Laurel A. Copeland Ph.D.

Copeland, L. A., E. P. Finley, M. J. Bollinger, M. E. Amuan and M. J. Pugh (2016). “Comorbidity correlates of death among new veterans of iraq and afghanistan deployment.” Med Care 54(12): 1078-1081.

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BACKGROUND: Veterans of the wars in Iraq and Afghanistan who receive care in the Veterans Health Administration (VA) have high disease burden. Distinct comorbidity patterns have been shown to be differentially associated with adverse outcomes, including death. This study determined correlates of 5-year mortality. MATERIALS AND METHODS: VA demographic, military, homelessness, and clinical measures informed this retrospective analysis. Previously constructed comorbidity classifications over 3 years of care were entered into a Cox proportional hazards model of death. RESULTS: There were 164,933 veterans in the cohort, including African Americans (16%), Hispanics (11%), and whites (65%). Most were in their 20s at baseline (60%); 12% were women; 4% had attempted suicide; 4% had been homeless. Having clustered disorders of pain, posttraumatic stress disorder, and traumatic brain injury was associated with death [hazard ratio (HR)=2.0]. Mental disorders including substance abuse were similarly associated (HR=2.1). Prior suicide attempt (HR=2.2) or drug overdose (HR=3.0) considerably increased risk of death over 5 years. CONCLUSIONS: As congressional actions such as Veterans Choice Act offer more avenues to seek care outside of VA, coordination of care, and suicide prevention outreach for recent veterans may require innovative approaches to preserve life.

Henry, C., C. Boethel, L. A. Copeland, S. Ghamande, A. C. Arroliga and H. D. White (2016). “Clinical utility of testing for legionella pneumonia in central texas.” Ann Am Thorac Soc: 2016 Oct [Epub ahead of print].

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RATIONALE: Legionella pneumophila is an uncommon cause of community-acquired pneumonia in south central United States and regular testing may not be cost-effective in areas of low incidence. OBJECTIVES: To evaluate the incidence of Legionella in central Texas and determine the costeffectiveness of Legionella urinary antigen testing. METHODS: We performed a single-center retrospective cohort study of patients admitted with pneumonia between January 2001 and December 2013. Patients were identified by Binax Legionella urinary antigen and ICD-9 codes. Demographic characteristics and clinical history of the confirmed Legionella pneumonia cases were obtained by chart review. Descriptive statistics were used to describe patient characteristics. MEASUREMENTS AND MAIN RESULTS: Over 12 years 5,807 patients with 11,377 admissions for pneumonia were tested for Legionella urinary antigen. A positive Legionella urinary antigen was found in 17 patients. Cumulative incidence during the study period was 0.23%. Among the Legionella positive patients, intensive care unit admission and median length of stay were 58.8% and 8.5 days, respectively. Most patients met ATS criteria for severe pneumonia (64.7%). All patients empirically received either a macrolide or fluoroquinolone covering Legionella. There were 2 in-hospital and 3 total 90-day deaths in those with a positive urinary antigen. The estimated cost of screening this population with Legionella urinary antigen was $214,438 over 13 years. CONCLUSIONS: This study reveals the low incidence of Legionella pneumonia in central Texas. Use of guideline-concordant antibiotic treatment provides coverage for Legionella. We speculate that testing in a low-prevalence area would not influence outcomes or be cost-effective.

Morris, M. S., L. A. Graham, J. S. Richman, R. H. Hollis, C. E. Jones, T. Wahl, K. M. Itani, H. J. Mull, A. K. Rosen, L. Copeland, E. Burns, G. Telford, J. Whittle, M. Wilson, S. J. Knight and M. T. Hawn (2016). “Postoperative 30-day readmission: Time to focus on what happens outside the hospital.” Ann Surg 264(4): 621-631.

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OBJECTIVE: The aim of this study is to understand the relative contribution of preoperative patient factors, operative characteristics, and postoperative hospital course on 30-day postoperative readmissions. BACKGROUND: Determining the risk of readmission after surgery is difficult. Understanding the most important contributing factors is important to improving prediction of and reducing postoperative readmission risk. METHODS: National Veterans Affairs Surgical Quality Improvement Program data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital signs, prior healthcare utilization, and postoperative complications data. Variables were categorized as preoperative, operative, postoperative/predischarge, and postdischarge. Logistic models predicting 30-day readmission were compared using adjusted R and c-statistics with cross-validation to estimate predictive discrimination. RESULTS: Our study sample included 237,441 surgeries: 43% orthopedic, 39% general, and 18% vascular. Overall 30-day unplanned readmission rate was 11.1%, differing by surgical specialty (vascular 15.4%, general 12.9%, and orthopedic 7.6%, P < 0.001). Most common readmission reasons were wound complications (30.7%), gastrointestinal (16.1%), bleeding (4.9%), and fluid/electrolyte (7.5%) complications. Models using information available at the time of discharge explained 10.4% of the variability in readmissions. Of these, preoperative patient-level factors contributed the most to predictive models (R 7.0% [c-statistic 0.67]); prediction was improved by inclusion of intraoperative (R 9.0%, c-statistic 0.69) and postoperative variables (R 10.4%, c-statistic 0.71). Including postdischarge complications improved predictive ability, explaining 19.6% of the variation (R 19.6%, c-statistic 0.76). CONCLUSIONS: Postoperative readmissions are difficult to predict at the time of discharge, and of information available at that time, preoperative factors are the most important.

Scherrer, J. F., J. Salas, L. A. Copeland, E. M. Stock, F. D. Schneider, M. Sullivan, K. K. Bucholz, T. Burroughs and P. J. Lustman (2016). “Response to ruan et al. Letter to the editor: Increased risk of depression recurrence after initiation of prescription opioids in noncancer pain patients.” J Pain 17(8): 946-947.

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Whether opioids lead to depression and increase recurrence is best studied in a prospective cohort design. Our results suggest an association that now needs to be confirmed via primary data collection. Our stepwise approach to a novel research question is addressed in a cost-effective manner by starting with existing patient data to support the longer and more costly prospective study.

Copeland, L. A., E. P. Finley, M. J. Bollinger, M. E. Amuan and M. J. Pugh (2016). “Comorbidity correlates of death among new veterans of iraq and afghanistan deployment.” Med Care: 2016 June [Epub ahead of print].

Full text of this article.

BACKGROUND: Veterans of the wars in Iraq and Afghanistan who receive care in the Veterans Health Administration (VA) have high disease burden. Distinct comorbidity patterns have been shown to be differentially associated with adverse outcomes, including death. This study determined correlates of 5-year mortality. MATERIALS AND METHODS: VA demographic, military, homelessness, and clinical measures informed this retrospective analysis. Previously constructed comorbidity classifications over 3 years of care were entered into a Cox proportional hazards model of death. RESULTS: There were 164,933 veterans in the cohort, including African Americans (16%), Hispanics (11%), and whites (65%). Most were in their 20s at baseline (60%); 12% were women; 4% had attempted suicide; 4% had been homeless. Having clustered disorders of pain, posttraumatic stress disorder, and traumatic brain injury was associated with death [hazard ratio (HR)=2.0]. Mental disorders including substance abuse were similarly associated (HR=2.1). Prior suicide attempt (HR=2.2) or drug overdose (HR=3.0) considerably increased risk of death over 5 years. CONCLUSIONS: As congressional actions such as Veterans Choice Act offer more avenues to seek care outside of VA, coordination of care, and suicide prevention outreach for recent veterans may require innovative approaches to preserve life.