Colonoscopy and Colorectal Cancer Mortality in the Veterans Affairs Health Care System: A Case-Control Study

BACKGROUND

Colonoscopy is widely used in the Veterans Affairs (VA) health care system for colorectal cancer (CRC) prevention, but its effect on CRC mortality is unknown.

OBJECTIVE

To determine whether colonoscopy is associated with decreased CRC mortality in veterans and whether its effect differs by anatomical location of CRC.

DESIGN

Case-control study.

SETTING

VA-Medicare administrative data.

PARTICIPANTS

Case patients were veterans aged 52 years or older who were diagnosed with CRC between 2002 and 2008 and died of the disease by the end of 2010. Case patients were matched to 4 control patients without prior CRC on the basis of age, sex, and facility. Conditional logistic regression was performed to calculate odds ratios (ORs) for exposure to colonoscopy, with adjustment for race, Charlson Comorbidity Index score, selected chronic conditions, nonsteroidal anti-inflammatory drug use, and family history of CRC.

MEASUREMENTS

Exposure to colonoscopy was determined from 1997 to 6 months before CRC diagnosis in case patients and to a corresponding date in control patients. Subgroup analysis was performed for patients who had undergone screening colonoscopy.

RESULTS

A total of 4964 case patients and 19 856 control patients were identified. Case patients were significantly less likely to have undergone any colonoscopy (OR, 0.39 [95% CI, 0.35 to 0.43]). Colonoscopy was associated with reduced mortality for left-sided cancer (OR, 0.28 [CI, 0.24 to 0.32]) and right-sided cancer (OR, 0.54 [CI, 0.47 to 0.63]). The results were similar for patients who had undergone screening colonoscopy (overall OR, 0.30 [CI, 0.24 to 0.38]). Sensitivity analyses that varied the interval between CRC diagnosis and colonoscopy exposure did not affect the primary findings.

LIMITATION

Unmeasured confounding.

CONCLUSION

In this study using national VA-Medicare data, colonoscopy was associated with significant reductions in CRC mortality among veterans and was associated with greater benefit for left-sided cancer than right-sided cancer.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs.

Comparison of Risk Factor Control in the Year After Discharge for Ischemic Stroke Versus Acute Myocardial Infarction

Background and Purpose—

The Veterans Health Administration has engaged in quality improvement to improve vascular risk factor control. We sought to examine blood pressure (<140/90 mm Hg), lipid (LDL [low-density lipoprotein] cholesterol <100 mg/dL), and glycemic control (hemoglobin A1c <9%), in the year post-hospitalization for acute ischemic stroke or acute myocardial infarction (AMI).

Methods—

We identified patients who were hospitalized (fiscal year 2011) with ischemic stroke, AMI, congestive heart failure, transient ischemic attack, or pneumonia/chronic obstructive pulmonary disease. The primary analysis compared risk factor control after incident ischemic stroke versus AMI. Facilities were included if they cared for ≥25 ischemic stroke and ≥25 AMI patients. A generalized linear mixed model including patient- and facility-level covariates compared risk factor control across diagnoses.

Results—

Forty thousand two hundred thirty patients were hospitalized (n=75 facilities): 2127 with incident ischemic stroke and 4169 with incident AMI. Fewer stroke patients achieved blood pressure control than AMI patients (64%; 95% confidence interval, 0.62–0.67 versus 77%; 95% confidence interval, 0.75–0.78; P <0.0001). After adjusting for patient and facility covariates, the odds of blood pressure control were still higher for AMI than ischemic stroke patients (odds ratio, 1.39; 95% confidence interval, 1.21–1.51). There were no statistical differences for AMI versus stroke patients in hyperlipidemia ( P =0.534). Among patients with diabetes mellitus, the odds of glycemic control were lower for AMI than ischemic stroke patients (odds ratio, 0.72; 95% confidence interval, 0.54–0.96).

Conclusions—

Given that hypertension control is a cornerstone of stroke prevention, interventions to improve poststroke hypertension management are needed.

Impact of Hospital Admission for Patients with Transient Ischemic Attack

OBJECTIVES

To determine the impact of admission among transient ischemic attack (TIA) patients in the emergency department (ED).

STUDY DESIGN

Retrospective cohort study using national Veterans Health Administration data (2008).

METHODS

We first analyzed whether admitted patients were discharged from the hospital with a diagnosis of TIA. We then analyzed whether admission was associated with a composite outcome (new stroke, new myocardial infarction, or death in the year after TIA) using multivariate logistic regression modeling with propensity score matching.

RESULTS

Among 3623 patients assigned a diagnosis of TIA in the ED, 2118 (58%) were admitted to the hospital or placed in observation compared with 1505 (42%) who were discharged from the ED. Among the 2118 patients who were admitted, 903 (43% of admitted group) were discharged from the hospital with a diagnosis of TIA, and 548 (26% of admitted group) were discharged with a diagnosis of stroke. Admitted patients were more likely than nonadmitted patients to receive processes of care (i.e., brain imaging, carotid imaging, echocardiography). In matched analyses using propensity scores, the 1-year composite outcome in the admitted group (15.3%) was not lower than the discharged group (13.3%, OR 1.17 [.94-1.46], P = .17).

CONCLUSIONS

Less than half of patients admitted with a diagnosis of TIA retained that diagnosis at hospital discharge. Although admitted patients were more likely to receive diagnostic procedures, we did not identify improvements in outcomes among admitted patients; however, evaluating care for patients with TIA is limited by the reliability of secondary data analysis.

Medication Use among Veterans across Health Care Systems

INTRODUCTION

Dual healthcare system use can create gaps and fragments of information for patient care. The Department of Veteran Affairs is implementing a health information exchange (HIE) program called the Virtual Lifetime Electronic Record (VLER), which allows providers to access and share information across healthcare systems. HIE has the potential to improve the safety of medication use. However, data regarding the pattern of outpatient medication use across systems of care is largely unknown. Therefore, the objective of this study is to describe the prevalence of medication dispensing across VA and non-VA health care systems among a cohort Veteran population.

METHODS

This study included all Veterans who had two outpatient visits or one inpatient visit at the Indianapolis VA during a 1-year period prior to VLER enrollment. Source of medication data was assessed at the subject level, and categorized as VA, INPC (non-VA), or both. The primary target was identification of sources for medication data. Then, we compared the mean number of prescriptions, as well as overall and pairwise differences in medication dispensing.

RESULTS

Out of 52,444 Veterans, 17.4% of subjects had medication data available in a regional HIE. On average, 40 prescriptions per year were prescribed for Veterans who used both sources compared to 29 prescriptions per year from VA only and 25 prescriptions per year from INPC only sources. The annualized prescription rate of Veterans in the dual use group was 36% higher than those who had only VA data available and 61% higher than those who had only INPC data available.

CONCLUSIONS

Our data demonstrated that 17.4% of subjects had medication use identified from non-VA sources, including prescriptions for antibiotics, antineoplastics, and anticoagulants. These data support the need for HIE programs to improve coordination of information, with the potential to reduce adverse medication interactions and improve medication safety.

Have clinicians adopted the use of brain MRI for patients with TIA and minor stroke?

BACKGROUND

Use of MRI with diffusion-weighted imaging (DWI) can identify infarcts in 30%-50% of patients with TIA. Previous guidelines have indicated that MRI-DWI is the preferred imaging modality for patients with TIA. We assessed the frequency of MRI utilization and predictors of MRI performance.

METHODS

A review of TIA and minor stroke patients evaluated at Veterans Affairs hospitals was conducted with regard to medical history, use of diagnostic imaging within 2 days of presentation, and in-hospital care variables. Chart abstraction was performed in a subset of hospitals to assess clinical variables not available in the administrative data.

RESULTS

A total of 7,889 patients with TIA/minor stroke were included. Overall, 6,694 patients (84.9%) had CT or MRI, with 3,396/6,694 (50.7%) having MRI. Variables that were associated with increased odds of CT performance were age >80 years, prior stroke, history of atrial fibrillation, heart failure, coronary artery disease, anxiety, and low hospital complexity, while blood pressure >140/90 mm Hg and high hospital complexity were associated with increased likelihood of MRI. Diplopia (87% had MRI, p = 0.03), neurologic consultation on the day of presentation (73% had MRI, p < 0.0001), and symptom duration of >6 hours (74% had MRI, p = 0.0009) were associated with MRI performance.

CONCLUSIONS

Within a national health system, about 40% of patients with TIA/minor stroke had MRI performed within 2 days. Performance of MRI appeared to be influenced by several patient and facility-level variables, suggesting that there has been partial acceptance of the previous guideline that endorsed MRI for patients with TIA.

Which veterans enroll in a VA health information exchange program?

OBJECTIVE

To characterize patients who voluntarily enrolled in an electronic health information exchange (HIE) program designed to share data between Veterans Health Administration (VHA) and non-VHA institutions.

MATERIALS AND METHODS

Patients who agreed to participate in the HIE program were compared to those who did not. Patient characteristics associated with HIE enrollment were examined using a multivariable logistic regression model. Variables selected for inclusion were guided by a health care utilization model adapted to explain HIE enrollment. Data about patients' sociodemographics (age, gender), comorbidity (Charlson index score), utilization (primary and specialty care visits), and access (distance to VHA medical center, insurance, VHA benefits) were obtained from VHA and HIE electronic health records.

RESULTS

Among 57 072 patients, 6627 (12%) enrolled in the HIE program during its first year. The likelihood of HIE enrollment increased among patients ages 50-64, of female gender, with higher comorbidity, and with increasing utilization. Living in a rural area and being unmarried were associated with decreased likelihood of enrollment.

DISCUSSION AND CONCLUSION

Enrollment in HIE is complex, with several factors involved in a patient's decision to enroll. To broaden HIE participation, populations less likely to enroll should be targeted with tailored recruitment and educational strategies. Moreover, inclusion of special populations, such as patients with higher comorbidity or high utilizers, may help refine the definition of success with respect to HIE implementation.

Abstract TP165: Cardiac Screening Does not Improve One-year Mortality Among Patients With Cerebrovascular Disease

Introduction: Guidelines recommend the use of cardiac stress testing to screen for occult coronary heart disease (CHD) among patients with ischemic stroke/TIA who have a ‘high risk’ Framingham Cardiac Risk score (FCRS). It is unclear whether implementation of this guideline confers a mortality benefit among patients with cerebrovascular disease.

Hypothesis: We assessed the hypothesis that cardiac stress testing would be associated with lower odds of one-year all-cause mortality.

Methods: Administrative data from a sample of 11,306 Veterans admitted to 134 Veterans Health Administration (VHA) facilities with a stroke or TIA in fiscal year 2011 were analyzed. Patients were excluded (n=6915) on the basis of: prior CHD history, receipt of cardiac stress testing within 18-months prior to cerebrovascular event, death within 90 days of discharge, being discharged to hospice, transferred to a non-VHA acute care facility, or missing/unknown race. A FCRS was calculated for each patient; a score of ≥ 20% was classified as ‘high risk’ of having CHD. Administrative data were used to identify whether cardiac stress testing was performed within 90-days after the cerebrovascular event. Logistic regression was used to assess whether cardiac stress testing was associated with one-year all-cause mortality.

Results: Of the 4391 eligible patients, 62.8% (2759) had FCRS ≥ 20%, with 4.5% (n=123) of these patients receiving cardiac stress testing within 90 days of discharge. After adjusting for sociodemographic characteristics and medical comorbidities, FCRS ≥ 20% was associated with one-year mortality (aOR=2.18; CI 95 :1.59, 3.00), however, receipt of stress testing was not (aOR=0.59; CI 95 :0.26, 1.30).

Conclusion: Cardiac screening did not confer a one-year all-cause mortality benefit among patients with cerebrovascular disease. Additional work is needed to assess outcomes among patients with cerebrovascular disease who are at ‘high risk’ for CHD.

Short-Term Medical Costs of a VHA Health Information Exchange: A CHEERS-Compliant Article

The Virtual Lifetime Electronic Record (VLER) Health program provides the Veterans Health Administration (VHA) a framework whereby VHA providers can access the veterans' electronic health record information to coordinate healthcare across multiple sites of care. As an early adopter of VLER, the Indianapolis VHA and Regenstrief Institute implemented a regional demonstration program involving bi-directional health information exchange (HIE) between VHA and non-VHA providers.The aim of the study is to determine whether implementation of VLER HIE reduces 1 year VHA medical costs.A cohort evaluation with a concurrent control group compared VHA healthcare costs using propensity score adjustment. A CHEERs compliant checklist was used to conduct the cost evaluation.Patients were enrolled in the VLER program onsite at the Indianapolis VHA in outpatient clinics or through the release-of-information office.VHA cost data (in 2014 dollars) were obtained for both enrolled and nonenrolled (control) patients for 1 year prior to, and 1 year after, the index date of patient enrollment.There were 6104 patients enrolled in VLER and 45,700 patients in the control group. The annual adjusted total cost difference per patient was associated with a higher cost for VLER enrollees $1152 (95% CI: $807-1433) (P < 0.01) (in 2014 dollars) than VLER nonenrollees.Short-term evaluation of this demonstration project did not show immediate reductions in healthcare cost as might be expected if HIE decreased redundant medical tests and treatments. Cost reductions from shared health information may be realized with longer time horizons.

A qualitative study of chronic pain in Operation Enduring Freedom/Operation Iraqi Freedom veterans: "A burden on my soul"

OBJECTIVES

Over half of the veterans returning from the conflicts in Iraq and Afghanistan are burdened with chronic pain. Although these young veterans may have to live with pain for the rest of their lives, little is known about the struggles this new group of veterans faces, or their perceptions of support from family, friends, and others. The purpose of this study is to understand Operation Enduring Freedom/Operation Iraqi Freedom veterans' experiences with chronic pain and social support.

METHODS

In-depth qualitative interviews were conducted with veterans who participated in an intervention for chronic pain. Grounded theory guided data analysis.

RESULTS

Veterans described a range of emotions associated with chronic pain, including hopelessness, anger, and fear that their pain would worsen. For some, talking about their pain was helpful, but others avoided talking about their pain, often because people did not understand or overreacted.

CONCLUSION

Although support from friends and family is often effective, veterans and others with chronic pain are uniquely positioned to offer support to others with pain. Clinically, an approach to pain management in which veteran peers are integrated into chronic pain treatment approaches, similar to the Veterans Affairs' mental health model of care, might offer additional benefits for veterans with chronic pain.

Abstract T P140: Predictors of Optimal Post-Stroke Hypertension Control

Introduction: Significant patient- and facility-level predictors of optimal post-stroke hypertension (HTN) control have not been identified; their identification may inform future intervention studies.

Methods: This was a secondary analysis of a retrospective cohort study that included 3965 Veterans who were admitted with ischemic stroke at 131 Veterans Health Administration (VHA) facilities (fiscal year 2007). Blood pressure (BP) values at 6-month post-stroke were used to define optimal (<140/90 mmHg) and suboptimal (≥140/90 mmHg) control among patients with a history of HTN. Among facilities that admitted at least 25 stroke patients annually, we used multivariate logistic regression with backward elimination to identify patient- (e.g., stroke severity) and facility-level (e.g., hospital level complexity) characteristics that independently predicted optimal BP control 6-months post-stroke while adjusting for age, race, marital status, and post-stroke follow-up care.

Results: A total of 2541 (64.1%) patients had a history of HTN, with 33.4% of patients achieving goal BP at 6-months. A past medical history of congestive heart failure (CHF; adjusted OR [aOR]: 2.5, 95% CI: 1.02 to 6.26; p=0.046) and being discharged on a lipid lowering agent (aOR: 2.5, 95% CI: 1.26 to 5.03) were associated with optimal BP control 6-months post-stroke. Admission stroke severity (aOR: 0.998, 95% CI: 0.996-1.110), Charlson comorbidity score (aOR: 0.875, 95% CI: 0.59-1.30), past history of ischemic stroke (aOR: 1.41, 95% CI: 0.74-2.67), and medical record documentation of a post-discharge plan for HTN management (aOR: 1.00, 95% CI: 0.99-1.02; p=0.47) were not predictive of optimal BP control. Facility-level characteristics, including hospital level complexity (aOR: 0.998, 95% CI: 0.992-1.005; p=0.16) and the number of stroke patients seen annually at a facility (aOR 0.997, 95% CI: 0.993-1.001; p=0.17) were also not associated with optimal post-stroke BP control.

Conclusions: Future work should seek to understand why current approaches to improving post-stroke BP control are inadequate for a majority of patients and whether lessons might be learned from the care of patients with stroke and CHF that could be applied to the general post-stroke population.

A brief peer support intervention for veterans with chronic musculoskeletal pain: a pilot study of feasibility and effectiveness

OBJECTIVE

The aim of this study was to pilot test a peer support intervention, involving peer delivery of pain self-management strategies, for veterans with chronic musculoskeletal pain.

DESIGN

Pretest/posttest with 4-month intervention period.

METHODS

Ten peer coaches were each assigned 2 patients (N = 20 patients). All had chronic musculoskeletal pain. Guided by a study manual, peer coach-patient pairs were instructed to talk biweekly for 4 months. Pain was the primary outcome and was assessed with the PEG, a three-item version of the Brief Pain Inventory, and the PROMIS Pain Interference Questionnaire. Several secondary outcomes were also assessed. To assess change in outcomes, a linear mixed model with a random effect for peer coaches was applied.

RESULTS

Nine peer coaches and 17 patients completed the study. All were male veterans. Patients' pain improved at 4 months compared with baseline but did not reach statistical significance (PEG: P = 0.33, ICC [intra-class correlation] = 0.28, Cohen's d = -0.25; PROMIS: P = 0.17, d = -0.35). Of secondary outcomes, self-efficacy (P = 0.16, ICC = 0.56, d = 0.60) and pain centrality (P = 0.06, ICC = 0.32, d = -0.62) showed greatest improvement, with moderate effect sizes.

CONCLUSIONS

This study suggests that peers can effectively deliver pain self-management strategies to other veterans with pain. Although this was a pilot study with a relatively short intervention period, patients improved on several outcomes.

Hypertension treatment intensification among stroke survivors with uncontrolled blood pressure

BACKGROUND AND PURPOSE

We examined blood pressure 1 year after stroke discharge and its association with treatment intensification.

METHODS

We examined the systolic blood pressure (SBP) stratified by discharge SBP (≤140, 141-160, or >160 mm Hg) among a national cohort of Veterans discharged after acute ischemic stroke. Hypertension treatment opportunities were defined as outpatient SBP >160 mm Hg or repeated SBPs >140 mm Hg. Treatment intensification was defined as the proportion of treatment opportunities with antihypertensive changes (range, 0%-100%, where 100% indicates that each elevated SBP always resulted in medication change).

RESULTS

Among 3153 patients with ischemic stroke, 38% had ≥1 elevated outpatient SBP eligible for treatment intensification in the 1 year after stroke. Thirty percent of patients had a discharge SBP ≤140 mm Hg, and an average 1.93 treatment opportunities and treatment intensification occurred in 58% of eligible visits. Forty-seven percent of patients discharged with SBP 141 to160 mm Hg had an average of 2.1 opportunities for intensification and treatment intensification occurred in 60% of visits. Sixty-three percent of the patients discharged with an SBP >160 mm Hg had an average of 2.4 intensification opportunities, and treatment intensification occurred in 65% of visits.

CONCLUSIONS

Patients with discharge SBP >160 mm Hg had numerous opportunities to improve hypertension control. Secondary stroke prevention efforts should focus on initiation and review of antihypertensives before acute stroke discharge; management of antihypertensives and titration; and patient medication adherence counseling.

Effect of clinical and social risk factors on hospital profiling for stroke readmission: a cohort study

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) and Veterans Health Administration (VA) will report 30-day stroke readmission rates as a measure of hospital quality. A national debate on whether social risk factors should be included in models developed for hospital profiling is ongoing.

OBJECTIVE

To compare a CMS-based model of 30-day readmission with a more comprehensive model that includes measures of social risk (such as homelessness) or clinical factors (such as stroke severity and functional status).

DESIGN

Data from a retrospective cohort study were used to develop a CMS-based 30-day readmission model that included age and comorbid conditions based on codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (model 1). This model was then compared with one that included administrative social risk factors (model 2). Finally, the CMS model (model 1) was compared with a model that included social risk and clinical factors from chart review (model 3). These 3 models were used to rank hospitals by 30-day risk-standardized readmission rates and examine facility rankings among the models.

SETTING

Hospitals in the VA.

PARTICIPANTS

Patients hospitalized with stroke in 2007.

MEASUREMENTS

30-day readmission rates.

RESULTS

The 30-day readmission rate was 12.8%. The c-statistics for the 3 models were 0.636, 0.646, and 0.661, respectively. All hospitals were classified as performing "as expected" using all 3 models (that is, performance did not differ from the VA national average); therefore, the addition of detailed clinical information or social risk factors did not alter assessment of facility performance.

LIMITATION

A predominantly male veteran cohort limits the generalizability of these findings.

CONCLUSION

In the VA, more comprehensive models that included social risk and clinical factors did not affect hospital comparisons based on 30-day readmission rates.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs.

Lower endoscopy reduces colorectal cancer incidence in older individuals

BACKGROUND & AIMS

In older individuals, there are unclear effects of lower endoscopy on incidence of colorectal cancer (CRC) and of colonoscopy on site of CRC. We investigated whether sigmoidoscopy or colonoscopy is associated with a decreased incidence of CRC in older individuals, and whether the effect of colonoscopy differs by anatomic location.

METHODS

We performed a case-control study using linked US Veterans Affairs and Medicare data. Cases were veterans aged 75 years or older diagnosed with CRC in fiscal year 2007. Cases were matched for age and sex to 3 individuals without a CRC diagnosis (controls). We determined the number of cases and controls who received colonoscopies or sigmoidoscopies from fiscal year 1997 to a date 6 months before the diagnosis of CRC (for cases) or to a corresponding index date (for controls). The probability of exposure was modeled using generalized linear mixed equations, adjusted for potential confounders. For the analysis of CRC risk in different anatomic locations, the proximal colon was defined as proximal to the splenic flexure.

RESULTS

We identified 623 cases and 1869 controls (mean age, 81 y; 98.7% male, 86.2% Caucasian). Among cases, 243 (39.0%) underwent any lower endoscopy (177 colonoscopies). Among controls, 978 (52.3%) underwent any lower endoscopy (758 colonoscopies). Cases were significantly less likely than controls to have undergone lower endoscopy within the preceding 10 years (adjusted odds ratio [aOR], 0.58; 95% confidence interval [CI], 0.48-0.69). This effect was significant for colonoscopy (aOR, 0.57; 95% CI, 0.47-0.70), but not sigmoidoscopy. Similar results were observed when a 5-year exposure window was applied. Colonoscopy was associated with a reduced risk of distal CRC (aOR, 0.45; 95% CI, 0.32-0.62) and proximal CRC (aOR, 0.65; 95% CI, 0.46-0.92).

CONCLUSIONS

In a study of the US Veterans Affairs and Medicare databases, lower endoscopy in the preceding 10 years was associated with a significant reduction in CRC incidence among older veterans. Colonoscopy was associated with significant reductions in distal and proximal CRC.

Abstract W P303: Clinical Inertia in the Management of Blood Pressure after a Stroke

Background: Control of blood pressure (BP) is required in the year after a stroke because that is when the risk of stroke recurrence is highest. Although the management of BP has been improving in the general population, it has not been extensively studied in the post-stroke period. Our objective was to examine BP control and BP medication adherence and intensification in a cohort of Veterans in the year after their stroke.

Method: We reviewed the medical charts of 3987 Veterans, representing an 80% subsample among all Veterans admitted with a diagnosis of acute ischemic stroke in fiscal year 2007 to a Veterans Administration (VA) Medical Center. We identified 2832 Veterans who had visits to VA primary care clinics both in the year prior to and in the year after the hospitalization for stroke. We used administrative databases to obtain BP values and prescribed BP medications in the year before and after index stroke hospitalization. Medication adherence was assessed by calculating the mean medication possession ratio among individual BP medications. We identified opportunities for treatment intensification if a Veteran had a systolic BP value ≥ 160 mm Hg (Stage 2 hypertension). We defined treatment intensification as any BP medication dose increase or addition of a new BP medication within 14 days of the intensification opportunity. We used paired t-tests to compare changes across the two years.

Results: There were significant improvements in the mean systolic BP and the proportion of patients with controlled BP. Medication adherence was high both before and after the stroke. However, of the 640 opportunities for treatment intensification, we observed that intensification occurred only 193 (30%) times.

Conclusion: Blood pressure control did improve in the year after a stroke. However, there remains a group who do not have their BP controlled. Among patients with very high systolic BP values, there remain missed opportunities for treatment intensification.

Postdischarge quality of care: do age disparities exist among Department of Veterans Affairs ischemic stroke patients?

This study examined whether age disparities existed across postdischarge quality indicators (QIs) for veterans with ischemic stroke who received care at Department of Veterans Affairs medical centers (VAMCs). This retrospective cohort included a national sample of 3,196 veterans who were diagnosed with ischemic stroke and received acute and postdischarge stroke care at 127 VAMCs in fiscal year 2007 (10/1/06 through 9/30/07). Data included an assessment of postdischarge stroke QIs in the outpatient setting during the 6 mo postdischarge. The QIs included measurement of and goal achievement for (1) blood pressure, (2) serum international normalized ratio (INR) for all patients discharged on warfarin, (3) cholesterol (low-density lipoprotein [LDL]) levels, (4) serum glycosylated hemoglobin, and (5) depression treatment. The mean age for the 3,196 veterans included in this study was 67.2 +/- 11.3 yr. Before risk adjustment, there were age differences in (1) depression screening/treatment, (2) blood pressure goals, and (3) LDL levels. After we adjusted for patient sociodemographic, clinical, and facility-level characteristics by using hierarchical linear mixed modeling, none of these differences remained significant but INR goals for patients discharged on warfarin differed significantly by age. After we adjusted for patient and facility characteristics, fewer age differences were found in the postdischarge stroke QIs. Clinical trial registration was not required.

Computer-delivered tailored intervention improves colon cancer screening knowledge and health beliefs of African-Americans

We conducted a randomized controlled trial among African-American patients attending a primary-care provider visit to compare efficacy of a computer-delivered tailored intervention to increase colorectal cancer (CRC) screening (n = 273) with non-tailored print material-an American Cancer Society brochure on CRC screening (n = 283). Health Belief Model constructs were used to develop tailored messages and examined as outcomes. Analysis of covariance models were used to compare changes between CRC knowledge and health belief scores at baseline and 1 week post-intervention. At 1 week, patients who received the computer-delivered tailored intervention had greater changes in CRC knowledge scores (P < 0.001), perceived CRC risk scores (P = 0.005), FOBT barriers scores (P = 0.034) and colonoscopy benefit scores (P < 0.001). Findings show that computer-delivered tailored interventions are an effective adjunct to the clinical encounter that can improve knowledge and health beliefs about CRC screening, necessary precursors to behavior change.

Abstract 147: The Association Between Hematocrit and Mortality among Ischemic Stroke Patients

Introduction: Anemia is associated with higher mortality among patients with such non-stroke vascular conditions as heart failure and myocardial infarction. Less is known regarding the relationship between anemia and mortality among patients with acute ischemic stroke.

Methods: Medical records were abstracted for a sample of 3965 veterans from 131 Veterans Health Administration (VHA) facilities who were admitted for a confirmed diagnosis of ischemic stroke (fiscal year 2007). Hematocrit (Hct) values from 24-hours of admission were categorized into 6-tiers (≤27%, 28-32%, 33-37%, 38-42%, 43-47%, ≥48%). We excluded patients with: female gender (n=95), incomplete Hct data (n=94), thrombolysis (n=32), and inconsistent death dates (n=6). We used multivariate logistic regression to examine the relationship between anemia and in-hospital, 30-day, 60-day and one-year mortality using multivariate logistic regression models for each time point, adjusting for age, NIHSS, comorbidity (including pneumonia), and Acute Physiology and Chronic Health Evaluation (APACHE)-III scores. The discrimination (c-statistics) and calibration (Hosmer-Lemeshow goodness of fit [HLGOF]) statistics were generated to gauge model performance and fit.

Results: Approximately 2.1% of the N=3750 patients presented with Hcts ≤27%, 6.2% were 28-32%, 17.9% were 33-37%, 36.4% were 38-42%, 28.2% were 43-47%, and 9.1% were ≥48%. Adjusted mortality odds at all time points were 2.5 to 3.5 times higher for those with ≤Hct 27% (p values < 0.013 for in-hospital and 30-day mortality; p values at 6 months and one year were 0.002 and 0.001, respectively). Mortality risk at 6 months and 1 year showed a significant and dose-response relationship to Hct for all Hct groups <38%. High Hcts were independently associated only with in-hospital mortality and only in those with Hct ≥48 (OR 2.9, p=0.004). Models performed well across time points (C=0.813, HLGOF=0.9684 [in-hospital]; C=0.832, HLGOF=0.8186 [30-day]; C=0.863, HLGOF=0.7307 [60-day]; C=0.880, HLGOF=0.4313 [one-year]).

Conclusions: Even a moderate level of anemia is independently associated with an increased risk of death during the first year following acute ischemic stroke. Very low or very high Hct is associated with early post-stroke mortality. Further work is required to evaluate whether interventions that treat anemia, its complications and underlying etiologies may also reduce post-stroke mortality.

Estimating and reporting on the quality of inpatient stroke care by Veterans Health Administration Medical Centers

BACKGROUND

Reporting of quality indicators (QIs) in Veterans Health Administration Medical Centers is complicated by estimation error caused by small numbers of eligible patients per facility. We applied multilevel modeling and empirical Bayes (EB) estimation in addressing this issue in performance reporting of stroke care quality in the Medical Centers.

METHODS AND RESULTS

We studied a retrospective cohort of 3812 veterans admitted to 106 Medical Centers with ischemic stroke during fiscal year 2007. The median number of study patients per facility was 34 (range, 12-105). Inpatient stroke care quality was measured with 13 evidence-based QIs. Eligible patients could either pass or fail each indicator. Multilevel modeling of a patient's pass/fail on individual QIs was used to produce facility-level EB-estimated QI pass rates and confidence intervals. The EB estimation reduced interfacility variation in QI rates. Small facilities and those with exceptionally high or low rates were most affected. We recommended 8 of the 13 QIs for performance reporting: dysphagia screening, National Institutes of Health Stroke Scale documentation, early ambulation, fall risk assessment, pressure ulcer risk assessment, Functional Independence Measure documentation, lipid management, and deep vein thrombosis prophylaxis. These QIs displayed sufficient variation across facilities, had room for improvement, and identified sites with performance that was significantly above or below the population average. The remaining 5 QIs were not recommended because of too few eligible patients or high pass rates with little variation.

CONCLUSIONS

Considerations of statistical uncertainty should inform the choice of QIs and their application to performance reporting.

Abstract 1817: A computer-tailored intervention increases patient-provider discussion and appointment making for colorectal cancer screening

BACKGROUND: Colorectal cancer (CRC) will affect more than 142,000 Americans and almost 52,000 will die from this disease this year. Approximately half of these deaths could be prevented if CRC screening were consistently implemented. Both CRC incidence and mortality rates are highest among African Americans compared to all other racial groups due, in part, to suboptimal screening rates. Interactive health communication, defined as “computer technology designed to access or transmit tailored health information or receive tailored guidance and support on a health-related issue”, can be efficacious in changing individual behavior.

PURPOSE: Our objective was to determine if a tailored, interactive computer-based intervention (ICI) on CRC would increase screening discussions between African American patients and their primary care providers. Applying Health Belief Model constructs, we developed an ICI which featured CRC-risk based screening recommendations as well as individually tailored and culturally appropriate messages. The program operated on a user-friendly tablet platform and required an average of 17 minutes to complete.

METHODS: We enrolled 556 African Americans who were due for CRC screening in a randomized clinical trial. The sample was predominantly low income (58% &lt; $15,000 annual income) and 50% male with a mean age of 58 years (sd = 6.3). Demographics did not vary significantly between the two treatment arms. Prior to meeting with primary care providers in the clinic, 273 (49%) patients used the ICI. The remaining 283 (51%) patients received a “usual care” intervention – a non-tailored, CRC screening informational brochure developed by the American Cancer Society. Follow-up telephone interviews were conducted within one week of the clinic visit.

RESULTS: Patients in the ICI group were significantly more likely to report talking with their doctor about having a colon screening test (ICI group = 63%, brochure group = 49%, p = 0.001). Colonoscopy was reported as the most frequently discussed test (ICI group = 54%, brochure group = 45%, p = 0.06). Importantly, 30% of the ICI group further reported having an appointment scheduled for a colonoscopy, compared to 21% of the brochure group (p = 0.02). Fecal occult blood test was reportedly discussed by less than one third of patients in both groups (ICI group = 32%, brochure group = 27%, p = 0.15). Few patients reported discussing sigmoidoscopy (ICI group = 9%, brochure group = 7%, p = 0.29).

CONCLUSION: Tailored interactive health communications can prompt patient-provider dialogue on CRC screening and colonoscopy appointment making. Future analyses will determine if discussions translate into completion of these preventive tests which, in turn, can decrease cancer incidence and mortality.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 1817. doi:10.1158/1538-7445.AM2011-1817