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George EL, Jacobs MA, Reitz KM, Massarweh NN, Youk AO, Arya S, Hall DE. Outcomes of Women Undergoing Noncardiac Surgery in Veterans Affairs Compared With Non-Veterans Affairs Care Settings. JAMA Surg 2024; 159:501-509. [PMID: 38416481 PMCID: PMC10902781 DOI: 10.1001/jamasurg.2023.8081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/25/2023] [Indexed: 02/29/2024]
Abstract
Importance Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non-VA care settings are lacking. Objective To compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals. Design, Setting, and Participants This coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older. Exposures Surgical care in VA or private-sector hospitals. Main Outcomes and Measures Postoperative 30-day mortality and failure to rescue (FTR). Results Among 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P < .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P < .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P < .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P < .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P < .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P < .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P < .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures. Conclusions and Relevance Although women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.
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Affiliation(s)
- Elizabeth L George
- Division of Vascular Surgery, Stanford University School of Medicine, California
- Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, California
| | - Michael A Jacobs
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
| | | | - Nader N Massarweh
- Perioperative and Surgical Care Service, Atlanta Veterans Affairs Healthcare System, Decatur, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| | - Ada O Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pennsylvania
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, California
- Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, California
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pennsylvania
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Mares JG, Lund BC, Adamowicz JL, Burgess DJ, Rothmiller SJ, Hadlandsmyth K. Differences in chronic pain care receipt among veterans from differing racialized groups and the impact of rural versus urban residence. J Rural Health 2023. [PMID: 36695646 DOI: 10.1111/jrh.12744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE The current study aimed to identify differences in Veterans Affairs (VA) chronic pain care for Black, Asian, and Hispanic Americans, compared to non-Hispanic White Americans, and examine the intersection of race and rurality. METHODS Using national administrative data, all veterans who presented to the VA for chronic pain in 2018 were included. Demographic and comorbidity variables were built from 2018 data and health care utilization variables from 2019 data. Multivariate log-binomial regression models examined differences between racialized groups, and interactions with rural/urban residence, for each health care utilization variable. FINDINGS The full cohort included 2,135,216 veterans with chronic pain. There were no differences between racialized groups in pain-related primary care visits. Black Americans were less likely to receive pain clinic visits (aRR = 0.87, CI: 0.86-0.88). Rurality further decreased the likelihood of Black Americans visiting a pain clinic. Black, Hispanic, and Asian Americans were more likely to receive pain-related physical therapy visits relative to White Americans. Black and Hispanic Americans were more likely to present to emergency/urgent care for chronic pain. While there were no differences in pain-related primary care visits, the decreased likelihood of pain clinic visits and increased use of emergency department/urgent care among Black Americans could indicate inadequate management of chronic pain. CONCLUSIONS Tailored strategies are needed to provide equitable care that meets the needs of patients from racialized groups while accounting for systemic and cultural factors.
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Affiliation(s)
- Jasmine G Mares
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Brian C Lund
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Jenna L Adamowicz
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Psychological & Brain Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Diana J Burgess
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
| | - Shamira J Rothmiller
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Counselor Education, University of Iowa, Iowa City, Iowa, USA
| | - Katherine Hadlandsmyth
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
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Friedman S, Shaw JG, Hamilton AB, Vinekar K, Washington DL, Mattocks K, Yano EM, Phibbs CS, Johnson AM, Saechao F, Berg E, Frayne SM. Gynecologist Supply Deserts Across the VA and in the Community. J Gen Intern Med 2022; 37:690-697. [PMID: 36042097 PMCID: PMC9481821 DOI: 10.1007/s11606-022-07591-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 04/01/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND The Veterans Health Administration (VA) refers patients to community providers for specialty services not available on-site. However, community-level specialist shortages may impede access to care. OBJECTIVE Compare gynecologist supply in veterans' county of residence versus at their VA site. DESIGN We identified women veteran VA patients from fiscal year (FY) 2017 administrative data and assessed availability of a VA gynecologist within 50 miles (hereafter called "local") of veterans' VA homesites (per national VA organizational survey data). For the same cohort, we then assessed community-level gynecologist availability; counties with < 2 gynecologists/10,000 women (per the Area Health Resource File) were "inadequate-supply" counties. We examined the proportion of women veterans with local VA gynecologist availability in counties with inadequate versus adequate gynecologist supply, stratified by individual and VA homesite characteristics. Chi-square tests assessed statistical differences. PARTICIPANTS All women veteran FY2017 VA primary care users nationally. MAIN MEASURES Availability of a VA gynecologist within 50 miles of a veteran's VA homesite; county-level "inadequate-supply" of gynecologists. KEY RESULTS Among 407,482 women, 9% were in gynecologist supply deserts (i.e., lacking local VA gynecologist and living in an inadequate-supply county). The sub-populations with the highest proportions in gynecologist supply deserts were rural residents (24%), those who got their primary care at non-VAMC satellite clinics (13%), those who got their care at a site without a women's clinic (13%), and those with American Indian or Alaska Native (12%), or white (12%) race. Among those in inadequate-supply counties, 59.9% had gynecologists at their local VA; however, 40.1% lacked a local VA gynecologist. CONCLUSIONS Most veterans living in inadequate-supply counties had local VA gynecology care, reflecting VA's critical role as a safety net provider. However, for those in gynecologist supply deserts, expanded transportation options, modified staffing models, or tele-gynecology hubs may offer solutions to extend VA gynecology capacity.
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Affiliation(s)
- Sarah Friedman
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA.
- School of Public Health, University of Nevada Reno, Reno, NV, USA.
| | - Jonathan G Shaw
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Alison B Hamilton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kavita Vinekar
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ciaran S Phibbs
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
- VA Health Economics Resource Center, Menlo Park, CA, USA
| | | | - Fay Saechao
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Eric Berg
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
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Minegishi T, Young GJ, Madison KM, Pizer SD. Regional Economic Conditions and Preventable Hospitalization Among Older Patients With Diabetes. Med Care 2022; 60:212-218. [PMID: 35157621 DOI: 10.1097/mlr.0000000000001672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim was to explore the relationship between changes in regional economic conditions and quality of care-preventable hospitalization or death among older patients with diabetes at Veterans Health Administration (VHA), safety-net system for veterans. SUBJECTS VHA patients aged 65 years and older with a diabetes diagnosis between July 2012 and June 2014, who had at least 1 primary care visit in the past year. MEASURES County-level and state-level public data were used to characterize regional health insurance coverage and affluence surrounding the VHA facilities. Each patient was associated with a VHA facility and its corresponding regional market variables, and followed up to 48 months or until they experienced diabetes-related Prevention Quality Indicators or death. RESULTS Discrete-time Cox proportional hazards models estimated that changes in regional market variables characterizing regional health insurance coverage and affluence were significant factors associated with preventable hospitalization or death. All regional market variables were combined into a demand index, where 1 SD decrease in the demand index was associated with a 2.0-point increase in predicted survival for an average patient at an average VHA facility. For comparison, a 1 SD increase in primary care capacity was associated with 4.7-point increase. CONCLUSIONS Downturns in regional economic conditions could increase demand for VHA care and raise the risk of diabetes-related preventable hospitalization or death among older VHA patients diagnosed with diabetes. Safety-net hospitals may be unfairly penalized for lower quality of care when experiencing higher demand for care because of an economic downturn.
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Affiliation(s)
- Taeko Minegishi
- Bouvé College of Health Sciences, Northeastern University
- VA Boston Healthcare System, Partnered Evidence-based Policy Research Center (PEPReC)
| | - Gary J Young
- Bouvé College of Health Sciences, Northeastern University
- Center for Health Policy and Healthcare Research, Northeastern University
- D'Amore-McKim School of Business, Northeastern University
| | - Kristin M Madison
- Bouvé College of Health Sciences, Northeastern University
- School of Law, Northeastern University
| | - Steven D Pizer
- VA Boston Healthcare System, Partnered Evidence-based Policy Research Center (PEPReC)
- School of Public Health, Boston University, Boston, MA
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George EL, Massarweh NN, Youk A, Reitz KM, Shinall MC, Chen R, Trickey AW, Varley PR, Johanning J, Shireman PK, Arya S, Hall DE. Comparing Veterans Affairs and Private Sector Perioperative Outcomes After Noncardiac Surgery. JAMA Surg 2022; 157:231-239. [PMID: 34964818 PMCID: PMC8717209 DOI: 10.1001/jamasurg.2021.6488] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. However, contemporary data comparing the quality and safety of VA and non-VA surgical care are lacking. Objective To compare perioperative outcomes among veterans treated in VA hospitals with patients treated in private-sector hospitals. Design, Setting, and Participants This cohort study took place across 8 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 1, 2015, through December 31, 2018. Multivariable log-binomial modeling was used to evaluate the association between VA vs private sector care settings and 30-day mortality. Unmeasured confounding was quantified using the E-value. Patients 18 years and older undergoing a noncardiac procedures were included. Exposures Surgical care in either a VA or private sector setting. Main Outcomes and Measures Primary outcome was 30-day postoperative mortality. Secondary outcome was failure to rescue, defined as a postoperative death after a complication. Results Of 3 910 752 operations (3 174 274 from NSQIP and 736 477 from VASQIP), 1 498 984 (92.1%) participants in NSQIP were male vs 678 382 (47.2%) in VASQIP (mean difference, -0.449 [95% CI, -0.450 to -0.448]; P < .001), and 441 894 (60.0%) participants in VASQIP were frail or very frail vs 676 525 (21.3%) in NSQIP (mean difference, -0.387 [95% CI, -0.388 to -0.386]; P < .001). Overall, rates of 30-day mortality, complications, and failure to rescue were 0.8%, 9.5%, and 4.7%, respectively, in NSQIP (n = 3 174 274 operations) and 1.1%, 17.1%, and 6.7%, respectively in VASQIP (736 477) (differences in proportions, -0.003 [95% CI, -0.003 to -0.002]; -0.076 [95% CI, -0.077 to -0.075]; 0.020 [95% CI, 0.018-0.021], respectively; P < .001). Compared with private sector care, VA surgical care was associated with a lower risk of perioperative death (adjusted relative risk, 0.59 [95% CI, 0.47-0.75]; P < .001). This finding was robust in multiple sensitivity analyses performed, including among patients who were frail and nonfrail, with or without complications, and undergoing low and high physiologic stress procedures. These findings were also consistent when year was included as a covariate and in nonparsimonious modeling for patient-level factors. Compared with private sector care, VA surgical care was also associated with a lower risk of failure to rescue (adjusted relative risk, 0.55 [95% CI, 0.44-0.68]). An unmeasured confounder (present disproportionately in NSQIP data) would require a relative risk of 2.78 [95% CI, 2.04-3.68] to obviate the main finding. Conclusions and Relevance VA surgical care is associated with lower perioperative mortality and decreased failure to rescue despite veterans having higher-risk characteristics. Given the unique needs and composition of the veteran population, health policy decisions and budgetary appropriations should reflect these important differences.
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Affiliation(s)
- Elizabeth L. George
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California,Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California,Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California
| | - Nader N. Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine M. Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Myrick C. Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rui Chen
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California
| | | | - Jason Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha,Nebraska Western Iowa Veterans Affairs Health System, Omaha
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio,South Texas Veterans Health Care System, San Antonio
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California,Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California,Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania,Geriatric Research Educational and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Wray C, Tang J, Byers A, Keyhani S. Digital Health Skillsets and Digital Preparedness: Comparison of Veterans Health Administration Users and Other Veterans Nationally. JMIR Form Res 2022; 6:e32764. [PMID: 35089147 PMCID: PMC8838565 DOI: 10.2196/32764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/03/2021] [Accepted: 12/13/2021] [Indexed: 02/06/2023] Open
Abstract
Background As health care systems shift to greater use of telemedicine and digital tools, an individual’s digital health literacy has become an important skillset. The Veterans Health Administration (VA) has invested resources in providing digital health care; however, to date, no study has compared the digital health skills and preparedness of veterans receiving care in the VA to veterans receiving care outside the VA. Objective The goal of the research was to describe digital health skills and preparedness among veterans who receive care within and outside the VA health care system and examine whether receiving care in the VA is associated with digital preparedness (reporting more than 2 digital health skills) after accounting for demographic and social risk factors. Methods We used cross-sectional data from the 2016-2018 National Health Interview Survey to identify veterans (aged over 18 years) who obtain health care either within or outside the VA health care system. We used multivariable logistic regression models to examine the association of sociodemographic (age, sex, race, ethnicity), social risk factors (economic instability, disadvantaged neighborhood, low educational attainment, and social isolation), and health care delivery location (VA and non-VA) with digital preparedness. Results Those who received health care within the VA health care system (n=3188) were younger (age 18-49 years: 33.3% [95% CI 30.7-36.0] vs 24.2% [95% CI 21.9-26.5], P<.01), were more often female (34.7% [95% CI 32.0-37.3] vs 6.6% [95% CI 5.5-7.6], P<.01) and identified as Black (13.1% [95% CI 11.2-15.0] vs 10.2% [95% CI 8.7-11.8], P<.01), and reported greater economic instability (8.3% [95% CI 6.9-9.8] vs 5.5% [95% CI 4.6-6.5], P<.01) and social isolation (42.6% [95% CI 40.3-44.9] vs 35.4% [95% CI 33.4-37.5], P<.01) compared to veterans who received care outside the VA (n=3393). Veterans who obtained care within the VA reported more digital health skills than those who obtained care outside the VA, endorsing greater rates of looking up health information on the internet (51.8% [95% CI 49.2-54.4] vs 45.0% [95% CI 42.6-47.3], P<.01), filling a prescription using the internet (16.2% [95% CI 14.5-18.0] vs 11.3% [95% CI 9.6-13.0], P<.01), scheduling a health care appointment on the internet (14.1% [95% CI 12.4-15.8] vs 11.6% [95% CI 10.1-13.1], P=.02), and communicating with a health care provider by email (18.0% [95% CI 16.1-19.8] vs 13.3% [95% CI 11.6-14.9], P<.01). Following adjustment for sociodemographic and social risk factors, receiving health care from the VA was the only characteristic associated with higher odds (adjusted odds ratio [aOR] 1.36, 95% CI 1.12-1.65) of being digitally prepared. Conclusions Despite these demographic disadvantages to digital uptake, veterans who receive care in the VA reported more digital health skills and appear more digitally prepared than veterans who do not receive care within the VA, suggesting a positive, system-level influence on this cohort.
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Affiliation(s)
- Charlie Wray
- Section of Hospital Medicine, San Francisco Department of Veterans Affairs Medical Center, San Francisco, CA, United States
| | - Janet Tang
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Amy Byers
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Division of Mental Health Services, San Francisco Department of Veterans Affairs Medical Center, San Francisco, CA, United States.,Department of Psychiatry and Behavioral Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Salomeh Keyhani
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
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7
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Upchurch DM, Wong MS, Yuan AH, Haderlein TP, McClendon J, Christy A, Washington DL. COVID-19 Infection in the Veterans Health Administration: Gender-specific Racial and Ethnic Differences. Womens Health Issues 2022; 32:41-50. [PMID: 34702652 PMCID: PMC8486675 DOI: 10.1016/j.whi.2021.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 09/10/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Racial/ethnic minoritized groups, women, and economically disadvantaged groups are disproportionately affected by the COVID-19 pandemic. We investigated racial/ethnic differences by gender in correlates of COVID-19 infection among veterans seeking health care services at the Veterans Health Administration. Little is known about gender-specific factors associated with infection among veterans. This study seeks to fill this gap. METHODS The sample was veterans with results from a COVID-19 test (polymerase chain reaction) conducted at Veterans Health Administration facilities between March 1, 2020, and August 5, 2020, and linked to the Centers for Disease Control and Prevention Social Vulnerability Index data (39,223 women and 316,380 men). Bivariate, multivariate logistic, and predicted probability analyses were conducted. All analyses were stratified by gender. RESULTS Similar percentages of women and men tested positive for COVID-19 (9.6% vs. 10.0%). In multivariate analysis, compared with non-Hispanic White women, American Indian/Alaska Native, Black, and Hispanic women all had significantly higher odds of infection. Similar racial/ethnic differences were found for men. Both older men and women (>40 years) had lower odds of infection, but the age cut points differed (40 for women, 55 for men). Men 80 years and older had a higher odds than those aged less than 40 years of age. For men, but not for women, being employed (vs. unemployed) was associated with an increased odds of infection, and having comorbidities was associated with decreased odds. There were significant differences within and across gender-by-race/ethnicity in infection, after adjusting for covariates. CONCLUSIONS American Indian/Alaska Native, Hispanic, and Black women and men veterans are disproportionately impacted by COVID-19 infection. Widespread testing and tracking, education, and outreach regarding COVID-19 mitigation and vaccination efforts are recommended.
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Affiliation(s)
- Dawn M Upchurch
- Department of Community Health Sciences, UCLA Fielding School of Public Health, Los Angeles, California.
| | - Michelle S Wong
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Anita H Yuan
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Taona P Haderlein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Juliette McClendon
- National Center for PTSD, Women's Health Science Division, VA Boston Health Care System, Boston, Massachusetts; Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Alicia Christy
- Women's Health Services, Veterans Health Administration, Washington, District of Columbia
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California; Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles Geffen School of Medicine, Los Angeles, California
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8
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Tsai J, Szymkowiak D, Wilkinson ST, Holtzheimer PE. Twenty-year trends in use of electroconvulsive therapy among homeless and domiciled veterans with mental illness. CNS Spectr 2021; 28:1-7. [PMID: 34895380 DOI: 10.1017/s1092852921001061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND To examine socioeconomic disparities in use of electroconvulsive therapy (ECT) among homeless or unstably housed (HUH) veterans with mental illness. METHODS National data from medical records in years 2000 to 2019 on 4 to 6 million veterans with mental illness, including 140 000 to 370 000 homeless veterans served annually from the U.S. Department of Veterans Affairs (VA) healthcare system, were analyzed to examine ECT utilization and changes in utilization over time. RESULTS ECT utilization was higher among HUH veterans (58-104 per 1000) than domiciled veterans with mental illness (9-15 per 1000) across years with a trend toward increasing use of ECT use among HUH veterans over time. Among HUH and domiciled veterans who received ECT, veterans received an average of 5 to 9 sessions of ECT. There were great regional differences in rates of ECT utilization among HUH and domiciled veterans with the highest overall rates of ECT use at VA facilities in the Northeast and Northwest regions of the country. DISCUSSION ECT is commonly and safely used in HUH veterans in a comprehensive healthcare system, but geographic and local factors may impede access to ECT for veterans who may benefit from this treatment. Efforts should be made to reduce barriers to ECT in the HUH population.
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Affiliation(s)
- Jack Tsai
- National Center on Homelessness among Veterans, Homeless Program Office, U.S. Department of Veterans Affairs, Tampa, Florida, USA
- School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Dorota Szymkowiak
- National Center on Homelessness among Veterans, Homeless Program Office, U.S. Department of Veterans Affairs, Tampa, Florida, USA
| | - Samuel T Wilkinson
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Paul E Holtzheimer
- Executive Division, National Center for Posttraumatic Stress Disorder, U.S. Department of Veterans Affairs, White River Junction, Vermont, USA
- Departments of Psychiatry and Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Reitz KM, Varley PR, Liang NL, Youk A, George EL, Shinall MC, Shireman PK, Arya S, Tzeng E, Hall DE. The Correlation Between Case Total Work Relative Value Unit, Operative Stress, and Patient Frailty: Retrospective Cohort Study. Ann Surg 2021; 274:637-645. [PMID: 34506319 PMCID: PMC8433485 DOI: 10.1097/sla.0000000000005068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Assess the relationships between case total work relative value units (wRVU), patient frailty, and the physiologic stress of surgical interventions. SUMMARY OF BACKGROUND DATA Surgeon reimbursement is frequently apportioned by wRVU. These subjective, procedure-specific valuations generated by physician survey estimate the intensity and time for typical patient care services. We hypothesized wRVU would not adequately account for patient-specific factors, such as frailty, that modify the required physician work, regardless of procedural complexity. METHODS Using National and Veterans Affairs Surgical Quality Improvement Programs (2015-2018), we evaluated the correlation between case total wRVU, patient frailty (risk analysis index) and physiologic surgical stress (operative stress score). RESULTS Of 4,111,371 (86%) cases, the correlation between total wRVU and operative stress was moderate [ρs = 0.587 (95% confidence interval, 0.586-0.587)], but negligible with frailty ρ = 0.177 (95% confidence interval, 0.176-0.178)]. Very high operative stress procedures [n = 34,047 (1%)] generated a mean total wRVU of 55.1 (standard deviation, 12.9), comprising 7%, 2%, and 1% of thoracic, vascular, and general surgical cases, respectively. Very frail patients [n = 152,535 (4%)] accounted for 9% of thoracic, 9% of vascular, 4% of general, 5% of urologic, and 4% of neurologic surgical cases, generating 21.0 (standard deviation, 12.4) mean total wRVU. Some nonfrail patients undergoing low operative stress procedures [n = 60,128 (2%)] nonetheless generated the highest quintile wRVU; these comprised >15% of plastic, gynecologic, and urologic surgical cases. CONCLUSIONS Surgeon reimbursement correlates with operative stress but not patient frailty. The total wRVU does not adequately reflect patient-specific factors that increase the physician workload required to render optimal care to complex patients.
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Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick R Varley
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nathan L Liang
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Elizabeth L George
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
- Department of Surgery, South Texas Veterans Health Care System, San Antonio, Texas
- University Health System, San Antonio, Texas
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Wolff Center, UPMC, Pittsburgh, Pennsylvania
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10
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Gabrielian S, Hellemann G, Koosis ER, Green MF, Young AS. Do cognition and other person-level characteristics determine housing outcomes among homeless-experienced adults with serious mental illness? Psychiatr Rehabil J 2021; 44:176-185. [PMID: 33048564 PMCID: PMC8435461 DOI: 10.1037/prj0000457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objective: Many persons with serious mental illness (SMI) who have experienced homelessness struggle to sustain stable and independent housing. We know little about determinants of this population's housing status. This study aimed to identify person-level determinants of housing status among homeless-experienced veterans with SMI, focused primarily on cognition. Method: We administered cross-sectional surveys and detailed cognitive assessments on a convenience sample of homeless-experienced veterans with SMI (n = 90); we also reviewed these participants' medical records. We captured person-level potential predictors of housing status (demographics, cognition, diagnoses, symptoms, and service utilization) and 2 years of retrospective housing history. Participants' housing status was conceptualized as the setting (stable housing, other sheltered settings, and streets) they lived in for >50% of the past 2 years. We used the chi-square test and analysis of variance to determine how potential predictors differed by housing status. We used recursive partitioning to identify the combination of potential predictors and corresponding scores that best-differentiated participants by housing status. Results: No between-groups differences (p < .05) in cognition, symptoms, or other person-level factors were found among participants grouped by housing status. Recursive partitioning did not yield a stable model to predict housing status from the potential predictor variables. Conclusions and Implications for Practice: These data suggest that clinical interventions addressing studied person-level factors (e.g., cognitive rehabilitation) may not affect housing status for homeless-experienced veterans. As housing is highly influenced by social determinants of health, policies, and practices that affect contextual factors (e.g., affordable housing supply) may be more likely to improve housing status. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Sonya Gabrielian
- Mental Illness Research, Education, and Clinical Center, VA Greater Los Angeles
| | - Gerhard Hellemann
- Mental Illness Research, Education, and Clinical Center, VA Greater Los Angeles
| | - Ella R Koosis
- Mental Illness Research, Education, and Clinical Center, VA Greater Los Angeles
| | - Michael F Green
- Mental Illness Research, Education, and Clinical Center, VA Greater Los Angeles
| | - Alexander S Young
- Mental Illness Research, Education, and Clinical Center, VA Greater Los Angeles
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11
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Christofferson DE, Dennis PA, Hertzberg JS, Beckham JC, Knoeppel J, Hamlett-Berry K. Real-World Utilization and Outcomes of the Veterans Health Administration's Smoking Cessation Text Message Program. Nicotine Tob Res 2021; 23:931-938. [PMID: 32945887 DOI: 10.1093/ntr/ntaa183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 09/15/2020] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Smoking cessation mobile health (mHealth) programs are effective and have been recommended for integration into health care services but have not been evaluated in real-world health care settings. The Veterans Health Administration, a safety net health care provider, provides health care for 9 million US military veterans. Veterans Health Administration implemented the SmokefreeVET text message program in 2013. METHODS A retrospective evaluation of 6153 SmokefreeVET subscribers was conducted. The primary outcome was 30-day self-reported abstinence at 6 months. Secondary outcomes included percentage of opt outs, program completers, and 30-day self-reported abstinence at 3 months. RESULTS SmokefreeVET subscribers were on average 47.5 years old and 71.4% male. Smoking cessation medication use was reported by 11.5% of subscribers at the start of their quit attempt and subscribers enrolled in the program for an average of 29 days. Subscribers who were younger, female, and heavier smokers were more likely to opt out of the six-week program early. The abstinence rate for the primary outcome, self-reported 30-day abstinence at 6 months among all subscribers was 3.7%. CONCLUSIONS SmokefreeVET enrolled a younger and more female population of subscribers than other studies of veterans interested in tobacco treatment. The mHealth program was generally acceptable to veterans, yet strategies to increase retention may improve completion rates and outcomes. In this real-world setting, nearly half of the mHealth program subscribers combined use of the text program with smoking cessation medication. Further study of the optimal combination of mHealth with smoking cessation treatments is needed. IMPLICATIONS mHealth smoking cessation programs can be effectively implemented within real-world health care settings, even in those serving disadvantaged populations. Further research to improve mHealth program efficacy and integration into clinical settings will increase the population-level impact of these effective smoking cessation programs.
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Affiliation(s)
- Dana E Christofferson
- Veterans Health Administration, Office of Mental Health and Suicide Prevention, Washington, DC
| | - Paul A Dennis
- Durham VA Medical Center, Durham, NC.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | | | - Jean C Beckham
- Durham VA Medical Center, Durham, NC.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC.,VA Mid-Atlantic Mental Illness Research Education and Clinical Center, Durham, NC
| | - Jennifer Knoeppel
- Veterans Health Administration, Office of Mental Health and Suicide Prevention, Washington, DC
| | - Kim Hamlett-Berry
- Veterans Health Administration, Office of Mental Health and Suicide Prevention, Washington, DC
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12
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Vernon SW, Del Junco DJ, Coan SP, Murphy CC, Walters ST, Friedman RH, Bastian LA, Fisher DA, Lairson DR, Myers RE. A stepped randomized trial to promote colorectal cancer screening in a nationwide sample of U.S. Veterans. Contemp Clin Trials 2021; 105:106392. [PMID: 33823295 DOI: 10.1016/j.cct.2021.106392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/24/2021] [Accepted: 03/29/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) screening (CRCS) facilitates early detection and lowers CRC mortality. OBJECTIVES To increase CRCS in a randomized trial of stepped interventions. Step 1 compared three modes of delivery of theory-informed minimal cue interventions. Step 2 was designed to more intensively engage those not completing CRCS after Step 1. METHODS Recruitment packets (60,332) were mailed to a random sample of individuals with a record of U.S. military service during the Vietnam-era. Respondents not up-to-date with CRCS were randomized to one of four Step 1 groups: automated telephone, telephone, letter, or survey-only control. Those not completing screening after Step 1 were randomized to one of three Step 2 groups: automated motivational interviewing (MI) call, counselor-delivered MI call, or Step 2 control. Intention-to-treat (ITT) analyses assessed CRCS on follow-up surveys mailed after each step. RESULTS After Step 1 (n = 1784), CRCS was higher in the letter, telephone, and automated telephone groups (by 1%, 5%, 7%) than in survey-only controls (43%), although differences were not statistically significant. After Step 2 (n = 516), there were nonsignificant increases in CRCS in the two intervention groups compared with the controls. CRCS following any combination of stepped interventions overall was 7% higher (P = 0.024) than in survey-only controls (55.6%). CONCLUSIONS In a nationwide study of Veterans, CRCS after each of two stepped interventions of varying modes of delivery did not differ significantly from that in controls. However, combined overall, the sequence of stepped interventions significantly increased CRCS.
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Affiliation(s)
- Sally W Vernon
- Department of Health Promotion and Behavioral Sciences, UTHealth School of Public Health, Houston, TX, United States.
| | - Deborah J Del Junco
- Department of Surgery, Center for Translational Injury Research, The University of Texas McGovern Medical School, Houston, TX, United States
| | - Sharon P Coan
- Department of Health Promotion and Behavioral Sciences, UTHealth School of Public Health, Houston, TX, United States
| | - Caitlin C Murphy
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Scott T Walters
- Health Behavior and Health Systems, University of North Texas Health Science Center, Ft. Worth, TX, United States
| | - Robert H Friedman
- Medical Information Systems Unit, Boston University School of Medicine and Boston Medical Center, Boston, MA, United States
| | - Lori A Bastian
- General Internal Medicine, VA Connecticut, West Haven, CT 06516 and Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, United States
| | | | - David R Lairson
- Department of Management Policy and Community Health, UTHealth School of Public Health, Houston, TX, United States
| | - Ronald E Myers
- Division of Population Science, Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
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13
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Tsai J, Mehta K, Hunt-Johnson N, Pietrzak RH. Experiences and Knowledge of US Department of Veterans Affairs Clinical Services, Research, and Education: Results From a National Survey of Veterans. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 27:173-185. [PMID: 31592984 DOI: 10.1097/phh.0000000000001053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study examined (1) sociodemographic, health, and psychosocial characteristics associated with using the Department of Veterans Affairs (VA) health care system as a primary health care provider; (2) veterans' experience and knowledge of VA clinical services, research, and education; and (3) veteran characteristics associated with VA experience and knowledge. DESIGN A nationally representative survey was conducted in 2018; eligibility criteria for participation were adults aged 18 years or older, currently living in the United States, and having served on active duty in the US military. SETTING The survey was conducted online using large national survey panels. PARTICIPANTS A sample of 1002 veterans across 49 states participated. MAIN OUTCOME MEASURES The survey assessed experience and knowledge of majority of VA clinical services, research, and education. RESULTS One-quarter of the total sample reported that the VA was their primary health care provider. Among veterans who had ever used VA health care, the majority (68%) reported overall high satisfaction with VA health care but also agreed with "privatizing parts of the VA" (70%). The majority (51%-73%) of veterans reported knowledge of major VA clinical services, with the exception of comprehensive management for chronic pain (24%) and treatment of opioid use disorders (31%). One-quarter to one-half also reported knowledge of several VA research and education centers. Less than 10% of veterans reported having ever used a VA mobile app. CONCLUSIONS The US veterans generally reported positive experiences and good knowledge of VA services and resources. Greater awareness of available VA services for chronic pain and opioid use disorders, as well as VA mobile apps, may help promote more comprehensive care in this population.
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Affiliation(s)
- Jack Tsai
- US Department of Veterans Affairs, National Center on Homelessness among Veterans, West Haven, Connecticut (Dr Tsai); US Department of Veterans Affairs, National Center on Homelessness among Veterans, Bedford, Massachusetts (Mr Mehta); US Department of Veterans Affairs, National Center on Homelessness among Veterans, Philadelphia, Pennsylvania (Hunt-Johnson); Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (Drs Tsai and Pietrzak); and US Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, Connecticut (Dr Pietrzak)
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Ambrose M, Roselle GA, Kralovic SM, Gamage SD. Healthcare-Associated Legionella Disease: A Multi-Year Assessment of Exposure Settings in a National Healthcare System in the United States. Microorganisms 2021; 9:264. [PMID: 33525457 PMCID: PMC7911807 DOI: 10.3390/microorganisms9020264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 01/08/2023] Open
Abstract
Healthcare facilities are high-risk environments for Legionella disease (LD), including Legionnaires' disease, but transmission in these settings is often overlooked. We used the LD database at the U.S. Department of Veterans Affairs (VA) national healthcare system to assess the type of healthcare exposure for LD cases. Cases were extracted from the database for 1 September 2012 through 31 July 2019, focusing on cases with an overnight stay at a VA facility during the 10-day exposure window prior to symptom onset. Patient medical charts were reviewed for demographics and types of healthcare setting exposure(s). There were 99 LD cases in the cohort: 31.3% were classified as having definite VA exposure, 37.4% were classified as possible VA with inpatient exposure, and 31.3% were classified as possible VA with both inpatient and outpatient exposure. For definite VA LD cases, 67.7% had some type of exposure in the long-term care setting. While 63% of the 99 cases had exposure in the acute care setting only, both the long-term care and acute care settings contributed substantially to the total number of exposure days. A review of patient movement during the exposure period showed the variable and sometimes extensive use of the VA system, and it provides insights useful for epidemiologic investigations and potential preventive actions.
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Affiliation(s)
- Meredith Ambrose
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC 20420, USA; (M.A.); (G.A.R.); (S.M.K.)
| | - Gary A. Roselle
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC 20420, USA; (M.A.); (G.A.R.); (S.M.K.)
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
- Medical Service, Cincinnati VA Medical Center, Cincinnati, OH 45220, USA
| | - Stephen M. Kralovic
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC 20420, USA; (M.A.); (G.A.R.); (S.M.K.)
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
- Medical Service, Cincinnati VA Medical Center, Cincinnati, OH 45220, USA
| | - Shantini D. Gamage
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC 20420, USA; (M.A.); (G.A.R.); (S.M.K.)
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
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15
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Gamage SD, Ross N, Kralovic SM, Simbartl LA, Roselle GA, Berkelman RL, Chamberlain AT. Health after Legionnaires' disease: A description of hospitalizations up to 5 years after Legionella pneumonia. PLoS One 2021; 16:e0245262. [PMID: 33428684 PMCID: PMC7799844 DOI: 10.1371/journal.pone.0245262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/26/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Research on Legionnaires' Disease (LD) suggests there may be long-term health complications, but data are limited. This study investigated whether Intensive Care Unit (ICU) admission during LD hospitalization may be associated with adverse health outcomes and characterized subsequent discharge diagnoses in patients with LD up to 5 years post-LD. METHODS We conducted a retrospective case series study with follow up for 5 years among patients hospitalized at a Department of Veterans Affairs (VA) Medical Center between 2005 and 2010 with LD. Data were collected from medical records on health history, LD severity (including ICU admission), and discharge diagnoses for 5 years post-LD or until death. We used ordinal logistic regression to explore associations between ICU admission and hospitalizations post-LD. Frequency counts were used to determine the most prevalent discharge diagnoses in the 5 years post-LD. RESULTS For the 292 patients with laboratory-confirmed LD, those admitted to the ICU during LD hospitalization were more likely to have a greater number of hospitalizations within 5 years compared to non-ICU patients (ORHosp 1.92 CI95% 1.25, 2.95). Fifty-five percent (161/292) had ≥ 1 hospitalization within 5 years post-LD. After accounting for pre-existing diagnosis codes in patients with at least one hospitalization in the 2 years prior to LD (n = 77/161 patients, 47.8%), three of the four most frequent new diagnoses in the 5 years post-LD were non-chronic conditions: acute renal failure (n = 22, 28.6%), acute respiratory failure (n = 17, 22.1%) and unspecified pneumonia (n = 15, 19.5%). CONCLUSIONS Our findings indicate that LD requiring ICU admission is associated with more subsequent hospitalizations, a factor that could contribute to poorer future health for people with severe LD. In addition to chronic conditions prevalent in this study population, we found new diagnoses in the 5-year post-LD period including acute renal failure. With LD incidence increasing, more research is needed to understand conditions and factors that influence long term health after LD.
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Affiliation(s)
- Shantini D. Gamage
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, District of Columbia, United States of America
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Natasha Ross
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Stephen M. Kralovic
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, District of Columbia, United States of America
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio, United States of America
| | - Loretta A. Simbartl
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, District of Columbia, United States of America
| | - Gary A. Roselle
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, District of Columbia, United States of America
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio, United States of America
| | - Ruth L. Berkelman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Allison T. Chamberlain
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- * E-mail:
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16
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Waldo SW, Glorioso TJ, Barón AE, Plomondon ME, Valle JA, Schofield R, Ho PM. Outcomes Among Patients Undergoing Elective Percutaneous Coronary Intervention at Veterans Affairs and Community Care Hospitals. J Am Coll Cardiol 2020; 76:1112-1116. [DOI: 10.1016/j.jacc.2020.05.086] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/10/2020] [Indexed: 11/28/2022]
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17
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Mattocks KM, Cunningham K, Elwy AR, Finley EP, Greenstone C, Mengeling MA, Pizer SD, Vanneman ME, Weiner M, Bastian LA. Recommendations for the Evaluation of Cross-System Care Coordination from the VA State-of-the-art Working Group on VA/Non-VA Care. J Gen Intern Med 2019; 34:18-23. [PMID: 31098968 PMCID: PMC6542862 DOI: 10.1007/s11606-019-04972-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In response to widespread concerns regarding Veterans' access to VA care, Congress enacted the Veterans Access, Choice and Accountability Act of 2014, which required VA to establish the Veterans Choice Program (VCP). Since the inception of VCP, more than two million Veterans have received care from community providers, representing approximately 25% of Veterans enrolled in VA care. However, expanded access to non-VA care has created challenges in care coordination between VA and community health systems. In March 2018, the VA Health Services Research & Development Service hosted a VA State of the Art conference (SOTA) focused on care coordination. The SOTA convened VA researchers, program directors, clinicians, and policy makers to identify knowledge gaps regarding care coordination within the VA and between VA and community systems of care. This article provides a summary and synthesis of relevant literature and provides recommendations generated from the SOTA about how to evaluate cross-system care coordination. Care coordination is typically evaluated using health outcomes including hospital readmissions and death; however, in cross-system evaluations of care coordination, measures such as access, cost, Veteran/patient and provider satisfaction (including with cross-system communication), comparable quality metrics, context (urban vs. rural), and patient complexity (medical and mental health conditions) need to be included to fully evaluate care coordination effectiveness. Future research should examine the role of multiple individuals coordinating VA and non-VA care, and how these coordinators work together to optimize coordination.
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Affiliation(s)
- Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA. .,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
| | | | - A Rani Elwy
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA.,Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI, USA
| | - Erin P Finley
- South Texas Veterans Health Care System, San Antonio, TX, USA.,University of Texas Health Science Center, San Antonio, TX, USA
| | - Clinton Greenstone
- VHA Office of Community Care, Washington, DC, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michelle A Mengeling
- The Center for Comprehensive Access & Delivery Research and Evaluation (CADRE) and VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Steven D Pizer
- VA Boston Healthcare System, Boston, MA, USA.,Boston University School of Public Health, Boston, MA, USA
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Department of Internal Medicine/Division of Epidemiology & Department of Population Health Sciences/Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Michael Weiner
- VA Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.,Regenstrief Institute, Inc., Indianapolis, IN, USA.,Center for Health Services and Outcomes Research, Indiana University, Indianapolis, IN, USA
| | - Lori A Bastian
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.,Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
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Ingram PB, Tarescavage AM, Ben-Porath YS, Oehlert ME. Descriptive Profiles of the MMPI-2-Restructured Form (MMPI-2-RF) across a National Sample of Four Veteran Affairs Treatment Settings. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2019. [DOI: 10.1007/s10862-019-09727-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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19
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Challenges of Practicing Rheumatology in a Government Setting: A County Hospital and Veterans Affairs Hospital Perspective. Rheum Dis Clin North Am 2018; 45:39-51. [PMID: 30447745 DOI: 10.1016/j.rdc.2018.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In this article, we review the challenges and opportunities afforded by working in a government setting by providing the perspective of the Veterans Affairs experience as well as the county/public hospital experience from Los Angeles County Department of Health Services. This article highlights processes and services that are unique to practicing rheumatology in a government setting, specifically, resource allocation with clinic space and staffing; protocols for access to conventional and biologic disease modifying antirheumatic drugs; and research opportunities for rheumatologists working in a government setting. Our aim is to expand the reader's understanding of this practice setting.
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Gamage SD, Ambrose M, Kralovic SM, Simbartl LA, Roselle GA. Legionnaires Disease Surveillance in US Department of Veterans Affairs Medical Facilities and Assessment of Health Care Facility Association. JAMA Netw Open 2018; 1:e180230. [PMID: 30646071 PMCID: PMC6324594 DOI: 10.1001/jamanetworkopen.2018.0230] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Legionnaires disease (LD) incidence is increasing in the United States. Health care facilities are a high-risk setting for transmission of Legionella bacteria from building water systems to occupants. However, the contribution of LD in health care facilities to national LD rates is not well characterized. OBJECTIVES To determine the burden of LD in US Department of Veterans Affairs (VA) patients and to assess the amount of LD with VA exposure. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of reported LD data in VA medical facilities in a national VA LD surveillance system from January 1, 2014, to December 31, 2016. The study population included total veteran enrollees and enrollees who used the VA health care system. MAIN OUTCOMES AND MEASURES The primary outcome was assessment of annual LD rates, categorized by VA and non-VA exposure. Legionnaires disease rates for cases with VA exposure were determined on both population and exposure potential levels. Rates by VA exposure potential were calculated using inpatient bed days of care, long-term care resident days, or outpatient encounters. In addition, types and amounts of LD diagnostic testing were calculated. Case and testing data were analyzed nationally and regionally. RESULTS There were 491 LD cases in the case report surveillance system from January 1, 2014, to December 31, 2016. Most cases (447 [91%]) had no VA exposure or only outpatient VA exposure. The remaining 44 cases had VA exposure from overnight stays. Total LD rates from January 1, 2014, to December 31, 2016, increased for all VA enrollees (from 1.5 to 2.0 per 100 000 enrollees; P = .04) and for users of VA health care (2.3 to 3.0 per 100 000 enrollees; P = .04). The LD rate for the subset who had no VA exposure also increased (0.90 to 1.47 per 100 000 enrollees; P < .001). In contrast, the LD rate for patients with VA overnight stay decreased on a population level (5.0 to 2.3 per 100 000 enrollees; P < .001) and an exposure level (0.31 to 0.15 per 100 000 enrollees; P < .001). Regionally, the eastern United States had the highest LD rates. The urine antigen test was the most used LD diagnostic method; 49 805 tests were performed in 2015-2016 with 335 positive results (0.67%). CONCLUSIONS AND RELEVANCE Data in the VA LD databases showed an increase in overall LD rates over the 3 years, driven by increases in rates of non-VA LD. Inpatient VA-associated LD rates decreased, suggesting that the VA's LD prevention efforts have contributed to improved patient safety.
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Affiliation(s)
- Shantini D. Gamage
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Meredith Ambrose
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC
| | - Stephen M. Kralovic
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Cincinnati VA Medical Center, Cincinnati, Ohio
| | - Loretta A. Simbartl
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC
| | - Gary A. Roselle
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Cincinnati VA Medical Center, Cincinnati, Ohio
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Ohl ME, Carrell M, Thurman A, Weg MV, Hudson T, Mengeling M, Vaughan-Sarrazin M. "Availability of healthcare providers for rural veterans eligible for purchased care under the veterans choice act". BMC Health Serv Res 2018; 18:315. [PMID: 29807536 PMCID: PMC5972410 DOI: 10.1186/s12913-018-3108-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 04/11/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Military Veterans in the United States are more likely than the general population to live in rural areas, and often have limited geographic access to Veterans Health Administration (VHA) facilities. In an effort to improve access for Veterans living far from VHA facilities, the recently-enacted Veterans Choice Act directed VHA to purchase care from non-VHA providers for Veterans who live more than 40 miles from the nearest VHA facility. To explore potential impacts of these reforms on Veterans and healthcare providers, we identified VHA-users who were eligible for purchased care based on distance to VHA facilities, and quantified the availability of various types of non-VHA healthcare providers in counties where these Veterans lived. METHODS We combined 2013 administrative data on VHA-users with county-level data on rurality, non-VHA provider availability, population, household income, and population health status. RESULTS Most (77.9%) of the 416,338 VHA-users who were eligible for purchased care based on distance lived in rural counties. Approximately 16% of these Veterans lived in primary care shortage areas, while the majority (70.2%) lived in mental health care shortage areas. Most lived in counties that lacked specialized health care providers (e.g. cardiologists, pulmonologists, and neurologists). Counterintuitively, VHA played a greater role in delivering healthcare for the overall adult population in counties that were farther from VHA facilities (30.7 VHA-users / 1000 adults in counties over 40 miles from VHA facilities, vs. 22.4 VHA-users / 1000 adults in counties within 20 miles of VHA facilities, p < 0.01). CONCLUSIONS Initiatives to purchase care for Veterans living more than 40 miles from VHA facilities may not significantly improve their access to care, as these areas are underserved by non-VHA providers. Non-VHA providers in the predominantly rural areas more than 40 miles from VHA facilities may be asked to assume care for relatively large numbers of Veterans, because VHA has recently cared for a greater proportion of the population in these areas, and these Veterans are now eligible for purchased care.
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Affiliation(s)
- Michael E Ohl
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center- Iowa City, Iowa City VA Medical Center, Iowa City, IA, USA. .,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Mailstop 152, Iowa City VAMC, 52246m, Iowa City, IA, USA. .,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
| | - Margaret Carrell
- Department of Geographical and Sustainability Sciences, University of Iowa, Iowa City, IA, USA
| | - Andrew Thurman
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Mailstop 152, Iowa City VAMC, 52246m, Iowa City, IA, USA
| | - Mark Vander Weg
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Mailstop 152, Iowa City VAMC, 52246m, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Teresa Hudson
- Center for Mental Healthcare and Outcomes Research, Central Arkansas VA, Little Rock, AR, USA
| | - Michelle Mengeling
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Mailstop 152, Iowa City VAMC, 52246m, Iowa City, IA, USA
| | - Mary Vaughan-Sarrazin
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Mailstop 152, Iowa City VAMC, 52246m, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Zenk SN, Tarlov E, Powell LM, Wing C, Matthews SA, Slater S, Gordon HS, Berbaum M, Fitzgibbon ML. Weight and Veterans' Environments Study (WAVES) I and II: Rationale, Methods, and Cohort Characteristics. Am J Health Promot 2018; 32:779-794. [PMID: 29214851 PMCID: PMC5876028 DOI: 10.1177/0890117117694448] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE To present the rationale, methods, and cohort characteristics for 2 complementary "big data" studies of residential environment contributions to body weight, metabolic risk, and weight management program participation and effectiveness. DESIGN Retrospective cohort. SETTING Continental United States. PARTICIPANTS A total of 3 261 115 veterans who received Department of Veterans Affairs (VA) health care in 2009 to 2014, including 169 910 weight management program participants and a propensity score-derived comparison group. INTERVENTION The VA MOVE! weight management program, an evidence-based lifestyle intervention. MEASURES Body mass index, metabolic risk measures, and MOVE! participation; residential environmental attributes (eg, food outlet availability and walkability); and MOVE! program characteristics. ANALYSIS Descriptive statistics presented on cohort characteristics and environments where they live. RESULTS Forty-four percent of men and 42.8% of women were obese, whereas 4.9% of men and 9.9% of women engaged in MOVE!. About half of the cohort had at least 1 supermarket within 1 mile of their home, whereas they averaged close to 4 convenience stores (3.6 for men, 3.9 for women) and 8 fast-food restaurants (7.9 for men, 8.2 for women). Forty-one percent of men and 38.6% of women did not have a park, and 35.5% of men and 31.3% of women did not have a commercial fitness facility within 1 mile. CONCLUSION Drawing on a large nationwide cohort residing in diverse environments, these studies are poised to significantly inform policy and weight management program design.
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Affiliation(s)
- Shannon N Zenk
- 1 Department of Health Systems Science, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Elizabeth Tarlov
- 1 Department of Health Systems Science, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
- 2 Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines VA Hospital, Hines, IL, USA
| | - Lisa M Powell
- 3 Health Policy and Administration Division, University of Illinois at Chicago School of Public Health, Chicago, IL, USA
- 4 Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Coady Wing
- 5 Indiana University-Bloomington School of Public and Environmental Affairs, Bloomington, IN, USA
| | - Stephen A Matthews
- 6 Department of Sociology, Anthropology, and Demography, Pennsylvania State University, University Park, PA, USA
| | - Sandy Slater
- 3 Health Policy and Administration Division, University of Illinois at Chicago School of Public Health, Chicago, IL, USA
- 4 Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Howard S Gordon
- 7 Jesse Brown VA Medical Center, Chicago, IL, USA
- 8 Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael Berbaum
- 4 Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Marian L Fitzgibbon
- 3 Health Policy and Administration Division, University of Illinois at Chicago School of Public Health, Chicago, IL, USA
- 4 Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, USA
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Hageman SA, Tarzian AJ, Cagle J. Challenges of Dealing with Financial Concerns during Life-Threatening Illness: Perspectives of Health Care Practitioners. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2018; 14:28-43. [PMID: 29505397 DOI: 10.1080/15524256.2018.1432008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The costs of serious medical illness and end of life care are often a heavy burden for patients and families (Collins, Stepanczuk, Williams, & Rich, 2016 ; Kim, 2007 ; May et al., 2014 ; Zarit, 2004 ). Twenty-six practitioners, including social workers, managers/administrators, supervisors, and case managers from five health care settings, participated in qualitative semistructured interviews about financial challenges patients encountered. Seven practitioners took part in a focus group. Practitioners were recruited from hospice (n = 5), long-term care (n = 5), intensive care (n = 5), dialysis (n = 6), and oncology (n = 5). Interview and focus group questions focused on financial challenges patients encountered when facing life-threatening illness. Interview data were transcribed and thematically coded and trustworthiness of data was established with peer debriefing, member checking, and agreement on themes among the authors. Practitioners described interacting micro, meso, and macroinfluences on the financial well-being and challenges patients encountered. Microlevel influences involved patient characteristics, such as their demographic profile and/or health status that set them up for financial aptitude or challenges. Macrolevel influences involved the larger health care/safety net system, which provided valuable resources for some patients but not others. Practitioners also discussed the mesolevel of influence, the local setting where they worked to match available resources with patients' individual needs given the constraints emerging from the micro and macrolevels. Practitioners described how they navigated the interplay of these three areas to meet patients' needs and cope with financial challenges. Implications for practice point to directly addressing the kind of financial concerns that patients and families facing financial burden from serious medical illness have, and identifying ways to bridge knowledge and resource access gaps at the individual, organizational, and societal levels.
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Affiliation(s)
- Sally A Hageman
- a University of Maryland, Baltimore, School of Social Work , Baltimore , Maryland , USA
| | - Anita J Tarzian
- b University of Maryland, Baltimore, School of Nursing , Baltimore , Maryland , USA
| | - John Cagle
- a University of Maryland, Baltimore, School of Social Work , Baltimore , Maryland , USA
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Singh JA, Herbey I, Bharat A, Dinnella JE, Pullman-Mooar S, Eisen S, Ivankova N. Gout Self-Management in African American Veterans: A Qualitative Exploration of Challenges and Solutions From Patients' Perspectives. Arthritis Care Res (Hoboken) 2017; 69:1724-1732. [PMID: 28118526 DOI: 10.1002/acr.23202] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 01/17/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To explore gout self-management and associated challenges and solutions in African Americans. METHODS We conducted semistructured interviews with 35 African American veterans with gout, who received health care at Birmingham or Philadelphia Veterans Affairs (VA) medical centers, had filled urate-lowering therapy (ULT; most commonly allopurinol) for at least 6 months, and had a ULT medication possession ratio ≥80%. The interview protocol was constructed to explore key concepts related to gout self-management, including initial diagnosis of gout, beginning medical care for gout, the course of the gout, ULT medication adherence, dietary strategies, comorbidity and side effects, and social support. RESULTS Thirty-five African American male veterans with gout who had ≥80% ULT adherence (most commonly, allopurinol) were interviewed at Birmingham (n = 18) or Philadelphia (n = 17) VA medical centers. Mean age was 65 years, mean body mass index was 31.9 kg/m2 , 97% had hypertension, 23% had coronary artery disease, and 31% had renal failure. The main themes motivating African American veterans to better gout self-management were fear of pain, adherence to medications, self-discipline, lifestyle changes, information gathering, and developing a positive outlook. Birmingham participants more frequently revealed skipping gout medications. More Philadelphia participants discussed lifestyle/diet changes to prevent gout flares, indicated limiting social activities that involved drinking, and sought more information about gout self-management from health care providers and internet sources. CONCLUSION Identified themes, including cultural differences by site, led to the development of a patient-centered intervention to improve gout self-management in African American men with gout.
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Affiliation(s)
- Jasvinder A Singh
- VA Medical Center and University of Alabama at Birmingham, and Mayo Clinic College of Medicine, Rochester, Minnesota
| | | | | | - Janet E Dinnella
- Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sally Pullman-Mooar
- Philadelphia VA Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Seth Eisen
- Washington University School of Medicine and St. Louis VA Medical Center, St. Louis, Missouri
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Dill C, Gonzalez-Aviles A. Letter to the Editor regarding "Severe mental illness and emergency department service use nationally in the Veterans Health Administration". Gen Hosp Psychiatry 2017; 47:112. [PMID: 28185674 DOI: 10.1016/j.genhosppsych.2017.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 01/09/2017] [Accepted: 01/14/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Curt Dill
- Emergency Medicine, VA-NYHHS-NY, 423 East 23 Street 1551a, New York, NY 10010, United States.
| | - Arnaldo Gonzalez-Aviles
- Emergency Psychiatry, VA-NYHHS-NY, 423 East 23 Street 1551a, New York, NY 10010, United States.
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Breland JY, Phibbs CS, Hoggatt KJ, Washington DL, Lee J, Haskell S, Uchendu US, Saechao FS, Zephyrin LC, Frayne SM. The Obesity Epidemic in the Veterans Health Administration: Prevalence Among Key Populations of Women and Men Veterans. J Gen Intern Med 2017; 32:11-17. [PMID: 28271422 PMCID: PMC5359156 DOI: 10.1007/s11606-016-3962-1] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Most US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services. OBJECTIVES To inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA patients. DESIGN Cross-sectional descriptive analyses of fiscal year 2014 (FY2014) national VHA administrative and clinical data, stratified by gender. Differences ≥5% higher than the population mean were considered clinically significant. PARTICIPANTS Veteran VHA primary care patients with a valid weight within ±365 days of their first FY2014 primary care visit, and a valid height (98% of primary care patients). MAIN MEASURES We used VHA vital signs data to ascertain height and weight and calculate body mass index, and VHA outpatient, inpatient, and fee basis data to identify sociodemographic- and comorbidity-based subpopulations. KEY RESULTS Among nearly five million primary care patients (347,112 women, 4,567,096 men), obesity prevalence was 41% (women 44%, men 41%), and overweight prevalence was 37% (women 31%, men 38%). Across the VHA's 140 facilities, obesity prevalence ranged from 28% to 49%. Among gender-stratified subpopulations, obesity prevalence was high among veterans under age 65 (age 18-44: women 40%, men 46%; age 45-64: women 49%, men 48%). Obesity prevalence varied across racial/ethnic and comorbidity subpopulations, with high obesity prevalence among black women (51%), women with schizophrenia (56%), and women and men with diabetes (68%, 56%). CONCLUSIONS Overweight and obesity are common among veterans served by the VHA. VHA's weight management initiatives have the potential to avert long-term morbidity arising from obesity-related conditions. High-risk groups-such as black women veterans, women veterans with schizophrenia, younger veterans, and Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans-may require particular attention to ensure that systems improvement efforts at the population level do not inadvertently increase health disparities.
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Affiliation(s)
- Jessica Y Breland
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA, 94025, USA.
- Stanford University School of Medicine, Stanford, CA, USA.
| | - Ciaran S Phibbs
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA, 94025, USA
- Stanford University School of Medicine, Stanford, CA, USA
| | - Katherine J Hoggatt
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jimmy Lee
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA, 94025, USA
| | - Sally Haskell
- United States Department of Veterans Affairs Central Office, Women's Health Services, Washington, DC, USA
- West Haven VA, West Haven, CT, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Uchenna S Uchendu
- United States Department of Veterans Affairs Central Office, Office of Health Equity, Washington, DC, USA
| | - Fay S Saechao
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA, 94025, USA
| | - Laurie C Zephyrin
- United States Department of Veterans Affairs Central Office, Women's Health Services, Washington, DC, USA
- New York University School of Medicine, New York, NY, USA
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA, 94025, USA
- Stanford University School of Medicine, Stanford, CA, USA
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Fu SS, Sherman SE, Yano EM, van Ryn M, Lanto AB, Joseph AM. Ethnic Disparities in the Use of Nicotine Replacement Therapy for Smoking Cessation in an Equal Access Health Care System. Am J Health Promot 2016; 20:108-16. [PMID: 16295702 DOI: 10.4278/0890-1171-20.2.108] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose. To examine ethnic variations in the use of nicotine replacement therapy (NRT) in an equal access health care system. Design. Cross-sectional survey. Setting. Eighteen Veterans Affairs medical and ambulatory care centers. Subjects. A cohort of male current smokers (n = 1606). Measures. Use of NRT (nicotine patch or nicotine gum), ethnicity, sociodemographics, health status, smoking-related history, and facility prescribing policy. Results. Overall, only 34% of African-American and 26% of Hispanic smokers have ever used NRT as a cessation aid compared with 50% of white smokers. In the past year, African-American smokers were most likely to have attempted quitting. During a serious past-year quit attempt, however, African-American and Hispanic smokers reported lower rates of NRT use than white smokers (20% vs. 22% vs. 34%, respectively, p = .001). In multivariate analyses, ethnicity was independently associated with NRT use during a past-year quit attempt. Compared with white smokers, African-American (adjusted odds ratio, .53; 95% confidence interval, .34–.83) and Hispanic (adjusted odds ratio, .55; 95% confidence interval, .28–1.08) smokers were less likely to use NRT. Conclusions. Assessment of variations in use of NRT demonstrates that African-American and Hispanic smokers are less likely to use NRT during quit attempts. Future research is needed on the relative contributions of patient, physician, and system features to gaps in guideline implementation to provide treatment for ethnic minority smokers.
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Affiliation(s)
- Steven S Fu
- Section of General Internal Medicine, Center for Chronic Disease Outcomes Research, Veterans Affairs Medical Center, Minneapolis, Minnesota 55417, USA.
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Tsai J, Rosenheck RA. US Veterans’ Use Of VA Mental Health Services And Disability Compensation Increased From 2001 To 2010. Health Aff (Millwood) 2016; 35:966-73. [DOI: 10.1377/hlthaff.2015.1555] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jack Tsai
- Jack Tsai ( ) is a core investigator for the Veterans Affairs (VA) New England Mental Illness, Research, Education, and Clinical Center and an assistant professor of psychiatry at the Yale University School of Medicine, both in West Haven, Connecticut
| | - Robert A. Rosenheck
- Robert A. Rosenheck is a senior investigator for the VA New England Mental Illness, Research, Education, and Clinical Center and a professor of psychiatry at the Yale University School of Medicine
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Overall and recurrence-free survival among black and white bladder cancer patients in an equal-access health system. Cancer Epidemiol 2016; 42:154-8. [PMID: 27161431 DOI: 10.1016/j.canep.2016.04.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 04/06/2016] [Accepted: 04/23/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND While the incidence of bladder cancer is twice as high among whites than among blacks, mortality is higher among blacks than whites. Unequal access to medical care may be an important factor. Insufficient access to care could delay cancer detection and treatment, which can result in worse survival. The purpose of this study was to evaluate whether survival differed between black and white bladder cancer patients in the Department of Defense (DoD), which provides universal healthcare to all beneficiaries regardless of racial background. METHODS This study was based on data from the U.S. DoD Automated Central Tumor Registry (ACTUR). White and black patients histologically diagnosed with bladder cancer between 1990 and 2004 were included in the study and followed to the end of 2007. The outcomes were all-cause mortality and recurrence. We assessed the relationship between race and outcomes of interest using Cox proportional hazard ratios (HRs) for all, non-muscle invasive (NMIBC), and muscle invasive (MIBC) bladder cancers, separately. RESULTS The survival of black and white individuals did not differ statistically. No significant racial differences in survival (HR: 0.96, 95% CI: 0.76-1.22) or recurrence-free survival (HR: 0.94, 95% CI: 0.69-1.30) were observed after adjustment for demographic variables, tumor characteristics, and treatment. Similar findings were observed for NMIBC and MIBC patients, respectively. CONCLUSION Black patients were more likely to present with MIBC than white patients. However, white and black patients with bladder cancer were not significantly different in overall and recurrence-free survival regardless of muscle invasion. Our study suggests the importance of equal access to healthcare in reducing racial disparities in bladder cancer survival.
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Nguyen OK, Makam AN, Halm EA. National Use of Safety-Net Clinics for Primary Care among Adults with Non-Medicaid Insurance in the United States. PLoS One 2016; 11:e0151610. [PMID: 27027617 PMCID: PMC4814117 DOI: 10.1371/journal.pone.0151610] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 03/01/2016] [Indexed: 11/19/2022] Open
Abstract
Objective To describe the prevalence, characteristics, and predictors of safety-net use for primary care among non-Medicaid insured adults (i.e., those with private insurance or Medicare). Methods Cross-sectional analysis using the 2006–2010 National Ambulatory Medical Care Surveys, annual probability samples of outpatient visits in the U.S. We estimated national prevalence of safety-net visits using weighted percentages to account for the complex survey design. We conducted bivariate and multivariate logistic regression analyses to examine characteristics associated with safety-net clinic use. Results More than one-third (35.0%) of all primary care safety-net clinic visits were among adults with non-Medicaid primary insurance, representing 6,642,000 annual visits nationally. The strongest predictors of safety-net use among non-Medicaid insured adults were: being from a high-poverty neighborhood (AOR 9.53, 95% CI 4.65–19.53), being dually eligible for Medicare and Medicaid (AOR 2.13, 95% CI 1.38–3.30), and being black (AOR 1.97, 95% CI 1.06–3.66) or Hispanic (AOR 2.28, 95% CI 1.32–3.93). Compared to non-safety-net users, non-Medicaid insured adults who used safety-net clinics had a higher prevalence of diabetes (23.5% vs. 15.0%, p<0.001), hypertension (49.4% vs. 36.0%, p<0.001), multimorbidity (≥2 chronic conditions; 53.5% vs. 40.9%, p<0.001) and polypharmacy (≥4 medications; 48.8% vs. 34.0%, p<0.001). Nearly one-third (28.9%) of Medicare beneficiaries in the safety-net were dual eligibles, compared to only 6.8% of Medicare beneficiaries in non-safety-net clinics (p<0.001). Conclusions Safety net clinics are important primary care delivery sites for non-Medicaid insured minority and low-income populations with a high burden of chronic illness. The critical role of safety-net clinics in care delivery is likely to persist despite expanded insurance coverage under the Affordable Care Act.
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas, United States of America
- * E-mail:
| | - Anil N. Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas, United States of America
| | - Ethan A. Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, United States of America
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas, United States of America
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Pucheril D, Sammon JD, Sood A, Abdollah F, Choueiri TK, Meyer C, Hanske J, Kim SP, Nguyen PL, Kibel AS, Weissman JS, Menon M, Trinh QD. Contemporary nationwide patterns of self-reported prostate-specific antigen screening in US veterans. Urol Oncol 2015; 33:503.e7-15. [DOI: 10.1016/j.urolonc.2015.07.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/15/2015] [Accepted: 07/26/2015] [Indexed: 11/24/2022]
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Wong ES, Wang V, Liu CF, Hebert PL, Maciejewski ML. Do Veterans Health Administration Enrollees Generalize to Other Populations? Med Care Res Rev 2015; 73:493-507. [PMID: 26589675 DOI: 10.1177/1077558715617382] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 10/23/2015] [Indexed: 11/16/2022]
Abstract
The Veterans Health Administration (VHA) has historically served a disproportionately male patient population with lower income and greater rates of mental illness than non-VHA populations. The generalizability of research based on VHA enrollees is unknown because the overlap between VHA and non-VHA populations has never been empirically examined. This study used 2013 National Health Interview Survey data to examine the extent to which VHA enrollees had similar demographic and health characteristics as individuals with Medicaid, Medicare, or private insurance coverage, based on propensity score models. A majority of male VHA enrollees were similar to Medicare beneficiaries suggesting greater generalizability of VHA studies than commonly hypothesized. Overlap declined when comparing with Medicaid enrollees or privately insured individuals, suggesting more limited generalizability of VHA studies to these populations.
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Affiliation(s)
- Edwin S Wong
- VA Puget Sound Health Care System, Seattle, WA, USA University of Washington, Seattle, WA, USA
| | - Virginia Wang
- Durham VA Medical Center, Durham, NC, USA Duke University, Durham, NC, USA
| | - Chuan-Fen Liu
- VA Puget Sound Health Care System, Seattle, WA, USA University of Washington, Seattle, WA, USA
| | - Paul L Hebert
- VA Puget Sound Health Care System, Seattle, WA, USA University of Washington, Seattle, WA, USA
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West AN, Charlton ME, Vaughan-Sarrazin M. Dual use of VA and non-VA hospitals by Veterans with multiple hospitalizations. BMC Health Serv Res 2015; 15:431. [PMID: 26416176 PMCID: PMC4587652 DOI: 10.1186/s12913-015-1069-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 08/26/2015] [Indexed: 11/23/2022] Open
Abstract
Background Veterans who are hospitalized in both VA and non-VA hospitals within a short timespan may be at risk for fragmented or conflicting care. To determine the characteristics of these “dual users,” we analyzed administrative hospital discharge data for VA-enrolled veterans of any age in seven states, including any VA or non-VA hospitalizations they had in 2004–2007. Method For VA enrollees in Arizona, Iowa, Louisiana, Florida, South Carolina, Pennsylvania, or New York in 2007, we merged 2004–2007 discharge data for all VA hospitalizations and all non-VA hospitalizations listed in state health department or hospital association databases. For patients hospitalized in 2007, we compared those younger or older than 65 years who had one or multiple hospitalizations during the year, split into users of VA hospitals, non-VA hospitals, or both (“dual users”), on demographics, priority for VA care, travel times, principal diagnoses, co-morbidities, lengths of stay, and prior (2004–2006) hospitalizations, using chi-square analysis or ANOVA. Multiply hospitalized patients were compared with multinomial logistic regressions to predict non-VA and dual use. Payers for non-VA hospitalizations also were compared across groups. Results Of unique inpatients in 2007, 38 % of those 65 or older were hospitalized more than once during the year, as were 32 % of younger patients; 3 and 8 %, respectively, were dual users. Dual users averaged the most index-year (3.7) and prior (1.5) hospitalizations, split evenly between VA and non-VA. They also had higher rates of admission for circulatory diseases, symptoms/signs/ill-defined conditions, and injury and poisoning, and more admissions for multiple diagnostic categories; among younger patients they had the highest rate of mental disorders admissions. Higher income, non-rural residence, greater time to VA care, lower VA priority, prior non-VA hospitalization, no prior VA hospitalization, and several medical categories predicted greater non-VA use. Among younger patients, however, mental disorders predicted more dual use but less exclusively non-VA use. Dual users’ non-VA admissions were more likely than others’ to be covered by payers other than Medicare or commercial insurance. Conclusions Younger dual users require more medical and psychiatric treatment, and rely more on government funding sources. Effective care coordination for these inpatients might improve outcomes while reducing taxpayer burden.
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Affiliation(s)
- Alan N West
- Research Service, VA Medical Center (10A5A), 215 N. Main St., White River Junction, Vermont, 05009, USA. .,Geisel Medical School (formerly Dartmouth Medical School), Hanover, New Hampshire, USA. .,Veterans Rural Health Resource Center - Eastern Region, White River Junction, Vermont, USA.
| | - Mary E Charlton
- Iowa City VA Health Care System, Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City, Iowa, USA. .,Department of Epidemiology, The University of Iowa College of Public Health, Iowa City, Iowa, USA.
| | - Mary Vaughan-Sarrazin
- Iowa City VA Health Care System, Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City, Iowa, USA. .,Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
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Wong ES, Hebert PL, Nelson KM, Hernandez SE, Sylling PW, Fihn SD, Liu CF. Local Area Unemployment and the Demand for Inpatient Care Among Veterans Affairs Enrollees. Med Care Res Rev 2015; 72:468-80. [DOI: 10.1177/1077558715583790] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 03/28/2015] [Indexed: 11/17/2022]
Abstract
Prior research examining the relationship between economic conditions and health service demand has focused primarily on outpatient use. This study examines whether local area unemployment, as an indicator of economic conditions, was associated with use of inpatient care, which is theoretically less subject to discretionary use. Using a random sample of 131,603 patients dually enrolled in the Veterans Affairs (VA) Health System and fee-for-service Medicare, we measured VA, Medicare, and total (VA and Medicare) hospitalizations. Overall, local unemployment was not associated with VA, Medicare, or total hospitalization probability. Among low-income veterans exempt from VA copayments, higher local unemployment was moderately associated with a lower probability of hospitalization through Medicare. For veterans subject to VA copayments, higher local unemployment was moderately associated with a higher likelihood of VA hospitalization. These results suggest inpatient use is less sensitive to the economy, although worse economic conditions slightly affected inpatient demand for select veterans.
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Affiliation(s)
- Edwin S. Wong
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Paul L. Hebert
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Karin M. Nelson
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | | | | | | | - Chuan-Fen Liu
- Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
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Abstract
Homelessness among US veterans has been a focus of research for over 3 decades. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this is the first systematic review to summarize research on risk factors for homelessness among US veterans and to evaluate the evidence for these risk factors. Thirty-one studies published from 1987 to 2014 were divided into 3 categories: more rigorous studies, less rigorous studies, and studies comparing homeless veterans with homeless nonveterans. The strongest and most consistent risk factors were substance use disorders and mental illness, followed by low income and other income-related factors. There was some evidence that social isolation, adverse childhood experiences, and past incarceration were also important risk factors. Veterans, especially those who served since the advent of the all-volunteer force, were at greater risk for homelessness than other adults. Homeless veterans were generally older, better educated, and more likely to be male, married/have been married, and to have health insurance coverage than other homeless adults. More studies simultaneously addressing premilitary, military, and postmilitary risk factors for veteran homelessness are needed. This review identifies substance use disorders, mental illness, and low income as targets for policies and programs in efforts to end homelessness among veterans.
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Affiliation(s)
- Jack Tsai
- VA New England Mental Illness Research, Education, and Clinical Center, West Haven, Connecticut (Jack Tsai, Robert A. Rosenheck); Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Jack Tsai, Robert A. Rosenheck); and Department of Epidemiology and Public Health, Yale School of Public Health, New Haven, Connecticut (Robert A. Rosenheck)
| | - Robert A. Rosenheck
- VA New England Mental Illness Research, Education, and Clinical Center, West Haven, Connecticut (Jack Tsai, Robert A. Rosenheck); Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Jack Tsai, Robert A. Rosenheck); and Department of Epidemiology and Public Health, Yale School of Public Health, New Haven, Connecticut (Robert A. Rosenheck)
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Bui CN, Wang L, Baser O. Resource utilization and use of life-extending therapies and corticosteroids in prostate cancer patients with corticosteroid-sensitive comorbidities. Curr Med Res Opin 2014; 30:2355-64. [PMID: 25133961 DOI: 10.1185/03007995.2014.955170] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Corticosteroids (CSs) are used concomitantly with life-extending therapies (LETs) in patients with castration-resistant prostate cancer (CRPC). This study examined time to LETs, LETs and concomitant CS adherence, and monthly all-cause healthcare utilization and costs in patients with CPRC with and without CS-sensitive comorbidities in the Veterans Health Administration population. METHODS Patients had CRPC if records showed prostate cancer diagnosis, medical/surgical castration and ≥2 prostate-specific antigen increases through 1 June 2007-31 May 2012. CS-sensitive comorbidities were assessed 6 months prior to the index date. Adherence, defined as medication possession ratio (MPR) ≥0.8, among patients initiating LETs (cabazitaxel, docetaxel, or abiraterone acetate) before 30 November 2011, resource utilization and costs among patients with concomitant CS were assessed. Statistical analysis included descriptive, Cox proportional hazards, and logistic regression models. RESULTS Common CS-sensitive conditions among 12,128 patients with CRPC included hypertension (75.74%) and hyperlipidemia (54.69%). Those with glaucoma (hazard ratio [HR] = 0.67), ischemic heart disease (HR = 0.78), and peripheral vascular disease (PVD) (HR = 0.78) were less likely to be prescribed LETs (all p < 0.01). Duration of LET was shorter among patients with CS-sensitive comorbidities (125.02 vs 133.08 days; p = 0.04) in the 6 month follow-up period. Among LET-treated patients with and without CS-sensitive comorbidities, less than half had MPR ≥ 0.8 (LET: 48.72% vs 54.05%; concomitant CS: 42.19% vs 40.54%, respectively). Cerebrovascular disease (odds ratio = 0.107; 95% confidence interval = 0.012 to 0.966) and PVD (odds ratio = 0.523; 95% confidence interval = 0.276 to 0.991) were associated with reduced CS adherence. Among patients with concomitant CS, those with CS-sensitive comorbidities had more inpatient stays than those without (20.45% vs 12.88%; p = 0.033), incurring higher monthly inpatient costs ($1157 vs $342; p < 0.0001) and total costs ($5725 vs $4772; p = 0.036). CONCLUSION CS-sensitive conditions influence initiation and duration of LETs, concomitant CS adherence, inpatient stays, and total costs. Future efforts should focus on specific strategies for treating prostate cancer patients with CS-sensitive comorbidities to ensure that they have appropriate access to LETs and to reduce costs and inpatient stays. Study limitations include the use of retrospective claims data and the relatively restricted subpopulation of older North American males.
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Affiliation(s)
- Cat N Bui
- Astellas Scientific and Medical Affairs , Northbrook, IL , USA
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Higgins DM, Buta E, Dorflinger L, Heapy AA, Ruser CB, Goulet JL, Masheb RM. Psychometric properties of a MOVE!23 subscale: Perceived Contributors to Weight Change in a national sample of veterans. J Health Psychol 2014; 21:1394-403. [PMID: 25293969 DOI: 10.1177/1359105314554530] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The MOVE!23, a questionnaire to assess weight-related domains in veterans, was examined. Factor analysis of Perceived Contributors to Weight Change revealed three factors (psychosocial, eating behavior, and medical) that were positively correlated with body mass index, and psychiatric and medical comorbidity (p's < 0.001). Multivariable cumulative logit models modeling the factor scores indicated that women were more likely than men to endorse psychosocial (odds ratio = 2.15, confidence interval = 2.04-2.27) and medical (odds ratio = 1.69, confidence interval = 1.59-1.79) items. The MOVE!23 Perceived Contributors to Weight Change subscale is a reliable and valid measure that is associated with body mass index and may assist in tailoring treatments according to gender and comorbidity.
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Affiliation(s)
| | - Eugenia Buta
- VA Connecticut Healthcare System, USA Yale University, USA
| | | | - Alicia A Heapy
- VA Connecticut Healthcare System, USA Yale University, USA
| | | | | | - Robin M Masheb
- VA Connecticut Healthcare System, USA Yale University, USA
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Wang L, Barron R, Baser O, Langeberg WJ, Dale DC. Cancer chemotherapy treatment patterns and febrile neutropenia in the US Veterans Health Administration. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2014; 17:739-743. [PMID: 25236998 DOI: 10.1016/j.jval.2014.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 05/15/2014] [Accepted: 06/22/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND The Veterans Health Administration (VHA) is the largest integrated health care system in the United States and a major cancer care provider. OBJECTIVE To use VHA database to conduct a population-based study of patterns of myelosuppressive chemotherapy use and to assess the incidence and management of febrile neutropenia (FN) among VHA patients with lung, colorectal, or prostate cancer or non-Hodgkin lymphoma (NHL). METHODS Data were extracted for the initial myelosuppressive chemotherapy course for 27,899 patients who began treatment in the period 2006 to 2011. FN-related costs were defined as claims containing FN diagnosis. RESULTS Most patients were men (98.0%); most were 65 years or older (55.8%). Patients received a mean 3.4 to 3.9 chemotherapy cycles/course (median cycle duration 34-43 days). The incidence of FN among patients with lung, colorectal, or prostate cancer or NHL was 10.2%, 4.6%, 5.4%, and 17.3%, respectively. Primary or secondary prophylactic antibiotics/colony-stimulating factors were received by 21% and 12% of patients, respectively. Antibiotics were more commonly given as primary or secondary prophylaxis for patients with lung, colorectal, and prostate cancer; colony-stimulating factors were more common for patients with NHL. Among patients with FN, those with lung cancer had the highest inpatient mortality (10%); patients with NHL had the highest costs ($24,571) and the longest hospital length of stay (15.4 days). CONCLUSIONS VHA cancer care was generally consistent with National Comprehensive Cancer Network recommendations; however, compared with the general population, chemotherapy cycles were longer, combination chemotherapy was used less, and treatment to prevent FN was used less, differences that may be attributed to the unique VHA patient population. The impact of these practices warrants further investigation.
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Affiliation(s)
- Li Wang
- STATinMED Research, Plano, TX
| | | | - Onur Baser
- STATinMED Research, Plano, TX; MEF University, Istanbul, Turkey
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Tsai J, Doran KM, Rosenheck RA. When health insurance is not a factor: national comparison of homeless and nonhomeless US veterans who use Veterans Affairs Emergency Departments. Am J Public Health 2013; 103 Suppl 2:S225-31. [PMID: 24148061 DOI: 10.2105/ajph.2013.301307] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the proportion of homeless veterans among users of Veterans Affairs (VA) emergency departments (EDs) and compared sociodemographic and clinical characteristics of homeless and nonhomeless VA emergency department users nationally. METHODS We used national VA administrative data from fiscal year 2010 for a cross-sectional study comparing homeless (n = 64,091) and nonhomeless (n = 866,621) ED users on sociodemographics, medical and psychiatric diagnoses, and other clinical characteristics. RESULTS Homeless veterans had 4 times the odds of using EDs than nonhomeless veterans. Multivariate analyses found few differences between homeless and nonhomeless ED users on the medical conditions examined, but homeless ED users were more likely to have been diagnosed with a drug use disorder (odds ratio [OR] = 4.12; 95% confidence interval [CI] = 3.97, 4.27), alcohol use disorder (OR = 3.67; 95% CI = 3.55, 3.79), or schizophrenia (OR = 3.44; 95% CI = 3.25, 3.64) in the past year. CONCLUSIONS In a national integrated health care system with no specific requirements for health insurance, the major differences found between homeless and nonhomeless ED users were high rates of psychiatric and substance abuse diagnoses. EDs may be an important location for specialized homeless outreach (or "in" reach) services to address mental health and addictive disorders.
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Affiliation(s)
- Jack Tsai
- Jack Tsai and Robert A. Rosenheck are with the Veterans Affairs New England Mental Illness Research, Education, and Clinical Center, West Haven, CT; the Veterans Affairs Connecticut Healthcare System, West Haven; and the Department of Psychiatry, Yale University School of Medicine, New Haven, CT. Kelly M. Doran is with the Robert Wood Johnson Foundation Clinical Scholars Program and the Department of Emergency Medicine, Yale University School of Medicine, New Haven
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Stroupe KT, Smith BM, Hogan TP, St. Andre JR, Gellad WF, Weiner S, Lee TA, Burk M, Cunningham F, Piette JD, Rogers TJ, Huo Z, Weaver FM. Medication acquisition across systems of care and patient–provider communication among older veterans. Am J Health Syst Pharm 2013; 70:804-13. [DOI: 10.2146/ajhp120222] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Bridget M. Smith
- Center for Management of Complex Chronic Care (CMC3), Edward Hines, Jr. VA (Veterans Affairs) Hospital, Hines, IL
| | - Timothy P. Hogan
- Center for Health Quality, Outcomes and Economic Research and eHealth Quality Enhancement Research Initiative (QUERI), National eHealth QUERI Coordinating Center, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
| | | | - Walid F. Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and Assistant Professor, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Muriel Burk
- VA Pharmacy Benefit Management/Strategic Healthcare Group
| | - Francesca Cunningham
- VA Pharmacy Benefit Management/Strategic Healthcare Group, Edward Hines, Jr. VA Hospital
| | - John D. Piette
- Center for Clinical Management Research, University of Michigan, Ann Arbor
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Dobalian A, Stein JA, Heslin KC, Riopelle D, Venkatesh B, Lanto AB, Simon B, Yano EM, Rubenstein LV. Impact of the Northridge Earthquake on the Mental Health of Veterans: Results From a Panel Study. Disaster Med Public Health Prep 2013; 5 Suppl 2:S220-6. [DOI: 10.1001/dmp.2011.60] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
ABSTRACTObjective: The 1994 earthquake that struck Northridge, California, led to the closure of the Veterans Health Administration Medical Center at Sepulveda. This article examines the earthquake's impact on the mental health of an existing cohort of veterans who had previously used the Sepulveda Veterans Health Administration Medical Center.Methods: From 1 to 3 months after the disaster, trained interviewers made repeated attempts to contact participants by telephone to administer a repeated measures follow-up design survey based on a survey that had been done preearthquake. Postearthquake data were obtained on 1144 of 1800 (64%) male veterans for whom there were previous data. We tested a predictive latent variable path model of the relations between sociodemographic characteristics, predisaster physical and emotional health measures, and postdisaster emotional health and perceived earthquake impact.Results: Perceived earthquake impact was predicted by predisaster emotional distress, functional limitations, and number of health conditions. Postdisaster emotional distress was predicted by preexisting emotional distress and earthquake impact. The regression coefficient from earthquake impact to postearthquake emotional distress was larger than that of the stability coefficient from preearthquake emotional distress. Postearthquake emotional distress also was affected indirectly by preearthquake emotional distress, health conditions, younger age, and lower socioeconomic status.Conclusions: The postdisaster emotional health of veterans who experienced greater earthquake impact would have likely benefited from postdisaster intervention, regardless of their predisaster emotional health. Younger veterans and veterans with generally poor physical and emotional health were more vulnerable to greater postearthquake emotional distress. Veterans of lower socioeconomic status were disproportionately likely to experience more effects of the disaster because they had more predisaster emotional distress, more functional limitations, and a greater number of health conditions. Because many veterans use non–Department of Veterans Affairs (VA) health care providers for at least some of their health needs, future disaster planning for both VA and non-VA providers should incorporate interventions targeted at these groups.(Disaster Med Public Health Preparedness. 2011;5:S220-S226)
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Wong ES, Liu CF. The relationship between local area labor market conditions and the use of Veterans Affairs health services. BMC Health Serv Res 2013; 13:96. [PMID: 23496888 PMCID: PMC3607916 DOI: 10.1186/1472-6963-13-96] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 02/27/2013] [Indexed: 11/16/2022] Open
Abstract
Background In the U.S., economic conditions are intertwined with labor market decisions, access to health care, health care utilization and health outcomes. The Veterans Affairs (VA) health care system has served as a safety net provider by supplying free or reduced cost care to qualifying veterans. This study examines whether local area labor market conditions, measured using county-level unemployment rates, influence whether veterans obtain health care from the VA. Methods We used survey data from the Behavioral Risk Factor Surveillance System in years 2000, 2003 and 2004 to construct a random sample of 73,964 respondents self-identified as veterans. VA health service utilization was defined as whether veterans received all, some or no care from the VA. Hierarchical ordered logistic regression was used to address unobserved state and county random effects while adjusting for individual characteristics. Local area labor market conditions were defined as the average 12-month unemployment rate in veterans’ county of residence. Results The mean unemployment rate for veterans receiving all, some and no care was 5.56%, 5.37% and 5.24%, respectively. After covariate adjustment, a one percentage point increase in the unemployment rate in a veteran’s county of residence was associated with an increase in the probability of receiving all care (0.34%, p-value = 0.056) or some care (0.29%, p-value = 0.023) from the VA. Conclusions Our findings suggest that the important role of the VA in providing health care services to veterans is magnified in locations with high unemployment.
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Affiliation(s)
- Edwin S Wong
- Northwest Center for Outcomes Research in Older Adults, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA.
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Ellis C, Knapp RG, Gilbert GE, Egede LE. Factors associated with delays in seeking treatment for stroke care in veterans. J Stroke Cerebrovasc Dis 2012; 22:e136-41. [PMID: 23219014 DOI: 10.1016/j.jstrokecerebrovasdis.2012.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 09/25/2012] [Accepted: 09/30/2012] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Our objective was to examine the association between delay in seeking treatment (DST) for stroke care and demographic and clinical characteristics variables in a sample of veterans. METHODS We used survey data from 100 veterans with a diagnosis of stroke who were receiving poststroke care at a Veterans Affairs (VA) Medical Center in the southeastern United States to evaluate the relationship between DST and key sample demographic and clinical characteristics. We used backward stepwise logistic regression models to assess the independent association between DST and demographic and clinical variables. RESULTS We found that stroke survivors reporting DST were more likely to be black (56.4% versus 32.8%; P = .02) and younger at the time of stroke onset (58.1 years versus 63.7 years; P = .02). In backward stepwise logistic regression models, being black was an independent predictor of DST (odds ratio [OR] 2.76; 95% confidence interval [CI], 1.04-7.30; P = .04) in this veteran population. CONCLUSIONS Race appears to be a key factor associated with an increased likelihood of delays in seeking urgent stroke care in veterans. Future studies need to further examine the complex sociodemographic profile of patients who are most likely to delay seeking care for stroke and to develop interventions to reduce the impact of DST.
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Affiliation(s)
- Charles Ellis
- VA Center for Disease Prevention and Health Interventions for Diverse Populations, Ralph H. Johnson VA Medical Center, Charleston, South Carolina; Department of Health Sciences & Research, Medical University of South Carolina, Charleston, South Carolina.
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Cheng EM, Keyhani S, Ofner S, Williams LS, Hebert PL, Ordin DL, Bravata DM. Lower use of carotid artery imaging at minority-serving hospitals. Neurology 2012; 79:138-44. [PMID: 22700815 DOI: 10.1212/wnl.0b013e31825f04c5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE We determined whether site of care explains a previously identified racial disparity in carotid artery imaging. METHODS In this retrospective cohort study, data were obtained from a chart review of veterans hospitalized with ischemic stroke at 127 Veterans Administration hospitals in 2007. Extensive exclusion criteria were applied to obtain a sample who should have received carotid artery imaging. Minority-serving hospitals were defined as the top 10% of hospitals ranked by the proportion of stroke patients who were black. Population level multivariate logistic regression models with adjustment for correlation of patients in hospitals were used to calculate predictive probabilities of carotid artery imaging by race and minority-service hospital status. Bootstrapping was used to obtain 95% confidence intervals (CIs). RESULTS The sample consisted of 1,534 white patients and 628 black patients. Nearly 40% of all black patients were admitted to 1 of 13 minority-serving hospitals. No racial disparity in receipt of carotid artery imaging was detected within nonminority serving hospitals. However, the predicted probability of receiving carotid artery imaging for white patients at nonminority-serving hospitals (89.7%, 95% CI [87.3%, 92.1%]) was significantly higher than both white patients (78.0% [68.3%, 87.8%] and black patients (70.5% [59.3%, 81.6%]) at minority-serving hospitals. CONCLUSIONS Underuse of carotid artery imaging occurred most often among patients hospitalized at minority-serving hospitals. Further work is required to explore why site of care is a mechanism for racial disparities in this clinically important diagnostic test.
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Affiliation(s)
- Eric M Cheng
- Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, USA.
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Davis CL, Kilbourne AM, Blow FC, Pierce JR, Winkel BM, Huycke E, Langberg R, Lyle D, Phillips Y, Visnic S. Reduced mortality among Department of Veterans Affairs patients with schizophrenia or bipolar disorder lost to follow-up and engaged in active outreach to return for care. Am J Public Health 2012; 102 Suppl 1:S74-9. [PMID: 22390607 PMCID: PMC3496434 DOI: 10.2105/ajph.2011.300502] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2011] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We determined whether contacting Department of Veterans Affairs (VA) patients with schizophrenia or bipolar disorders (serious mental illness [SMI]) who had dropped out of care for prolonged periods resulted in reengagement with VA services and decreased mortality. METHODS We developed a list of patients with SMI who were last treated in fiscal years 2005 to 2006, and were lost to follow-up care for at least 1 year. VA medical centers used our list to contact patients and schedule appointments. Additional VA administrative data on patient utilization and mortality through May 2009 were analyzed. RESULTS About 72% (2375 of 3306) of the patients who VA staff attempted to contact returned for VA care. The mortality rate of returning patients was significantly lower than that for patients not returning (0.5% vs 3.9%; adjusted odds ratio = 5.8; P < .001), after demographic and clinical factors were controlled. CONCLUSIONS The mortality rate for returning patients with SMI was almost 6 times less than for those who did not return for medical care. Proactive outreach might result in patients returning to care and should be implemented to reengage this vulnerable group.
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Affiliation(s)
- Chester L Davis
- Veterans Health Administration, Office of Medical Inspector, Washington, DC 20420, USA.
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Ko LK, Allicok M, Campbell MK, Valle CG, Armstrong-Brown J, Carr C, Dundon M, Anthony T. An examination of sociodemographic, health, psychological factors, and fruit and vegetable consumption among overweight and obese U.S. veterans. Mil Med 2012; 176:1281-6. [PMID: 22165657 DOI: 10.7205/milmed-d-11-00021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
A diet high in fruits and vegetables (F&Vs) is associated with decreased risk for cardiovascular disease, diabetes, and cancer. This study investigated the relationship between sociodemographic, health, and psychosocial factors and F&V consumption among overweight and obese U.S. veterans. Participants were recruited from two Veterans Affairs medical center sites in 2005. Two hundred eighty-nine participants completed a self-administered survey. Bivariate and multivariate linear regression models were built to examine the association between sociodemographic, health, and psychosocial variables and F&V consumption. Older age (B = 0.01; p < 0.001) and being Black (B = -0.18; p < 0.05) were related to increased F&V consumption. Reported tobacco use was inversely associated with F&V consumption (B = -0.30; p < 0.01). Greater self-efficacy (B = 0.07; p < 0.05), fewer perceived barriers (B = -0.14; p < 0.01), and correct knowledge of recommended daily F&V intake (B = 0.12; p <0.05) were related to eating more F&Vs. U.S. veterans disproportionately experience overweight and obese conditions. Age, race, tobacco use, and psychosocial factors should be considered carefully when developing dietary interventionsamong overweight ana obese U.S. veterans.
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Affiliation(s)
- Linda K Ko
- Lineberger Comprehensive Cancer Center, University of North Carolina, 1700 Martin Luther King Jr. Boulevard, Chapel Hill, NC 27599-7294, USA
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Baser O, Du J, Xie L, Wang H, Dysinger AH, Wang L. Derivation of severity index for rheumatoid arthritis and its association with healthcare outcomes. J Med Econ 2012; 15:918-24. [PMID: 22533525 DOI: 10.3111/13696998.2012.688905] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To develop a claims-based severity index for rheumatoid arthritis (RA) using the Veterans Health Administration (VHA) database. METHODS Adult patients with at least two RA diagnoses 2 months apart were identified between 10/1/2008-09/30/2009. Patients were required to have at least 12 months continuous health plan enrollment before and after the index date (first RA diagnosis date) for an overall study period of 10/1/2007-09/30/2010. A severity index for rheumatoid arthritis (SIFRA, a proprietary algorithm of SIMR, Inc. [STATinMED Research]) was developed by calculating a weighted sum of 34 RA-related indicators assessed by an expert Delphi panel of six rheumatologists, including laboratory, clinical, and functional status, extra-articular manifestations, surgical history, and medications, during a 1-year pre-index period. Separate SIFRA versions were derived for patients with and without laboratory information. Correlations between SIFRA and previously validated claims-based indexes for RA severity (CIRAS), and other traditional comorbidity indexes were calculated during the pre-index period. The relationship between SIFRA and follow-up healthcare outcomes was also examined using histograms. RESULTS The Spearman's rank correlations between SIFRA and CIRAS were 0.525 for SIFRA without and 0.539 with laboratory data. The correlations between SIFRA and the Charlson Comorbidity Index (CCI) (0.1503 without, 0.1135 with laboratory data), Elixhauser Index (ELIX) (0.105 without, 0.079 with laboratory data), and Chronic Disease Score (CDS) (0.255 without, 0.239 with laboratory data) were low. Histograms showed that patients in the upper tercile of SIFRA incurred $9123 more all-cause and $1326 more RA-related healthcare costs during the 1-year post-index period than patients in the lower tercile. Using SIFRA in combination with CCI, CDS, or ELIX significantly increased the percentage of variation explained in outcomes measures. LIMITATIONS Patients in the VHA database may not represent typical RA patients since the database generally contains older, economically disadvantaged men with a high disease burden. Validity of the score is indirectly based on disease activity score 28 (DAS28), which measures disease activity rather than severity. CONCLUSIONS SIFRA was found to have moderate correlations with the previously validated CIRAS score, and demonstrated evidence of being a significant determinant of total and RA-related healthcare costs for RA patients. This study suggests that SIFRA could be an important methodological tool to control for severity in RA-related outcomes research. The algorithm can be applied to any claims dataset.
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Affiliation(s)
- O Baser
- STATinMED Research, Ann Arbor, MI 48104, USA.
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Yoon J, Scott JY, Phibbs CS, Wagner TH. Recent trends in Veterans Affairs chronic condition spending. Popul Health Manag 2011; 14:293-8. [PMID: 22044350 DOI: 10.1089/pop.2010.0079] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The change in prevalence and total Veterans Affairs (VA) spending were estimated for 16 chronic condition categories between 2000 and 2008. The drivers of changes in spending also were examined. Chronic conditions were identified through diagnoses in encounter records, and treatment costs per patient were estimated using VA cost data and regression models. The estimated differences in total VA spending between 2000 and 2008 and the contributions of population increase, differences in prevalence, and differences in treatment costs were evaluated. Most of the spending increases during the study period were driven by the increase in the VA patient population from 3.3 million in 2000 to 4.9 million in 2008. Spending on renal failure increased the most, by more than $1.5 billion, primarily because of higher prevalence. Higher treatment costs did not contribute much to higher spending; lower costs per patient for several conditions may have helped to slow spending for diabetes, chronic obstructive pulmonary disease, heart conditions, renal failure, dementia, and stroke. Lowering treatment costs per patient for common conditions can help slow spending for chronic conditions, but most of the increase in spending in the study period was the result of more patients seeking care from VA providers and the higher prevalence of conditions among patients. As the VA patient population continues to age and to develop more co-morbidities, and as returning veterans seek care for service-related problems, higher spending on chronic conditions will become a more prominent issue for the VA health care system.
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Affiliation(s)
- Jean Yoon
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California 94025, USA.
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Ekundayo OJ, Vassar SD, Williams LS, Bravata DM, Cheng EM. Using administrative databases to calculate Framingham scores within a large health care organization. Stroke 2011; 42:1982-7. [PMID: 21546488 DOI: 10.1161/strokeaha.110.603340] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Framingham calculators are typically implemented in 1-on-1 settings to determine if a patient is at high risk for development of cardiovascular disease in the next 10 years. Because health care administrative datasets are including more clinical information, we explored how well administrative data-derived Framingham scores could identify persons who would have stroke develop in the next year. METHODS Using a nested case-control design, we compared all 313 persons who had a first-time stroke at 5 Veterans Administration Medical Centers with a random sample of 25,361 persons who did not have a first-time stroke in 2008. We compared Framingham scores and risk using administrative data available at the end of 2007. RESULTS Stroke patients had higher risk profile than controls: older age, higher systolic blood pressure and total cholesterol, more likely to have diabetes, cardiovascular disease, left ventricular hypertrophy, and more likely to use treatment for blood pressure (P<0.05). The mean Framingham generalized cardiovascular disease score (18.0 versus 14.5) as well as the mean Framingham stroke-specific score (13.2 versus 10.2) was higher for stroke cases than controls (both P<0.0001). The c-statistic for the generalized cardiovascular disease score was 0.68 (95% CI, 0.65-0.70) and for the stroke score was 0.64 (95% CI, 0.62-0.67). CONCLUSIONS Persons who had a stroke develop in the next year had a worse Framingham risk profile, as determined by administrative data. Future studies should examine how to improve the stroke predictive tools and to identify the appropriate populations and uses for applying stroke risk predictive tools.
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Kramer JR, Kanwal F, Richardson P, Giordano TP, Petersen LA, El-Serag HB. Importance of patient, provider, and facility predictors of hepatitis C virus treatment in veterans: a national study. Am J Gastroenterol 2011; 106:483-91. [PMID: 21063393 DOI: 10.1038/ajg.2010.430] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Several patient characteristics are known to impact hepatitis C virus (HCV) antiviral treatment rates. However, it is unclear whether, and to what extent, health-care providers or facility characteristics impact HCV treatment rates. METHODS Using national data obtained from the Department of Veterans Affairs (VA) HCV Clinical Case Registry, we conducted a retrospective cohort study of patients with active HCV viremia, who were diagnosed between 2003 and 2004. We evaluated patient-, provider-, and facility-level predictors of receipt of HCV treatment with hierarchical logistic regression. RESULTS The overall HCV treatment rate in 29,695 patients was 14.2%. The strongest independent predictor for receipt of treatment was consultation with an HCV specialist (odds ratio=9.34; 8.03-10.87). Patients were less likely to receive HCV treatment if they were Black, older, male, current users of alcohol or drugs, had HCV genotype 1 or 4, had higher creatinine levels, or had severe anxiety/post-traumatic stress disorder or depression. Patients with high hemoglobin levels, cirrhosis, and persistently high liver enzyme levels were more likely to receive treatment. Patient, provider, and facility factors explained 15, 4, and 4%, respectively, of the variation in treatment rates. CONCLUSIONS Treatment rates for HCV are low in the VA. In addition to several important patient-level characteristics, a specialist consultant has a vital role in determining whether a patient should receive HCV treatment. These findings support the development of patient-level interventions targeted at identifying and managing comorbidities and contraindications and fostering greater involvement of specialists in the care of HCV.
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Affiliation(s)
- Jennifer R Kramer
- Houston VA Health Services Research & Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas 77030, USA.
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