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Cheng D, DuMontier C, Yildirim C, Charest B, Hawley CE, Zhuo M, Paik JM, Yaksic E, Gaziano JM, Do N, Brophy M, Cho K, Kim DH, Driver JA, Fillmore NR, Orkaby AR. Updating and Validating the U.S. Veterans Affairs Frailty Index: Transitioning From ICD-9 to ICD-10. J Gerontol A Biol Sci Med Sci 2021; 76:1318-1325. [PMID: 33693638 PMCID: PMC8202143 DOI: 10.1093/gerona/glab071] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The Veterans Affairs Frailty Index (VA-FI) is an electronic frailty index developed to measure frailty using administrative claims and electronic health records data in Veterans. An update to ICD-10 coding is needed to enable contemporary measurement of frailty. METHOD International Classification of Diseases, ninth revision (ICD-9) codes from the original VA-FI were mapped to ICD-10 first using the Centers for Medicaid and Medicare Services (CMS) General Equivalence Mappings. The resulting ICD-10 codes were reviewed by 2 geriatricians. Using a national cohort of Veterans aged 65 years and older, the prevalence of deficits contributing to the VA-FI and associations between the VA-FI and mortality over years 2012-2018 were examined. RESULTS The updated VA-FI-10 includes 6422 codes representing 31 health deficits. Annual cohorts defined on October 1 of each year included 2 266 191 to 2 428 115 Veterans, for which the mean age was 76 years, 97%-98% were male, 78%-79% were White, and the mean VA-FI was 0.20-0.22. The VA-FI-10 deficits showed stability before and after the transition to ICD-10 in 2015, and maintained strong associations with mortality. Patients classified as frail (VA-FI > 0.2) consistently had a hazard of death more than 2 times higher than nonfrail patients (VA-FI ≤ 0.1). Distributions of frailty and associations with mortality varied with and without linkage to CMS data and with different assessment periods for capturing deficits. CONCLUSIONS The updated VA-FI-10 maintains content validity, stability, and predictive validity for mortality in a contemporary cohort of Veterans aged 65 years and older, and may be applied to ICD-9 and ICD-10 claims data to measure frailty.
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Affiliation(s)
- David Cheng
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Clark DuMontier
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Cenk Yildirim
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Brian Charest
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Chelsea E Hawley
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
| | - Min Zhuo
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Julie M Paik
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
| | - Enzo Yaksic
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - J Michael Gaziano
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Nhan Do
- Boston VA Cooperative Studies Program, Massachusetts, USA
- Boston University School of Medicine, Massachusetts, USA
| | - Mary Brophy
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Kelly Cho
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
| | - Dae H Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Jane A Driver
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nathanael R Fillmore
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ariela R Orkaby
- New England ‡, GRECC (Geriatrics Research, Education and Clinical Center), VA Boston Healthcare System, Massachusetts, USA
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Maynard C, Boyko EJ. Differences in cause of death of Washington State veterans who did and did not use Department of Veterans Affairs healthcare services. ACTA ACUST UNITED AC 2008; 43:825-30. [PMID: 17436169 DOI: 10.1682/jrrd.2006.01.0004] [Citation(s) in RCA: 5] [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: 11/05/2022]
Abstract
Relatively little is known about the cause of death in the veteran population, although more is known about the cause of death in Vietnam veterans or veterans receiving mental health services. This article compares characteristics and causes of death in Washington State veterans who did and did not use Department of Veterans Affairs (VA) healthcare services in the 5 years prior to death. This study included 62,080 veterans who died between 1998 and 2002, of whom 21% were users of VA healthcare services. The veterans who used VA healthcare services were younger, more often men, less educated, more often divorced, and more often smokers than the veterans who did not use VA healthcare services. Both female and male veterans who used VA healthcare services were more likely to die from drug- and/or alcohol-related causes. These findings suggest that the VA patient population is socially disadvantaged and more severely affected by substance-use disorders compared with veterans who do not use VA healthcare services.
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Affiliation(s)
- Charles Maynard
- Department of Veterans Affairs Epidemiologic Research and Information Center (152), 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA.
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Goodrich SG. Modeling an Integrative Physical Examination Program for the Departments of Defense and Veterans Affairs. Mil Med 2006; 171:962-6. [PMID: 17076447 DOI: 10.7205/milmed.171.10.962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Current policies governing the Departments of Defense and Veterans Affairs physical examination programs are out of step with current evidence-based medical practice. Replacing periodic and other routine physical examination types with annual preventive health assessments would afford our service members additional health benefit at reduced cost. Additionally, the Departments of Defense and Veterans Affairs repeat the physical examination process at separation and have been unable to reconcile their respective disability evaluation systems to reduce duplication and waste. A clear, coherent, and coordinated strategy to improve the relevance and utility of our physical examination programs is long overdue. This article discusses existing physical examination programs and proposes a model for a new integrative physical examination program based on need, science, and common sense.
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Affiliation(s)
- Scott G Goodrich
- Department of Veterans Affairs, Veterans Health Administration, VA/DoD Liaison Office, 810 Vermont Avenue NW, Washington, DC 20420, USA
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Abstract
OBJECTIVES This research examines the relationship of veteran status with functional status transitions in older Americans. METHODS Data for this study come from the Survey of Asset and Health Dynamics among the Oldest Old. We use a structural multinomial logit model to decompose the effect of older veterans into the direct effect and the indirect effects via physical health conditions and mental disorders on functional status transitions. RESULTS Although there is no distinct association among those functionally independent at baseline, veteran status significantly impacts age-dependent transitions from functional dependence to other statuses. At age 85, the excess mortality and the lower level of functional resolution among functionally dependent veterans are considerable. CONCLUSIONS Physical health is more important than mental health in transmitting the effect of veteran status on functional status transitions in functionally dependent persons.
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Affiliation(s)
- Xian Liu
- Deployment Health Clinical Center, Building 2, Room 3G04, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307, USA
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Kramer BJ, Wang M, Hoang T, Harker JO, Finke B, Saliba D. Identification of American Indian and Alaska Native veterans in administrative data of the Veterans Health Administration and the Indian Health Service. Am J Public Health 2006; 96:1577-8. [PMID: 16873744 PMCID: PMC1551963 DOI: 10.2105/ajph.2005.073205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [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: 11/04/2022]
Abstract
We sought to determine the extent to which the Indian Health Service (IHS) identified enrollees who also use the Veterans Health Administration (VHA) as veterans. We used a bivariate analysis of administrative data from fiscal years 2002-2003 to study the target population. Of the 32259 IHS enrollees who received care as veterans in the VHA, only 44% were identified by IHS as veterans. IHS data underestimates the number of veterans, and both IHS and VHA need mechanisms to recognize mutual beneficiaries in order to facilitate better coordination of strategic planning and resource sharing among federal health care agencies.
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Affiliation(s)
- B Josea Kramer
- Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Geriatric Research Education and Clinical Center, and the David Geffen School of Medicine, University of California, Los Angeles, CA 91343, USA.
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Wells TS, Wang LZ, Spooner CN, Smith TC, Hiliopoulos KM, Kamens DR, Gray GC, Sato PA. Self-reported reproductive outcomes among male and female 1991 Gulf War era US military veterans. Matern Child Health J 2006; 10:501-10. [PMID: 16832610 DOI: 10.1007/s10995-006-0122-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2005] [Accepted: 05/09/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Following the 1991 Gulf War, some veterans expressed concerns regarding their reproductive health. Our objective was to assess whether an association exists between deployment to the 1991 Gulf War and self-reported adverse pregnancy outcomes. METHODS Using a modified Dillman technique with telephone follow-up, we conducted a survey via a postal questionnaire from February 1996-August 1997 to compare selected reproductive outcomes among 10,000 US veterans deployed to the 1991 Gulf War with those of 10,000 nondeployed Gulf War era veterans. RESULTS A total of 8742 individuals responded to the survey, a response rate of 51 percent. Using multivariable analyses, results showed no differences in number of reported pregnancies between Gulf War veterans and nondeployed veterans. Among 2233 female and 2159 male participants, there were no differences in birth weight of infants born to Gulf War veterans compared with nondeployed Gulf War era veterans. In multivariable models, male and female Gulf War veterans did not significantly differ in risk for ectopic pregnancies, stillbirths, or miscarriages when compared with nondeployed veterans of the same era. CONCLUSIONS These results do not suggest an association between service in the 1991 Gulf War and adverse reproductive outcomes for both male and female veterans during the 4 years after the war.
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Affiliation(s)
- Timothy S Wells
- Department of Defense Center for Deployment Health Research, Naval Health Research Center, San Diego, CA, USA.
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Glass DC, Sim MR, Kelsall HL, Ikin JF, McKenzie D, Forbes A, Ittak P. What Was Different about Exposures Reported by Male Australian Gulf War Veterans for the 1991 Persian Gulf War, Compared with Exposures Reported for Other Deployments? Mil Med 2006; 171:632-8. [PMID: 16895130 DOI: 10.7205/milmed.171.7.632] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [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: 11/11/2022] Open
Abstract
This study identified chemical and environmental exposures specifically associated with the 1991 Persian Gulf War. Exposures were self-reported in a postal questionnaire, in the period of 2000-2002, by 1,424 Australian male Persian Gulf War veterans in relation to their 1991 Persian Gulf War deployment and by 625 Persian Gulf War veterans and 514 members of a military comparison group in relation to other active deployments. Six of 28 investigated exposures were experienced more frequently during the Persian Gulf War than during other deployments; these were exposure to smoke (odds ratio [OR], 4.4; 95% confidence interval, 3.0-6.6), exposure to dust (OR, 3.7; 95% confidence interval, 2.6-5.3), exposure to chemical warfare agents (OR, 3.9; 95% confidence interval, 2.1-7.9), use of respiratory protective equipment (OR, 13.6; 95% confidence interval, 7.6-26.8), use of nuclear, chemical, and biological protective suits (OR, 8.9; 95% confidence interval, 5.4-15.4), and entering/inspecting enemy equipment (OR, 3.1; 95% confidence interval, 2.1-4.8). Other chemical and environmental exposures were not specific to the Persian Gulf War deployment but were also reported in relation to other deployments. The number of exposures reported was related to service type and number of deployments but not to age or rank.
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Affiliation(s)
- Deborah C Glass
- Monash University, Department of Epidemiology and Preventive Medicine, Central and Eastern Clinical School, Alfred Hospital, Melbourne, Victoria 3004, Australia
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Wendel CS, Shah JH, Duckworth WC, Hoffman RM, Mohler MJ, Murata GH. Racial and ethnic disparities in the control of cardiovascular disease risk factors in Southwest American veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study. BMC Health Serv Res 2006; 6:58. [PMID: 16716235 PMCID: PMC1513224 DOI: 10.1186/1472-6963-6-58] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2005] [Accepted: 05/23/2006] [Indexed: 01/15/2023] Open
Abstract
Background Racial/ethnic disparities in cardiovascular disease complications have been observed in diabetic patients. We examined the association between race/ethnicity and cardiovascular disease risk factor control in a large cohort of insulin-treated veterans with type 2 diabetes. Methods We conducted a cross-sectional observational study at 3 Veterans Affairs Medical Centers in the American Southwest. Using electronic pharmacy databases, we randomly selected 338 veterans with insulin-treated type 2 diabetes. We collected medical record and patient survey data on diabetes control and management, cardiovascular disease risk factors, comorbidity, demographics, socioeconomic factors, psychological status, and health behaviors. We used analysis of variance and multivariate linear regression to determine the effect of race/ethnicity on glycemic control, insulin treatment intensity, lipid levels, and blood pressure control. Results The study cohort was comprised of 72 (21.3%) Hispanic subjects (H), 35 (10.4%) African Americans (AA), and 226 (67%) non-Hispanic whites (NHW). The mean (SD) hemoglobin A1c differed significantly by race/ethnicity: NHW 7.86 (1.4)%, H 8.16 (1.6)%, AA 8.84 (2.9)%, p = 0.05. The multivariate-adjusted A1c was significantly higher for AA (+0.93%, p = 0.002) compared to NHW. Insulin doses (unit/day) also differed significantly: NHW 70.6 (48.8), H 58.4 (32.6), and AA 53.1 (36.2), p < 0.01. Multivariate-adjusted insulin doses were significantly lower for AA (-17.8 units/day, p = 0.01) and H (-10.5 units/day, p = 0.04) compared to NHW. Decrements in insulin doses were even greater among minority patients with poorly controlled diabetes (A1c ≥ 8%). The disparities in glycemic control and insulin treatment intensity could not be explained by differences in age, body mass index, oral hypoglycemic medications, socioeconomic barriers, attitudes about diabetes care, diabetes knowledge, depression, cognitive dysfunction, or social support. We found no significant racial/ethnic differences in lipid or blood pressure control. Conclusion In our cohort, insulin-treated minority veterans, particularly AA, had poorer glycemic control and received lower doses of insulin than NHW. However, we found no differences for control of other cardiovascular disease risk factors. The diabetes treatment disparity could be due to provider behaviors and/or patient behaviors or preferences. Further research with larger sample sizes and more geographically diverse populations are needed to confirm our findings.
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Affiliation(s)
| | - Jayendra H Shah
- Southern Arizona VA Health Care System, Tucson, AZ, 85723, USA
- University of Arizona College of Medicine, Tucson, AZ, 85724, USA
| | - William C Duckworth
- University of Arizona College of Medicine, Tucson, AZ, 85724, USA
- Carl T. Hayden VA Medical Center, Phoenix, AZ, 85012, USA
| | - Richard M Hoffman
- New Mexico VA Health Care System, Albuquerque, NM, 87108, USA
- University of New Mexico School of Medicine, Albuquerque, NM, 87131, USA
| | - M Jane Mohler
- Southern Arizona VA Health Care System, Tucson, AZ, 85723, USA
- University of Arizona College of Medicine, Tucson, AZ, 85724, USA
| | - Glen H Murata
- New Mexico VA Health Care System, Albuquerque, NM, 87108, USA
- University of New Mexico School of Medicine, Albuquerque, NM, 87131, USA
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Abstract
The objectives of this study were to describe the military experiences of Native American veterans and to explore how factors related to veteran identity influence their use of health services. Study participants completed a demographic and health questionnaire, followed by participation in a focus group session. The findings revealed that, despite their negative experiences during military service, most participants had a positive veteran identity. Almost 46% of participants reported having a service-related illness or injury. Almost one-third (28.2%) used the Indian Health Service (IHS) exclusively for their health care, followed by those who used both IHS and Veterans Affairs (VA) services (23.5%), followed by VA-only users (21.2%). We conclude that Native American veterans highly identify with their military service but may turn to IHS for their medical care. The data support the current VA policy of strengthening coordination with the IHS to ensure that the medical needs of Native American veterans are addressed.
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Affiliation(s)
- Nancy D Harada
- Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA 90073, USA
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10
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Abstract
Currently, the US Department of Veterans Affairs provides medical care to more than four million veterans across the nation. Given the limited resources and increasing demand, the US Department of Veterans Affairs Health Administration (VA) is required by law to ensure that veterans with similar economic status and eligibility priority have similar access to VA health care, regardless of where they reside. This study, using descriptive statistics and logistic regression techniques, examines the factors that affect veterans' eligibility-status changes. This study found that veterans' demographics are correlated with the likelihood of eligibility-status conversion. More importantly, this study concludes that eligibility-status changes have a geographic pattern. These findings are important and useful in planning workload, as well as improving equal access of health care.
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Affiliation(s)
- Jian Gao
- Department of Veterans Affairs (VA), Healthcare Network Upstate New York, Albany, NY 12208, USA.
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Abstract
OBJECTIVE This study investigated the prevalence of incarceration and the association with deployment among veterans of the first Persian Gulf War (GW). METHODS A structured telephone interview of military personnel from Iowa deployed to the Persian Gulf and a comparison sample of nondeployed military personnel was conducted. The interview consisted of validated questions, validated instruments, and investigator-derived questions to assess relevant medical and psychiatric conditions. A total of 4,886 subjects were randomly drawn from one of four study domains, i.e., GW regular military, GW National Guard/Reserve, non-GW regular military, or non-GW National Guard/Reserve. Symptoms of medical conditions, psychiatric disorders, and health care utilization were the main outcome measures. RESULTS Nearly one-quarter (845 of 3,695 subjects, 22.9%) had been incarcerated at some point before the interview ("ever incarcerated"). Ever incarcerated veterans had a higher frequency of psychiatric and medical comorbidity and higher rates of health care utilization. Ever incarcerated status was associated with male gender, enlisted rank, lower educational levels, low levels of military preparedness, discharge from service, cigarette smoking, antisocial traits, court martial and/or other military discipline, having seen a mental health professional, and having used illegal drugs. GW veterans who participated in combat had a modestly higher risk for incarceration after the GW than did noncombatants (odds ratio, 1.6; 95% confidence interval, 1.0-2.5). CONCLUSIONS Military recruits with a history of incarceration more often displayed problematic behaviors, more often developed psychiatric/medical conditions, and had high rates of health care utilization. A history of incarceration may be a behavioral marker for substance abuse, antisocial behavior, and mental illness. Importantly, GW deployment carried no increased risk of subsequent incarceration overall.
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Affiliation(s)
- Donald W Black
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
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Murdoch M, van Ryn M, Hodges J, Cowper D. Mitigating effect of Department of Veterans Affairs disability benefits for post-traumatic stress disorder on low income. Mil Med 2005; 170:137-40. [PMID: 15782835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
OBJECTIVE The goal was to assess the impact of Veterans Affairs (VA) disability benefits for post-traumatic stress disorder (PTSD) on veterans' odds of poverty. Women and African American veterans were of special interest, because they are less likely than other groups to receive PTSD disability benefits. METHODS A cross-sectional survey of 4,918 veterans who applied for VA disability benefits for PTSD between 1994 and 1998 was performed. Responses were linked to administrative data. RESULTS Overall, 42% reported low income (defined as household income less than or equal to 20,000 dollars per year). Men's and women's odds of reporting poverty were similar, but receipt of PTSD disability benefits mediated African American veterans' odds of poverty. Veterans' odds of impoverishment were reduced considerably if they received VA PTSD disability benefits and identified themselves as disabled. CONCLUSIONS VA disability benefits for PTSD reduced odds of impoverishment for psychiatrically ill veterans. This effect appeared to be especially important for African American veterans and for veterans self-identifying as disabled.
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Affiliation(s)
- Maureen Murdoch
- Minneapolis VAMC/Center for Chronic Disease Outcomes Research and Department of Medicine, University of Minnesota School of Medicine, One Veterans Drive (111-0), Minneapolis, MN 55417, USA
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Abstract
OBJECTIVES To establish the prevalence of major depressive episode (MDE) in a large sample of veterans with multiple sclerosis (MS); to identify demographic characteristics, aspects of disease presentation, and perceptions of disability associated with greater concurrent risk for MDE; and to examine the relationship between MDE, service utilization, and activity participation. METHODS Veterans with MS (n = 1,032) were identified via computer database and surveyed by mail; 451 (43.7%) responded. RESULTS Twenty-two percent of the sample met criteria for current MDE. Low income, unemployment, presence of falls, younger age, absence of a marital partner, and high levels of perceived disability due to bowel functioning were independently associated with MDE. Disease subtype, disease duration, use of disease modifying therapies, and perceived disability due to mobility or bladder problems were unrelated to MDE. Current MDE was in turn associated with increased primary care visits and increased impact of disease upon activity participation. Similar correlates were associated with minor depressive episode. CONCLUSIONS Unlike the general population, rates of depression in this predominantly male sample were similar to those found in predominantly female samples of persons with multiple sclerosis. Specific aspects of disability were differentially associated with depression, and depression was independently associated with increased service utilization and increased participation limitations.
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Affiliation(s)
- R M Williams
- Department of Veterans Administration Puget Sound Health Care System, Seattle Division, Rehabilitation Care Services, S-117, 1660 S. Columbian Way, Seattle, WA 98108, USA.
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Yu W, Ravelo A, Wagner TH, Barnett PG. The relationships among age, chronic conditions, and healthcare costs. Am J Manag Care 2004; 10:909-16. [PMID: 15617366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
OBJECTIVE To learn how age and chronic illness affect costs in the Veterans Affairs healthcare system. STUDY DESIGN Veterans Affairs patients 65 years or older were identified from administrative data. We noted their healthcare utilization, cost, and diagnosis of any of 29 common chronic conditions (CCs). We examined how those 80 years or older differed from the younger patients. RESULTS The Department of Veterans Affairs spent dollars 8.5 billion to treat 1.6 million older patients in fiscal year 2000. Age was less important than chronic illness in explaining cost differences. The oldest patients incurred a mean of dollars 1295 greater costs than the younger patients, primarily because they were more likely to have a high-cost CC. The oldest patients incurred higher total costs than the younger patients in only 14 of 29 groups defined by CC. Long-term care accounted for most of the extra cost of the oldest patients. When this cost was excluded, the oldest patients incurred only dollars 266 more cost than the younger patients. CONCLUSIONS Growth in the population of the oldest patients will increase the number of individuals with CCs requiring long-term care. With its limited long-term care benefit, Medicare will avoid much of this financial consequence. In contrast, the financial risk of acute and long-term care gives the Department of Veterans Affairs an incentive to develop strategies to prevent CCs associated with long-term care.
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Affiliation(s)
- Wei Yu
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA 94025, USA.
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Abstract
The purpose of this study was to compare the neuropsychological functioning of 12 veterans who were HIV-positive to 21 age-matched veterans who were HIV-negative. Consistent with expectations, the HIV-positive group was found to perform more poorly in areas related to attention and concentration, immediate and delayed verbal recall, immediate and delayed visual recall, visual learning, and tasks requiring psychomotor speed, while a number of language tasks were left intact. This was similar to dysfunction often seen in HIV-related dementia cases. However, this group was also significantly more impaired in confrontation naming, planning, mental calculations, and abstract thought when compared to the HIV-negative group. Comorbid substance abuse found in the majority of our HIV-positive subjects was thought to contribute to the HIV-related dysfunction.
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Abstract
OBJECTIVES Medicare administrative and claims files maintained by the Centers for Medicare and Medicaid Services (CMS) are frequently used to examine racial and ethnic disparities in healthcare use. However, identification of Hispanic ethnicity for beneficiaries in the Medicare claims files is problematic, greatly limiting the use of these administrative data for examining race/ethnicity differences. This article reports on 2 studies assessing the effectiveness of a Hispanic surname match for improving the accuracy of race/ethnicity codes for elderly males in the Medicare data sets. METHODS Study 1 used survey data to compare a Medicare race code + Spanish surname composite indicator to self-identification as Hispanic. Study 2 used Medicare administrative files and U.S. Census 2000 data to identify how well the Medicare race code alone and the Medicare race code + Spanish surname composite indicator compared with estimates obtained from census data for 16 U.S. counties dispersed across 5 states. RESULTS Using self-identification as the gold standard, including the Spanish surname match increased accuracy for Hispanics and whites compared with the Medicare race code alone. The Spanish surname match also dramatically improved the Medicare code's estimation of elderly Hispanic and white males compared with county-level census data. CONCLUSIONS Augmenting the Medicare race code with a match to Spanish surnames yields substantial improvement in the identification of elderly Hispanic and white non-Hispanic male Medicare beneficiaries. Using surname information to supplement the Medicare race code could greatly enhance researchers' ability to examine healthcare equity.
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Affiliation(s)
- Robert O Morgan
- Houston Center for Quality of Care and Utilization Studies, Houston Veterans Affairs Medical Center, Houston, Texas 77030, USA.
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Yi MS, Luckhaupt S, Mrus JM, Tsevat J. Do medical house officers value the health of veterans differently from the health of non-veterans? Health Qual Life Outcomes 2004; 2:19. [PMID: 15070409 PMCID: PMC406418 DOI: 10.1186/1477-7525-2-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2004] [Accepted: 04/07/2004] [Indexed: 11/10/2022] Open
Abstract
Background Little information is available regarding medical residents' perceptions of patients' health-related quality of life. Patients cared for by residents have been shown to receive differing patterns of care at Veterans Affairs facilities than at community or university settings. We therefore examined: 1) how resident physicians value the health of patients; 2) whether values differ if the patient is described as a veteran; and 3) whether residency-associated variables impact values. Methods All medicine residents in a teaching hospital were asked to watch a digital video of an actor depicting a 72-year-old patient with mild-moderate congestive heart failure. Residents were randomized to 2 groups: in one group, the patient was described as a veteran of the Korean War, and in the other, he was referred to only as a male. The respondents assessed the patient's health state using 4 measures: rating scale (RS), time tradeoff (TTO), standard gamble (SG), and willingness to pay (WTP). We also ascertained residents' demographics, risk attitudes, residency program type, post-graduate year level, current rotation, experience in a Veterans Affairs hospital, and how many days it had been since they were last on call. We performed univariate and multivariable analyses using the RS, TTO, SG and WTP as dependent variables. Results Eighty-one residents (89.0% of eligible) participated, with 36 (44.4%) viewing the video of the veteran and 45 (55.6%) viewing the video of the non-veteran. Their mean (SD) age was 28.7 (3.1) years; 51.3% were female; and 67.5% were white. There were no differences in residents' characteristics or in RS, TTO, SG and WTP scores between the veteran and non-veteran groups. The mean RS score was 0.60 (0.14); the mean TTO score was 0.80 (0.20); the mean SG score was 0.91 (0.10); and the median (25th, 75th percentile) WTP was $10,000 ($7600, $20,000) per year. In multivariable analyses, being a resident in the categorical program was associated with assigning higher RS scores, but no residency-associated variables were associated with the TTO, SG or WTP scores. Conclusion Physicians in training appear not to be biased either in favor of or against military veterans when judging the value of a patient's health.
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Affiliation(s)
- Michael S Yi
- Department of Internal Medicine, Division of General Internal Medicine, Section of Outcomes Research, University of Cincinnati Medical Center, USA
- Center for Clinical Effectiveness, Institute for Health Policy and Health Services Research, University of Cincinnati Medical Center, USA
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, USA
| | - Sara Luckhaupt
- Department of Internal Medicine, Division of General Internal Medicine, Section of Outcomes Research, University of Cincinnati Medical Center, USA
| | - Joseph M Mrus
- Department of Internal Medicine, Division of General Internal Medicine, Section of Outcomes Research, University of Cincinnati Medical Center, USA
- Center for Clinical Effectiveness, Institute for Health Policy and Health Services Research, University of Cincinnati Medical Center, USA
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, USA
- HSR&D Service, Cincinnati Veterans Affairs Medical Center and Veterans Healthcare System of Ohio, Cincinnati, USA
| | - Joel Tsevat
- Department of Internal Medicine, Division of General Internal Medicine, Section of Outcomes Research, University of Cincinnati Medical Center, USA
- Center for Clinical Effectiveness, Institute for Health Policy and Health Services Research, University of Cincinnati Medical Center, USA
- HSR&D Service, Cincinnati Veterans Affairs Medical Center and Veterans Healthcare System of Ohio, Cincinnati, USA
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Abstract
OBJECTIVES We examined agreement of administrative data with self-reported race/ethnicity and identified correlates of agreement. METHODS We used Veterans Affairs administrative data and VA 1999 Large Health survey race/ethnicity data. RESULTS Relatively low rates of agreement (approximately 60%) between data sources were largely the result of administrative data from patients whose race/ethnicity was unknown, with least agreement for Native American, Asian, and Pacific Islander patients. After exclusion of patients with missing race/ethnicity, agreement improved except for Native Americans. Agreement did not increase substantially after inclusion of data from individuals indicating multiple race/ethnicities. Patients for whom there was better agreement between data sources tended to be less educated, non-solitary living, younger, and White; to have sufficient food; and to use more inpatient Department of Veterans Affairs (VA) care. CONCLUSIONS Better reporting of race/ethnicity data will improve agreement between data sources. Previous studies using VA administrative data may have underestimated racial disparities.
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Affiliation(s)
- Nancy R Kressin
- Center for Health Quality, Outcomes and Economic Research (a Veterans Affairs Health Services Research and Development National Center of Excellence), Bedford VA Medical Center, Bedford, MA 01730, USA.
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19
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McGinnis KA, Fine MJ, Sharma RK, Skanderson M, Wagner JH, Rodriguez-Barradas MC, Rabeneck L, Justice AC. Understanding racial disparities in HIV using data from the veterans aging cohort 3-site study and VA administrative data. Am J Public Health 2003; 93:1728-33. [PMID: 14534229 PMCID: PMC1448041 DOI: 10.2105/ajph.93.10.1728] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We identified race-associated differences in survival among HIV-positive US veterans to examine possible etiologies for these differences. METHODS We used national administrative data to compare survival by race and used data from the Veterans Aging Cohort 3-Site Study (VACS 3) to compare patients' health status, clinical management, and adherence to medication by race. RESULTS Nationally, minority veterans had higher mortality rates than did white veterans with HIV. Minority veterans had poorer health than white veterans with HIV. No significant differences were found in clinical management or adherence. CONCLUSIONS HIV-positive minority veterans experience poorer survival than white veterans. This difference may derive from differences in comorbidities and in the severity of illness of HIV-related disease.
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Affiliation(s)
- Kathleen A McGinnis
- Veterans Aging Cohort Study Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
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20
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Abstract
Can the Veterans Affairs (VA) health care system, long an important part of the safety net for disabled and poor veterans, survive the loss of World War II veterans--once its largest constituency and still its most important advocates? A recent shift in emphasis from acute hospital-based care to care of chronic illness in outpatient settings, as well as changes in eligibility allowing many more nonpoor and nondisabled veterans into the VA system, will be key determinants of long-term survivability. Although allowing less needy veterans into the system runs the risk of diluting services to those most in need, the long-run effect may be to increase support among a larger and younger group of veterans, thereby enhancing political clout and ensuring survivability. It may be that the best way to maintain the safety net for veterans is to continue to cast it more widely.
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Affiliation(s)
- John S Hughes
- Department of Medicine, VA Connecticut Health Care System, Yale University School of Medicine, West Haven, Conn., USA
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21
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Sloan KL, Sales AE, Liu CF, Fishman P, Nichol P, Suzuki NT, Sharp ND. Construction and characteristics of the RxRisk-V: a VA-adapted pharmacy-based case-mix instrument. Med Care 2003; 41:761-74. [PMID: 12773842 DOI: 10.1097/01.mlr.0000064641.84967.b7] [Citation(s) in RCA: 164] [Impact Index Per Article: 7.8] [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: 11/25/2022]
Abstract
BACKGROUND Assessment of disease burden is the key to many aspects of health care management. Patient diagnoses are commonly used for case-mix assessment. However, issues pertaining to diagnostic data availability and reliability make pharmacy-based strategies attractive. Our goal was to provide a reliable and valid pharmacy-based case-mix classification system for chronic diseases found in the Veterans Health Administration (VHA) population. OBJECTIVE To detail the development and category definitions of a VA-adapted version of the RxRisk (formerly the Chronic Disease Score); to describe category prevalence and reliability; to check category criterion validity against ICD-9 diagnoses; and to assess category-specific regression coefficients in concurrent and prospective cost models. RESEARCH DESIGN Clinical and pharmacological review followed by cohort analysis of diagnostic, pharmacy, and utilization databases. SUBJECTS 126,075 veteran users of VHA services in Washington, Oregon, Idaho, and Alaska. METHODS We used Kappa statistics to evaluate RxRisk category reliability and criterion validity, and multivariate regression to estimate concurrent and prospective cost models. RESULTS The RxRisk-V classified 70.5% of the VHA Northwest Network 1998 users into an average of 2.61 categories. Of the 45 classes, 33 classes had good-excellent 1-year reliability and 25 classes had good-excellent criterion validity against ICD-9 diagnoses. The RxRisk-V accounts for a distinct proportion of the variance in concurrent (R2 = 0.18) and prospective cost (R2 = 0.10) models. CONCLUSIONS The RxRisk-V provides a reliable and valid method for administrators to describe and understand better chronic disease burden of their treated populations. Tailoring to the VHA permits assessment of disease burden specific to this population.
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Affiliation(s)
- Kevin L Sloan
- VA Puget Sound Health Care System, Seattle, Washington 98108, USA.
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22
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Fong T. An army of patients. The VA struggles with a growing population of veterans using its healthcare system as it works to boost quality and capacity. Mod Healthc 2003; 33:48-50, 62. [PMID: 12800589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
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Abstract
BACKGROUND "Service connected" veterans are those with documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the Veterans Affairs (VA) health care system. For some veterans, service connection represents the difference between access to VA health care facilities and no access. OBJECTIVES To determine whether there are racial discrepancies in the granting of service connection for posttraumatic stress disorder (PTSD) by the Department of Veterans Affairs and, if so, to determine whether these discrepancies could be attributed to appropriate subject characteristics, such as differences in PTSD symptom severity or functional status. RESEARCH DESIGN Mailed survey linked to administrative data. Claims audits were conducted on 11% of the sample. SETTING AND SUBJECTS The study comprised 2700 men and 2700 women randomly selected from all veterans filing PTSD disability claims between January 1, 1994 and December 31, 1998. RESULTS A total of 3337 veterans returned usable surveys, of which 17% were black. Only 16% of respondents carried private health insurance, and 44% reported incomes of 20,000 US dollars or less. After adjusting for respondents' sociodemographic characteristics, symptom severity, functional status, and trauma histories, black persons' rate of service connection for PTSD was 43% compared with 56% for other respondents (P = 0.003). CONCLUSION Black persons' rates of service connection for PTSD were substantially lower than other veterans even after adjusting for differences in PTSD severity and functional status.
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Affiliation(s)
- Maureen Murdoch
- Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minnesota 55417, USA.
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Abstract
OBJECTIVE This study compared client characteristics, service use, and health care costs of two groups of veterans who were contacted by outreach workers: a group of veterans who were contacted while incarcerated at the Los Angeles jail and a group of homeless veterans who were contacted in community settings. METHODS Between May 1, 1997, and October 1, 1999, a total of 1,676 veterans who were in jail and 6,560 community homeless veterans were assessed through a structured intake procedure that documented their demographic, clinical, and social adjustment characteristics. Data on the use and costs of health services during the year after outreach contact were obtained from national databases of the Department of Veterans Affairs (VA). Chi square and t tests were used for statistical comparisons. RESULTS The veterans who were contacted in jail obtained higher scores on several measures of social stability (marital status and homelessness status) but had higher rates of unemployment. They had fewer medical problems but higher levels of psychiatric and substance use problems, although the rate of current substance use was lower among these veterans than among the community homeless veterans. One-year service access for the jailed veterans was half that of the community homeless veterans. No differences were observed in the intensity of use of mental health services among those who used services, but the jailed outreach clients used fewer residential, medical, and surgical services. Total health care expenditures for the veterans who received outreach contact in jail were $2,318 less, or 30 percent less, than for those who were contacted through community outreach. CONCLUSIONS Specialized outreach services appear to be modestly effective in linking veterans who become incarcerated with VA health care services. Although it is clinically challenging to link this group with services, the fact that the rate of current substance use is lower during incarceration may provide a window of opportunity for developing linkages between inmates and community rehabilitative services.
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Affiliation(s)
- James McGuire
- Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut, USA.
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25
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Boehmer U, Kressin NR, Berlowitz DR, Christiansen CL, Kazis LE, Jones JA. Self-reported vs administrative race/ethnicity data and study results. Am J Public Health 2002; 92:1471-2. [PMID: 12197976 PMCID: PMC1447261 DOI: 10.2105/ajph.92.9.1471] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Ulrike Boehmer
- The authors are with the Department of Health Services, Boston University School of Public Health, Boston, Mass 01730, USA.
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26
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Borowsky SJ, Nelson DB, Nugent SM, Bradley JL, Hamann PR, Stolee CJ, Rubins HB. Characteristics of veterans using Veterans Affairs community-based outpatient clinics. J Health Care Poor Underserved 2002; 13:334-46. [PMID: 12152504 DOI: 10.1353/hpu.2010.0731] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [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: 11/11/2022]
Abstract
In the late 1990s, the Department of Veterans Affairs (VA) initiated a system of community-based outpatient clinics to enhance access to care. The purpose of this study was to explore factors that may be related to veterans' desire to transfer care from VA-based to community clinics. Among 1,452 veterans who were currently receiving VA clinic care and were eligible for care in two community-based clinics in rural Minnesota, 85 percent responded to a survey. Fifty-four percent of respondents requested community-based outpatient clinic care. Multivariate analysis revealed that veterans less satisfied with VA care were more likely to request a transfer to a community clinic, whereas Veterans SF-36 scale scores were not strongly associated with request for community-based outpatient clinic care. Veterans who had more VA clinic visits were less likely to request community-based outpatient clinic care. The likelihood of requesting also varied across the VA facilities and by VA eligibility level.
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Affiliation(s)
- Steven J Borowsky
- Minneapolis Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, and University of Minnesota, USA
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27
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Abstract
This study examines veterans' satisfaction with outpatient care within the context of outpatient user type, race/ethnicity, and veteran identity. The sample includes 2652 veterans who participated in the VIP 2001 Survey. After controlling for enabling and need characteristics in logistic regression models, Veterans Administration (VA)-only users were 2 to 8 times more satisfied with their outpatient care than were VA nonusers on 5 out of 10 satisfaction measures. White veterans were 1.5 to 3.4 times more satisfied than nonwhite veterans on 8 out of 10 satisfaction measures. Members of veterans' organizations were less satisfied with their outpatient care than nonmembers on 5 out of 10 satisfaction measures. Factors associated with race/ethnicity and veteran identity may be incorporated into interventions to improve VA outpatient care satisfaction.
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Affiliation(s)
- Nancy D Harada
- Health Services Research, Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, UCLA School of Medicine and UCLA School of Public Health, Los Angeles, CA 90073, USA.
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28
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Murphy PA, Cowper DC, Seppala G, Stroupe KT, Hynes DM. Veterans Health Administration inpatient and outpatient care data: an overview. Eff Clin Pract 2002; 5:E4. [PMID: 12166925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Affiliation(s)
- Patricia A Murphy
- VA Information Resource Center, Health Services Research and Development Service, Department of Veterans Affairs, Edward Hines, Jr. Hospital, Hines, Ill 60141, USA
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29
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Washington DL, Harada ND, Villa VM, Damron-Rodriguez J, Dhanani S, Shon H, Makinodan T. Racial variations in Department of Veterans Affairs ambulatory care use and unmet health care needs. Mil Med 2002; 167:235-41. [PMID: 11901574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Our objective was to describe racial/ethnic variations in Department of Veterans Affairs (VA) ambulatory care use and its association with the presence of unmet health care needs. Using the 1992 National Survey of Veterans, we examined race/ethnicity and unmet health care need for ambulatory care users of VA and non-VA facilities. Black and Hispanic veterans were more likely to report any VA use. In unadjusted analyses, American Indian/Eskimo, Hispanic, and black veterans were 4.4, 2.5, and 1.9 times more likely, respectively, than white veterans to report an inability to get needed care. Adjusting for VA ambulatory care use diminished the disparity in inability to get needed care between American Indian/Eskimo or Hispanic veterans and white veterans and eliminated the disparity between black and white veterans. Our findings support the VA's role as a medical safety net provider and suggest that VA ambulatory care use is effective in mitigating health-related racial disparities for some veterans. Additional facilitators for reducing unmet need should be explored.
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Affiliation(s)
- Donna L Washington
- Department of Medicine, VA Greater Los Angeles Healthcare System, School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
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30
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Horner RD, Oddone EZ, Stechuchak KM, Grambow SC, Gray J, Khuri SF, Henderson WG, Daley J. Racial variations in postoperative outcomes of carotid endarterectomy: evidence from the Veterans Affairs National Surgical Quality Improvement Program. Med Care 2002; 40:I35-43. [PMID: 11789630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
CONTEXT Black patients and Hispanic patients receive carotid endarterectomy (CEA) at lower rates than white patients. It is unclear whether worse surgical outcomes are influencing clinical decision-making regarding use of the operation among minority group patients. OBJECTIVE To determine if there are racial differences in postoperative outcomes for patients undergoing CEA at Veterans Affairs (VA) medical centers. DESIGN Secondary analysis of data from an ongoing, prospective study on surgical quality and outcomes in the VA health care system. SETTING One hundred thirty-two VA Medical Centers that were part of the VA National Surgical Quality Improvement Program. PATIENTS A cohort of 6551 men (91.4% white, 5.3% black, and 3.3% Hispanic) who had CEA performed between October 1, 1994 and September 30, 1997. MAIN OUTCOME MEASURES Primary outcomes were stroke or death and stroke, myocardial infarction (MI), or death within 30 days of the operation. RESULTS Thirty-day postoperative rates of stroke or death and of stroke, MI, or death were generally low for all racial/ethnic groups, ranging between 2.6% and 6.5%. Within clinical states that define indications for CEA, rates were also low (1.6% to 3.2%) among asymptomatic patients across racial/ethnic groups. However, among patients with transient ischemic attack (TIA), Hispanic patients had significantly worse outcomes than white patients with a postoperative rate of stroke or death of 10.5% (P < 0.05) and stroke, MI, or death of 13.2% (P < 0.05) compared with 3.1% to 3.5% for white patients. Hispanic patients did not differ from black patients for stroke, death/stroke, death, or MI. CONCLUSION Rates of major postoperative complications after CEA are low within the VA and similar across racial/ethnic groups with the possible exception of Hispanic men with TIA. Further investigation of this elevated complication rate among Hispanic men with TIA may be warranted.
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Affiliation(s)
- Ronnie D Horner
- VA Epidemiologic Research and Information Center, Center for Health Services Research in Primary Care, Stroke QUERI Program, Durham, North Carolina, USA.
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31
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Kressin NR, Clark JA, Whittle J, East M, Peterson ED, Chang BH, Rosen AK, Ren XS, Alley LG, Kroupa L, Collins TC, Petersen LA. Racial differences in health-related beliefs, attitudes, and experiences of VA cardiac patients: scale development and application. Med Care 2002; 40:I72-85. [PMID: 11789634 DOI: 10.1097/00005650-200201001-00009] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [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
OBJECTIVES To deternine whether there are racial differences in patients' health-related attitudes, beliefs, and experiences regarding invasive cardiac procedures, and to develop psychometrically and conceptually valid scales and single items to assess these dimensions. METHODS A survey was designed and administered to 854 white and black patients with ischemic heart disease at five VA medical centers. Patients were queried about the domains proposed to be important to treatment decision making by the Health Decision Model: sociodemographic characteristics, social interactions, health care experiences, patient preferences for care, knowledge about diseases and potential treatments, and health beliefs. Using multitrait analysis, the psychometric properties of scales assessing these domains were examined. It was then assessed whether there were racial differences in scale or individual item scores using chi2 and t test analyses. RESULTS The analyses yielded eight psychometrically valid scales: disease severity, patient evaluation of physician's interpersonal style, patient evaluations of VA care, satisfaction with treatment decision making, perceived urgency of catheterization, vulnerability to catheterization, bodily impact of catheterization, and attitudes toward religion. There were only racial differences on mean scores for the latter scale. Individual item analyses indicated that black patients were less likely to have been encouraged by friends or family to have cardiac catheterization, and had less personal or familial experiences with this or other surgical procedures. In contrast to expectations, white patients were more likely to be skeptical of medical care. CONCLUSIONS The multiple dimensions of white and black patients' health-related attitudes, beliefs, and experiences were examined, and few differences were found. These results suggest that racial differences in patients' attitudes, beliefs, and experiences are not a likely source of racial disparities in cardiac care. Future research will examine the association of beliefs, attitudes and experiences with actual use of invasive cardiac procedures.
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Affiliation(s)
- Nancy R Kressin
- Center for Health Quality, Outcomes and Economic Research (a VA Health Services Research and Development National Center of Excellence), Bedford VA Medical Center, Massachusetts 01730, USA.
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32
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Abstract
BACKGROUND Race and ethnicity are used as predictors of outcome in health services research. Often, however, race and ethnicity serve merely as proxies for the resources, values, beliefs, and behaviors (ie, ecology and culture) that are assumed to correlate with them. "Unpacking" proxy variables-directly measuring the variables believed to underlie them-would provide a more reliable and more interpretable way of looking at group differences. OBJECTIVE To assess the use of a measure of ecocultural domains that is correlated with ethnicity in accounting for variance in adherence, quality of life, clinical outcomes, and service utilization. DESIGN A cross-sectional observational study. PARTICIPANTS Twenty-six Hispanic and 29 non-Hispanic white VA primary care patients with type 2 diabetes mellitus. MEASURES The independent variables were patient ethnicity and a summed score of ecocultural domains representing patient adaptation to illness. The outcomes were adherence to treatment, health-related quality of life, clinical indicators of disease management, and utilization of urgent health care services. RESULTS Patient adaptation was correlated with ethnicity and accounted for more variance in all outcomes than did ethnicity. The unique variance accounted for by adaptation was small to moderate, whereas that accounted for by ethnicity was negligible. CONCLUSIONS It is possible to identify and measure ecocultural domains that better account for variation in important health services outcomes for patients with type 2 diabetes than does ethnicity. Going beyond the study of ethnic differences alone and measuring the correlated factors that play a role in disease management can advance understanding of the phenomena involved in this variation and provide better direction for service design and delivery.
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Affiliation(s)
- Michele E Walsh
- Southern Arizona Veterans Affairs Health Care System, Tucson, USA.
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33
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Abstract
OBJECTIVES This study examines differences in treatment process and outcomes among minority veterans treated in specialized intensive VA programs for war-related Posttraumatic Stress Disorder (PTSD). DESIGN A concurrent panel study assessing four different types of intensive PTSD treatment program. SUBJECTS Black (n = 2,906; 23.4%), Hispanic (n = 661, 5.3%), and white veterans. METHODS Hierarchical linear modeling was used to compare black and Hispanic veterans with white veterans on admission characteristics, treatment process, and outcomes, overall, and to determine whether treatment in three newer types of programs, each designed to improve efficiency, was associated with in changes in minority group experiences. RESULTS At the time of program admission, black patients had less education, were less likely to be married or to receive VA compensation, and had more severe alcohol and drug problems, but had less severe PTSD symptoms than either white patients or Hispanic patients. There were no differences among groups on 8 of 11 measures of treatment process or outcome but black patients showed greater improvement than white patients on one measure of PTSD symptoms and Hispanic patients were more satisfied with their treatment than white patients although they showed smaller gains in employment income. There were few changes associated with newer program types: gains for minorities were observed on three measures and losses on two. CONCLUSIONS Using data from a large national sample, this study found little evidence of systematic differences in either treatment process or outcome between white, black, and Hispanic patients overall, or in association with the implementation of more efficient program types.
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Affiliation(s)
- Robert Rosenheck
- Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut 06516, USA
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34
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Abstract
OBJECTIVES The goal of this study was to assess racial differences in process of care and outcome for acute myocardial infarction in the VA health care system. DESIGN Retrospective cohort study using clinical data. SETTING Eighty-one acute care VA hospitals. PATIENTS Four thousand seven hundred sixty veterans discharged with a confirmed diagnosis of acute myocardial infarction. The analysis was restricted to 606 black and 4005 white patients. MAIN OUTCOME MEASURES Comparison of use of guideline-based medications, invasive cardiac procedures, and all-cause mortality at 30 days, 1 year, and 3 years. RESULTS Black patients were equally likely to receive beta-blockers, more likely than white patients to receive aspirin (86.8% vs. 82.0%; P <0.05), and marginally more likely to receive angiotensin converting enzyme inhibitors (55.7% vs. 49.6%; P = 0.07) at the time of discharge. In contrast, black patients were less likely than white patients to receive thrombolytic therapy at the time of arrival (32.4% vs. 48.2%; P <0.01). There was no significant difference in refusal of angiography or percutaneous transluminal coronary angioplasty between black patients and white patients, or in crude rates of either of these procedures. There was also no difference overall in the percentage of patients who refused coronary artery bypass graft surgery. However, black patients were less likely than white patients to undergo bypass surgery (6.9% vs. 12.5% by 90 days; P <0.001). Black patients remained less likely to undergo bypass surgery even when high-risk specific coronary anatomy subgroups were examined. There was no difference in mortality in the two groups. CONCLUSIONS In this integrated health care system, no significant racial disparities in use of noninterventional therapies, diagnostic coronary angiography, or short- or long-term mortality was found. Disparities in use of thrombolytic therapy and coronary artery bypass surgery existed, however, even after accounting for differences in clinical indications for treatment and patient refusals. Further work should assess the role of the medical interaction and physician behavior in racial disparities in use of health care.
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Affiliation(s)
- Laura A Petersen
- Houston Center for Quality of Care and Utilization Studies, a Health Services Research and Development Center of Excellence, Houston VA Medical Center, Texas 77030, USA.
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Abstract
CONTEXT Prior studies have found racial differences in the use of invasive procedures and in cancer survival. OBJECTIVE To assess the influence of race on the treatment and survival of patients with distal esophageal cancer. DESIGN Retrospective cohort study. SETTING All Veterans Affairs Medical Centers. PATIENTS One thousand two hundred ninety white and 231 black male veterans with a new diagnosis of distal esophageal cancer during 1993 to 1997. MAIN OUTCOME MEASURES Utilization of surgical resection, chemotherapy, radiation therapy, and survival. RESULTS Black patients with esophageal adenocarcinoma were less likely to undergo surgery (OR, 0.54; 95% CI, 0.30-0.96) but had similar odds of undergoing chemotherapy and radiation therapy. Black patients with squamous cell carcinoma (SCC) were less likely to undergo surgical resection (OR, 0.45; 95% CI, 0.29-0.70), but were more likely to undergo radiation therapy (OR, 1.72; 95% CI, 1.21-2.47) and chemotherapy (OR, 1.74; 95% CI, 1.19-2.54). Mortality was increased for black patients with SCC (adjusted risk ratio 1.33; 95% CI, 1.10-1.61) but not adenocarcinoma. Among those veterans who underwent surgical resection (n = 502), similar results were found. CONCLUSIONS Black veterans with distal SCC are less likely than white veterans to undergo surgical resection, whereas the use of radiation therapy and chemotherapy, as well as mortality, is increased. Black patients with distal esophageal adenocarcinoma have lower odds of undergoing surgical resection but have similar utilization of radiation therapy and chemotherapy and similar survival. Despite the presence of an equal access medical system, treatment and outcomes differ for black and white veterans with distal esophageal cancer.
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Affiliation(s)
- Jason A Dominitz
- Seattle Epidemiologic Research and Information Center, Department of Surgery, VA Puget Sound Health Care System, Washington 98108-1597, USA.
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Collins TC, Johnson M, Henderson W, Khuri SF, Daley J. Lower extremity nontraumatic amputation among veterans with peripheral arterial disease: is race an independent factor? Med Care 2002; 40:I106-16. [PMID: 11789623 DOI: 10.1097/00005650-200201001-00012] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [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: 01/09/2023]
Abstract
OBJECTIVES To determine if race/ethnicity is independently associated with an increased risk for nontraumatic lower extremity amputation versus lower extremity bypass revascularization among patients with peripheral arterial disease (PAD). METHODS Data were analyzed from the National VA Surgical Quality Improvement Program (NSQIP) and from the Veterans Affairs Patient Treatment File (PTF). Race/ethnicity was defined as non-Hispanic white, black, or Hispanic. Variables that were univariately associated (P < or = 0.05) with the outcome of amputation were placed into a multiple logistic regression model to determine independent predictors for the dependent variable, lower extremity amputation versus lower extremity bypass revascularization. RESULTS Three thousand eighty-five lower extremity amputations and 8409 lower extremity bypass operations were identified. Among all cases included, there were 416 Hispanic patients (3.6%), 2337 black patients (20.3%), and 8741 non-Hispanic white patients (76.1%). Among all variables within the model, Hispanic and black race were each associated with a greater risk for amputation than a history of rest pain/gangrene (Hispanic race 1.4, 95% CI 1.1, 1.9; black race 1.5, 95% CI 1.4, 1.7; rest pain/gangrene 1.1, 95% CI 1.0, 1.3). The final model had a c statistic of 0.83. CONCLUSION Hispanic race and black race were independent risk factors for lower extremity amputation in patients with PAD. Although the burden of certain atherosclerotic risk factors (eg, diabetes and hypertension) is higher in minority patients, the impact of this burden does not account for the increased risk for the outcome of lower extremity amputation in these two populations. Further research is needed to better understand the reason(s) why race/ethnicity is independently associated with poor outcomes in PAD.
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Affiliation(s)
- Tracie C Collins
- Houston Center for Quality of Care and Utilization Studies, Houston VA Medical Center, Texas, USA.
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Abstract
BACKGROUND Racial differences exist in the management of coronary artery disease. One hypothesis is that black patients delay seeking care and that this delay may influence the management of coronary artery disease. OBJECTIVES To assess delay in seeking care for heart disease. RESEARCH DESIGN Cross-sectional survey. SUBJECTS One thousand six hundred and fifty-two patients awaiting coronary angiography at three VA and one non-VA Medical Center. MEASURES Patients were asked to retrospectively report the time between symptom onset and presentation for medical care and what if any were the reasons for delay. RESULTS One thousand five hundred eleven patients (12% VA & 43% non-VA) answered questions regarding delay in treatment. Overall, 73% reported delaying 1 month or more and 16% reported delaying more than 6 months. Black patients and white patients were equally likely to delay as were older persons (> or = 65) compared with younger. Patients at the VA hospitals reported longer delays and patients with prior revascularization were less likely to report delays. We used ordinal logistic regression to predict delay using site type and prior revascularization as covariates. VA site of care independently predicted longer delays whereas prior revascularization predicted less delay. Among patients who reported at least a 1 month delay, patients at the non-VA hospital were more likely to cite ignoring symptoms as their reason for delay (72% vs. 61%; P = 0.03) as were those with at least a high school education 69% versus 50%; P = 0.003). Black patients reported that they ignored their symptom more often but this was marginally significant (77% vs. 63%; P = 0.053). CONCLUSIONS Race was not associated with delay in seeking care among patients awaiting coronary angiography. Non-VA patients, and those with past revascularization, were less likely to delay. Ignoring symptoms was the most common reason for delays greater than 1 month. Further study of the sequence of patient and provider decisions that ultimately lead to revascularization is needed.
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Affiliation(s)
- Joseph Conigliaro
- Section of General Internal Medicine, Center for Health Equity Research and Promotion, Geriatric Research Education and Clinical Center, Pittsburgh, Pennsylvania, USA.
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Ibrahim SA, Siminoff LA, Burant CJ, Kwoh CK. Understanding ethnic differences in the utilization of joint replacement for osteoarthritis: the role of patient-level factors. Med Care 2002; 40:I44-51. [PMID: 11789631 DOI: 10.1097/00005650-200201001-00006] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.9] [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: 10/27/2022]
Abstract
BACKGROUND There is a marked difference between black patients and white patients in the utilization of joint replacement therapy. The reasons behind this disparity remain unknown. OBJECTIVES To examine how black and white potential candidates for joint replacement compare with respect to their overall familiarity with joint replacement as an option, as well as their perceptions of the risks/benefits of this procedure. METHODS Cross-sectional survey of 596 elderly patients with symptomatic osteoarthritis of the knee or hip or both attending primary care clinics at Cleveland VAMC. RESULTS Black (44%) and white (56%) patients in this cohort were comparable with respect to age and clinical factors. However, black patients were less likely to be employed (8% vs. 15%, P = 0.017) or to be married (39% vs. 56%, P = 0.000), but more likely to report an annual household income of less than $10,000 (41% vs. 20%, P = 0.000) and less than high school education (43% vs. 29%, P = 0.001). Black patients were less likely than white patients to have had family or friends who had had joint replacement (OR, 0.39 [0.26-0.61]), or to report a good understanding of joint replacement as a form of treatment (OR, 0.62 [0.42-0.92]). They were more likely than white patients to expect longer hospital course (OR, 4.09 [2.57-6.54]), moderate to extreme pain (OR, 2.61 [1.74-3.89]), and moderate to extreme difficulty walking after replacement surgery (OR, 2.76 [1.83-4.16]). CONCLUSION Black patients were less likely than white patients to be familiar with joint replacement surgery and more likely to express concerns about postsurgical pain and difficulty walking.
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Affiliation(s)
- Said A Ibrahim
- Louis Stokes Department of VAMC, University Hospitals of Cleveland, Ohio, USA.
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Abstract
OBJECTIVES Recent studies documenting racial variation in the use of cardiac procedures highlight the need to understand if there are racial differences in processes of communication and decision making. Investigations of patients' perceptions of their interaction with providers regarding cardiac testing were conducted. METHODS Four focus groups were convened with 13 patients who had undergone cardiac stress testing with positive results, stratified by race (white vs. black). Verbatim transcripts of discussions of their interactions with providers relating to their cardiac problems were analyzed qualitatively by a team of behavioral scientists and general internists to identify significant dimensions of communication and patient-provider relationships. RESULTS Four domains of communication were identified that appeared to bear on patients' comfort and preferences regarding cardiac procedures. First, the substance of the information that was provided by physicians and other providers was described as incomplete, vague, ambiguous, and unclear. Second, some recommendations either were inconsistent with expectations or awakened fears based on distressing previous experiences. Third, patients said they needed to be convinced of the need for additional, invasive tests and therapeutic procedures, and in some cases providers' arguments failed in this regard. Fourth, the patients highlighted the importance of trusting their provider. Although there were no apparent differences by race in patients' perception of the information they received, black patients consistently expressed a preference for building a relationship with physicians (trust) before agreeing to an invasive cardiac procedure, and just as consistently complained that trust was lacking. Conversely, white patients tended to emphasize that they were inadequately convinced of the need for recommended procedures. CONCLUSIONS This study provided qualitative information regarding patients' perceptions of physician-patient communication and racial differences in such perceptions. For both black and white patients, we found problematic aspects of the patients' experiences regarding communication about cardiac testing. Our findings suggest that although patients desire clarity from physicians, they are often confused regarding the information received. Both a lack of substance and vagueness of the information received may be linked to feelings of mistrust toward physicians when considering further diagnostic testing. Mistrust may be a source of some of the documented racial variation in health care utilization.
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Affiliation(s)
- Tracie C Collins
- Houston Center for Quality of Care and Utilization Studies, Houston VA Medical Center, Texas, USA
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Harada ND, Damron-Rodriguez J, Villa VM, Washington DL, Dhanani S, Shon H, Chattopadhyay M, Fishbein H, Lee M, Makinodan T, Andersen R. Veteran identity and race/ethnicity: influences on VA outpatient care utilization. Med Care 2002; 40:I117-28. [PMID: 11789624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND "Veteran identity" is defined as veterans' self-concept that derives from his/her military experience within a sociohistorical context. Veteran identity may vary by race/ethnicity because the sociohistorical context of the military experience varies by race. OBJECTIVES To explore veteran identity and how it varies by race/ethnicity, and to identify aspects of veteran identity that significantly influence preferences for, and use of, VA outpatient care. RESEARCH DESIGN Focus groups were conducted at community sites to explore concepts related to veteran identity, race/ethnicity, military experience, and health services use. The focus groups informed the development of a telephone survey, which was administered to veterans of four racial/ethnic groups in Southern California and Southern Nevada. SUBJECTS One hundred seventy-eight veterans participated in the focus groups, and 3,227 veterans completed the telephone survey. MEASURES Dependent variables include: (1) preference for VA health services, (2) VA-only outpatient use, (3) Any VA outpatient use, and (4) number of outpatient visits within the previous 12 months. Independent variables include veteran identity, sociodemographic, and health-related characteristics. RESULTS All veteran identity variables were significantly associated with race/ethnicity. Race/ethnicity, eg, being black or Hispanic, in addition to veteran identity factors, significantly influenced preferences for VA outpatient care. Veteran identity factors, however, had less influence on VA outpatient service utilization than socioeconomic factors. CONCLUSIONS Minority veterans who highly identify with their veteran status may prefer the VA to other systems of care. Factors associated with veteran identity may be useful for incorporation into interventions to improve access to VA care.
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Affiliation(s)
- Nancy D Harada
- VA Greater Los Angeles Healthcare System, West Los Angeles Healthcare Center, UCLA, California 90073, USA.
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Rabiner DJ, Branch LG, Sullivan RJ. Patient factors related to the odds of receiving prevention services in Veterans Health Administration medical centers. Am J Manag Care 1999; 5:1153-60. [PMID: 10621081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
OBJECTIVE To examine the association between patient characteristics and the odds of receiving 13 health promotion/disease prevention services recommended by the US Preventive Services Task Force (USPSTF) for average-risk individuals. METHODS A mail survey was sent to a random sample of 68,422 veterans who obtained primary care from any of the 153 Veterans Health Administration facilities in 1996; 44,304 responded (adjusted response rate was 68%). Multivariate logistic regression models were used. RESULTS Demographic factors, health risk behaviors, and self-reported health were associated with the odds of receiving prevention services. Current smokers, heavy alcohol drinkers, and females were less likely to receive many health promotion services, whereas regular exercisers, overweight individuals, males, those reporting poorer health, individuals reporting high or controlled blood pressure, and those reporting high or controlled cholesterol levels were more likely to receive USPSTF-recommended prevention services. CONCLUSION Substantial proportions of veterans were likely to obtain prevention services recommended by the USPSTF for average-risk individuals. Nevertheless, veterans who reported being current smokers, heavy drinkers, or female were less likely to obtain these services. These subgroups may benefit from additional initiatives.
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Affiliation(s)
- D J Rabiner
- Research Triangle Institute, Research Triangle Park, NC, USA
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Cook CA, Booth BM, Blow FC, Gogineni A, Bunn JY. Alcoholism treatment, severity of alcohol-related medical complications, and health services utilization. J Ment Health Adm 1999; 19:31-40. [PMID: 10128721 DOI: 10.1007/bf02521305] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In efforts to contain costs and efficiently allocate resources, evaluation studies in alcoholism have increasingly assessed the effect of treatment on the use of health services through comparisons of treated and untreated alcoholics. The success of this approach requires that evaluators identify and adjust for differences between these two groups, thereby decreasing the likelihood that health utilization outcomes are attributed to the effects of treatment when in fact they may be related more to unidentified group differences. Using a sample of 63,873 hospitalized alcoholics, this study focused on one critical group difference, the severity of alcohol-related medical complications. Comparisons between treated alcoholics who either completed alcoholism treatment or detoxification only and untreated alcoholics with either primary medical/surgical or psychiatric diagnoses demonstrated the following: (a) untreated alcoholics with medical/surgical diagnoses were more likely to have severe alcohol-related medical complications than the other groups; (b) a positive linear relationship between health services utilization in the previous year and the severity of medical complications existed for all groups, except untreated alcoholics with psychiatric diagnoses; and (c) untreated alcoholics with psychiatric diagnoses with the most severe complications used fewer health services than any of the other three groups. Differences between treated and untreated alcoholics in both severity of medical complications and previous health utilization patterns demonstrate the need to identify and adjust for these factors in evaluation studies that examine the outcomes of alcoholism treatment.
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Affiliation(s)
- C A Cook
- George Warren Brown School of Social Work, Washington University, St. Louis, MO 63130
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Schedule for rating disabilities: cold injuries--VA. Final rule. Fed Regist 1998; 63:37778-9. [PMID: 10181244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
This document amends the Department of Veterans Affairs (VA) Schedule for Rating Disabilities by revising the provisions governing evaluations for cold injury residuals. The intended effect of this amendment is to provide evaluation criteria based on current medical knowledge about the long-term effects of cold injury that can be applied to any part of the body affect by cold injury.
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Enrollment--provision of hospital and outpatient care to veterans--VA. Proposed rule. Fed Regist 1998; 63:37299-307. [PMID: 10181057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
This document proposes to amend VA's medical regulations. The Veterans' Health Care Eligibility Reform Act of 1996 mandates that VA implement a national enrollment system to manage the delivery of healthcare services. Accordingly, the medical regulations are proposed to be amended to establish provisions consistent with this mandate. Starting October 1, 1998, most veterans must be enrolled in the VA healthcare system as a condition of receiving VA hospital and outpatient care. Veterans would be allowed to apply to be enrolled at any time. They would be eligible to be enrolled based on funding availability and their priority status. In accordance with statutory provisions, the proposed rule also states that some categories of veterans would be eligible for VA hospital and outpatient care even if not enrolled. This document further proposes to establish a "medical benefits package" setting forth, with certain exceptions, the hospital and outpatient care that would be provided to enrolled veterans and certain other veterans.
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Kashner TM, Muller A, Richter E, Hendricks A, Lukas CV, Stubblefield DR. Private health insurance and veterans use of Veterans Affairs care. RATE Project Committee. Rate Alternative Technical Evaluation. Med Care 1998; 36:1085-97. [PMID: 9674625 DOI: 10.1097/00005650-199807000-00014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study examined the effect of private health insurance on the use of medical, surgical, psychiatric, and addiction services for patients eligible for publicly supported care. METHODS The authors assembled administrative databases describing 350,000 noninstitutionalized veterans who had been discharged from a Veterans Affairs (VA) inpatient medicine or surgery bed section during a 1-year period. Patient use of care was followed for 1 year after the index discharge. Patient insurance information came from Medical Care Cost Recovery Billing and Collection files obtained separately from each of 162 VA Medical Centers. Distances between VA and non-VA sources of care were estimated from the Health Care Financing Administration's Hospital Distance File. RESULTS Insured patients were less likely to seek surgical care but were 12 times (65 years of age and older) and 73 times (63 years of age and younger) more likely to initiate outpatient medical visits than were their counterparts, adjusted for patient demographic, diagnostic, and index facility characteristics. Patients who had private health insurance also were 3.4 (> or = 65) and 2.6 (< or = 64) times less likely to use VA surgical care in response to changes in available surgical staff-to-patient ratios than were their uninsured counterparts. CONCLUSIONS Private health insurance may substitute (reduce) or complement (increase) the continued use of publicly supported health care services, depending on patient age, care setting, and service type.
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Affiliation(s)
- T M Kashner
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas VA Center for Health Services Research, 75247-9141, USA
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Abstract
OBJECTIVES The authors describe the role the Veterans Affairs (VA) medical system plays as a provider of clinic and hospital services by examining utilization levels and users' characteristics. METHODS The Veterans Affairs hospital discharge database, the Veterans Affairs outpatient clinic files, and the veteran population files were used to estimate the number of persons using the Veterans Affairs medical care system in 1994 and the intensity of their clinic and hospital use. Demographic and clinical characteristics of users were tabulated. RESULTS In 1994, 2.7 million veterans, 10.3% of all US veterans, and approximately 23% of veterans who would have met the statutory eligibility requirements for Veterans Affairs care, used the hospital and/or clinic components of the Veterans Affairs medical system. Sixty-three percent of the system's users were younger than age 65, and 10.5% were women. These 2.7 million veterans had 901,665 Veterans Affairs hospital stays, 15.5 million bed-days, and 31.2 million outpatient visits in fiscal year 1994. The average number of hospitalizations per hospital user was 1.71; the average number of visits per clinic user was 11.7. Medical, surgical, and psychiatric diagnosis-related groups (DRGs) accounted for 56%, 21%, and 23%, respectively, of hospitalizations, but psychiatric diagnosis-related groups accounted for 43% of all inpatient days. Principal medicine clinic visits and psychiatry clinic visits accounted for 21% and 16% of Veterans Affairs ambulatory care. CONCLUSIONS Because the patient population served by the Veterans Affairs system is skewed in a number of ways, its contribution as a provider of health services in the United States varies by gender, age, socioeconomic status, and diagnosis.
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Affiliation(s)
- C M Ashton
- Center for Quality of Care and Utilization Studies, Veterans Affairs Medical Center, Houston, TX 77030, USA
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Abstract
OBJECTIVES This study examined factors that affect access to Veterans Administration mental health services. METHODS Data from national Veterans Affairs databases and the 1990 Decennial Census were used to estimate rates of Veterans Affairs mental health service use in each US county (n = 3,156) among all US veterans and in three subpopulations defined by eligibility and clinical status. Independent variables examined in standard multivariate analyses and using hierarchical linear modeling techniques included county-level sociodemographic characteristics (age, race, and income); "unmanaged" service system characteristics (those not directly controlled by Veterans Affairs program managers, eg, distance from residence to Veterans Affairs and to non-Veterans Affairs services, local supply of non-Veterans Affairs services); and "managed" service system factors (those directly controlled by Veterans Affairs program managers, eg, per capita Veterans Affairs funding level and the efficiency of Veterans Affairs service delivery). RESULTS Altogether, 2.0% of US veterans used Veterans Affairs mental health services. More than one third (36%) of the variance in utilization was explained by sociodemographic factors; 8% was explained by unmanaged service system factors and 7% was explained by managed service system factors, with variations among subgroups. Substitution effects were demonstrated between Veterans Affairs and non-Veterans Affairs systems and appeared to be diagnosis-specific. CONCLUSIONS Both per capita funding levels and efficient service delivery were significantly associated with increased access to mental health services. Implications for health system performance assessment and management are discussed.
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Affiliation(s)
- R Rosenheck
- Northeast Program Evaluation Center, Veterans Administration Medical Center, West Haven, CT 06516, USA
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Gardner J. VA disability rating schedule under study. Mod Healthc 1996; 26:40. [PMID: 10154991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
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Abstract
OBJECTIVE The study examined characteristics of patients who made repeat visits to the psychiatric emergency service of a Veterans Affairs medical center. METHODS Computer records of patients who visited the emergency service were retrospectively examined for a one-year period after their index visit. Patients were divided into three groups according to the number of visits; nonrepeaters had only one visit, occasional repeaters had two or three visits, and frequent repeaters had four or more visits. RESULTS Of 1,144 patients who visited the emergency service during the one-year study period, 26 percent were occasional repeaters and 8 percent were frequent repeaters; the latter group accounted for 24 percent of all visits. Schizophrenic patients were overrepresented among frequent repeaters. Compared with nonrepeaters, repeat visitors were admitted to the hospital more often and were less likely to be referred to an outpatient clinic for follow-up. Frequent repeaters were more likely than occasional repeaters to revisit within one month and to visit during evening hours. CONCLUSIONS One-third of patients seen during a one-year period revisited the emergency service, a rate substantially higher than those reported for large urban non-VA hospitals. The higher rate may have been due to the longer sampling period, to a more seriously ill population, or to fewer community resources for veterans because of misperceptions about their eligibility.
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Affiliation(s)
- T E Hansen
- Veterans Affairs Medical Center, Portland, OR 97207
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Adena MA, Cobbin DM, Fett MJ, Forcier L, Hudson HM, Long AA, Nairn JR, O'Toole BI. Mortality among Vietnam veterans compared with non-veterans and the Australian population. Med J Aust 1985; 143:541-4. [PMID: 3831743 DOI: 10.5694/j.1326-5377.1985.tb119945.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A retrospective cohort study of mortality was conducted to assess whether the military service of young Australian men in Vietnam has influenced their overall death rates, or those from specific causes. The study was of all national servicemen who were conscripted during the conflict and served in the Army for at least 12 months. Of these, 19 205 served in Vietnam (veterans) while 25 677 served only in Australia (non-veterans). These men were traced from the end of their national service (between 1966 and 1973) until the beginning of 1982. For most causes of death, the observed number of deaths of veterans and of non-veterans was less than expected from Australian population death rates, and for no cause was there a statistically significant excess of deaths compared with that of the Australian population. Similarly, when veterans were compared with non-veterans, there was no statistically significant difference in deaths for all causes combined, for diseases of the circulatory system, for deaths in motor vehicle accidents, for suicide and for all external causes after adjustment for the different subsequent death rates of men who had served in different Army corps. All seven deaths from diseases of the digestive system were of veterans. There was no excess of deaths among veterans from cancer or from atypical causes of death in this group of young men. Three-quarters of deaths of both veterans and non-veterans were from external causes, often involving motor vehicle accidents.
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