Evaluation of the causal pathways through which subjective norms influence mammography intention and stage of change in a national sample of women veterans

Few studies have investigated causal pathways linking psychosocial factors to each other and to screening mammography. Conflicting hypotheses exist in the theoretic literature regarding the role and importance of subjective norms, a person's perceived social pressure to perform the behavior and his/her motivation to comply. The Theory of Reasoned Action (TRA) hypothesizes that subjective norms directly affect intention; while the Transtheoretical Model (TTM) hypothesizes that attitudes mediate the influence of subjective norms on stage of change. No one has examined which hypothesis best predicts the effect of subjective norms on mammography intention and stage of change. Two statistical methods are available for testing mediation, sequential regression analysis (SRA) and latent variable structural equation modeling (LVSEM); however, software to apply LVSEM to dichotomous variables like intention has only recently become available. No one has compared the methods to determine whether or not they yield similar results for dichotomous variables. ^ Study objectives were to: (1) determine whether the effect of subjective norms on mammography intention and stage of change are mediated by pros and cons; and (2) compare mediation results from the SRA and LVSEM approaches when the outcome is dichotomous. We conducted a secondary analysis of data from a national sample of women veterans enrolled in Project H.O.M.E. (H&barbelow;ealthy O&barbelow;utlook on the M&barbelow;ammography E&barbelow;xperience), a behavioral intervention trial. ^ Results showed that the TTM model described the causal pathways better than the TRA one; however, we found support for only one of the TTM causal mechanisms. Cons was the sole mediator. The mediated effect of subjective norms on intention and stage of change by cons was very small. These findings suggest that interventionists focus their efforts on reducing negative attitudes toward mammography when resources are limited. ^ Both the SRA and LVSEM methods provided evidence for complete mediation, and the direction, magnitude, and standard errors of the parameter estimates were very similar. Because SRA parameter estimates were not biased toward the null, we can probably assume negligible measurement error in the independent and mediator variables. Simulation studies are needed to further our understanding of how these two methods perform under different data conditions. ^

Risk factors for Clostridium difficile nosocomial diarrhea in patients at the Michael E. Debakey Veterans Affairs Medical Center, Houston, Texas

Background. Clostridium difficile is the leading cause of hospital associated infectious diarrhea and colitis. About 3 million cases of Clostridium difficile diarrhea occur each year with an annual cost of $1 billion. ^ About 20% of patients acquire C. difficile during hospitalization. Infection with Clostridium difficile can result in serious complications, posing a threat to the patient's life. ^ Purpose. The aim of this research was to demonstrate the uniqueness in the characteristics of C. difficile positive nosocomial diarrhea cases compared with C. difficile negative nosocomial diarrhea controls admitted to a local hospital. ^ Methods. One hundred and ninety patients with a positive test and one hundred and ninety with a negative test for Clostridium difficile nosocomial diarrhea, selected from patients tested between January 1, 2002 and December 31, 2003, comprised the study population. Demographic and clinical data were collected from medical records. Logistic regression analyses were conducted to determine the associated odds between selected variables and the outcome of Clostridium difficile nosocomial diarrhea. ^ Results. For the antibiotic classes, cephalosporins (OR, 1.87; CI 95, 1.23 to 2.85), penicillins (OR, 1.57; CI 95, 1.04 to 2.37), fluoroquinolones (OR, 1.65; CI 95, 1.09 to 2.48) and antifungals (OR, 2.17; CI 95, 1.20 to 3.94), were significantly associated with Clostridium difficile nosocomial diarrhea Ceftazidime (OR, 1.95; CI 95, 1.25 to 3.03, p=0.003), gatifloxacin (OR, 1.97; CI 95, 1.31 to 2.97, p=0.001), clindamycin (OR, 3.13; CI 95, 1.99 to 4.93, p<0.001) and vancomycin (OR, 1.77; CI 95, 1.18 to 2.66, p=0.006, were also significantly associated with the disease. Vancomycin was not statistically significant when analyzed in a multivariable model. Other significantly associated drugs were, antacids, laxatives, narcotics and ranitidine. Prolong use of antibiotics and an increased number of comorbid conditions were also associated with C. difficile nosocomial diarrhea. ^ Conclusion. The etiology for C. difficile diarrhea is multifactorial. Exposure to antibiotics and other drugs, prolonged antibiotic usage, the presence and severity of comorbid conditions and prolonged hospital stay were shown to contribute to the development of the disease. It is imperative that any attempt to prevent the disease, or contain its spread, be done on several fronts. ^

Pancreatic cancer deaths in Texas veterans

Background/objective. Several studies have found an increased risk of pancreatic cancer in veterans deployed to Vietnam during the Vietnam War. Diabetes, a known risk factor for pancreatic cancer, has been designated as a service-connected illness in deployed Vietnam veterans. The majority of Vietnam veterans, now between the ages of 55 to 65, have not yet reached the ages of pancreatic cancer’s greatest prevalence, ages 65 to 79. This case-control study utilized 1998 electronic Texas death certificate data for white, black and Hispanic men to explore the question of whether military service was a risk factor for deaths due to pancreatic cancer among men who died in 1998.^ Methods. The primary study included men born between 1927 and 1953, and was a matched case-control study with two control groups; 431 pancreatic cancer cases were birth-year and race-matched one case to two non-neoplastic death controls and, for the second control group, were matched 1:1 with 431 accidental death controls. The exposure was military service, recorded as “yes”, “no” or “unknown” on the death certificate. Conditional logistic regression was used for the data analysis. Logistic regression was used in two additional unmatched analyses to examine the same exposure, military service, within different birth cohorts, again using pancreatic cancer cases with non-neoplastic and accidental death controls.^ Results. For pancreatic cancer cases matched to non-neoplastic controls, the association with military service showed an elevated odds ratio (OR) of 1.40 (95% confidence interval [CI] 1.10-1.79); matched to accidental death controls, a similar association with military service was detected [OR=1.40 (95% CI 1.04-1.89)]. The association was not seen in all time periods and was greatest for those within a birth cohort specific for Vietnam Era service. For men born between 1946 and 1950, OR=1.90 (95% CI 1.03-3.50) for comparison with non-neoplastic controls and OR=1.91 (95% CI 0.9995-3.64) for accidental death controls. ^ Conclusion. In Texas, for men aged 44-71, who died in 1998, military service was associated with an approximately 40% increased risk for pancreatic cancer. For men ages 48-52, military service was associated with an approximately 90% increased risk for pancreatic cancer.^

A comparison of techniques for forecasting utilization of Veterans Affairs hospitals

This study demonstrated that accurate, short-term forecasts of Veterans Affairs (VA) hospital utilization can be made using the Patient Treatment File (PTF), the inpatient discharge database of the VA. Accurate, short-term forecasts of two years or less can reduce required inventory levels, improve allocation of resources, and are essential for better financial management. These are all necessary achievements in an era of cost-containment.^ Six years of non-psychiatric discharge records were extracted from the PTF and used to calculate four indicators of VA hospital utilization: average length of stay, discharge rate, multi-stay rate (a measure of readmissions) and days of care provided. National and regional levels of these indicators were described and compared for fiscal year 1984 (FY84) to FY89 inclusive.^ Using the observed levels of utilization for the 48 months between FY84 and FY87, five techniques were used to forecast monthly levels of utilization for FY88 and FY89. Forecasts were compared to the observed levels of utilization for these years. Monthly forecasts were also produced for FY90 and FY91.^ Forecasts for days of care provided were not produced. Current inpatients with very long lengths of stay contribute a substantial amount of this indicator and it cannot be accurately calculated.^ During the six year period between FY84 and FY89, average length of stay declined substantially, nationally and regionally. The discharge rate was relatively stable, while the multi-stay rate increased slightly during this period. FY90 and FY91 forecasts show a continued decline in the average length of stay, while the discharge rate is forecast to decline slightly and the multi-stay rate is forecast to increase very slightly.^ Over a 24 month ahead period, all three indicators were forecast within a 10 percent average monthly error. The 12-month ahead forecast errors were slightly lower. Average length of stay was less easily forecast, while the multi-stay rate was the easiest indicator to forecast.^ No single technique performed significantly better as determined by the Mean Absolute Percent Error, a standard measure of error. However, Autoregressive Integrated Moving Average (ARIMA) models performed well overall and are recommended for short-term forecasting of VA hospital utilization. ^

THE RELATIONSHIP OF PRESCRIPTION RECEIPT AND EXPECTATION OF SICK-ROLE LEGITIMATION BY AMBULATORY VETERANS

This study explored the relationship of attitudes, needs, and health services utilization patterns of elderly veterans who were identified and categorized by their expectation for and receipt of sick-role legitimation. Three prescription types (new, change, renewal) were defined as the operational variables. A population of 676 ambulatory, chronically ill (average age 60 years) veterans were sent a questionnaire (74% response rate). In addition, retrospective medical and prescription record review was performed for a 45% sample of respondents. The results were analyzed using discriminant function and regression analysis. Fewer than 20% of the veterans responding expected to receive more prescriptions than were presently prescribed, whereas over 80% expected refill authorizations. Distinct attitudinal, need, and utilization patterns were identified. ^

Posttraumatic stress disorder among veterans of the Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) wars: Psychological comorbidities, postdeployment social support and unit support

Much attention has been given to treating Operation Iraqi Freedom/Operation Enduring (OIF/OEF) Veterans with posttraumatic stress disorder (PTSD). However, little attention is given to those Veterans who do not meet diagnostic criteria for PTSD but who may still benefit from intervention. Research is needed to investigate the impact of how different racial/ethnic backgrounds, different levels of social support and comorbid mental health disorders impact OIF/OEF Veterans with varying levels of PTSD. The purpose of this dissertation is to examine the association of comorbid Axis I disorders, race/ethnicity, different levels of postdeployment social support and unit support on OIF/OEF Veterans with varying levels of PTSD. Data for this dissertation were from postdeployment screenings of OIF/OEF Veterans from a large Veterans Affairs hospital in southeast Texas. To examine the study hypotheses, we conducted multinomial logistic regressions of the clinician reported data. ^ The first article examined the prevalence of subthreshold and full levels of PTSD and compared Axis I and alcohol use comorbidity rates among 1,362 OIF/OEF Veterans with varying levels of PTSD. Results suggest that OIF/OEF Veterans with subthreshold PTSD experience similar levels of psychological distress as those with full PTSD and highlight the need to provide timely and appropriate mental health services to individuals who may not meet the diagnostic criteria for full PTSD. ^ These results suggest that OIF/OEF Veterans of all race/ethnicities can benefit from strong social support systems. Postdeployment social support was found to be a protective factor against the development of PTSD among White, Black and Hispanic veterans while deployment unit support was a protective factor only among Black Veterans. The second article investigated the association between postdeployment social support and unit support with varying levels of PTSD by race/ethnicity among 1,115 OIF/OEF Veterans. ^ The results of this study can help to formulate treatment and interventions for OIF/OEF Veterans with varying levels of PTSD and social support systems.^

Prevalence and determinants of hepatitis B co-infection among a United States Veterans Administration cohort with hepatitis C

Background and aim. Hepatitis B virus (HBV) and hepatitis C virus (HCV) co-infection is associated with increased risk of cirrhosis, decompensation, hepatocellular carcinoma, and death. Yet, there is sparse epidemiologic data on co-infection in the United States. Therefore, the aim of this study was to determine the prevalence and determinants of HBV co-infection in a large United States population of HCV patients. ^ Methods. The National Veterans Affairs HCV Clinical Case Registry was used to identify patients tested for HCV during 1997–2005. HCV exposure was defined as two positive HCV tests (antibody, RNA or genotype) or one positive test combined with an ICD-9 code for HCV. HCV infection was defined as only a positive HCV RNA or genotype. HBV exposure was defined as a positive test for hepatitis B core antibodies, hepatitis B surface antigen, HBV DNA, hepatitis Be antigen, or hepatitis Be antibody. HBV infection was defined as only a positive test for hepatitis B surface antigen, HBV DNA, or hepatitis Be antigen within one year before or after the HCV index date. The prevalence of exposure to HBV in patients with HCV exposure and the prevalence of HBV infection in patients with HCV infection were determined. Multivariable logistic regression was used to identify demographic and clinical determinants of co-infection. ^ Results. Among 168,239 patients with HCV exposure, 58,415 patients had HBV exposure for a prevalence of 34.7% (95% CI 34.5–35.0). Among 102,971 patients with HCV infection, 1,431 patients had HBV co-infection for a prevalence of 1.4% (95% CI 1.3–1.5). The independent determinants for an increased risk of HBV co-infection were male sex, positive HIV status, a history of hemophilia, sickle cell anemia or thalassemia, history of blood transfusion, cocaine and other drug use. Age >50 years and Hispanic ethnicity were associated with a decreased risk of HBV co-infection. ^ Conclusions. This is the largest cohort study in the United States on the prevalence of HBV co-infection. Among veterans with HCV, exposure to HBV is common (∼35%), but HBV co-infection is relatively low (1.4%). There is an increased risk of co-infection with younger age, male sex, HIV, and drug use, with decreased risk in Hispanics.^

Treatment modalities of female Operation Iraqi Freedom/Operation Enduring Freedom Veterans with posttraumatic stress disorder: A systematic review of the literature

Objective. To review professional literature regarding treatment modalities of post-traumatic stress disorder (PTSD) amongst female Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans, to assess the efficacy of these treatment options, and to summarize implications of the findings from this literature. Design. Systematic review of published literature. Data sources. Medline, Pubmed, Psycinfo. Review Methods. Articles selected for the literature review pertain to the treatment options of female OIF or OEF veterans who have a diagnosis of PTSD. In addition, other relevant articles, such as articles that discuss the prevalence of the problem, access to care, and similar treatment modalities for PTSD in other war settings, were selected for background information for the review. Results. The search strategy identified 1,305 potential journal articles, taken from thorough searches in Medline, Pubmed, and Psycinfo. These articles were then imported into Refworks. Following final screening, there were 18 articles included in the systematic review and 28 articles used as background information. The remaining articles were excluded following screening of abstract and/or full text of articles. Treatment modalities presented in these trials include: Exposure Therapy (average of 68% reduction in PTSD symptoms), Imagery Rehearsal Therapy (23% reduction), Body-Oriented Therapy (57% reduction), Electroconvulsive Therapy (35% reduction), Holographic Reprocessing (47% reduction), a self-defense training program (13% reduction), Cognitive Behavioral Therapy (65% reduction) and a variety of pharmacotherapies (antipsychotics at 81% reduction, sympatholytic drug at 100% reduction). Outcomes of the studies included in this systematic review were measured by using personal assessment of whether there was a reduction in symptoms of PTSD, based on the results in each study. Conclusion. Overall, all of the treatment modalities investigated in the systematic review proved to be somewhat effective in relieving the burden of symptoms of PTSD amongst female veterans of OIF/OEF. In addition to pharmacotherapy, which had the highest reduction in PTSD symptoms, both the Exposure Therapy and the Cognitive Behavioral Therapy techniques proved to have the most positive results. As all of the therapies had a positive effect on this population, to some degree, a study needs to be done in the future to compare and contrast the efficacy of each therapy intervention when applied to a standardized population.^

Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication.

BACKGROUND: Early detection of colorectal cancer through timely follow-up of positive Fecal Occult Blood Tests (FOBTs) remains a challenge. In our previous work, we found 40% of positive FOBT results eligible for colonoscopy had no documented response by a treating clinician at two weeks despite procedures for electronic result notification. We determined if technical and/or workflow-related aspects of automated communication in the electronic health record could lead to the lack of response. METHODS: Using both qualitative and quantitative methods, we evaluated positive FOBT communication in the electronic health record of a large, urban facility between May 2008 and March 2009. We identified the source of test result communication breakdown, and developed an intervention to fix the problem. Explicit medical record reviews measured timely follow-up (defined as response within 30 days of positive FOBT) pre- and post-intervention. RESULTS: Data from 11 interviews and tracking information from 490 FOBT alerts revealed that the software intended to alert primary care practitioners (PCPs) of positive FOBT results was not configured correctly and over a third of positive FOBTs were not transmitted to PCPs. Upon correction of the technical problem, lack of timely follow-up decreased immediately from 29.9% to 5.4% (p<0.01) and was sustained at month 4 following the intervention. CONCLUSION: Electronic communication of positive FOBT results should be monitored to avoid limiting colorectal cancer screening benefits. Robust quality assurance and oversight systems are needed to achieve this. Our methods may be useful for others seeking to improve follow-up of FOBTs in their systems.

Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?

BACKGROUND: Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic imaging results remains a challenge. We hypothesized that an electronic medical record (EMR) that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem. METHODS: We studied critical imaging alert notifications in the outpatient setting of a tertiary care Department of Veterans Affairs facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (ie, health care practitioner/provider [HCP] opened the message for viewing) within 2 weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted HCPs to determine timely follow-up actions (eg, ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by HCPs analyzed predictors for 2 outcomes: lack of acknowledgment and lack of timely follow-up. RESULTS: Of 123 638 studies (including radiographs, computed tomographic scans, ultrasonograms, magnetic resonance images, and mammograms), 1196 images (0.97%) generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when the ordering HCPs were trainees (odds ratio [OR], 5.58; 95% confidence interval [CI], 2.86-10.89) and when dual-alert (>1 HCP alerted) as opposed to single-alert communication was used (OR, 2.02; 95% CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs 9.7%; P = .22). Risk for lack of timely follow-up was higher with dual-alert communication (OR, 1.99; 95% CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12; 95% CI, 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment. CONCLUSIONS: Critical imaging results may not receive timely follow-up actions even when HCPs receive and read results in an advanced, integrated electronic medical record system. A multidisciplinary approach is needed to improve patient safety in this area.

A comparison of Markov and generalized linear models of hospital mortality

This paper reports a comparison of three modeling strategies for the analysis of hospital mortality in a sample of general medicine inpatients in a Department of Veterans Affairs medical center. Logistic regression, a Markov chain model, and longitudinal logistic regression were evaluated on predictive performance as measured by the c-index and on accuracy of expected numbers of deaths compared to observed. The logistic regression used patient information collected at admission; the Markov model was comprised of two absorbing states for discharge and death and three transient states reflecting increasing severity of illness as measured by laboratory data collected during the hospital stay; longitudinal regression employed Generalized Estimating Equations (GEE) to model covariance structure for the repeated binary outcome. Results showed that the logistic regression predicted hospital mortality as well as the alternative methods but was limited in scope of application. The Markov chain provides insights into how day to day changes of illness severity lead to discharge or death. The longitudinal logistic regression showed that increasing illness trajectory is associated with hospital mortality. The conclusion is reached that for standard applications in modeling hospital mortality, logistic regression is adequate, but for new challenges facing health services research today, alternative methods are equally predictive, practical, and can provide new insights. ^

Comparison of a traditional and a multilevel Cox Proportional Hazards model

Hierarchically clustered populations are often encountered in public health research, but the traditional methods used in analyzing this type of data are not always adequate. In the case of survival time data, more appropriate methods have only begun to surface in the last couple of decades. Such methods include multilevel statistical techniques which, although more complicated to implement than traditional methods, are more appropriate. ^ One population that is known to exhibit a hierarchical structure is that of patients who utilize the health care system of the Department of Veterans Affairs where patients are grouped not only by hospital, but also by geographic network (VISN). This project analyzes survival time data sets housed at the Houston Veterans Affairs Medical Center Research Department using two different Cox Proportional Hazards regression models, a traditional model and a multilevel model. VISNs that exhibit significantly higher or lower survival rates than the rest are identified separately for each model. ^ In this particular case, although there are differences in the results of the two models, it is not enough to warrant using the more complex multilevel technique. This is shown by the small estimates of variance associated with levels two and three in the multilevel Cox analysis. Much of the differences that are exhibited in identification of VISNs with high or low survival rates is attributable to computer hardware difficulties rather than to any significant improvements in the model. ^

Hypogonadism in male cancer patients: A cross-sectional study

Introduction. Cancer is the second most common cause of death in the USA (2). Studies have shown a coexistence of cancer and hypogonadism (9,31,13). The majority of patients with cancer develop cachexia, which cannot be solely explained by anorexia seen in these patients. Testosterone is a male sex hormone which is known to increase muscle mass and strength, maintain cancellous bone mass, and increase cortical bone mass, in addition to improving libido, sexual desire, and fantasy (14). If a high prevalence of hypogonadism is detected in male cancer patients, and a significant difference exists in testosterone levels in cancer patients with cachexia versus those without cachexia, testosterone may be administered in future randomized trials to help alleviate cachexia. Study group and design The study group consisted of male cancer patients and non-cancer controls aged between 40 and 70 years. The primary study design was cross-sectional with a sample size of 135. The present data analysis is done on a subset convenience sample of 72 patients recruited between November 2006 and January 2010. ^ Methods. Patients aged 40-70 years with or without a diagnosis of cancer were recruited into the study. All patients with a BMI over 35, significant edema, non-melanomatous skin cancer, current alcohol or illicit drug abuse, concomitant usage of medications interfering with gonadal axis, and anabolic agents, patients on tube feeds or parenteral nutrition within 3 months prior to enrollment were excluded from the study. The study was approved by the Institutional Review Board of Baylor College of Medicine and is being conducted at the Michael E. DeBakey Veterans Affairs Medical Center at Houston. My thesis is a pilot data analysis that employs a smaller subset convenience sample of 72 patients determined by using the data available for the 72 patients (of the intended sample of 135 patients) recruited between November 2006 and January 2010. The primary aim of this analysis is to compare the proportion of patients with hypogonadism in the male cancer and non-cancer control groups, and to evaluate if a significant difference exists with respect to testosterone levels in male cancer patients with cachexia versus those without cachexia. The procedures of the study relevant to the current data analysis included blood collection to measure levels of testosterone and measurement of body weight to categorize cancer patients into cancer cachexia and cancer non-cachexia sub-groups. ^ Results. After logarithmic transformation of data of cancer and control groups, the unpaired t test with unequal variances was done. The proportion of patients with hypogonadism in the male cancer and non-cancer control groups was 47.5% and 22.7% with a Pearson chi2 statistic of 1.6036 and a p value of 0.205. Comparing the mean calculated Bioavailable testosterone in male cancer patients and non-cancer controls resulted in a t statistic of 21.83 and a p value less than 0.001. When the cancer group alone was taken, the mean free testosterone, calculated bioavailable testosterone and total testosterone levels in the cancer non-cachexia sub-group were 3.93, 5.09, 103.51 respectively and in the cancer cachexia sub-group were 3.58, 4.17, 84.08 respectively. The unpaired t test with equal variances showed that the two sub-groups had p values of 0.2015, 0.1842, and 0.4894 with respect to calculated bioavailable testosterone, free testosterone, and total testosterone respectively. ^ Conclusions. The small sample size of this exploratory study, resulting in a small power, does not allow us to draw definitive conclusions. For the given sub-sample, the proportion of patients with hypogonadism in the cancer group was not significantly different from that of patients with hypogonadism in the control group. Inferences on prevalence of hypogonadism in male cancer patients could not be made in this paper as the sub-sample is small and therefore not representative of the general population. However, there was a statistically significant difference in calculated Bioavailable testosterone levels in male cancer patients versus non-cancer controls. Analysis of cachectic and non-cachectic patients within the male cancer group showed no significant difference in testosterone levels (total, free, and calculated bioavailable testosterone) between both sub-groups. However, to re-iterate, this study is exploratory and the results may change once the complete dataset is obtained and analyzed. It however serves as a good template to guide further research and analysis.^

Family health history discussion in patient-provider encounters

Ascertaining the family health history (FHH) may provide insight into genetic and environmental susceptibilities specific to a variety of chronic diseases, including type II diabetes mellitus. However, discussion of FHH during patient-provider encounters has been limited and uncharacterized. A longitudinal, observational study was conducted in order to compare the content of FHH topics in a convenience sample of 37 patients, 13 new and 24 established. Each patient had an average of three follow-up encounters involving 6 staff physicians at the Audie L. Murphy Memorial Veterans Hospital (VHA) in San Antonio, TX from 2003 to 2005. A total of 131 encounters were analyzed in this study. The average age of the selected population was 68 years and included 35 males and two females. Transcriptions of encounters were obtained, coded and analyzed, in NVIVO 8. Of the 131 total encounters transcribed among the 37 patients, only 24 encounters (18.3%) included discussion of FHH. Additionally, the relationship between FHH discussion and discussion of self-care management (SCM) topics were assessed. In this study, providers were more likely to initiate discussion on family health history among new patients in the first encounter (ORnew = 8.55, 95% CI: 1.49–52.90). The discussion of FHH occurred sporadically in established patients throughout the longitudinal study with no apparent pattern. Provider-initiated FHH discussion most frequently had satisfactory level(s) of discussion while patient-initiated FHH discussion most frequently had minimal level(s) of discussion. FHH discussion most oftentimes involved topics of cancer and cardiovascular disease among primary-degree familial relationships. Overall, family health histories are largely, an underutilized tool in personalized preventive care.^