767 met inclusion criteria, with the majority including orthopedic (37%), general (29%), and vascular procedures (14%). Evidence of proteinuria was shown in 43.8% of the population (trace: 20.6%, 1+: 16.0%, 2+: 5.5%, 3+: 1.6%) with 20.4%, 14.9%, 4.3%, and 0.9%, respectively, of the patients having a normal preoperative estimated glomerular filtration rate (eGFR). In unadjusted analysis, preoperative proteinuria was significantly associated with postoperative AKI (negative: 8.6%, trace: 12%, 1+: 14.5%, 2+: 21.2%, 3+: 27.6%; P < .001) and readmission (9.3%, 11.3%, 13.3%, 15.8%, 17.5%, respectively, P < .001). After adjustment, preoperative proteinuria was associated with postoperative AKI in a dose-dependent relationship (trace: odds ratio [OR], 1.2; 95% CI, 1.1-1.3, to 3+: OR, 2.0; 95% CI, 1.8-2.2) and 30-day unplanned readmission (trace: OR, 1.0; 95% CI, 1.0-1.1, to 3+: OR, 1.3; 95% CI, 1.1-1.4). Preoperative proteinuria was associated with AKI independent of eGFR. Conclusions and Relevance: Proteinuria was associated with postoperative AKI and 30-day unplanned readmission independent of preoperative eGFR. Simple urine assessment for proteinuria may identify patients at higher risk of AKI and readmission to guide perioperative management.

Stock, E. M., J. E. Zeber, C. J. McNeal, J. E. Banchs and L. A. Copeland (2018). “Psychotropic Pharmacotherapy Associated With QT Prolongation Among Veterans With Posttraumatic Stress Disorder.” Ann Pharmacother 52(9): 838-848.

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BACKGROUND: In 2012, the Food and Drug Administration issued Drug Safety Communications on several drugs associated with QT prolongation and fatal ventricular arrhythmias. Among these was citalopram, a selective serotonin reuptake inhibitor (SSRI) approved for depression and commonly used for posttraumatic stress disorder (PTSD). Evaluation of the risk for QT prolongation among other psychotropic drugs for individuals with PTSD remains limited. OBJECTIVE: Explore psychotropic drugs associated with QT prolongation among veterans with PTSD. METHODS: Patients in the Veterans Health Administration in 2006-2009 with PTSD and QT prolongation (176 cases) were matched 1:4 on age, gender, visit date and setting, and physical comorbidity. Classification trees assessed QT prolongation risk among prescribed medications (n=880). RESULTS: Receipt of any drug with known risk of QT prolongation varied by group (23% QT cases vs 15% control, p<0.01). Psychotropic medications conferring significant risks included ziprasidone (3% vs 1%, p=0.02) and buspirone (6% vs 2%, p=0.01). Increased risk was not observed for the SSRIs, citalopram and fluoxetine. Classification trees found that sotalol and amitriptyline carried greater risk among cardiac patients and methadone, especially if prescribed with quetiapine, among noncardiac patients. Per adjusted survival model, patients with QT prolongation were at increased risk for death (hazard ratio=1.60; 95% CI=1.04-2.44). CONCLUSIONS: Decision models are particularly advantageous when exploring nonlinear relationships or nonadditive interactions. These findings may potentially affect clinical decision-making concerning treatment for PTSD. For patients at higher risk of QT prolongation, antidepressants other than amitriptyline should be considered. Medications for comorbid conditions should also be closely monitored for heightened QT prolongation risk.

Wahl, T. S., L. A. Graham, M. S. Morris, J. S. Richman, R. H. Hollis, C. E. Jones, K. M. Itani, T. H. Wagner, H. J. Mull, J. C. Whittle, G. L. Telford, A. K. Rosen, L. A. Copeland, E. A. Burns and M. T. Hawn (2018). “Association Between Preoperative Proteinuria and Postoperative Acute Kidney Injury and Readmission.” JAMA Surg Jul 3: [Epub ahead of print].

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Importance: Proteinuria indicates renal dysfunction and is a risk factor for morbidity among medical patients, but less is understood among surgical populations. There is a paucity of studies investigating how preoperative proteinuria is associated with surgical outcomes, including postoperative acute kidney injury (AKI) and readmission. Objective: To assess preoperative urine protein levels as a biomarker for adverse surgical outcomes. Design, Setting, and Participants: A retrospective, population-based study was conducted in a cohort of patients with and without known preoperative renal dysfunction undergoing elective inpatient surgery performed at 119 Veterans Affairs facilities from October 1, 2007, to September 30, 2014. Data analysis was conducted from April 4 to December 1, 2016. Preoperative dialysis, septic, cardiac, ophthalmology, transplantation, and urologic cases were excluded. Exposures: Preoperative proteinuria as assessed by urinalysis using the closest value within 6 months of surgery: negative (0 mg/dL), trace (15-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-300 mg/dL), 3+ (301-1000 mg/dL), and 4+ (>1000 mg/dL). Main Outcomes and Measures: Primary outcome was postoperative predischarge AKI and 30-day postdischarge unplanned readmission. Secondary outcomes included any 30-day postoperative outcome. Results: Of 346676 surgeries, 153767 met inclusion criteria, with the majority including orthopedic (37%), general (29%), and vascular procedures (14%). Evidence of proteinuria was shown in 43.8% of the population (trace: 20.6%, 1+: 16.0%, 2+: 5.5%, 3+: 1.6%) with 20.4%, 14.9%, 4.3%, and 0.9%, respectively, of the patients having a normal preoperative estimated glomerular filtration rate (eGFR). In unadjusted analysis, preoperative proteinuria was significantly associated with postoperative AKI (negative: 8.6%, trace: 12%, 1+: 14.5%, 2+: 21.2%, 3+: 27.6%; P < .001) and readmission (9.3%, 11.3%, 13.3%, 15.8%, 17.5%, respectively, P < .001). After adjustment, preoperative proteinuria was associated with postoperative AKI in a dose-dependent relationship (trace: odds ratio [OR], 1.2; 95% CI, 1.1-1.3, to 3+: OR, 2.0; 95% CI, 1.8-2.2) and 30-day unplanned readmission (trace: OR, 1.0; 95% CI, 1.0-1.1, to 3+: OR, 1.3; 95% CI, 1.1-1.4). Preoperative proteinuria was associated with AKI independent of eGFR. Conclusions and Relevance: Proteinuria was associated with postoperative AKI and 30-day unplanned readmission independent of preoperative eGFR. Simple urine assessment for proteinuria may identify patients at higher risk of AKI and readmission to guide perioperative management.