1
|
Wakefield BJ, Holman JE. Functional Trajectories Associated With Hospitalization in Older Adults. West J Nurs Res 2016; 29:161-77; discussion 178-82. [PMID: 17337620 DOI: 10.1177/0193945906293809] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
For older adults, acute-care hospital stays can result in functional decline that leads to increased risk of hospitalization, nursing home admission, or mortality. This study describes functional trajectories in hospitalized older adults and identifies risk factors associated with those trajectories. Respondents ( N = 45) exhibited five of six possible functional trajectory patterns. The largest change in functional status was a decline in activities of daily living (ADL) from baseline at 2 weeks before admission to the time of admission; ADL did not return to baseline during the first 4 days in the hospital. Depression scores were significantly higher in respondents who reported experiencing ADL decline before admission. Respondents whose ADL scores declined during hospitalization (regardless of baseline status) were more likely than others to die within 3 months of discharge. Functional trajectory in hospitalized elderly patients is an important and underappreciated prognostic concept requiring further attention.
Collapse
Affiliation(s)
- Bonnie J Wakefield
- Harry S. Truman Memorial Veterans Hospital, Health Services Research and Development, Columbia, USA
| | | |
Collapse
|
2
|
Diaz K, Faverio P, Hospenthal A, Restrepo MI, Amuan ME, Pugh MJV. Obstructive sleep apnea is associated with higher healthcare utilization in elderly patients. Ann Thorac Med 2014; 9:92-8. [PMID: 24791172 PMCID: PMC4005168 DOI: 10.4103/1817-1737.128854] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 11/21/2013] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is an important cause of morbidity in the elderly population. Limited data are available regarding the healthcare utilization and predisposing conditions related to OSA in the elderly. Our aim was to evaluate the healthcare utilization and the conditions associated with new and chronic diagnosis of OSA in a large cohort of elderly patients in the Veterans Health Administration (VHA). MATERIALS AND METHODS This retrospective cohort study used inpatient and outpatient VHA data to identify the individuals diagnosed with OSA using ICD-9 codes during the fiscal years 2003-2005. Primary outcomes were emergency department (ED) visits and hospitalizations. Multivariable logistic regression analysis was performed to identify the demographic and clinical characteristics associated with new and chronic diagnosis of OSA. RESULTS Of 1,867,876 elderly veterans having 2 years of care, 82,178 (4.4%) were diagnosed with OSA. Individuals with OSA were younger and more likely to have chronic diseases than those without OSA. Individuals with chronic OSA were more likely to have diagnoses of congestive heart failure (CHF), pulmonary circulation disorders, COPD, and obesity and less likely to have diagnoses of hypertension, osteoarthritis, and stroke than individuals with newly diagnosed OSA. The proportion of patients with new OSA diagnosis who required at least one ED visit was higher than the proportion of chronic OSA and no OSA patients (37%, 32%, and 15%, respectively; P-value <0.05). The proportion of new OSA patients who required at least one hospitalization was also higher than the proportion of chronic OSA and no OSA patients (24%, 17%, and 7%, respectively; P-value <0.05). CONCLUSION Patients with OSA had a higher incidence of healthcare utilization compared to patients without OSA. New OSA patients had a higher rate of healthcare utilization in the year of diagnosis compared to chronic patients and patients without OSA. Early OSA recognition may reduce healthcare utilization in these patients.
Collapse
Affiliation(s)
- Karla Diaz
- Department of Respiratory and Critical Care Medicine, University of Texas, Health Science Center, Monza, Italy
| | - Paola Faverio
- Department of Respiratory and Critical Care Medicine, University of Texas, Health Science Center, Monza, Italy ; Department of Health Science, University of Milan-Bicocca, Respiratory Unit, San Gerardo Hospital, Monza, Italy
| | - Angela Hospenthal
- Department of Respiratory and Critical Care Medicine, University of Texas, Health Science Center, Monza, Italy
| | - Marcos I Restrepo
- Department of Respiratory and Critical Care Medicine, University of Texas, Health Science Center, Monza, Italy ; VERDICT/South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Megan E Amuan
- Center for Health Quality, Outcomes and Economic Research, Edith Nourse Rogers VA Hospital, Bedford, MA 01730, England, USA
| | - Mary Jo V Pugh
- VERDICT/South Texas Veterans Health Care System, San Antonio, TX, USA ; Departments of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, USA ; Department of Medicine Bryan, Texas A&M Health Science Center, College of Medicine, TX, USA
| |
Collapse
|
3
|
Persson EC, Quraishi SM, Welzel TM, Carreon JD, Gridley G, Graubard BI, McGlynn KA. Risk of liver cancer among US male veterans with cirrhosis, 1969-1996. Br J Cancer 2012; 107:195-200. [PMID: 22588556 PMCID: PMC3389404 DOI: 10.1038/bjc.2012.193] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: Liver cancer incidence rates in the United States have increased for several decades for reasons that are not entirely clear. Regardless of aetiology, cirrhosis is a strong risk factor for liver cancer. As mortality from cirrhosis has been declining in recent decades, it is possible that the risk of liver cancer among persons with cirrhosis has been affected. Methods: Data from the US Veterans Affairs medical records database were analysed after adjustment for attained age, race, number of hospital visits, obesity, diabetes, and chronic obstructive pulmonary disease. Hazard ratio (HR) and 95% confidence interval (95% CI) were calculated using Cox proportional hazards modelling. Survival analyses were conducted using age as the time metric and incidence of cirrhosis as a time-dependent covariate. Results: Among 103 257 men with incident cirrhosis, 788 liver cancers developed. The HR of liver cancer was highest among men with viral-related cirrhosis (HR=37.59, 95% CI: 22.57–62.61), lowest among men with alcohol-related cirrhosis (HR=8.20, 95% CI: 7.55–8.91) and intermediate among men with idiopathic cirrhosis (HR=10.45, 95% CI: 8.52–12.81), when compared with those without cirrhosis. Regardless of cirrhosis type, white men had higher HRs than black men. The HR of developing liver cancer increased from 6.40 (95% CI: 4.40–9.33) in 1969–1973 to 34.71 (95% CI: 23.10–52.16) in 1992–1996 for those with cirrhosis compared with those without. Conclusion: In conclusion, the significantly increased HR of developing liver cancer among men with cirrhosis compared with men without cirrhosis in the United States may be contributing to the increasing incidence of liver cancer.
Collapse
Affiliation(s)
- E C Persson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD 20852-7234 USA.
| | | | | | | | | | | | | |
Collapse
|
4
|
Samson P, Casey KR, Knepler J, Panos RJ. Clinical characteristics, comorbidities, and response to treatment of veterans with obstructive sleep apnea, Cincinnati Veterans Affairs Medical Center, 2005-2007. Prev Chronic Dis 2012; 9:E46. [PMID: 22280961 PMCID: PMC3337849 DOI: 10.5888/pcd9.110117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Obstructive sleep apnea (OSA) is a common disorder that is associated with significant morbidity. Veterans may be at an elevated risk for OSA because of increased prevalence of factors associated with the development and progression of OSA. The objective of this study was to determine the clinical characteristics, comorbidities, polysomnographic findings, and response to treatment of veterans with OSA. Methods We performed a retrospective chart review of 596 patients undergoing polysomnography at the Cincinnati Veterans Affairs Medical Center from February 2005 through December 2007. We assessed potential correlations of clinical data with polysomnography findings and response to treatment. Results Polysomnography demonstrated OSA in 76% of patients; 30% had mild OSA, 23% moderate OSA, and 47% severe OSA. Increasing body mass index, neck circumference, Epworth Sleepiness Scale score, hypertension, congestive heart failure, and type 2 diabetes correlated with increasing OSA severity. Positive airway pressure treatment was initiated in 81% of veterans with OSA, but only 59% reported good adherence to this treatment method. Of the patients reporting good adherence, a greater proportion of those with severe OSA (27%) than with mild or moderate disease (0%-12%) reported an excellent response to treatment. Conclusion The prevalence of metabolic and cardiovascular comorbidities increased with increasing OSA severity. Only 59% of treated patients reported good adherence to treatment with positive airway pressure, and response to treatment correlated with OSA severity.
Collapse
Affiliation(s)
- Pamela Samson
- Cincinnati Veterans Affairs Medical Center, Cincinnati, OH 45220, USA
| | | | | | | |
Collapse
|
5
|
Kramer BJ, Jouldjian S, Wang M, Dang J, Mitchell MN, Finke B, Saliba D. Do correlates of dual use by American Indian and Alaska Native Veterans operate uniformly across the Veterans Health Administration and the Indian Health Service? J Gen Intern Med 2011; 26 Suppl 2:662-8. [PMID: 21989619 PMCID: PMC3191227 DOI: 10.1007/s11606-011-1834-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To determine if the combined effects of patient-level (demographic and clinical characteristics) and organizational-level (structure and strategies to improve access) factors are uniformly associated with utilization of Indian Health Service (IHS) and/or Veterans Health Administration (VHA) by American Indian and Alaska Native (AIAN) Veterans to inform policy which promotes dual use. METHODS We estimated correlates and compared two separate multilevel logistic regression models of VHA-IHS dual versus IHS-only and VHA-IHS dual versus VHA-only in a sample of 18,892 AIAN Veterans receiving care at 201 VHA and IHS facilities during FY02 and FY03. Demographic, diagnostic, eligibility, and utilization data were drawn from administrative records. A survey of VHA and IHS facilities defined availability of services and strategies to enhance access to healthcare for AIAN Veterans. RESULTS Facility level strategies that are generally associated with enhancing access to healthcare (e.g., population-based services and programs, transportation or co-location) were not significant factors associated with dual use. In both models the common variable of dual use was related to medical need, defined as the number of diagnoses per patient. Other significant demographic, medical need and organizational factors operated in opposing manners. For instance, age increased the likelihood of dual use versus IHS-only but decreased the likelihood of dual use versus VHA-only. CONCLUSIONS Efforts to enhance access through population-based and consumer-driven strategies may add value but be less important to utilization than availability of healthcare resources needed by this population. Sharing health records and co-management strategies would improve quality of care while policies allow and promote dual use.
Collapse
Affiliation(s)
- B Josea Kramer
- VA Greater Los Angeles Healthcare System, Geriatric Research Education Clinical Center, 16111 Plummer Street (11E), Sepulveda, CA 91343, USA.
| | | | | | | | | | | | | |
Collapse
|
6
|
Burgess JF, Maciejewski ML, Bryson CL, Chapko M, Fortney JC, Perkins M, Sharp ND, Liu CF. Importance of health system context for evaluating utilization patterns across systems. HEALTH ECONOMICS 2011; 20:239-251. [PMID: 20169587 DOI: 10.1002/hec.1588] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Measuring health services provided to patients can be difficult when patients see providers across multiple health systems and all visits are rarely captured in a single data source covering all systems where patients receive care. Studies that account for only one system will omit the out-of-system health-care use at the patient level. Combining data across systems and comparing utilization patterns across health systems creates complications for both aggregation and accuracy because data-generating processes (DGPs) tend to vary across systems. We develop a hybrid methodology for aggregation across systems, drawing on the strengths of the DGP in each system, and demonstrate its validity for answering research questions requiring cross-system assessments of health-care utilization. Positive and negative predictive probabilities can be useful to assess the impact of the hybrid methodology. We illustrate these issues comparing public sector (administrative records from the US Department of Veterans Affairs system) and private sector (billing records from the US Medicare system) patient level data to identify primary-care utilization. Understanding the context of a particular health system and its effect on the DGP is important in conducting effective valid evaluations.
Collapse
Affiliation(s)
- James F Burgess
- Center for Organization, Leadership and Management Research, Department of Veterans Affairs, Boston, MA, USA.
| | | | | | | | | | | | | | | |
Collapse
|
7
|
|
8
|
Thorpe JM, Van Houtven CH, Sleath BL. Barriers to Outpatient Care in Community-Dwelling Elderly with Dementia. J Appl Gerontol 2009. [DOI: 10.1177/0733464808328605] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The purpose of this study was to examine the relationship between informal caregiver life satisfaction and receipt of outpatient medical care in persons with dementia. We obtained data from the National Longitudinal Caregiver Survey (NLCS), a survey of 1,269 veterans with dementia and their primary informal caregivers. NLCS data were merged with 12 months of Veteran Administration outpatient claims. Outpatient visits were classified as (a) primary, (b) specialty, or (c) mental health care. Greater levels of caregiver-reported life dissatisfaction were associated with decreased likelihood of care-recipient outpatient visits for both primary and mental health care. In addition, we found that care-recipients with African American caregivers were less likely to receive a mental health visit, and those coresiding with their caregiver were more likely to receive a specialty care visit. Our findings suggest that low caregiver life satisfaction may signal an impending breakdown in care-recipients' access to primary and mental health care.
Collapse
|
9
|
Ratliff J, Anand N, Vaccaro AR, Lim MR, Lee JY, Arnold P, Harrop JS, Rampersaud R, Bono CM, Gahr RH. Regional variability in use of a novel assessment of thoracolumbar spine fractures: United States versus international surgeons. World J Emerg Surg 2007; 2:24. [PMID: 17825106 PMCID: PMC2045082 DOI: 10.1186/1749-7922-2-24] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Accepted: 09/07/2007] [Indexed: 11/24/2022] Open
Abstract
Background Considerable variability exists in clinical approaches to thoracolumbar fractures. Controversy in evaluation and nomenclature contribute to this confusion, with significant differences found between physicians, between different specialties, and in different geographic regions. A new classification system for thoracolumbar injuries, the Thoracolumbar Injury Severity Score (TLISS), was recently described by Vaccaro. No assessment of regional differences has been described. We report regional variability in use of the TLISS system between United States and non-US surgeons. Methods Twenty-eight spine surgeons (8 neurosurgeons and 20 orthopedic surgeons) reviewed 56 clinical thoracolumbar injury case histories, which included pertinent imaging studies. Cases were classified and scored using the TLISS system. After a three month period, the case histories were re-ordered and the physicians repeated the exercise; 22 physicians completed both surveys and were used to assess intra-rater reliability. The reliability and treatment validity of the TLISS was assessed. Surgeons were grouped into US (n = 15) and non-US (n = 13) cohorts. Inter-rater (both within and between different geographic groups) and intra-rater reliability was assessed by percent agreement, Cohen's kappa, kappa with linear weighting, and Spearman's rank-order correlation. Conclusion Non-US surgeons were found to have greater inter-rater reliability in injury mechanism, while agreement on neurological status and posterior ligamentous complex integrity tended to be higher among US surgeons. Inter-rater agreement on management was moderate, although it tended to be higher in US-surgeons. Inter-rater agreement between US and non-US surgeons was similar to within group inter-rater agreement for all categories. While intra-rater agreement for mechanism tended to be higher among US surgeons, intra-rater reliability for neurological status and PLC was slightly higher among non-US surgeons. Intra-rater reliability for management was substantial in both US and non-US surgeons. The TLISS incorporates generally accepted features of spinal injury assessment into a simple patient evaluation tool. The management recommendation of the treatment algorithm component of the TLISS shows good inter-rater and substantial intra-rater reliability in both non-US and US based spine surgeons. The TLISS may improve communication between health providers and may contribute to more efficient management of thoracolumbar injuries.
Collapse
Affiliation(s)
- John Ratliff
- Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Neel Anand
- Department of Orthpaedics, Cedars Sinai Medical Center, Los Angeles, USA
| | - Alexander R Vaccaro
- Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Moe R Lim
- Department of Orthpaedics University of North Carolina, Raleigh, USA
| | - Joon Y Lee
- Department of Orthpaedics University of Pittsburgh, Pittsburgh, USA
| | - Paul Arnold
- Department of Neurosurgery, Kansas University, Kansas City, USA
| | - James S Harrop
- Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Raja Rampersaud
- Department of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Ralf H Gahr
- Dept. of Othopaedic Surgery, Trauma Center St. Georg, Leipzig, Germany
| | | |
Collapse
|
10
|
Morey MC, Ekelund C, Pearson M, Crowley G, Peterson M, Sloane R, Pieper C, McConnell E, Bosworth H. Project LIFE: a partnership to increase physical activity in elders with multiple chronic illnesses. J Aging Phys Act 2006; 14:324-43. [PMID: 17090809 DOI: 10.1123/japa.14.3.324] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The authors describe a medical center-based randomized trial aimed at determining the feasibility and effectiveness of partnering patients and primary-care providers with an exercise health counselor. Study participants included 165 veterans age 70 years and older. The primary end point was change in physical activity at 3 and 6 months comparing patients receiving high-intensity physical activity counseling, attention control counseling, and usual care after receiving standardized clinic-based counseling. We noted a significant Group x Time interaction (p = .041) for physical activity frequency and a similar effect for caloric expenditure (p = .054). Participants receiving high-intensity counseling and usual care increased physical activity over the short term, but those with usual care returned to baseline by the end of the study. The intervention was well received by practitioners and patients. We conclude that partnering primary-care providers with specialized exercise counselors for age- and health-appropriate physical activity counseling is effective.
Collapse
Affiliation(s)
- Miriam C Morey
- Geriatric Research, Education and Clinical Center, Durham VA Medical Center, Durham, NC, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
McGinnis KA, Fultz SL, Skanderson M, Conigliaro J, Bryant K, Justice AC. Hepatocellular Carcinoma and Non-Hodgkin's Lymphoma: The Roles of HIV, Hepatitis C Infection, and Alcohol Abuse. J Clin Oncol 2006; 24:5005-9. [PMID: 17075119 DOI: 10.1200/jco.2006.05.7984] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To explore the relationship of HIV, hepatitis C (HCV), and alcohol abuse/dependence to risk for hepatocellular carcinoma and non-Hodgkin's lymphoma (NHL). Patients and Methods Male veterans (n = 14,018) with a first HIV diagnosis in the Veterans Affairs Healthcare System from October 1997 to September 2004; and 28,036 age-, race-, sex-, and location-matched HIV-negative veterans were identified. We examined the incidence of hepatocellular carcinoma and NHL and presence of HCV and alcohol abuse/dependence using International Classification of Diseases, ninth revision (ICD-9-CM) codes. HIV-positive to HIV-negative incident rate ratios (IRRs) and 95% CIs for the occurrence of hepatocellular carcinoma and NHL were calculated using Poisson regression models. Results HIV-positive veterans were at greater risk for hepatocellular carcinoma than HIV-negative veterans (IRR = 1.68; 95% CI, 1.02 to 2.77). After adjusting for HCV infection and alcohol abuse/dependence, HIV status was not independently associated with hepatocellular cancer (IRR = 0.96; 95% CI, 0.56 to 1.63). HIV-positive veterans had 9.71 times (95% CI, 6.99 to 13.49) greater risk of NHL than HIV-negative veterans. After adjusting for HCV and alcohol abuse/dependence, the IRR for NHL comparing HIV-positive with HIV-negative veterans is similar (IRR = 10.03, 95% CI, 7.19 to 13.97). Conclusion HIV-positive veterans have a higher relative incidence of hepatocellular carcinoma and NHL than HIV-negative veterans. For hepatocellular carcinoma, this association appears to be largely explained by the higher prevalence of HCV and alcohol abuse/dependence. Efforts to decrease hepatocellular carcinoma among persons with HIV should focus primarily on detecting and treating HCV and reducing heavy alcohol use.
Collapse
Affiliation(s)
- Kathleen A McGinnis
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | | | | | | | | | | |
Collapse
|
12
|
Calhoun PS, Bosworth HB, Stechuchak KA, Strauss J, Butterfield MI. The impact of posttraumatic stress disorder on quality of life and health service utilization among veterans who have schizophrenia. J Trauma Stress 2006; 19:393-7. [PMID: 16789002 DOI: 10.1002/jts.20114] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The present study examined the impact of comorbid posttraumatic stress disorder (PTSD) on health-related quality of life and objective measures of health service utilization in 165 male veterans who have primary schizophrenia. Comorbid PTSD was assessed with the PTSD Checklist. Comorbid PTSD was significantly associated with decreased quality of life and increased medical service utilization, including increased psychiatric hospitalization and increased outpatient physical health visits, even after controlling for other clinical and demographic variables among this sample of patients who had primary schizophrenia. Veterans who have schizophrenia should be screened carefully for exposure to trauma and posttraumatic stress disorder.
Collapse
Affiliation(s)
- Patrick S Calhoun
- VA Mid-Atlantic Mental Illness Research Education and Clinical Center, USA.
| | | | | | | | | |
Collapse
|
13
|
French DD, Campbell R, Spehar A, Cunningham F, Bulat T, Luther SL. Drugs and falls in community-dwelling older people: a national veterans study. Clin Ther 2006; 28:619-30. [PMID: 16750473 DOI: 10.1016/j.clinthera.2006.04.011] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2006] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this study was to identify which specific medications within recognized major problematic drug categories that increase risk of falling were prescribed to veterans before their out-patient treatment for a fall. METHODS This was a retrospective, cross-sectional national secondary outpatient data analysis with an age- and sex-matched comparison group. The setting was the national Veterans Health Administration (VHA) ambulatory health care system in fiscal year (FY) 2004. The study population was VHA patients aged>or=65 years who had fall-related outpatient clinical health care encounters in FY 2004 (as indicated by diagnostic codes) and who received >or=1 outpatient medication during the study period. The age- and sex-matched comparison group consisted of an equal number of patients with nonspecific chest pain. The percentage of patients in each group receiving medications (at the time of the outpatient encounter) that affect the cardiovascular system (CVS), central nervous system (CNS), or musculoskeletal system (MSS) was compared with Bonferrom-adjusted P values. RESULTS The study sample consisted of 20,551 patients; the comparison group included the same number of patients. More patients with fall-coded encounters used CNS drugs than those with nonspecific chest pain (42.05% vs 29.29%). Also, within the CNS category, more patients with fall-coded encounters used antiparkinsonian medications (3.67% vs 1.32%), Alzheimer's disease medications (ie, cholinesterase inhibitors [5.40% vs 2.35%]), anticonvulsants/barbiturates (8.95% vs 5.18%), antidepressants (22.50% vs 14.16%), antipsychotics (4.68% vs 2.01%), opioid analgesics and narcotics (11.21% vs 9.09%), and benzodiazepines (7.60% vs 5.96%) (all, P<0.002). More patients with nonspecific chest pain received CVS drugs compared with the fall-coded group (69.13% vs 63.07%; P<0.002). Within the CVS category, more patients in the nonspecific chest pain group received angiotensin-II receptor antagonists, angiotensin-converting enzyme inhibitors, beta-blockers, calcium channel blockers, vasodilators, diuretics, and antiarrhythmics (all, P<0.002). No differences were noted between groups in the MSS category, except for NSAIDs, which more patients in the nonspecific chest pain group used than in the fall-coded group (6.44% vs 5.63%; P<0.002). CONCLUSION In this study, subjects with a health care encounter for a fall (as indicated by diagnostic code) were prescribed significantly more CNS-category medications than subjects in the age- and sex-matched comparison group.
Collapse
Affiliation(s)
- Dustin D French
- Patient Safety Center, Veterans Integrated System Network 8, James A. Haley Hospital, and University of South Florida College of Public Health, Tampa, Florida 33612, USA.
| | | | | | | | | | | |
Collapse
|
14
|
Goldzweig CL, Balekian TM, Rolón C, Yano EM, Shekelle PG. The state of women veterans' health research. Results of a systematic literature review. J Gen Intern Med 2006; 21 Suppl 3:S82-92. [PMID: 16637952 PMCID: PMC1513165 DOI: 10.1111/j.1525-1497.2006.00380.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Assess the state of women veterans' health research. DESIGN Systematic review of studies that pertained specifically to or included explicit information about women veterans. A narrative synthesis of studies in 4 domains/topics was conducted: Stress of military life; Health and performance of military/VA women; Health services research/quality of care; and Psychiatric conditions. MEASUREMENTS AND MAIN RESULTS We identified 182 studies. Of these, 2 were randomized-controlled trials (RCTs) and the remainder used observational designs. Forty-five percent of studies were VA funded. We identified 77 studies pertaining to the stress of military life, of which 21 reported on sexual harassment or assault. Rates of harassment ranged from 55% to 79% and rates of sexual assault from 4.2% to 7.3% in active duty military women and 11% to 48% among women veterans. Forty-two studies concerned the health and performance of military/VA women, with 21 studies evaluating sexual assault and posttraumatic stress disorder (PTSD) and their effect on health. Fifty-nine studies assessed various aspects of health services research. Eight studies assessed quality of care and 5, patient satisfaction. Twenty-five studies assessed utilization and health care organization, and findings include that women veterans use the VA less than men, that gender-specific reasons for seeking care were common among female military and veteran personnel, that provision of gender-specific care increased women veterans' use of VA, and that virtually all VAs have available on-site basic women's health services. Fifty studies were classified as psychiatric; 31 of these were about the risk, prevalence, and treatment of PTSD. CONCLUSIONS Most research on VA women's health is descriptive in nature and has concerned PTSD, sexual harassment and assault, the utilization and organization of care, and various psychiatric conditions. Experimental studies and studies of the quality of care are rare.
Collapse
Affiliation(s)
- Caroline L Goldzweig
- Southern California Evidence-Based Practice Center, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA.
| | | | | | | | | |
Collapse
|
15
|
DeSalvo KB, Fisher WP, Tran K, Bloser N, Merrill W, Peabody J. Assessing Measurement Properties of Two Single-item General Health Measures. Qual Life Res 2006; 15:191-201. [PMID: 16468076 DOI: 10.1007/s11136-005-0887-2] [Citation(s) in RCA: 264] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND Multi-item health status measures can be lengthy, expensive, and burdensome to collect. Single-item measures may be an alternative. We compared measurement properties of two single-item, general self-rated health (GSRH) questions to assess how well they captured information in a validated, multi-item instrument. METHODS We administered a general health survey (SF-12V) that included "standard" and "comparative" forms of a GSRH. We repeated the survey two weeks later to the same 75 medically stable outpatients to test for GSRH reproducibility, reliability, and validity using SF-12V Physical Functioning and Emotional Health subscales as a reference. RESULTS At each survey administration, the two GSRH questions demonstrated good alternate forms reliability (first administration: r = 0.74, p < 0.001; second administration: r = 0.74, p < 0.001) and good reproducibility ("standard": ICC 0.69; "comparative": ICC 0.85). Both GSRH items correlated with physical functioning ("standard": r = 0.66; "comparative": r = 0.56) and emotional health measures ("standard": r = 0.65; "comparative": r = 0.59). Mean subscale measures associated with responses in each GSRH category were significantly different (ANOVA, p < 0.001), indicating strong discriminant scale performance. CONCLUSIONS Our single-item, GSRH questions demonstrated good reproducibility, reliability, and strong concurrent and discriminant scale performance with an established health status measure.
Collapse
Affiliation(s)
- Karen B DeSalvo
- Section of General Internal Medicine and Geriatrics, Tulane University Health Sciences Center, New Orleans, LA 70112, USA.
| | | | | | | | | | | |
Collapse
|
16
|
Bosworth HB, Dudley T, Olsen MK, Voils CI, Powers B, Goldstein MK, Oddone EZ. Racial differences in blood pressure control: potential explanatory factors. Am J Med 2006; 119:70.e9-15. [PMID: 16431192 DOI: 10.1016/j.amjmed.2005.08.019] [Citation(s) in RCA: 163] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2005] [Revised: 08/12/2005] [Accepted: 08/12/2005] [Indexed: 11/23/2022]
Abstract
PURPOSE Poor blood pressure control remains a common problem that contributes to significant cardiovascular morbidity and mortality, particularly among African Americans. We explored antihypertensive medication adherence and other factors that may explain racial differences in blood pressure control. METHODS Baseline data were obtained from the Veteran's Study to Improve The Control of Hypertension, a randomized controlled trial designed to improve blood pressure control. Clinical, demographic, and psychosocial factors relating to blood pressure control were examined. RESULTS A total of 569 patients who were African American (41%) or white (59%) were enrolled in the study. African Americans were more likely to have inadequate baseline blood pressure control than whites (63% vs 50%; odds ratio = 1.70; 95% confidence interval [CI] 1.20-2.41). Among 20 factors related to blood pressure control, African Americans also had a higher odds ratio of being nonadherent to their medication, being more functionally illiterate, and having a family member with hypertension compared with whites. Compared with whites, African Americans also were more likely to perceive high blood pressure as serious and to experience the side effect of increased urination compared with whites. Adjusting for these differences reduced the odds ratio of African Americans having adequate blood pressure control to 1.59 (95% confidence interval 1.09-2.29). CONCLUSIONS In this sample of hypertensive patients who have good access to health care and medication benefits, African Americans continued to have lower levels of blood pressure control despite considering more than 20 factors related to blood pressure control. Interventions designed to improve medication adherence need to take race into account. Patients' self-reports of failure to take medications provide an opportunity for clinicians to explore reasons for medication nonadherence, thereby improving adherence and potentially blood pressure control.
Collapse
Affiliation(s)
- Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA.
| | | | | | | | | | | | | |
Collapse
|
17
|
Campione JR, Sleath B, Biddle AK, Weinberger M. The influence of physicians' guideline compliance on patients' statin adherence: A retrospective cohort study. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.amjopharm.2005.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
18
|
Hong TB, Oddone EZ, Dudley TK, Bosworth HB. Subjective and objective evaluations of health among middle-aged and older veterans with hypertension. J Aging Health 2005; 17:592-608. [PMID: 16177452 DOI: 10.1177/0898264305279780] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The congruence between self-rated health and objective health was examined for associations with health factors related to hypertension (health behaviors, medication barriers, and perceived blood-pressure control). METHODS The Charlson Comorbidity Index was cross classified with self-rated health, producing four health-congruence groups: good health realists, poor health realists, health optimists, and health pessimists. Data for this study were obtained from 588 hypertensive veterans (mean age = 63) at baseline of a clinical trial to improve blood-pressure control before randomization to an intervention. RESULTS Optimists had higher perceived control of their hypertension when compared to pessimists. Additionally, optimists had higher levels of exercise and fewer medication barriers when compared to poor health realists. DISCUSSION Health congruence classification could be a useful tool to alert practitioners of patients who may be having difficulties managing their hypertension.
Collapse
Affiliation(s)
- Tantina B Hong
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Duke University Medical Center, Building 16, Room 70, 508 Fulton St., Durham, NC 27705, USA.
| | | | | | | |
Collapse
|
19
|
Luther SL, French DD, Powell-Cope G, Rubenstein LZ, Campbell R. Using administrative data to track fall-related ambulatory care services in the Veterans Administration Healthcare system. Aging Clin Exp Res 2005; 17:412-8. [PMID: 16392417 DOI: 10.1007/bf03324631] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS The Veterans Administration (VA) Healthcare system, containing hospital and community-based outpatient clinics, provides the setting for the study. Summary data was obtained from the VA Ambulatory Events Database for fiscal years (FY) 1997-2001 and in-depth data for FY 2001. In FY 2001, the database included approximately 4 million unique patients with 60 million encounters. The purpose of this study was: 1) to quantify injuries and use of services associated with falls among the elderly treated in Veterans Administration (VA) ambulatory care settings using administrative data; 2) to compare fall-related services provided to elderly veterans with those provided to younger veterans. METHODS Retrospective analysis of administrative data. This study describes the trends (FY 1997-2001) and patterns of fall-related ambulatory care encounters (FY 2001) in the VA Healthcare System. RESULTS An approximately four-fold increase in both encounters and patients seen was observed in FY 1997-2001, largely paralleling the growth of VA ambulatory care services. More than two-thirds of the patients treated were found to be over the age of 65. Veterans over the age of 65 were found to be more likely to receive care in the non-urgent setting and had higher numbers of co-morbid conditions than younger veterans. While nearly half of the encounters occurred in the Emergency/Urgent Care setting, fall-related injuries led to services across a wide spectrum of medical and surgical providers/departments. CONCLUSIONS This study represents the first attempt to use the VA Ambulatory Events Database to study fall-related services provided to elderly veterans. In view of the aging population served by the VA and the movement to provide increased services in the outpatient setting, this database provides an important resource for researchers and administrators interested in the prevention and treatment of fall-related injuries.
Collapse
Affiliation(s)
- Stephen L Luther
- Veterans Integrated Service Network 8, Patient Safety Center of Inquiry, James A. Haley Veterans Administration Medical Center, Tampa, Florida 33612, USA.
| | | | | | | | | |
Collapse
|
20
|
Newland PK, Wipke-Tevis DD, Williams DA, Rantz MJ, Petroski GF. Impact of Pain on Outcomes in Long-Term Care Residents with and without Multiple Sclerosis. J Am Geriatr Soc 2005; 53:1490-6. [PMID: 16137277 DOI: 10.1111/j.1532-5415.2005.53465.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare long-term care (LTC) residents with and without multiple sclerosis (MS); to compare admission status of pain, physical disability, pressure ulcers, depression, and cognitive performance in LTC residents with and without MS; and to examine the impact of MS and pain on outcomes 90 and 180 days after LTC admission. DESIGN Retrospective analysis of a large data set. SETTING LTC facilities in Missouri. PARTICIPANTS Residents admitted to non-hospital-based LTC facilities. MEASUREMENTS Minimum Data Set/Resident Assessment Instrument, Version 2.0; Activities of Daily Living Scale; Cognitive Performance Scale. RESULTS Residents with and without MS had similar pain prevalence and intensity after admission, with daily pain more frequent in residents with MS (P=.03). On admission, residents with MS had more physical disability (P<.001) and a greater prevalence of pressure ulcers (P=.004) and depression (P<.001) than residents without MS. In all LTC residents, initial pain status was associated with physical disability (P<.001), pressure ulcers (P<.001), depression (P<.001), and cognitive performance (P<.001) 90 and 180 days after admission. A diagnosis of MS was associated with physical disability (P<.001) 90 and 180 days after admission and pressure ulcer development 180 days after admission (P=.02). CONCLUSION Residents with MS were more physically disabled and had more frequent pain and a higher prevalence of pressure ulcers and depression on admission than residents without MS. Pain, or lack thereof, in residents with and without MS on admission may warn of problems that could occur within 6 months after admission to a LTC facility.
Collapse
Affiliation(s)
- Pamela K Newland
- MU Sinclair School of Nursing, University of Missouri-Columbia, Missouri, USA.
| | | | | | | | | |
Collapse
|
21
|
Auman C, Bosworth HB, Hess TM. Effect of health-related stereotypes on physiological responses of hypertensive middle-aged and older men. J Gerontol B Psychol Sci Soc Sci 2005; 60:P3-P10. [PMID: 15643036 DOI: 10.1093/geronb/60.1.p3] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study examined the influence of health stereotypes on stress response among middle-aged and older men. It was hypothesized that anxiety and cardiovascular reactivity would increase when health stereotypes were activated among veterans seeking care in an outpatient setting. Among a sample of 122 veteran patients with hypertension, the level of stereotype activation varied by means of reference to either their health status (health stereotypes) or, conversely, some personally valued leisure activities (no stereotype activation). Predicted stereotype-related increases in anxiety, galvanized skin conductance, and blood pressure were evident. Potential explanations for these results are explored, including those relating to the negative health stereotypes associated with being a patient.
Collapse
Affiliation(s)
- Corinne Auman
- Psychology Department, North Carolina State University, Raleigh, USA.
| | | | | |
Collapse
|
22
|
Blow FC, Zeber JE, McCarthy JF, Valenstein M, Gillon L, Bingham CR. Ethnicity and diagnostic patterns in veterans with psychoses. Soc Psychiatry Psychiatr Epidemiol 2004; 39:841-51. [PMID: 15669666 DOI: 10.1007/s00127-004-0824-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Differential diagnosis of schizophrenia and bipolar disorder is a challenging but important task. These conditions often exhibit overlapping clinical symptomatology, but have different prognoses and pharmacological management strategies. Factors other than clinical presentation may influence diagnosis. Past studies suggest that ethnicity is one such factor, with variations observed in diagnostic rates of serious mental illness (SMI). With increasing attention paid to provider cultural competency, we investigate current diagnostic practices within a veteran population. METHOD Controlling for patient need characteristics and illness severity, we examine whether ethnic differences in diagnosis continue to exist. If so, race may adversely enter the evaluation process. A national database of all SMI veterans explores the relationship between ethnicity and diagnosis. The role of symptomatology is also examined. Given minimal variation in veteran socioeconomic status, the Department of Veterans Affairs (VA) provides a natural setting to address this confounding factor. The 1999 National Psychosis Registry provides a sample of 134,523 veterans diagnosed with schizophrenia, schizoaffective disorder, or bipolar disorder. Multinomial logistic regression yielded odds ratios (OR) for being diagnosed with schizophrenia versus bipolar disorder; the schizoaffective versus bipolar risk was likewise assessed, exploring theoretical aspects of a psychosis-affective 'continuum'. RESULTS Small effects were observed for being male, single or rural resident. However, the demographic characteristic most strongly associated with a schizophrenia diagnosis was race. The OR for African Americans was 4.05, and 3.15 for Hispanics. Similar though less dramatic results were revealed for schizoaffective disorder. CONCLUSIONS This study confirms continued ethnic disparities in diagnostic patterns, and highlights the importance of recognizing ethnic differences in symptom presentation while emphasizing greater cultural competency.
Collapse
Affiliation(s)
- Frederic C Blow
- Dept of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | | | | | | | | | | |
Collapse
|
23
|
McQueen L, Mittman BS, Demakis JG. Overview of the Veterans Health Administration (VHA) Quality Enhancement Research Initiative (QUERI). J Am Med Inform Assoc 2004; 11:339-43. [PMID: 15187071 PMCID: PMC516239 DOI: 10.1197/jamia.m1499] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The U.S. Veterans Health Administration (VHA)'s Quality Enhancement Research Initiative (QUERI) is an innovative integration of health services research, policy, and clinical care delivery designed to improve the quality, outcomes, and efficiency of VHA health care through the identification and implementation of evidence-based practices in routine care settings. A total of eight condition-specific QUERI centers are currently in operation, each pursuing an integrated portfolio of activities designed to identify and correct gaps in clinical quality and performance and to derive generalizable scientific knowledge regarding quality improvement processes and methods and their effectiveness. This overview article describes QUERI's mission, history, structure, and activities and provides a brief summary of key findings and impacts.
Collapse
Affiliation(s)
- Lynn McQueen
- Office of Quality and Performance, US Department of Veterans Affairs (10Q), 810 Vermont Avenue, NW, Washington, DC 20420, USA.
| | | | | |
Collapse
|
24
|
Abstract
OBJECTIVE To provide an overview of databases that are maintained by the Department of Veterans Affairs (VA) and are of relevance to investigators involved in epidemiologic, clinical, and health services research. RESEARCH DESIGN AND METHODS We reviewed both national and local VA databases and identified their strengths and limitations. We also referenced specific studies that have assessed the validity and reliability of VA databases. RESULTS There are numerous national databases housed at the Austin Automation Center in Austin, Texas. These include the Patient Treatment File (hospital abstracts), the Outpatient Care File, the Beneficiary Identification Record Locator System death file for assessing vital status, and the Decision Support System, which provides integrated clinical and financial information for managerial decision making. The major limitation of these databases is that clinical detail below the level of ICD-9-CM diagnosis and procedure codes is not uniformly available nationally. These databases offer an excellent opportunity to monitor the health of veterans over time because they track all inpatient and outpatient utilization in the VA. However, at the local or medical center level, the Veterans Health Information and Systems and Technology Architecture contains extensive clinical information, but has fewer patients, varies in format across medical centers, and poses difficulties with data extraction for statistical analysis. CONCLUSIONS Both local and national VA databases are valuable resources for investigators who have interests in a wide array of research topics, including diabetes. The potential for investigating important scientific questions with VA databases becomes greater as communications and database management technologies improve.
Collapse
Affiliation(s)
- Charles Maynard
- HSR&D Center of Excellence, VA Puget Sound Health Care System, and the Department of Health Services, University of Washington, Seattle, Washington, USA.
| | | |
Collapse
|
25
|
Ouimette P, Wolfe J, Daley J, Gima K. Use of VA health care services by women veterans: findings from a national sample. Women Health 2004; 38:77-91. [PMID: 14655796 DOI: 10.1300/j013v38n02_06] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Department of Veterans Affairs (VA) has a Congressional mandate but few empirical data on which to design and improve national health care services for women. We examined characteristics associated with women's current, former and non-use of the VA health care system. The study included 1,500 female veterans sampled from the Department of Veterans Affairs National Registry of Women Veterans. Women completed a 45-minute telephone survey assessing multiple domains of functional status and health service use. Using multivariate logistic regression, use of VA health care was associated with older age, more education, not being married, lower rates of insurance coverage, and poorer physical and psychological health. Women who were former users of VA health care were more likely to be ethnic minorities, have children, served less time in the military, had higher rates of insurance coverage and better physical and psychological health than current users. Prominent military experiences (e.g., service in a war-zone, exposure to trauma) were associated with former use and never using the VA health care system. Women who use VA health care are at greater economic, social, and health risk than nonusers, factors that have personal implications for the veteran as well as cost and service implications for VA. Additional research is needed to better understand the role of military experiences in women veterans' choice of health care.
Collapse
Affiliation(s)
- Paige Ouimette
- Washington Institute for Mental Illness Research and Training, Washington State University, Spokane, USA.
| | | | | | | |
Collapse
|
26
|
Liu CF, Sales AE, Sharp ND, Fishman P, Sloan KL, Todd-Stenberg J, Nichol WP, Rosen AK, Loveland S. Case-mix adjusting performance measures in a veteran population: pharmacy- and diagnosis-based approaches. Health Serv Res 2003; 38:1319-37. [PMID: 14596393 PMCID: PMC1360949 DOI: 10.1111/1475-6773.00179] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To compare the rankings for health care utilization performance measures at the facility level in a Veterans Health Administration (VHA) health care delivery network using pharmacy- and diagnosis-based case-mix adjustment measures. DATA SOURCES/STUDY SETTING The study included veterans who used inpatient or outpatient services in Veterans Integrated Service Network (VISN) 20 during fiscal year 1998 (October 1997 to September 1998; N = 126,076). Utilization and pharmacy data were extracted from VHA national databases and the VISN 20 data warehouse. STUDY DESIGN We estimated concurrent regression models using pharmacy or diagnosis information in the base year (FY1998) to predict health service utilization in the same year. Utilization measures included bed days of care for inpatient care and provider visits for outpatient care. PRINCIPAL FINDINGS Rankings of predicted utilization measures across facilities vary by case-mix adjustment measure. There is greater consistency within the diagnosis-based models than between the diagnosis- and pharmacy-based models. The eight facilities were ranked differently by the diagnosis- and pharmacy-based models. CONCLUSIONS Choice of case-mix adjustment measure affects rankings of facilities on performance measures, raising concerns about the validity of profiling practices. Differences in rankings may reflect differences in comparability of data capture across facilities between pharmacy and diagnosis data sources, and unstable estimates due to small numbers of patients in a facility.
Collapse
Affiliation(s)
- Chuan-Fen Liu
- VA Puget Sound Health Care System, Seattle, WA 98108, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
McGinnis KA, Fine MJ, Sharma RK, Skanderson M, Wagner JH, Rodriguez-Barradas MC, Rabeneck L, Justice AC. Understanding racial disparities in HIV using data from the veterans aging cohort 3-site study and VA administrative data. Am J Public Health 2003; 93:1728-33. [PMID: 14534229 PMCID: PMC1448041 DOI: 10.2105/ajph.93.10.1728] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We identified race-associated differences in survival among HIV-positive US veterans to examine possible etiologies for these differences. METHODS We used national administrative data to compare survival by race and used data from the Veterans Aging Cohort 3-Site Study (VACS 3) to compare patients' health status, clinical management, and adherence to medication by race. RESULTS Nationally, minority veterans had higher mortality rates than did white veterans with HIV. Minority veterans had poorer health than white veterans with HIV. No significant differences were found in clinical management or adherence. CONCLUSIONS HIV-positive minority veterans experience poorer survival than white veterans. This difference may derive from differences in comorbidities and in the severity of illness of HIV-related disease.
Collapse
Affiliation(s)
- Kathleen A McGinnis
- Veterans Aging Cohort Study Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Neuzil KM, Maynard C, Griffin MR, Heagerty P. Winter respiratory viruses and health care use: a population-based study in the northwest United States. Clin Infect Dis 2003; 37:201-7. [PMID: 12856212 DOI: 10.1086/375604] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2003] [Accepted: 03/13/2003] [Indexed: 11/03/2022] Open
Abstract
To quantify health care use among adults during influenza and respiratory syncytial virus (RSV) seasons, we identified a cohort of veterans aged >or=18 years who used Department of Veterans Affairs (VA) facilities in Oregon and Washington states as their source of health care. During 1998-2000, veterans accrued 237,159 person-years of follow-up. Using VA data sources, we measured acute cardiopulmonary hospitalizations and primary care and urgent care visits. Differences between rates of study events when influenza and/or RSV were circulating and event rates when neither virus was circulating were used to calculate winter virus-attributable morbidity. Inpatient and outpatient event rates were consistently higher during winter virus season, compared with non-winter virus season. Annual rates of cardiopulmonary hospitalizations attributable to influenza or RSV infection ranged from 0.8 (95% confidence interval [CI], 0.1-1.5) per 1000 low-risk individuals aged 18-49 years, to 10.6 (95% CI, 7.5-13.6) per 1000 high-risk individuals aged >or=65 years. Each year, circulation of influenza and RSV coincide with predictable increases in medical care use.
Collapse
Affiliation(s)
- Kathleen M Neuzil
- Department of Medicine, University of Washington School of Medicine, Seattle, USA.
| | | | | | | |
Collapse
|
29
|
Murdoch M, Hodges J, Cowper D, Fortier L, van Ryn M. Racial disparities in VA service connection for posttraumatic stress disorder disability. Med Care 2003; 41:536-49. [PMID: 12665717 DOI: 10.1097/01.mlr.0000053232.67079.a5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND "Service connected" veterans are those with documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the Veterans Affairs (VA) health care system. For some veterans, service connection represents the difference between access to VA health care facilities and no access. OBJECTIVES To determine whether there are racial discrepancies in the granting of service connection for posttraumatic stress disorder (PTSD) by the Department of Veterans Affairs and, if so, to determine whether these discrepancies could be attributed to appropriate subject characteristics, such as differences in PTSD symptom severity or functional status. RESEARCH DESIGN Mailed survey linked to administrative data. Claims audits were conducted on 11% of the sample. SETTING AND SUBJECTS The study comprised 2700 men and 2700 women randomly selected from all veterans filing PTSD disability claims between January 1, 1994 and December 31, 1998. RESULTS A total of 3337 veterans returned usable surveys, of which 17% were black. Only 16% of respondents carried private health insurance, and 44% reported incomes of 20,000 US dollars or less. After adjusting for respondents' sociodemographic characteristics, symptom severity, functional status, and trauma histories, black persons' rate of service connection for PTSD was 43% compared with 56% for other respondents (P = 0.003). CONCLUSION Black persons' rates of service connection for PTSD were substantially lower than other veterans even after adjusting for differences in PTSD severity and functional status.
Collapse
Affiliation(s)
- Maureen Murdoch
- Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minnesota 55417, USA.
| | | | | | | | | |
Collapse
|
30
|
Metlay JP, Hardy C, Strom BL. Agreement between patient self-report and a Veterans Affairs national pharmacy database for identifying recent exposures to antibiotics. Pharmacoepidemiol Drug Saf 2003; 12:9-15. [PMID: 12622056 DOI: 10.1002/pds.772] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE The dramatic rise in antibiotic drug resistance among community pathogens has stimulated interest in the epidemiological relationship between antibiotic exposure and drug resistance. In assessing the strength of this relationship, studies are hampered by the lack of data on the accuracy of subject self-report of antibiotic exposure. The authors compared self-report with pharmacy dispensing data to determine the accuracy of self-reported antibiotic exposure. METHODS The study design was a cross-sectional survey of veterans seen at the Philadelphia Veterans Affairs (VA) Medical Center in 1999 and 2000. Subjects reported exposures to antibiotics, antihypertensive drugs and nonsteroidal anti-inflammatory drugs through a structured telephone interview. The instrument included open-ended questions, condition-specific prompts and drug-specific prompts. Subject responses were linked to a national VA pharmacy database that served as the reference standard for evaluating self-reported exposures. RESULTS The authors found that the sensitivity of self-report of antibiotic exposure increased with increasing use of prompts. A comprehensive assessment of antibiotic exposure identified 73% of antibiotic exposures, compared to 73% of antihypertensive drug exposures and 92% of nonsteroidal anti-inflammatory drug exposures. CONCLUSIONS Assessment of antibiotic exposure appears to be comparable to assessment of other chronic and episodic drugs. Multistep assessment of exposure improves the sensitivity of assessment.
Collapse
Affiliation(s)
- Joshua P Metlay
- Philadelphia Veterans Affairs Medical Center, Division of General Internal Medicine, Department of Medicine, Center for Clinical Epidemiology and Biostatistics, Univ. of Pennsylvania, Philadelphia, PA, USA.
| | | | | |
Collapse
|
31
|
Chapko MK, Borowsky SJ, Fortney JC, Hedeen AN, Hoegle M, Maciejewski ML, VanDeusen Lukas C. Evaluation of the Department of Veterans Affairs community-based outpatient clinics. Med Care 2002; 40:555-60. [PMID: 12142770 DOI: 10.1097/00005650-200207000-00001] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This paper describes the history of the Department of Veterans Affairs (VA) Community-Based Outpatient Clinics (CBOCs), CBOC Performance Evaluation Project, and characteristics of CBOCs within the VA, and summarizes the findings and implications of the CBOC Performance Evaluation Project. SUBJECTS There were 139 CBOCs in operation at the end of fiscal year 1998. Ninety-eight percent of CBOCs offered primary health care, and 28% offered primary health care and primary mental health care. The average CBOC was 70.7 miles from its parent VAMC. Sixty-one percent of the CBOCs were located in urban areas and 39% were in rural areas. Sixty-four percent of the CBOCs were VA-staff and 36% were contract. RESULTS The details of the project's findings are reported in four companion papers that describe, respectively, health care access and utilization, cost of care, patient perceptions of care, and quality of care in VA CBOCs. For most measures, CBOC performance was equivalent to their parent VAMCs. However, there were a few areas of potential concern: CBOCs had fewer patients that reported having one provider or team in charge of care; CBOC patients had fewer specialty visits; and CBOCs served a smaller percent of women and black persons. CONCLUSION CBOCs appear to be performing comparably to their parent medical centers but will benefit from ongoing monitoring.
Collapse
Affiliation(s)
- Michael K Chapko
- Health Services Research and Development, Northwest Center for Outcomes Research in Older Adults, VA Puget Sound Health Care System, Seattle, Washington 98108, USA.
| | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
Elderly individuals are at risk for acute confusion (AC) during hospitalization. Using a prospective design, this study assessed the relationship between admission risk factors and subsequent development of AC in 117 elderly hospitalized patients. AC was ascertained using the NEECHAM Confusion Scale. Other measures included demographic data, cognitive status, physical function, laboratory data, medications, infections, activity, pain, and nursing acuity. The cumulative incidence estimate was 14%. Patients who developed AC were more likely to be admitted to the hospital from somewhere other than home, to have lower admission NEECHAM and MMSE scores, and to have restricted activity levels, an infection, and abnormal lab values. These patients were more cognitively and physically frail and may have been chronically undernourished and dehydrated on admission to the hospital. Nurses can be trained to routinely assess for acute confusion using easily implemented instruments incorporated into a research-based protocol.
Collapse
|
33
|
Abstract
The objective was to use secondary analysis of prevalence data from a prospective cohort study to ascertain the accuracy of self-reported stroke among veterans. The study comprised a community-dwelling population of 88 elderly veterans (from five counties in the Northern Piedmont of North Carolina, USA) who received health care at the local Veterans Health Administration (VHA) medical center and were respondents at the North Carolina site of the NIH-funded Established Populations for Epidemiologic Studies of the Elderly (EPESE) project. Self-report of stroke from the baseline interview of the EPESE project; and occurrence of stroke as verified by the national VHA hospital discharge database and the patients' medical records was measured. Results showed that self-report of stroke had a sensitivity of 86% and a specificity of 100%; the predictive value of a positive report was 100%. Veterans' self-reports of stroke are sufficiently accurate to use in preliminary epidemiological studies and health services research of cerebrovascular disease.
Collapse
Affiliation(s)
- R D Horner
- Durham Veterans Affairs Medical Center, Duke University Medical Center, USA.
| | | | | |
Collapse
|
34
|
Kominski G, Andersen R, Bastani R, Gould R, Hackman C, Huang D, Jarvik L, Maxwell A, Moye J, Olsen E, Rohrbaugh R, Rosansky J, Taylor S, Van Stone W. UPBEAT: the impact of a psychogeriatric intervention in VA medical centers. Unified Psychogeriatric Biopsychosocial Evaluation and Treatment. Med Care 2001; 39:500-12. [PMID: 11317098 DOI: 10.1097/00005650-200105000-00010] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT) program provides individualized interdisciplinary mental health treatment and care coordination to elderly veterans whose comorbid depression, anxiety, or alcohol abuse may result in overuse of inpatient services and underuse of outpatient services. OBJECTIVES To determine whether proactive screening of hospitalized patients can identify unrecognized comorbid psychiatric conditions and whether comprehensive assessment and psychogeriatric intervention can improve care while reducing inpatient use. DESIGN Randomized trial. SUBJECTS Veterans aged 60 and older hospitalized for nonpsychiatric medical or surgical treatment in 9 VA sites (UPBEAT, 814; usual care, 873). MEASURES The Mental Health Inventory (MHI) anxiety and depression subscales, the Alcohol Use Disorder Identification Test (AUDIT) scores, RAND 36-Item Health Survey Short Form (SF-36), inpatient days and costs, ambulatory care clinic stops and costs, and mortality and readmission rates. RESULTS Mental health and general health status scores improved equally from baseline to 12-month follow-up in both groups. UPBEAT increased outpatient costs by $1,171 (P <0.001) per patient, but lowered inpatient costs by $3,027 (P = 0.017), for an overall savings of $1,856 (P = 0.156). Inpatient savings were attributable to fewer bed days of care (3.30 days; P = 0.016) rather than fewer admissions. Patients with 1 or more pre-enrollment and postenrollment hospitalizations had the greatest overall savings ($6,015; P = 0.069). CONCLUSIONS UPBEAT appears to accelerate the transition from inpatient to outpatient care for acute nonpsychiatric admissions. Care coordination and increased access to ambulatory psychiatric services produces similar improvement in mental health and general health status as usual care.
Collapse
Affiliation(s)
- G Kominski
- UCLA School of Public Health, Los Angeles, CA, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Sontag SJ, O'Connell S, Schnell T, Chejfec G, Seidel J, Sonnenberg A. Reduced symptoms and need for antisecretory therapy in veterans 3 years after Helicobacter pylori eradication with ranitidine bismuth citrate/amoxicillin/clarithromycin. Am J Gastroenterol 2001; 96:1390-5. [PMID: 11374672 DOI: 10.1111/j.1572-0241.2001.03771.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The most effective combination therapy to eradicate Helicobacter pylori has not yet been found. The perfect combination would be effective, relatively free of side effects, and easy to comply with. We studied a 14-day course of three medications taken twice daily by H. pylori-infected patients who were enrolled in the outpatient Veterans Affairs (VA) clinics. The two major objectives were 1) to determine the effectiveness of the combination therapy and 2) to determine the compliance of patients in a VA population. METHODS Fifty-two male patients were identified with H. pylori infection by positive CLO (Rapid Urease Test) test, positive Giemsa stain, or positive serology. Active infection was confirmed by a positive 13C urea breath test (UBT). Patients were treated for 14 days with open-label triple-combination therapy of ranitidine bismuth citrate (RBC; 400 mg b.i.d.), amoxicillin (1000 mg b.i.d.), and clarithromycin (500 mg b.i.d.). Successful eradication of H. pylori was confirmed by repeat UBT at 6-8 wk after the final dose of therapy. RESULTS Of the 52 enrolled patients, 49 (94.2%) met the criteria for successful completion of the study (per protocol analysis based on compliance with at least 80% of medication and performance of both UBTs). Of the three patients who did not successfully complete, one was cured (after 6 days of treatment), and two remained infected (after 3 days and 9 days of treatment). Of the 49 completed patients, 45 (91.8%) were cured, and four remained infected. Overall, regardless of compliance (intent-to-treat analysis), 46 of the 52 (88.4%) patients had documented cure of H. pylori infection as determined by the posttreatment UBT. By 3 yr after H. pylori eradication, two of 15 (13.3%) patients who were not on baseline medications had developed the need for antisecretory therapy, but 18 of 31 (58.1%) who were on baseline medications were able to stop therapy. Thus, at 3 yr, successful H. pylori eradication decreased the need for antisecretory therapy from 67.4% of the H. pylori-infected population to 43% of the H. pylori-eradicated population. The effect of H. pylori eradication in improving symptoms at 3 yr was statistically significant in both the ulcer population and the nonulcer population. Adverse events were mild, and included diarrhea (26 patients), bad taste in mouth (24 patients), nausea/upset stomach (nine patients), and headache (two patients). The diarrhea was self-limiting in 25 of the 26 patients. Only two patients discontinued medication because of adverse events. CONCLUSION The RBC/amoxicillin/clarithromycin combination was, in our VA population, an easily complied with, highly effective, and safe triple therapy with a 90% H. pylori eradication rate. Successful eradication of H. pylori leads to a dramatic decrease in upper-gut symptoms and decreased need for antisecretory therapy.
Collapse
Affiliation(s)
- S J Sontag
- Department of Medicine, Veterans Affairs Hospital, Hines, Illinois 60141-5000, USA
| | | | | | | | | | | |
Collapse
|
36
|
Stineman MG, Ross RN, Hamilton BB, Maislin G, Bates B, Granger CV, Asch DA. Inpatient rehabilitation after stroke: a comparison of lengths of stay and outcomes in the Veterans Affairs and non-Veterans Affairs health care system. Med Care 2001; 39:123-37. [PMID: 11176550 DOI: 10.1097/00005650-200102000-00003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients have longer lengths of hospital stay (LOS) in VA medical centers than in the general health care system. OBJECTIVE The objective of this study was to determine whether resource use and outcome differences between VA and non-VA inpatient rehabilitation facilities remain after controlling for patient and medical care delivery differences. DESIGN This analysis involved 60 VA inpatient rehabilitation units and 467 non-VA rehabilitation hospitals and units. Multivariate adjusted resource use and patient outcome differences were compared across setting within patients grouped by severity of disability at admission through assignment to the Function Related Group (FRG) patient classification system. SUBJECTS The study included 55,438 stroke patients. MEASURES Study measures were LOS, functional status at discharge, and community discharge. RESULTS The VA serves a higher proportion of patients who are single, separated, or divorced; are unemployed or retired as a result of disability, and are not white (P < 0.0001). These traits tended to be associated with longer LOS, lower functional outcomes, and reduced rates of community discharge. After adjusting for these and other differences, depending on FRG, average LOS remained from 30% to 200% longer in the VA centers (P < 0.05); average functional outcomes were significantly higher in 8 and lower in 2 FRGs (P < 0.05); and community discharge rates were lower in 12 FRGs (P < 0.05). CONCLUSIONS While certain variables accounted for some of the observed differences in resource use and outcomes, differences remained after adjustment. Fewer incentives for cost containment and less support in patients' home environments may be among the most important unmeasured determinants of VA differences.
Collapse
Affiliation(s)
- M G Stineman
- Department of Rehabilitation Medicine, Leonard Davis Institute of Health Economics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, USA
| | | | | | | | | | | | | |
Collapse
|
37
|
Ashton CM, Bozkurt B, Colucci WB, Kiefe CI, Mann DL, Massie BM, Slawsky MT, Tierney WM, West JA, Whellan DJ, Wray NP. Veterans Affairs Quality Enhancement Research Initiative in chronic heart failure. Med Care 2000; 38:I26-37. [PMID: 10843268 DOI: 10.1097/00005650-200006001-00004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Chronic heart failure (CHF) is a highly prevalent condition associated with serious morbidity, intense levels of health services use, and shortened survival. It is also a condition for which ameliorative therapies exist. The evidence indicates that there is substantial need to change clinical practice and health care delivery for people with CHF and thereby improve their outcomes. The goal of the Veterans Affairs (VA) Quality Enhancement Research Initiative in CHF (CHF QUERI) is to create measurable, rapid, and sustainable improvements in quality of care and health outcomes of veterans with heart failure. This article describes the current state of knowledge and practice in care for people with CHF. Using the framework of the 5 steps of the QUERI process, we point out the gaps in research and practice that must be filled if the CHF QUERI is to achieve its goal. We relate our recommendations for how the VA can put its research and administrative infrastructure to work to fill the gaps. Lessons learned about CHF in the course of the CHF QUERI will be applicable to all people with heart failure and to all health care systems--VA as well as non-VA--that care for them.
Collapse
Affiliation(s)
- C M Ashton
- Houston Center for Quality of Care and Utilization Studies, Veterans Affairs Medical Center of Houston, Texas 77030, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Wilt TJ, Cowper DC, Gammack JK, Going DR, Nugent S, Borowsky SJ. An evaluation of radical prostatectomy at Veterans Affairs Medical Centers: time trends and geographic variation in utilization and outcomes. Med Care 1999; 37:1046-56. [PMID: 10524371 DOI: 10.1097/00005650-199910000-00008] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine temporal trends and geographic variation in utilization of radical prostatectomy (RP) as well as 30-day mortality and complication rates. DESIGN Administrative data-base study of radical prostatectomy (RP) using the Department of Veterans Affairs Patient Treatment File and Outpatient Clinic File between 1986 to 1996. Logistic regression was used to estimate temporal and geographic effects on the use of RP. SETTING All Departments of Veterans Affairs Medical Centers (VAMC) in the contiguous United States. PATIENTS Men aged 45 to 84 years who underwent RP at a VAMC (n = 13,398). MAIN OUTCOME MEASURES Number and utilization of RP, rate of 30-day mortality, major cardiopulmonary or vascular complications, and colorectal injuries requiring surgical repair within 30 days of RP. RESULTS From 1986 to 1996, the annual number of RP at VAMCs (range, 695-1,545 RP) more than doubled, and the rate of RP at VAMCs per male VA user increased by 40% (range, 48/100,000-66/100,000). After controlling for age and year, the utilization of RP in West North Central, Mountain, West South Central, and Pacific census divisions was 70%, 14%, 10%, and 8% higher, respectively, whereas the utilization of RP in New England, East North Central, and Mid-Atlantic divisions was 38%, 31%, and 25% lower, respectively, than the rest of the nation (P<0.001). Geographic variation in utilization decreased during the period between 1986 and 1996, but a twofold difference in RP utilization in 1996 remained between high- and low-utilization divisions. Major cardiopulmonary complications, vascular complications, and colorectal injuries occurred in 1.7%, 0.2%, and 1.8% of men, respectively. Thirty-day mortality was 0.73%, declined from 1986 to 1996, and was associated with a history of diabetes and congestive heart failure. CONCLUSION Utilization of RP at VAMCs increased over time and varied across geographic areas. Thirty-day mortality was less than 1% and decreased with time. Differences in utilization may be caused by uncertainty regarding the effectiveness of early detection and treatment of prostate cancer.
Collapse
Affiliation(s)
- T J Wilt
- Section of General Internal Medicine and Minneapolis VA:VISN 13 Center for Chronic Disease Outcomes Research, MN 55417, USA.
| | | | | | | | | | | |
Collapse
|
39
|
Noronha SF, Desai PN. Psychiatric emergency services in the Veterans Health Administration: a review. NEW DIRECTIONS FOR MENTAL HEALTH SERVICES 1999:75-84. [PMID: 10380538 DOI: 10.1002/yd.23319998210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The VA health care system is the largest source of public mental health care in the country, providing specialty mental health care services to more than 550,000 veterans annually. This chapter reviews the nature and scope of VA psychiatric emergency services.
Collapse
Affiliation(s)
- S F Noronha
- VA Chicago Health Care Systems, West Side Division, USA
| | | |
Collapse
|
40
|
Ashton CM, Petersen NJ, Souchek J, Menke TJ, Yu HJ, Pietz K, Eigenbrodt ML, Barbour G, Kizer KW, Wray NP. Geographic variations in utilization rates in Veterans Affairs hospitals and clinics. N Engl J Med 1999; 340:32-9. [PMID: 9878643 DOI: 10.1056/nejm199901073400106] [Citation(s) in RCA: 175] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In the United States, geographic variation in hospital use is common. It is uncertain whether there are similar geographic variations in the health care system of the Department of Veterans Affairs (VA), which differs from the private sector because it predominantly serves men with annual incomes below $20,000, has a central system of administration, and uses salaried physicians. Thus, it might be less likely to have geographic variations. METHODS We used VA data bases to obtain information on patients treated for eight diseases (chronic obstructive pulmonary disease, pneumonia, congestive heart failure, angina, diabetes, chronic renal failure, bipolar disorder, and major depression). We analyzed their use of hospital and outpatient services by assessing the risk-adjusted numbers of hospital days (the average number of days a patient spent in the hospital per 12 months of follow-up, regardless of the number of hospital stays), hospital-discharge rates, and clinic-visit rates from 1991 through 1995 for the entire system and within the 22 geographically based health care networks. RESULTS We found substantial geographic variation in hospital use for all eight cohorts of patients and all the years studied. Variations in the numbers of hospital days per person-year among the networks were greatest among patients with chronic obstructive pulmonary disease (ranging from a factor of 2.7 to a factor of 3.1) during a given year and smallest among patients with angina (ranging from a factor of 1.5 to a factor of 2.1). Levels of hospital use were highest in the Northeast and lowest in the West. The variation in the rates of clinic visits for principal medical care among the networks ranged from a factor of approximately 1.6 to a factor of 4.0; variations in the rates were greatest among patients with chronic renal failure and smallest among patients with chronic obstructive pulmonary disease. There was no clear geographic pattern in the rates of outpatient-clinic use. CONCLUSIONS There are significant geographic variations in the use of hospital and outpatient services in the VA health care system. Because VA physicians are unable to increase their income by changing their patterns of practice, our findings suggest that their practice styles are similar to those of other physicians in their geographic regions.
Collapse
Affiliation(s)
- C M Ashton
- Center for Quality of Care and Utilization Studies, Veterans Affairs Medical Center, Houston, TX 77030, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Ashton CM, Petersen NJ, Souchek J, Menke TJ, Pietz K, Yu HJ, Wray NP. Rates of health services utilization and survival in patients with heart failure in the Department of Veterans Affairs medical care system. Am J Med Qual 1999; 14:55-63. [PMID: 10446664 DOI: 10.1177/106286069901400108] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study was to describe patterns of hospital and clinic use and survival for a large nationwide cohort of patients with heart failure. A retrospective cohort study of patients treated in the Veterans Affairs medical care system was conducted using linked administrative databases as data sources. In 1996, the average heart failure cohort member had 1-2 hospitalizations, 14 inpatient days, 6-7 visits with the primary physician, 15 other visits for consultations or tests, and 1-2 urgent care visits per 12 months. The overall risk-adjusted 5-year survival rate was 36%. Hospital use rates in the cohort fell dramatically between 1992 and 1996. One-year survival rates increased slightly over the period. Patients with heart failure are heavy users of services and have a very poor prognosis. Utilization and outcome data indicate the need for major efforts to assure quality of care and to devise innovative ways of delivering comprehensive services.
Collapse
Affiliation(s)
- C M Ashton
- Center for Quality of Care and Utilization Studies, VA Medical Center, Houston, TX, USA.
| | | | | | | | | | | | | |
Collapse
|