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Khan Y, Verhaeghe N, De Pauw R, Devleesschauwer B, Gadeyne S, Gorasso V, Lievens Y, Speybroek N, Vandamme N, Vandemaele M, Van den Borre L, Vandepitte S, Vanthomme K, Verdoodt F, De Smedt D. Evaluating the health and health economic impact of the COVID-19 pandemic on delayed cancer care in Belgium: A Markov model study protocol. PLoS One 2023; 18:e0288777. [PMID: 37903130 PMCID: PMC10615261 DOI: 10.1371/journal.pone.0288777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 06/28/2023] [Indexed: 11/01/2023] Open
Abstract
INTRODUCTION Cancer causes a substantial burden to our society, both from a health and an economic perspective. To improve cancer patient outcomes and lower society expenses, early diagnosis and timely treatment are essential. The recent COVID-19 crisis has disrupted the care trajectory of cancer patients, which may affect their prognosis in a potentially negative way. The purpose of this paper is to present a flexible decision-analytic Markov model methodology allowing the evaluation of the impact of delayed cancer care caused by the COVID-19 pandemic in Belgium which can be used by researchers to respond to diverse research questions in a variety of disruptive events, contexts and settings. METHODS A decision-analytic Markov model was developed for 4 selected cancer types (i.e. breast, colorectal, lung, and head and neck), comparing the estimated costs and quality-adjusted life year losses between the pre-COVID-19 situation and the COVID-19 pandemic in Belgium. Input parameters were derived from published studies (transition probabilities, utilities and indirect costs) and administrative databases (epidemiological data and direct medical costs). One-way and probabilistic sensitivity analyses are proposed to consider uncertainty in the input parameters and to assess the robustness of the model's results. Scenario analyses are suggested to evaluate methodological and structural assumptions. DISCUSSION The results that such decision-analytic Markov model can provide are of interest to decision makers because they help them to effectively allocate resources to improve the health outcomes of cancer patients and to reduce the costs of care for both patients and healthcare systems. Our study provides insights into methodological aspects of conducting a health economic evaluation of cancer care and COVID-19 including insights on cancer type selection, the elaboration of a Markov model, data inputs and analysis.
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Affiliation(s)
- Yasmine Khan
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
- Interface Demography, Department of Sociology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Nick Verhaeghe
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- Research Institute for Work and Society, KU Leuven, Leuven, Belgium
| | - Robby De Pauw
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
- Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
| | - Brecht Devleesschauwer
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
- Department of Translational Physiology, Infectiology and Public Health, Ghent University, Merelbeke, Belgium
| | - Sylvie Gadeyne
- Interface Demography, Department of Sociology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Vanessa Gorasso
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
| | - Yolande Lievens
- Radiation Oncology Department, Ghent University Hospital and Ghent University, Ghent, Belgium
| | - Niko Speybroek
- Research Institute of Health and Society, University of Louvain, Brussels, Belgium
| | - Nancy Vandamme
- Research Department, Belgian Cancer Registry, Brussels, Belgium
| | - Miet Vandemaele
- Radiation Oncology Department, Ghent University Hospital and Ghent University, Ghent, Belgium
| | - Laura Van den Borre
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium
- Interface Demography, Department of Sociology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Sophie Vandepitte
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Katrien Vanthomme
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- Interface Demography, Department of Sociology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Freija Verdoodt
- Research Department, Belgian Cancer Registry, Brussels, Belgium
| | - Delphine De Smedt
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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2
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Dinesh D, Shao Q, Palnati M, McDannold S, Zhang Q, Monfared AAT, Jasuja GK, Davila H, Xia W, Moo LR, Miller DR, Palacios N. The epidemiology of mild cognitive impairment, Alzheimer's disease and related dementia in U.S. veterans. Alzheimers Dement 2023; 19:3977-3984. [PMID: 37114952 DOI: 10.1002/alz.13071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/25/2022] [Accepted: 11/10/2022] [Indexed: 04/29/2023]
Abstract
INTRODUCTION US veterans have a unique dementia risk profile that may be evolving over time. METHODS Age-standardized incidence and prevalence of Alzheimer's disease (AD), AD and related dementias (ADRD), and mild cognitive impairment (MCI) was estimated from electronic health records (EHR) data for all veterans aged 50 years and older receiving Veterans Health Administration (VHA) care from 2000 to 2019. RESULTS The annual prevalence and incidence of AD declined, as did ADRD incidence. ADRD prevalence increased from 1.07% in 2000 to 1.50% in 2019, primarily due to an increase in the prevalence of dementia not otherwise specified. The prevalence and incidence of MCI increased sharply, especially after 2010. The prevalence and incidence of AD, ADRD, and MCI were highest in the oldest veterans, in female veterans, and in African American and Hispanic veterans. DISCUSSION We observed 20-year trends of declining prevalence and incidence of AD, increasing prevalence of ADRD, and sharply increasing prevalence and incidence of MCI.
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Affiliation(s)
- Deepika Dinesh
- Department of Public Health, University of Massachusetts at Lowell, Zuckerberg College of Health Sciences, Lowell, Massachusetts, USA
- Center for Population Health, Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, Massachusetts, USA
| | - Qing Shao
- Bedford VA Healthcare System, Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
| | - Madhuri Palnati
- Bedford VA Healthcare System, Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
| | - Sarah McDannold
- Bedford VA Healthcare System, Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
| | - Quanwu Zhang
- Easai Inc., Neurology Business Group, Woodcliff Lake, New Jersey, USA
| | - Amir Abbas Tahami Monfared
- Easai Inc., Neurology Business Group, Woodcliff Lake, New Jersey, USA
- McGill University, Epidemiology, Biostatistics, and Occupational Health, Montreal, Quebec, Canada
| | - Guneet K Jasuja
- Bedford VA Healthcare System, Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Heather Davila
- Center for Access & Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa, USA
- General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Weiming Xia
- Bedford VA Healthcare System, Geriatric Research and Education Clinical Center, Bedford, Massachusetts, USA
- Department of Pharmacology and Experimental Therapeutics, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Lauren R Moo
- Bedford VA Healthcare System, Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
- Bedford VA Healthcare System, Geriatric Research and Education Clinical Center, Bedford, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Donald R Miller
- Center for Population Health, Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, Massachusetts, USA
- Bedford VA Healthcare System, Center for Healthcare Organization and Implementation Research, Bedford, Massachusetts, USA
| | - Natalia Palacios
- Department of Public Health, University of Massachusetts at Lowell, Zuckerberg College of Health Sciences, Lowell, Massachusetts, USA
- Center for Population Health, Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, Massachusetts, USA
- Bedford VA Healthcare System, Geriatric Research and Education Clinical Center, Bedford, Massachusetts, USA
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Rose L, Schmidt A, Gehlert E, Graham LA, Aouad M, Wagner TH. Association Between Self-Reported Health and Reliance on Veterans Affairs for Health Care Among Veterans Affairs Enrollees. JAMA Netw Open 2023; 6:e2323884. [PMID: 37459100 PMCID: PMC10352854 DOI: 10.1001/jamanetworkopen.2023.23884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/02/2023] [Indexed: 07/20/2023] Open
Abstract
This cross-sectional study using survey data investigates the association between level of reliance on the Department of Veterans Affairs for health care and self-reported health by type of insurance coverage among VA enrollees.
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Affiliation(s)
- Liam Rose
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement and Education Center, Stanford Medicine, Stanford, California
| | - Anna Schmidt
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Elizabeth Gehlert
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Laura A. Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement and Education Center, Stanford Medicine, Stanford, California
| | - Marion Aouad
- Department of Economics, University of California, Irvine
| | - Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Stanford Surgery Policy Improvement and Education Center, Stanford Medicine, Stanford, California
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Wang H, Cai S, Caprio T, Goulet J, Intrator O. Opioid administration trends among long-stay community living centers residents with dementia. J Am Geriatr Soc 2022; 70:2393-2403. [PMID: 35397116 DOI: 10.1111/jgs.17785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pain assessment and management of Veterans with Alzheimer's disease and Related Dementia (ADRD) living in Community Living Centers (CLCs) is challenging. Safe and effective use of opioids in the treatment of pain is of great concern to patients and providers promulgating national policies and guidelines. METHODS This study examined long-stay CLC Veterans with ADRD identified in three regulatory periods (period 1: 10/2012-6/2013, n = 3347; period 2: 1/2014-11/2015, n = 4426; period 3: 1/2017-9/2018, n = 4444; Total N = 12,217).This population-based observational study used CLC Minimum Data Set (MDS) data in Fiscal Years (FYs) 2013-2018 and VA bar-code medication administration (BCMA) data. Opioid administration measures included: any opioids, long-term opioids, high-dose opioids, and co-administration with benzodiazepine. Measures were modeled using negative binomial regression with length of stay in CLC as offset adjusting for Veteran predisposing, enabling and need measures from the MDS. RESULTS Compared to period 1, any opioid administration was 26% lower in period 2, and 34% lower in period 3. Among Veterans who received any opioid medications over the three regulatory periods, high-dose and long-term opioid administration were more than 40% lower in periods 2 and 3 compared to period 1. Co-administration of opioid with benzodiazepine versus no opioid was 11% lower in period 2 and 34% lower in period 3 after adjusting for patient level covariates. CONCLUSIONS All patterns of opioid administration decreased over the four opioid regulations periods when guidelines were promulgated across the VA health system. Further research should clarify whether decreasing opioids among patients with ADRD impacted health outcomes.
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Affiliation(s)
- Huiying Wang
- Geriatrics and Extended Care Data and Analysis Center (GECDAC), Finger Lakes Healthcare System, Canandaigua, New York, USA.,Public Health Sciences, University of Rochester, Rochester, New York, USA
| | - Shubing Cai
- Geriatrics and Extended Care Data and Analysis Center (GECDAC), Finger Lakes Healthcare System, Canandaigua, New York, USA.,Public Health Sciences, University of Rochester, Rochester, New York, USA
| | - Thomas Caprio
- Department of Medicine, University of Rochester, Rochester, New York, USA
| | - Joseph Goulet
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Orna Intrator
- Geriatrics and Extended Care Data and Analysis Center (GECDAC), Finger Lakes Healthcare System, Canandaigua, New York, USA.,Public Health Sciences, University of Rochester, Rochester, New York, USA
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Nakanishi Y, Tsugihashi Y, Akahane M, Noda T, Nishioka Y, Myojin T, Kubo S, Higashino T, Okuda N, Robine JM, Imamura T. Comparison of Japanese Centenarians' and Noncentenarians' Medical Expenditures in the Last Year of Life. JAMA Netw Open 2021; 4:e2131884. [PMID: 34739063 PMCID: PMC8571656 DOI: 10.1001/jamanetworkopen.2021.31884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Although research has shown that centenarians tend to experience shorter periods of serious illness compared with other age groups, few studies have focused on the medical expenditures of centenarians as a potential indicator of the scale of medical resources used in their last year of life. OBJECTIVE To compare Japanese centenarians' and noncentenarians' monthly medical expenditures during the year before death according to age and sex. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used linked national health and long-term care insurance data collected from April 2013 to March 2018 in Nara Prefecture, Japan, for residents aged 75 years or older who were insured under the Medical Care System for older adults and died between April 2014 and March 2018. Data were analyzed from April 2013 to March 2018. EXPOSURES Age of 100 years or older (centenarians) vs 75 to 99 years (noncentenarians). MAIN OUTCOMES AND MEASURES The numbers of unique inpatients and outpatients and medical expenditures related to decedents' hospitalization and outpatient care were extracted and analyzed based on sex and age group. The Jonckheere-Terpstra test was used to identify trends in unadjusted medical expenditures by age group, and generalized estimating equations were used to estimate monthly median expenditures by age group with adjustment for comorbidity burden and functional status. RESULTS Of 34 317 patients aged 75 to 109 years (16 202 men [47.2%] and 18 115 women [52.8%]) who died between April 2014 and March 2018, 872 (2.5%) were aged 100 to 104 years (131 men [15.0%] and 741 women [85.0%]) and 78 (0.2%) were aged 105 to 109 years (fewer than 10 were men). The analysis of unadjusted medical expenditures in the last year of life showed a significant trend of lower expenditures for the older age groups; the median adjusted total expenditures during the 30 days before death by age group were $6784 (IQR, $4884-$9703) for ages 75 to 79 years, $5894 (IQR, $4292-$8536) for 80 to 84 years, $5069 (IQR, $3676-$7150) for 85 to 89 years, $4205 (IQR, $3085-$5914) for 90 to 94 years, $3522 (IQR, $2626-$4861) for 95 to 99 years, $2898 (IQR, $2241-$3835) for 100 to 104 years, and $2626 (IQR, $1938-$3527) for 105 to 109 years. The proportion of inpatients among all patients in the year before death also decreased with increasing age: 4311 of all 4551 patients aged 75 to 79 years (94.7%); 43 of all 78 patients aged 105 to 109 years (55.1%); 2831 of 2956 men aged 75 to 79 years (95.8%); 50.0% of men aged 105 to 109 years (the number is not reported owing to the small sample size); 1480 of 1595 women aged 75 to 79 years (92.8%); and 55.7% of women aged 105 to 109 years (the number of women is not reported to prevent back-calculation of the number of men). Specifically, 274 of 872 patients aged 100 to 104 years (31.4%) and 35 of 78 patients aged 105 to 109 years (44.9%) had not been admitted to a hospital in the year before death. CONCLUSIONS AND RELEVANCE This cohort study found that medical expenditures in the last year of life tended to be lower for centenarians than for noncentenarians aged 75 years or older in Japan. The proportion of inpatients also decreased with increasing age. These findings may inform future health care services coverage and policies for centenarians.
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Affiliation(s)
- Yasuhiro Nakanishi
- Department of Health and Welfare Services, National Institute of Public Health, Wako, Saitama, Japan
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Nara, Japan
| | - Yukio Tsugihashi
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Nara, Japan
| | - Manabu Akahane
- Department of Health and Welfare Services, National Institute of Public Health, Wako, Saitama, Japan
| | - Tatsuya Noda
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Nara, Japan
| | - Yuichi Nishioka
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Nara, Japan
| | - Tomoya Myojin
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Nara, Japan
| | - Shinichiro Kubo
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Nara, Japan
| | - Tsuneyuki Higashino
- Healthcare and Wellness Division, Mitsubishi Research Institute Inc, Chiyoda, Tokyo, Japan
| | - Naoko Okuda
- Japan Medical Association Research Institute, Tokyo, Japan
| | - Jean-Marie Robine
- Mécanismes Moléculaires Dans les Démences, École Pratique des Hautes Études, Institut National de la Santé et de la Recherche Médicale, University of Montpellier, Montpellier, France, and Paris Sciences & Lettres Research University, Montpellier, France
- Centre de Recherche Médecine, Sciences, Santé, Santé Mentale, Société, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Ecole des Hautes Études en Sciences Sociales, University of Paris, Paris, France
| | - Tomoaki Imamura
- Department of Public Health, Health Management and Policy, Nara Medical University, Kashihara, Nara, Japan
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Lei L, Cai S, Conwell Y, Fortinsky RH, Intrator O. Continuity of Care and Successful Hospital Discharge of Older Veterans With Dementia. J Appl Gerontol 2021; 41:1035-1046. [PMID: 34686087 DOI: 10.1177/07334648211051867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Care transitions are frequent among patients with dementia. This study aimed to estimate the impact of continuity of care (COC) on successful community discharge after hospitalization. METHODS National Veterans Health Administration data linked to Medicare claims in fiscal years 2014-2015. Community-dwelling older veterans with dementia with an acute hospitalization were included (n = 31,648). COC was measured by the Bice-Boxerman Continuity of Care (BBC) index (0-1). Association of COC before hospitalization on successful community discharge was examined separately among veterans discharged to the community directly and through post-acute care facilities. RESULTS Veterans with a 0.1 higher BBC were 4.6% (p = .06) more likely to have successful direct community discharge; but BBC had no demonstrable effect when discharge was through post-acute care facilities. CONCLUSION Better COC may have impact at improving successful direct community discharge, although the effect is small and the type I error rate (statistical significance) was 6%.
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Affiliation(s)
- Lianlian Lei
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.,VHA Office Geriatrics & Extended Care Data & Analyses Center (GECDAC), Washington, DC, USA
| | - Shubing Cai
- VHA Office Geriatrics & Extended Care Data & Analyses Center (GECDAC), Washington, DC, USA.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | | | - Orna Intrator
- VHA Office Geriatrics & Extended Care Data & Analyses Center (GECDAC), Washington, DC, USA.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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7
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Sontheimer N, Konnopka A, König HH. The Excess Costs of Dementia: A Systematic Review and Meta-Analysis. J Alzheimers Dis 2021; 83:333-354. [PMID: 34334395 DOI: 10.3233/jad-210174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Dementia is one of the costliest diseases for health care systems with growing importance for policy makers. OBJECTIVE The aim of this study is to systematically review the current literature of excess cost studies for dementia and to analyze excess costs in a meta-analysis. METHODS A systematic literature search was conducted in PubMed, EconLit, NHS-EED, and Cochrane Library. 22 studies were included and assigned to one of three subgroups according to the time period that they analyzed during disease progression: the time of diagnosis, the time between diagnosis and death, and the time prior to death. Excess costs were analyzed using the ratio of means (ROM) and meta-analysis was performed by pooling ROMs in a random effects model. RESULTS Total costs were significantly higher for demented persons compared to non-demented persons at the time of diagnosis (ROM: 2.08 [1.71, 2.54], p < 0.00001, I2 = 98%) and in the time period between diagnosis and death (ROM: 2.19 [1.97, 2.44], p < 0.00001, I2 = 100%). The ROM was highest for professional home care (ROM: 4.96 [2.62, 9.40], p < 0.0001, I2 = 88%) and for nursing facilities (ROM: 4.02 [2.53, 6.40], p < 0.00001, I2 = 100%) for the time period between diagnosis and death. CONCLUSION This meta-analysis is the first to assess excess costs of dementia by the ROM method on a global scale. We conclude that our findings demonstrate that costs of dementia constitute a substantial economic burden.
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Affiliation(s)
- Nadine Sontheimer
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Konnopka
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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8
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Zhu CW, Sano M. Demographic, Health, and Exposure Risks Associated With Cognitive Loss, Alzheimer's Disease and Other Dementias in US Military Veterans. Front Psychiatry 2021; 12:610334. [PMID: 33716816 PMCID: PMC7947283 DOI: 10.3389/fpsyt.2021.610334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 02/04/2021] [Indexed: 11/13/2022] Open
Abstract
The US military veteran population receiving care through the Veterans Health Administration (VHA) is particularly susceptible to cognitive impairment and dementias such as Alzheimer's disease and related dementias due to demographic, clinical, and economic factors. In this report we summarize the prevalence of dementia among US veterans and risks associated with AD and related dementias. We discuss the likelihood that these risks may be increasing in those about to enter the age in which dementias are common. We propose that VHA, the largest integrated health care system in the US, has shown promise in managing health risks that impact dementia prevention and propose further system wide approaches to be assessed for effective dementia prevention and care delivery.
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Affiliation(s)
- Carolyn W Zhu
- Icahn School of Medicine at Mount Sinai, New York, NY, United States.,James J. Peters VA Medical Center, Bronx, NY, United States
| | - Mary Sano
- Icahn School of Medicine at Mount Sinai, New York, NY, United States.,James J. Peters VA Medical Center, Bronx, NY, United States
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9
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Gidwani R, Asch SM, Needleman J, Faricy-Anderson K, Boothroyd DB, Illarmo S, Lorenz KA, Patel MI, Hsin G, Ramchandran K, Wagner TH. End-of-Life Cost Trajectories in Cancer Patients Treated by Medicare versus the Veterans Health Administration. J Am Geriatr Soc 2020; 69:916-923. [PMID: 33368171 DOI: 10.1111/jgs.16941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/29/2020] [Accepted: 10/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES To evaluate differences in end-of-life cost trajectories for cancer patients treated through Medicare versus by the Veterans Health Administration (VA). DESIGN A retrospective analysis of VA and Medicare administrative data from FY 2010 to 2014. We employed three-level generalized estimating equations to evaluate monthly cost trajectories experienced by patients in their last year of life, with patients nested within hospital referral region. SETTING Care received at VA facilities or by Medicare-reimbursed providers nationwide. PARTICIPANTS A total of 36,401 patients dying from cancer and dually enrolled in VA and Medicare. MEASUREMENTS We evaluated trajectories for total, inpatient, outpatient, and drug costs, using the last 12 months of life. Cost trajectories were prioritized as costs are not directly comparable across Medicare and VA. Patients were assigned to be VA-reliant, Medicare-reliant or Mixed-reliant based on their healthcare utilization in the last year of life. RESULTS All three groups experienced significantly different cost trajectories for total costs in the last year of life. Inpatient cost trajectories were significantly different between Medicare-reliant and VA-reliant patients, but did not differ between VA-reliant and Mixed-reliant patients. Outpatient and drug cost trajectories exhibited the inverse pattern: they were significantly different between VA-reliant and Mixed-reliant patients, but not between VA-reliant and Medicare-reliant patients. However, visual examination of cost trajectories revealed similar cost patterns in the last year of life among all three groups; there was a sharp rise in costs as patients approach death, largely due to inpatient care. CONCLUSION Despite substantially different financial incentives and organization, VA- and Medicare-treated patients exhibit similar patterns of increasing end-of-life costs, largely driven by inpatient costs. Both systems require improvement to ensure quality of end-of-life care is aligned with recommended practice.
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Affiliation(s)
- Risha Gidwani
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Jack Needleman
- Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Katherine Faricy-Anderson
- Providence VA Medical Center, Providence, Rhode Island, USA.,Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Derek B Boothroyd
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Samantha Illarmo
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Karl A Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Manali I Patel
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California, USA.,VA Palo Alto Health Care System, Palo Alto, California, USA.,Division of Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Gary Hsin
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.,VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Kavitha Ramchandran
- Division of Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Todd H Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, USA.,Department of Surgery, Stanford University, Stanford, California, USA
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10
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Ahearn EP, Szymanski BR, Chen P, Sajatovic M, Katz IR, McCarthy JF. Increased Risk of Dementia Among Veterans With Bipolar Disorder or Schizophrenia Receiving Care in the VA Health System. Psychiatr Serv 2020; 71:998-1004. [PMID: 32517643 PMCID: PMC8011612 DOI: 10.1176/appi.ps.201900325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The Veterans Health Administration (VHA) provides a continuum of care over the life course. Among U.S. adults, bipolar disorder and schizophrenia are associated with increased risk of dementia. To inform service planning, this study assessed the incidence of dementia among veteran VHA patients with bipolar disorder or schizophrenia, with adjustment for comorbid medical conditions. METHODS Using data from the VHA Corporate Data Warehouse, the authors identified all veterans who received VHA care in 2004 and 2005 without a dementia diagnosis and who were alive and between ages 18 and 100 as of January 1, 2006. Individuals were categorized as having bipolar disorder, schizophrenia, or neither condition on the basis of diagnoses in 2004-2005. Among ongoing VHA users, incidence of dementia was assessed for up to 10 years (2006-2015). RESULTS The cohort included 3,648,852 individuals. After analyses controlled for baseline comorbid general medical conditions and substance use disorders, the incidence rate ratios (IRRs) for dementia were 2.92 for those with schizophrenia and 2.26 for those with bipolar disorder, compared with VHA patients with neither condition. CONCLUSIONS Among veterans receiving VHA care, diagnoses of bipolar disorder and schizophrenia were each associated with increased risk of receiving a new diagnosis of dementia, even when analyses controlled for baseline medical comorbidities. IRRs were elevated for patients with either condition, compared with those with neither condition, and highest for those with schizophrenia. VHA clinicians should evaluate patients for dementia when signs or symptoms of cognitive impairment are present.
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Affiliation(s)
- Eileen P Ahearn
- Department of Psychiatry, William S. Middleton Department of Veterans Affairs (VA) Hospital, Madison, Wisconsin, and Department of Psychiatry, University of Wisconsin-Madison, Madison (Ahearn); Office of Mental Health and Suicide Prevention, VA, Washington, D.C. (Szymanski, Katz, McCarthy); Department of Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland (Chen); Department of Psychiatry, Case Western Reserve University, Cleveland (Chen, Sajatovic)
| | - Benjamin R Szymanski
- Department of Psychiatry, William S. Middleton Department of Veterans Affairs (VA) Hospital, Madison, Wisconsin, and Department of Psychiatry, University of Wisconsin-Madison, Madison (Ahearn); Office of Mental Health and Suicide Prevention, VA, Washington, D.C. (Szymanski, Katz, McCarthy); Department of Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland (Chen); Department of Psychiatry, Case Western Reserve University, Cleveland (Chen, Sajatovic)
| | - Peijun Chen
- Department of Psychiatry, William S. Middleton Department of Veterans Affairs (VA) Hospital, Madison, Wisconsin, and Department of Psychiatry, University of Wisconsin-Madison, Madison (Ahearn); Office of Mental Health and Suicide Prevention, VA, Washington, D.C. (Szymanski, Katz, McCarthy); Department of Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland (Chen); Department of Psychiatry, Case Western Reserve University, Cleveland (Chen, Sajatovic)
| | - Martha Sajatovic
- Department of Psychiatry, William S. Middleton Department of Veterans Affairs (VA) Hospital, Madison, Wisconsin, and Department of Psychiatry, University of Wisconsin-Madison, Madison (Ahearn); Office of Mental Health and Suicide Prevention, VA, Washington, D.C. (Szymanski, Katz, McCarthy); Department of Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland (Chen); Department of Psychiatry, Case Western Reserve University, Cleveland (Chen, Sajatovic)
| | - Ira R Katz
- Department of Psychiatry, William S. Middleton Department of Veterans Affairs (VA) Hospital, Madison, Wisconsin, and Department of Psychiatry, University of Wisconsin-Madison, Madison (Ahearn); Office of Mental Health and Suicide Prevention, VA, Washington, D.C. (Szymanski, Katz, McCarthy); Department of Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland (Chen); Department of Psychiatry, Case Western Reserve University, Cleveland (Chen, Sajatovic)
| | - John F McCarthy
- Department of Psychiatry, William S. Middleton Department of Veterans Affairs (VA) Hospital, Madison, Wisconsin, and Department of Psychiatry, University of Wisconsin-Madison, Madison (Ahearn); Office of Mental Health and Suicide Prevention, VA, Washington, D.C. (Szymanski, Katz, McCarthy); Department of Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland (Chen); Department of Psychiatry, Case Western Reserve University, Cleveland (Chen, Sajatovic)
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11
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Dillard LK, Saunders GH, Zobay O, Naylor G. Insights Into Conducting Audiological Research With Clinical Databases. Am J Audiol 2020; 29:676-681. [PMID: 32946255 DOI: 10.1044/2020_aja-19-00067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Purpose The clinical data stored in electronic health records (EHRs) provide unique opportunities for audiological clinical research. In this article, we share insights from our experience of working with a large clinical database of over 730,000 cases. Method Under a framework outlining the process from patient care to researcher data use, we describe issues that can arise in each step of this process and how we overcame specific issues in our data set. Results Correct interpretation of findings depends on an understanding of the data source and structure, and efforts to establish confidence in the data through the processes are discussed under the framework. Conclusion We conclude that EHRs have considerable utility in audiological research, though researchers must exhibit caution and consideration when working with EHRs.
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Affiliation(s)
- Lauren K. Dillard
- School of Medicine and Public Health, University of Wisconsin–Madison
- VA Rehabilitation Research and Development, National Center for Rehabilitative Auditory Research, Portland, OR
| | - Gabrielle H. Saunders
- VA Rehabilitation Research and Development, National Center for Rehabilitative Auditory Research, Portland, OR
- Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, United Kingdom
| | - Oliver Zobay
- VA Rehabilitation Research and Development, National Center for Rehabilitative Auditory Research, Portland, OR
- School of Medicine, University of Nottingham, United Kingdom
| | - Graham Naylor
- School of Medicine, University of Nottingham, United Kingdom
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12
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Lei L, Intrator O, Conwell Y, Fortinsky RH, Cai S. Continuity of care and health care cost among community-dwelling older adult veterans living with dementia. Health Serv Res 2020; 56:378-388. [PMID: 32812658 DOI: 10.1111/1475-6773.13541] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community-dwelling older veterans with dementia. DATA SOURCES Combined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014-2015. STUDY DESIGN FY 2014 COC was measured by the Bice-Boxerman Continuity of Care (BBC) index on a 0-1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long-/short-stay nursing home, and noninstitutional long-term care (LTC) cost for medical (like skilled-) and social (like unskilled-) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders. DATA COLLECTION Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073). PRINCIPAL FINDINGS Mean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute inpatient cost, $119 lower ED cost, $4368 lower long-stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short-stay nursing home cost. CONCLUSIONS COC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care.
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Affiliation(s)
- Lianlian Lei
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, New York
| | - Orna Intrator
- Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, New York.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Richard H Fortinsky
- Center on Aging, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Shubing Cai
- Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, New York.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
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13
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Song W, Intrator O, Twersky J, Davagnino J, Kinosian B, Wieland D. Utilization and Cost Effects of the VHA Caring for Older Adults and Caregivers at Home (COACH) Program. Med Care Res Rev 2020; 78:736-746. [PMID: 32646276 DOI: 10.1177/1077558720929592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since 2010, the Veterans Health Administration has initiated a home-based Caring for Older Adults and Caregivers at Home (COACH) program to provide clinical support to dementia patients and family caregivers. But its impact on health care utilization and costs is unknown. We compared 354 COACH care recipients with a propensity score weighted comparison group of 9,857 community-dwelling Veterans during fiscal years 2010-2015. In 1-year follow-up, COACH program was associated with a lower rate of long-term nursing home placement (average treatment effect on the treated [ATT] -3%; p = .01). The program increased utilization of emergency services (ATT 6%; p = .01), hospitals (ATT 10%; p < .001), and personal care services (ATT 31%; p < .001). Health care costs were also significantly increased. Improved access to services may have enabled COACH Veterans to stay at home longer. As one of Veterans Health Administration's top priorities to expand caregiver assistance programs, COACH seems to be a promising model for a nationwide implementation.
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Affiliation(s)
- Wei Song
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, NY, USA.,Department of Public Health Sciences, University of Rochester, Rochester, NY, USA
| | - Orna Intrator
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, NY, USA.,Department of Public Health Sciences, University of Rochester, Rochester, NY, USA
| | - Jack Twersky
- Geriatric Research, Education and Clinical Center, VA Medical Center, Durham, NC, USA
| | - Judith Davagnino
- Geriatric Research, Education and Clinical Center, VA Medical Center, Durham, NC, USA
| | - Bruce Kinosian
- Geriatrics and Extended Care Data Analysis Center and Center for Health Equity Research and Promotion, Cpl. Michael J Crescenz VA Medical Center, Philadelphia, USA.,Department of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Darryl Wieland
- Geriatric Research, Education and Clinical Center, VA Medical Center, Durham, NC, USA
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14
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Gidwani-Marszowski R, Asch SM, Mor V, Wagner TH, Faricy-Anderson K, Illarmo S, Hsin G, Patel MI, Ramchandran K, Lorenz KA, Needleman J. Health System and Beneficiary Costs Associated With Intensive End-of-Life Medical Services. JAMA Netw Open 2019; 2:e1912161. [PMID: 31560384 PMCID: PMC6777391 DOI: 10.1001/jamanetworkopen.2019.12161] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Despite recommendations to reduce intensive medical treatment at the end of life, many patients with cancer continue to receive such services. OBJECTIVE To quantify expected beneficiary and health system costs incurred in association with receipt of intensive medical services in the last month of life. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data collected nationally from Medicare and the Veterans Health Administration for care provided in fiscal years 2010 to 2014. Participants were 48 937 adults aged 66 years or older who died of solid tumor and were continuously enrolled in fee-for-service Medicare and the Veterans Health Administration in the 12 months prior to death. The data were analyzed from February to August 2019. EXPOSURES American Society of Clinical Oncology metrics regarding medically intensive services provided in the last month of life, including hospital stay, intensive care unit stay, chemotherapy, 2 or more emergency department visits, or hospice for 3 or fewer days. MAIN OUTCOMES AND MEASURES Costs in the last month of life associated with receipt of intensive medical services were evaluated for both beneficiaries and the health system. Costs were estimated from generalized linear models, adjusting for patient demographics and comorbidities and conditioning on geographic region. RESULTS Of 48 937 veterans who received care through the Veterans Health Administration and Medicare, most were white (90.8%) and male (98.9%). More than half (58.9%) received at least 1 medically intensive service in the last month of life. Patients who received no medically intensive service generated a mean (SD) health system cost of $7660 ($1793), whereas patients who received 1 or more medically intensive services generated a mean (SD) health system cost of $23 612 ($5528); thus, the additional financial consequence to the health care system for medically intensive services was $15 952 (95% CI, $15 676-$16 206; P < .001). The biggest contributor to these differences was $21 093 (95% CI, $20 364-$21 689) for intensive care unit stay, while the smallest contributor was $3460 (95% CI, $2927-$3880) for chemotherapy. Mean (SD) expected beneficiary costs for the last month of life were $133 ($50) for patients with no medically intensive service and $1257 ($408) for patients with at least 1 medically intensive service (P < .001). CONCLUSIONS AND RELEVANCE Given the low income of many elderly patients in the United States, the financial consequences of medically intensive services may be substantial. Costs of medically intensive services at the end of life, including patient financial consequences, should be considered by both physicians and families.
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Affiliation(s)
- Risha Gidwani-Marszowski
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University, Stanford, California
| | - Steven M. Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University, Stanford, California
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
| | - Katherine Faricy-Anderson
- Providence VA Medical Center, Providence, Rhode Island
- Alpert Medical School, Brown University, Providence, Rhode Island
| | - Samantha Illarmo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Gary Hsin
- Division of Primary Care and Population Health, Stanford University, Stanford, California
- VA Palo Alto Health Care System, Palo Alto, California
| | - Manali I. Patel
- VA Palo Alto Health Care System, Palo Alto, California
- Division of Medical Oncology, Stanford University, Stanford, California
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University, Stanford, California
| | | | - Karl A. Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University, Stanford, California
| | - Jack Needleman
- Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles
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15
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Hynes DM, Maciejewski ML, Atkins D. HSR Commentary: Linking VA and Non-VA Data to Address Important US Veteran Health Services Research Issues. Health Serv Res 2019; 53 Suppl 3:5133-5139. [PMID: 30430570 DOI: 10.1111/1475-6773.13081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE This commentary summarizes the methods and topics addressed in the special issue of HSR focused on linkage of United States Department of Veterans Affairs (VA) and non-VA datasets. The issue illustrates that researchers are increasingly linking diverse datasets as a valuable method for obtaining outcomes, treatments, and covariates to evaluate and examine health care delivery that includes non-VA services. The issue serves as a reference to VA and non-VA investigators alike who employ data linkage methods to address high-impact clinical and health policy evaluations that span different care systems and different datasets.
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Affiliation(s)
- Denise M Hynes
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland VA Health Care System, Portland, OR.,Veterans Affairs Information Resource Center, Hines, IL.,College of Public Health and Human Sciences, Oregon State University, Corvallis, OR
| | - Matthew L Maciejewski
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, NC.,Department of Department of Population Health Sciences, Duke University, Durham, NC
| | - David Atkins
- Department of Veterans Affairs, Office of Research and Development, Washington, DC
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