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Rosen AK, Beilstein-Wedel E, Chan J, Borzecki A, Miech EJ, Mohr DC, Yackel EE, Flynn J, Shwartz M. Standardizing Patient Safety Event Reporting between Care Delivered or Purchased by the Veterans Health Administration (VHA). Jt Comm J Qual Patient Saf 2024; 50:247-259. [PMID: 38228416 DOI: 10.1016/j.jcjq.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Increasing community care (CC) use by veterans has introduced new challenges in providing integrated care across the Veterans Health Administration (VHA) and CC. VHA's well-recognized patient safety program has been particularly challenging for CC staff to adopt and implement. To standardize VHA safety practices across both settings, VHA implemented the Patient Safety Guidebook in 2018. The authors compared national- and facility-level trends in VHA and CC safety event reporting post-Guidebook implementation. METHODS In this retrospective study using patient safety event data from VHA's event reporting system (2020-2022), the research team examined trends in patient safety events, adverse events, close calls (near misses), and recovery rates (ratio of close calls to adverse events plus close calls) in VHA and CC using linear regression models to determine whether the average changes in VHA and CC safety events at the national and facility levels per quarter were significant. RESULTS A total of 499,332 safety events were reported in VHA and CC. Although VHA patient safety event trends were not significant (p > 0.05), there was a significant negative trend for adverse events (p = 0.02) and positive trends for close calls (p = 0.003) and recovery rates (p = 0.004). In CC there were significant negative trends for patient safety events and adverse events (p = 0.02) and a significant positive trend for recovery rates (p = 0.03). There was less variation in VHA than in CC facilities with significant decreases (for example, interquartile ranges in VHA and CC were 0.03 vs. 0.05, respectively). CONCLUSION Fluctuations in different safety events over time were likely due to the disruption of care caused by COVID-19 as well as organizational factors. Notably, the increases in recovery rates reflect less staff focus on harmful events and more attention to close calls (preventable events). Although safety practice adoption from VHA to CC was feasible, additional implementation strategies are needed to sustain standardized safety reporting across settings.
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Shwartz M, Rosen AK, Beilstein-Wedel E, Davila H, Harris AH, Gurewich D. Using the Kitagawa Decomposition to Measure Overall-and Individual Facility Contributions to-Within-facility and Between-facility Differences: Analyzing Racial and Ethnic Wait Time Disparities in the Veterans Health Administration. Med Care 2023; 61:392-399. [PMID: 37068035 PMCID: PMC10175195 DOI: 10.1097/mlr.0000000000001849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
BACKGROUND Identifying whether differences in health care disparities are due to within-facility or between-facility differences is key to disparity reductions. The Kitagawa decomposition divides the difference between 2 means into within-facility differences and between-facility differences that are measured on the same scale as the original disparity. It also enables the identification of facilities that contribute most to within-facility differences (based on facility-level disparities and the proportion of patient population served) and between-facility differences. OBJECTIVES Illustrate the value of a 2-stage Kitagawa decomposition to partition a disparity into within-facility and between-facility differences and to measure the contribution of individual facilities to each type of difference. SUBJECTS Veterans receiving a new outpatient consult for cardiology or orthopedic services during fiscal years 2019-2021. MEASURES Wait time for a new-patient consult. METHODS In stage 1, we predicted wait time for each Veteran from a multivariable model; in stage 2, we aggregated individual predictions to determine mean adjusted wait times for Hispanic, Black, and White Veterans and then decomposed differences in wait times between White Veterans and each of the other groups. RESULTS Noticeably longer wait times were experienced by Hispanic Veterans for cardiology (2.32 d, 6.8% longer) and Black Veterans for orthopedics (3.49 d, 10.3% longer) in both cases due entirely to within-facility differences. The results for Hispanic Veterans using orthopedics illustrate how positive within-facility differences (0.57 d) can be offset by negative between-facility differences (-0.34 d), resulting in a smaller overall disparity (0.23 d). Selecting 10 facilities for interventions in orthopedics based on the largest contributions to within-in facility differences instead of the largest disparities resulted in a higher percentage of Veterans impacted (31% and 12% of Black and White Veterans, respectively, versus 9% and 10% of Black and White Veterans, respectively) and explained 21% of the overall within-facility difference versus 11%. CONCLUSIONS The Kitagawa approach allows the identification of disparities that might otherwise be undetected. It also allows the targeting of interventions at those facilities where improvements will have the largest impact on the overall disparity.
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Affiliation(s)
| | - Amy K Rosen
- VA Boston Healthcare System, Boston, MA
- Boston University School of Medicine, Boston, MA
| | | | - Heather Davila
- VA Iowa City Health Care System, Iowa City, IA
- University of Iowa Carver College of Medicine, Iowa City, IA
| | - Alex Hs Harris
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA
- Department of Surgery, Stanford-Surgery Policy Improvement Research and Education Center, Palo Alto, CA
| | - Deborah Gurewich
- VA Boston Healthcare System, Boston, MA
- Boston University School of Medicine, Boston, MA
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Vanneman ME, Rosen AK, Wagner TH, Shwartz M, Gordon SH, Greenberg G, Zheng T, Cook J, Beilstein-Wedel E, Greene T, Kelley AT. Differences Between VHA-Delivered and VHA-Purchased Behavioral Health Care in Service and Patient Characteristics. Psychiatr Serv 2023; 74:148-157. [PMID: 36039555 PMCID: PMC10069743 DOI: 10.1176/appi.ps.202100730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Federal legislation has expanded Veterans Health Administration (VHA) enrollees' access to VHA-purchased "community care." This study examined differences in the amount and type of behavioral health care delivered in VHA and purchased in the community, along with patient characteristics and area supply and demand factors. METHODS This retrospective cross-sectional study examined data for 204,094 VHA enrollees with 448,648 inpatient behavioral health stays and 3,467,010 enrollees with 55,043,607 outpatient behavioral health visits from fiscal years 2016 to 2019. Standardized mean differences (SMDs) were calculated for patient and provider characteristics at the outpatient-visit level for VHA and community care. Linear probability models assessed the association between severity of behavioral health condition and site of care. RESULTS Twenty percent of inpatient stays were purchased through community care, with severe behavioral health conditions more likely to be treated in VHA inpatient care. In the outpatient setting, community care accounted for 3% of behavioral health care visits, with increasing use over time. For outpatient care, veterans receiving community care were more likely than those receiving VHA care to see clinicians with fewer years of training (SMD=1.06). CONCLUSIONS With a large portion of inpatient behavioral health care occurring in the community and increased use of outpatient behavioral health care with less highly trained community providers, coordination between VHA and the community is essential to provide appropriate inpatient follow-up care and address outpatient needs. This is especially critical given VHA's expertise in providing behavioral health care to veterans and its legislative responsibility to ensure integrated care.
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Affiliation(s)
- Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Amy K Rosen
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Todd H Wagner
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Michael Shwartz
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Sarah H Gordon
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Greg Greenberg
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Tianyu Zheng
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - James Cook
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Erin Beilstein-Wedel
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Tom Greene
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - A Taylor Kelley
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
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Gurewich D, Beilstein-Wedel E, Shwartz M, Davila H, Rosen AK. Disparities in Wait Times for Care Among US Veterans by Race and Ethnicity. JAMA Netw Open 2023; 6:e2252061. [PMID: 36689224 PMCID: PMC9871804 DOI: 10.1001/jamanetworkopen.2022.52061] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/30/2022] [Indexed: 01/24/2023] Open
Abstract
Importance Prior studies indicate that Black and Hispanic vs White veterans wait longer for care. However, these studies do not capture the COVID-19 pandemic, which caused care access disruptions, nor implementation of the US Department of Veterans Affairs (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION), which is intended to improve care access by increasing veterans' options to use community clinicians. Objective To determine whether wait times increased differentially for Black and Hispanic compared with White veterans from the pre-COVID-19 to COVID-19 periods given concurrent MISSION implementation. Design, Setting, and Participants This cross-sectional study used data from the VA's Corporate Data Warehouse for fiscal years 2019 to 2021 (October 1, 2018, to September 30, 2021). Participants included Black, Hispanic, and White veterans with a new consultation for outpatient cardiology and/or orthopedic services during the study period. Multivariable mixed-effects models were used to estimate individual-level adjusted wait times and a likelihood ratio test of the significance of wait time disparity change over time. Main Outcomes and Measures Overall mean wait times and facility-level adjusted relative mean wait time ratios. Results The study included 1 162 148 veterans (mean [SD] age, 63.4 [14.4] years; 80.8% men). Significant wait time disparities were evident for orthopedic services (eg, Black veterans had wait times 2.09 [95% CI, 1.57-2.61] days longer than those for White veterans) in the pre-COVID-19 period, but not for cardiology services. Mean wait times increased from the pre-COVID-19 to COVID-19 periods for both services for all 3 racial and ethnic groups (eg, Hispanic wait times for cardiology services increased 5.09 [95% CI, 3.62-6.55] days). Wait time disparities for Black veterans (4.10 [95% CI, 2.44-5.19] days) and Hispanic veterans (4.40 [95% CI, 2.76-6.05] days) vs White veterans (3.75 [95% CI, 2.30-5.19] days) increased significantly from the pre-COVID-19 to COVID-19 periods (P < .001). During the COVID-19 period, significant disparities were evident for orthopedic services (eg, mean wait times for Hispanic vs White veterans were 1.98 [95% CI, 1.32-2.64] days longer) but not for cardiology services. Although there was variation in wait time ratios across the 140 facilities, only 6 facility wait time ratios were significant during the pre-COVID-19 period and 26 during the COVID-19 period. Conclusions and Relevance These findings suggest that wait time disparities increased from the pre-COVID-19 to COVID-19 periods, especially for orthopedic services for both Black and Hispanic veterans, despite MISSION's goal to improve access. Facility-level analyses identified potential sites that could be targeted to reduce disparities.
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Affiliation(s)
- Deborah Gurewich
- Center for Health Care Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Erin Beilstein-Wedel
- Center for Health Care Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
| | - Michael Shwartz
- Center for Health Care Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
| | - Heather Davila
- Center for Access & Delivery Research and Evaluation, VA Iowa City Health Care System, Iowa City, Iowa
- General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Amy K. Rosen
- Center for Health Care Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
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Linsky AM, Kressin NR, Stolzmann K, Pendergast J, Rosen AK, Bokhour BG, Simon SR. Direct-to-consumer strategies to promote deprescribing in primary care: a pilot study. BMC Prim Care 2022; 23:53. [PMID: 35317734 PMCID: PMC8939089 DOI: 10.1186/s12875-022-01655-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 02/28/2022] [Indexed: 11/21/2022]
Abstract
Background Deprescribing, or the intentional discontinuation or dose-reduction of medications, is an approach to reduce harms associated with inappropriate medication use. We sought to determine how direct-to-patient educational materials impacted patient-provider discussion about and deprescribing of potentially inappropriate medications. Methods We conducted a pre-post pilot trial, using an historical control group, at an urban VA medical center. We included patients in one of two cohorts: 1) chronic proton pump inhibitor users (PPI), defined as use of any dose for 90 consecutive days, or 2) patients at hypoglycemia risk, defined by diabetes diagnosis; prescription for insulin or sulfonylurea; hemoglobin A1c < 7%; and age ≥ 65 years, renal insufficiency, or cognitive impairment. The intervention consisted of mailing medication-specific patient-centered EMPOWER (Eliminating Medications Through Patient Ownership of End Results) brochures, adapted to a Veteran patient population, two weeks prior to scheduled primary care appointments. Our primary outcome – deprescribing – was defined as clinical documentation of target medication discontinuation or dose-reduction. Our secondary outcome was documentation of a discussion about the target medication (yes/possible vs. no/absent). Covariates included age, sex, race, specified comorbidities, medications, and utilization. We used chi-square tests to examine the association of receiving brochures with each outcome. Results The 348 subjects (253 intervention, 95 historical control) were primarily age ≥ 65 years, white, and male. Compared to control subjects, intervention subjects were more likely to have deprescribing (36 [14.2%] vs. 4 [4.2%], p = 0.009) and discussions about the target medication (31 [12.3%] vs. 1 [1.1%], p = 0.001). Conclusions Targeted mailings of EMPOWER brochures temporally linked to a scheduled visit in primary care clinics are a low-cost, low-technology method associated with increases in both deprescribing and documentation of patient-provider medication discussions in a Veteran population. Leveraging the potential for patients to initiate deprescribing discussions within clinical encounters is a promising strategy to reduce drug burden and decrease adverse drug effects and harms.
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Itani KMF, Rosen AK. Association of Expanded Health Care Options for Community Care With Veterans' Surgical Outcomes. JAMA Surg 2022; 157:1123-1124. [PMID: 36223140 DOI: 10.1001/jamasurg.2022.4986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Kamal M F Itani
- Department of Surgery, VA Boston Health Care System, Boston, Massachusetts.,Department of Surgery, Boston University, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Amy K Rosen
- Department of Surgery, Boston University, Boston, Massachusetts.,Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Health Care System, Boston, Massachusetts
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Giori NJ, Beilstein-Wedel EE, Shwartz M, Harris AHS, Vanneman ME, Wagner TH, Rosen AK. Association of Quality of Care With Where Veterans Choose to Get Knee Replacement Surgery. JAMA Netw Open 2022; 5:e2233259. [PMID: 36178687 PMCID: PMC9526089 DOI: 10.1001/jamanetworkopen.2022.33259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/08/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Recent legislation expanded veterans' access to Veterans Health Administration (VA)-purchased care. Quality should be considered when choosing where to get total knee arthroplasty (TKA), but currently available quality metrics provide little guidance. Objective To determine whether an association exists between the proportion of TKAs performed (vs purchased) at each VA facility and the quality of care provided (as measured by short-term complication rates). Design, Setting, and Participants This 3-year cohort study used VA and community care data (fiscal year 2017 to fiscal year 2019) from the VA's Corporate Data Warehouse. Complications were defined following the Centers for Medicare and Medicaid Services' methodology. The setting included 140 VA health care facilities performing or purchasing TKAs. Participants included veterans who had 43 371 primary TKA procedures that were either VA-performed or VA-purchased during the study period. Exposures Of the 43 371 primary TKA procedures, 18 964 (43.7%) were VA-purchased. Main Outcomes and Measures The primary outcome was risk-standardized short-term complication rates of VA-performed or VA-purchased TKAs. The association between the proportion of TKAs performed at each VA facility and quality of VA-performed and VA-purchased care was examined using a regression model. Subgroups were also identified for facilities that had complication rates above or below the overall mean complication rate and for facilities that performed more or less than half of the facility's TKAs. Results Among the study sample's 41 775 veterans who underwent 43 371 TKAs, 38 725 (89.3%) were male, 6406 (14.8%) were Black, 33 211 (76.6%) were White, and 1367 (3.2%) had other race or ethnicity (including American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander); mean (SD) age was 66.9 (8.5) years. VA-performed and VA-purchased TKAs had a mean (SD) raw overall short-term complication rate of 2.97% (0.08%). There was no association between the proportion of TKAs performed in VA facilities and risk-standardized complication rates for VA-performed TKAs, and no association for VA-purchased TKAs. Conclusions and Relevance In this cohort study, surgical quality did not have an association with where veterans had TKA, possibly because meaningful comparative data are lacking. Reporting local and community risk-standardized complication rates may inform veterans' decisions and improve care. Combining these data with the proportion of TKAs performed at each site could facilitate administrative decisions on where resources should be allocated to improve care.
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Affiliation(s)
- Nicholas J. Giori
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
- Department of Orthopedic Surgery, Stanford University, Redwood City, California
| | - Erin E. Beilstein-Wedel
- Center for Health Care Organization and Implementation Research, VA Boston Health Care System, Boston, Massachusetts
| | - Michael Shwartz
- Center for Health Care Organization and Implementation Research, VA Boston Health Care System, Boston, Massachusetts
| | - Alex H. S. Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
- Department of Surgery, Stanford University, Stanford, California
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City
| | - Todd H. Wagner
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Amy K. Rosen
- Center for Health Care Organization and Implementation Research, VA Boston Health Care System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
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McGrath BM, Takamine L, Hogan CK, Hofer TP, Rosen AK, Sussman JB, Wiitala WL, Ryan AM, Prescott HC. Interpretability, credibility, and usability of hospital-specific template matching versus regression-based hospital performance assessments; a multiple methods study. BMC Health Serv Res 2022; 22:739. [PMID: 35659234 PMCID: PMC9166576 DOI: 10.1186/s12913-022-08124-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/23/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Hospital-specific template matching (HS-TM) is a newer method of hospital performance assessment. OBJECTIVE To assess the interpretability, credibility, and usability of HS-TM-based vs. regression-based performance assessments. RESEARCH DESIGN We surveyed hospital leaders (January-May 2021) and completed follow-up semi-structured interviews. Surveys included four hypothetical performance assessment vignettes, with method (HS-TM, regression) and hospital mortality randomized. SUBJECTS Nationwide Veterans Affairs Chiefs of Staff, Medicine, and Hospital Medicine. MEASURES Correct interpretation; self-rated confidence in interpretation; and self-rated trust in assessment (via survey). Concerns about credibility and main uses (via thematic analysis of interview transcripts). RESULTS In total, 84 participants completed 295 survey vignettes. Respondents correctly interpreted 81.8% HS-TM vs. 56.5% regression assessments, p < 0.001. Respondents "trusted the results" for 70.9% HS-TM vs. 58.2% regression assessments, p = 0.03. Nine concerns about credibility were identified: inadequate capture of case-mix and/or illness severity; inability to account for specialized programs (e.g., transplant center); comparison to geographically disparate hospitals; equating mortality with quality; lack of criterion standards; low power; comparison to dissimilar hospitals; generation of rankings; and lack of transparency. Five concerns were equally relevant to both methods, one more pertinent to HS-TM, and three more pertinent to regression. Assessments were mainly used to trigger further quality evaluation (a "check oil light") and motivate behavior change. CONCLUSIONS HS-TM-based performance assessments were more interpretable and more credible to VA hospital leaders than regression-based assessments. However, leaders had a similar set of concerns related to credibility for both methods and felt both were best used as a screen for further evaluation.
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Affiliation(s)
- Brenda M. McGrath
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA
| | - Linda Takamine
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA
| | - Cainnear K. Hogan
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA
| | - Timothy P. Hofer
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
| | - Amy K. Rosen
- grid.410370.10000 0004 4657 1992VA Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA USA ,grid.189504.10000 0004 1936 7558Department of Surgery, Boston University School of Medicine, Boston, MA USA
| | - Jeremy B. Sussman
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
| | - Wyndy L. Wiitala
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA
| | - Andrew M. Ryan
- grid.214458.e0000000086837370Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Hallie C. Prescott
- grid.497654.d0000 0000 8603 8958VA Center for Clinical Management Research, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
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Rosen AK, Beilstein-Wedel EE, Harris AHS, Shwartz M, Vanneman ME, Wagner TH, Giori NJ. Comparing Postoperative Readmission Rates Between Veterans Receiving Total Knee Arthroplasty in the Veterans Health Administration Versus Community Care. Med Care 2022; 60:178-186. [PMID: 35030566 DOI: 10.1097/mlr.0000000000001678] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND There are growing concerns that Veterans' increased use of Veterans Health Administration (VA)-purchased care in the community may lead to lower quality of care. OBJECTIVE We compared rates of hospital readmissions following elective total knee arthroplasties (TKAs) that were either performed in VA or purchased by VA through community care (CC) at both the national and facility levels. METHODS Three-year cohort study using VA and CC administrative data from the VA's Corporate Data Warehouse (October 1, 2016-September 30, 2019). We obtained Medicare data to capture readmissions that were paid by Medicare. We used the Centers for Medicare and Medicaid Services (CMS) methods to identify unplanned, 30-day, all-cause readmissions. A secondary outcome, TKA-related readmissions, identified readmissions resulting from complications of the index surgery. We ran mixed-effects logistic regression models to compare the risk-adjusted odds of all-cause and TKA-related readmissions between TKAs performed in VA versus CC, adjusting for patients' sociodemographic and clinical characteristics. PRINCIPAL FINDINGS Nationally, the odds of experiencing an all-cause or TKA-related readmission were significantly lower for TKAs performed in VA versus CC (eg, the odds of experiencing an all-cause readmission in VA were 35% of those in CC. At the facility level, most VA facilities performed similarly to their corresponding CC providers, although there were 3 VA facilities that performed worse than their corresponding CC providers. CONCLUSIONS Given VA's history in providing high-quality surgical care to Veterans, it is important to closely monitor and track whether the shift to CC for surgical care will impact quality in both settings over time.
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Affiliation(s)
- Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Erin E Beilstein-Wedel
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Alex H S Harris
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Livermore
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System
- Departments of Internal Medicine and Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
| | - Todd H Wagner
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Livermore
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
- VA Health Economics Resource Center (HERC), Menlo Park, CA
| | - Nicholas J Giori
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Livermore
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA
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Vincent BM, Molling D, Escobar GJ, Hofer TP, Iwashyna TJ, Liu VX, Rosen AK, Ryan AM, Seelye S, Wiitala WL, Prescott HC. Hospital-specific Template Matching for Benchmarking Performance in a Diverse Multihospital System. Med Care 2021; 59:1090-1098. [PMID: 34629424 PMCID: PMC8802232 DOI: 10.1097/mlr.0000000000001645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hospital-specific template matching is a newer method of hospital performance measurement that may be fairer than regression-based benchmarking. However, it has been tested in only limited research settings. OBJECTIVE The objective of this study was to test the feasibility of hospital-specific template matching assessments in the Veterans Affairs (VA) health care system and determine power to detect greater-than-expected 30-day mortality. RESEARCH DESIGN Observational cohort study with hospital-specific template matching assessment. For each VA hospital, the 30-day mortality of a representative subset of hospitalizations was compared with the pooled mortality from matched hospitalizations at a set of comparison VA hospitals treating sufficiently similar patients. The simulation was used to determine power to detect greater-than-expected mortality. SUBJECTS A total of 556,266 hospitalizations at 122 VA hospitals in 2017. MEASURES A number of comparison hospitals identified per hospital; 30-day mortality. RESULTS Each hospital had a median of 38 comparison hospitals (interquartile range: 33, 44) identified, and 116 (95.1%) had at least 20 comparison hospitals. In total, 8 hospitals (6.6%) had a significantly lower 30-day mortality than their benchmark, 5 hospitals (4.1%) had a significantly higher 30-day mortality, and the remaining 109 hospitals (89.3%) were similar to their benchmark. Power to detect a standardized mortality ratio of 2.0 ranged from 72.5% to 79.4% for a hospital with the fewest (6) versus most (64) comparison hospitals. CONCLUSIONS Hospital-specific template matching may be feasible for assessing hospital performance in the diverse VA health care system, but further refinements are needed to optimize the approach before operational use. Our findings are likely applicable to other large and diverse multihospital systems.
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Affiliation(s)
| | - Daniel Molling
- VA Center for Clinical Management Research, Ann Arbor, MI
| | - Gabriel J. Escobar
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Timothy P. Hofer
- VA Center for Clinical Management Research, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Theodore J. Iwashyna
- VA Center for Clinical Management Research, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Survey Research Center, Institute for Social Research, Ann Arbor, MI
| | - Vincent X Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Amy K. Rosen
- VA Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
| | - Andrew M. Ryan
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Sarah Seelye
- VA Center for Clinical Management Research, Ann Arbor, MI
| | | | - Hallie C. Prescott
- VA Center for Clinical Management Research, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Jreige N, Talutis SD, Zambrano S, Heckscher D, Mehrazarin K, Rosen AK. Health Care Needs of Incarcerated Patients: A Case Study at a Large Urban Hospital. J Correct Health Care 2021; 27:272-279. [PMID: 34788134 DOI: 10.1089/jchc.19.10.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study examined a sample of incarcerated patients who received health care at an urban safety-net hospital in Massachusetts. Sociodemographic, clinical, and utilization data were obtained from patients' charts and administrative data. Our sample was 87% male and 36% Black and included a large proportion of patients with substance-related use. Incarcerated patients receiving outside care had a wide range of acute and chronic medical and surgical conditions, necessitating both emergent and scheduled care. The most frequent outpatient encounters included surgery (neurosurgery and oral/maxillofacial surgery), ophthalmology, medicine, and radiation oncology. Our findings provide a better understanding of the health care services that incarcerated patients may require outside their facilities and the kinds of interventions and policies that are needed to increase access to more timely care.
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Affiliation(s)
- Nina Jreige
- Department of Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Stephanie D Talutis
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sarah Zambrano
- Department of Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Dylan Heckscher
- Department of Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Kian Mehrazarin
- Department of Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Amy K Rosen
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, USA.,Research Service, Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, USA
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Davila H, Rosen AK, Stolzmann K, Zhang L, Linsky AM. Factors influencing providers' willingness to deprescribe medications. J Am Coll Clin Pharm 2021. [DOI: 10.1002/jac5.1537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Heather Davila
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston Massachusetts USA
- Section of General Internal Medicine Boston University School of Medicine Boston Massachusetts USA
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston Massachusetts USA
- Department of Surgery Boston University School of Medicine Boston Massachusetts USA
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston Massachusetts USA
| | - Libin Zhang
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston Massachusetts USA
| | - Amy M. Linsky
- Center for Healthcare Organization and Implementation Research VA Boston Healthcare System Boston Massachusetts USA
- Section of General Internal Medicine Boston University School of Medicine Boston Massachusetts USA
- General Internal Medicine VA Boston Healthcare System Boston Massachusetts USA
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13
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Harris AHS, Beilstein-Wedel EE, Rosen AK, Shwartz M, Wagner TH, Vanneman ME, Giori NJ. Comparing Complication Rates After Elective Total Knee Arthroplasty Delivered Or Purchased By The VA. Health Aff (Millwood) 2021; 40:1312-1320. [PMID: 34339235 DOI: 10.1377/hlthaff.2020.01679] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Department of Veterans Affairs (VA) both delivers health care in its own facilities and, increasingly, purchases care for veterans in the community. Policy makers, administrators, health care providers, and veterans frequently face decisions about which services should be delivered versus purchased by the VA. Comparisons of quality across settings are essential if veterans are to receive care that is consistently accessible, patient centered, effective, and safe. We compared risk-adjusted major postoperative complication rates for total knee arthroplasties that were delivered in VA facilities versus purchased from community providers. Overall, adjusted complication rates were significantly lower for arthroplasties delivered by the VA compared with those that were purchased. However, hospital-level comparisons revealed five locations where VA-purchased care outperformed VA-delivered care. As the amount of VA-purchased care continues to increase under the Veterans Access, Choice, and Accountability Act of 2014 and the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, these results support VA monitoring of overall and local comparative hospital performance to improve the quality of the care that the VA delivers while ensuring optimal outcomes in VA-purchased care.
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Affiliation(s)
- Alex H S Harris
- Alex H. S. Harris is a research career scientist at the Veterans Affairs (VA) Palo Alto Health Care System's Center for Innovation to Implementation, in Menlo Park, California
| | - Erin E Beilstein-Wedel
- Erin E. Beilstein-Wedel is a research scientist at the VA Boston Healthcare System's Center for Healthcare Organization and Implementation Research, in Boston, Massachusetts
| | - Amy K Rosen
- Amy K. Rosen is a senior research career scientist at the VA Boston Healthcare System's Center for Healthcare Organization and Implementation Research
| | - Michael Shwartz
- Michael Shwartz is a research scientist at the VA Boston Healthcare System's Center for Healthcare Organization and Implementation Research
| | - Todd H Wagner
- Todd H. Wagner is the director of the Health Economics Resource Center and assistant director and research career scientist at the VA Palo Alto Health Care System's Center for Innovation to Implementation
| | - Megan E Vanneman
- Megan E. Vanneman is a research scientist at the VA Salt Lake City's Informatics, Decision-Enhancement and Analytic Sciences Center, in Salt Lake City, Utah
| | - Nicholas J Giori
- Nicholas J. Giori is the chief of orthopedic surgery at the VA Palo Alto Health Care System
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Wagner TH, Lo J, Beilstein-Wedel E, Vanneman ME, Shwartz M, Rosen AK. Estimating the Cost of Surgical Care Purchased in the Community by the Veterans Health Administration. MDM Policy Pract 2021; 6:23814683211057902. [PMID: 34820527 PMCID: PMC8606928 DOI: 10.1177/23814683211057902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022] Open
Abstract
Background. Veterans' access to Veterans Affairs (VA)-purchased community care expanded due to large increases in funding provided in the 2014 Veterans Choice Act. Objectives. To compare costs between VA-delivered care and VA payments for purchased care for two commonly performed surgeries: total knee arthroplasties (TKAs) and cataract surgeries. Research Design. Descriptive statistics and regressions examining costs in VA-delivered and VA-purchased care (fiscal year [FY] 2018 [October 2017 to September 2018]). Subjects. A total of 13,718 TKAs, of which 6,293 (46%) were performed in VA. A total of 91,659 cataract surgeries, of which 65,799 (72%) were performed in VA. Measures. Costs of VA-delivered care based on activity-based cost estimates; costs of VA-purchased care based on approved and paid claims. Results. Ninety-eight percent of VA-delivered TKAs occurred in inpatient hospitals, with an average cost of $28,969 (SD $10,778). The majority (86%) of VA-purchased TKAs were also performed at inpatient hospitals, with an average payment of $13,339 (SD $23,698). VA-delivered cataract surgeries were performed at hospitals as outpatient procedures, with an average cost of $4,301 (SD $2,835). VA-purchased cataract surgeries performed at hospitals averaged $1,585 (SD $629); those performed at ambulatory surgical centers cost an average of $1,346 (SD $463). We also found significantly higher Nosos risk scores for patients who used VA-delivered versus VA-purchased care. Conclusions. Costs of VA-delivered care were higher than payments for VA-purchased care, but this partly reflects legislative caps limiting VA payments to community providers to Medicare amounts. Higher patient risk scores in the VA could indicate that community providers are reluctant to accept high-risk patients because of Medicare reimbursements, or that VA providers prefer to keep the more complex patients in VA.
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Affiliation(s)
- Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
- Department of Surgery, Stanford University, Stanford, California
| | - Jeanie Lo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Erin Beilstein-Wedel
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
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Mengeling MA, Mattocks KM, Hynes DM, Vanneman ME, Matthews KL, Rosen AK. Partnership Forum: The Role of Research in the Transformation of Veterans Affairs Community Care. Med Care 2021; 59:S232-S241. [PMID: 33976072 PMCID: PMC8132916 DOI: 10.1097/mlr.0000000000001488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Supplemental Digital Content is available in the text.
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Affiliation(s)
- Michelle A. Mengeling
- Center for 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
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Kristin M. Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Denise M. Hynes
- Center to Improve Veterans Involvement in Care (CIVIC) and Evidence Synthesis Program, Portland VA Healthcare System, Portland
- Health Management and Policy, College of Public Health and Human Sciences, and Health Data and Informatics, Center for Genome Research and Biocomputing, Oregon State University, Corvallis, OR
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System
- 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
| | - Kameron L. Matthews
- Office of Community Care, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Surgery, Boston University School of Medicine, Boston, MA
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Davila H, Rosen AK, Beilstein-Wedel E, Shwartz M, Chatelain L, Gurewich D. Rural Veterans' Experiences With Outpatient Care in the Veterans Health Administration Versus Community Care. Med Care 2021; 59:S286-S291. [PMID: 33976078 PMCID: PMC8132914 DOI: 10.1097/mlr.0000000000001552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The 2014 Veterans Access, Choice and Accountability Act was intended to improve Veterans' access to timely health care by expanding their options to receive community care (CC) paid for by the Veterans Health Administration (VA). Although CC could particularly benefit rural Veterans, we know little about rural Veterans' experiences with CC. OBJECTIVE The objective of this study was to compare rural Veterans' experiences with CC and VA outpatient health care services to those of urban Veterans and examine changes over time. RESEARCH DESIGN Retrospective, cross-sectional study using data from the Survey of Healthcare Experiences of Patients (SHEP) and VA Corporate Data Warehouse. Subjects: All Veterans who responded to the SHEP survey in Fiscal Year (FY) 16 or FY19. MEASURES Outcomes were 4 measures of care experience (Access, Communication, Coordination, and Provider Rating). Independent variables included care setting (CC/VA), rural/urban status, and demographic and clinical characteristics. RESULTS Compared with urban Veterans, rural Veterans rated CC the same (for specialty care) or better (for primary care). Rural Veterans reported worse experiences in CC versus VA, except for specialty care Access. Rural Veterans' care experiences improved between FY16 and FY19 in both CC and VA, with greater improvements in CC. CONCLUSIONS Rural Veterans' reported comparable or better experiences in CC compared with urban Veterans, but rural Veterans' CC experiences still lagged behind their experiences in VA for primary care. As growing numbers of Veterans use CC, VA should ensure that rural and urban Veterans' experiences with CC are at least comparable to their experiences with VA care.
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Affiliation(s)
- Heather Davila
- VA Boston Healthcare System
- Boston University School of Medicine
| | - Amy K. Rosen
- VA Boston Healthcare System
- Boston University School of Medicine
| | | | - Michael Shwartz
- VA Boston Healthcare System
- Boston University Questrom School of Business, Boston, MA
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Janeway MG, Sanchez SE, Rosen AK, Patts G, Allee LC, Lasser KE, Dechert TA. Disparities in Utilization of Ambulatory Cholecystectomy: Results From Three States. J Surg Res 2021; 266:373-382. [PMID: 34087621 DOI: 10.1016/j.jss.2021.03.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/18/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Inpatient cholecystectomy is associated with higher cost and morbidity relative to ambulatory cholecystectomy, yet the latter may be underutilized by minority and underinsured patients. The purpose of this study was to examine the effects of race, income, and insurance status on receipt of and outcomes following ambulatory cholecystectomy. MATERIALS AND METHODS Retrospective observational cohort study of patients 18-89 undergoing cholecystectomy for benign indications in Florida, Iowa, and New York, 2011-2014 using administrative databases. The primary outcome of interest was odds of having ambulatory cholecystectomy; secondary outcomes included intraoperative and postoperative complications, and 30-day unplanned admissions following ambulatory cholecystectomy. RESULTS Among 321,335 cholecystectomies, 190,734 (59.4%) were ambulatory and 130,601 (40.6%) were inpatient. Adjusting for age, sex, insurance, income, residential location, and comorbidities, the odds of undergoing ambulatory versus inpatient cholecystectomy were significantly lower in black (aOR = 0.71, 95% CI [0.69, 0.73], P< 0.001) and Hispanic (aOR = 0.71, 95% CI [0.69, 0.72], P< 0.001) patients compared to white patients, and significantly lower in Medicare (aOR = 0.77, 95% CI [0.75, 0.80] P < 0.001), Medicaid (aOR = 0.56, 95% CI [0.54, 0.57], P< 0.001) and uninsured/self-pay (aOR = 0.28, 95% CI [0.27, 0.28], P< 0.001) patients relative to privately insured patients. Patients with Medicaid and those classified as self-pay/uninsured had higher odds of postoperative complications and unplanned admission as did patients with Medicare compared to privately insured individuals. CONCLUSIONS Racial and ethnic minorities and the underinsured have a higher likelihood of receiving inpatient as compared to ambulatory cholecystectomy. The higher incidence of postoperative complications in these patients may be associated with unequal access to ambulatory surgery.
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Affiliation(s)
- Megan G Janeway
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Amy K Rosen
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Gregory Patts
- Boston University School of Public Health, Boston, Massachusetts
| | - Lisa C Allee
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Karen E Lasser
- Department of Medicine, Boston Medical Center, Boston University School of Medicine, Crosstown Center, Boston, Massachusetts
| | - Tracey A Dechert
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.
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Abstract
BACKGROUND The 2014 Veterans Choice Program aimed to improve care access for Veterans through expanded availability of community care (CC). Increased access to CC could particularly benefit rural Veterans, who often face obstacles in obtaining medical care at the Veterans Health Administration (VHA). However, whether Veterans Choice Program improved timely access to care for this vulnerable population is understudied. OBJECTIVES To examine wait times among rural and urban Veterans for 5 outpatient specialty care services representing the top requests for CC services among rural Veterans. RESEARCH DESIGN Retrospective study using VHA and CC outpatient consult data from VHA's Corporate Data Warehouse in Fiscal Year (FY) 2015 (October 1, 2014 to September 30, 2015) and FY2018 (October 1, 2017 to September 30, 2018). SUBJECTS All Veterans who received a new patient consult for physical therapy, cardiology, optometry, orthopedics, and/or dental services in VHA and/or CC. MEASURES Wait time, care setting (VHA/CC), rural/urban status, sociodemographics, and comorbidities. RESULTS Our sample included 1,112,876 Veterans. Between FY2015 and FY2018, mean wait times decreased for all services for both rural and urban Veterans; declines were greatest in VHA (eg, mean optometry wait times for rural Veterans in VHA vs. CC declined 8.3 vs. 6.4 d, respectively, P<0.0001). By FY2018, for both rural and urban Veterans, CC mean wait times for most services were longer than VHA wait times. CONCLUSIONS Timely care access for all Veterans improved between FY15 and FY18, particularly in VHA. As expansion of CC continues under the MISSION Act, more research is needed to evaluate quality of care across VHA and CC and what role, if any, wait times play.
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Affiliation(s)
| | - Michael Shwartz
- VA Boston Healthcare System
- Richard D. Cohen Professor of Health Care and Operations Management Emeritus, Boston University Questrom School of Business, Boston, MA
| | | | | | - Amy K. Rosen
- VA Boston Healthcare System
- Boston University School of Medicine
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Gordon SH, Beilstein-Wedel E, Rosen AK, Zheng T, Kelley AT, Cook J, Zahakos SS, Wagner TH, Vanneman ME. County-level Predictors of Growth in Community-based Primary Care Use Among Veterans. Med Care 2021; 59:S301-S306. [PMID: 33976080 PMCID: PMC8132896 DOI: 10.1097/mlr.0000000000001555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The 2014 Choice Act expanded the Veterans Health Administration's (VA) capacity to purchase services for VA enrollees from community providers, yet little is known regarding the growth of Veterans' primary care use in community settings. OBJECTIVES The aim was to measure county-level growth in VA community-based primary care (CBPC) penetration following the Choice Act and to assess whether CBPC penetration increased in rural counties with limited access to VA facilities. DATA AND SAMPLE A total of 3132 counties from VA administrative data from 2015 to 2018, Area Health Resources Files, and County Health Rankings. ANALYSIS We defined the county-level CBPC penetration rate as the proportion of VA-purchased primary care out of all VA-purchased primary care (ie, within and outside VA). We estimated county-level multivariate linear regression models to assess whether rurality and supply of primary care providers and health care facilities were significantly associated with CBPC growth. RESULTS Nationally, CBPC penetration rates increased from 2.7% in 2015 to 7.3% in 2018. The rurality of the county was associated with a 2-3 percentage point (pp) increase in CBPC penetration growth (P<0.001). The presence of a VA facility was associated with a 1.7 pp decrease in CBPC penetration growth (P<0.001), while lower primary care provider supply was associated with a 0.6 pp increase in CBPC growth (P<0.001). CONCLUSION CBPC as a proportion of all VA-purchased primary care was small but increased nearly 3-fold between 2015 and 2018. Greater increases in CBPC penetration were concentrated in rural counties and counties without a VA facility, suggesting that community care may enhance primary care access in rural areas with less VA presence.
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Affiliation(s)
- Sarah H. Gordon
- Partnered Evidence-Based Policy Resource Center, VA Boston Medical Center
- Department of Health Law, Policy, and Management, Boston University School of Public Health
| | - Erin Beilstein-Wedel
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Tianyu Zheng
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine
| | - Alan Taylor Kelley
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System
- Department of Internal Medicine, Division of General Internal Medicine
| | - James Cook
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Sarah S. Zahakos
- Department of Health Law, Policy, and Management, Boston University School of Public Health
| | - Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park CA
- Stanford University Department of Surgery, Palo Alto CA
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
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Pettey WB, Wagner TH, Rosen AK, Beilstein-Wedel E, Shwartz M, Vanneman ME. Comparing Driving Miles for Department of Veterans Affairs-delivered Versus Department of Veterans Affairs-purchased Cataract Surgery. Med Care 2021; 59:S307-S313. [PMID: 33976081 PMCID: PMC8132907 DOI: 10.1097/mlr.0000000000001491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Veterans Choice Act of 2014 increased the number of Veterans eligible for Department of Veterans Affairs (VA)-purchased care delivered in non-VA community care (CC) facilities. Driving >40 miles from home to a VA facility is a key eligibility criterion for CC. It remains unclear whether this policy change improved geographical access by reducing drive distance for Veterans. OBJECTIVES Describe the driving distance for Veterans receiving cataract surgery in VA and CC facilities, and if they visited the closest-to-home facility or if they drove to farther facilities. SUBJECTS Veterans who had cataract surgery in federal fiscal year 2015. MEASURES We calculated driving miles to the Closest VA and CC facilities that performed cataract surgeries, and to the location where Veterans received care. RESULTS A total of 61,746 Veterans received 83,875 cataract surgeries. More than 50% of CC surgeries occurred farther than the Closest CC facility providing cataract surgery (median Closest CC facility 8.7 miles vs. Actual CC facility, 19.7 miles). Most (57%) Veterans receiving cataract surgery at a VA facility used the Closest VA facility (median Closest VA facility 28.1 miles vs. Actual VA facility at 31.2 miles). In all, 26.1% of CC procedures occurred in facilities farther away than the Closest VA facility. CONCLUSIONS Although many Veterans drove farther than needed to get cataract surgery in CC, this was not true for obtaining care in the VA. Our findings suggest that there may be additional reasons, besides driving distance, that affect whether Veterans choose CC and, if they do, where they seek CC.
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Affiliation(s)
- Warren B.P. Pettey
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Todd H. Wagner
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Erin Beilstein-Wedel
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
- Department of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City, UT
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Affiliation(s)
- Kristin M. Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds
- University of Massachusetts Medical School, Worcester, MA
| | | | - Clinton Greenstone
- VHA Office of Community Care, US Department of Veterans Affairs, Washington, DC
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - David Atkins
- Health Services Research and Development, US Department of Veterans Affairs, Washington, DC
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation research, VA Boston and Boston University School of Medicine, Boston, MA
| | - Mark Upton
- VHA Office of Community Care, US Department of Veterans Affairs, Washington, DC
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Mull HJ, Rosen AK, Charns MP, Itani KM, Rivard PE. Identifying Risks and Opportunities in Outpatient Surgical Patient Safety: A Qualitative Analysis of Veterans Health Administration Staff Perceptions. J Patient Saf 2021; 17:e177-e185. [PMID: 29112029 PMCID: PMC8445239 DOI: 10.1097/pts.0000000000000311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Little is known about patient safety risks in outpatient surgery. Inpatient surgical adverse events (AEs) risk factors include patient- (e.g., advanced age), process- (e.g., inadequate preoperative assessment), or structure-related characteristics (e.g., low surgical volume); however, these factors may differ from outpatient care where surgeries are often elective and in younger/healthier patients. We undertook an exploratory qualitative research project to identify risk factors for AEs in outpatient surgery. METHODS We developed a conceptual framework of patient, process, and structure factors associated with surgical AEs on the basis of a literature review. This framework informed our semistructured interview guide with (1) open-ended questions about a specific outpatient AE that the participant experienced and (2) outpatient surgical patient safety risk factors in general. We interviewed nationwide Veterans Health Administration surgical staff. Results were coded on the basis of categories in the conceptual framework, and additional themes were identified using content analysis. RESULTS Fourteen providers representing diverse surgical roles participated. Ten reported witnessing an AE, and everyone provided input on risk factors in our conceptual framework. We did not find evidence that patient race/age, surgical technique, or surgical volume affected patient safety. Emerging factors included patient compliance, postoperative patient assessments/instruction, operating room equipment needs, and safety culture. CONCLUSIONS Surgical staff are familiar with AEs and patient safety problems in outpatient surgery. Our results show that processes of care undertaken by surgical providers, as opposed to immutable patient characteristics, may affect the occurrence of AEs. The factors we identified may facilitate more targeted research on outpatient surgical AEs.
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Affiliation(s)
- Hillary J. Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA
- Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Martin P. Charns
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
| | - Kamal M.F. Itani
- Department of Surgery, Boston University School of Medicine, Boston, MA
- Department of Surgery, VA Boston Healthcare System, West Roxbury, MA
- Harvard Medical School, Boston, MA
| | - Peter E. Rivard
- Healthcare Administration, Sawyer Business School Suffolk University, Boston, MA
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Sunthankar KI, Griffith KN, Talutis SD, Rosen AK, McAneny DB, Kulke MH, Tseng JF, Sachs TE. Cancer stage at presentation for incarcerated patients at a single urban tertiary care center. PLoS One 2020; 15:e0237439. [PMID: 32931490 PMCID: PMC7491712 DOI: 10.1371/journal.pone.0237439] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 07/27/2020] [Indexed: 12/15/2022] Open
Abstract
Patients who are incarcerated are a vulnerable patient population and may suffer from less access to routine cancer screenings compared to their non-incarcerated counterparts. Therefore, a thorough evaluation of potential differences in cancer diagnosis staging is needed. We sought to examine whether there are differences in cancer stage at initial diagnosis between non-incarcerated and incarcerated patients by pursuing a retrospective chart review from 2010–2017 for all patients who were newly diagnosed with cancer at an urban safety net hospital. Incarceration status was determined by insurance status. Our primary outcome was incarceration status at time of initial cancer diagnosis. Overall, patients who were incarcerated presented at a later cancer stage for all cancer types compared to the non-incarcerated (+.14 T stage, p = .033; +.23 N stage, p < .001). Incarcerated patients were diagnosed at later stages for colorectal (+0.93 T stage, p < .001; +.48 N stage, p < .001), oropharyngeal (+0.37 N stage, p = .003), lung (+0.60 N stage, p = .018), skin (+0.59 N stage, p = 0.014), and screenable cancers (colorectal, prostate, lung) as a whole (+0.23 T stage, p = 0.002; +0.17 N stage, p = 0.008). Incarcerated patients may benefit from more structured screening protocols in order to improve the stage at presentation for certain malignancies.
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Affiliation(s)
- Kathryn I. Sunthankar
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Kevin N. Griffith
- Boston University School of Public Health, Boston, MA, United States of America
| | | | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, United States of America
| | - David B. McAneny
- Boston University School of Medicine, Boston, MA, United States of America
| | - Matthew H. Kulke
- Boston University School of Medicine, Boston, MA, United States of America
| | - Jennifer F. Tseng
- Boston University School of Medicine, Boston, MA, United States of America
| | - Teviah E. Sachs
- Boston University School of Medicine, Boston, MA, United States of America
- * E-mail:
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Vanneman ME, Wagner TH, Shwartz M, Meterko M, Francis J, Greenstone CL, Rosen AK. Veterans' Experiences With Outpatient Care: Comparing The Veterans Affairs System With Community-Based Care. Health Aff (Millwood) 2020; 39:1368-1376. [PMID: 32744943 PMCID: PMC10031805 DOI: 10.1377/hlthaff.2019.01375] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Timely access to outpatient care was a primary driver behind the Department of Veterans Affairs' (VA's) increased purchase of community-based care under the Veterans Access, Choice, and Accountability Act of 2014, known as the Choice Act. To compare veterans' experiences in VA-delivered and community-based outpatient care after implementation of the act, we assessed veterans' scores on four dimensions of experience-access, communication, coordination, and provider rating-for outpatient specialty, primary, and mental health care received during 2016-17. Patient experiences were better for VA than for community care in all respects except access. For specialty care, access scores were better in the community; for primary and mental health care, access scores were similar in the two settings. Although all specialty care scores and the primary care coordination score improved over time, the gaps between settings did not shrink. As purchased care further expands under the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, which replaced the Choice Act in 2019, monitoring of meaningful differences between settings should continue, with the results used to inform both VA purchasing decisions and patients' care choices.
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Affiliation(s)
- Megan E Vanneman
- Megan E. Vanneman is a core investigator and Career Development Award recipient at the Veterans Affairs (VA) Salt Lake City's Informatics, Decision-Enhancement and Analytic Sciences Center, in Salt Lake City, Utah
| | - Todd H Wagner
- Todd H. Wagner is the director of the Health Economics Resource Center and assistant director and research career scientist at the VA Palo Alto Health Care System's Center for Innovation to Implementation, in Menlo Park, California
| | - Michael Shwartz
- Michael Shwartz is an investigator at the VA Boston Healthcare System's Center for Healthcare Organization and Implementation Research, in Boston, Massachusetts
| | - Mark Meterko
- Mark Meterko is a survey methodologist in the Office of Reporting, Analytics, Performance, Improvement, and Deployment at the ENRM Veterans Affairs Medical Center, in Bedford, Massachusetts
| | - Joseph Francis
- Joseph Francis is the chief improvement and analytics officer in the Office of Reporting, Analytics, Performance, Improvement, and Deployment at the Veterans Health Administration, Department of Veterans Affairs, in Washington, D.C
| | - Clinton L Greenstone
- Clinton L. Greenstone is the deputy executive director of clinical integration in the Office of Community Care at the Veterans Health Administration, Department of Veterans Affairs
| | - Amy K Rosen
- Amy K. Rosen is a core investigator and senior research career scientist at the VA Boston Healthcare System's Center for Healthcare Organization and Implementation Research
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Rosen AK, Vanneman ME, O'Brien WJ, Pershing S, Wagner TH, Beilstein-Wedel E, Lo J, Chen Q, Cockerham GC, Shwartz M. Comparing cataract surgery complication rates in veterans receiving VA and community care. Health Serv Res 2020; 55:690-700. [PMID: 32715468 DOI: 10.1111/1475-6773.13320] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To compare 90-day postoperative complication rates between Veterans receiving cataract surgery in VA vs Community Care (CC) during the first year of implementation of the Veterans Choice Act. DATA SOURCES Fiscal Year (FY) 2015 VA and CC outpatient data from VA's Corporate Data Warehouse (CDW) 10/01/14-9/30/15). FY14 data were used to obtain baseline clinical information prior to surgery. STUDY DESIGN Retrospective one-year study using secondary data to compare 90-day complication rates following cataract surgery (measured using National Quality Forum (NQF) criteria) in VA vs CC. NQF defines major complications from a specified list of Current Procedural Terminology (CPT) codes. We ran a series of logistic regression models to predict 90-day complication rates, adjusting for Veterans' sociodemographic characteristics, comorbidities, preoperative ocular conditions, eye risk group, and type of cataract surgery (classified as routine vs complex). DATA COLLECTION We linked VA and CC users through patient identifiers obtained from the CDW files. Our sample included all enrolled Veterans who received outpatient cataract surgery either in the VA or through CC during FY15. Cataract surgeries were identified through CPT codes 66 984 (routine) and 66 982 (complex). PRINCIPAL FINDINGS Of the 83,879 cataract surgeries performed in FY15, 31 percent occurred through CC. Undergoing complex surgery and having a high-risk eye (based on preoperative ocular conditions) were the strongest clinical predictors of 90-day postoperative complications. Overall, we found low complication rates, ranging from 1.1 percent in low-risk eyes to 3.6 percent in high-risk eyes. After adjustment for important confounders (eg, race, rurality, and preoperative ocular conditions), there were no statistically significant differences in 90-day complication rates between Veterans receiving cataract surgery in VA vs CC. CONCLUSIONS As more Veterans seek care through CC, future studies should continue to monitor quality of care across the two care settings to help inform VA's "make vs buy decisions."
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Affiliation(s)
- Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - William J O'Brien
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Suzann Pershing
- Department of Ophthalmology, VA Palo Alto Health Care System, Palo Alto, California
| | - Todd H Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Erin Beilstein-Wedel
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Jeanie Lo
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
| | - Qi Chen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
| | - Glenn C Cockerham
- Department of Ophthalmology, Stanford University School of Medicine, Stanford, California
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts
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Molling D, Vincent BM, Wiitala WL, Escobar GJ, Hofer TP, Liu VX, Rosen AK, Ryan AM, Seelye S, Prescott HC. Developing a template matching algorithm for benchmarking hospital performance in a diverse, integrated healthcare system. Medicine (Baltimore) 2020; 99:e20385. [PMID: 32541458 PMCID: PMC7302661 DOI: 10.1097/md.0000000000020385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.
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Affiliation(s)
- Daniel Molling
- VA Center for Clinical Management Research, Ann Arbor, MI
| | | | | | - Gabriel J. Escobar
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Timothy P. Hofer
- VA Center for Clinical Management Research, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Amy K. Rosen
- VA Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
| | - Andrew M. Ryan
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Sarah Seelye
- VA Center for Clinical Management Research, Ann Arbor, MI
| | - Hallie C. Prescott
- VA Center for Clinical Management Research, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan
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Fouayzi H, Ash AS, Rosen AK. A cardiovascular disease risk prediction algorithm for use with the Medicare current beneficiary survey. Health Serv Res 2020; 55:568-577. [PMID: 32285938 DOI: 10.1111/1475-6773.13290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To develop a cardiovascular disease (CVD) risk score that can be used to quantify CVD risk in the Medicare Current Beneficiary Survey (MCBS). DATA SOURCES We used 1999-2013 MCBS data. STUDY DESIGN We used a backward stepwise approach and cox proportional hazards regressions to build and validate a new CVD risk score, similar to the Framingham Risk Score (FRS), using only information available in MCBS. To assess its performance, we calculated C statistics and examined calibration plots. DATA COLLECTION/EXTRACTION METHODS We studied 21 968 community-dwelling Medicare beneficiaries aged 65 years or older without pre-existing CVD. We obtained risk factors from both survey and claims data. We used claims data to derive "CVD event within 3 years" following the FRS definition of CVD. PRINCIPAL FINDINGS About five percent of MCBS participants developed a CVD event over a mean follow-up period of 348 days. Our final MCBS-based model added morbidity burden, reported general health status, and functional limitation to the traditional FRS predictors of CVD. This model had relatively fair discrimination (C statistic = 0.69; 95% confidence interval [CI], 0.67-0.71) and performed well on validation (C = 0.68; CI, 0.66-0.70). More importantly, the plot of observed CVD outcomes versus predicted ones showed that this model had a good calibration. CONCLUSIONS Our new CVD risk score can be calculated using MCBS data, thereby extending the survey's ability to quantify CVD risk in the Medicare population and better inform both health policy and health services research.
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Affiliation(s)
- Hassan Fouayzi
- Meyers Primary Care Institute (A Joint Endeavor of the University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health), Worcester, Massachusetts
| | - Arlene S Ash
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, School of Medicine, Boston University, Boston, Massachusetts
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Talutis SD, Chen Q, Wang N, Rosen AK. Comparison of Risk-Standardized Readmission Rates of Surgical Patients at Safety-Net and Non-Safety-Net Hospitals Using Agency for Healthcare Research and Quality and American Hospital Association Data. JAMA Surg 2020; 154:391-400. [PMID: 30649141 DOI: 10.1001/jamasurg.2018.5242] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Medical patients discharged from safety-net hospitals (SNHs) experience higher readmission rates compared with those discharged from non-SNHs. However, little is known about whether this association persists for surgical patients. Objectives To examine differences in readmission rates between SNHs and non-SNHs among surgical patients after discharge and determine whether hospital characteristics might account for some of the variation. Design, Setting, and Participants This observational retrospective study linked the Healthcare Cost and Utilization Project State Inpatient Databases of the Agency for Healthcare Research and Quality from January 1, 2011, through December 31, 2014, for 4 states (New York, Florida, Iowa, and Washington) with data from the 2014 American Hospital Association annual survey. After identifying surgical discharges, SNHs were defined as those with the top quartile of inpatient stays paid by Medicaid or self-paid. Hospital-level risk-standardized readmission rates (RSRRs) for surgical discharges were calculated. The association between hospital RSRRs and hospital characteristics was evaluated with bivariate analyses. An estimated multivariable hierarchical linear regression model was used to examine variation in hospital RSRRs, adjusting for hospital characteristics, state, year, and SNH status. Data were analyzed from June 1, 2017, through March 1, 2018. Exposures Surgical care at an SNH. Main Outcomes and Measures Readmission after an index surgical admission. Results A total of 1 252 505 patients across all 4 years and states were included in the analysis (51.7% women; mean [SD] age, 52.7 [18.1] years). Bivariate analyses found that SNHs had higher mean (SD) surgical RSRRs compared with non-SNHs; significant differences were found for New York (9.6 [0.1] vs 10.9 [0.1]; P < .001) and Florida (11.6 [0.1] vs 12.1 [0.1]; P = .001). The SNHs also had higher RSRRs in these 2 states when stratified by hospital funding (nonfederal government SNHs in New York, 11.9 [0.2]; for-profit, private SNHs in Florida, 13.1 [0.2]; P < .001 for both); however, bed size was a significant factor for higher mean (SD) RSRRs only for New York (200 to 399 beds, 12.0 [0.4]; P = .006). Similar results were found for multivariable linear regression models; RSRRs were 1.02% higher for SNHs compared with non-SNHs (95% CI, 0.75%-1.29%; P < .001). Increased RSRRs were observed for hospitals in New York and Florida, teaching hospitals, and investor-owned hospitals. Factors associated with reduced RSRRs included presence of an ambulatory surgery center, cardiac catheterization capabilities, and high surgical volume. Conclusions and Relevance According to results of this study, surgical patients treated at SNHs experienced slightly higher RSRRs compared with those treated at non-SNHs. This association persisted after adjusting for year, state, and hospital factors, including teaching status, hospital bed size, and hospital volume.
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Affiliation(s)
| | - Qi Chen
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Na Wang
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Amy K Rosen
- Department of Surgery, Boston Medical Center, Boston, Massachusetts.,Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
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Sullivan JL, Davila HW, Rosen AK. The Changing Dynamics of Providing Health Care to Older Veterans in the 21 st Century: How Do We Best Serve Those Who Have Borne the Battle? Public Policy Aging Rep 2020; 30:3-5. [PMID: 36046846 DOI: 10.1093/ppar/prz028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Jennifer L Sullivan
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA.,Department of Health Law, Policy & Management, School of Public Health, Boston University, Boston, MA
| | - Heather W Davila
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA
| | - Amy K Rosen
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA.,Department of Surgery, School of Medicine, Boston University, Boston, MA
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Mull HJ, Graham LA, Morris MS, Rosen AK, Richman JS, Whittle J, Burns E, Wagner TH, Copeland LA, Wahl T, Jones C, Hollis RH, Itani KMF, Hawn MT. Association of Postoperative Readmissions With Surgical Quality Using a Delphi Consensus Process to Identify Relevant Diagnosis Codes. JAMA Surg 2019; 153:728-737. [PMID: 29710234 DOI: 10.1001/jamasurg.2018.0592] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Postoperative readmission data are used to measure hospital performance, yet the extent to which these readmissions reflect surgical quality is unknown. Objective To establish expert consensus on whether reasons for postoperative readmission are associated with the quality of surgery in the index admission. Design, Setting, and Participants In a modified Delphi process, a panel of 14 experts in medical and surgical readmissions comprising physicians and nonphysicians from Veterans Affairs (VA) and private-sector institutions reviewed 30-day postoperative readmissions from fiscal years 2008 through 2014 associated with inpatient surgical procedures performed at a VA medical center between October 1, 2007, and September 30, 2014. The consensus process was conducted from January through May 2017. Reasons for readmission were grouped into categories based on International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. Panelists were given the proportion of readmissions coded by each reason and median (interquartile range) days to readmission. They answered the question, "Does the readmission reason reflect possible surgical quality of care problems in the index admission?" on a scale of 1 (never related) to 5 (directly related) in 3 rounds of consensus building. The consensus process was completed in May 2017 and data were analyzed in June 2017. Main Outcomes and Measures Consensus on proportion of ICD-9-coded readmission reasons that reflected quality of surgical procedure. Results In 3 Delphi rounds, the 14 panelists achieved consensus on 50 reasons for readmission; 12 panelists also completed group telephone calls between rounds 1 and 2. Readmissions with diagnoses of infection, sepsis, pneumonia, hemorrhage/hematoma, anemia, ostomy complications, acute renal failure, fluid/electrolyte disorders, or venous thromboembolism were considered associated with surgical quality and accounted for 25 521 of 39 664 readmissions (64% of readmissions; 7.5% of 340 858 index surgical procedures). The proportion of readmissions considered to be not associated with surgical quality varied by procedure, ranging from to 21% (613 of 2331) of readmissions after lower-extremity amputations to 47% (745 of 1598) of readmissions after cholecystectomy. Conclusions and Relevance One-third of postoperative readmissions are unlikely to reflect problems with surgical quality. Future studies should test whether restricting readmissions to those with specific ICD-9 codes might yield a more useful quality measure.
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Affiliation(s)
- Hillary J Mull
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Laura A Graham
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Melanie S Morris
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Joshua S Richman
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Jeffery Whittle
- Medicine Division, Milwaukee VA Medical Center, Milwaukee, Wisconsin.,Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Edith Burns
- Medicine Division, Milwaukee VA Medical Center, Milwaukee, Wisconsin.,Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Todd H Wagner
- VA Palo Alto Medical Center, Palo Alto, California.,Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds.,University of Massachusetts Medical School, Worcester.,Baylor Scott & White Health, Center for Applied Health Research, Temple, Texas
| | - Tyler Wahl
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Caroline Jones
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Robert H Hollis
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Kamal M F Itani
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts.,Harvard University School of Medicine, Boston, Massachusetts
| | - Mary T Hawn
- VA Palo Alto Medical Center, Palo Alto, California.,Department of Surgery, Stanford University School of Medicine, Palo Alto, California
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Graham LA, Mull HJ, Wagner TH, Morris MS, Rosen AK, Richman JS, Whittle J, Burns E, Copeland LA, Itani KMF, Hawn MT. Comparison of a Potential Hospital Quality Metric With Existing Metrics for Surgical Quality-Associated Readmission. JAMA Netw Open 2019; 2:e191313. [PMID: 31002316 PMCID: PMC6481441 DOI: 10.1001/jamanetworkopen.2019.1313] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/29/2019] [Indexed: 11/16/2022] Open
Abstract
Importance The existing readmission quality metric does not meaningfully distinguish readmissions associated with surgical quality from those that are not associated with surgical quality and thus may not reflect the quality of surgical care. Objective To compare a quality metric that classifies readmissions associated with surgical quality with the existing metric of any unplanned readmission in a surgical population. Design, Setting, and Participants Cohort study using US nationwide administrative data collected on 4 high-volume surgical procedures performed at 103 Veterans Affairs hospitals from October 1, 2007, through September 30, 2014. Data analysis was conducted from October 1, 2017, to January 24, 2019. Main Outcomes and Measures Hospital-level rates of unplanned readmission (existing metric) and surgical readmissions associated with surgical quality (new metric) in the 30 days following hospital discharge for an inpatient surgical procedure. Results The study population included 109 258 patients who underwent surgery at 103 hospitals. Patients were majority male (94.1%) and white (78.2%) with a mean (SD) age of 64.0 (10.0) years at the time of surgery. After case-mix adjustment, 30-day surgical readmissions ranged from 4.6% (95% CI, 4.5%-4.8%) among knee arthroplasties to 11.1% (95% CI, 10.9%-11.3%) among colorectal resections. The new surgical readmission metric was significantly correlated with facility-level postdischarge complications for all procedures, with ρ coefficients ranging from 0.33 (95% CI, 0.13-0.51) for cholecystectomy to 0.52 (95% CI, 0.38-0.68) for colorectal resection. Correlations between postdischarge complications and the new surgical readmission metric were higher than correlations between complications and the existing readmission metric for all procedures examined (knee arthroplasty: 0.50 vs 0.48; hip replacement: 0.44 vs 0.18; colorectal resection: 0.52 vs 0.42; and cholecystectomy: 0.33 vs 0.10). When compared with using the existing readmission metric, using the new surgical readmission metric could change hip replacement-associated payment penalty determinations in 28.4% of hospitals and knee arthroplasty-associated penalties in 26.0% of hospitals. Conclusions and Relevance In this study, surgical quality-associated readmissions were more correlated with postdischarge complications at a higher rate than were unplanned readmissions. Thus, a metric based on such readmissions may be a better measure of surgical care quality. This work provides an important step in the development of future value-based payments and promotes evidence-based quality metrics targeting the quality of surgical care.
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Affiliation(s)
- Laura A. Graham
- Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Hillary J. Mull
- Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Todd H. Wagner
- Veterans Affairs, Palo Alto, Veterans Affairs Medical Center, Palo Alto, California
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Melanie S. Morris
- Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Joshua S. Richman
- Health Services Research and Development Unit, Birmingham VA Medical Center, Birmingham, Alabama
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Jeffery Whittle
- Milwaukee Veterans Affairs Medical Center, Milwaukee, Wisconsin
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Edith Burns
- Milwaukee Veterans Affairs Medical Center, Milwaukee, Wisconsin
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Laurel A. Copeland
- Veterans Affairs Central Western Massachusetts Healthcare System, Leeds
- University of Massachusetts Medical School, Worcester
| | - Kamal M. F. Itani
- Center for Healthcare Organization and Implementation Research, Boston VA Healthcare System, Boston, Massachusetts
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
- Harvard University School of Medicine, Boston, Massachusetts
| | - Mary T. Hawn
- Veterans Affairs, Palo Alto, Veterans Affairs Medical Center, Palo Alto, California
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
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Branch-Elliman W, Pizer SD, Dasinger EA, Gold HS, Abdulkerim H, Rosen AK, Charns MP, Hawn MT, Itani KMF, Mull HJ. Facility type and surgical specialty are associated with suboptimal surgical antimicrobial prophylaxis practice patterns: a multi-center, retrospective cohort study. Antimicrob Resist Infect Control 2019; 8:49. [PMID: 30886702 PMCID: PMC6404270 DOI: 10.1186/s13756-019-0503-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/27/2019] [Indexed: 12/13/2022] Open
Abstract
Background Guidelines recommend discontinuation of antimicrobial prophylaxis within 24 h after incision closure in uninfected patients. However, how facility and surgical specialty factors affect the implementation of these evidence-based surgical prophylaxis guidelines in outpatient surgery is unknown. Thus, we sought to measure how facility complexity, including ambulatory surgical center (ASC) status and availability of ancillary services, impact adherence to guidelines for timely discontinuation of antimicrobial prophylaxis after outpatient surgery. A secondary aim was to measure the association between surgical specialty and guideline compliance. Methods A multi-center, national Veterans Health Administration retrospective cohort from 10/1/2015-9/30/2017 including any Veteran undergoing an outpatient surgical procedure in any of five specialties (general surgery, urology, ophthalmology, ENT, orthopedics) was created. The primary outcome was the association between facility complexity and proportion of surgeries not compliant with discontinuation of antimicrobials within 24 h of incision closure. Data were analyzed using logistic regression with adjustments for patient and procedural factors. Results Among 153,097 outpatient surgeries, 7712 (5.0%) received antimicrobial prophylaxis lasting > 24 h after surgery; rates ranged from 0.4% (eye surgeries) to 13.7% (genitourinary surgeries). Cystoscopies and cystoureteroscopy with lithotripsy procedures had the highest rates (16 and 20%), while hernia repair, cataract surgeries, and laparoscopic cholecystectomies had the lowest (0.2-0.3%). In an adjusted logistic regression model, lower complexity ASC and hospital outpatient departments had higher odds of prolonged antimicrobial prophylaxis compared to complex hospitals (OR ASC, 1.3, 95% CI: 1.2-1.5). Patient factors associated with higher odds of noncompliance with antimicrobial discontinuation included younger age, female sex, and white race. Genitourinary and ear/nose/throat surgeries were associated with the highest odds of prolonged antimicrobial prophylaxis. Conclusions Facility complexity appears to play a role in adherence to surgical infection prevention guidelines. Lower complexity facilities with limited infection prevention and antimicrobial stewardship resources may be important targets for quality improvement. Such interventions may be especially useful for genitourinary and ear/nose/throat surgical subspecialties. Increasing pharmacy, antimicrobial stewardship and/or infection prevention resources to promote more evidence-based care may support surgical providers in lower complexity ambulatory surgery centers and hospital outpatient departments in their efforts to improve this facet of patient safety.
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Affiliation(s)
- Westyn Branch-Elliman
- 1Department of Medicine, Section of Infectious Diseases, VA Boston Healthcare System, MA 1400 VFW Parkway West Roxbury, Boston, MA 02132 USA.,2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA.,3Harvard Medical School, 25 Shattuck Street Boston, Boston, MA 02115 USA
| | - Steven D Pizer
- 4Partnered Evidence-based Policy Resource Center (PEPReC), Department of Veterans Affairs, 150 South Huntington Avenue Boston, Boston, MA 02130 USA.,5Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118 USA
| | - Elise A Dasinger
- VA Quality Scholars Program, Birmingham VA Medical Center, Birmingham, 700 19th Street S, AL 35233 England
| | - Howard S Gold
- 3Harvard Medical School, 25 Shattuck Street Boston, Boston, MA 02115 USA.,7Beth Israel Deaconess Medical Center, Division of Infectious Diseases, 110 Francis Street, Boston, MA 02115 USA
| | - Hassen Abdulkerim
- 2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA
| | - Amy K Rosen
- 2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA.,8Department of Surgery, Boston University School of Medicine, 88 East Newton Street, C515, Boston, MA 02118 USA
| | - Martin P Charns
- 2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA
| | - Mary T Hawn
- 9Palo Alto VA Medical Center, 3801 Miranda Ave, Palo Alto, CA 95010 USA.,10Stanford University School of Medicine, 291 Campus Drive Stanford, Stanford, CA 94305 USA
| | - Kamal M F Itani
- 11Department of Surgery, VA Boston Healthcare System, 1400 VFW Parkway West Roxbury, Boston, MA 02132 USA.,3Harvard Medical School, 25 Shattuck Street Boston, Boston, MA 02115 USA.,8Department of Surgery, Boston University School of Medicine, 88 East Newton Street, C515, Boston, MA 02118 USA
| | - Hillary J Mull
- 2Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Healthcare System, 150 South Huntington Avenue, Boston, MA 02130 USA.,8Department of Surgery, Boston University School of Medicine, 88 East Newton Street, C515, Boston, MA 02118 USA
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Dasinger EA, Graham LA, Wahl TS, Richman JS, Baker SJ, Hawn MT, Hernandez-Boussard T, Rosen AK, Mull HJ, Copeland LA, Whittle JC, Burns EA, Morris MS. Preoperative opioid use and postoperative pain associated with surgical readmissions. Am J Surg 2019; 218:828-835. [PMID: 30879796 DOI: 10.1016/j.amjsurg.2019.02.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/14/2019] [Accepted: 02/26/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND The extent of preoperative opioid utilization and the relationship with pain-related readmissions are not well understood. METHODS VA Surgical Quality Improvement Program data on general, vascular, and orthopedic surgeries (2007-2014) were merged with pharmacy data to evaluate preoperative opioid use and pain-related readmissions. Opioid use in the 6-month preoperative period was categorized as none, infrequent, frequent, and daily. RESULTS In the six-month preoperative period, 65.7% had no opioid use, 16.7% had infrequent use, 6.3% frequent use, and 11.4% were daily opioid users. Adjusted odds of pain-related readmission were higher for opioid-exposed groups vs the opioid-naïve group: infrequent (OR 1.17; 95% CI:1.04-1.31), frequent (OR 1.28; 95% CI:1.08-1.52), and daily (OR 1.49; 95% CI:1.27-1.74). Among preoperative opioid users, those with a pain-related readmission had higher daily preoperative oral morphine equivalents (mean 44.5 vs. 36.1, p < 0.001). CONCLUSIONS Patients using opioids preoperatively experienced higher rates of pain-related readmissions, which increased with frequency and dosage of opioid exposure.
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Affiliation(s)
- Elise A Dasinger
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Laura A Graham
- Veterans Affairs, Palo Alto, Veterans Affairs Medical Center, Palo Alto, CA, USA; Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tyler S Wahl
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joshua S Richman
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Samantha J Baker
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mary T Hawn
- Veterans Affairs, Palo Alto, Veterans Affairs Medical Center, Palo Alto, CA, USA; Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Hillary J Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, MA, USA; University of Massachusetts Medical School, Worcester, MA, USA
| | - Jeffrey C Whittle
- Milwaukee Veterans Affairs Medical Center, Milwaukee, WI, USA; Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Edith A Burns
- Milwaukee Veterans Affairs Medical Center, Milwaukee, WI, USA; Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Melanie S Morris
- Birmingham VA Medical Center, Birmingham, AL, USA; Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Dasinger EA, Branch-Elliman W, Pizer SD, Abdulkerim H, Rosen AK, Charns MP, Hawn MT, Itani KMF, Mull HJ. Association between postoperative opioid use and outpatient surgical adverse events. Am J Surg 2019; 217:605-612. [PMID: 30639132 DOI: 10.1016/j.amjsurg.2018.12.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/26/2018] [Accepted: 12/31/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Opioid-related adverse drug events are common following inpatient surgical procedures. Little is known about opioid prescribing after outpatient surgical procedures and if opioid use is associated with short term risks of outpatient surgical adverse events (AEs). METHODS VA Corporate Data Warehouse was used to identify opioid use within 48 h for FY2012-14 chart-reviewed cases from a larger VA study of AEs in outpatient surgeries. We estimated a multilevel logistic regression model to determine the effect of opioid exposure on risk of AEs between 2 and 30 days postoperatively. RESULTS Of the 1730 outpatient surgical cases, 628 (36%) had postoperative opioid use and 12% had an AE. Opioid use following outpatient surgery was not significantly associated with higher surgical AE rates after controlling for relevant covariates (OR = 1.1 95% CI 0.79-1.54). Only procedure RVUs were associated with higher odds of postoperative AEs. CONCLUSIONS Postoperative opioid use following outpatient surgery is not a significant driver of postoperative AEs.
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Affiliation(s)
- Elise A Dasinger
- VA Quality Scholars Program, Birmingham VA Medical Center, Birmingham, AL, United States.
| | - Westyn Branch-Elliman
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Medicine, VA Boston Healthcare System, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Steven D Pizer
- Partnered Evidence-based Policy Resource Center (PEPReC), Department of Veterans Affairs, Boston, MA, United States; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States
| | - Hassen Abdulkerim
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Surgery, Boston University School of Medicine, Boston, MA, United States
| | - Martin P Charns
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States
| | - Mary T Hawn
- Palo Alto VA Medical Center, Palo Alto, CA, United States; Stanford University School of Medicine, Stanford, CA, United States
| | - Kamal M F Itani
- Harvard Medical School, Boston, MA, United States; Department of Surgery, Boston University School of Medicine, Boston, MA, United States; Department of Surgery, VA Boston Healthcare System, Boston, MA, United States
| | - Hillary J Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Surgery, Boston University School of Medicine, Boston, MA, United States
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Rosen AK, Wagner TH, Pettey WBP, Shwartz M, Chen Q, Lo J, O'Brien WJ, Vanneman ME. Differences in Risk Scores of Veterans Receiving Community Care Purchased by the Veterans Health Administration. Health Serv Res 2018; 53 Suppl 3:5438-5454. [PMID: 30251367 PMCID: PMC6235821 DOI: 10.1111/1475-6773.13051] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess differences in risk (measured by expected costs associated with sociodemographic and clinical profiles) between Veterans receiving outpatient services through two community care (CC) programs: the Fee program ("Fee") and the Veterans Choice Program ("Choice"). DATA SOURCES/STUDY SETTING Administrative data from VHA's Corporate Data Warehouse in fiscal years (FY) 2014-2015. STUDY DESIGN We compared the clinical characteristics of Veterans across three groups (Fee only, Choice only, and Fee & Choice). We classified Veterans into risk groups based on Nosos risk scores and examined the relationship between type of outpatient utilization and risk within each CC group. We also examined changes in utilization of VHA and CC in FY14-FY15. We used chi-square tests, t tests, and ANOVAs to identify significant differences between CC groups. PRINCIPAL FINDINGS Of the 1,400,977 Veterans using CC in FY15, 91.4 percent were Fee-only users, 4.4 percent Choice-only users, and 4.2 percent Fee & Choice users. Mean concurrent risk scores were higher for Fee only and Fee & Choice (1.9, SD = 2.7; 1.8, SD = 2.2) compared to Choice-only users (1.0, SD = 1.2) (p < .0001). Most CC users were "dual users" of both VHA and CC in FY14-FY15. CONCLUSIONS As care transitions from VHA to CC, VHA should consider how best to coordinate care with community providers to reduce duplication of efforts, improve handoffs, and achieve the best outcomes for Veterans.
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Affiliation(s)
- Amy K. Rosen
- Center for Healthcare, Organization and Implementation ResearchBostonMA
| | - Todd H. Wagner
- Health Economics Resource CenterPalo Alto VAMenlo ParkCA
- Center for Innovation to ImplementationPalo Alto VAMenlo ParkCA
- Department of SurgeryStanford UniversityMenlo ParkCA
| | - Warren B. P. Pettey
- VA Salt Lake City Health Care SystemSalt Lake CityUT
- University of Utah School of MedicineSalt Lake CityUT
| | - Michael Shwartz
- Center for Healthcare, Organization and Implementation ResearchBostonMA
| | - Qi Chen
- Center for Healthcare, Organization and Implementation ResearchBostonMA
| | - Jeanie Lo
- Health Economics Resource CenterMenlo ParkCA
| | | | - Megan E. Vanneman
- InformaticsDecision‐Enhancement and Analytic Sciences CenterVA Salt Lake City Health Care SystemSalt Lake CityUT
- Department of Internal MedicineDivision of EpidemiologyUniversity of Utah School of MedicineSalt LakeUT
- Department of Population Health SciencesDivision of Health System Innovation and ResearchUniversity of Utah School of MedicineSalt Lake CityUT
- EpidemiologyUniversity of Utah HealthSalt Lake CityUT
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Talutis SD, Chen Q, Wang N, Rosen AK. Comparing Risk Standardized Readmission Rates of Surgical Patients at Safety Net and Non-Safety Net Hospitals. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wahl TS, Graham LA, Morris MS, Richman JS, Hollis RH, Jones CE, Itani KM, Wagner TH, Mull HJ, Whittle JC, Telford GL, Rosen AK, Copeland LA, Burns EA, Hawn MT. Association Between Preoperative Proteinuria and Postoperative Acute Kidney Injury and Readmission. JAMA Surg 2018; 153:e182009. [PMID: 29971429 DOI: 10.1001/jamasurg.2018.2009] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Proteinuria indicates renal dysfunction and is a risk factor for morbidity among medical patients, but less is understood among surgical populations. There is a paucity of studies investigating how preoperative proteinuria is associated with surgical outcomes, including postoperative acute kidney injury (AKI) and readmission. Objective To assess preoperative urine protein levels as a biomarker for adverse surgical outcomes. Design, Setting, and Participants A retrospective, population-based study was conducted in a cohort of patients with and without known preoperative renal dysfunction undergoing elective inpatient surgery performed at 119 Veterans Affairs facilities from October 1, 2007, to September 30, 2014. Data analysis was conducted from April 4 to December 1, 2016. Preoperative dialysis, septic, cardiac, ophthalmology, transplantation, and urologic cases were excluded. Exposures Preoperative proteinuria as assessed by urinalysis using the closest value within 6 months of surgery: negative (0 mg/dL), trace (15-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-300 mg/dL), 3+ (301-1000 mg/dL), and 4+ (>1000 mg/dL). Main Outcomes and Measures Primary outcome was postoperative predischarge AKI and 30-day postdischarge unplanned readmission. Secondary outcomes included any 30-day postoperative outcome. Results Of 346 676 surgeries, 153 767 met inclusion criteria, with the majority including orthopedic (37%), general (29%), and vascular procedures (14%). Evidence of proteinuria was shown in 43.8% of the population (trace: 20.6%, 1+: 16.0%, 2+: 5.5%, 3+: 1.6%) with 20.4%, 14.9%, 4.3%, and 0.9%, respectively, of the patients having a normal preoperative estimated glomerular filtration rate (eGFR). In unadjusted analysis, preoperative proteinuria was significantly associated with postoperative AKI (negative: 8.6%, trace: 12%, 1+: 14.5%, 2+: 21.2%, 3+: 27.6%; P < .001) and readmission (9.3%, 11.3%, 13.3%, 15.8%, 17.5%, respectively, P < .001). After adjustment, preoperative proteinuria was associated with postoperative AKI in a dose-dependent relationship (trace: odds ratio [OR], 1.2; 95% CI, 1.1-1.3, to 3+: OR, 2.0; 95% CI, 1.8-2.2) and 30-day unplanned readmission (trace: OR, 1.0; 95% CI, 1.0-1.1, to 3+: OR, 1.3; 95% CI, 1.1-1.4). Preoperative proteinuria was associated with AKI independent of eGFR. Conclusions and Relevance Proteinuria was associated with postoperative AKI and 30-day unplanned readmission independent of preoperative eGFR. Simple urine assessment for proteinuria may identify patients at higher risk of AKI and readmission to guide perioperative management.
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Affiliation(s)
- Tyler S Wahl
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Laura A Graham
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Melanie S Morris
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Joshua S Richman
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Robert H Hollis
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Caroline E Jones
- Birmingham and Tuscaloosa Health Services Research and Development Unit, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.,Department of Surgery, University of Alabama at Birmingham
| | - Kamal M Itani
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts.,School of Medicine, Harvard University, Boston, Massachusetts
| | - Todd H Wagner
- Veterans Affairs Palo Alto Healthcare System, Palo Alto, California.,Department of Surgery, Stanford University, Stanford, California
| | - Hillary J Mull
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Jeffrey C Whittle
- Milwaukee Veterans Affairs Medical Center, Milwaukee, Wisconsin.,Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Gordon L Telford
- Milwaukee Veterans Affairs Medical Center, Milwaukee, Wisconsin.,Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Laurel A Copeland
- Veterans Affairs Central Western Massachusetts Health Care System, Leeds.,Center for Applied Health Research, Baylor Scott and White Health, Temple, Texas.,Department of Medicine, Texas A&M Health Science Center, Temple
| | - Edith A Burns
- Milwaukee Veterans Affairs Medical Center, Milwaukee, Wisconsin.,Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Mary T Hawn
- Veterans Affairs Palo Alto Healthcare System, Palo Alto, California.,Department of Surgery, Stanford University, Stanford, California
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Mull HJ, Itani KMF, Pizer SD, Charns MP, Rivard PE, McIntosh N, Hawn MT, Rosen AK. Development of an Adverse Event Surveillance Model for Outpatient Surgery in the Veterans Health Administration. Health Serv Res 2018; 53:4507-4528. [PMID: 30151826 DOI: 10.1111/1475-6773.13037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Develop and validate a surveillance model to identify outpatient surgical adverse events (AEs) based on previously developed electronic triggers. DATA SOURCES Veterans Health Administration's Corporate Data Warehouse. STUDY DESIGN Six surgical AE triggers, including postoperative emergency room visits and hospitalizations, were applied to FY2012-2014 outpatient surgeries (n = 744,355). We randomly sampled trigger-flagged and unflagged cases for nurse chart review to document AEs and measured positive predictive value (PPV) for triggers. Next, we used chart review data to iteratively estimate multilevel logistic regression models to predict the probability of an AE, starting with the six triggers and adding in patient, procedure, and facility characteristics to improve model fit. We validated the final model by applying the coefficients to FY2015 outpatient surgery data (n = 256,690) and reviewing charts for cases at high and moderate probability of an AE. PRINCIPAL FINDINGS Of 1,730 FY2012-2014 reviewed surgeries, 350 had an AE (20 percent). The final surveillance model c-statistic was 0.81. In FY2015 surgeries with >0.8 predicted probability of an AE (n = 405, 0.15 percent), PPV was 85 percent; in surgeries with a 0.4-0.5 predicted probability of an AE, PPV was 38 percent. CONCLUSIONS The surveillance model performed well, accurately identifying outpatient surgeries with a high probability of an AE.
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Affiliation(s)
- Hillary J Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA.,Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Kamal M F Itani
- Department of Surgery, Boston University School of Medicine, Boston, MA.,Department of Surgery, VA Boston Healthcare System, Boston, MA.,Harvard Medical School, Boston, MA
| | - Steven D Pizer
- Department of Veterans Affairs, Partnered Evidence-based Policy Resource Center (PEPReC), Boston, MA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
| | - Martin P Charns
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
| | - Peter E Rivard
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA.,Healthcare Administration, Sawyer Business School Suffolk University, Boston, MA
| | | | - Mary T Hawn
- Palo Alto VA Medical Center, Palo Alto, CA.,Stanford University School of Medicine, Stanford, CA
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA.,Department of Surgery, Boston University School of Medicine, Boston, MA
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Sullivan JL, Shin MH, Engle RL, Yaksic E, VanDeusen Lukas C, Paasche-Orlow MK, Starr LM, Restuccia JD, Holmes SK, Rosen AK. Evaluating the Implementation of Project Re-Engineered Discharge (RED) in Five Veterans Health Administration (VHA) Hospitals. Jt Comm J Qual Patient Saf 2018; 44:663-673. [PMID: 30097383 DOI: 10.1016/j.jcjq.2018.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 01/16/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Improving the process of hospital discharge is a critical priority. Interventions to improve care transitions have been shown to reduce the rate of early unplanned readmissions, and consequently, there is growing interest in improving transitions of care between hospital and home through appropriate interventions. Project Re-Engineered Discharge (RED) has shown promise in strengthening the discharge process. Although studies have analyzed the implementation of RED among private-sector hospitals, little is known about how hospitals in the Veterans Health Administration (VHA) have implemented RED. The RED implementation process was evaluated in five VHA hospitals, and contextual factors that may impede or facilitate the undertaking of RED were identified. METHODS A qualitative evaluation of VHA hospitals' implementation of RED was conducted through semistructured telephone interviews with personnel involved in RED implementation. Qualitative data from these interviews were coded and used to compare implementation activities across the five sites. In addition guided by the Practical, Robust Implementation and Sustainability Model (PRISM), cross-site analyses of the contextual factors were conducted using a consensus process. RESULTS Progress and adherence to the RED toolkit implementation steps and intervention components varied across study sites. A majority of contextual factors identified were positive influences on sites' implementation. CONCLUSION Although the study sites were able to tailor and implement RED because of its adaptability, redesigning discharge processes is a significant undertaking, requiring additional support/resources to incorporate into an organization's existing practices. Lessons learned from the study should be useful to both VHA and private-sector hospitals interested in implementing RED and undertaking a care transition intervention.
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Borzecki AM, Chen Q, O'Brien W, Shwartz M, Najjar PA, Itani KMF, Rosen AK. The Patient Safety Indicator Perioperative Pulmonary Embolism or Deep Vein Thrombosis: Is there associated surveillance bias in the Veterans Health Administration? Am J Surg 2018; 216:974-979. [PMID: 30005806 DOI: 10.1016/j.amjsurg.2018.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 06/15/2018] [Accepted: 06/21/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Studies disagree whether surveillance bias is associated with perioperative venous thromboembolism (VTE) performance measures. A prior VA study used a chart-based outcome; no studies have used the fully specified administrative data-based AHRQ Patient Safety Indicator, PSI-12, as their primary outcome. If surveillance bias were present, we hypothesized that inpatient surveillance rates would be associated with higher PSI-12 rates, but with lower post-discharge VTE rates. METHODS Using VA data, we examined Pearson correlations between hospital-level VTE imaging rates and risk-adjusted PSI-12 rates and post-discharge VTE rates. To determine the robustness of findings, we conducted several sensitivity analyses. RESULTS Hospital imaging rates were positively correlated with both PSI-12 (r = 0.24, p = 0.01) and post-discharge VTE rates (r = 0.16, p = 0.09). Sensitivity analyses yielded similar findings. CONCLUSIONS Like the prior VA study, we found no evidence of PSI-12-related surveillance bias. Given the use of PSI-12 in nationwide measurement, these findings warrant replication using similar methods in the non-VA setting.
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Affiliation(s)
- Ann M Borzecki
- Center for Healthcare Organization and Implementation Research, Bedford VAMC, Bedford, MA, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA.
| | - Qi Chen
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| | - William O'Brien
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA; Boston University, Questrom School of Business, Boston, MA, USA
| | - Peter A Najjar
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Kamal M F Itani
- VA Boston Healthcare System, Boston, MA, USA; Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Amy K Rosen
- Boston University School of Medicine, Boston, MA, USA; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
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Ivy KS, Griffith KN, Rosen AK, Talutis SD, McAneny DB, Kulke MH, Tseng JF, Sachs TE. Stage at presentation for incarcerated patients at a single urban tertiary care center. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e18649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Amy K. Rosen
- Boston University School of Medicine, Boston, MA
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Mull HJ, Rosen AK, Pizer SD, Itani KMF. Association Between Postoperative Admission and Location of Hernia Surgery: A Matched Case-Control Study in the Veterans Administration. JAMA Surg 2018; 151:1187-1190. [PMID: 27682221 DOI: 10.1001/jamasurg.2016.3113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Hillary J Mull
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts2Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts2Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Steven D Pizer
- Health Care Financing & Economics, Department of Veterans Affairs, Boston, Massachusetts4Northeastern University, Boston, Massachusetts
| | - Kamal M F Itani
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts5Department of Surgery, VA Boston Healthcare System, Boston, Massachusetts6Harvard Medical School, Boston, Massachusetts
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Chen Q, Rosen AK, Amirfarzan H, Rochman A, Itani KMF. Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their contribution to postoperative outcomes. Am J Surg 2018; 216:846-850. [PMID: 29563021 DOI: 10.1016/j.amjsurg.2018.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 02/25/2018] [Accepted: 03/02/2018] [Indexed: 12/18/2022]
Abstract
Our knowledge of the types of intraoperative patient safety events, their harm to patients, and relationship to postoperative complications is sparse. This study examined intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) voluntarily reported by providers using two programs at our hospital: surgical debriefing and incident reporting. Among the 3020 surgical procedures assessed, 142 iMEs and 103 iAEs were reported, yielding an overall rate of 8%. Of these events, 135 (55%) were obtained from incident reporting and 110 (45%) from surgical debriefing. The overall association between intraoperative events (iMEs and iAEs) and 30-day postoperative morbidity was significant (adjusted odds ratio = 1.08 with 95% confidence interval (CI) of (1.03, 1.13). This association was stronger when we included only the iAEs (1.47, 95% CI (1.35, 1.58)). Our findings suggest that hospitals should consider using both programs to obtain a more complete picture of intraoperative patient safety and to reduce postoperative morbidity.
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Affiliation(s)
- Qi Chen
- Patient Safety Center of Inquiry on Measurement to Advance Patient Safety, Boston, MA, USA; Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA.
| | - Amy K Rosen
- Patient Safety Center of Inquiry on Measurement to Advance Patient Safety, Boston, MA, USA; Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Houman Amirfarzan
- Patient Safety Center of Inquiry on Measurement to Advance Patient Safety, Boston, MA, USA; Department of Anesthesiology, Critical Care and Pain Medicine, VA Boston Healthcare System, Boston, MA, USA
| | - Alexandra Rochman
- Patient Safety Center of Inquiry on Measurement to Advance Patient Safety, Boston, MA, USA; Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA
| | - Kamal M F Itani
- Patient Safety Center of Inquiry on Measurement to Advance Patient Safety, Boston, MA, USA; Department of Surgery, Boston University School of Medicine, Boston, MA, USA; Department of Surgery, VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Shin MH, Rivard PE, Shwartz M, Borzecki A, Yaksic E, Stolzmann K, Zubkoff L, Rosen AK. Tailoring an educational program on the AHRQ Patient Safety Indicators to meet stakeholder needs: lessons learned in the VA. BMC Health Serv Res 2018; 18:114. [PMID: 29444671 PMCID: PMC5813330 DOI: 10.1186/s12913-018-2904-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/31/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Given that patient safety measures are increasingly used for public reporting and pay-for performance, it is important for stakeholders to understand how to use these measures for improvement. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are one particularly visible set of measures that are now used primarily for public reporting and pay-for-performance among both private sector and Veterans Health Administration (VA) hospitals. This trend generates a strong need for stakeholders to understand how to interpret and use the PSIs for quality improvement (QI). The goal of this study was to develop an educational program and tailor it to stakeholders' needs. In this paper, we share what we learned from this program development process. METHODS Our study population included key VA stakeholders involved in reviewing performance reports and prioritizing and initiating quality/safety initiatives. A pre-program formative evaluation through telephone interviews and web-based surveys assessed stakeholders' educational needs/interests. Findings from the formative evaluation led to development and implementation of a cyberseminar-based program, which we tailored to stakeholders' needs/interests. A post-program survey evaluated program participants' perceptions about the PSI educational program. RESULTS Interview data confirmed that the concepts we had developed for the interviews could be used for the survey. Survey results informed us on what program delivery mode and content topics were of high interest. Six cyberseminars were developed-three of which focused on two content areas that were noted of greatest interest: learning how to use PSIs for monitoring trends and understanding how to interpret PSIs. We also used snapshots of VA PSI reports so that participants could directly apply learnings. Although initial interest in the program was high, actual attendance was low. However, post-program survey results indicated that perceptions about the program were positive. CONCLUSIONS Conducting a formative evaluation was a highly important process in program development. The useful information that we collected through the interviews and surveys allowed us to tailor the program to stakeholders' needs and interests. Our experiences, particularly with the formative evaluation process, yielded valuable lessons that can guide others when developing and implementing similar educational programs.
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Affiliation(s)
- Marlena H. Shin
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA USA
| | - Peter E. Rivard
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA USA
- Sawyer Business School, Suffolk University, Boston, MA USA
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA USA
- Questrom School of Business, Boston University, Boston, MA USA
| | - Ann Borzecki
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford VA Medical Center, Bedford, MA USA
- Department of Internal Medicine, Boston University School of Medicine, Boston, MA USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA USA
| | - Enzo Yaksic
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA USA
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA USA
| | - Lisa Zubkoff
- VA National Center for Patient Safety, Field Office, White River Junction, VT USA
- White River Junction VA Medical Center, White River Junction, VT USA
- Geisel School of Medicine, Dartmouth College, Hanover, NH USA
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA USA
- Department of Surgery, Boston University School of Medicine, Boston, MA USA
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Mull HJ, Rosen AK, O'Brien WJ, McIntosh N, Legler A, Hawn MT, Itani KMF, Pizer SD. Factors Associated with Hospital Admission after Outpatient Surgery in the Veterans Health Administration. Health Serv Res 2018; 53:3855-3880. [PMID: 29363106 DOI: 10.1111/1475-6773.12826] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine factors associated with 0- to 7-day admission after outpatient surgery in high-volume specialties: general surgery, orthopedics, urology, ear/nose/throat, and podiatry. STUDY DESIGN We calculated rates and assessed diagnosis codes for 0- to 7-day admission after outpatient surgery for Centers for Medicare and Medicaid Services (CMS) and Veterans Health Administration (VA) dually enrolled patients age 65 and older. We also estimated separate multilevel logistic regression models to compare patient, procedure, and facility characteristics associated with postoperative admission. DATA COLLECTION 2011-2013 surgical encounter data from the VA Corporate Data Warehouse; geographic data from the Area Health Resources File; CMS enrollment and hospital admission data. PRINCIPAL FINDINGS Among 63,585 outpatient surgeries in 124 facilities, 0- to 7-day admission rates ranged from 5 percent (podiatry) to 28 percent (urology); nearly 66 percent of the admissions occurred on the day of surgery. Only 97 admissions were detected in the CMS data (1 percent). Surgical complications were diagnosed in 4 percent of admissions. Procedure complexity, measured by relative value units or anesthesia risk score, was associated with admission across all specialties. CONCLUSION As many as 20 percent of VA outpatient surgeries result in an admission. Complex procedures are more likely to be followed by admission, but more evidence is required to determine how many of these reflect potential safety or quality problems.
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Affiliation(s)
- Hillary J Mull
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA.,Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA.,Department of Surgery, Boston University School of Medicine, Boston, MA
| | - William J O'Brien
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA
| | | | - Aaron Legler
- Department of Veterans Affairs, Partnered Evidence-based Policy Resource Center (PEPReC), Boston, MA
| | - Mary T Hawn
- Palo Alto VA Medical Center, Palo Alto, CA.,Stanford University School of Medicine, Stanford, CA
| | - Kamal M F Itani
- Department of Surgery, Boston University School of Medicine, Boston, MA.,Department of Surgery, VA Boston Healthcare System, Boston, MA.,Harvard Medical School, Boston, MA
| | - Steven D Pizer
- Department of Veterans Affairs, Partnered Evidence-based Policy Resource Center (PEPReC), Boston, MA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA
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Sullivan JL, Rivard PE, Shin MH, Rosen AK. Applying the High Reliability Health Care Maturity Model to Assess Hospital Performance: A VA Case Study. Jt Comm J Qual Patient Saf 2017; 42:389-411. [PMID: 27535456 DOI: 10.1016/s1553-7250(16)42080-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The lack of a tool for categorizing and differentiating hospitals according to their high reliability organization (HRO)-related characteristics has hindered progress toward implementing and sustaining evidence-based HRO practices. Hospitals would benefit both from an understanding of the organizational characteristics that support HRO practices and from knowledge about the steps necessary to achieve HRO status to reduce the risk of harm and improve outcomes. The High Reliability Health Care Maturity (HRHCM) model, a model for health care organizations' achievement of high reliability with zero patient harm, incorporates three major domains critical for promoting HROs-Leadership, Safety Culture, and Robust Process Improvement ®. A study was conducted to examine the content validity of the HRHCM model and evaluate whether it can differentiate hospitals' maturity levels for each of the model's components. METHODS Staff perceptions of patient safety at six US Department of Veterans Affairs (VA) hospitals were examined to determine whether all 14 HRHCM components were present and to characterize each hospital's level of organizational maturity. RESULTS Twelve of the 14 components from the HRHCM model were detected; two additional characteristics emerged that are present in the HRO literature but not represented in the model-teamwork culture and system-focused tools for learning and improvement. Each hospital's level of organizational maturity could be characterized for 9 of the 14 components. DISCUSSION The findings suggest the HRHCM model has good content validity and that there is differentiation between hospitals on model components. Additional research is needed to understand how these components can be used to build the infrastructure necessary for reaching high reliability.
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Affiliation(s)
- Jennifer L Sullivan
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, USA
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Chen L, Chan JA, Alligood E, Rosen AK, Borzecki AM. Does Surveillance Bias Influence the Validity of Measures of Inpatient Complications? A Systematic Review. Am J Med Qual 2017; 33:291-302. [PMID: 28958153 DOI: 10.1177/1062860617730900] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Surveillance bias may threaten the accuracy of inpatient complication measures. A systematic literature review was conducted to examine whether surveillance bias influences the validity of selected Patient Safety Indicator- and health care associated infection-related measures. Ten venous thromboembolism (VTE) articles were identified: 7 trauma related, 3 postoperative, and 1 central line-associated bloodstream infection (CLABSI) article. Nine VTE articles found positive associations between deep vein thrombosis imaging and VTE diagnoses. Because imaging also may be symptom driven, most studies performed additional analyses to corroborate findings. Six trauma-related and 2 postoperative VTE studies concluded that surveillance bias was present, the latter based on circumstantial evidence. The non-VTE study found a significant positive correlation between surveillance aggressiveness and intensive care unit CLABSI rates. Even considering VTE, relatively little is known about the impact of surveillance bias on inpatient complication measures. Given the implications of misclassifying hospitals on quality, this issue requires further investigation using more direct measurement methods.
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Affiliation(s)
- Liang Chen
- 1 Bedford VA Medical Center, Bedford, MA.,2 Boston University School of Public Health, Boston, MA.,3 Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | | | | | - Ann M Borzecki
- 1 Bedford VA Medical Center, Bedford, MA.,2 Boston University School of Public Health, Boston, MA.,5 Boston University School of Medicine, Boston, MA
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Hanchate AD, Stolzmann KL, Rosen AK, Fink AS, Shwartz M, Ash AS, Abdulkerim H, Pugh MJV, Shokeen P, Borzecki A. Does adding clinical data to administrative data improve agreement among hospital quality measures? Healthc (Amst) 2017; 5:112-118. [PMID: 27932261 PMCID: PMC5772776 DOI: 10.1016/j.hjdsi.2016.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 10/03/2016] [Accepted: 10/05/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospital performance measures based on patient mortality and readmission have indicated modest rates of agreement. We examined if combining clinical data on laboratory tests and vital signs with administrative data leads to improved agreement with each other, and with other measures of hospital performance in the nation's largest integrated health care system. METHODS We used patient-level administrative and clinical data, and hospital-level data on quality indicators, for 2007-2010 from the Veterans Health Administration (VA). For patients admitted for acute myocardial infarction (AMI), heart failure (HF) and pneumonia we examined changes in hospital performance on 30-d mortality and 30-d readmission rates as a result of adding clinical data to administrative data. We evaluated whether this enhancement yielded improved measures of hospital quality, based on concordance with other hospital quality indicators. RESULTS For 30-d mortality, data enhancement improved model performance, and significantly changed hospital performance profiles; for 30-d readmission, the impact was modest. Concordance between enhanced measures of both outcomes, and with other hospital quality measures - including Joint Commission process measures, VA Surgical Quality Improvement Program (VASQIP) mortality and morbidity, and case volume - remained poor. CONCLUSIONS Adding laboratory tests and vital signs to measure hospital performance on mortality and readmission did not improve the poor rates of agreement across hospital quality indicators in the VA. INTERPRETATION Efforts to improve risk adjustment models should continue; however, evidence of validation should precede their use as reliable measures of quality.
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Affiliation(s)
- Amresh D Hanchate
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA 02130, USA; Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA.
| | - Kelly L Stolzmann
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA 02130, USA
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA 02130, USA; Department of Surgery, Boston University School of Medicine, Boston, MA 02118, USA
| | - Aaron S Fink
- Professor Emeritus of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA 02130, USA; Department of Operations and Technology Management, Boston University School of Management, Boston, MA 02215, USA
| | - Arlene S Ash
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Hassen Abdulkerim
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA 02130, USA
| | - Mary Jo V Pugh
- South Texas Veterans Health Care System, San Antonio, TX 78229, USA; Department of Epidemiology and Biostatistics, University of Texas Health Science Center, San Antonio, TX 78229, USA
| | - Priti Shokeen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA 02130, USA
| | - Ann Borzecki
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA; Center for Healthcare Organization and Implementation Research (CHOIR), Bedford VAMC, Bedford, MA 01730, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA 02118, USA
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Elwy AR, Itani KMF, Bokhour BG, Mueller NM, Glickman ME, Zhao S, Rosen AK, Lynge D, Perkal M, Brotschi EA, Sanchez VM, Gallagher TH. Surgeons' Disclosures of Clinical Adverse Events. JAMA Surg 2017; 151:1015-1021. [PMID: 27438083 DOI: 10.1001/jamasurg.2016.1787] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Surgeons are frequently faced with clinical adverse events owing to the nature of their specialty, yet not all surgeons disclose these events to patients. To sustain open disclosure programs, it is essential to understand how surgeons are disclosing adverse events, factors that are associated with reporting such events, and the effect of disclosure on surgeons. Objective To quantitatively assess surgeons' reports of disclosure of adverse events and aspects of their experiences with the disclosure process. Design, Setting, and Participants An observational study was conducted from January 1, 2011, to December 31, 2013, involving a 21-item baseline questionnaire administered to 67 of 75 surgeons (89%) representing 12 specialties at 3 Veterans Affairs medical centers. Sixty-two surveys of their communication about adverse events and experiences with disclosing such events were completed by 35 of these 67 surgeons (52%). Data were analyzed using mixed linear random-effects and logistic regression models. Main Outcomes and Measures Self-reports of disclosure assessed by 8 items from guidelines and pilot research, surgeons' perceptions of the adverse event, reported personal effects from disclosure, and baseline attitudes toward disclosure. Results Most of the surgeons completing the web-based surveys (41 responses from men and 21 responses from women) used 5 of the 8 recommended disclosure items: explained why the event happened (55 of 60 surveys [92%]), expressed regret for what happened (52 of 60 [87%]), expressed concern for the patient's welfare (57 of 60 [95%]), disclosed the adverse event within 24 hours (58 of 60 [97%]), and discussed steps taken to treat any subsequent problems (59 of 60 [98%]). Fewer surgeons apologized to patients (33 of 60 [55%]), discussed whether the event was preventable (33 of 60 [55%]), or how recurrences could be prevented (19 of 59 [32%]). Surgeons who were less likely to have discussed prevention (33 of 60 [55%]), those who stated the event was very or extremely serious (40 of 61 surveys [66%]), or reported very or somewhat difficult experiences discussing the event (16 of 61 [26%]) were more likely to have been negatively affected by the event. Surgeons with more negative attitudes about disclosure at baseline reported more anxiety about patients' surgical outcomes or events following disclosure (odds ratio, 1.54; 95% CI, 1.16-2.06). Conclusions and Relevance Surgeons who reported they were less likely to discuss preventability of the adverse event, or who reported difficult communication experiences, were more negatively affected by disclosure than others. Quality improvement efforts focused on recognizing the association between disclosure and surgeons' well-being may help sustain open disclosure policies.
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Affiliation(s)
- A Rani Elwy
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts2Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts3Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Kamal M F Itani
- Department of Surgery, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts5Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts3Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Nora M Mueller
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts6Department of Behavioral and Community Health, University of Maryland School of Public Health, College Park
| | - Mark E Glickman
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts7Department of Statistics, Harvard University, Cambridge, Massachusetts
| | - Shibei Zhao
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
| | - Amy K Rosen
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts5Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Dana Lynge
- Department of Surgery, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington9Department of Surgery, University of Washington Healthcare System, Seattle
| | - Melissa Perkal
- Department of Surgery, Veterans Affairs Connecticut Healthcare System, West Haven11Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Erica A Brotschi
- Department of Surgery, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts5Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Vivian M Sanchez
- Department of Surgery, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts5Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Thomas H Gallagher
- Department of Bioethics, University of Washington Medical School, Seattle13Department of Medicine, University of Washington Medical School, Seattle
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