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Hausmann LRM, Goodrich DE, Rodriguez KL, Beyer N, Michaels Z, Cantor G, Armstrong N, Eliacin J, Gurewich DA, Cohen AJ, Mor MK. Participation of Veterans Affairs Medical Centers in veteran-centric community-based service navigation networks: A mixed methods study. Health Serv Res 2024; 59:e14286. [PMID: 38258302 PMCID: PMC11063092 DOI: 10.1111/1475-6773.14286] [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: 01/24/2024] Open
Abstract
OBJECTIVE To understand the determinants and benefits of cross-sector partnerships between Veterans Affairs Medical Centers (VAMCs) and geographically affiliated AmericaServes Network coordination centers that address Veteran health-related social needs. DATA SOURCES AND SETTING Semi-structured interviews were conducted with AmericaServes and VAMC staff across seven regional networks. We matched administrative data to calculate the percentage of AmericaServes referrals that were successfully resolved (i.e., requested support was provided) in each network overall and stratified by whether clients were also VAMC patients. STUDY DESIGN Convergent parallel mixed-methods study guided by Himmelman's Developmental Continuum of Change Strategies (DCCS) for interorganizational collaboration. DATA COLLECTION Fourteen AmericaServes staff and 17 VAMC staff across seven networks were recruited using snowball sampling and interviewed between October 2021 and April 2022. Rapid qualitative analysis methods were used to characterize the extent and determinants of VAMC participation in networks. PRINCIPAL FINDINGS On the DCCS continuum of participation, three networks were classified as networking, two as coordinating, one as cooperating, and one as collaborating. Barriers to moving from networking to collaborating included bureaucratic resistance to change, VAMC leadership buy-in, and not having VAMCs staff use the shared technology platform. Facilitators included ongoing communication, a shared mission of serving Veterans, and having designated points-of-contact between organizations. The percentage of referrals that were successfully resolved was lowest in networks engaged in networking (65.3%) and highest in cooperating (85.6%) and collaborating (83.1%) networks. For coordinating, cooperating, and collaborating networks, successfully resolved referrals were more likely among Veterans who were also VAMC patients than among Veterans served only by AmericaServes. CONCLUSIONS VAMCs participate in AmericaServes Networks at varying levels. When partnerships are more advanced, successful resolution of referrals is more likely, especially among Veterans who are dually served by both organizations. Although challenges to establishing partnerships exist, this study highlights effective strategies to overcome them.
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Affiliation(s)
- Leslie R. M. Hausmann
- Center for Health Equity Research and PromotionVeterans Affairs (VA) Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
- Division of General Internal Medicine, Department of MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - David E. Goodrich
- Center for Health Equity Research and PromotionVeterans Affairs (VA) Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
| | - Keri L. Rodriguez
- Center for Health Equity Research and PromotionVeterans Affairs (VA) Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
| | - Nicole Beyer
- Center for Health Equity Research and PromotionVeterans Affairs (VA) Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
| | - Zachary Michaels
- Center for Health Equity Research and PromotionVeterans Affairs (VA) Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
| | - Gilly Cantor
- D'Aniello Institute for Veterans and Military FamiliesSyracuse UniversitySyracuseNew YorkUSA
| | - Nicholas Armstrong
- D'Aniello Institute for Veterans and Military FamiliesSyracuse UniversitySyracuseNew YorkUSA
| | - Johanne Eliacin
- National Center for PTSDVA Boston Healthcare SystemBostonMassachusettsUSA
- Center for Health Information and CommunicationRichard L. Roudebush VA Medical CenterIndianapolisIndianaUSA
- Department of Internal Medicine and GeriatricsIndiana University School of MedicineIndianapolisIndianaUSA
| | - Deborah A. Gurewich
- Center for Healthcare Implementation and Research (CHOIR)VA Boston Health Care SystemBedfordMassachusettsUSA
- Section of Internal MedicineBoston University Chobanian and Avedisian School of MedicineBostonMassachusettsUSA
| | - Alicia J. Cohen
- Center of Innovation in Long Term Services and Supports (LTSS‐COIN)VA Providence Healthcare SystemProvidenceRhode IslandUSA
- Department of Family MedicineWarren Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Maria K. Mor
- Center for Health Equity Research and PromotionVeterans Affairs (VA) Pittsburgh Healthcare SystemPittsburghPennsylvaniaUSA
- Graduate School of Public HealthUniversity of PittsburghPittsburghPennsylvaniaUSA
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Essien UR, Kim N, Hausmann LRM, Washington DL, Mor MK, Gellad WF, Fine MJ. Facility-Level Variation in Racial Disparities in Anticoagulation for Atrial Fibrillation: The REACH-AF Study. J Gen Intern Med 2024:10.1007/s11606-024-08643-8. [PMID: 38308154 DOI: 10.1007/s11606-024-08643-8] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/17/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Oral anticoagulation reduces stroke risk for patients with atrial fibrillation (AF). Prior research demonstrates lower anticoagulant prescribing in Black than in White individuals but few studies have examined racial differences in facility-level anticoagulant prescribing for AF. OBJECTIVE To assess variation in anticoagulant initiation by race within Veterans Health Administration (VA) facilities. DESIGN Retrospective cohort study. PARTICIPANTS Black and White patients enrolled in the VA with incident AF from 2020 through 2021. MAIN MEASURES The primary outcome was rate of any anticoagulant initiation (i.e., warfarin or direct oral anticoagulant [DOAC]) or any DOAC therapy within 90 days of an AF diagnosis, overall and for Black and White patients at each facility. We also estimated the adjusted Black-White risk difference. KEY RESULTS In 82 VA facilities serving 26,832 Black and White patients, overall unadjusted rates of any anticoagulant therapy ranged from 56.8 to 87.1% across facilities; the corresponding ranges for Black and White patients were 47.6 to 91.3% and 58.2 to 87.1%, respectively. Overall unadjusted rates of DOAC therapy ranged from 55.1 to 85.5% by facility; ranges for Black and White patients were 42.8 to 86.9% and 56.4 to 85.5%, respectively. The adjusted risk difference between Black and White patients ranged from - 29.9 (95% CI, - 54.9 to - 4.8) to 14.2 (95% CI, - 9.1 to 25.0) across facilities for any anticoagulant therapy and from - 28.8 (95% CI, - 58.3 to 0.8) to 15.0 (95% CI, - 8.0 to 38.1) for DOAC therapy. For any anticoagulant therapy there were 3 facilities where prescribing was statistically higher in White than Black patients; for DOAC therapy there were 5 such facilities. CONCLUSIONS In a national cohort of patients with AF, we observed large facility-level variation and adjusted risk differences in any anticoagulant and DOAC initiation, overall and by race. These findings represent a target for local quality improvement in AF care.
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Affiliation(s)
- Utibe R Essien
- HSRD Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA.
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA.
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Donna L Washington
- HSRD Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Almklov E, Cohen AJ, Russell LE, Mor MK, Fine MJ, Hausmann LRM, Moy E, Washington DL, Jones KT, Long JA, Pittman J. Assessing an electronic self-report method for improving quality of ethnicity and race data in the Veterans Health Administration. JAMIA Open 2023; 6:ooad020. [PMID: 37063405 PMCID: PMC10097454 DOI: 10.1093/jamiaopen/ooad020] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/18/2023] [Accepted: 03/29/2023] [Indexed: 04/18/2023] Open
Abstract
Objective Evaluate self-reported electronic screening (eScreening) in a VA Transition Care Management Program (TCM) to improve the accuracy and completeness of administrative ethnicity and race data. Materials and Methods We compared missing, declined, and complete (neither missing nor declined) rates between (1) TCM-eScreening (ethnicity and race entered into electronic tablet directly by patient using eScreening), (2) TCM-EHR (Veteran-completed paper form plus interview, data entered by staff), and (3) Standard-EHR (multiple processes, data entered by staff). The TCM-eScreening (n = 7113) and TCM-EHR groups (n = 7113) included post-9/11 Veterans. Standard-EHR Veterans included all non-TCM Gulf War and post-9/11 Veterans at VA San Diego (n = 92 921). Results Ethnicity: TCM-eScreening had lower rates of missingness than TCM-EHR and Standard-EHR (3.0% vs 5.3% and 8.6%, respectively, P < .05), but higher rates of "decline to answer" (7% vs 0.5% and 1.2%, P < .05). TCM-EHR had higher data completeness than TCM-eScreening and Standard-EHR (94.2% vs 90% and 90.2%, respectively, P < .05). Race: No differences between TCM-eScreening and TCM-EHR for missingness (3.5% vs 3.4%, P > .05) or data completeness (89.9% vs 91%, P > .05). Both had better data completeness than Standard-EHR (P < .05), which despite the lowest rate of "decline to answer" (3%) had the highest missingness (10.3%) and lowest overall completeness (86.6%). There was strong agreement between TCM-eScreening and TCM-EHR for ethnicity (Kappa = .92) and for Asian, Black, and White Veteran race (Kappas = .87 to .97), but lower agreement for American Indian/Alaska Native (Kappa = .59) and Native Hawaiian/Other Pacific Islander (Kappa = .50) Veterans. Conculsions eScreening is a promising method for improving ethnicity and race data accuracy and completeness in VA.
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Affiliation(s)
- Erin Almklov
- Corresponding Author: Erin Almklov, PhD, VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA 92161, USA;
| | - Alicia J Cohen
- VA Center of Innovation in Long Term Services and Supports (LTSS-COIN), VA Providence Healthcare System, Providence, Rhode Island, USA
- Department of Family Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Lauren E Russell
- VHA Office of Health Equity, Washington, District of Columbia, USA
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Michael J Fine
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Leslie R M Hausmann
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ernest Moy
- VHA Office of Health Equity, Washington, District of Columbia, USA
| | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles Geffen School of Medicine, Los Angeles, California, USA
| | - Kenneth T Jones
- VHA Office of Health Equity, Washington, District of Columbia, USA
| | - Judith A Long
- Corporal Michael J. Crescenz VA Medical Center, VA Center for Health Equity Research and Promotion (CHERP), Philadelphia, Pennsylvania, USA
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James Pittman
- VA Center of Excellence for Stress and Mental Health, San Diego, California, USA
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, San Diego, California, USA
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Mahorter S, Vinekar K, Shaw JG, Mor MK, Pleasure ZH, Gawron LM, Callegari LS. Variations in Provision of Long-Acting Reversible Contraception Across Veterans Health Administration Facilities. J Gen Intern Med 2023:10.1007/s11606-023-08123-5. [PMID: 37340270 DOI: 10.1007/s11606-023-08123-5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 02/24/2023] [Indexed: 06/22/2023]
Affiliation(s)
- Siobhan Mahorter
- Health Services Research & Development (HSR&D) Seattle-Denver Center of Innovation for Veteran Centered & Value Driven Care, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Kavita Vinekar
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Obstetrics & Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jonathan G Shaw
- VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Primary Care & Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Maria K Mor
- VA HSR&D Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Zoe H Pleasure
- Health Services Research & Development (HSR&D) Seattle-Denver Center of Innovation for Veteran Centered & Value Driven Care, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems & Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Lori M Gawron
- Health Services Research & Development, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Obstetrics & Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Lisa S Callegari
- Health Services Research & Development (HSR&D) Seattle-Denver Center of Innovation for Veteran Centered & Value Driven Care, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.
- Department of Health Systems & Population Health, University of Washington School of Public Health, Seattle, WA, USA.
- Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, WA, USA.
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Makaroun LK, Rosland AM, Mor MK, Zhang H, Lovelace E, Rosen T, Dichter ME, Thorpe CT. Frailty predicts referral for elder abuse evaluation in a nationwide healthcare system-Results from a case-control study. J Am Geriatr Soc 2023; 71:1724-1734. [PMID: 36695515 PMCID: PMC10258119 DOI: 10.1111/jgs.18245] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Received: 07/21/2022] [Revised: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Elder abuse (EA) is common and has devastating health impacts. Frailty may increase susceptibility to and consequences of EA for older adults, making healthcare system detection more likely, but this relationship has been difficult to study. We examined the association between a recently validated frailty index and referral to social work (SW) for EA evaluation in the Veterans Administration (VA) healthcare system. METHODS We conducted a case-control study of veterans aged ≥60 years evaluated by SW for suspected EA between 2010 and 2018 (n = 14,723) and controls receiving VA primary care services in the same 60-day window (n = 58,369). We used VA and Medicare claims data to measure frailty (VA Frailty Index) and comorbidity burden (the Elixhauser Comorbidity Index) in the 2 years prior to the index. We used adjusted logistic regression models to examine the association of frailty or comorbidity burden with referral to SW for EA evaluation. We used Akaike Information Criterion (AIC) values to evaluate model fit and likelihood ratio (LR) tests to assess the statistical significance of including frailty and comorbidity in the same model. RESULTS The sample (n = 73,092) had a mean age 72 years; 14% were Black, and 6% were Hispanic. More cases (67%) than controls (36%) were frail. LR tests comparing the nested models were highly significant (p < 0.001), and AIC values indicated superior model fit when including both frailty and comorbidity in the same model. In a model adjusting for comorbidity and all covariates, pre-frailty (aOR vs. robust 1.7; 95% CI 1.5-1.8) and frailty (aOR vs. robust 3.6; 95% CI 3.3-3.9) were independently associated with referral for EA evaluation. CONCLUSIONS A claims-based measure of frailty predicted referral to SW for EA evaluation in a national healthcare system, independent of comorbidity burden. Electronic health record measures of frailty may facilitate EA risk assessment and detection for this important but under-recognized phenomenon.
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Affiliation(s)
- Lena K. Makaroun
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- VA Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Maria K. Mor
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hongwei Zhang
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Elijah Lovelace
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Tony Rosen
- Department of Emergency Medicine, Weill Cornell Medical College/New-York Presbyterian Hospital, New York, New York, USA
| | - Melissa E. Dichter
- VA Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- School of Social Work, Temple University Philadelphia, PA
| | - Carolyn T. Thorpe
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
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Weisbord SD, Mor MK, Hochheiser H, Kim N, Ho PM, Bhatt DL, Fine MJ, Palevsky PM. Utilization and Outcomes of Clinically Indicated Invasive Cardiac Care in Veterans with Acute Coronary Syndrome and Chronic Kidney Disease. J Am Soc Nephrol 2023; 34:694-705. [PMID: 36735537 PMCID: PMC10103279 DOI: 10.1681/asn.0000000000000067] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 12/08/2022] [Indexed: 02/04/2023] Open
Abstract
SIGNIFICANCE STATEMENT Of studies reporting an association of CKD with lower use of invasive cardiac care to treat acute coronary syndrome (ACS), just one accounted for the appropriateness of such care. However, its findings in patients hospitalized nearly 30 years ago may not apply to current practice. In a more recent cohort of 64,695 veterans hospitalized with ACS, CKD was associated with a 32% lower likelihood of receiving invasive care determined to be clinically indicated. Among patients with CKD, not receiving such care was associated with a 1.39-fold higher risk of 6-month mortality. Efforts to elucidate the reasons for this disparity in invasive care in patients with ACS and CKD and implement tailored interventions to enhance its use in this population may offer the potential to improve clinical outcomes. BACKGROUND Previous studies have shown that patients with CKD are less likely than those without CKD to receive invasive care to treat acute coronary syndrome (ACS). However, few studies have accounted for whether such care was clinically indicated or assessed whether nonuse of such care was associated with adverse health outcomes. METHODS We conducted a retrospective cohort study of US veterans who were hospitalized at Veterans Affairs Medical Centers from January 2013 through December 2017 and received a discharge diagnosis of ACS. We used multivariable logistic regression to investigate the association of CKD with use of invasive care (coronary angiography, with or without revascularization; coronary artery bypass graft surgery; or both) deemed clinically indicated based on Global Registry of Acute Coronary Events 2.0 risk scores that denoted a 6-month predicted all-cause mortality ≥5%. Using propensity scoring and inverse probability weighting, we examined the association of nonuse of clinically indicated invasive care with 6-month all-cause mortality. RESULTS Among 34,430 patients with a clinical indication for invasive care, the 18,780 patients with CKD were less likely than the 15,650 without CKD to receive such care (adjusted odds ratio, 0.68; 95% confidence interval, 0.65 to 0.72). Among patients with CKD, nonuse of invasive care was associated with higher risk of 6-month all-cause mortality (absolute risk, 21.5% versus 15.5%; absolute risk difference 6.0%; adjusted risk ratio, 1.39; 95% confidence interval, 1.29 to 1.49). Findings were consistent across multiple sensitivity analyses. CONCLUSIONS In contemporary practice, veterans with CKD who experience ACS are less likely than those without CKD to receive clinically indicated invasive cardiac care. Nonuse of such care is associated with increased mortality.
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Affiliation(s)
- Steven D. Weisbord
- From the Renal Section, VA Pittsburgh Healthcare System, Pittsburgh Pennsylvania
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria K. Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Harry Hochheiser
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - P. Michael Ho
- Cardiology Section, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paul M. Palevsky
- From the Renal Section, VA Pittsburgh Healthcare System, Pittsburgh Pennsylvania
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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McDermott A, Kim N, Hausmann LRM, Magnani JW, Good CB, Litam TMA, Mor MK, Omole TD, Gellad WF, Fine MJ, Essien UR. Association of Neighborhood Disadvantage and Anticoagulation for Patients with Atrial Fibrillation in the Veterans Health Administration: the REACH-AF Study. J Gen Intern Med 2023; 38:848-856. [PMID: 36151447 PMCID: PMC10039185 DOI: 10.1007/s11606-022-07810-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Received: 02/21/2022] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common arrhythmia, the management of which includes anticoagulation for stroke prevention. Although disparities in anticoagulant prescribing have been well documented for individual socioeconomic factors, less is known about the association of neighborhood-level disadvantage and anticoagulation for AF. OBJECTIVE To assess the association between neighborhood disadvantage and anticoagulant initiation for patients with incident AF. DESIGN Retrospective cohort study. PARTICIPANTS A cohort of patients enrolled in the Veterans Health Administration (VA) with incident AF from January 2014 through December 2020 from the Race, Ethnicity, and Anticoagulant CHoice in Atrial Fibrillation (REACH-AF) Study. MAIN MEASURES The primary exposure was neighborhood disadvantage quantified using area deprivation index (ADI), classified by quintiles (Q). The outcomes were initiation of any anticoagulant therapy (warfarin or direct oral anticoagulant, DOAC) within 90 days of AF diagnosis and DOAC use among initiators. We used mixed effects logistic regression to assess the association between ADI and anticoagulant therapy, incorporating a fixed effect for treatment site and baseline patient, provider, and facility covariates. KEY RESULTS Among 161,089 patients, 105,489 (65.5%) initiated any anticoagulant therapy, and 78,903 (74.8%) used DOACs. Any anticoagulant therapy increased 3.2 percentage points (63.0% to 66.2%; p<.001) from Q1 to Q5, whereas DOAC use decreased 8.2 percentage points (79.4% to 71.2%; p<.0001) across quintiles. The adjusted odd ratios of any anticoagulant therapy were non-significantly different for Q2-Q5 than Q1. The adjusted odds of DOAC use decreased progressively from 0.89 (95% CI, 0.84-0.94) in Q2 to 0.77 (95% CI, 0.73-0.83) in Q5 compared to Q1 (p<.0001). CONCLUSIONS Among Veterans with incident AF, we observed similar initiation of any anticoagulant, though neighborhood deprivation was associated with decreased DOAC use among anticoagulant initiators. Future interventions to improve pharmacoequity in anticoagulant prescribing for AF should consider the role of neighborhood-level determinants of health inequities.
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Affiliation(s)
- Annie McDermott
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, PA, USA
| | - Terrence M A Litam
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Toluwa D Omole
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Niznik JD, Zhao X, Slieanu F, Mor MK, Aspinall SL, Gellad WF, Ersek M, Hickson RP, Springer SP, Schleiden LJ, Hanlon JT, Thorpe JM, Thorpe CT. Effect of Deintensifying Diabetes Medications on Negative Events in Older Veteran Nursing Home Residents. Diabetes Care 2022; 45:1558-1567. [PMID: 35621712 PMCID: PMC9274227 DOI: 10.2337/dc21-2116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 04/17/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Guidelines advocate against tight glycemic control in older nursing home (NH) residents with advanced dementia (AD) or limited life expectancy (LLE). We evaluated the effect of deintensifying diabetes medications with regard to all-cause emergency department (ED) visits, hospitalizations, and death in NH residents with LLE/AD and tight glycemic control. RESEARCH DESIGN AND METHODS We conducted a national retrospective cohort study of 2,082 newly admitted nonhospice veteran NH residents with LLE/AD potentially overtreated for diabetes (HbA1c ≤7.5% and one or more diabetes medications) in fiscal years 2009-2015. Diabetes treatment deintensification (dose decrease or discontinuation of a noninsulin agent or stopping insulin sustained ≥7 days) was identified within 30 days after HbA1c measurement. To adjust for confounding, we used entropy weights to balance covariates between NH residents who deintensified versus continued medications. We used the Aalen-Johansen estimator to calculate the 60-day cumulative incidence and risk ratios (RRs) for ED or hospital visits and deaths. RESULTS Diabetes medications were deintensified for 27% of residents. In the subsequent 60 days, 28.5% of all residents were transferred to the ED or acute hospital setting for any cause and 3.9% died. After entropy weighting, deintensifying was not associated with 60-day all-cause ED visits or hospitalizations (RR 0.99 [95% CI 0.84, 1.18]) or 60-day mortality (1.52 [0.89, 2.81]). CONCLUSIONS Among NH residents with LLE/AD who may be inappropriately overtreated with tight glycemic control, deintensification of diabetes medications was not associated with increased risk of 60-day all-cause ED visits, hospitalization, or death.
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Affiliation(s)
- Joshua D Niznik
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina School of Medicine, Chapel Hill, NC.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Florentina Slieanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Sherrie L Aspinall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,VA Center for Medication Safety, Hines, Illinois.,University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Mary Ersek
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA.,School of Nursing, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Ryan P Hickson
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Sydney P Springer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of New England School of Pharmacy, Portland, ME
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
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9
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Wilson DA, Boadu O, Jones AL, Kim N, Mor MK, Hausmann LRM, Essien UR. Analysis of Initiating Anticoagulant Therapy for Atrial Fibrillation Among Persons Experiencing Homelessness in the Veterans Affairs Health System. JAMA Netw Open 2022; 5:e2223815. [PMID: 35881400 PMCID: PMC9327581 DOI: 10.1001/jamanetworkopen.2022.23815] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/09/2022] [Indexed: 01/14/2023] Open
Affiliation(s)
- David A. Wilson
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Osei Boadu
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Audrey L. Jones
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria K. Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Leslie R. M. Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Utibe R. Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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10
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Barlas RS, Clark AB, Loke YK, Kwok CS, Angus DC, Uranga A, España PP, Eurich DT, Huang DT, Man SY, Rainer TH, Yealy DM, Myint PK, Mor MK, Fine MJ. Comparison of the prognostic performance of the CURB-65 and a modified version of the pneumonia severity index designed to identify high-risk patients using the International Community-Acquired Pneumonia Collaboration Cohort. Respir Med 2022; 200:106884. [PMID: 35767924 DOI: 10.1016/j.rmed.2022.106884] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/13/2022] [Accepted: 05/14/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although the PSI and CURB-65 represent well-validated prediction rules for pneumonia prognosis, PSI was designed to identify patients at low risk and CURB- 65 patients at high risk of mortality. We compared the prognostic performance of a modified version of the PSI designed to identify high-risk patients (i.e., PSI-HR) to CURB-65 in predicting short-term mortality. METHODS Using data from 6 pneumonia cohorts, we designed PSI-HR as a 6-class prediction rule using the original prognostic weights of all PSI variables and modifying the risk score thresholds to define risk classes. We calculated the proportion of low-risk and high-risk patients using CURB-65 and PSI-HR and 30-day mortality in these subgroups. We compared the rules' sensitivity, specificity, positive and negative predictive values for mortality at all risk class thresholds and assessed discriminatory power using areas under their receiver operating characteristic curves (AUROCs). RESULTS Among 13,874 patients with pneumonia, 1,036 (7.5%) died. For PSI-HR versus CURB-65, aggregate mortality was lower in low-risk patients (1.6% vs. 2.2%, p = 0.005) and higher in high-risk patients (36.5% vs. 32.2%, p = 0.27). PSI-HR had higher sensitivities than CURB-65 at all thresholds; PSI-HR also had higher specificities at the 3 lowest thresholds and specificities within 0.5% points of CURB-65 at the 2 highest thresholds. The AUROC was larger for PSI-HR than CURB- 65 (0.82 vs. 0.77, p < 0.0001). CONCLUSIONS PSI-HR demonstrated superior prognostic accuracy to CURB-65 at the lower end of the severity spectrum and identified high-risk patients with nonsignificant higher short-term mortality at the higher end.
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Affiliation(s)
- Raphae S Barlas
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Allan B Clark
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Derek C Angus
- The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ane Uranga
- Servicio de Neumología, Hospital de Galdakao, Galdakao, Bizkaia, Spain
| | - Pedro P España
- Servicio de Neumología, Hospital de Galdakao, Galdakao, Bizkaia, Spain
| | - Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - David T Huang
- The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shin Y Man
- Emergency Medicine Unit, Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Timothy H Rainer
- Emergency Medicine Unit, Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Donald M Yealy
- Department of Emergency Medicine at the University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Phyo K Myint
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK; Norwich Medical School, University of East Anglia, Norwich, UK
| | - Maria K Mor
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael J Fine
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
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11
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Bachrach RL, Chinman M, Rodriguez KL, Mor MK, Kraemer KL, Garfunkel CE, Williams EC. Using practice facilitation to improve alcohol-related care in primary care: a mixed-methods pilot study protocol. Addict Sci Clin Pract 2022; 17:19. [PMID: 35287714 PMCID: PMC8919159 DOI: 10.1186/s13722-022-00300-x] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/24/2022] [Indexed: 11/11/2022] Open
Abstract
Background Alcohol use is a significant risk factor for disability and death in U.S. adults, and approximately one out of every six Veterans seen in primary care (PC) report unhealthy alcohol use. Unhealthy alcohol use is associated with increased risk for poor medical outcomes, substantial societal costs, and death, including suicide. Based on substantial evidence from randomized controlled trials and the U.S. Preventive Services Task Force, VA/DoD clinical guidelines stipulate that all Veterans screening positive for unhealthy alcohol use should receive evidence-based alcohol care in PC, including brief counseling interventions (BI) and additional treatment (e.g., pharmacotherapy) for those with alcohol use disorders (AUD). The VA pioneered implementing alcohol screening and BI in PC, yet substantial implementation gaps remain. To improve alcohol-related care, this study will conduct a pilot study to assess whether a multi-faceted evidence-based implementation strategy—practice facilitation—has the potential to improve PC-based alcohol-related care at a single VA clinic. Methods We will first recruit and conduct qualitative interviews with Veterans with unhealthy alcohol use (n = 20–25) and PC stakeholders (N = 10–15) to understand barriers and facilitators to high-quality alcohol care and use results to refine and hone the multifaceted practice facilitation intervention. Qualitative interviews, analysis, and refinement of the intervention will be guided by the Consolidated Framework for Implementation Research (CFIR). Focus groups with a small sample of PC providers and staff (n = 5–7) will be used to further refine the practice facilitation intervention and assess its acceptability and feasibility. The refined practice facilitation intervention will then be offered in the PC clinic to assess implementation (e.g., reach) and effectiveness (reduced drinking) outcomes based on the RE-AIM framework. Discussion This research directly addresses one of the largest public health crises of our time, as alcohol kills more people than opioids and is associated with increased risk of suicide. If successful, this pilot may generate an intervention with far-reaching effects on adverse outcomes experienced by Veterans with unhealthy alcohol use, including increased access to care and suicide prevention. Trial registration Clinicaltrials.gov identifier: NCT04565899; Date of registration: 9/25/2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13722-022-00300-x.
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Affiliation(s)
- Rachel L Bachrach
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240-1001, USA. .,Mental Illness Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240, USA. .,Department of Psychology, University of Pittsburgh, Pittsburgh, PA, 15260, USA.
| | - Matthew Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240-1001, USA.,Mental Illness Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240, USA.,The RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA, 15213, USA
| | - Keri L Rodriguez
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240-1001, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240-1001, USA.,Deparatment of Biostistic, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Kevin L Kraemer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151R-U), University Drive C, Pittsburgh, PA, 15240-1001, USA.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Cécile E Garfunkel
- Division of Geriatrics, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, 98195, USA.,Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, 98108, USA
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12
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McCarthy SA, Chinman M, Rogal SS, Klima G, Hausmann LRM, Mor MK, Shah M, Hale JA, Zhang H, Gordon AJ, Gellad WF. Tracking the randomized rollout of a Veterans Affairs opioid risk management tool: A multi-method implementation evaluation using the Consolidated Framework for Implementation Research (CFIR). Implementation Research and Practice 2022; 3:26334895221114665. [PMID: 37091078 PMCID: PMC9924239 DOI: 10.1177/26334895221114665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Background The Veterans Health Administration (VHA) developed the Stratification Tool for Opioid Risk Mitigation (STORM) dashboard to assist in identifying Veterans at risk for adverse opioid overdose or suicide-related events. In 2018, a policy was implemented requiring VHA facilities to complete case reviews of Veterans identified by STORM as very high risk for adverse events. Nationally, facilities were randomized in STORM implementation to four arms based on required oversight and by the timing of an increase in the number of required case reviews. To help evaluate this policy intervention, we aimed to (1) identify barriers and facilitators to implementing case reviews; (2) assess variation across the four arms; and (3) evaluate associations between facility characteristics and implementation barriers and facilitators. Method Using the Consolidated Framework for Implementation Research (CFIR), we developed a semi-structured interview guide to examine barriers to and facilitators of implementing the STORM policy. A total of 78 staff from 39 purposefully selected facilities were invited to participate in telephone interviews. Interview transcripts were coded and then organized into memos, which were rated using the −2 to + 2 CFIR rating system. Descriptive statistics were used to evaluate the mean ratings on each CFIR construct, the associations between ratings and study arm, and three facility characteristics (size, rurality, and academic detailing) associated with CFIR ratings. We used the mean CFIR rating for each site to determine which constructs differed between the sites with highest and lowest overall CFIR scores, and these constructs were described in detail. Results Two important CFIR constructs emerged as barriers to implementation: Access to knowledge and information and Evaluating and reflecting. Little time to complete the CASE reviews was a pervasive barrier. Sites with higher overall CFIR scores showed three important facilitators: Leadership engagement, Engaging, and Implementation climate. CFIR ratings were not significantly different between the four study arms, nor associated with facility characteristics. Plain Language Summary: The Veterans Health Administration (VHA) created a tool called the Stratification Tool for Opioid Risk Mitigation dashboard. This dashboard shows Veterans at risk for opioid overdose or suicide-related events. In 2018, a national policy required all VHA facilities to complete case reviews for Veterans who were at high risk for these events. To evaluate this policy implementation, 78 staff from 39 facilities were interviewed. The Consolidated Framework for Implementation Research (CFIR) implementation framework was used to create the interview. Interview transcripts were coded and organized into site memos. The site memos were rated using CFIR's −2 to +2 rating system. Ratings did not differ for four study arms related to oversight and timing. Ratings were not associated with facility characteristics. Leadership, engagement and implementation climate were the strongest facilitators for implementation. Lack of time, knowledge, and feedback were important barriers.
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Affiliation(s)
- Sharon A. McCarthy
- Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Matthew Chinman
- Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- RAND Corporation, Pittsburgh, PA, USA
| | - Shari S. Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Gloria Klima
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Leslie R. M. Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Maria K. Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Mala Shah
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jennifer A. Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Hongwei Zhang
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Adam J. Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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13
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Arnold J, Zhao X, Cashy JP, Sileanu FE, Mor MK, Moyo P, Thorpe CT, Good CB, Radomski TR, Fine MJ, Gellad WF. An Interrupted Time-series Evaluation of the Association Between State Laws Mandating Prescriber Use of Prescription Drug Monitoring Programs and Discontinuation of Chronic Opioid Therapy in US Veterans. Med Care 2021; 59:1042-1050. [PMID: 34670221 DOI: 10.1097/mlr.0000000000001643] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Most states have recently passed laws requiring prescribers to use prescription drug monitoring programs (PDMPs) before prescribing opioid medications. The impact of these mandates on discontinuing chronic opioid therapy among Veterans managed in the Veterans Health Administration (VA) is unknown. We assess the association between the earliest of these laws and discontinuation of chronic opioid therapy in Veterans receiving VA health care. METHODS We conducted a comparative interrupted time-series study in the 5 states mandating PDMP use before August 2013 (Ohio, West Virginia, Kentucky, New Mexico, and Tennessee), adjusting for trends in the 17 neighboring control states without such mandates. We modeled 25 months of prescribing for each state centered on the month the mandate became effective. We included Veterans prescribed long-term outpatient opioid therapy (305 of the preceding 365 d). Our outcomes were discontinuation of chronic opioid therapy (primary outcome) and the average daily quantity of opioids per Veteran over the following 6 months (secondary outcome). RESULTS We included 250 monthly cohorts with 225,665 unique Veterans and 3.4 million Veteran-months. Baseline discontinuation rates before the PDMP mandates were 0.4%-2.7% per month. Kentucky saw a discontinuation increase of 1 absolute percentage point following its PDMP mandate which decreased over time. The other 4 states had no significant association between their mandates and change in opioid discontinuation. There was no evidence of decreasing opioid quantities following PDMP mandates. CONCLUSION We did not find consistent evidence that state laws mandating provider PDMP use were associated with the discontinuation of chronic opioid therapy within the VA for the time period studied.
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Affiliation(s)
- Jonathan Arnold
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | - John P Cashy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | - Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, Chapel Hill, NC
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
- Centers for High Value Healthcare and Value Based Pharmacy Initiatives, UPMC Health Plan Insurance Division, Pittsburgh, PA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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14
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Makaroun LK, Thorpe CT, Mor MK, Zhang H, Lovelace E, Rosen T, Dichter ME, Rosland AM. Medical and Social Factors Associated with Referral for Elder Abuse Services in a National Healthcare System. J Gerontol A Biol Sci Med Sci 2021; 77:1706-1714. [PMID: 34849854 PMCID: PMC9373957 DOI: 10.1093/gerona/glab354] [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: 05/24/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Elder abuse (EA) is common and has devastating health consequences yet is not systematically assessed or documented in most health systems, limiting efforts to target healthcare-based interventions. Our objective was to examine sociodemographic and medical characteristics associated with documented referrals for EA assessment or services in a national US healthcare system. METHODS We conducted a national case-control study in US Veterans Health Administration facilities of primary care (PC)-engaged Veterans age ≥60 years who were evaluated by social work (SW) for EA-related concerns between 2010-18. Cases were matched 1:5 to controls with a PC visit within 60 days of the matched case SW encounter. We examined the association of patient sociodemographic and health factors with receipt of EA services in unadjusted and adjusted models. RESULTS Of 5,567,664 Veterans meeting eligibility criteria during the study period, 15,752 (0.3%) received services for EA (cases). Cases were mean age 74, and 54% unmarried. In adjusted logistic regression models (aOR; 95%CI), age ≥85 (3.56 v. age 60-64; 3.24-3.91), female sex (1.96; 1.76-2.21), child as next-of-kin (1.70 v. spouse; 1.57-1.85), lower neighborhood socioeconomic status (1.18 per higher quartile; 1.15-1.21), dementia diagnosis (3.01; 2.77-3.28) and receiving a VA pension (1.34; 1.23-1.46) were associated with receiving EA services. CONCLUSION In the largest cohort of patients receiving EA-related healthcare services studied to date, this study identified novel factors associated with clinical suspicion of EA that can be used to inform improvements in healthcare-based EA surveillance and detection.
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Affiliation(s)
- Lena K Makaroun
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,VA Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh PA.,Department of Medicine, School of Medicine, University of Pittsburgh
| | - Carolyn T Thorpe
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh
| | - Hongwei Zhang
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Elijah Lovelace
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Tony Rosen
- New-York Presbyterian Hospital Weill Cornell Medical College, New York, NY
| | - Melissa E Dichter
- VA Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA.,School of Social Work, Temple University Philadelphia, PA
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Department of Medicine, School of Medicine, University of Pittsburgh
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15
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Essien UR, Kim N, Magnani JW, Good CB, Litam TMA, Hausmann LRM, Mor MK, Gellad WF, Fine MJ. Association of Race and Ethnicity and Anticoagulation in Patients with Atrial Fibrillation Dually Enrolled in VA and Medicare: Effects of Medicare Part D on Prescribing Disparities. Circ Cardiovasc Qual Outcomes 2021; 15:e008389. [PMID: 34779655 DOI: 10.1161/circoutcomes.121.008389] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Racial and ethnic disparities in anticoagulation exist in atrial fibrillation (AF) management in Medicare and the Veterans Health Administration (VA), but the influence of dual VA and Medicare enrollment is unclear. We compared anticoagulant initiation by race and ethnicity in dually enrolled patients and assessed the role of Medicare Part D enrollment on anticoagulation disparities. Methods: We identified patients with incident AF (2014-2018) dually enrolled in VA and Medicare. We assessed any anticoagulant initiation (warfarin or direct-acting oral anticoagulants, DOACs) within 90 days of AF diagnosis and DOAC use among anticoagulant initiators. We modeled anticoagulant initiation, adjusting for patient, provider, and facility factors, including main effects for race and ethnicity and Medicare Part D enrollment and an interaction term for these variables. Results: In 43,789 patients, 8.9% were Black, 3.6% Hispanic, and 87.5% White; 10.9% participated in Medicare Part D. Overall, 29,680 (67.8%) patients initiated any anticoagulant, of which 17,568 (59.2%) initiated DOACs. Lower proportions of Black (65.2%) than Hispanic (67.6%) or White (68.0%) patients initiated any anticoagulant (p= 0.001), and lower proportions of Black (56.3%) and Hispanic (55.9%) than White (59.6%) patients (p=0.001) initiated DOACs. Compared to White patients, Black patients had significantly lower initiation of any anticoagulant, adjusted odds ratio (aOR) 0.89; 95% CI 0.82-0.97. The aORs for DOAC initiation were significantly lower for Black (0.72; 95% CI, 0.65-0.81) and Hispanic (0.84; 95% CI, 0.70-1.00) than White patients.The interaction between race and ethnicity and Medicare Part D enrollment was non-significant for any anticoagulant (p=0.99) and DOAC (p=0.27) therapies. Conclusions: In dually enrolled VA and Medicare patients with AF, Black patients were less likely to initiate any anticoagulant and Black and Hispanic patients were less likely to initiate DOACs. Medicare Part D enrollment did not moderate the associations between race and ethnicity and anticoagulant therapies.
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Affiliation(s)
- Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, PA
| | - Terrence M A Litam
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Lee AA, Heisler M, Trivedi R, Obrosky DS, Mor MK, Piette JD, Rosland AM. Diabetes Distress Among Dyads of Patients and Their Health Supporters: Links With Functional Support, Metabolic Outcomes, and Cardiac Risk. Ann Behav Med 2021; 55:949-955. [PMID: 33044495 DOI: 10.1093/abm/kaaa081] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Patients with diabetes (PWD) often experience diabetes distress which is associated with worse self-management and glycemic control. In contrast, PWD who receive support from family and friends (supporters) have better diabetes outcomes. PURPOSE To examine the associations of PWD diabetes distress and supporters' distress about PWDs' diabetes with supporters' roles and PWD cardiometabolic outcomes. METHODS We used baseline data from 239 adults with Type 2 diabetes and their supporters participating in a longitudinal trial. PWD and supporter diabetes distress (high vs. low) were determined using the Problem Areas in Diabetes Scale-5. Outcomes included PWD-reported help from supporters with self-care activities, supporter-reported strain, PWD metabolic outcomes (glycemic control [HbA1c], systolic blood pressure [SBP], and non-HDL cholesterol) and 5 and 10 year risk of cardiac event (calculated using the United Kingdom Prospective Diabetes Study algorithm). RESULTS PWDs with high diabetes distress were more likely to report that their supporters helped with taking medications, coordinating medical care, and home glucose testing (p's < .05), but not more likely to report help with diet or exercise. High supporter distress was associated with greater supporter strain (p < .001). High supporter diabetes distress was associated with higher PWD HbA1c (p = .045), non-HDL cholesterol (p = .011), and 5 (p = .002) and 10 year (p = .001) cardiac risk. CONCLUSIONS Adults with high diabetes distress report more supporter help with medically focused self-management but not with diet and exercise. Supporter distress about PWD diabetes was consistently associated with worse outcomes. PWD diabetes distress had mixed associations with their diabetes outcomes.
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Affiliation(s)
- Aaron A Lee
- Department of Psychology, University of Mississippi, MS
| | - Michele Heisler
- VA Center for Clinical Management Research, Ann Arbor, MI.,Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Ranak Trivedi
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA.,Department of Psychiatry and Behavioral Sciences, Division of Population Sciences and Public Mental Health, Stanford University, Stanford, CA
| | - D Scott Obrosky
- VA Center for Health Equity Research and Promotion, Pittsburgh, PA.,Department of Internal Medicine, University of Pittsburgh Medical School, Pittsburgh, PA
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, Pittsburgh, PA
| | - John D Piette
- VA Center for Clinical Management Research, Ann Arbor, MI.,Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, Pittsburgh, PA.,Department of Internal Medicine, University of Pittsburgh Medical School, Pittsburgh, PA
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17
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Essien UR, Kim N, Hausmann LRM, Mor MK, Good CB, Magnani JW, Litam TMA, Gellad WF, Fine MJ. Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System. JAMA Netw Open 2021; 4:e2114234. [PMID: 34319358 PMCID: PMC8319757 DOI: 10.1001/jamanetworkopen.2021.14234] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [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] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Atrial fibrillation is a common cardiac rhythm disturbance causing substantial morbidity and mortality that disproportionately affects racial/ethnic minority groups. Anticoagulation reduces stroke risk in atrial fibrillation, yet studies show it is underprescribed in racial/ethnic minority patients. OBJECTIVE To compare initiation of anticoagulant therapy by race/ethnicity for patients in the Veterans Health Administration (VA) system with atrial fibrillation. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included 111 666 patients within the VA system with incident atrial fibrillation between January 1, 2014, and December 31, 2018. Data were analyzed between December 1, 2019, and March 31, 2020. EXPOSURES Any anticoagulation was defined as receipt of warfarin or direct-acting oral anticoagulants, apixaban, dabigatran, edoxaban, or rivaroxaban. MAIN OUTCOMES AND MEASURES Initiation of any anticoagulation (or direct-acting oral anticoagulant therapy in those who initiated any anticoagulation) was examined within 90 days of an index atrial fibrillation diagnosis. RESULTS Our final cohort comprised 111 666 patients (109 386 men [98.0%] and 95 493 White patients [85.5%]; mean [SD] age, 72.9 [10.4] years). A total of 69 590 patients (62.3%) initiated any anticoagulant therapy, varying 10.5 percentage points by race/ethnicity (P < .001); initiation was lowest in Asian (52.2% [n = 676]) and Black (60.3% [n = 6177]) patients and highest in White patients (62.7% [n = 59 881]). Among anticoagulant initiators, 45 381 (65.2%) used direct-acting oral anticoagulants, varying 7.2 percentage points by race/ethnicity (P < .001); initiation was lowest in Hispanic (58.3% [n = 1470]), American Indian/Alaska Native (59.8% [n = 201]), and Black (60.9% [n = 3763]) patients and highest in White patients (66.0% [n = 39 502). Compared with White patients, the odds of initiating any anticoagulant therapy were significantly lower for Asian (adjusted odds ratio [aOR], 0.82; 95% CI, 0.72-0.94) and Black (aOR, 0.90; 95% CI 0.85-0.95) patients. Among initiators, the adjusted odds of direct-acting oral anticoagulant initiation were significantly lower for Hispanic (aOR, 0.79; 95% CI, 0.70-0.89), American Indian/Alaska Native (aOR, 0.75; 95% CI, 0.57-0.99), and Black (aOR, 0.74; 95% CI 0.69-0.80) patients. CONCLUSIONS AND RELEVANCE This cohort study found that in patients with incident atrial fibrillation managed in the VA system, race/ethnicity was independently associated with initiating any anticoagulant therapy and direct-acting oral anticoagulant use among anticoagulant initiators. Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial/ethnic minority patients treated in the VA system.
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Affiliation(s)
- Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, Pennsylvania
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Terrence M A Litam
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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18
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Burkitt KH, Rodriguez KL, Mor MK, Fine MJ, Clark WJ, Macpherson DS, Mannozzi CM, Muldoon MF, Long JA, Hausmann LRM. Evaluation of a collaborative VA network initiative to reduce racial disparities in blood pressure control among veterans with severe hypertension. Healthc (Amst) 2021; 8 Suppl 1:100485. [PMID: 34175098 DOI: 10.1016/j.hjdsi.2020.100485] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 09/24/2020] [Accepted: 10/14/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Compared to White patients in the United States, Black patients have a higher prevalence of hypertension and more severe forms of this condition. OBJECTIVE To decrease racial disparities in blood pressure (BP) control among Black veterans with severe hypertension within a regional network of Veterans Affairs Medical Centers (VAMCs). METHODS Health system leaders, clinicians, and health services researchers collaborated on a 12-month quality improvement (QI) project to: (1) examine project implementation and the QI strategies used to improve BP control and (2) assess the effect of the initiative on Black-White differences in BP control among veterans with severe hypertension. RESULTS Within 9 participating VAMCs, the most frequently used QI strategies involved provider education (n=9), provider audit and feedback (n=8), and health care team change (n=7). Among 141,124 veterans with a diagnosis of hypertension, 9,913 had severe hypertension [2,533 (25.6%) Black and 7380 (74.4%) White]. Over the course of the project, the proportion of Black veterans with severe hypertension decreased from 7.5% to 6.6% (p=.002) and the racial difference in proportions for this condition decreased 0.9 percentage points, from 2.9% to 2.0% (p=.01). CONCLUSIONS A multicenter, equity-focused QI project in VA reduced the proportion of Black veterans with severe hypertension and ameliorated observed racial disparities for this condition. Embedding health services researchers within a QI team facilitated an evaluation of the processes and effectiveness of our initiative, providing a successful model for QI within a learning health care system.
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Affiliation(s)
- Kelly H Burkitt
- Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.
| | - Keri L Rodriguez
- Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maria K Mor
- Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael J Fine
- Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walter J Clark
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - David S Macpherson
- Retired, Veterans Integrated Service Network (VISN) 4, Pittsburgh, PA, USA
| | | | - Matthew F Muldoon
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Judith A Long
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Center for Health Equity Research and Promotion, Philadelphia, PA, USA; University of Pennsylvania, Perelman School of Medicine, Division of General Internal Medicine, Philadelphia, PA, USA
| | - Leslie R M Hausmann
- Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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19
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Fields B, Lee A, Piette JD, Trivedi R, Mor MK, Obrosky DS, Heisler M, Rosland AM. Relationship between adult and family supporter health literacy levels and supporter roles in diabetes management. Fam Syst Health 2021; 39:224-233. [PMID: 33370140 PMCID: PMC8717858 DOI: 10.1037/fsh0000503] [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] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Among adults with Type 2 diabetes, low health literacy (HL) is a risk factor for negative health outcomes. Support from family and friends can improve adults' self-management and health-related outcomes. We examined whether supporters provided unique help to adults with diabetes and low HL and whether HL was associated with adults' perception of supporter helpfulness. METHODS We used cross-sectional baseline survey data from 239 adult patients with diabetes enrolled in a randomized controlled trial with a support person. Patients reported level of supporter involvement with self-management roles. HL among patients and supporters was assessed using a validated HL screening tool. Patient perception of supporter helpfulness was assessed with a single item. We used multivariable logistic regression to examine associations of patient and supporter HL levels with supporter roles and patients' perception of supporter helpfulness. RESULTS Patients with low HL were more likely to have a supporter with low HL (39% vs. 26%, p = .04). Patients with low HL had higher odds of receiving supporter help with calling health care providers (adjusted odds ratio [AOR] = 2.09, 95% CI [1.00, 4.39]), remembering medical appointments (AOR = 2.24, 95% CI [1.07, 4.69]), and giving directions when blood sugars were low (AOR = 2.51, 95% CI [1.20, 5.37]). Neither patient nor supporter HL was significantly associated with patients' perception of supporter helpfulness. DISCUSSION Adults with diabetes and low HL reported more supporter involvement with specific self-management tasks than patients with adequate HL. Providers could consider targeted involvement of supporters to assist patients with chronic diseases and low HL, although they should be aware that supporters may be challenged by low HL. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Beth Fields
- Department of Kinesiology, University of Wisconsin-Madison
| | - Aaron Lee
- Department of Psychology, University of Mississippi
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20
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Pittman JOE, Lindamer L, Afari N, Depp C, Villodas M, Hamilton A, Kim B, Mor MK, Almklov E, Gault J, Rabin B. Implementing eScreening for suicide prevention in VA post-9/11 transition programs using a stepped-wedge, mixed-method, hybrid type-II implementation trial: a study protocol. Implement Sci Commun 2021; 2:46. [PMID: 33926577 PMCID: PMC8082763 DOI: 10.1186/s43058-021-00142-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 03/15/2021] [Accepted: 03/25/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Post-9/11 veterans who enroll in VA health care frequently present with suicidal ideation and/or recent suicidal behavior. Most of these veterans are not screened on their day of enrollment and their risk goes undetected. Screening for suicide risk, and associated mental health factors, can lead to early detection and referral to effective treatment, thereby decreasing suicide risk. eScreening is an innovative Gold Standard Practice with evidence to support its effectiveness and implementation potential in transition and care management (TCM) programs. We will evaluate the impact of eScreening to improve the rate and speed of suicide risk screening and referral to mental health care compared to current screening methods used by transition care managers. We will also evaluate the impact of an innovative, multicomponent implementation strategy (MCIS) on the reach, adoption, implementation, and sustained use of eScreening. METHODS This is an eight-site 4-year, stepped-wedge, mixed-method, hybrid type-II implementation trial comparing eScreening to screening as usual while also evaluating the potential impact of the MCIS focusing on external facilitation and Lean/SixSigma rapid process improvement workshops in TCM. The aims will address: 1) whether using eScreening compared to oral and/or paper-based methods in TCM programs is associated with improved rates and speed of PTSD, depression, alcohol, and suicide screening & evaluation, and increased referral to mental health treatment; 2) whether and to what degree our MCIS is feasible, acceptable, and has the potential to impact adoption, implementation, and maintenance of eScreening; and 3) how contextual factors influence the implementation of eScreening between high- and low-eScreening adopting sites. We will use a mixed methods approach guided by the RE-AIM outcomes of the Practical Robust Implementation and Sustainability Model (PRISM). Data to address Aim 1 will be collected via medical record query while data for Aims 2 and 3 will be collected from TCM staff questionnaires and qualitative interviews. DISCUSSION The results of this study will help identify best practices for screening in suicide prevention for Post-9/11 veterans enrolling in VA health care and will provide information on how best to implement technology-based screening into real-world clinical care programs. TRIAL REGISTRATION ClinicalTrials.gov : NCT04506164; date registered: August 20, 2020; retrospectively registered.
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Affiliation(s)
- James O E Pittman
- VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr, San Diego, CA, USA.
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, USA.
- Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, USA.
| | - Laurie Lindamer
- VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr, San Diego, CA, USA
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, USA
| | - Niloofar Afari
- VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr, San Diego, CA, USA
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, USA
| | - Colin Depp
- VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr, San Diego, CA, USA
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, USA
| | - Miguel Villodas
- San Diego State University, 5500 Campanile Dr, San Diego, CA, USA
| | - Alison Hamilton
- VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, USA
| | - Bo Kim
- HSR&D Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, 25 Shattuck Street, Boston, MA, USA
| | - Maria K Mor
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- VA Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Erin Almklov
- VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr, San Diego, CA, USA
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, USA
| | - John Gault
- VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr, San Diego, CA, USA
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, USA
| | - Borsika Rabin
- VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Dr, San Diego, CA, USA
- UC San Diego Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, USA
- UC San Diego Dissemination and Implementation Science Center, University of California San Diego, 9500 Gilman Dr, La Jolla, CA, USA
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21
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Lee AA, Heisler M, Trivedi R, Leukel P, Mor MK, Rosland AM. Autonomy support from informal health supporters: links with self-care activities, healthcare engagement, metabolic outcomes, and cardiac risk among Veterans with type 2 diabetes. J Behav Med 2021; 44:241-252. [PMID: 33247416 PMCID: PMC8744428 DOI: 10.1007/s10865-020-00196-5] [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] [Received: 05/19/2020] [Accepted: 11/11/2020] [Indexed: 12/01/2022]
Abstract
This study examined the role of autonomy support from adults' informal health supporters (family or friends) in diabetes-specific health behaviors and health outcomes. Using baseline data from 239 Veterans with type 2 diabetes at risk of complications enrolled in behavioral trial, we examined associations between autonomy support from a support person and that support person's co-residence with the participant's diabetes self-care activities, patient activation, cardiometabolic measures, and predicted risk of a cardiac event. Autonomy support from supporters was associated with significantly increased adherence to healthy lifestyle behaviors (diet, p < .001 and exercise, p = .003); higher patient activation (p < .001); greater patient efficacy in interacting with healthcare providers, and lower 5-year (p = .044) and 10-year (p = .027) predicted cardiac risk. Autonomy support was not significantly associated with diabetes-specific behaviors (checking blood glucose, foot care, or medication taking); or hemoglobin A1c, systolic blood pressure, or non-HDL cholesterol. There was a significant interaction of autonomy support and supporter residence in one model such that lack of autonomy support was associated with lower patient activation only among individuals with in-home supporters. No other interactions were significant. Findings suggest that autonomy support from family and friends may play a role in patient self-management, patient activation, and lower cardiac risk.
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Affiliation(s)
- Aaron A Lee
- Department of Psychology, University of Mississippi, 310C Peabody Hall, University, MS, 38677, USA.
| | - Michele Heisler
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ranak Trivedi
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Population Sciences and Public Mental Health, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Patric Leukel
- Department of Psychology, University of Mississippi, 310C Peabody Hall, University, MS, 38677, USA
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
- Department of Internal Medicine, University of Pittsburgh Medical School, Pittsburgh, PA, USA
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22
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Hernandez SE, Sylling PW, Mor MK, Fine MJ, Nelson KM, Wong ES, Liu CF, Batten AJ, Fihn SD, Hebert PL. Developing an Algorithm for Combining Race and Ethnicity Data Sources in the Veterans Health Administration. Mil Med 2021; 185:e495-e500. [PMID: 31603222 DOI: 10.1093/milmed/usz322] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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] Open
Abstract
INTRODUCTION Racial/ethnic disparities exist in the Veterans Health Administration (VHA), despite financial barriers to care being largely mitigated and Veterans Administration's (VA) organizational commitment to health equity. Accurately identifying minority veterans is critical to monitoring progress toward equity as the VHA treats an increasingly racially and ethnically diverse veteran population. Although the VHA's completeness of race and ethnicity data is generally better than its public sector and private counterparts, the accuracy of the race and ethnicity in the various databases available to VHA is variable, as is the accuracy in identifying specific minority groups. The purpose of this article was to develop an algorithm for constructing race and ethnicity variables from data sources available to VHA researchers, to present demographic differences cross the data sources, and to apply the algorithm to one study year. MATERIALS AND METHODS We used existing VHA survey data from the Survey of Healthcare Experiences of Patients (SHEP) and three commonly used administrative databases from 2003 to 2015: the VA Corporate Data Warehouse (CDW), VA Defense Identity Repository (VADIR), and Medicare. Using measures of agreement such as sensitivity, specificity, positive and negative predictive values, and Cohen kappa, we compared self-reported race and ethnicity from the SHEP and each of the other data sources. Based on these results, we propose an algorithm for combining data on race and ethnicity from these datasets. We included VHA patients who completed a SHEP and had race/ethnicity recorded in CDW, VADIR, and/or Medicare. RESULTS Agreement between SHEP and other sources was high for Whites and Blacks and substantially lower for other minority groups. The CDW demonstrated better agreement than VADIR or Medicare. CONCLUSIONS We developed an algorithm of data source precedence in the VHA that improves the accuracy of the identification of historically under-identified minorities: (1) SHEP, (2) CDW, (3) Department of Defense's VADIR, and (4) Medicare.
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Affiliation(s)
- Susan E Hernandez
- Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660.,Assessment, Policy Development & Evaluation Unit, Public Health-Seattle & King County, 401 5th Ave, Suite #1300, Seattle, WA 98104
| | - Philip W Sylling
- King County Department of Community and Human Services, Performance Measurement and Evaluation, 401 5th Ave, Suite #500, Seattle, WA 98104
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System University Drive (151C), Pittsburgh, PA 15240.,Biostatistics, Informatics, and Computing Core (BICC), Pittsburgh CHERP, VA Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA 15240.,Pitt Public Health, University of Pittsburgh, 130 De Soto Street, Pittsburgh, PA 15261
| | - Michael J Fine
- VA Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System University Drive (151C), Pittsburgh, PA 15240.,Center for Research on Health Care, School of Medicine, University of Pittsburgh, Pittsburgh, PA.,School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213
| | - Karin M Nelson
- PACT Demonstration Laboratory Initiative, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108.,School of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195
| | - Edwin S Wong
- Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660.,Health Sciences Research & Development, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108
| | - Chuan-Fen Liu
- Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660.,Health Sciences Research & Development, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108
| | - Adam J Batten
- PACT Demonstration Laboratory Initiative, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108
| | - Stephan D Fihn
- School of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195.,VHA Office of Clinical Systems Development and Evaluation, 1700 N Wheeling St, Aurora, CO 80045
| | - Paul L Hebert
- Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660.,Health Sciences Research & Development, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108
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23
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Cashion W, Gellad WF, Sileanu FE, Mor MK, Fine MJ, Hale J, Hall DE, Rogal S, Switzer G, Ramkumar M, Wang V, Bronson DA, Wilson M, Gunnar W, Weisbord SD. Source of Post-Transplant Care and Mortality among Kidney Transplant Recipients Dually Enrolled in VA and Medicare. Clin J Am Soc Nephrol 2021; 16:437-445. [PMID: 33602753 PMCID: PMC8011004 DOI: 10.2215/cjn.10020620] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/21/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Many kidney transplant recipients enrolled in the Veterans Health Administration are also enrolled in Medicare and eligible to receive both Veterans Health Administration and private sector care. Where these patients receive transplant care and its association with mortality are unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective cohort study of veterans who underwent kidney transplantation between 2008 and 2016 and were dually enrolled in Veterans Health Administration and Medicare at the time of surgery. We categorized patients on the basis of the source of transplant-related care (i.e., outpatient transplant visits, immunosuppressive medication prescriptions, calcineurin inhibitor measurements) delivered during the first year after transplantation defined as Veterans Health Administration only, Medicare only (i.e., outside Veterans Health Administration using Medicare), or dual care (mixed use of Veterans Health Administration and Medicare). Using multivariable Cox regression, we examined the independent association of post-transplant care source with mortality at 5 years after kidney transplantation. RESULTS Among 6206 dually enrolled veterans, 975 (16%) underwent transplantation at a Veterans Health Administration hospital and 5231 (84%) at a non-Veterans Health Administration hospital using Medicare. Post-transplant care was received by 752 patients (12%) through Veterans Health Administration only, 2092 (34%) through Medicare only, and 3362 (54%) through dual care. Compared with patients who were Veterans Health Administration only, 5-year mortality was significantly higher among patients who were Medicare only (adjusted hazard ratio, 2.2; 95% confidence interval, 1.5 to 3.1) and patients who were dual care (adjusted hazard ratio, 1.5; 95% confidence interval, 1.1 to 2.1). CONCLUSIONS Most dually enrolled veterans underwent transplantation at a non-Veterans Health Administration transplant center using Medicare, yet many relied on Veterans Health Administration for some or all of their post-transplant care. Veterans who received Veterans Health Administration-only post-transplant care had the lowest 5-year mortality.
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Affiliation(s)
- Winn Cashion
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Florentina E. Sileanu
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria K. Mor
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Hale
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Departments of Surgery, Anesthesia and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shari Rogal
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Galen Switzer
- Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mohan Ramkumar
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,Medical Service, Renal Section, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina,Department of Population Health Sciences and Department of Medicine, Duke University, Durham, North Carolina
| | - Douglas A. Bronson
- Department of Veterans Affairs, Veterans Health Administration, Washington, D.C
| | - Mark Wilson
- Department of Veterans Affairs, Veterans Health Administration, Washington, D.C
| | - William Gunnar
- Department of Veterans Affairs, Veterans Health Administration, Washington, D.C.,Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven D. Weisbord
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Medical Service, Renal Section, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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24
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Lipkin JS, Thorpe JM, Gellad WF, Hanlon JT, Zhao X, Thorpe CT, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Good CB, Fine MJ, Hausmann LRM. Identifying sociodemographic profiles of veterans at risk for high-dose opioid prescribing using classification and regression trees. J Opioid Manag 2021; 16:409-424. [PMID: 33428188 DOI: 10.5055/jom.2020.0599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To identify sociodemographic profiles of patients prescribed high-dose opioids. DESIGN Cross-sectional cohort study. SETTING/PATIENTS Veterans dually-enrolled in Veterans Health Administration and Medicare Part D, with ≥1 opioid pre-scription in 2012. MAIN OUTCOME MEASURES We identified five patient-level demographic characteristics and 12 community variables re-flective of region, socioeconomic deprivation, safety, and internet connectivity. Our outcome was the proportion of vet-erans receiving >120 morphine milligram equivalents (MME) for ≥90 consecutive days, a Pharmacy Quality Alliance measure of chronic high-dose opioid prescribing. We used classification and regression tree (CART) methods to identify risk of chronic high-dose opioid prescribing for sociodemographic subgroups. RESULTS Overall, 17,271 (3.3 percent) of 525,716 dually enrolled veterans were prescribed chronic high-dose opioids. CART analyses identified 35 subgroups using four sociodemographic and five community-level measures, with high-dose opioid prescribing ranging from 0.28 percent to 12.1 percent. The subgroup (n = 16,302) with highest frequency of the outcome included veterans who were with disability, age 18-64 years, white or other race, and lived in the Western Census region. The subgroup (n = 14,835) with the lowest frequency of the outcome included veterans who were with-out disability, did not receive Medicare Part D Low Income Subsidy, were >85 years old, and lived in communities within the second and sixth to tenth deciles of community public assistance. CONCLUSIONS Using CART analyses with sociodemographic and community-level variables only, we identified sub-groups of veterans with a 43-fold difference in chronic high-dose opioid prescriptions. Interactions among disability, age, race/ethnicity, and region should be considered when identifying high-risk subgroups in large populations.
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Affiliation(s)
- Jacob S Lipkin
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, Pennsylvania; Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - John P Cashy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, Pennsylvania
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Center for Value Based Pharmacy Initiatives, UPMC Health Plan, Pittsburgh, Pennsylvania
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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25
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Quinn DA, Sileanu FE, Zhao X, Mor MK, Judge-Golden C, Callegari LS, Borrero S. History of unintended pregnancy and patterns of contraceptive use among racial and ethnic minority women veterans. Am J Obstet Gynecol 2020; 223:564.e1-564.e13. [PMID: 32142832 PMCID: PMC7528209 DOI: 10.1016/j.ajog.2020.02.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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] [Received: 09/06/2019] [Revised: 01/31/2020] [Accepted: 02/21/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nearly half of all pregnancies in the United States each year are unintended, with the highest rates observed among non-Hispanic black and Hispanic women. Little is known about whether variations in unintended pregnancy and contraceptive use across racial and ethnic groups persist among women veteran Veterans Affairs users who have more universal access than other populations to health care and contraceptive services. OBJECTIVES The objectives of this study were to identify a history of unintended pregnancy and describe patterns of contraceptive use across racial and ethnic groups among women veterans accessing Veterans Affairs primary care. STUDY DESIGN Cross-sectional data from a national random sample of women veterans (n = 2302) aged 18-44 years who had accessed Veterans Affairs primary care in the previous 12 month were used to assess a history of unintended pregnancy (pregnancies reported as either unwanted or having occurred too soon). Any contraceptive use at last sex (both prescription and nonprescription methods) and prescription contraceptive use at last sex were assessed in the subset of women (n = 1341) identified as being at risk for unintended pregnancy. Prescription contraceptive methods include long-acting reversible contraceptive methods (intrauterine devices and subdermal implants), hormonal methods (pill, patch, ring, and injection), and female or male sterilization; nonprescription methods include barrier methods (eg, condoms, diaphragm), fertility-awareness methods, and withdrawal. Multivariable logistic regression models were used to examine the relationship between race/ethnicity with unintended pregnancy and contraceptive use at last sex. RESULTS Overall, 94.4% of women veterans at risk of unintended pregnancy used any method of contraception at last sex. Intrauterine devices (18.9%), female surgical sterilization (16.9%), and birth control pills (15.9%) were the 3 most frequently used methods across the sample. Intrauterine devices were the most frequently used method for Hispanic, non-Hispanic white, and other non-Hispanic women, while female surgical sterilization was the most frequently used method among non-Hispanic black women. In adjusted models, Hispanic women (adjusted odds ratio, 1.60, 95% confidence interval, 1.15-2.21) and non-Hispanic black women (adjusted odds ratio, 1.84, 95% confidence interval, 1.44-2.36) were significantly more likely than non-Hispanic white women to report any history of unintended pregnancy. In the subcohort of 1341 women at risk of unintended pregnancy, there were no significant racial/ethnic differences in use of any contraception at last sex. However, significant differences were observed in the use of prescription methods at last sex. Hispanic women (adjusted odds ratio, 0.51, 95% confidence interval, 0.35-0.75) and non-Hispanic black women (adjusted odds ratio, 0.69, 95% confidence interval, 0.51-0.95) were significantly less likely than non-Hispanic white women to have used prescription contraception at last sex. CONCLUSION Significant racial and ethnic differences exist in unintended pregnancy and contraceptive use among women veterans using Veterans Affairs care, suggesting the need for interventions to address potential disparities. Improving access to and delivery of patient-centered reproductive goals assessment and contraceptive counseling that can address knowledge gaps while respectfully considering individual patient preferences is needed to support women veterans' decision making and ensure equitable reproductive health services across Veterans Affairs.
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Affiliation(s)
- Deirdre A Quinn
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA.
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Colleen Judge-Golden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Lisa S Callegari
- Departments of Obstetrics and Gynecology and Health Services, University of Washington, Seattle, WA; Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Sonya Borrero
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA; Center for Women's Health Research and Innovation, University of Pittsburgh, Pittsburgh, PA
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26
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Liu C, Mor MK, Palevsky PM, Kaufman JS, Thiessen Philbrook H, Weisbord SD, Parikh CR. Postangiography Increases in Serum Creatinine and Biomarkers of Injury and Repair. Clin J Am Soc Nephrol 2020; 15:1240-1250. [PMID: 32839195 PMCID: PMC7480551 DOI: 10.2215/cjn.15931219] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 07/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES It is unknown whether iodinated contrast causes kidney parenchymal damage. Biomarkers that are more specific to nephron injury than serum creatinine may provide insight into whether contrast-associated AKI reflects tubular damage. We assessed the association between biomarker changes after contrast angiography with contrast-associated AKI and 90-day major adverse kidney events and death. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a longitudinal analysis of participants from the biomarker substudy of the Prevention of Serious Adverse Events following Angiography trial. We measured injury (kidney injury molecule-1, neutrophil gelatinase-associated lipocalin, IL-18) and repair (monocyte chemoattractant protein-1, uromodulin, YKL-40) proteins from plasma and urine samples at baseline and 2-4 hours postangiography. We assessed the associations between absolute changes and relative ratios of biomarkers with contrast-associated AKI and 90-day major adverse kidney events and death. RESULTS Participants (n=922) were predominately men (97%) with diabetes (82%). Mean age was 70±8 years, and eGFR was 48±13 ml/min per 1.73 m2; 73 (8%) and 60 (7%) participants experienced contrast-associated AKI and 90-day major adverse kidney events and death, respectively. No postangiography urine biomarkers were associated with contrast-associated AKI. Postangiography plasma kidney injury molecule-1 and IL-18 were significantly higher in participants with contrast-associated AKI compared with those who did not develop contrast-associated AKI: 428 (248, 745) versus 306 (179, 567) mg/dl; P=0.04 and 325 (247, 422) versus 280 (212, 366) mg/dl; P=0.009, respectively. The majority of patients did not experience an increase in urine or plasma biomarkers. Absolute changes in plasma IL-18 were comparable in participants with contrast-associated AKI (-30 [-71, -9] mg/dl) and those without contrast-associated AKI (-27 [-53, -10] mg/dl; P=0.62). Relative ratios of plasma IL-18 were also comparable in participants with contrast-associated AKI (0.91; 0.86, 0.97) and those without contrast-associated AKI (0.91; 0.85, 0.96; P=0.54). CONCLUSIONS The lack of significant differences in the absolute changes and relative ratios of injury and repair biomarkers by contrast-associated AKI status suggests that the majority of mild contrast-associated AKI cases may be driven by hemodynamic changes at the kidney.
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Affiliation(s)
- Caroline Liu
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania .,Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Paul M Palevsky
- Renal Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - James S Kaufman
- Division of Nephrology, Veterans Affairs New York Harbor Healthcare System and New York University School of Medicine, New York, New York
| | | | - Steven D Weisbord
- Renal Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Renal Section, Medical Service and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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27
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Thorpe CT, Sileanu FE, Mor MK, Zhao X, Aspinall S, Ersek M, Springer S, Niznik JD, Vu M, Schleiden LJ, Gellad WF, Hunnicutt J, Thorpe JM, Hanlon JT. Discontinuation of Statins in Veterans Admitted to Nursing Homes near the End of Life. J Am Geriatr Soc 2020; 68:2609-2619. [PMID: 32786004 DOI: 10.1111/jgs.16727] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND/OBJECTIVES Geriatric guidelines recommend against statin use in older adults with limited life expectancy (LLE) or advanced dementia (AD). This study examined resident and facility factors predicting statin discontinuation after nursing home (NH) admission in veterans with LLE/AD taking statins for secondary prevention. DESIGN Retrospective cohort study of Veterans Affairs (VA) bar code medication administration records, Minimum Data Set (MDS) assessments, and utilization records linked to Medicare claims. SETTING VA NHs, known as community living centers (CLCs). PARTICIPANTS Veterans aged 65 and older with coronary artery disease, stroke, or diabetes mellitus, type II, admitted in fiscal years 2009 to 2015, who met criteria for LLE/AD on their admission MDS and received statins in the week after admission (n = 13,110). MEASUREMENTS Residents were followed until statin discontinuation (ie, gap in statin use ≥14 days), death, or censoring due to discharge, day 91 of the stay, or end of the study period. Competing risk models assessed cumulative incidence and predictors of discontinuation, stratified by whether the resident had their end-of-life (EOL) status designated or used hospice at admission. RESULTS Overall cumulative incidence of statin discontinuation was 31% (95% confidence interval [CI] = 30%-32%) by day 91, and it was markedly higher in those with (52%; 95% CI = 50%-55%) vs without (25%; 95% CI = 24%-26%) EOL designation/hospice. In patients with EOL designation/hospice (n = 2,374), obesity, congestive heart failure, and admission from nonhospital settings predicted decreased likelihood of discontinuation; AD, dependency in activities of daily living, greater number of medications, and geographic region predicted increased likelihood of discontinuation. In patients without EOL designation/hospice (n = 10,736), older age and several specific markers of poor prognosis predicted greater discontinuation, whereas obesity/overweight predicted decreased discontinuation. CONCLUSION Most veterans with LLE/AD taking statins for secondary prevention do not discontinue statins following CLC admission. Designating residents as EOL status, hospice use, and individual clinical factors indicating poor prognosis may prompt deprescribing.
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Affiliation(s)
- Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Sherrie Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,VA Center for Medication Safety, Hines, Illinois.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Mary Ersek
- Veterans Experience Center and the Center for Health Equity Research and Promotion; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sydney Springer
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,University of New England College of Pharmacy, Portland, Maine
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina.,Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michelle Vu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,VA Center for Medication Safety, Hines, Illinois
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob Hunnicutt
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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28
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Vu M, Sileanu FE, Aspinall SL, Niznik JD, Springer SP, Mor MK, Zhao X, Ersek M, Hanlon JT, Gellad WF, Schleiden LJ, Thorpe JM, Thorpe CT. Antihypertensive Deprescribing in Older Adult Veterans at End of Life Admitted to Veteran Affairs Nursing Homes. J Am Med Dir Assoc 2020; 22:132-140.e5. [PMID: 32723537 DOI: 10.1016/j.jamda.2020.05.060] [Citation(s) in RCA: 7] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/26/2020] [Accepted: 05/26/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Geriatric palliative care approaches support deprescribing of antihypertensives in older nursing home (NH) residents with limited life expectancy and/or advanced dementia (LLE/AD) who are intensely treated for hypertension (HTN), but information on real-world deprescribing patterns in this population is limited. We examined the incidence and factors associated with antihypertensive deprescribing. DESIGN National, retrospective cohort study. SETTING AND PARTICIPANTS Older Veterans with LLE/AD and HTN admitted to VA NHs in fiscal years 2009-2015 with potential overtreatment of HTN at admission, defined as receiving at least 1 antihypertensive class of medications and mean daily systolic blood pressure (SBP) <120 mm Hg. MEASURES Deprescribing was defined as subsequent dose reduction or discontinuation of an antihypertensive for ≥7 days. Competing risk models assessed cumulative incidence and factors associated with deprescribing. RESULTS Within our sample (n = 10,574), cumulative incidence of deprescribing at 30 days was 41%. Veterans with the greatest level of overtreatment (ie, multiple antihypertensives and SBP <100 mm Hg) had an increased likelihood (hazard ratio 1.75, 95% confidence interval 1.59, 1.93) of deprescribing vs those with the lowest level of overtreatment (ie, one antihypertensive and SBP ≥100 to <120 mm Hg). Several markers of poor prognosis (ie, recent weight loss, poor appetite, dehydration, dependence for activities of daily living, pain) and later admission year were associated with increased likelihood of deprescribing, whereas cardiovascular risk factors (ie, diabetes, congestive heart failure, obesity), shortness of breath, and admission source from another NH or home/assisted living setting (vs acute hospital) were associated with decreased likelihood. CONCLUSIONS AND IMPLICATIONS Real-world deprescribing patterns of antihypertensives among NH residents with HTN and LLE/AD appear to reflect variation in recommendations for HTN treatment intensity and individualization of patient care in a population with potential overtreatment. Factors facilitating deprescribing included treatment intensity and markers of poor prognosis. Comparative effectiveness and safety studies are needed to guide clinical decisions around deprescribing and HTN management.
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Affiliation(s)
- Michelle Vu
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Veteran Affairs Pharmacy Benefits Management Service, Center for Medication Safety, Hines, IL, USA
| | - Florentina E Sileanu
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
| | - Sherrie L Aspinall
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Veteran Affairs Pharmacy Benefits Management Service, Center for Medication Safety, Hines, IL, USA; Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Joshua D Niznik
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of North Carolina School of Medicine, Chapel Hill, NC, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Sydney P Springer
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of New England College of Pharmacy, Portland, ME, USA
| | - Maria K Mor
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
| | - Xinhua Zhao
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
| | - Mary Ersek
- Corporal Michael J. Crescenz Veterans Affair's Medical Center, Center for Health Equity Research and Promotion, Philadelphia, PA, USA; University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Joseph T Hanlon
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Loren J Schleiden
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Joshua M Thorpe
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Carolyn T Thorpe
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA.
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Rogal SS, Chinman M, Gellad WF, Mor MK, Zhang H, McCarthy SA, Mauro GT, Hale JA, Lewis ET, Oliva EM, Trafton JA, Yakovchenko V, Gordon AJ, Hausmann LRM. Tracking implementation strategies in the randomized rollout of a Veterans Affairs national opioid risk management initiative. Implement Sci 2020. [PMID: 32576214 DOI: 10.1186/s13012‐020‐01005‐y] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND In 2018, the Department of Veterans Affairs (VA) issued Notice 2018-08 requiring facilities to complete "case reviews" for Veterans identified in the Stratification Tool for Opioid Risk Mitigation (STORM) dashboard as high risk for adverse outcomes among patients prescribed opioids. Half of the facilities were randomly assigned to a Notice version including additional oversight. We evaluated implementation strategies used, whether strategies differed by randomization arm, and which strategies were associated with case review completion rates. METHODS Facility points of contact completed a survey assessing their facility's use of 68 implementation strategies based on the Expert Recommendations for Implementing Change taxonomy. We collected respondent demographic information, facility-level characteristics, and case review completion rates (percentage of high-risk patients who received a case review). We used Kruskal-Wallis tests and negative binomial regression to assess strategy use and factors associated with case reviews. RESULTS Contacts at 89 of 140 facilities completed the survey (64%) and reported using a median of 23 (IQR 16-31) strategies. The median case review completion rate was 71% (IQR 48-95%). Neither the number or types of strategies nor completion rates differed by randomization arm. The most common strategies were using the STORM dashboard (97%), working with local opinion leaders (80%), and recruiting local partners (80%). Characteristics associated with case review completion rates included respondents being ≤ 35 years old (incidence rate ratio, IRR 1.35, 95% CI 1.09-1.67) and having < 5 years in their primary role (IRR 1.23; 95% CI 1.01-1.51), and facilities having more prior academic detailing around pain and opioid safety (IRR 1.40, 95% CI 1.12-1.75). Controlling for these characteristics, implementation strategies associated with higher completion rates included (1) monitoring and adjusting practices (adjusted IRR (AIRR) 1.40, 95% CI 1.11-1.77), (2) identifying adaptations while maintaining core components (AIRR 1.28, 95% CI 1.03-1.60), (3) conducting initial training (AIRR 1.16, 95% CI 1.02-1.50), and (4) regularly sharing lessons learned (AIRR 1.32, 95% CI 1.09-1.59). CONCLUSIONS In this national evaluation of strategies used to implement case reviews of patients at high risk of opioid-related adverse events, point of contact age and tenure in the current role, prior pain-related academic detailing at the facility, and four specific implementation strategies were associated with case review completion rates, while randomization to additional centralized oversight was not. TRIAL REGISTRATION This project is registered at the ISRCTN Registry with number ISRCTN16012111. The trial was first registered on May 3, 2017.
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Affiliation(s)
- Shari S Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA. .,Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Matthew Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,RAND Corporation, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Hongwei Zhang
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Sharon A McCarthy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Genna T Mauro
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Eleanor T Lewis
- VA Office of Mental Health and Suicide Prevention, VA Palo Alto Healthcare System, Menlo Park, CA, USA.,VA Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Elizabeth M Oliva
- VA Office of Mental Health and Suicide Prevention, VA Palo Alto Healthcare System, Menlo Park, CA, USA.,VA Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Jodie A Trafton
- VA Office of Mental Health and Suicide Prevention, VA Palo Alto Healthcare System, Menlo Park, CA, USA.,VA Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Vera Yakovchenko
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy, University of Utah School of Medicine, Salt Lake City, UT, USA.,Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Rogal SS, Chinman M, Gellad WF, Mor MK, Zhang H, McCarthy SA, Mauro GT, Hale JA, Lewis ET, Oliva EM, Trafton JA, Yakovchenko V, Gordon AJ, Hausmann LRM. Tracking implementation strategies in the randomized rollout of a Veterans Affairs national opioid risk management initiative. Implement Sci 2020; 15:48. [PMID: 32576214 PMCID: PMC7313133 DOI: 10.1186/s13012-020-01005-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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] [Received: 02/04/2020] [Accepted: 05/29/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In 2018, the Department of Veterans Affairs (VA) issued Notice 2018-08 requiring facilities to complete "case reviews" for Veterans identified in the Stratification Tool for Opioid Risk Mitigation (STORM) dashboard as high risk for adverse outcomes among patients prescribed opioids. Half of the facilities were randomly assigned to a Notice version including additional oversight. We evaluated implementation strategies used, whether strategies differed by randomization arm, and which strategies were associated with case review completion rates. METHODS Facility points of contact completed a survey assessing their facility's use of 68 implementation strategies based on the Expert Recommendations for Implementing Change taxonomy. We collected respondent demographic information, facility-level characteristics, and case review completion rates (percentage of high-risk patients who received a case review). We used Kruskal-Wallis tests and negative binomial regression to assess strategy use and factors associated with case reviews. RESULTS Contacts at 89 of 140 facilities completed the survey (64%) and reported using a median of 23 (IQR 16-31) strategies. The median case review completion rate was 71% (IQR 48-95%). Neither the number or types of strategies nor completion rates differed by randomization arm. The most common strategies were using the STORM dashboard (97%), working with local opinion leaders (80%), and recruiting local partners (80%). Characteristics associated with case review completion rates included respondents being ≤ 35 years old (incidence rate ratio, IRR 1.35, 95% CI 1.09-1.67) and having < 5 years in their primary role (IRR 1.23; 95% CI 1.01-1.51), and facilities having more prior academic detailing around pain and opioid safety (IRR 1.40, 95% CI 1.12-1.75). Controlling for these characteristics, implementation strategies associated with higher completion rates included (1) monitoring and adjusting practices (adjusted IRR (AIRR) 1.40, 95% CI 1.11-1.77), (2) identifying adaptations while maintaining core components (AIRR 1.28, 95% CI 1.03-1.60), (3) conducting initial training (AIRR 1.16, 95% CI 1.02-1.50), and (4) regularly sharing lessons learned (AIRR 1.32, 95% CI 1.09-1.59). CONCLUSIONS In this national evaluation of strategies used to implement case reviews of patients at high risk of opioid-related adverse events, point of contact age and tenure in the current role, prior pain-related academic detailing at the facility, and four specific implementation strategies were associated with case review completion rates, while randomization to additional centralized oversight was not. TRIAL REGISTRATION This project is registered at the ISRCTN Registry with number ISRCTN16012111. The trial was first registered on May 3, 2017.
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Affiliation(s)
- Shari S Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Matthew Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- RAND Corporation, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Hongwei Zhang
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Sharon A McCarthy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Genna T Mauro
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Eleanor T Lewis
- VA Office of Mental Health and Suicide Prevention, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- VA Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Elizabeth M Oliva
- VA Office of Mental Health and Suicide Prevention, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- VA Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Jodie A Trafton
- VA Office of Mental Health and Suicide Prevention, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- VA Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Vera Yakovchenko
- Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Jones AL, Kertesz SG, Hausmann LRM, Mor MK, Suo Y, Pettey WBP, Schaefer JH, Gundlapalli AV, Gordon AJ. Primary care experiences of veterans with opioid use disorder in the Veterans Health Administration. J Subst Abuse Treat 2020; 113:107996. [PMID: 32359670 DOI: 10.1016/j.jsat.2020.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/16/2020] [Accepted: 02/25/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND While patients with substance use disorders (SUDs) are thought to encounter poor primary care experiences, the perspectives of patients with opioid use disorder (OUD), specifically, are unknown. This study compares the primary care experiences of patients with OUD, other SUDs and no SUD in the Veterans Health Administration. METHODS The sample included Veterans who responded to the national Patient-Centered Medical Home Survey of Healthcare Experiences of Patients, 2013-2015. Respondents included 3554 patients with OUD, 36,175 with other SUDs, and 756,386 with no SUD; 742 OUD-diagnosed patients received buprenorphine. Multivariable multinomial logistic regressions estimated differences in the probability of reporting positive and negative experiences (0-100 scale) for patients with OUD, compared to patients with other SUDs and no SUD, and for OUD-diagnosed patients treated versus not treated with buprenorphine. RESULTS Of all domains, patients with OUD reported the least positive experiences with access (31%) and medication decision-making (35%), and the most negative experiences with self-management support (35%) and provider communication (23%). Compared to the other groups, patients diagnosed with OUD reported fewer positive and/or more negative experiences with access, communication, office staff, provider ratings, comprehensiveness, care coordination, and self-management support (adjusted risk differences[aRDs] range from |2.9| to |7.0|). Among OUD-diagnosed patients, buprenorphine was associated with more positive experiences with comprehensiveness (aRD = 8.3) and self-management support (aRD = 7.1), and less negative experiences with care coordination (aRD = -4.9) and medication shared decision-making (aRD = -5.4). CONCLUSIONS In a national sample, patients diagnosed with OUD encounter less positive and more negative experiences than other primary care patients, including those with other SUDs. Buprenorphine treatment relates positively to experiences with care comprehensiveness, medication decisions, and care coordination. As stakeholders encourage more primary care providers to manage OUD, it will be important for healthcare systems to attend to patient access and experiences with care in these settings.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Stefan G Kertesz
- Birmingham VA Medical Center, Birmingham, AL, USA; University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA.
| | - Leslie R M Hausmann
- Center for Health Equity and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Maria K Mor
- Center for Health Equity and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
| | - Ying Suo
- Informatics, Decision Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Warren B P Pettey
- Informatics, Decision Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - James H Schaefer
- Department of Veterans Affairs Office of Reporting, Analytics, Performance, Improvement and Deployment, Durham, NC, USA.
| | - Adi V Gundlapalli
- Informatics, Decision Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Adam J Gordon
- Informatics, Decision Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, USA.
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Essien UR, Sileanu FE, Zhao X, Liebschutz JM, Thorpe CT, Good CB, Mor MK, Radomski TR, Hausmann LRM, Fine MJ, Gellad WF. Racial/Ethnic Differences in the Medical Treatment of Opioid Use Disorders Within the VA Healthcare System Following Non-Fatal Opioid Overdose. J Gen Intern Med 2020; 35:1537-1544. [PMID: 31965528 PMCID: PMC7210353 DOI: 10.1007/s11606-020-05645-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/30/2019] [Accepted: 01/03/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND After non-fatal opioid overdoses, opioid prescribing patterns are often unchanged and the use of medications for opioid use disorder (MOUDs) remains low. Whether such prescribing differs by race/ethnicity remains unknown. OBJECTIVE To assess the association of race/ethnicity with the prescribing of opioids and MOUDs after a non-fatal opioid overdose. DESIGN Retrospective cohort study. PARTICIPANTS Patients prescribed ≥ 1 opioid from July 1, 2010, to September 30, 2015, with a non-fatal opioid overdose in the Veterans Health Administration (VA). MAIN MEASURES Primary outcomes were the proportion of patients prescribed: (1) any opioid during the 30 days before and after overdose and (2) MOUDs within 30 days after overdose by race and ethnicity. We conducted difference-in-difference analyses using multivariable regression to assess whether the change in opioid prescribing from before to after overdose differed by race/ethnicity. We also used multivariable regression to test whether MOUD prescribing after overdose differed by race/ethnicity. KEY RESULTS Among 16,210 patients with a non-fatal opioid overdose (81.2% were white, 14.3% black, and 4.5% Hispanic), 10,745 (66.3%) patients received an opioid prescription (67.1% white, 61.7% black, and 65.9% Hispanic; p < 0.01) before overdose. After overdose, the frequency of receiving opioids was reduced by 18.3, 16.4, and 20.6 percentage points in whites, blacks, and Hispanics, respectively, with no significant difference-in-difference in opioid prescribing by race/ethnicity (p = 0.23). After overdose, 526 (3.2%) patients received MOUDs (2.9% white, 4.6% black, and 5.5% Hispanic; p < 0.01). Blacks (adjusted OR (aOR) 1.6; 95% CI 1.2, 1.9) and Hispanics (aOR 1.8; 95% CI 1.2, 2.6) had significantly larger odds of receiving MOUDs than white patients. CONCLUSIONS In a national cohort of patients with non-fatal opioid overdose in VA, there were no racial/ethnic differences in changes in opioid prescribing after overdose. Although blacks and Hispanics were more likely than white patients to receive MOUDs in the 30 days after overdose, less than 4% of all groups received such therapy.
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Affiliation(s)
- Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Judge-Golden CP, Wolgemuth TE, Zhao X, Mor MK, Borrero S. Agreement between Self-Reported "Ideal" and Currently Used Contraceptive Methods among Women Veterans Using the Veterans Affairs Healthcare System. Womens Health Issues 2020; 30:283-291. [PMID: 32321666 DOI: 10.1016/j.whi.2020.03.002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 03/01/2020] [Accepted: 03/11/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Women veterans who use the Veterans Affairs Healthcare System theoretically have access to the full range of contraceptive methods. This study explores match between currently used and self-reported "ideal" methods as a potential marker of contraceptive access and preference matching. METHODS This mixed methods study uses data from a nationally representative survey of reproductive-aged women veterans who use the Veterans Affairs Healthcare System for primary care, including 979 participants at risk of unintended pregnancy. Women reported all contraceptive methods used in the past month and were asked, "If you could choose any method of contraception or birth control to prevent pregnancy, what would be your ideal choice?" and selected a single "ideal" method. If applicable, participants were additionally asked, "Why aren't you currently using this method of contraception?" We used adjusted logistic regression to identify patient-, provider-, and system-level factors associated with ideal-current method match. We qualitatively analyzed open-ended responses about reasons for ideal method nonuse. RESULTS Overall, 58% were currently using their ideal method; match was greatest among women selecting an IUD as ideal (73%). Non-White race/ethnicity (adjusted odds ratio, 0.68; 95% confidence interval, 0.52-0.89) and mental illness (adjusted odds ratio, 0.69; 95% confidence interval, 0.52-0.92) were negatively associated with ideal-current match in adjusted analyses; the presence of a gynecologist at the primary care site was associated with an increased odds of match (adjusted odds ratio, 1.35; 95% confidence interval, 1.03-1.75). Modifiable barriers to ideal method use were cited by 23% of women, including access issues, cost concerns, and provider-level barriers; 79% of responses included nonmodifiable reasons for mismatch including relationship factors and pregnancy plans incongruent with ideal method use, suggesting limitations of our measure based on differential interpretation of the word "ideal." CONCLUSIONS Many women veterans are not currently using the contraceptive method they consider ideal. Results emphasize the complexity of contraceptive method selection and of measuring contraceptive preference matching.
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Affiliation(s)
| | | | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sonya Borrero
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
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Niznik JD, Hunnicutt JN, Zhao X, Mor MK, Sileanu F, Aspinall SL, Springer SP, Ersek MJ, Gellad WF, Schleiden LJ, Hanlon JT, Thorpe JM, Thorpe CT. Deintensification of Diabetes Medications among Veterans at the End of Life in VA Nursing Homes. J Am Geriatr Soc 2020; 68:736-745. [PMID: 32065387 DOI: 10.1111/jgs.16360] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [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: 11/18/2019] [Revised: 01/13/2020] [Accepted: 01/13/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Many older adults with limited life expectancy and/or advanced dementia (LLE/AD) are potentially overtreated for diabetes and may benefit from deintensification. Our aim was to examine the incidence and predictors of diabetes medication deintensification in older Veterans with LLE/AD who were potentially overtreated at admission to Veterans Affairs (VA) nursing homes (community living centers [CLCs]). DESIGN Retrospective cohort study using linked VA and Medicare clinical/administrative data and Minimum Data Set assessments. SETTING VA CLCs. PARTICIPANTS A total of 6960 Veterans with diabetes and LLE/AD admitted to VA CLCs in fiscal years 2009 to 2015 with hemoglobin (Hb)A1c measured within 90 days of admission. MEASUREMENTS We evaluated treatment deintensification (discontinuation or dose reduction for a consecutive 7-day period) among residents who were potentially overtreated (HbA1c ≤7.5% and receiving hypoglycemic medications). Competing risk models assessed 90-day cumulative incidence of deintensification. RESULTS More than 40% (n = 3056) of Veteran CLC residents with diabetes were potentially overtreated. The cumulative incidence of deintensification at 90 days was 45.5%. Higher baseline HbA1c values were associated with a lower likelihood of deintensification (e.g., HbA1c 7.0-7.5% vs <6.0%; adjusted risk ratio [aRR] = .57; 95% confidence interval [CI] = .50-.66). Compared with non-sulfonylurea oral agents (e.g., metformin), other treatment regimens were more likely to be deintensified (aRR = 1.31-1.88), except for basal insulin (aRR = .59; 95% CI = .52-.66). The only resident factor associated with increased likelihood of deintensification was documented end-of-life status (aRR = 1.12; 95% CI = 1.01-1.25). Admission from home/assisted living (aRR = .85; 95% CI = .75-.96), obesity (aRR = .88; 95% CI = .78-.99), and peripheral vascular disease (aRR = .90; 95% CI = .81-.99) were associated with decreased likelihood of deintensification. CONCLUSION Deintensification of treatment regimens occurred in less than one-half of potentially overtreated Veterans and was more strongly associated with low HbA1c values and use of medications with high risk for hypoglycemia, rather than other resident characteristics. J Am Geriatr Soc 68:736-745, 2020.
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Affiliation(s)
- Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Jacob N Hunnicutt
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Florentina Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Sherrie L Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,VA Center for Medication Safety, Hines, Illinois.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Sydney P Springer
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of New England College of Pharmacy, Portland, Maine
| | - Mary J Ersek
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Veterans Experience Center; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
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Springer SP, Mor MK, Sileanu F, Zhao X, Aspinall SL, Ersek M, Niznik JD, Hanlon JT, Hunnicutt J, Gellad WF, Schleiden LJ, Thorpe JM, Thorpe CT. Incidence and Predictors of Aspirin Discontinuation in Older Adult Veteran Nursing Home Residents at End of Life. J Am Geriatr Soc 2020; 68:725-735. [PMID: 32052858 DOI: 10.1111/jgs.16346] [Citation(s) in RCA: 7] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/22/2019] [Accepted: 01/01/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Continuation of aspirin for secondary prevention in persons with limited life expectancy (LLE) is controversial. We sought to determine the incidence and predictors of aspirin discontinuation in veterans with LLE and/or advanced dementia (LLE/AD) who were taking aspirin for secondary prevention at nursing home admission, stratified by whether their limited prognosis (LP) was explicitly documented at admission. DESIGN Retrospective cohort study using linked Veterans Affairs (VA) and Medicare clinical/administrative data and Minimum Data Set resident assessments. SETTING All VA nursing homes (referred to as community living centers [CLCs]) in the United States. PARTICIPANTS Older (≥65 y) CLC residents with LLE/AD, admitted for 7 days or longer in fiscal years 2009 to 2015, who had a history of coronary artery disease and/or stroke/transient ischemic attack, and used aspirin within the first week of CLC admission (n = 13 844). MEASUREMENTS The primary dependent variable was aspirin discontinuation within the first 90 days after CLC admission, defined as 14 consecutive days of no aspirin receipt. Independent variables included an indicator for explicit documentation of LP, sociodemographics, environment of care characteristics, cardiovascular risk factors, bleeding risk factors, individual markers of poor prognosis (eg, cancer, weight loss), and facility characteristics. Fine and Gray subdistribution hazard models with death as a competing risk were used to assess predictors of discontinuation. RESULTS Cumulative incidence of aspirin discontinuation was 27% (95% confidence interval [CI] = 26%-28%) in the full sample, 34% (95% CI = 33%-36%) in residents with explicit documentation of LP, and 24% (95% CI = 23%-25%) in residents with no such documentation. The associations of independent variables with aspirin discontinuation differed in residents with vs without explicit LP documentation at admission. CONCLUSION Just over one-quarter of patients discontinued aspirin, possibly reflecting the unclear role of aspirin in end of life among prescribers. Future research should compare outcomes of aspirin deprescribing in this population. J Am Geriatr Soc 68:725-735, 2020.
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Affiliation(s)
- Sydney P Springer
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania.,University of New England College of Pharmacy, Department of Pharmacy Practice, Portland, ME
| | - Maria K Mor
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Division of General Internal Medicine, Pittsburgh, PA
| | - Florentina Sileanu
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Division of General Internal Medicine, Pittsburgh, PA
| | - Sherrie L Aspinall
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Mary Ersek
- Corporal Michael J. Crescenz VA Medical Center, Center for Health Equity Research and Promotion, Philadelphia, PA.,University of Pennsylvania School of Nursing, Department of Biobehavioral Health Sciences, Philadelphia, PA
| | - Joshua D Niznik
- University of North Carolina School of Medicine, Division of Geriatric Medicine, Chapel Hill, NC
| | - Joseph T Hanlon
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Division of General Internal Medicine, Pittsburgh, PA
| | - Jacob Hunnicutt
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of New England College of Pharmacy, Department of Pharmacy Practice, Portland, ME
| | - Loren J Schleiden
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joshua M Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of North Carolina Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, Chapel Hill, NC
| | - Carolyn T Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of North Carolina Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, Chapel Hill, NC
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Arora KS, Zhao X, Judge-Golden C, Mor MK, Callegari LS, Borrero S. Factors Associated with Choice of Sterilization Among Women Veterans. J Womens Health (Larchmt) 2020; 29:989-995. [PMID: 32017866 DOI: 10.1089/jwh.2019.8036] [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: 12/11/2022] Open
Abstract
Background: We sought to compare associations of contraceptive preferences, beliefs, self-efficacy, and knowledge with use of sterilization versus other methods of contraception. Materials and Methods: This is a secondary analysis of a telephone-based survey of a nationally representative sample of women Veterans not desiring future pregnancy. Contraceptive method used at last sex was categorized as female sterilization, long-acting reversible contraception (LARC), short-acting methods, or nonprescription methods/no method. Multinomial regression models were performed to compare the association between independent variables (contraceptive preferences, beliefs, self-efficacy, and knowledge) and use of sterilization versus other contraceptive methods. Results: Six hundred twelve women Veterans aged 18-44 years who were sexually active with men, had no history of hysterectomy or infertility, did not desire future pregnancy, and were not using male sterilization as their method of contraception were surveyed. A total of 208 women Veterans reported using female sterilization (34.0%). While method effectiveness was rated as extremely important by the majority of participants, there was no association between perceiving method effectiveness as extremely important and method selected in adjusted multinomial models. Women Veterans were more likely to use sterilization compared to hormonal methods of contraception if they reported that lack of hormones was an extremely important contraceptive method characteristic (aRRR 3.69, 95% CI 1.94-7.03). Women Veterans who strongly agreed with the belief that birth control decisions are mainly a woman's responsibility were less likely to use sterilization compared to LARC (aRRR 0.54, 95% CI 0.29-0.98). Conclusion: Associations between contraceptive preferences, beliefs, self-efficacy, and knowledge and use of sterilization in a population of women Veterans not desiring future pregnancy are complex, and decisions may not solely be driven by desire to select a highly effective method.
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Affiliation(s)
- Kavita Shah Arora
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Colleen Judge-Golden
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lisa S Callegari
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington.,Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, Washington
| | - Sonya Borrero
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
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Parikh CR, Liu C, Mor MK, Palevsky PM, Kaufman JS, Thiessen Philbrook H, Weisbord SD. Kidney Biomarkers of Injury and Repair as Predictors of Contrast-Associated AKI: A Substudy of the PRESERVE Trial. Am J Kidney Dis 2020; 75:187-194. [PMID: 31547939 PMCID: PMC7012712 DOI: 10.1053/j.ajkd.2019.06.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [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] [Received: 02/07/2019] [Accepted: 06/20/2019] [Indexed: 02/07/2023]
Abstract
RATIONALE & OBJECTIVE The PRESERVE trial used a 2 × 2 factorial design to compare intravenous saline solution with intravenous sodium bicarbonate solution and oral N-acetylcysteine with placebo for the prevention of 90-day major adverse kidney events and death (MAKE-D) and contrast-associated acute kidney injury (CA-AKI) among patients with chronic kidney disease undergoing angiography. In this ancillary study, we evaluated the predictive capacities of preangiography injury and repair proteins in urine and plasma for MAKE-D, CA-AKI, and their impact on trial design. STUDY DESIGN Longitudinal analysis. SETTING & PARTICIPANTS A subset of participants from the PRESERVE trial. EXPOSURES Injury (KIM-1, NGAL, and IL-18) and repair (MCP-1, UMOD, and YKL-40) proteins in urine and plasma 1 to 2 hours preangiography. OUTCOMES MAKE-D and CA-AKI. ANALYTICAL APPROACH We analyzed the associations of preangiography biomarkers with MAKE-D and with CA-AKI. We evaluated whether the biomarker levels could enrich the MAKE-D event rate and improve future clinical trial efficiency through an online biomarker prognostic enrichment tool available at prognosticenrichment.com. RESULTS We measured plasma biomarkers in 916 participants and urine biomarkers in 797 participants. After adjusting for urinary albumin-creatinine ratio and baseline estimated glomerular filtration rate, preangiography levels of 4 plasma (KIM-1, NGAL, UMOD, and YKL-40) and 3 urine (NGAL, IL-18, and YKL-40) biomarkers were associated with MAKE-D. Only plasma KIM-1 level was significantly associated with CA-AKI after adjustment. Biomarker levels provided modest discriminatory capacity for MAKE-D. Screening patients using the 50th percentile of preangiography plasma KIM-1 or YKL-40 levels would have reduced the required sample size by 30% (∼2,000 participants). LIMITATIONS Evaluation of prognostic enrichment does not account for changing trial costs, time needed to screen patients, or loss to follow-up. Most participants were male, limiting the generalizability of our findings. CONCLUSIONS Preangiography levels of injury and repair biomarkers modestly predict the development of MAKE-D and can be used to improve the efficiency of future CA-AKI trials.
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Affiliation(s)
- Chirag R Parikh
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Caroline Liu
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Maria K Mor
- VA Pittsburgh Healthcare System, Pittsburgh, PA; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Paul M Palevsky
- VA Pittsburgh Healthcare System, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - James S Kaufman
- Division of Nephrology, VA New York Harbor Healthcare System and New York University School of Medicine, New York, NY
| | | | - Steven D Weisbord
- VA Pittsburgh Healthcare System, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
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Britton LE, Judge-Golden CP, Wolgemuth TE, Zhao X, Mor MK, Callegari LS, Borrero S. Associations Between Perceived Susceptibility to Pregnancy and Contraceptive Use in a National Sample of Women Veterans. Perspect Sex Reprod Health 2019; 51:211-218. [PMID: 31749310 PMCID: PMC7147948 DOI: 10.1363/psrh.12122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 04/26/2019] [Accepted: 06/24/2019] [Indexed: 05/29/2023]
Abstract
CONTEXT Women may be at risk for unintended pregnancy if they forgo contraception or use ineffective methods because they erroneously believe they are unlikely to conceive. However, the relationship between perceived susceptibility to pregnancy and contraceptive use is not fully understood. METHODS Data collected in 2014-2016 for the Examining Contraceptive Use and Unmet Needs study were used to examine perceived susceptibility to pregnancy among 969 women veterans aged 20-45 who were at risk for unintended pregnancy and received primary care through the U.S. Veterans Affairs Healthcare System. Multivariable logistic regression was used to identify associations between perceived susceptibility to pregnancy (perceived likelihood during one year of unprotected intercourse) and use of any contraceptive at last sex. Multinomial regression models were used to examine method effectiveness among women who used a contraceptive at last sex. RESULTS Forty percent of women perceived their susceptibility to pregnancy to be low. Compared with women with high perceived susceptibility to pregnancy, those with low perceived susceptibility were less likely to have used any contraceptive at last sex (86% vs. 96%; adjusted odds ratio, 0.2). Among contraceptive users, women with low perceived susceptibility were less likely than those with high perceived susceptibility to have used a highly effective method (26% vs. 34%; adjusted relative risk ratio, 0.6) or moderately effective method (34% vs. 39%; 0.6) at last sex. CONCLUSIONS Identifying and addressing fertility misperceptions among women with low perceived susceptibility to pregnancy could help promote informed decision making about contraception and reduce the risk of unintended pregnancy.
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Affiliation(s)
- Laura E Britton
- Postdoctoral Fellow, Columbia University School of Nursing, New York
| | | | | | - Xinhua Zhao
- Core Investigator and Statistician, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | - Maria K Mor
- Director, Biostatistics and Informatics Core, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and adjunct research assistant professor, Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh
| | - Lisa S Callegari
- Core Investigator, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound, Seattle, and associate professor, Departments of Obstetrics & Gynecology and Health Services, University of Washington
| | - Sonya Borrero
- Associate Director, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and professor, Department of Medicine, University of Pittsburgh
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Judge-Golden CP, Smith KJ, Mor MK, Borrero S. Financial Implications of 12-Month Dispensing of Oral Contraceptive Pills in the Veterans Affairs Health Care System. JAMA Intern Med 2019; 179:1201-1208. [PMID: 31282923 PMCID: PMC6618816 DOI: 10.1001/jamainternmed.2019.1678] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The Veterans Affairs (VA) health care system is the largest integrated health care system in the United States. Like most US health plans, the VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). However, 12-month OCP dispensing has been shown to improve continuation of use, decrease coverage gaps, and reduce unintended pregnancy in other practice settings. OBJECTIVE To estimate the financial and reproductive health implications for the VA of implementing a 12-month OCP dispensing option, with the goal of informing policy change. DESIGN, SETTING, AND PARTICIPANTS A decision model from the VA payer perspective was developed to estimate incremental costs to the health care system of allowing the option to receive a 12-month supply of OCPs up front, compared with the standard 3-month maximum, during a 1-year time horizon. A model cohort of 24 309 reproductive-aged, heterosexually active, female VA enrollees who wish to avoid pregnancy for at least 1 year was assumed. Probabilities of continuation of OCP use, coverage gaps, pregnancy, and pregnancy outcomes were drawn from published data. Costs of OCP provision and pregnancy-related care and the number of women using OCPs were drawn from VA administrative data. One-way and probabilistic sensitivity analyses were performed to assess model robustness. MAIN OUTCOMES AND MEASURES Incremental per-woman and total costs to the VA of allowing for 12-month dispensing of OCPs compared with standard 3-month dispensing. RESULTS The 12-month OCP dispensing option, modeled from the VA health system perspective using a cohort of 24 309 women, resulted in anticipated VA annual cost savings of $87.12 per woman compared with the cost of 3-month dispensing, or an estimated total savings of $2 117 800 annually. Cost savings resulted from an absolute reduction of 24 unintended pregnancies per 1000 women per year with 12-month dispensing, or 583 unintended pregnancies averted annually. Expected cost savings with 12-month dispensing were sensitive to changes in the probability of OCP coverage gaps with 3-month dispensing, the probability of pregnancy during coverage gaps, and the proportion of pregnancies paid for by the VA. When simultaneously varying all variables across plausible ranges, the 12-month strategy was cost saving in 95.4% of model iterations. CONCLUSIONS AND RELEVANCE Adoption of a 12-month OCP dispensing option is expected to produce substantial cost savings for the VA while better supporting reproductive autonomy and reducing unintended pregnancy among women veterans.
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Affiliation(s)
- Colleen P Judge-Golden
- Medical Scientist Training Program, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kenneth J Smith
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sonya Borrero
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania.,Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
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Barnett ML, Zhao X, Fine MJ, Thorpe CT, Sileanu FE, Cashy JP, Mor MK, Radomski TR, Hausmann LRM, Good CB, Gellad WF. Emergency Physician Opioid Prescribing and Risk of Long-term Use in the Veterans Health Administration: an Observational Analysis. J Gen Intern Med 2019; 34:1522-1529. [PMID: 31144281 PMCID: PMC6667564 DOI: 10.1007/s11606-019-05023-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/05/2019] [Accepted: 03/21/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Treatment by high-opioid prescribing physicians in the emergency department (ED) is associated with higher rates of long-term opioid use among Medicare beneficiaries. However, it is unclear if this result is true in other high-risk populations such as Veterans. OBJECTIVE To estimate the effect of exposure to high-opioid prescribing physicians on long-term opioid use for opioid-naïve Veterans. DESIGN Observational study using Veterans Health Administration (VA) encounter and prescription data. SETTING AND PARTICIPANTS Veterans with an index ED visit at any VA facility in 2012 and without opioid prescriptions in the prior 6 months in the VA system ("opioid naïve"). MEASUREMENTS We assigned patients to emergency physicians and categorized physicians into within-hospital quartiles based on their opioid prescribing rates. Our primary outcome was long-term opioid use, defined as 6 months of days supplied in the 12 months subsequent to the ED visit. We compared rates of long-term opioid use among patients treated by high versus low quartile prescribers, adjusting for patient demographic, clinical characteristics, and ED diagnoses. RESULTS We identified 57,738 and 86,393 opioid-naïve Veterans managed by 362 and 440 low and high quartile prescribers, respectively. Patient characteristics were similar across groups. ED opioid prescribing rates varied more than threefold between the low and high quartile prescribers within hospitals (6.4% vs. 20.8%, p < 0.001). The frequency of long-term opioid use was higher among Veterans treated by high versus low quartile prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%; adjusted OR 1.11, 95% CI 0.997-1.24, p = 0.056). In subgroup analyses, there were significant associations for patients with back pain (adjusted OR 1.25, 95% CI 1.01-1.55, p = 0.04) and for those with a history of depression (adjusted OR 1.28, 95% CI 1.08-1.51, p = 0.004). CONCLUSIONS ED physician opioid prescribing varied by over 300% within facility, with a statistically non-significant increased rate of long-term use among opioid-naïve Veterans exposed to the highest intensity prescribers.
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Affiliation(s)
- Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
| | - John P Cashy
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Center for High Value Health Care, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, USA.
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Koenig AF, Borrero S, Zhao X, Callegari L, Mor MK, Sonalkar S. Factors associated with long-acting reversible contraception use among women Veterans in the ECUUN study. Contraception 2019; 100:234-240. [PMID: 31152697 DOI: 10.1016/j.contraception.2019.05.010] [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: 10/15/2018] [Revised: 05/19/2019] [Accepted: 05/20/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective of this study is to understand patient-, provider- and system-level factors associated with long-acting reversible contraception (LARC) use among women Veterans and with receipt of LARC methods within the Veterans Affairs (VA) system. STUDY DESIGN We analyzed data from a national telephone-based survey of 2302 women ages 18-44 receiving primary care in VA. Multivariable regression was used to examine adjusted associations of participant-reported patient-, provider- and facility-level factors with LARC use and within-VA receipt of LARC among women Veterans. RESULTS Among 987 women Veterans at risk of unintended pregnancy, 294 (30%) reported using LARC, 65% of whom had received their method within VA. Higher LARC use was observed among women who were multiparous vs. nulliparous [adjusted odds ratio (aOR)=1.52; 95% confidence interval (CI)=1.04-2.22] and did not desire future pregnancies (aOR=1.88; 95% CI=1.31-2.68). Although overall LARC uptake was not associated with any provider- or facility-level factors, receipt of these methods within VA was associated with receiving both general and gender-specific health care by a single provider (aOR=2.81; 95% CI=1.20-6.61) and with receiving care within a women's health clinic (aOR=2.54; 95% CI=1.17-5.50). CONCLUSIONS While patient-level factors were more strongly correlated with use of LARC, provider- and system-level factors influence whether women received these methods within VA. IMPLICATIONS This study of patient-, provider- and system-level correlates of LARC use in VA, the country's largest integrated healthcare system, highlights that women Veterans share similar patient-level factors associated with LARC use as the general population and that continuity with providers and comprehensive women's health services can facilitate LARC access.
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Affiliation(s)
- Angela F Koenig
- Department of Obstetrics and Gynecology, The Hospital of the University of Pennsylvania.
| | - Sonya Borrero
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System; Center for Research on Health Care, University of Pittsburgh School of Medicine
| | - Xinhua Zhao
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | - Lisa Callegari
- VA Health Services Research and Development Center of Innovation for Veteran-Centered and Value Driven Care, VA Puget Sound Healthcare System; Department of Obstetrics and Gynecology, University of Washington School of Medicine
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, The Hospital of the University of Pennsylvania
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Radomski TR, Zhao X, Hanlon JT, Thorpe JM, Thorpe CT, Naples JG, Sileanu FE, Cashy JP, Hale JA, Mor MK, Hausmann LRM, Donohue JM, Suda KJ, Stroupe KT, Good CB, Fine MJ, Gellad WF. Use of a medication-based risk adjustment index to predict mortality among veterans dually-enrolled in VA and medicare. Healthc (Amst) 2019; 7:S2213-0764(18)30230-6. [PMID: 31031120 DOI: 10.1016/j.hjdsi.2019.04.003] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 04/09/2019] [Accepted: 04/13/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is systemic undercoding of medical comorbidities within administrative claims in the Department of Veterans Affairs (VA). This leads to bias when applying claims-based risk adjustment indices to compare outcomes between VA and non-VA settings. Our objective was to compare the accuracy of a medication-based risk adjustment index (RxRisk-VM) to diagnostic claims-based indices for predicting mortality. METHODS We modified the RxRisk-V index (RxRisk-VM) by incorporating VA and Medicare pharmacy and durable medical equipment claims in Veterans dually-enrolled in VA and Medicare in 2012. Using the concordance (C) statistic, we compared its accuracy in predicting 1 and 3-year all-cause mortality to the following models: demographics only, demographics plus prescription count, or demographics plus a diagnostic claims-based risk index (e.g., Charlson, Elixhauser, or Gagne). We also compared models containing demographics, RxRisk-VM, and a claims-based index. RESULTS In our cohort of 271,184 dually-enrolled Veterans (mean age = 70.5 years, 96.1% male, 81.7% non-Hispanic white), RxRisk-VM (C = 0.773) exhibited greater accuracy in predicting 1-year mortality than demographics only (C = 0.716) or prescription counts (C = 0.744), but was less accurate than the Charlson (C = 0.794), Elixhauser (C = 0.80), or Gagne (C = 0.810) indices (all P < 0.001). Combining RxRisk-VM with claims-based indices enhanced its accuracy over each index alone (all models C ≥ 0.81). Relative model performance was similar for 3-year mortality. CONCLUSIONS The RxRisk-VM index exhibited a high level of, but slightly less, accuracy in predicting mortality in comparison to claims-based risk indices. IMPLICATIONS Its application may enhance the accuracy of studies examining VA and non-VA care and enable risk adjustment when diagnostic claims are not available or biased. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Thomas R Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, 230 McKee Place Suite 600, Pittsburgh, PA, 15213, USA.
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA; Division of Geriatrics, Department of Medicine, University of Pittsburgh School of Medicine, 3471 5th Ave, Kaufmann Building Suite 500, Pittsburgh, PA, 15213, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA; Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA; Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Jennifer G Naples
- Division of Geriatrics, Department of Medicine, University of Pittsburgh School of Medicine, 3471 5th Ave, Kaufmann Building Suite 500, Pittsburgh, PA, 15213, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA
| | - John P Cashy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, 230 McKee Place Suite 600, Pittsburgh, PA, 15213, USA
| | - Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 De Soto Street, Pittsburgh, PA, 15261, USA
| | - Katie J Suda
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, PO Box 1033, 5000 S. 5th Ave, Hines, IL, USA; Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago College of Pharmacy, 833 S. Wood Street, Chicago, IL, 60612, USA
| | - Kevin T Stroupe
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago College of Pharmacy, 833 S. Wood Street, Chicago, IL, 60612, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, 230 McKee Place Suite 600, Pittsburgh, PA, 15213, USA; Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, 230 McKee Place Suite 600, Pittsburgh, PA, 15213, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, 230 McKee Place Suite 600, Pittsburgh, PA, 15213, USA; Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 De Soto Street, Pittsburgh, PA, 15261, USA
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Moyo P, Zhao X, Thorpe CT, Thorpe JM, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Donohue JM, Hausmann LRM, Hanlon JT, Good CB, Fine MJ, Gellad WF. Dual Receipt of Prescription Opioids From the Department of Veterans Affairs and Medicare Part D and Prescription Opioid Overdose Death Among Veterans: A Nested Case-Control Study. Ann Intern Med 2019; 170:433-442. [PMID: 30856660 PMCID: PMC6736692 DOI: 10.7326/m18-2574] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND More than half of enrollees in the U.S. Department of Veterans Affairs (VA) are also covered by Medicare and can choose to receive their prescriptions from VA or from Medicare-participating providers. Such dual-system care may lead to unsafe opioid use if providers in these 2 systems do not coordinate care or if prescription use is not tracked between systems. OBJECTIVE To evaluate the association between dual-system opioid prescribing and death from prescription opioid overdose. DESIGN Nested case-control study. SETTING VA and Medicare Part D. PARTICIPANTS Case and control patients were identified from all veterans enrolled in both VA and Part D who filled at least 1 opioid prescription from either system. The 215 case patients who died of a prescription opioid overdose in 2012 or 2013 were matched (up to 1:4) with 833 living control patients on the basis of date of death (that is, index date), using age, sex, race/ethnicity, disability, enrollment in Medicaid or low-income subsidies, managed care enrollment, region and rurality of residence, and a medication-based measure of comorbid conditions. MEASUREMENTS The exposure was the source of opioid prescriptions within 6 months of the index date, categorized as VA only, Part D only, or VA and Part D (that is, dual use). The outcome was unintentional or undetermined-intent death from prescription opioid overdose, identified from the National Death Index. The association between this outcome and source of opioid prescriptions was estimated using conditional logistic regression with adjustment for age, marital status, prescription drug monitoring programs, and use of other medications. RESULTS Among case patients, the mean age was 57.3 years (SD, 9.1), 194 (90%) were male, and 181 (84%) were non-Hispanic white. Overall, 60 case patients (28%) and 117 control patients (14%) received dual opioid prescriptions. Dual users had significantly higher odds of death from prescription opioid overdose than those who received opioids from VA only (odds ratio [OR], 3.53 [95% CI, 2.17 to 5.75]; P < 0.001) or Part D only (OR, 1.83 [CI, 1.20 to 2.77]; P = 0.005). LIMITATION Data are from 2012 to 2013 and cannot capture prescriptions obtained outside the VA or Medicare Part D systems. CONCLUSION Among veterans enrolled in VA and Part D, dual use of opioid prescriptions was independently associated with death from prescription opioid overdose. This risk factor for fatal overdose among veterans underscores the importance of care coordination across health care systems to improve opioid prescribing safety. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
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Affiliation(s)
- Patience Moyo
- Brown University School of Public Health, Providence, Rhode Island (P.M.)
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - Carolyn T Thorpe
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina (C.T.T., J.M.T.)
| | - Joshua M Thorpe
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina (C.T.T., J.M.T.)
| | - Florentina E Sileanu
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - John P Cashy
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - Jennifer A Hale
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - Maria K Mor
- VA Pittsburgh Healthcare System and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (M.K.M., J.M.D.)
| | - Thomas R Radomski
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F.)
| | - Julie M Donohue
- VA Pittsburgh Healthcare System and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (M.K.M., J.M.D.)
| | - Leslie R M Hausmann
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F.)
| | - Joseph T Hanlon
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania; VA Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, Pennsylvania (J.T.H.)
| | - Chester B Good
- VA Pittsburgh Healthcare System, University of Pittsburgh School of Medicine, and UPMC Health Plan, Pittsburgh, Pennsylvania (C.B.G.)
| | - Michael J Fine
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F.)
| | - Walid F Gellad
- VA Pittsburgh Healthcare System, and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (W.F.G.)
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Chinman M, Gellad WF, McCarthy S, Gordon AJ, Rogal S, Mor MK, Hausmann LRM. Protocol for evaluating the nationwide implementation of the VA Stratification Tool for Opioid Risk Management (STORM). Implement Sci 2019; 14:5. [PMID: 30658658 PMCID: PMC6339438 DOI: 10.1186/s13012-019-0852-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 12/18/2018] [Accepted: 01/07/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Mitigating the risks of adverse outcomes from opioids is critical. Thus, the Veterans Affairs (VA) Healthcare System developed the Stratification Tool for Opioid Risk Management (STORM), a dashboard to assist clinicians with opioid risk evaluation and mitigation. Updated daily, STORM calculates a "risk score" of adverse outcomes (e.g., suicide-related events, overdoses, overdose death) from variables in the VA medical record for all patients with an opioid prescription and displays this information along with documentation of recommended risk mitigation strategies and non-opioid pain treatments. In March 2018, the VA issued a policy notice requiring VA Medical Centers (VAMCs) to complete case reviews for patients whom STORM identifies as very high-risk (i.e., top 1% of STORM risk scores). Half of VAMCs were randomly assigned notices that also stated that additional support and oversight would be required for VAMCs that failed to meet an established percentage of case reviews. Using a stepped-wedge cluster randomized design, VAMCs will be further randomized to conduct case reviews for an expanded pool of patients (top 5% of STORM risk scores vs. 1%) starting either 9 or 15 months after the notice was released, creating four natural arms. VA commissioned an evaluation to understand the implementation strategies and factors associated with case review completion rates, whose protocol is described in this report. METHODS This mixed-method study will include an online survey of all VAMCs to identify implementation strategies and interviews at a subset of facilities to identify implementation barriers and facilitators. The survey is based on the Expert Recommendations for Implementing Change (ERIC) project, which engaged experts to create consensus on 73 implementation strategies. We will use regression models to compare the number and types of implementation strategies across arms and their association with case review completion rates. Using questions from the Consolidated Framework for Implementation Research, we will interview stakeholders at 40 VAMCs with the highest and lowest adherence to opioid therapy guidelines. DISCUSSION By identifying which implementation strategies, barriers, and facilitators influence case reviews to reduce opioid-related adverse outcomes, this unique implementation evaluation will enable the VA to improve the design of future opioid safety initiatives. TRIAL REGISTRATION This project is registered at the ISRCTN Registry with number ISRCTN16012111 . The trial was first registered on 5/3/2017.
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Affiliation(s)
- Matthew Chinman
- Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh, Pittsburgh, PA USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh, Pittsburgh, PA USA
- RAND Corporation, Pittsburgh, PA USA
- VA Pittsburgh Healthcare System, Research Office Building (151R), University Drive C, Pittsburgh, PA 15240 USA
| | - Walid F. Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh, Pittsburgh, PA USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Sharon McCarthy
- Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh, Pittsburgh, PA USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh, Pittsburgh, PA USA
| | - Adam J. Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy, University of Utah School of Medicine, Salt Lake City, UT USA
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT USA
| | - Shari Rogal
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh, Pittsburgh, PA USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA USA
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Maria K. Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh, Pittsburgh, PA USA
| | - Leslie R. M. Hausmann
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh, Pittsburgh, PA USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA USA
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Judge-Golden CP, Borrero S, Zhao X, Mor MK, Callegari LS. The Association between Mental Health Disorders and History of Unintended Pregnancy among Women Veterans. J Gen Intern Med 2018; 33:2092-2099. [PMID: 30187377 PMCID: PMC6258629 DOI: 10.1007/s11606-018-4647-8] [Citation(s) in RCA: 11] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 07/18/2018] [Accepted: 08/21/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Women Veterans have high rates of mental health disorders and other psychosocial factors which may render this population particularly vulnerable to negative health outcomes associated with unintended pregnancy. OBJECTIVE The objective of our study was to assess the relationship between self-reported mental illness and history of unintended pregnancy among women Veterans. DESIGN AND PARTICIPANTS Data are from a nationally representative, cross-sectional telephone survey of women Veterans, ages 18-45, who used VA for primary care within 12 months prior to interview (survey completion rate 83%). MAIN MEASURES Predictors were self-report of any and number of mental health disorders (depression, anxiety, post-traumatic stress disorder, bipolar disorder, or schizophrenia). Outcomes were any and number of unintended pregnancies. Multivariable logistic and negative binomial regression were used to assess relationships between mental illness and unintended pregnancy. To assess women's current risk of unintended pregnancy, we examined associations between any mental health disorder and contraceptive use at last sex among heterosexually active women not desiring pregnancy. KEY RESULTS Among 2297 women Veterans, 1580 (68.8%) reported a history of at least one mental health disorder, with 20.1, 21.6, and 27.0% reporting one, two, or three or more conditions, respectively. Any history of unintended pregnancy was reported by 1315 women (57.3%); 28.3% reported one, 15.6% reported two, and 13.4% reported three or more. Compared to women with no mental illness, women with any mental health disorder were more likely to report any unintended pregnancy (60.3 vs. 50.5%; adjusted OR 1.40; 95% CI 1.15, 1.71) and to have experienced greater numbers of unintended pregnancies (adjusted incidence rate ratio 1.29; 95% CI 1.15, 1.44). Increasing numbers of mental health disorders were associated with greater numbers of unintended pregnancies. Contraceptive use and method efficacy at last sex did not differ by mental health status. CONCLUSIONS Women Veterans with mental health disorders are more likely to have experienced any and greater numbers of unintended pregnancies than Veterans without mental health disorders.
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Affiliation(s)
| | - Sonya Borrero
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, PA, USA.,Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Xinhua Zhao
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, PA, USA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lisa S Callegari
- Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, WA, USA.,Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA, USA
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Rondon-Berrios H, Tandukar S, Mor MK, Ray EC, Bender FH, Kleyman TR, Weisbord SD. Urea for the Treatment of Hyponatremia. Clin J Am Soc Nephrol 2018; 13:1627-1632. [PMID: 30181129 PMCID: PMC6237061 DOI: 10.2215/cjn.04020318] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [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] [Received: 03/29/2018] [Accepted: 08/07/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Current therapies for hyponatremia have variable effectiveness and tolerability, and in certain instances, they are very expensive. We examined the effectiveness, safety, and tolerability of urea for the treatment of inpatient hyponatremia. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We identified all patients hospitalized at the University of Pittsburgh Medical Center between July 2016 and August 2017 with hyponatremia (plasma sodium <135 mEq/L) who received urea, including a subgroup of patients who received urea as the sole drug therapy for hyponatremia (urea-only treated). We matched urea only-treated patients to a group of patients with hyponatremia who did not receive urea (urea untreated) and compared changes in plasma sodium at 24 hours and the end of therapy as well as the proportion of patients who achieved plasma sodium ≥135 mEq/L. We abstracted data on adverse events and reported side effects of urea. RESULTS Fifty-eight patients received urea (7.5-90 g/d) over a median of 4.5 (interquartile range, 3-8) days and showed an increase in plasma sodium from 124 mEq/L (interquartile range, 122-126) to 131 mEq/L (interquartile range, 127-134; P<0.001). Among 12 urea only-treated patients, plasma sodium increased from 125 mEq/L (interquartile range, 122-127) to 131 mEq/L (interquartile range, 129-136; P=0.001) by the end of urea therapy. There was a larger increase in plasma sodium at 24 hours in urea only-treated patients compared with urea-untreated patients (2.5 mEq/L; interquartile range, 0-4.5 versus -0.5 mEq/L; interquartile range, -2.5 to 1.5; P=0.04), with no difference in change in plasma sodium by the end of therapy (6 mEq/L; interquartile range, 3.5-10 versus 5.5 mEq/L; interquartile range, 3-7.5; P=0.51). A greater proportion of urea only-treated patients achieved normonatremia, but this difference was not statistically significant (33% versus 8%; P=0.08). No patients experienced overly rapid correction of plasma sodium, and no serious adverse events were reported. CONCLUSIONS Urea seems effective and safe for the treatment of inpatient hyponatremia, and it is well tolerated.
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Affiliation(s)
| | | | - Maria K. Mor
- Department of Biostatistics, Graduate School of Public Health, and
- Center for Health Equity Research and Promotion and
| | - Evan C. Ray
- Renal-Electrolyte Division, Department of Medicine
| | | | - Thomas R. Kleyman
- Renal-Electrolyte Division, Department of Medicine
- Departments of Cell Biology and
- Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Steven D. Weisbord
- Renal-Electrolyte Division, Department of Medicine
- Center for Health Equity Research and Promotion and
- Renal Section, Medicine Service Line, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Carico R, Zhao X, Thorpe CT, Thorpe JM, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Hausmann LRM, Donohue JM, Suda KJ, Stroupe K, Hanlon JT, Good CB, Fine MJ, Gellad WF. Receipt of Overlapping Opioid and Benzodiazepine Prescriptions Among Veterans Dually Enrolled in Medicare Part D and the Department of Veterans Affairs: A Cross-sectional Study. Ann Intern Med 2018; 169:593-601. [PMID: 30304353 PMCID: PMC6219924 DOI: 10.7326/m18-0852] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Overlapping use of opioids and benzodiazepines is associated with increased risk for overdose. Veterans receiving medications concurrently from the U.S. Department of Veterans Affairs (VA) and Medicare may be at higher risk for such overlap. OBJECTIVE To assess the association between dual use of VA and Medicare drug benefits and receipt of overlapping opioid and benzodiazepine prescriptions. DESIGN Cross-sectional. SETTING VA and Medicare. PARTICIPANTS All veterans enrolled in VA and Medicare Part D who filled at least 2 opioid prescriptions in 2013 (n = 368 891). MEASUREMENTS Outcomes were the proportion of patients with a Pharmacy Quality Alliance (PQA) measure of opioid-benzodiazepine overlap (≥2 filled prescriptions for benzodiazepines with ≥30 days of overlap with opioids) and the proportion of patients with high-dose opioid-benzodiazepine overlap (≥30 days of overlap with a daily opioid dose >120 morphine milligram equivalents). Augmented inverse probability weighting regression was used to compare these measures by prescription drug source: VA only, Medicare only, or VA and Medicare (dual use). RESULTS Of 368 891 eligible veterans, 18.3% received prescriptions from the VA only, 30.3% from Medicare only, and 51.4% from both VA and Medicare. The proportion with PQA opioid-benzodiazepine overlap was larger for the dual-use group than the VA-only group (23.1% vs. 17.3%; adjusted risk ratio [aRR], 1.27 [95% CI, 1.24 to 1.30]) and Medicare-only group (23.1% vs. 16.5%; aRR, 1.12 [CI, 1.10 to 1.14]). The proportion with high-dose overlap was also larger for the dual-use group than the VA-only group (4.7% vs. 2.3%; aRR, 2.23 [CI, 2.10 to 2.36]) and Medicare-only group (4.7% vs. 2.9%; aRR, 1.06 [CI, 1.02 to 1.11]). LIMITATION Data are from 2013 and cannot capture medications purchased without insurance; unmeasured confounding may remain in this cross-sectional study. CONCLUSION Among a national cohort of veterans dually enrolled in VA and Medicare, receiving prescriptions from both sources was associated with greater risk for receiving potentially unsafe overlapping prescriptions for opioids and benzodiazepines. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
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Affiliation(s)
- Ron Carico
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (R.C., X.Z., F.E.S., J.P.C., J.A.H.)
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (R.C., X.Z., F.E.S., J.P.C., J.A.H.)
| | - Carolyn T Thorpe
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and University of North Carolina School of Pharmacy, Chapel Hill, North Carolina (C.T.T., J.M.T.)
| | - Joshua M Thorpe
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and University of North Carolina School of Pharmacy, Chapel Hill, North Carolina (C.T.T., J.M.T.)
| | - Florentina E Sileanu
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (R.C., X.Z., F.E.S., J.P.C., J.A.H.)
| | - John P Cashy
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (R.C., X.Z., F.E.S., J.P.C., J.A.H.)
| | - Jennifer A Hale
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (R.C., X.Z., F.E.S., J.P.C., J.A.H.)
| | - Maria K Mor
- VA Pittsburgh Healthcare System and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (M.K.M., J.M.D.)
| | - Thomas R Radomski
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F., W.F.G.)
| | - Leslie R M Hausmann
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F., W.F.G.)
| | - Julie M Donohue
- VA Pittsburgh Healthcare System and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (M.K.M., J.M.D.)
| | - Katie J Suda
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania; Edward Hines, Jr. VA Hospital and University of Illinois at Chicago College of Pharmacy, Chicago, Illinois (K.J.S.)
| | - Kevin Stroupe
- Edward Hines, Jr. VA Hospital, Chicago, Illinois (K.S.)
| | - Joseph T Hanlon
- VA Pittsburgh Healthcare System, University of Pittsburgh School of Medicine, and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (J.T.H.)
| | - Chester B Good
- VA Pittsburgh Healthcare System, University of Pittsburgh School of Medicine, and UPMC Health Plan, Pittsburgh, Pennsylvania (C.B.G.)
| | - Michael J Fine
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F., W.F.G.)
| | - Walid F Gellad
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F., W.F.G.)
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Niznik JD, Zhang S, Mor MK, Zhao X, Ersek M, Aspinall SL, Gellad WF, Thorpe JM, Hanlon JT, Schleiden LJ, Springer S, Thorpe CT. Adaptation and Initial Validation of Minimum Data Set (MDS) Mortality Risk Index to MDS Version 3.0. J Am Geriatr Soc 2018; 66:2353-2359. [PMID: 30335184 DOI: 10.1111/jgs.15579] [Citation(s) in RCA: 11] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the predictive validity of an adapted version of the Minimum Data Set (MDS) Mortality Risk Index-Revised (MMRI-R) based on MDS version 3.0 assessment items (MMRI-v3) and to compare the predictive validity of the MMRI-v3 with that of a single MDS item indicating limited life expectancy (LLE). DESIGN Retrospective, cross-sectional study of MDS assessments. Other data sources included the Veterans Affairs (VA) Residential History File and Vital Status File. SETTING VA nursing homes (NHs). PARTICIPANTS Veterans aged 65 and older newly admitted to VA NHs between July 1, 2012, and September 30, 2015. MEASUREMENTS The dependent variable was death within 6 months of admission date. Independent variables included MDS items used to calculate MMRI-v3 scores (renal failure, chronic heart failure, sex, age, dehydration, cancer, unintentional weight loss, shortness of breath, activity of daily living scale, poor appetite, acute change in mental status) and the MDS item indicating LLE. RESULTS The predictive ability of the MMRI-v3 for 6-month mortality (c-statistic 0.81) is as good as that of the original MMRI-R (c-statistic 0.76). Scores generated using the MMRI-v3 had greater predictive ability than that of the single MDS indicator for LLE (c-statistic 0.76); using the 2 together resulted in greater predictive ability (c-statistic 0.86). CONCLUSION The MMRI-v3 is a useful tool in research and clinical practice that accurately predicts 6-month mortality in veterans residing in Veterans Affairs NHs. Identification of residents with LLE has great utility for studying palliative care interventions and may be helpful in guiding allocation of these services in clinical practice. J Am Geriatr Soc 66:2353-2359, 2018.
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Affiliation(s)
- Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania.,Geriatric Division, School of Medicine, Pittsburgh, Pennsylvania
| | - Song Zhang
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Mary Ersek
- National PROMISE Center; Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sherrie L Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania.,Veterans Affairs Center for Medication Safety, Hines, Illinois
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania.,Geriatric Division, School of Medicine, Pittsburgh, Pennsylvania
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania
| | - Sydney Springer
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania
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Moyo P, Zhao X, Thorpe CT, Thorpe JM, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Donohue JM, Hausmann LRM, Hanlon JT, Good CB, Fine MJ, Gellad WF. Patterns of opioid prescriptions received prior to unintentional prescription opioid overdose death among Veterans. Res Social Adm Pharm 2018; 15:1007-1013. [PMID: 30385111 DOI: 10.1016/j.sapharm.2018.10.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 03/29/2018] [Revised: 07/24/2018] [Accepted: 10/17/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Few studies have assessed prescription opioid supply preceding death in individuals dying from unintentional prescription opioid overdoses, or described the characteristics of these individuals, particularly among Veterans. OBJECTIVES To describe the history of prescription opioid supply preceding prescription opioid overdose death among Veterans. METHODS In a national cohort of Veterans who filled ≥1 opioid prescriptions from the Veterans Health Administration (VA) or Medicare Part D during 2008-2013, we identified deaths from unintentional or undetermined-intent prescription opioid overdoses in 2012-2013. We captured opioid prescriptions using both linked VA and Part D data, and VA data only. RESULTS Among 1181 decedents, 643 (54.4%) had prescription opioid supply on the day of death, and 735 (62.2%) within 30 days based on linked data, compared to 40.1% and 46.7%, respectively, using VA data alone. Decedents with prescription opioid supply were significantly older and less likely to have alcohol or illicit drugs as co-occurring substances involved in the overdose. Using linked data, 241 (20.4%) decedents lacked prescription opioid supply within a year of death. CONCLUSIONS Many VA patients who die from prescription opioid overdose receive opioid prescriptions outside VA or not at all. It is important to supplement VA with non-VA data to more accurately measure prescription opioid exposure and improve opioid medication safety.
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Affiliation(s)
- Patience Moyo
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - John P Cashy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jennifer A Hale
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Julie M Donohue
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA; Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA; Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Center for Value Based Pharmaceutical Initiatives, UPMC Health Plan, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh Health Policy Institute, Pittsburgh, PA, USA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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50
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Thorpe CT, Gellad WF, Mor MK, Cashy JP, Pleis JR, Van Houtven CH, Schleiden LJ, Hanlon JT, Niznik JD, Carico RL, Good CB, Thorpe JM. Effect of Dual Use of Veterans Affairs and Medicare Part D Drug Benefits on Antihypertensive Medication Supply in a National Cohort of Veterans with Dementia. Health Serv Res 2018; 53 Suppl 3:5375-5401. [PMID: 30328097 DOI: 10.1111/1475-6773.13055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 02/03/2023] Open
Abstract
OBJECTIVE To evaluate the effect of dual use of VA/Medicare Part D drug benefits on antihypertensive medication supply in older Veterans with dementia. DATA SOURCES/STUDY SETTING National, linked 2007-2010 Veterans Affairs (VA) and Medicare utilization and prescription records for 50,763 dementia patients with hypertension. STUDY DESIGN We used inverse probability of treatment (IPT)-weighted multinomial logistic regression to examine the association of dual prescription use with undersupply and oversupply of antihypertensives. DATA COLLECTION/EXTRACTION METHODS Veterans Affairs and Part D prescription records were used to classify patients as VA-only, Part D-only, or dual VA/Part D users of antihypertensives and summarize their antihypertensive medication supply in 2010: (1) appropriate supply of all prescribed antihypertensive classes, (2) undersupply of ≥1 class with no oversupply of another class, (3) oversupply of ≥1 class with no undersupply, or (4) both undersupply and oversupply. PRINCIPAL FINDINGS Dual prescription users were more likely than VA-only users to have undersupply only (aOR = 1.28; 95 percent CI = 1.18-1.39), oversupply only (aOR = 2.38; 95 percent CI = 2.15-2.64), and concurrent under- and oversupply (aOR = 2.89; 95 percent CI = 2.53-3.29), versus appropriate supply of all classes. CONCLUSIONS Obtaining antihypertensives through both VA and Part D was associated with increased antihypertensive under- and oversupply. Efforts to understand how best to coordinate dual-system prescription use are critically needed.
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Affiliation(s)
- Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,School of Medicine and Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - John P Cashy
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - John R Pleis
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Courtney H Van Houtven
- Durham Veterans Affairs Health Care System, VA Medical Center (152), Durham, NC.,Duke University School of Medicine, VA Medical Center (152), Durham, NC
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of Pittsburgh School of Pharmacy, Pittsburgh, PA.,Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ronald L Carico
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Center for High Value Pharmaceutical Purchasing, UPMC Health Plan, Pittsburgh, PA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
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