National Elderly Migration Patterns and Selectivity

The study of trends in elderly migration patterns and selectivity found that local mobility rates declined, while migration rates increased between 1960 and 1970. The top ten destination states receiving interstate migrants were similar in both time periods, but there was a discernible swing to the Sunbelt except for California and Mississippi. Intrastate and interstate flows became more selective in terms of household independence measures over the period.

An evaluation of radical prostatectomy at Veterans Affairs Medical Centers: time trends and geographic variation in utilization and outcomes

OBJECTIVE

To examine temporal trends and geographic variation in utilization of radical prostatectomy (RP) as well as 30-day mortality and complication rates.

DESIGN

Administrative data-base study of radical prostatectomy (RP) using the Department of Veterans Affairs Patient Treatment File and Outpatient Clinic File between 1986 to 1996. Logistic regression was used to estimate temporal and geographic effects on the use of RP.

SETTING

All Departments of Veterans Affairs Medical Centers (VAMC) in the contiguous United States.

PATIENTS

Men aged 45 to 84 years who underwent RP at a VAMC (n = 13,398).

MAIN OUTCOME MEASURES

Number and utilization of RP, rate of 30-day mortality, major cardiopulmonary or vascular complications, and colorectal injuries requiring surgical repair within 30 days of RP.

RESULTS

From 1986 to 1996, the annual number of RP at VAMCs (range, 695-1,545 RP) more than doubled, and the rate of RP at VAMCs per male VA user increased by 40% (range, 48/100,000-66/100,000). After controlling for age and year, the utilization of RP in West North Central, Mountain, West South Central, and Pacific census divisions was 70%, 14%, 10%, and 8% higher, respectively, whereas the utilization of RP in New England, East North Central, and Mid-Atlantic divisions was 38%, 31%, and 25% lower, respectively, than the rest of the nation (P<0.001). Geographic variation in utilization decreased during the period between 1986 and 1996, but a twofold difference in RP utilization in 1996 remained between high- and low-utilization divisions. Major cardiopulmonary complications, vascular complications, and colorectal injuries occurred in 1.7%, 0.2%, and 1.8% of men, respectively. Thirty-day mortality was 0.73%, declined from 1986 to 1996, and was associated with a history of diabetes and congestive heart failure.

CONCLUSION

Utilization of RP at VAMCs increased over time and varied across geographic areas. Thirty-day mortality was less than 1% and decreased with time. Differences in utilization may be caused by uncertainty regarding the effectiveness of early detection and treatment of prostate cancer.

Using administrative databases for outcomes research: select examples from VA Health Services Research and Development

The U.S. Department of Veterans Affairs (VA) operates and maintains one of the largest health care systems under a single management structure in the world. The coordination of administrative and clinical information on veterans served by the VA health care system is a daunting and critical function of the Department. This article provides an overview of VA Health Services Research and Development Service initiatives to assist researchers in using extant VA databases to study patient-centered health care outcomes. As examples, studies using the VA's Patient Treatment File (PTF) and the Beneficiary Identification and Records Locator System (BIRLS) Death File are described.

Using Department of Veterans Affairs Administrative databases to examine long-term care utilization for men and women veterans

We examined long-term care (LTC) utilization by male and female veterans using administrative databases maintained by VA. Research questions included: (1) Which LTC services are utilized? (2) Do utilization patterns of older veterans differ from those of elderly persons in the general U.S. population? (3) Do LTC needs of veterans vary by gender? We were unable to track LTC utilization of individuals across administrative databases. Some databases could only provide information at the national level, or alternatively, were available only at local facilities, or only at the patient or program-level data--making it impossible to get a clear picture of all the services received by an individual. Those planning to use administrative databases to conduct research must: (1) take more time than expected; (2) be flexible/willing to compromise, (3) "ferret out" information, and (4) recognize that because of dynamism inherent in information systems, results may change over time.

Dual use of VA and non-VA primary care

OBJECTIVE

To determine how frequently veterans use non-Department of Veterans Affairs (VA) sources of care in addition to primary care provided by the VA and to assess the association of this pattern of "dual use" to patient characteristics and satisfaction with VA care.

DESIGN

Cross-sectional telephone survey of randomly selected patients from four VA medical centers.

PARTICIPANTS

Of 1,240 eligible veterans, 830 (67%) participated in the survey.

MEASUREMENTS AND MAIN RESULTS

Survey data were used to assess whether a veteran reported receiving primary care from both VA and non-VA sources of care, as well as the proportion of all primary care visits made to non-VA providers. Of 577 veterans who reported VA primary care visits, 159 (28%) also reported non-VA primary care visits. Among these dual users the mean proportion of non-VA primary care visits was 0.50. Multivariate analysis revealed that the odds of dual use were reduced for those without insurance (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.18, 0.66) and with less education (OR 0.60; 95% CI 0.38, 0.92), while increased for those not satisfied with VA care (OR 2.40; 95% CI 1.40, 4.13). Among primary care dual users, the proportion of primary care visits made to non-VA providers was decreased for patients with heart disease ( p <.05) and patients with alcohol or drug dependence ( p <.05).

CONCLUSIONS

Primary care dual use was common among these veterans. Those with more education, those with any type of insurance, and those not satisfied with VA care were more likely to be dual users. Non-VA care accounted for approximately half of dual users' total primary care visits.

The ratio of observed-to-expected mortality as a quality of care indicator in non-surgical VA patients

This study attempts to validate the use of the observed-to-expected (O/E) mortality ratio as an indicator of quality of care. The primary objective is to determine whether medical records of 111 patients who died in Veterans Affairs (VA) hospitals with high overall ratios of observed-to-expected mortality rates show greater evidence that life might have been meaningfully prolonged with more expert care than the records of matched patients who died in VA hospitals with low O/E ratios. Patient matching criteria included: age, diagnosis responsible for length of stay, type of VA hospital, and the mortality probability predicted by logistic regression. Expert physicians blindly and independently reviewed pairs of medical records, assessing comparative care on a symmetrical, nine-alternative visual analog scale. A slight shift in distribution toward better care in low-ratio hospitals was not statistically significant. Results of an additional analysis, not dependent on pairing, showed that preventability of death is more strongly related to physicians' estimates of mortality risk at admission, whether transferred from a nursing home, do-not-resuscitate status, and accuracy of discharge coding than to VA Medical Center O/E ratios.

Veteran interstate migration and VA health service use

Resource allocations within the VA health care system are based in part on the number of veterans in an area plus the number of veterans expected to move into the area. This paper examines the relative importance of geographic mobility as a factor affecting the use of VA health services by the older veteran population in the U.S. Using a variety of secondary data sources, we found that the variation in state VA health service admission rates is better explained primarily by the characteristics of the resident nonmobile veteran population and the characteristics of veterans migrating to the state, not just by their numbers. Health care demand projections should take these findings into account.

The whole is greater than the sum of its parts: the anatomy of the Department of Veterans Affairs Medical District 17 Health Services Research and Development Field Program

The Medical District 17 Health Services Research and Development (HSR&D) Field Program was funded by the Veterans Administration (now the Department of Veterans Affairs--VA) in January 1983. This article describes the organization, progress, and accomplishments of this field program, and it provides a review of the breadth of health services research that is being conducted in Medical District 17. Overall, the field program has conducted research that addresses significant problems in the delivery of health care within the VA system. Resource utilization, cost effectiveness, and the care of geriatric patients have been some of the areas in which the Medical District 17 HSR&D Field Program has provided important research findings for VA. The field program plans to continue its response to the needs of VA. Moreover, HSR&D investigators will be collaborating with researchers of other services to conduct research that is both enlightening and highly relevant to the delivery of health care to the nation's veterans. The proposal for an HSR&D field program was developed by the Edward A. Hines Jr. VA Hospital in collaboration with the Center for Health Services and Policy Research (CHSPR) of Northwestern University. The program was funded in January 1983, as the result of a national competition to establish an HSR&D field program in each of the VA regions. The goals of the Medical District 17 Field Program are to improve the health care of veterans by conducting relevant research on the processes and outcomes of patient care; to provide comprehensive technical research assistance; and to educate VA managers, planners, and clinicians, as well as the general medical community, about advances in health care delivery. The field program's commitment to excellence is strengthened by its multidisciplinary approach, which enables physicians, nurses, social workers, psychologists, sociologists, economists, statisticians, administrators, and individuals in various related disciplines to cooperate in efforts to address a wide range of topical issues. These collaborations are a major strength of the field program. Primary research priorities of the field program are cost effectiveness of VA services (e.g., patient care technologies, delivery systems), long-term care, and rehabilitation. Investigators, however, are not limited to these topics and explore many other health services research issues of particular interest to them.