Access

• Barriers to Healthcare Access for Women Veterans
  This study examined the association of general and Veteran-specific barriers on access to healthcare among women Veterans. Findings showed that overall, almost 1 in 5 women Veterans (19%) delayed healthcare or went without needed care in the prior 12 months, including 14% of insured and 55% of uninsured women Veterans. VA healthcare users comprised 21% of those with and 13% of those without delayed healthcare or unmet needs. Younger age groups were associated with a higher prevalence of delayed care or unmet need. Among women Veterans delaying or going without care, barriers that varied by age group were: unaffordable healthcare; inability to take time off work; and transportation difficulties. A higher percentage of women with delayed care or unmet need, compared to those without, were racial/ethnic minorities, lacked a regular source or provider of healthcare, were uninsured, had low income, fair or poor health status, were disabled, and had mental health diagnoses. With respect to Veteran-related factors, women Veterans with delayed care or unmet need were more likely than those without to be OEF/OIF Veterans, in a high-priority group for VA enrollment, and to have experienced military sexual assault.
  
  Date: November 1, 2011
• Distance Most Important Barrier for Rural-Residing Veterans Seeking Healthcare
  This study of rural Veterans, providers, and staff examined the impact of travel distance on the use of VA healthcare services, satisfaction, and impact on care delivery. Findings showed that distance was identified by Veterans, providers, and staff as the most important barrier for rural Veterans seeking healthcare. The average one-way distance that Veterans traveled to a VA primary care clinic was 44.5 miles. The most common types of distance barriers discussed pertained to patient health, functioning, and financial or time resources. Other barriers frequently cited included challenges associated with travel, such as limited transportation and cost/expense. Veterans perceived the same travel distance as more burdensome when seeking care for regular services available locally (e.g. laboratory, podiatry), when compared with specialty care (e.g., cardiology, neurology). Many older Veterans who were able to drive viewed distance more as a ‘way of life’ than a ‘barrier.’ However, given that 44% of Veterans are >65 years old, travel distance is likely to become increasingly salient as a barrier in this aging population.
  
  Date: November 1, 2011
• JGIM Special Supplement Highlights Access to VA Healthcare
  The JGIM Supplement includes both the white papers commissioned as background for the September 2010 state-of-the-art (SOTA) conference on “Improving Access to VA Care” and manuscripts submitted in response to a post-SOTA solicitation for original research and reviews pertaining to improving access to VA care. Articles focus on a myriad of topics related to improving access to care for Veterans, including: eHealth technologies (e.g., Care Coordination Home Telehealth program, and My HealtheVet personal electronic health record); measuring the impact of access on healthcare utilization, quality, and outcomes; and redefining access for 21st century healthcare.
  
  Date: November 1, 2011
• Access to Healthcare and Framework for Reducing Hospital Readmissions
  This Commentary discusses how a patient’s level of access to healthcare can influence readmission risk, and proposes a broader framework that can be used to identify alternative strategies to reduce readmissions – a framework in which readmission rates are determined by access, social determinants of health, and regulatory policies.
  
  Date: October 26, 2011
• VA Travel Reimbursement Increases Outpatient Visits
  This study examined the effects of a February 2008 policy change to increase Veterans’ mileage reimbursement rate (from 11 cents per mile to 28.5 cents per mile) on utilization of outpatient, inpatient, and pharmacy services in the 10.5 months before the reimbursement rate increase and the 10.5 months after the rate increase. Findings showed that after the reimbursement rate increase, eligible Veterans at all distances were 7% more likely to have at least one VA outpatient visit and had 3% more outpatient visits compared to Veterans who were not eligible for the travel reimbursement. The increased reimbursement was associated with slightly larger increases in outpatient costs to provide care to Veterans who lived farther away from VA facilities compared to those who lived closer. The odds of having a prescription filled at a VA pharmacy increased by at least 4% for Veterans across all distance definitions, with patients living farther than 50 miles away experiencing the largest increase at 9%. The reimbursement rate also was associated with a significant increase in pharmacy costs to provide medications to Veterans living farther than 50 and 75 miles from a VA facility. Inpatient visits remained generally unaffected, and there was no significant increase in cost.
  
  Date: August 24, 2011
• Medicare-Eligible Veterans’ Reliance on VA Primary and Specialty Care Decreased Significantly from 2001 through 2004
  This study assessed longitudinal changes in patterns of cross-system healthcare use in VA and Medicare among Medicare-eligible Veterans who had used VA primary care in FY00. Findings showed that during the study period (FY01-FY04), 39% of all primary and specialty care visits occurred within VA, with almost three times more specialty care visits than primary care visits each year. However, a majority of specialty care and nearly half of all primary care for Medicare-eligible Veterans was provided outside VA over this time period. Reliance on both VA primary and specialty care decreased substantially over the study period but the decrease was greatest in specialty care. By FY04, only 20% of Medicare-eligible Veterans were completely reliant on Medicare for primary care (i.e., had 90% or more of their primary care visits with a Medicare provider) but 47% were completely reliant on Medicare for specialty care. Among Medicare-eligible Veterans, use of Medicare primary care increased among patients who were older, had a greater burden of illness, were served by a VA community-based outpatient clinic, or lived farther from a VA facility. Patient reductions in reliance on VA primary and specialty care suggest increasingly fragmented care and more difficult care coordination. Increasing use of non-VA services may complicate implementation of the PACT model, but also may emphasize new opportunities for care coordination initiatives within PACT.
  
  Date: June 16, 2011
• Integrated Primary Care Clinic Improves Access to Mental Health and Social Services for OEF/OIF Veterans
  In April 2007, an OEF/OIF Integrated Care (IC) Clinic was established at the San Francisco VAMC, as part of VA primary care system-wide priorities for improving mental health screening and treatment for OEF/OIF Veterans. This study evaluated whether an initial IC clinic visit improved mental health and social services use among OEF/OIF Veterans entering primary care at the San Francisco VAMC, compared to Veterans who received usual care. Findings showed that OEF/OIF Veterans seen in the IC clinic were significantly more likely to have had initial mental health and social work evaluations within 30 days. Moreover, IC clinic patients were significantly more likely than usual care patients to have had at least one follow-up specialty mental health visit within 90 days of initiating primary care. Women Veterans, younger Veterans, and those with positive mental health and TBI screens were significantly more likely to have had mental health and social service evaluations if seen in the IC versus the usual care clinic. While the Integrated Clinic increased initial mental health evaluations, there was no significant increase in longer-term retention in specialty mental health services among Veterans who screened positive for mental health problems.
  
  Date: June 7, 2011
• Less than One-Quarter of Veterans who Complete Suicide Access VA Healthcare in Year Prior to Death
  This study sought to determine the number of Veterans who completed suicide and who had accessed VA healthcare in the Pacific Northwest Region in the year prior to death. Findings show that of the 968 Veterans in this study who completed suicide, less than one-quarter (22%) accessed VA healthcare in the year prior to death, and a minority of those Veterans visited mental health providers. These numbers are consistent with current estimates of the number of Veterans accessing care at VA hospitals and clinics, and suggest that Veterans who go on to complete suicide may access VA healthcare at similar rates as Veterans who do not commit suicide. Of those Veterans who completed suicide, 57% did not have a mental health diagnosis, and 58% had not seen a mental health professional, suggesting that it is perhaps equally important to understand patients with general medical conditions who also may be likely to complete suicide. Of those who completed suicide, 55 were hospitalized during the year prior to death. Of these, 39% with a psychiatric hospitalization and 22% with a medical/surgical hospitalization completed suicide within 30 days. A large number of Veterans (73% of men; 36% of women) completed suicide by use of a firearm, supporting concerns from earlier studies over firearm access as a key risk factor in Veteran suicide.
  
  Date: April 4, 2011
• Increasing Access to VA Primary Care via Community Clinics May Alter Veterans’ Use of Healthcare
  This study examined trends in primary care, specialty care, and mental health services use in VA and Medicare among Medicare-eligible Veterans who obtained community-based primary care or hospital-based primary care. Findings show that VA primary care patients who were eligible for Medicare used significant primary care and specialty care outside of VA, but not mental health care. Community-based VA patients used less VA care and more Medicare services, suggesting possible unintended fragmentation of care. Hospital-based VA patients were more likely than community-based patients to obtain primary care and specialty care only at VA. Dual use of VA and Medicare specialty care was the most common care pattern and the most fragmented among both community and hospital-based patients. Mental healthcare services were not fragmented, as most patients used VA only for these services. Use of Medicare only for outpatient primary and specialty care increased over the 4-year study, while use of VA only for these services decreased.
  
  Date: October 1, 2010
• VA Increases Prescriptions for Smoking Cessation Medications among Veterans
  Since 2002, VA has implemented a range of policies and programs to increase evidence-based treatment for smoking. This study examined the change in rates of dispensing cessation-related medications to Veterans in the VA healthcare system to assess the impact of these policy changes. Findings show that VA policy initiatives instituted since 2002 have greatly increased prescriptions for smoking cessation medications among Veterans, while decreasing costs. The number of Veterans filling a prescription for nicotine replacement therapy (NRT) increased 63% from FY04 through FY08. Thirty-day-equivalent NRT prescriptions rose nearly 50% over the same period. Bupropion prescribing also rose sharply; the four-year growth rate among Veterans also prescribed a NRT was 61% greater than the 35% growth rate among all Veterans receiving bupropion prescriptions. While prescriptions for NRT and bupropion rose, spending per treated patient fell by 39% for bupropion and by 24% across all NRT formats (e.g., patch, gum).
  
  Date: September 24, 2010
• VHA Policymakers May Need to Consider Additional Classification Schemes when Planning Care for “Rural” Veterans
  To better understand the issues confronting Veterans living in rural settings, VHA developed a three-category classification system that designates locations throughout the U.S. as Urban, Rural, or Highly Rural. To understand the policy implications of the VA classification system, this study compared VA’s categories to three Office of Management and Budget (OMB) and four Rural-Urban Commuting Area (RUCA, developed by the University of Washington and the USDA) geographical categories. Findings show that although the three classification schemes differ considerably in the number of VHA healthcare enrollees designated as Rural residents, they all show that the proportions of rural Veterans among enrollees are substantial. VHA’s Rural category (36% of its enrollees) is broadly defined and includes up to 3 to 5 times the enrollees included in the middle RUCA or OMB categories. VHA’s Highly Rural and Urban categories are defined more narrowly than in the other schemes, suggesting that VHA’s categories may more accurately reflect specifically urban or remotely rural populations. Of Veterans enrolled in VA healthcare, roughly 1 in 60 is a Highly Rural resident. If policymakers rely solely on either the RUCA or OMB category scheme, they might conclude that access standards have been met for the majority of VHA enrollees. However, the VHA scheme indicates that access standards have not been met for Veterans living in highly rural settings. Thus, authors suggest that policymakers supplement analyses of Rural Veterans’ healthcare needs with more detailed breakdowns from other classification systems.
  
  Date: September 1, 2010
• Disparities in Healthcare Coverage and Access among American Indian/Alaska Native Veterans
  American Indian/Alaska Native (AIAN) Veterans have considerable disparities in healthcare coverage and acess to care compared to non-Hispanic white Veterans. For example, AIAN Veterans are nearly twice as likely to be uninsured, even after adjusting for sociodemographic and economic characteristics. AIAN Veterans are significantly less likely to report private coverage and significantly more likely to report public coverage, military coverage, and be uninsured. Regarding barriers to healthcare, AIAN Veterans were significantly more likely to delay healthcare due to not getting timely appointments, not getting through on the telephone, and having transportation problems.
  
  Date: June 1, 2010
• Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings
  Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and quality.
  
  Date: May 11, 2010
• VA Provides Broader Variety of Assistive Technologies for Veterans with Stroke at Lower Cost
  Findings from this study suggest that VA provides a broader variety of assistive technology devices (ATDs) at a lower cost than Medicare. In specific ATD comparisons, VA costs were substantially lower than Medicare for purchased items, and slightly lower than Medicare for capped rental payments. More than half of the ATDs provided by VA were ADL-related, compared to only 11% provided by Medicare. Findings also showed that 39% of the cohort had not received an ATD of any kind, while 56% received ATDs from VA only, 3% received ATDs from both systems, and 1% received an ATD from Medicare only. Analyses suggest that VA policy in providing ATDs is driven by Veterans’ needs, whereas Medicare policy may be driven, in part, by cost-containment needs associated with increases in fraudulent claims.
  
  Date: February 1, 2010
• Therapy via Video-Teleconference as Effective as In-Person Treatment in Reducing Anger Problems in Veterans with PTSD
  Cognitive behavioral therapy (CBT) anger management conducted via video-teleconference was as effective as in-person delivery of the same treatment in reducing anger problems among Veterans with PTSD who live in rural settings. Moreover, mean improvements in the video-teleconferencing group were actually slightly larger than in the in-person treatment group. Veterans in both treatment groups benefited from anger management therapy (AMT), making this one of the few large randomized controlled trials to show meaningful benefits for reducing anger problems in Veterans with PTSD. Veterans in both treatment groups reported high rates of treatment credibility, satisfaction with care, homework adherence, and high alliance with the therapist.
  
  Date: January 26, 2010
• Veterans’ Age and Disability Status Associated with Choice of Medicare Plans
  Medicare-eligible Veterans may choose between care in VA or Medicare (or both), and they also have to choose between obtaining Medicare services in the fee-for-service (FFS) sector or in a Medicare Advantage (MA) plan. This study sought to assess factors associated with enrollment in an MA vs. FFS plan in 2000-2004 among this population. Findings show that age and disability status were both significantly associated with choice of MA vs. FFS plan. For example, age-eligible Veterans were more likely to be enrolled in an MA plan if aged 75 or older, female, able to receive free VA care, or not enrolled in Medicaid, while disability-eligible Veterans were more likely to be enrolled if they were married or elderly. Minority Veterans and Veterans with lower disease risk scores (better average health) were more likely to be enrolled in an MA plan than white Veterans or Veterans with higher risk scores. Overall, Veterans living in zip codes with greater population density and higher per capita income were also more likely to enroll in an MA plan. The authors suggest that future studies examine the Medicare health plan choice of disabled Veterans, particularly OEF/OIF Veterans who begin to qualify for Medicare, to better understand the possible impact of MA enrollment on continuity, duplication, cost, and quality of care.
  
  Date: November 1, 2009
• Effect of Medicare Pharmacy Benefit Coverage on VA Healthcare Users
  This study examined the influence of Medicare pharmacy benefit coverage on VA pharmacy use among Veterans using the VA healthcare system during 2002, who had diabetes mellitus, ischemic heart disease, or chronic heart failure. Overall, results showed that Veterans dually enrolled in VA and Medicare fee-for-service (FFS) were less likely to receive condition-related medications from VA compared with Veterans enrolled in HMOs with lower levels of prescription drug coverage. One implication of the overall study findings is that VA will become less the healthcare system of choice for Veteran beneficiaries if Medicare pharmacy services become more affordable. Moreover, Veterans with chronic conditions that require many medications and who hit a coverage gap in Medicare Part D or have difficulty making the Medicare co-payments may turn to VA as a safety net at intermittent times rather than using VA pharmacy services more steadily.
  
  Date: October 1, 2009
• Geographic Access to Rehabilitation for OEF/OIF Veterans
  This study sought to ascertain specific geographic areas where the need for VHA rehabilitation services appears greatest and potential access gaps may exist. Findings show that VA provides access to rehabilitation care for the majority of traumatically injured OEF/OIF Veterans; however, more than 10% of Veterans may have potential access barriers due to excessive travel time. For the combined cohort, the median distance to Level I, Level II, and Level III facilities was 411 miles, 121 miles, and 64 miles respectively, and the median distance to the closest VA facility was 22 miles. Clark County, Nevada, and El Paso County, Texas had the highest number of patients with potential access gaps due to excessive travel times.
  
  Date: October 1, 2009
• Use of Medicare and VA Healthcare among Veterans with Dementia
  This study sought to characterize healthcare use among Veterans with dementia over a four-year period (1998-2001), and to determine predictors of whether a Veteran will be a VA-only, dual, or Medicare-only user. Findings show that during the four-year study period, Medicare-only use increased while VA-only use decreased. Results also show that an increased likelihood of some Medicare use was associated with being older, white, married, and having higher education, private insurance or Medicaid, and low VA priority level. Further, the number of functional limitations was associated with an increased likelihood of Medicare-only use and a decreased likelihood of VA-only use, while higher comorbidities were associated with a higher likelihood of dual use as opposed to any single system use. The authors suggest that these results imply that different aspects of Veterans’ needs have differential effects on where Veterans seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure patients receive high quality care, particularly among those with multiple comorbidities.
  
  Date: October 1, 2009
• Demands on VHA for Post-Deployment Healthcare Needs of OEF/OIF Veterans will be Overshadowed by the Needs of Older Veterans
  This article discusses the implications for the Veterans healthcare system of the demand for healthcare services from OEF/OIF Veterans. Findings show that although the pressing needs of newly discharged Veterans require immediate attention, especially in the areas of TBI, PTSD, and physical disability services, the demand for immediate post-deployment VA healthcare services by OEF/OIF Veterans will be overshadowed by the demands of aging Korean and Vietnam War Veterans (and, eventually, aging OEF/OIF Veterans), in terms of the number of patients and the average cost of their care. Thus, the major demand on VA healthcare services will be from aging Veterans whose usage and needs for services will be relatively stable and predictable; however, it is the extra cost for OEF/OIF Veterans that is difficult to quantify because of the unknowns (e.g., nature, severity, and number of PTSD and TBI cases).
  
  Date: September 1, 2009
• Healthcare Utilization among American Indian and Alaska Native Veterans
  Findings show that like other VA healthcare users, American Indian and Alaska Native (AIAN) patients had the same three most frequent diagnoses associated with healthcare encounters: post-traumatic stress disorder, hypertension, and diabetes. VHA-Indian Health Service (IHS) dual-users were more likely to receive primary care from IHS and to receive diagnostic and behavioral healthcare from VA. Many dual-users who had been diagnosed with diabetes, hypertension, and/or cardiovascular disease received overlapping healthcare services in VA and IHS. Therefore, authors suggest that strategies to improve outcomes among the AIAN Veteran population should target those receiving care in both systems and include information sharing or coordination of clinical care to reduce the potential for duplication and for treatment conflicts.
  
  Date: June 1, 2009
• Veterans with HIV Treated at Clinics with Integrated Specialty Services More Likely to Achieve Better Outcomes
  The most common way HIV clinics address patients with comorbidities is by integrating non-infectious disease providers (e.g., psychiatrists and social workers) into HIV primary care. This retrospective cohort study evaluated the association between Integrated HIV Care and patient outcomes among 1018 Veterans with HIV who received care at five VA facilities from 2000-2006. Findings show that Veterans who visited HIV clinics with more integrated specialty services were more likely to achieve viral suppression. In particular, Veterans visiting clinics that offered hepatitis, psychiatric, psychological, and social services in addition to primary care and HIV specialty services were three times more likely to achieve viral suppression than Veterans visiting clinics that offered only primary care and HIV specialty services. Results also showed that 93% of Veterans in this study had one or more comorbid conditions, with a mean of 3.2 comorbidities. Authors suggest that resources should be allocated to integrate sub-specialty services into HIV primary care clinics, and that providers should direct patients toward these clinics and retain them in care.
  
  Date: May 1, 2009
• Access to Healthcare among Veterans with Bipolar Disorder
  Findings from this study show that despite the fact that all Veterans were currently receiving VA treatment for bipolar disorder, 15%-20% experienced trouble obtaining different aspects of healthcare when needed. Compared with accessing psychiatric care, Veterans with bipolar disorder reported greater difficulty accessing general medical services. Veterans experiencing current bipolar symptoms more frequently avoided psychiatric care due to cost, and perceived greater problems accessing medical specialists. As with mental healthcare services, the dominant influences predicting limitations in obtaining needed general medical care included living alone, an inpatient stay, homelessness, and current bipolar symptoms. The authors suggest that current VA efforts to expand mental healthcare access should be coupled with efforts to ensure adequate access to medical services for Veterans with chronic mental illness.
  
  Date: April 1, 2009
• Diffusion of New Drug Therapy for PTSD Lessens with Distance
  This study sought to evaluate the pace and reach of the passive dissemination of a novel, but as yet un-established treatment with the drug prazosin for post-traumatic stress disorder (PTSD) within the VA health care system. Investigators used geographic surveillance data to track the diffusion of prazosin to treat Veterans diagnosed with PTSD in the VA Puget Sound Healthcare System (where the treatment was developed), and at VAMCs ranging up to 2500 miles or farther from Puget Sound. Findings show that the passive diffusion of a new treatment can be rapid in the immediate area in which it is developed, but the geographic gradient of use seems to be steep and changed little during a two-year period, even when cost and organizational barriers were minimal. Veterans with PTSD treated in the area nearest to Puget Sound (<499 miles) were about 63% less likely in 2004 and about 49% less likely in 2006 to be prescribed prazosin than their counterparts treated within Puget Sound. These results suggest that if and when new treatments are definitively demonstrated to be effective, more active dissemination is likely to be needed, especially in geographically remote areas.
  
  Date: April 1, 2009
• Teledermatology – Promising Technique for Improving Access to Care
  In this study, teledermatology demonstrated good performance in comparison to clinic-based consultation for diagnostic agreement and diagnostic accuracy. Regarding diagnosis, teledermatologists agreed with each other and with clinic-based dermatologists at a rate comparable to group agreement among clinic dermatologists. Regarding accuracy, when compared to the gold standard of histology, rates ranged from 30% to 92% for clinic dermatologists and from 19% to 95% for teledermatologists.
  
  Date: April 1, 2009
• Outpatient Healthcare Use for American Indian and Alaska Native Women Veterans
  American Indian and Alaska Native (AIAN) women are among the growing number of female Veterans who now seek VA healthcare. In 2003, VA and the Indian Health Service (IHS) executed a Memorandum of Understanding (MOU) to improve access and health outcomes for AIAN Veterans by encouraging cooperation and resource sharing. In order to inform inter-agency planning and coordination, this study reports on the demographic characteristics and healthcare utilization patterns of AIAN women Veterans at the outset of the MOU agreement. Findings show that regardless of group, the medical needs of female AIAN Veterans were similar to other Veterans, including other female Veterans. On average, Veteran dual-users received two-thirds of their healthcare at VA facilities, while non-Veteran dual-users received most of their healthcare at IHS facilities. The lowest outpatient utilization rate was for IHS-only users. Results also show that three of the most frequent diagnoses were hypertension, diabetes, and depression.
  
  Date: March 1, 2009
• Physicians May Need More Education about Long-Term Care Options for Veterans
  The purpose of this study was to obtain information about VA long-term care (LTC) referrals that could be used to develop interventions that increase the likelihood of referrals to home and community-based services (HCBS) instead of institutional care. Findings indicate that physicians are often seen as having limited familiarity with HCBS options and tend to refer Veterans with LTC needs to nursing homes. Training physicians about LTC referral options, with particular focus on how HCBS can be used to meet Veteran and caregiver needs, may help to increase those referrals.
  
  Date: February 1, 2009
• Increase in VA Prescription Co-Pay Leads to Decrease in Adherence to Statins for Veterans at Risk of Heart Disease
  VA’s increase in drug co-payments from $2 to $7 adversely affected lipid-lowering medication adherence among Veterans, including those at high risk of coronary heart disease. After the increase in medication co-payments, the percent of Veterans who were adherent to lipid-lowering therapy declined significantly, even for Veterans with no co-pay. The co-payment increase was also accompanied by a significant increase in the likelihood of having continuous gaps in lipid-lowering medication use.
  
  Date: January 27, 2009
• Barriers to Bone Density Testing for Patients with Spinal Cord Injury
  Several barriers to routine bone mineral density assessment among the SCI population were identified, e.g., scanner design that limits accessibility, and increased scanning time that requires additional staff. To help lessen these barriers, investigators recommend several changes, such as: installing ceiling-mounted hydraulic lifts and grab bars to facilitate transfers in the screening room, increasing staff during scans, and partnering with administrators and staff to raise awareness of access issues faced by individuals with spinal cord injury.
  
  Date: January 1, 2009
• Hospital Readmission More Likely Following VA vs. non-VA Hospitalization for Older Veterans Living in Rural and Urban Settings
  Regardless of where veterans lived (urban or rural setting), readmission after a VA hospitalization was more common than readmission after a non-VA hospitalization (20.7% vs. 16.8% for rural veterans; 21.2% vs. 16.1% for urban veterans). Authors suggest that VA consider using unplanned 30-day readmission rates as a component of quality assessment.
  
  Date: January 1, 2009
• Factors Associated with VA Employee Participation in Quality Improvement Program to Reduce Patient Wait Times
  Perceived group norms and attitudes were related to greater individual participation in the Advanced Clinic Access program, but perceived behavioral control was not found to be significant to participation. Overall, survey respondents typically engaged in just under half of the change behaviors. Employees with greater responsibility (e.g., nurse practitioners, RNs, and physicians) participated in more activities compared to other clinic employees. Team size, academic affiliation, and job satisfaction were not significant predictors of participation.
  
  Date: November 1, 2008
• Program Improves Access to Mental Health Care for Veterans
  This article discusses the implementation and outcomes for the first four years of the “Primary Mental Health Care Clinic” (PMHC) program, an innovative program developed at one VA medical center that shifted specialized staffing into an existing mental health clinic in primary care and added advanced clinical access in primary care. Waiting time for new appointments was shortened from a mean of 33 days to 19 minutes. Clinician productivity and evaluations of new referrals more than doubled. In addition, the program has reduced the number of veterans referred into the specialized mental health clinic, thus conserving resources.
  
  Date: November 1, 2008
• Most Elderly Veterans Obtain High-Risk Surgeries in Non-VA Hospitals
  Regardless of where they live (rural vs. suburban vs. urban), most elderly veterans obtain high-risk procedures such as heart, vascular, and cancer surgeries in non-VA hospitals. Veterans generally traveled about as long to get to higher performance hospitals as to reach lower performance hospitals. Authors suggest that veterans might benefit from an effort to direct them to higher performance hospitals for these high-risk surgeries, and that this effort might best be initiated by focusing on veterans living beyond urban areas.
  
  Date: October 1, 2008
• Psychotherapy Administered via Telephone Reduces Depression
  Findings show a significant reduction in depressive symptoms for patients enrolled in telephone-administered psychotherapy as compared to those in control conditions (e.g. treatment as usual). Moreover, attrition rates were considerably lower than rates reported in face-to-face psychotherapy.
  
  Date: September 1, 2008

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 Cancer

• Despite Guidelines to the Contrary, High Rates of PSA Screening Found among Older Veterans with Limited Life Expectancy
  This study sought to identify medical center characteristics associated with prostate-specific antigen (PSA) screening among men with limited life expectancy. Findings showed that high rates of PSA screening were found among older Veterans with life expectancy of less than 10 years, with substantial variation across VAMCs. Among Veterans with limited life expectancy, 45% received PSA screening in 2003. Across 104 VAMCs, the PSA screening rate for this population ranged from 25-79%. VA medical center characteristics associated with higher PSA screening rates included: no academic affiliation, a ratio of mid-level providers to physicians >3:4, and location in the South. Use of incentives and high scores on performance measures did not significantly affect screening practices. The percentages of men screened with limited and favorable life expectancies were highly correlated, indicating that screening is being poorly targeted. As a result of this and other studies, VHA’s National Center for Health Promotion and Disease Prevention has developed a set of goals to reduce over-screening in older adults starting in FY12.
  
  Date: December 17, 2011
• Caregivers of Veterans with Chronic Illness
  This study sought to identify predictors of caregiver strain and satisfaction associated with caring for Veterans with chronic illness. Findings showed that although 76% of caregivers reported feeling very self-confident in their caregiving role, more than one-third (37%) reported high strain. Overall, the mean caregiving satisfaction score indicated a moderate level of satisfaction. Caregiver characteristics that predicted strain included having less support, having depressive symptoms, and using paid help. Veteran characteristics that predicted caregiver strain included greater need for caregiving assistance in IADL (instrumental activities of daily living), and greater levels of depression. Predictors of lower caregiver satisfaction included less social support, older age, depression, and poor Veteran health status. Predictors of higher caregiver satisfaction included helping the Veteran with medical equipment and the coping style of “taking medication.” Both caregivers and Veterans reported similar levels of assistance provided, which were relatively low for ADL (activities of daily living) and IADL. However, caregivers reported providing a mean of 43 hours per week in assistance. Investigators suggest this may be due to the higher percentage of spouse caregivers in this sample, who are available for caregiving around the clock. A majority of caregivers expressed a need to know more about the Veteran’s medication.
  
  Date: November 22, 2011
• High Rates of CRC Screening among Veterans Receiving VA Care
  This study examined colorectal cancer (CRC) testing rates in a national sample of Veterans to determine the modalities of CRC testing used and factors associated with the lack of fecal occult blood test (FOBT) card return. Findings showed that overall rates of CRC screening in the VA healthcare system were high (80%) among Veterans aged 51-75 years. This rate compares favorably with population estimates for the U.S., where only 60% of eligible Americans are estimated to have undergone a CRC screening test with either lower endoscopy or FOBT. Of Veterans who had received appropriate screening, the majority underwent colonoscopy in the prior 10 years (72%), followed by FOBT in the prior year (24%). A total of 31% of Veterans did not return FOBT cards that were provided. Factors associated with a lack of return included: younger age, non-Caucasian race, and current smoking. Secondary analyses in an augmented sample of women Veterans showed that findings were similar for both genders. As with men, smoking was associated with lack of FOBT return.
  
  Date: September 16, 2011
• Long-Term Outcomes Following Positive Colorectal Screening
  Despite persistently low rates of follow-up colonoscopy in older adults with positive fecal occult blood test (FOBT) results, the long-term outcomes of screening and follow-up practices have not been described. This study examined outcomes following a positive screening FOBT result for 212 Veterans ages 70 years or older at four VA facilities in 2001. Both Veterans who did receive a follow-up colonoscopy and Veterans who did not were followed through 2008. Findings showed that, over a 7-year period, a little more than half of the older Veterans in this study received a follow-up colonoscopy after a positive FOBT. Among Veterans who received follow-up colonoscopy, more than 25% had significant adenomas or cancer detected, were treated, and survived for more than five years. Approximately 59% of Veterans who received follow-up colonoscopy had no significant findings, and 10% experienced complications from colonoscopy or cancer treatment. Among Veterans who did not receive follow-up colonoscopy, 57% underwent some form of follow-up other than colonoscopy (e.g., repeat FOBT or sigmoidoscopy) and 59% had more than one non-colonoscopy follow-up test. Nearly half of the non-colonoscopy group died of other causes within five years, and 3% ultimately died of colorectal cancer. Veterans with the best predicted life expectancy were less likely to experience net burden from screening than Veterans with the worst predicted life expectancy. These findings support guidelines that recommend using life expectancy to guide colorectal cancer screening decisions in older adults, and argue against one-size-fits-all interventions that simply aim to increase overall screening and follow-up rates.
  
  Date: May 9, 2011
• No Racial Disparities in Adherence to CRC Screening among Veterans Receiving VA Care
  This study examined the contribution of demographic/health-related factors, cognitive factors, and environmental factors to racial disparities in colorectal cancer (CRC) screening in a nationally representative survey of Veterans ages 50 to 75. The effect of race on adherence to CRC screening guidelines was non-significant after adjusting for demographic/health-related factors and environmental factors. Adherence in both African American and White groups was substantially higher than the national average. The high rates of CRC screening are likely, in part, a result of various VA efforts initiated over the past decade to increase screening adherence. There were no racial differences in physican recommendations for CRC screening: 84% for African Americans and 85% for Whites. Among those who were adherent to CRC screening, African American Veterans had significantly lower rates of colonoscopy compared with White Veterans (47% vs. 57%) and significantly higher rates of fecal occult blood testing (60% vs. 53%).
  
  Date: March 1, 2011
• Increased Wait Times for Surgical Cancer Treatment, Particularly at VA Medical Centers and NCI Cancer Centers
  This study sought to assess changes in wait times for initial cancer treatment over a decade (1995 - 2005) and to identify patient, tumor, and hospital factors associated with prolonged wait times, using data from National Cancer Institute (NCI)-designated cancer centers, VA medical centers, academic hospitals, and community hospitals. Findings show that wait times for cancer treatment progressively increased at all four hospital center types over the 10-year study period. The median time from diagnosis to treatment was significantly longer at VA medical centers and NCI-designated cancer centers compared to community hospitals for all eight cancers studied. For patients who were diagnosed and treated at the same hospital, the median time from diagnosis to treatment was longest at VA medical centers, and shortest at community hospitals. Patients were significantly more likely to undergo initial treatment more than 30 days following diagnosis if they were: older, African American, had more comorbidities, had Stage I disease, or were treated at NCI cancer centers or VA medical centers.
  
  Date: February 25, 2011
• Electronic Record Intervention Improves Follow-Up of Veterans with Positive Colorectal Cancer Screening
  This randomized trial of eight VAMCs evaluated an electronic record intervention for follow-up of Veterans with a positive fecal occult blood test (FOBT). Findings show that a simple electronic intervention involving an automatic GI consult for Veterans with a positive FOBT result improved follow-up and reduced the time between a positive FOBT and GI evaluation, as well as complete diagnostic evaluation (CDE). The 30, 90, and 180 day GI consult rates improved 21% to 33% among intervention sites, but did not change in the usual care sites. Thirty, 90, and 180 day CDE rates improved 9% to 31% in intervention sites, but did not significantly change in usual care sites. Time to GI consult and CDE decreased significantly over time in the intervention sites, but remained unchanged in the usual care sites.
  
  Date: February 15, 2011
• Rates of Liver Cancer and Cirrhosis Increase Significantly among Veterans with Hepatitis C Virus
  This study identified all Veterans with hepatitis C virus (HCV) who visited any of 128 VA medical centers over a 10-year period to examine the prevalence of cirrhosis, hepatic decompensation, and hepatocellular cancer, as well as risk factors that may be associated with an accelerated progression to cirrhosis. The number of Veterans diagnosed with HCV increased over the ten years from 17,261 to 106,242. Over the same time period, among HCV patients, the prevalence of cirrhosis increased from 9% to 18.5%, while the prevalence of liver cancer increased approximately 19-fold (from 0.07% to 1.3%). Regarding risk factors among HCV-infected Veterans, the proportion of patients with co-existing diabetes increased from 12% in to 23%, while the number of patients with HIV, hepatitis B virus, or a diagnosis of alcohol use declined slightly.
  
  Date: December 22, 2010
• Education Intervention Decreases Inappropriate Prostate Cancer Screening among Veterans
  This study tested an e-mail-based intervention called “spaced education” (SE) that was developed to reduce clinicians’ inappropriate screening for prostate cancer. Findings show that during the intervention period (36 weeks), clinicians who received the spaced education intervention ordered significantly fewer inappropriate PSA screening tests than clinicians in the control group. Over the 72-week follow-up period, SE clinicians continued to order fewer inappropriate tests compared to controls, representing a 40% relative reduction in inappropriate screening. The impact of the intervention was unaffected by clincians’ age, gender, or provider type.
  
  Date: November 1, 2010
• Prostate Screening Does Not Reduce Prostate Cancer or All-Cause Mortality
  In a 2006 review of the evidence, authors identified insufficient evidence to either support or refute the use of routine screening for prostate cancer. This article presents findings from their updated study, in which investigators sought to determine whether population-based screening reduces prostate cancer-specific mortality and/or all-cause mortality. They also examined its impact on quality of life, including adverse events (e.g., harms of screening from false-positive or false-negative results). Findings show that prostate cancer screening did not result in a statistically significant reduction in prostate cancer-specific or all-cause mortality. One of the studies in this review showed a marginally significant benefit for prostate cancer screening among a subgroup of men aged 55 to 69. Among this group, it was reported that 1,410 men would need to be screened, with 48 men needing prostate cancer treatment, to prevent one additional death from prostate cancer during a 9-year period. Any benefits from prosate cancer screening may take up to 10 years to accrue; therefore, the authors suggest that men with a life expectancy of less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. None of the studies reviewed provided detailed assessment of the effect of screening on quality of life or costs associated with screening.
  
  Date: September 1, 2010
• Study Identifies Preventable Delays in Lung Cancer Diagnosis
  Preventable delays in lung cancer diagnosis among Veterans at two VA medical centers arose mostly from failure to recognize abnormal imaging results documented in the patients’ electronic health records (EHR) – and failure to complete key diagnostic procedures in a timely manner. Missed diagnostic opportunities were identified in 222 of the 587 (37.8%) cases in this study. Patient adherence contributed to 44% of the missed opportunities. Among missed opportunities attributed to failure to recognize a clinical clue documented in the EHR, the most frequently missed clue was an abnormal chest x-ray. Delays in completing follow-up of an abnormal chest x-ray and in performing first needle biopsy were the most common causes of missed opportunities related to failure to complete a requested clinical action. Median time to diagnosis in cases with and without missed opportunities was 132 days and 19 days, respectively. The authors suggest several potential solutions, including using VA’s electronic health record to improve clinician recognition and tracking of abnormal test results.
  
  Date: June 7, 2010
• Study Examines the State of Colorectal Cancer and Finds Cause for Optimism, Particularly within the VA Healthcare System
  In contrast to the health disparities that are evident in the community, when colorectal cancer (CRC) outcomes were studied within an equal-access, integrated healthcare system, such as VA, racial disparities were markedly decreased or absent. The type of screening test used in the US has varied over the last decade, but colonoscopy is becoming the dominant modality. However, VA relies primarily on fecal occult blood tests (FOBT). From 1998 to 2003, the proportion of screened Veterans undergoing FOBT within VA increased from 82% to 90% compared to that of Veterans receiving screening colonoscopies, which decreased from 6% to 5%. From the perspective of population-based screening, VA is actually more successful than the general population at screening, and has CRC screening rates well above the national average.
  
  Date: June 1, 2010
• Communication Regarding Health-Related Quality of Life between Cancer Patients and Providers
  Health-related quality of life (HRQOL) discussions between oncologists and patients were common, but the emphasis was often on treatment (e.g., side effects) and symptoms (e.g., pain), even in patients with advanced disease. All provider/patient encounters included some talk of HRQOL, ranging from 3% to 75% of the total conversation, with the average HRQOL discussion taking up 25% of the conversation. An analysis of topics showed that 56% concerned treatment, 14% concerned disease, and 3% concerned testing. Talk of emotions, mental health, and psychological HRQOL was introduced into the conversations more frequently by patients than providers and occurred in only 9% of the audio segments studied. Spiritual HRQOL also was introduced into the conversations more frequently by patients than providers, and was discussed in only 1% of all audio segments. The authors suggest that given the often intense emotional experience of patients with advanced cancer, oncologists may need to pay more attention to psychological, social, and spiritual HRQOL concerns.
  
  Date: May 1, 2010
• Addressing Psychosocial Needs of Cancer Patients
  This Commentary discusses the nursing challenges of assessing and managing cancer-related distress, in addition to recommending assessment tools and further research. Measurement tools are available that are both well-established and feasible for nurses working within time-constrained environments.
  
  Date: April 1, 2010
• Possible Determinants of Colorectal Cancer Diagnostic Delays among Veterans
  Findings suggest that there is variation within the VA healthcare system regarding the time from initial clinical event until the diagnosis of colorectal cancer (CRC). The median times from initial event to diagnosis were 91 days for screen-detected cancers, 74 days for bleeding-detected cancers, and 73 days for “other.” The CRC stage was III or IV for 57% of the study participants. Compared to screen-detected, bleeding detected and other diagnostic categories were associated with an increased risk of late-stage disease at diagnosis. Older age and any comorbidity level (compared to no comorbidities) were associated with a longer time to diagnosis. The South and West-Midwest regions were associated with a shorter time to diagnosis compared to the Atlantic region.
  
  Date: March 18, 2010
• Surveillance Colonoscopy is Cost-Effective for Patients at High Risk for Developing Colorectal Cancer
  A modeling study examining different surveillance strategies for patients who have adenomas on their initial screening colonoscopy found that costs and benefits differed widely depending on the characteristics of the adenomas and the surveillance intervals. Performing routine screening colonoscopies every ten years in patients at low risk of developing colorectal cancer and surveillance colonoscopy every three years in patients at high risk was more costly, but also more effective than a “no surveillance” strategy where everyone got routine screening every ten years. Compared to no surveillance, this “3/10” strategy was highly cost-effective. Compared to the 3/10 strategy, a “3/5”strategy which conducted surveillance every 5 years on low-risk patients was considerably more costly, but only marginally more effective. A “3/3” strategy was cost-ineffective and potentially harmful in comparison to less intensive surveillance. Based on these results, the authors suggest that the 3/10 strategy is the optimal strategy under the vast majority of clinical circumstances for patients with adenomas on screening colonoscopy.
  
  Date: March 10, 2010
• Characteristics and Needs of Veteran Cancer Survivors
  Findings show that 11% of the Veterans treated within the VA healthcare system in FY07 were cancer survivors. The most common cancer types were prostate, skin (non-melanoma), and colorectal. Compared to the general population, Veteran cancer survivors are older (84% are older than 60) and predominantly male (97%). Cancer site prevalence statistics vary between the VA and general U.S. cancer patient populations due to differences in age, gender, and risk factors. Overall, the four common symptom concerns reported by cancer survivors are sexual dysfunction, fatigue, anxiety, and depression. The authors suggest that Veteran-specific research is needed on topics such as cancer survival among older Veterans, and the role of military exposures (physical, emotional, and psychological) in causing cancer and impacting recovery. The authors also suggest that four models of care may be relevant to improving care for Veterans who have survived cancer: 1) cancer survivorship clinics, 2) cancer care transition plans, 3) rehabilitation, and 4) chronic disease management. These models of care may help integrate the physical and mental health needs of cancer survivors.
  
  Date: March 1, 2010
• Fixing an Electronic Communication Problem that Reduced Follow-Up of Positive Cancer Screens at One VAMC
  This study sought to determine if technical and/or workflow-related aspects of automated communication in VA’s electronic health record could lead to the lack of response to a positive fecal occult blood test (FOBT). A problem with software configuration at one VA medical center intended to alert VA primary care physicians about positive FOBT results led to breakdowns in transmission of a subset of test results. About one-third of the 490 positive FOBTs examined for this study were not directly reported to PCPs as CPRS alerts. Upon correction of the technical problem, lack of timely follow-up of test results decreased from 29.9% to 5.4% -- and was sustained for four months following the intervention. The authors recommend that electronic communication of positive FOBT results should be monitored to avoid limiting the benefits of colorectal cancer screening. They are currently investigating whether this problem exists in other VA facilities, or if this was an isolated event.
  
  Date: December 9, 2009
• Intensive Surveillance following Colorectal Cancer Increases Survival
  This article reviews the clinical trials and evidence that inform the current approach to surveillance among colorectal cancer (CRC) survivors, as well as clinical guidelines developed by various organizations. Overall, findings suggest that intensive surveillance, particularly in the first 2-3 years of follow-up, appears to be associated with the early detection of recurrences, and thus has a beneficial impact on all-cause survival at five years. Imaging tests of the chest and abdomen have also increasingly been recommended by professional organizations to detect resectable recurrences.
  
  Date: December 1, 2009
• Electronic Reminder Increases Follow-Up Rates for Positive Fecal Occult Blood Tests
  Screening with fecal occult blood tests (FOBT) reduces colorectal cancer mortality by 15-33% and decreases the incidence of the disease by 20%; however, as many as 46-66% of patients with an abnormal FOBT do not receive proper diagnostic testing (e.g., follow-up colonoscopy). This study sought to determine the impact of an electronic reminder on the timeliness and proportion of Veterans referred to gastroenterology (GI) for evaluation after a positive FOBT. Findings show that the electronic reminder was associated with a significant improvement in the proportion and timeliness of follow-up for Veterans with a positive FOBT. The intervention was associated with a 20.3% increase in GI consultations within 14 days, and the median time to colonoscopy decreased by 38 days (105 vs. 143 days).
  
  Date: September 1, 2009
• Strategies to Improve Follow-Up for Positive Colorectal Cancer Screening
  In 2006, VA launched a national effort to increase the proportion of patients receiving a colonoscopy within 60 days of a positive fecal occult blood test (FOBT). This study sought to determine the proportion of VA patients with a positive FOBT between March and June of 2007 that received a colonoscopy within 60 days. Investigators also examined data from a 2007 web-based survey that was completed by 132 VAMCs on their FOBT follow-up quality improvement strategies. Results show that only 1 in 4 Veterans received follow-up colonoscopies within 60 days of a positive FOBT for colorectal cancer screening. Findings also show that developing QI infrastructure appears to be an effective strategy for improving FOBT follow-up, when this work is followed by process improvements (e.g., strategies to decrease cancellations, revise colonoscopy prep education protocols). On average, facilities indicated that they had fully implemented 6.84 of 16 improvement strategies. The number of strategies fully implemented was positively associated with 60-day follow-up. The most commonly cited barriers to improvement involved capacity constraints, e.g., sites listing insufficient gastroenterology staff as a barrier had a lower percentage of Veterans receiving timely follow-up. However, none of the improvement strategies designed to address gastroenterology capacity constraints were associated with timely follow-up, suggesting that this barrier may be more difficult or take more time to address than process inefficiencies.
  
  Date: August 1, 2009
• Many Healthy Older Veterans Not Being Screened for Colorectal Cancer
  Many healthy older Veterans with substantial life expectancies are not being screened, while some with severe comorbidity are being screened. For example, only 47% of Veterans aged >70 without comorbidity were screened despite having a high probability of living >5 years. Number of outpatient visits was a strong predictor of screening, independent of comorbidity. Veterans without comorbidity who did not attend a VA primary care, gastroenterology, or general surgery clinic had a lower incidence of screening than patients with severe comorbidity who visited these clinics.
  
  Date: April 7, 2009
• Multi-faceted Quality Improvement Intervention Improves Follow-up Colonoscopy for Veterans with Positive Colorectal Cancer Screening Test
  Inadequate follow-up of abnormal fecal occult blood test (FOBT) screening for colorectal cancer (CRC) may be related to patient, provider, or system-level factors. Thus, in calendar years 2004 and 2005 the Houston VAMC implemented multi-faceted quality improvement (QI) activities to improve follow-up of positive FOBT results. This study examined the effects of these activities on timeliness and appropriateness of positive-FOBT follow-up for 800 Veterans, and also identified factors that affect colonoscopy performance. Findings show that in cases where a colonoscopy was indicated, the proportion of Veterans who received timely referral and performance was significantly higher after the implementation of the QI activities. In addition, there was a significant decrease in median times to colonoscopy referral and performance. However, colonoscopy was not indicated in more than one-third of Veterans with positive FOBTs, raising concerns about current screening practices and the appropriate performance measures related to CRC screening.
  
  Date: April 1, 2009
• Ethnic Differences in Self-Reported Cancer Screening
  Several studies suggest that non-whites may be more likely than whites to over-report screening behavior, which may have considerable implications for research on racial and ethnic disparities in cancer screening. Findings from this study show that racial and ethnic minorities may be less likely to provide accurate reports of their cancer screening behavior and that over-reporting may be particularly problematic. Research suggests that this might be rectified by changing how screening questions are worded and developing different methods for data collection. A conceptual framework offered by study investigators has the potential to guide exploration of where and why possible bias may be occurring and suggests ways in which these biases might be reduced.
  
  Date: February 1, 2009
• Do Delays in Diagnostic Colonoscopy Affect Colorectal Cancer Outcomes?
  No meaningful association was found between mortality in veterans with colorectal cancer (CRC) and lag times between referral for colonoscopy and CRC diagnosis for periods up to two-three months.
  
  Date: November 1, 2008
• Physicians May Lack Empathy in Treating Veterans with Lung Cancer
  Physicians rarely responded empathically to lung cancer patients’ concerns and generally responded more consistently with empathy when patients presented concrete and positive, rather than abstract or negative concerns. The authors note that there may be several reasons why physicians may not display empathy; for example, they may be too busy to recognize opportunities, or they may believe that biomedical information is more reassuring.
  
  Date: September 22, 2008
• Cancer Treatment Rates Low among Elderly Veterans
  Cancer treatment was more common among younger elders (age 70-84) and the authors suggest that it is possible that an exaggerated level of trepidation regarding treatment ramifications among the elderly may be an obstacle to appropriate treatment in patients who could benefit from it.
  
  Date: September 1, 2008
• Variation in Care for Recurrent Non-Melanoma Skin Cancer in a University-Based vs. VA Practice
  Treatment choices differed significantly between the two sites: after adjusting for patient, tumor, and clinician characteristics that may have affected treatment choice, tumors treated at the university-based site remained significantly more likely to be treated with Mohs surgery. There was no evidence that the quality of care varied at the two sites.
  
  Date: September 1, 2008

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 COPD

• Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008
  This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care.
  
  Date: December 1, 2011
• Caregivers of Veterans with Chronic Illness
  This study sought to identify predictors of caregiver strain and satisfaction associated with caring for Veterans with chronic illness. Findings showed that although 76% of caregivers reported feeling very self-confident in their caregiving role, more than one-third (37%) reported high strain. Overall, the mean caregiving satisfaction score indicated a moderate level of satisfaction. Caregiver characteristics that predicted strain included having less support, having depressive symptoms, and using paid help. Veteran characteristics that predicted caregiver strain included greater need for caregiving assistance in IADL (instrumental activities of daily living), and greater levels of depression. Predictors of lower caregiver satisfaction included less social support, older age, depression, and poor Veteran health status. Predictors of higher caregiver satisfaction included helping the Veteran with medical equipment and the coping style of “taking medication.” Both caregivers and Veterans reported similar levels of assistance provided, which were relatively low for ADL (activities of daily living) and IADL. However, caregivers reported providing a mean of 43 hours per week in assistance. Investigators suggest this may be due to the higher percentage of spouse caregivers in this sample, who are available for caregiving around the clock. A majority of caregivers expressed a need to know more about the Veteran’s medication.
  
  Date: November 22, 2011
• Veterans with COPD Living in Isolated Rural Areas have Elevated Risk of Mortality
  This study sought to determine if COPD mortality is higher for Veterans living in isolated rural areas, and, if so, to assess whether or not hospital characteristics mediate such associations. Findings showed that Veterans living in the most isolated rural areas of the United States appear to have an elevated risk of COPD-related 30-day mortality. Overall unadjusted mortality was higher for Veterans from isolated rural areas (5.0%) and rural areas (4.0%) compared to Veterans from urban areas (3.8%). Hospital characteristics were not found to account for this effect. Veterans from isolated rural but not rural areas remained at higher risk for death after adjusting for clinical characteristics, the proportion of COPD admissions in hospitals that came from rural areas, and hospital volume.
  
  Date: July 19, 2011
• Simple Disease Management Program Significantly Reduces Hospitalizations and ED Visits for Veterans with COPD
  This study sought to determine if a simple disease management program, with a focus on early recognition and self-treatment of COPD exacerbations, would improve outcomes in Veterans with severe COPD. Findings show that the program reduced the total frequency of COPD hospitalizations and emergency visits by 41%. After one year of follow-up, the average number of COPD-related hospitalizations per patient was 30% lower in the disease management group compared to the usual care group, and the average number of COPD-related ED visits was 50% lower. The percentage of patients who experienced at least one COPD-related hospitalization was 23% in the usual care group and 17% in the disease management group; for COPD-related ED visits, the percentages were 23% and 14%, respectively. On average, patients in the disease management group spent 36% less time in the hospital for all causes, and also spent less time in the intensive care unit.
  
  Date: October 1, 2010
• Lower Mortality for African American Veterans with COPD Exacerbation not Explained by More Aggressive Care
  This study sought to determine the potential impact of racial differences in ICU admission and the use of ventilator support on mortality among African American and white Veterans admitted to VA hospitals with COPD (chronic obstructive pulmonary disease) exacerbation. Findings show that mortality was lower in African American Veterans compared to white Veterans, even after adjusting for differences in ICU admission rates and ventilator support. However, mortality was similar for African Americans and whites receiving mechanical ventilation (28.8% vs. 31.4%), thus the lower risk-adjusted mortality among African Americans was not explained by more aggressive care.
  
  Date: July 1, 2009
• Inhaled Corticosteroids Associated with Higher Glucose Levels in Veterans with Diabetes, but Effect was Dose-Dependent
  This study examined the association between inhaled corticosteroids and glucose concentration among Veterans who received care at seven VA primary care clinics between 12/96 and 5/01. Of the 1,698 Veterans in this study, 19% also had self-reported diabetes. Findings show that after controlling for systemic corticosteroid use and other potential confounders, no association was found between inhaled corticosteroids and serum glucose for Veterans without diabetes. However, among Veterans with diabetes, every additional 100 mcg of inhaled corticosteroid dose was associated with increased glucose concentration. Given this association, authors suggest that clinicians anticipate an increase in serum glucose for patients with diabetes who are using inhaled corticosteroids and adjust serum glucose monitoring accordingly.
  
  Date: May 1, 2009
• African-American Veterans More Likely than White Veterans to Receive Mechanical Ventilation for COPD
  African-American Veterans with COPD exacerbation in VA hospitals are more likely than white Veterans to receive mechanical ventilation, and this difference is not explained by available clinical or demographic variables. By contrast, African-American and white Veterans are equally likely to receive non-invasive ventilation (NIV) when being treated for COPD exacerbation. Authors suggest that there is no underuse of mechanical ventilation and NIV in the treatment of racial minorities in this patient population; however, unmeasured factors, such as patient preferences or disease severity may be affecting the use of mechanical ventilation, and thus warrant further investigation.
  
  Date: January 1, 2009
• Mortality Risk Associated with Respiratory Medications in Veterans with Newly Diagnosed COPD
  Inhaled corticosteroids and long-acting beta-agonists were associated with a reduction in the odds of all-cause death. Ipratropium was associated with an 11% increase in the risk of death.
  
  Date: September 16, 2008

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 Data Use

• Natural Language Processing with Electronic Medical Record Improves Identification of VA Post-Operative Complications
  This study evaluated a natural language processing (NLP) search approach to detect post-operative surgical complications within VA’s electronic medical record (EMR). Findings showed that, among Veterans undergoing inpatient VA surgery, NLP using the EMR greatly improved the identification of post-operative complications compared to an administrative-code based algorithm. NLP correctly identified 82% of acute renal failure cases compared with 38% for patient safety indicators; 59% vs. 46% for venous thromboembolism; 64% vs. 5% for pneumonia; 89% vs. 34% for sepsis; and 91% vs. 89% for post-operative MI. An accompanying Editorial states that NLP has the potential to greatly enhance the EMR with new applications, such as automated quality assessment to assist in the performance of comparative effectiveness research.
  
  Date: August 24, 2011
• Using Administrative Data to Measure Treatment for Veterans with PTSD May Overestimate Delivery of Psychotherapy
  This study sought to determine whether using administrative data to determine the number of psychotherapy sessions Veterans receive is equivalent to manual record review. Manually-classified notes were used to develop an automated coding protocol using the Automated Retrieval Console (ARC), a VA-developed natural language processing program. ARC was then used to independently code the notes, and the performance of the automated coding program was compared to manual coding. Findings showed that, of the notes that were administratively coded as individual psychotherapy for PTSD, 57% were coded as individual psychotherapy after manual review of records. Thus, nearly half of the encounters that would have been counted as the provision of psychotherapy in large administrative studies appeared to be records of services other than psychotherapy (e.g., intakes, psychological testing). Findings suggest that using counts of administrative codes over-estimates the amount of psychotherapy delivered to Veterans with PTSD. This suggests a potential limitation in current studies of the quality of care for PTSD in VA. The ARC program replicated the performance of the manual coders in classifying psychotherapy notes very well. This suggests that ARC may help bridge the gap between the accuracy of manual coding and the scope of administrative coding.
  
  Date: February 14, 2011
• Validity of Mental Health Diagnosis Using VA Administrative Data
  This study estimated the validity of eight ICD9-based algorithms for the identification of mental health disorders in administrative data among 124,716 Veterans with diabetes who used the VA healthcare system in 1998, and also participated in the 1999 Large Health Survey of Veteran Enrollees, which included questions about history of mental health diagnoses. Findings show that many Veterans with a diagnosed mental health disorder can be identified through VA administrative data; however, the choice of algorithm influenced conclusions. Since the limitations of administrative data cannot be fully eliminated with any algorithm, the authors suggest that investigators and quality improvement programs also consider conducting sensitivity analyses in which they vary the algorithm, in order to indicate how different assumptions affect conclusions.
  
  Date: January 1, 2010
• “Rights” of Safe Electronic Health Record Use
  This JAMA Commentary proposes eight “Rights” of safe electronic health record (EHR) use, which are grounded in an engineering model that addresses work-system design for patient safety. The authors recommend the use of the eight “Rights,” in order to address the complex interaction of organizational, technical, and cognitive factors that affect the safety and effectiveness of EHRs.
  
  Date: September 9, 2009
• Federal Investment in Electronic Medical Records
  The American Recovery and Reinvestment Act (ARRA) includes $19 billion in incentives for the adoption of electronic medical records (EMRs) and $50 billion to promote health information technology. Medicare physicians adopting and making “meaningful use” of EMRs in 2011 and 2012 will be eligible for an initial payment of up to $18,000, with reduced payments in 2013 and 2014. However, current EMR systems’ inability to learn from aggregated health data has led to implementations and hospital information technology departments that can actually obstruct quality improvement. For example, much of the information contained in EMRs is formatted as unstructured free text – useful for essential individual communication but unsuitable for detecting quantifiable trends. This commentary suggests that the Department of Health and Human Services capitalize on the opportunity to mandate EMRs that have the potential to learn from data in the EMR system.
  
  Date: September 9, 2009
• Focus Groups Recommend Strategies to Decrease Missed Test Results
  This paper reports on the efforts of two focus groups that formed as part of the Diagnostic Error in Medicine – A National Conference, which was held by the American Medical Informatics Association in 2008. Clinicians who were part of the focus groups were asked to develop interventions that might decrease the risk of diagnostic delay due to missed test results in the future. The focus groups concluded that while the electronic medical record helps to improve access to test results, eliminating all missed test results would be difficult to achieve. However, they did recommend several strategies that might decrease the rates of missed test results, including: improving standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow-up of test results, and systems re-engineering to improve the management and presentation of data. They also suggest that healthcare organizations focus initial quality improvement efforts on specific tests that have been identified as high-risk for adverse impact on patient outcomes, such as tests associated with a possible malignancy or acute coronary syndrome.
  
  Date: September 1, 2009
• Assessing Accuracy and Completeness of Research Data
  VA benefits from one of the most highly developed health information systems in the world, which includes the Immunology Case Registry (ICR) that was designed to monitor costs and quality of HIV care, and the Decision Support System (DSS) that was developed to monitor utilization and costs of Veterans in care. This study compared ICR and DSS datasets, which share overlapping laboratory data from the same VA electronic record system. Findings show that six of the laboratory tests for HIV patients that were studied demonstrated remarkably similar amounts of overlap (68% to 72%) between the two datasets, showing that ICR and DSS are both good sources of data for these tests. However, several other tests demonstrated much lower proportions of overlap (between 20% and 31%). These findings indicate that validation of laboratory data should be conducted prior to its use in quality and efficiency projects.
  
  Date: January 1, 2009
• Using VA Medical Data Alone May Underestimate Post-Stroke Depression and Geographic Variation in this Condition
  When VA medical data alone were used, investigators found no significant geographic variation in the detection of post-stroke depression (PSD). But when VA medical data were used along with Medicare and VA pharmacy data, significant geographic variation (nearly double – 39.1% vs. 20.0%) was observed. This suggests that to gain a comprehensive view of PSD detection in VA patients, investigators must evaluate non-VA data sources because 70% of VA stroke patients were multiple health program users.
  
  Date: December 1, 2008
• Association between Nurse Staffing Levels and Patient Mortality in VA Hospitals
  RN staffing was not significantly associated with in-hospital mortality for veterans with an ICU stay; however, increased RN staffing was significantly associated with decreased mortality among non-ICU patients. Continuing to estimate the effect of RN staffing and skill mix on patient outcomes using hospital-level data will provide poor estimates of outcome associations, such as in-hospital mortality.
  
  Date: September 1, 2008

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 Diabetes

• Diabetes Managed More Intensively in Older Veterans with Dementia and Cognitive Impairment
  This study sought to examine and compare anti-glycemic medication use, glycemic control, and risk of hypoglycemia in older Veterans with and without dementia or cognitive impairment. Findings showed that diabetes was managed more intensively in older Veterans with dementia or cognitive impairment than in those with no impairment, with more patients on insulin (30% vs. 24%) among those with cognitive problems. These conditions were independently associated with a greater risk of hypoglycemia. Of all Veterans taking insulin, the incidence of hypoglycemia was higher among those with dementia (27%) or cognitive impairment (20%) than among those with neither condition (14%). Veterans with dementia or cognitive impairment also had a greater decline in HbA1c over the 2-year study period. These findings suggest that providers were less likely to pursue individualized glycemic goals, as recommended by VA-DoD clinical practice guidelines (updated in 2010), when patients had cognitive problems.
  
  Date: December 8, 2011
• Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008
  This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care.
  
  Date: December 1, 2011
• Caregivers of Veterans with Chronic Illness
  This study sought to identify predictors of caregiver strain and satisfaction associated with caring for Veterans with chronic illness. Findings showed that although 76% of caregivers reported feeling very self-confident in their caregiving role, more than one-third (37%) reported high strain. Overall, the mean caregiving satisfaction score indicated a moderate level of satisfaction. Caregiver characteristics that predicted strain included having less support, having depressive symptoms, and using paid help. Veteran characteristics that predicted caregiver strain included greater need for caregiving assistance in IADL (instrumental activities of daily living), and greater levels of depression. Predictors of lower caregiver satisfaction included less social support, older age, depression, and poor Veteran health status. Predictors of higher caregiver satisfaction included helping the Veteran with medical equipment and the coping style of “taking medication.” Both caregivers and Veterans reported similar levels of assistance provided, which were relatively low for ADL (activities of daily living) and IADL. However, caregivers reported providing a mean of 43 hours per week in assistance. Investigators suggest this may be due to the higher percentage of spouse caregivers in this sample, who are available for caregiving around the clock. A majority of caregivers expressed a need to know more about the Veteran’s medication.
  
  Date: November 22, 2011
• Veterans with Diabetes and Major Depressive Disorder at Significantly Increased Risk of Myocardial Infarction
  This study sought to determine if major depressive disorder (MDD) complicates the course of type 2 diabetes and is associated with increased risk of myocardial infarction (MI) and mortality. Findings showed that Veterans with comorbid MDD and type 2 diabetes were 82% more likely to experience a MI compared to Veterans without MDD and type 2 diabetes. Veterans with MDD alone were 29% more likely to have a MI, and Veterans with type 2 diabetes alone were at 33% increased risk of MI. The incidence of MI increased in a step-wise fashion, from unaffected Veterans (2.6% incidence of MI) to those with depression only (3.5%) to those with diabetes only (5.9%) to Veterans with both conditions (7.4%). Veterans with PTSD, anxiety, and panic disorder were more likely to have a MI, as were Veterans with hypertension, hyperlipidemia, obesity, and nicotine dependence.
  
  Date: August 1, 2011
• Racial and Ethnic Differences in Blood Pressure Control among Veterans with Type 2 Diabetes
  This study examined racial/ethnic differences in blood pressure control among Veterans with type 2 diabetes and uncontrolled BP at baseline. Findings showed that the adjusted proportion of Veterans with uncontrolled BP (>=140/90 mmHg) decreased in all groups over the study period. However, ethnic minority Veterans had significantly increased odds of poor BP control over a mean follow-up of 5 years compared to non-Hispanic White Veterans, independent of socio-demographic factors and comorbidity patterns. Compared to non-Hispanic Whites (45%), 54% of non-Hispanic Black Veterans, 48% of Hispanic Veterans, and 49% of Veterans with unknown race had poor blood pressure control. In using a more stringent BP cutoff (>=130/80 mmHg) to define poor BP control, 74% of non-Hispanic White Veterans had poor blood pressure control over the 5 years compared to 82% of non-Hispanic Black Veterans, 75% of Hispanic Veterans, and 79% of Veterans with unknown race/ethnicity. The presence of a hypertension diagnosis at the time of study entry appears to be associated with higher odds of achieving BP control over time. Among other comorbidities, cancer, coronary heart disease, congestive heart failure, and substance use disorders were all associated with increased odds of good BP control over time.
  
  Date: June 14, 2011
• Nurse Case Management Decreases Cardiovascular Risk Factors among Veterans with Diabetes Compared to Usual Care
  This study sought to determine if nurse case management could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia among Veterans with diabetes compared to usual care. Findings showed that involving a nurse case manager in the care of patients with diabetes can significantly improve the number of individuals achieving target values for glycemia, lipids, and blood pressure compared to usual care. In this study, a greater number of Veterans in the intervention group had all three outcome measures under control compared to Veterans in the usual care group. In addition, a greater number of Veterans in the nurse case management group achieved individual treatment goals for blood pressure, lipids, and blood sugar compared to Veterans receiving usual care. Observed differences between groups were likely mediated both by enhanced lifestyle changes and a greater intensity of pharmacological treatment among Veterans in the intervention group.
  
  Date: June 2, 2011
• Improvements Using Patient-Aligned Group Clinics for Diabetes Care
  This study evaluated the comparative effectiveness of two group self-management interventions for glycemic control among Veterans with treated but uncontrolled diabetes. Findings show that Veterans who participated in the primary care-based “Empowering Patients in Care” (EPIC) intervention had significantly greater improvements in HbA1c levels immediately following the active intervention; these differences remained at one-year follow-up. Thus, primary care-based diabetes group clinics that include patient-aligned approaches to goal-setting (e.g., action plan) for medication management, and diet and exercise changes can significantly improve HbA1c levels. Diabetes self-efficacy measures improved immediately after the intervention in both the EPIC and comparison intervention groups, but were significantly higher in the EPIC group. Self-efficacy was associated with individual changes in HbA1c levels. At 1 year, differences in HbA1c levels between groups remained the same (i.e., there was no return to baseline, but also no further improvements). Self-efficacy levels dropped in both groups at 1 year; but the drop in the EPIC intervention participants was less than the diabetes education participants, resulting in modest (non-significant) differences between the groups at one year.
  
  Date: March 14, 2011
• Article Challenges Process for Disseminating Diabetes Performance Measures
  Pressure to develop more stringent measures for “optimal” control of risk factors in patients with diabetes has accelerated, despite the absence of new evidence from 1998 to 2008, and results from recent trials have cast new doubt on the benefits of achieving these “optimal” measures in many patients. This editorial suggests that an examination of Toyota, often portrayed as a leader in quality, may provide some answers as to how diabetes performance measures got ahead of the evidence.
  
  Date: February 16, 2011
• Peer Support Improves Diabetes Outcomes
  This study compared the effectiveness of a peer-support program with nurse care management alone in improving glycemic control in a real-world clinical setting. Findings show that among Veterans with diabetes, periodic nurse-facilitated, patient-driven group sessions supplemented with one-on-one peer-support telephone calls (RPS group) improved glycemic control and other key outcomes more than nurse care management services alone (NCM group). More Veterans assigned to peer-support started insulin than those assigned to nurse care management (8 vs. 1), and peer-support participants reported greater increases in diabetes-specific social support at six months.
  
  Date: October 19, 2010
• Threshold for Glycemic Control among Veterans with Diabetes
  In 2009, the National Committee for Quality Assurance (NCQA) – Healthcare Employer Information Data Set (HEDIS) measure for good (<7% A1c) glycemic control for individuals with diabetes was revised to apply only to persons younger than 65 years without cardiovascular disease, end-stage diabetes complications, or dementia. However, multiple guidelines recommend that glycemic control targets be individualized, especially in the presence of comorbid medical and mental health conditions. This retrospective study used the NCQA <7% measure to compare overall VA facility rankings with a subset of Veterans receiving complex glycemic treatment regimens (CGR). Findings show that the assessment of the quality of good glycemic control among VA facilities differs using the NCQA-HEDIS measure for the overall study population compared to a subset of patients receiving CGR. For example, the overall top 10% performing facilities achieved a rate of 57% at the <7% A1c threshold compared to 34% for Veterans on CGR using the same measure. Therefore, the authors suggest that reliance upon a <7% A1c threshold measure as the “quality standard” for public reporting or pay-for-performance could have the unintended consequence of adversely impacting patient safety. Moreover, they propose that rather than assessing “good glycemic control” by an all-or-none threshold, developers of measures should provide credit for an A1c result within an acceptable range (e.g. incremental credit for improvement between 7.9% and <7%) in order to balance the trade-offs of benefits, harms, and patient preferences.
  
  Date: October 1, 2010
• Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness
  This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains.
  
  Date: August 1, 2010
• Risk Related to Serious Hypoglycemia among Diabetics is Under-stated by Current Guidelines and Performance Measurements
  Rapidly evolving evidence from clinical trials and observational studies indicates that serious hypoglycemia is frequent among individuals with type 2 diabetes. Notwithstanding the absence of proven causality between hypoglycemia and mortality, the risks and consequences of hypoglycemia are significant. Despite the significant health burden associated with hypoglycemia, its risks appear to be understated by guideline and performance measurement groups. To increase public and professional awareness about this risk – and to decrease its occurrence, several recommendations are suggested.
  
  Date: May 26, 2010
• Interactive Communication between Primary Care and Specialty Care Improves Patient Outcomes
  This meta-analysis showed that interactive communications between collaborating PCPs and specialists were associated with improved patient outcomes. Interactive communication methods included: initial joint patient consultations, regular specialist attendance at primary care team meetings, telepsychiatry with primary care physicians, scheduled phone discussions, and shared electronic progress notes. The studies in this review all involved collaborations with psychiatrists for management of depression and other mental health disorders and with endocrinologists for management of diabetes; however, the consistency of the effects across different primary care-specialty collaborations, healthcare conditions, and study designs suggests the potential for improvement across other specialties and conditions. Effectiveness was enhanced by interventions to improve the quality of information exchange (e.g., needs assessment, joint care planning).
  
  Date: February 16, 2010
• Costs and Outcomes Associated with Newer Medications for Glycemic Control in Type 2 Diabetes
  Investigators in this study conducted a cost-effectiveness analysis to better understand the value of adding either of two newer medications (exenatide and sitagliptin) as second-line therapy to glycemic control strategies, compared to an older medication (glyburide), for new-onset type 2 diabetes in persons 25 to 64 years of age. Findings show that newer medications offer more options for glycemic control; however, they come at considerable costs. Exenatide and sitagliptin conferred 0.09 and 0.12 additional quality-adjusted life years respectively, relative to glyburide as second-line therapy. Using sitagliptin as a second-line treatment is associated with additional costs of $20,213 per person over their lifetime compared to a baseline strategy using glyburide as second-line therapy. Using exenatide as a second-line treatment is associated with an additional cost of $23,849 per person over their lifetime compared to glyburide as second-line therapy.
  
  Date: January 7, 2010
• Assessing New HEDIS Blood Pressure Quality Measure for Diabetes
  To encourage aggressive treatment of hypertension, the National Committee on Quality Assurance recently adopted a new HEDIS blood pressure performance measure of <130/80 mm Hg for patients with diabetes. Although there is nearly universal agreement on the benefits of aggressive BP treatment (3-4 BP medications) for those with diabetes, the new HEDIS performance measure has generated considerable controversy. This study examined BP levels and medication treatment intensity in patients with diabetes, in order to assess the reasons for failing to meet the new HEDIS measure. Findings suggest that the new diabetes BP measure may not accurately identify poor quality care and could promote overtreatment through its performance incentives. The new measure commonly mislabeled patients as being inadequately treated, especially elderly patients. Thus, the authors recommend that new BP measures be developed to encourage aggressive treatment of hypertension without unduly promoting overtreatment, especially among elderly patients.
  
  Date: January 1, 2010
• Long-Term Impact of Home Telehealth on Preventable Hospitalizations for Veterans with Diabetes
  This study assessed the longitudinal effect of a VA Care Coordination Home Telehealth (CCHT) program on preventable hospitalizations for Veterans with diabetes. Findings showed a statistically significant reduction in preventable hospitalizations for Veterans enrolled in the CCHT program during the initial 18 months of follow-up compared to Veterans in the control group, even after adjusting for potential socio-demographic and clinical risk factors. However, the program did not demonstrate a significant impact after the initial 18 months, which may largely be due to the fact that the control group had more deaths than the CCHT group during those 18 months, likely resulting in the control group’s decreased use of preventable hospitalizations during the remainder of the study period. Over the entire four-year study period, the CCHT group had a lower death rate and longer survival time than the control group, while the control group had much higher frequency in all diabetes-related ambulatory care sensitive conditions such as lower-extremity amputations, uncontrolled diabetes, and bacterial pneumonia.
  
  Date: October 1, 2009
• Regular Primary Care Associated with Better Survival Rates for Veterans with Schizophrenia and Diabetes
  Medical comorbidity among aging people with schizophrenia is common and many patients with schizophrenia have difficulty managing their medical healthcare needs, which may result in delayed treatment and poor outcomes. This retrospective cohort study assessed whether patterns of VA primary care use among Veterans with diabetes, schizophrenia , or both were a significant predictor of mortality over the study period (FY02-FY05). Findings show that regular primary care and high levels of primary care were associated with better survival for patients with chronic illness, whether psychiatric or medical. For example, increasing use of primary care was least common among Veterans with schizophrenia only (4%) compared with Veterans with diabetes only (7%), or those with both conditions (8%), – and was associated with improved survival. This suggests that innovations in treatment retention targeting at-risk groups can offer significant promise of improving outcomes.
  
  Date: July 26, 2009
• Self-Management Intervention for Hypertension has Modest “Spill-Over” Effect on Diabetes Control
  This study evaluated the effect of a tailored hypertension self-management intervention that had been shown to have a modest effect on blood pressure control on the unintended targets of diabetes and cholesterol control. Findings show a modest difference in glycemic control between Veterans with diabetes who received the intervention compared to usual care: the mean HbA1c decreased by 0.28% among Veterans in the intervention, while increasing 0.18% for those in usual care. LDL-C decreased over the two-year period in both groups, but there was no significant difference between the intervention group and usual care. Similar to results found in the analysis of HbA1c, Veterans with higher LDL-C at baseline had steeper rates of improvement over the study period; however, there was no differential effect between the intervention and usual care groups. Thus, this study shows some evidence that a telephone administered, nurse self-management intervention targeting hypertension may have a modest “spill-over” effect on diabetes control.
  
  Date: July 1, 2009
• HSR&D Investigators Propose New Measure to Assess Diabetes Care Quality
  This article discusses a conceptual framework for assessing the efficiency of pharmacologic control of three important risk factors for diabetes (glucose, blood pressure, and cholesterol) because of their central role in diabetes management, and policy implications related to higher medication costs. The authors note that a growing body of evidence indicates a need for more flexible measures of diabetes quality of care. Thus, rather than a single optimal threshold approach, they suggest a new framework for measuring quality of care that incorporates the benefit of incremental improvement among multiple populations that differ by age, diabetes duration, and co-existing illness. The new paradigm would assess pharmaceutical efficiency using quality-adjusted life years (QALYs), calculated separately within multiple age/risk categories, as the output (numerator) and acquisition costs of medications as the input (denominator). The QALYs/cost ratio will provide an assessment of the efficiency of pharmacologic utilization. Therefore, measuring efficiency in the treatment of glucose, blood pressure, and cholesterol in persons with diabetes would incorporate the evaluation of a future healthcare benefit that is “purchased” by direct pharmaceutical costs, linking expected healthcare benefits to actual costs.
  
  Date: June 1, 2009
• Physicians More Likely than Mid-Level Providers to Initiate Treatment Change for Veterans with Diabetes and Elevated Blood Pressure
  This study sought to examine whether treatment change for Veterans with diabetes and elevated blood pressure (BP) differed between physicians and mid-level providers (nurse practitioners, physician assistants), and to determine reasons for any observed differences. Findings show that mid-level providers were significantly less likely than physicians to change BP treatment for Veterans with diabetes and multiple chronic conditions, even after controlling for a number of patient, provider, and organizational characteristics. For example, after controlling for visit factors, provider practice style, measurement and organizational factors, mid-level providers were still less likely than physicians to initiate treatment change (37.5% vs. 52.5%) for elevated BP. Investigators also note that a fairly comprehensive set of potential explanatory variables did not account for any of the differences between physicians and mid-level providers.
  
  Date: June 1, 2009
• Inhaled Corticosteroids Associated with Higher Glucose Levels in Veterans with Diabetes, but Effect was Dose-Dependent
  This study examined the association between inhaled corticosteroids and glucose concentration among Veterans who received care at seven VA primary care clinics between 12/96 and 5/01. Of the 1,698 Veterans in this study, 19% also had self-reported diabetes. Findings show that after controlling for systemic corticosteroid use and other potential confounders, no association was found between inhaled corticosteroids and serum glucose for Veterans without diabetes. However, among Veterans with diabetes, every additional 100 mcg of inhaled corticosteroid dose was associated with increased glucose concentration. Given this association, authors suggest that clinicians anticipate an increase in serum glucose for patients with diabetes who are using inhaled corticosteroids and adjust serum glucose monitoring accordingly.
  
  Date: May 1, 2009
• Cardiovascular Risk Reduction Clinic for Veterans with Diabetes
  The Cardiovascular Risk Reduction Clinic (CRRC) is a pharmacist-coordinated clinic at the Providence VAMC designed to treat the four traditional cardiovascular risk factors (diabetes, dyslipidemia, hypertension, and smoking) to attain goals set forth by national guidelines for patients with diabetes or documented cardiovascular disease. Veterans are discharged from the CRRC when guideline-recommended goals for hemoglobin A1c, low-density lipoprotein cholesterol, blood pressure, and smoking are achieved or mostly achieved. This study evaluated the maintenance of these goals for two to three years after discharge from the CRRC. Findings show that Veterans who completed the program maintained two goals – HbA1c and LDL-C – over three years of observation. The effect on blood pressure was less durable, with half of the Veterans who were at target levels at discharge from the CRRC reaching systolic BP >130 within six months after discharge. Results also show that the most important factor to consider for risk of failure after successful attainment of a cardiovascular goal is how poorly controlled the goal was at baseline.
  
  Date: March 1, 2009
• Evaluating Profiling Program and New Quality Indicators for Diabetes Care
  This study evaluated the addition of new quality indicators to an ongoing clinician feedback initiative that profiles diabetes care and suggests that rather than relying on benchmarks with high and consistent attainment, profiling programs may want to target indicators that demonstrate low and variant performance to better differentiate care across sites.
  
  Date: March 1, 2009
• Transparency Standards for Diabetes Performance Measures
  The development and adoption of performance measures must be transparent. Transparency has been defined as “a process by which information about existing conditions, decisions and actions is made accessible, visible and understandable.” This JAMA Commentary discusses several examples of transparency that might help guide the development of hemoglobin A1c performance measures in the future. Authors suggest that, considering the potential effect on millions of patients and the high cost of antiglycemic medications alone, the upfront investment in ensuring evidence-based, transparently developed performance measures would be worthwhile to protect the public health and restore public and professional confidence.
  
  Date: January 14, 2009
• Need for Better Self-Management Education to Address Cultural Differences among Veterans with Diabetes
  Although non-white Veterans have documented disparities in the quality of some diabetes care processes and intermediate outcome measures, racial disparities in foot care examinations have not been widely explored. Findings from this study show that there are significant differences in self-reported foot care and education across racial and ethnic groups among Veterans with diabetes. Authors suggest the need for better self-management education to address culture, knowledge, preferences, and unique barriers to care.
  
  Date: January 1, 2009
• Reducing Cardiovascular Risk for Veterans with Diabetes and Depression
  The Cardiovascular Risk Reduction Clinic (CRRC) is an ongoing clinical, multi-disciplinary, disease management program at the Providence VAMC. Veterans with and without a depression diagnosis had a significant improvement in cardiovascular risk reduction after participation in the CRRC program. Veterans with a diagnosis of depression had significantly higher cardiovascular risk than those with no mental health condition, but they had greater improvement after participating in the program.
  
  Date: October 1, 2008
• Mental Illness and Substance Use Costs among Veteran Clinic Users with Diabetes
  Alcohol and drug use among veterans with diabetes increased healthcare costs due to greater use of inpatient services, regardless of the presence or severity of mental illness.
  
  Date: July 1, 2008

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 Disparities

• Telemedicine-Based Collaborative Care Intervention for Depression has Greater Effect on Minority vs. White Veterans
  The Telemedicine Enhanced Antidepressant Management (TEAM) study was a randomized trial of telemedicine-based collaborative care tailored for small, rural primary care practices. Investigators in the current study evaluated racial differences in clinical outcomes among 360 Veterans with depression who were randomized to usual care or the TEAM intervention. Findings showed that in the usual care group, minority Veterans had a lower treatment response rate (8%) than Caucasians (18%), but this was not significant. In contrast, minority Veterans in the TEAM intervention group had a significantly higher treatment response rate (42%) than Caucasians (19%) in the intervention group. Veterans in the minority group were significantly less likely to report that antidepressants were an acceptable form of treatment, and were significantly less likely to have had prior or current depression treatment. However, none of these variables were significantly related to treatment outcomes. Thus, the study was not able to determine why minorities responded better to the intervention than Caucasians.
  
  Date: November 1, 2011
• Depression and Race may Independently Affect Receipt of Some Surgeries
  This study examined race and ethnicity as factors potentially associated with surgeries experienced by Veterans with and without major depressive disorder (MDD). Findings show that Veterans with pre-existing MDD were less likely to undergo digestive, hip/knee, vascular, or CABG surgeries than Veterans without MDD. Minority Veterans were slightly less likely to receive vascular operations compared to white Veterans, but were more likely to undergo digestive system procedures. The effect of depression was independent of race and ethnicity; thus, depression and race would have an additive but not synergistic effect on the odds of receiving surgery. In addition, a gender effect was noted: women Veterans were more likely to have digestive procedures but were less likely to undergo CABG or vascular operations. Authors note that the lack of information regarding severity of illness makes it difficult to determine whether or not diagnostic differences explain differences in surgery.
  
  Date: October 1, 2011
• Veterans with COPD Living in Isolated Rural Areas have Elevated Risk of Mortality
  This study sought to determine if COPD mortality is higher for Veterans living in isolated rural areas, and, if so, to assess whether or not hospital characteristics mediate such associations. Findings showed that Veterans living in the most isolated rural areas of the United States appear to have an elevated risk of COPD-related 30-day mortality. Overall unadjusted mortality was higher for Veterans from isolated rural areas (5.0%) and rural areas (4.0%) compared to Veterans from urban areas (3.8%). Hospital characteristics were not found to account for this effect. Veterans from isolated rural but not rural areas remained at higher risk for death after adjusting for clinical characteristics, the proportion of COPD admissions in hospitals that came from rural areas, and hospital volume.
  
  Date: July 19, 2011
• Racial and Ethnic Differences in Blood Pressure Control among Veterans with Type 2 Diabetes
  This study examined racial/ethnic differences in blood pressure control among Veterans with type 2 diabetes and uncontrolled BP at baseline. Findings showed that the adjusted proportion of Veterans with uncontrolled BP (>=140/90 mmHg) decreased in all groups over the study period. However, ethnic minority Veterans had significantly increased odds of poor BP control over a mean follow-up of 5 years compared to non-Hispanic White Veterans, independent of socio-demographic factors and comorbidity patterns. Compared to non-Hispanic Whites (45%), 54% of non-Hispanic Black Veterans, 48% of Hispanic Veterans, and 49% of Veterans with unknown race had poor blood pressure control. In using a more stringent BP cutoff (>=130/80 mmHg) to define poor BP control, 74% of non-Hispanic White Veterans had poor blood pressure control over the 5 years compared to 82% of non-Hispanic Black Veterans, 75% of Hispanic Veterans, and 79% of Veterans with unknown race/ethnicity. The presence of a hypertension diagnosis at the time of study entry appears to be associated with higher odds of achieving BP control over time. Among other comorbidities, cancer, coronary heart disease, congestive heart failure, and substance use disorders were all associated with increased odds of good BP control over time.
  
  Date: June 14, 2011
• Despite Improved Quality of VA Healthcare, Racial Disparity Persists for Important Clinical Outcome
  This article reports on trends in the quality of care and racial disparities in relation to 10 VA clinical performance measures that assessed cancer screening, cardiovascular care, and diabetes care from 2000 to 2009. Findings show that in the decade following VA’s organizational transformation, quality of care improved and racial disparities were minimal for most process measures, such as glucose and LDL screening. However, these were not accompanied by meaningful reductions in racial disparity for important clinical outcomes, such as blood pressure, glucose, and cholesterol control. A gap in clinical outcomes of as much as nine percentage points was observed between African-American and white Veterans. Almost all of the disparity in outcomes was explained by within-facility disparity, which suggests that VA medical centers will need to measure and address racial gaps in care for their patient populations. Of the five performance measures with an absolute racial disparity of 5 percentage points or more in the initial year of the study, there were statistically significant reductions in racial disparity for three: glucose control, BP control, and CRC screening. However, the reductions in disparity were modest, and none were reduced by more than 2 percentage points.
  
  Date: April 1, 2011
• No Racial Disparities in Adherence to CRC Screening among Veterans Receiving VA Care
  This study examined the contribution of demographic/health-related factors, cognitive factors, and environmental factors to racial disparities in colorectal cancer (CRC) screening in a nationally representative survey of Veterans ages 50 to 75. The effect of race on adherence to CRC screening guidelines was non-significant after adjusting for demographic/health-related factors and environmental factors. Adherence in both African American and White groups was substantially higher than the national average. The high rates of CRC screening are likely, in part, a result of various VA efforts initiated over the past decade to increase screening adherence. There were no racial differences in physican recommendations for CRC screening: 84% for African Americans and 85% for Whites. Among those who were adherent to CRC screening, African American Veterans had significantly lower rates of colonoscopy compared with White Veterans (47% vs. 57%) and significantly higher rates of fecal occult blood testing (60% vs. 53%).
  
  Date: March 1, 2011
• VA Patient-Provider Communication Does Not Contribute to Racial Disparities in Use of Total Joint Replacement
  This study examined whether there were racial differences in patient-provider communication about treatment of chronic knee/hip osteoarthritis in African American and white Veterans referred to two VA orthopedic clinics over a 3-year period. Findings show that communication between VA orthopedic surgeons and patients regarding the management of chronic knee/hip osteoarthritis did not, for the most part, vary by patient race. No racial differences were observed with regard to length of visit, overall amount of dialogue, discussion of psychosocial issues, Veteran activation/engagement statements, physician verbal dominance, display of positive affect by Veterans or providers, or discussion related to informed decision-making. However, visits with African American Veterans contained less discussion of biomedical topics and more rapport-building statements than visits with white Veterans. These findings diminish the potential role of communication in VA orthopedic settings as an explanation for racial disparities in the use of total joint replacement.
  
  Date: January 10, 2011
• Disparities in Healthcare Coverage and Access among American Indian/Alaska Native Veterans
  American Indian/Alaska Native (AIAN) Veterans have considerable disparities in healthcare coverage and acess to care compared to non-Hispanic white Veterans. For example, AIAN Veterans are nearly twice as likely to be uninsured, even after adjusting for sociodemographic and economic characteristics. AIAN Veterans are significantly less likely to report private coverage and significantly more likely to report public coverage, military coverage, and be uninsured. Regarding barriers to healthcare, AIAN Veterans were significantly more likely to delay healthcare due to not getting timely appointments, not getting through on the telephone, and having transportation problems.
  
  Date: June 1, 2010
• Patient Treatment Preferences Play Important Role in Racial Disparities in Knee/Hip Total Joint Replacement
  Overall, 10.3% of Veterans treated for knee/hip osteoarthritis at two VA orthopedic clinics underwent total joint replacement (TJR) within six months of study enrollment. TJR was less likely for African-American Veterans compared to white Veterans of similar age and disease severity, but this difference was not significant after adjusting for whether patients had received a recommendation for the procedure from their orthopedic surgeon. African-American Veterans were less likely to receive a recommendation for TJR than white Veterans of similar age and disease severity. However, this difference was not significant after controlling for Veterans’ willingness to undergo TJR, as assessed prior to the visit with their surgeon. This suggests that the observed race differences in recommendations about joint replacement may result from orthopedic surgeons being responsive to patient preferences regarding the procedure.
  
  Date: May 28, 2010
• Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings
  Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and quality.
  
  Date: May 11, 2010
• Lower Mortality Rates for African American Compared with White Patients Hospitalized for Heart Failure
  This study examined research reporting mortality by race after hospitalization for heart failure (HF), and combined the results using meta-analyses. Adjusted mortality rates were 32% lower in short-term follow-up (0-30 days) and 16% lower in long-term follow-up (after 30 days) for African American compared with white patients. Authors suggest that differences in mortality imply unmeasured differences by race in clinical severity of illness at hospital admission and may lead to biased hospital mortality profiles.
  
  Date: March 1, 2010
• Rural-Dwelling VA Patients have Worse Physical Health but Better Mental Health than Urban-Dwelling Counterparts
  Rural Veterans reported worse physical health but better mental health when compared to their urban counterparts, and these differences persisted across the four survey years. The differences were substantial and statistically significant and persisted after correcting for age, gender, marital and employment status, educational level, and local income level.
  
  Date: March 1, 2010
• Veteran Minorities Equally Likely to Receive PTSD Treatment
  This study sought to determine the rates of mental health use in the six months after Veterans received a PTSD diagnosis – and to examine whether service use varied by race or ethnicity. Findings show that minority Veterans were similar to Whites in the likelihood of receiving VA mental health treatment in the six months following a diagnosis of PTSD. Of the 20,284 Veterans with PTSD in this study, 50% received psychotropics, 39% received counseling, and 64% received at least one of these forms of treatment. However, only 24% who received any counseling had at least eight sessions, and most had only one session. These findings indicate that possible treatment preferences exist. The authors suggest that incorporating preferences into treatment planning may facilitate treatment retention and help to maximize treatment outcomes for all Veterans with PTSD.
  
  Date: December 1, 2009
• Ethnic Disparities in Treatment for Chronic Pain
  This study sought to identify racial and ethnic differences in patient-reported rates of treatment for chronic pain and ratings of pain-treatment effectiveness among 255,522 Veterans who were treated at more than 800 VA healthcare facilities in FY05. Findings show that 35% of male Veterans and 44% of female Veterans reported receiving treatment for chronic pain. Male and female Veterans who were Hispanic or non-Hispanic black were more likely to report receiving treatment for chronic pain compared to non-Hispanic white Veterans. Among the Veterans who received treatment for chronic pain, non-Hispanic black men were one-fifth less likely to rate pain treatment effectiveness as very good or excellent compared to non-Hispanic white male Veterans.
  
  Date: October 1, 2009
• African Americans and Whites Equally Appropriate Candidates for Total Joint Arthroplasty
  This study sought to determine if racial differences in clinical appropriateness for surgery existed among a sample of primary care patients (425 whites and 260 African Americans) with moderate to severe symptomatic knee or hip osteoarthritis (OA) treated at one VA hospital and one county hospital between 3/03 and 9/06. Findings show that African Americans and whites were equally appropriate candidates for total joint arthroplasty (TJA). There were no significant ethnic differences found between the proportion of those deemed appropriate for TJA and those deemed inappropriate.
  
  Date: September 1, 2009
• Ethnic Disparities in the Treatment of Veterans with Dementia
  This study sought to determine if there were ethnic disparities in the evaluation and treatment of dementia among 410 Veterans treated at one VAMC between 4/05 and 6/05. Findings show that while laboratory and imaging workup (i.e., CT, MRI) did not differ between ethnic groups, there were significant differences in the treatment of dementia. For example, African American Veterans with dementia were 40% less likely than all other patients to receive acetylcholinesterase inhibitors. This treatment disparity did not appear to be due to differences in the evaluation of dementia, which was similar across groups, although significantly more Caucasian Veterans (43.8%) underwent neuropsychological testing compared to African American (24.8%) or Hispanic Veterans (32.4%).
  
  Date: September 1, 2009
• Lower Mortality for African American Veterans with COPD Exacerbation not Explained by More Aggressive Care
  This study sought to determine the potential impact of racial differences in ICU admission and the use of ventilator support on mortality among African American and white Veterans admitted to VA hospitals with COPD (chronic obstructive pulmonary disease) exacerbation. Findings show that mortality was lower in African American Veterans compared to white Veterans, even after adjusting for differences in ICU admission rates and ventilator support. However, mortality was similar for African Americans and whites receiving mechanical ventilation (28.8% vs. 31.4%), thus the lower risk-adjusted mortality among African Americans was not explained by more aggressive care.
  
  Date: July 1, 2009
• Perceived Racial Discrimination in Health Care Found to be Low and Similar among Veterans and Non-Veterans
  This study examined rates of perceived discrimination in healthcare settings for Veterans and non-Veterans, as well as for Veterans who used the VA healthcare system and those who did not. Overall, rates of perceived racial discrimination in healthcare were low and barely differed between Veterans (3.4%) and non-Veterans (3.5%). Rates of perceived racial discrimination were equally prevalent among Veterans who used the VA healthcare system and those who did not.
  
  Date: May 14, 2009
• Alcohol Misuse and Counseling among Minority Veterans
  This study sought to describe alcohol consumption across race and ethnicity groups among Veterans treated in VA during FY05, and examine associations between race and ethnicity and receipt of alcohol-related advice by clinicians. Findings show that overall, less than one-third of patients who drank at all and one-third of patients with positive alcohol misuse screens reported receiving alcohol-related advice. After adjusting for demographics, health status, and alcohol consumption, Veterans who self-identified as black, Hispanic, or American Indian/Alaska Native were more likely to report receiving alcohol-related advice from their VA healthcare providers compared to non-Hispanic whites. In addition, women and older Veterans were less likely to receive alcohol-related advice than their male and younger counterparts, respectively.
  
  Date: May 1, 2009
• Ethnic Differences in Self-Reported Cancer Screening
  Several studies suggest that non-whites may be more likely than whites to over-report screening behavior, which may have considerable implications for research on racial and ethnic disparities in cancer screening. Findings from this study show that racial and ethnic minorities may be less likely to provide accurate reports of their cancer screening behavior and that over-reporting may be particularly problematic. Research suggests that this might be rectified by changing how screening questions are worded and developing different methods for data collection. A conceptual framework offered by study investigators has the potential to guide exploration of where and why possible bias may be occurring and suggests ways in which these biases might be reduced.
  
  Date: February 1, 2009
• African-American Veterans More Likely than White Veterans to Receive Mechanical Ventilation for COPD
  African-American Veterans with COPD exacerbation in VA hospitals are more likely than white Veterans to receive mechanical ventilation, and this difference is not explained by available clinical or demographic variables. By contrast, African-American and white Veterans are equally likely to receive non-invasive ventilation (NIV) when being treated for COPD exacerbation. Authors suggest that there is no underuse of mechanical ventilation and NIV in the treatment of racial minorities in this patient population; however, unmeasured factors, such as patient preferences or disease severity may be affecting the use of mechanical ventilation, and thus warrant further investigation.
  
  Date: January 1, 2009
• Need for Better Self-Management Education to Address Cultural Differences among Veterans with Diabetes
  Although non-white Veterans have documented disparities in the quality of some diabetes care processes and intermediate outcome measures, racial disparities in foot care examinations have not been widely explored. Findings from this study show that there are significant differences in self-reported foot care and education across racial and ethnic groups among Veterans with diabetes. Authors suggest the need for better self-management education to address culture, knowledge, preferences, and unique barriers to care.
  
  Date: January 1, 2009
• Racial Differences in Coping with Chronic Osteoarthritis Pain
  Compared to white veterans, African American veterans were much more likely to perceive prayer as helpful (85% vs. 66%) and were more likely to have tried it for hip or knee pain (73% vs. 55%). Race was not associated with arthritis pain self-efficacy, arthritis function self-efficacy, or any other coping strategies.
  
  Date: December 1, 2008
• Students Attending Racially and Ethnically Diverse Medical Schools Report Being Better Prepared to Care for Patients in Diverse Society
  White students who attend racially diverse medical schools report feeling better prepared than students at less diverse schools to care for racial and ethnic minority patients. They also are more likely to endorse access to adequate health care as a right. However, investigators found no association between the diversity of a medical school and whether white students intended to provide care in underserved areas.
  
  Date: September 10, 2008
• Disease-Specific Differences in End-of-Life Treatment of Seriously Ill Veterans of Different Ethnic and Racial Backgrounds
  Differences in the level of end-of-life treatments were disease-specific and not based on race and/or ethnicity. In addition, increased end-of-life care for minorities was most pronounced in veterans with dementia, and non-cancer patients received more invasive care than patients with cancer or dementia, independent of their race or ethnicity.
  
  Date: September 1, 2008
• Perceived Racial Discrimination in U.S Healthcare More Prevalent among African Americans and Associated with Worse Health Outcomes
  The prevalence of perceived discrimination in U.S. healthcare is considerably higher for African Americans compared to Whites and Hispanics. [These results were not based on VA data.] Perceived discrimination was associated with worse health for both African Americans and Whites. Health care coverage was not significantly related to perceived discrimination for any of the racial/ethnic groups. However, not obtaining medical care due to cost was associated with a greater likelihood of perceiving discrimination for all groups.
  
  Date: September 1, 2008
• Variation in Care for Recurrent Non-Melanoma Skin Cancer in a University-Based vs. VA Practice
  Treatment choices differed significantly between the two sites: after adjusting for patient, tumor, and clinician characteristics that may have affected treatment choice, tumors treated at the university-based site remained significantly more likely to be treated with Mohs surgery. There was no evidence that the quality of care varied at the two sites.
  
  Date: September 1, 2008

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 Elder Care

• Adverse Drug Reactions Associated with Polypharmacy are Common Cause of Unplanned Hospitalizations among Older Veterans
  This study sought to describe the prevalence of unplanned hospitalizations caused by adverse drug reactions (ADRs) among older Veterans. Findings showed that adverse drug reactions are a common cause of unplanned hospitalization among older Veterans, are frequently preventable, and are associated with polypharmacy (overall, 45% of Veterans took >9 outpatient medications and 35% took 5 to 8). The most common ADRs that occurred were bradycardia, hypoglycemia, falls, and mental status changes. Of the 678 unplanned hospitalizations that occurred during the study period, 70 ADRs involving 113 drugs occurred in 68 older Veterans, of which 37% were preventable. Extrapolating to a population of more than 2.4 million older Veterans receiving care during this time, 8,000 hospitalizations costing about $110 million (using FY04 dollars) may have been unnecessary. The most common reason for a preventable ADR was suboptimal prescribing (52%), followed by patient non-adherence (28%), and suboptimal monitoring (12%). In addition, 4 medication classes (cardiovascular, central nervous system, anti-thrombotic, and endocrine) accounted for almost 80% of all the drugs implicated in ADRs.
  
  Date: December 8, 2011
• Diabetes Managed More Intensively in Older Veterans with Dementia and Cognitive Impairment
  This study sought to examine and compare anti-glycemic medication use, glycemic control, and risk of hypoglycemia in older Veterans with and without dementia or cognitive impairment. Findings showed that diabetes was managed more intensively in older Veterans with dementia or cognitive impairment than in those with no impairment, with more patients on insulin (30% vs. 24%) among those with cognitive problems. These conditions were independently associated with a greater risk of hypoglycemia. Of all Veterans taking insulin, the incidence of hypoglycemia was higher among those with dementia (27%) or cognitive impairment (20%) than among those with neither condition (14%). Veterans with dementia or cognitive impairment also had a greater decline in HbA1c over the 2-year study period. These findings suggest that providers were less likely to pursue individualized glycemic goals, as recommended by VA-DoD clinical practice guidelines (updated in 2010), when patients had cognitive problems.
  
  Date: December 8, 2011
• Quality Indicators may Lead to Unintended Harm in Elderly Patients with Complex Health Issues
  This article highlights two ways that current quality indicators may lead to unintended harms for older patients with complex medical problems and proposes ways to improve quality indicators by minimizing or preventing those harms. For example, current quality indicators are unbalanced, with many encouraging more appropriate care but few indicators discouraging inappropriate care, such as mammography screening for patients with pre-existing advanced cancer or advanced dementia, who are unlikely to benefit. The authors suggest that quality indicators be refined and improved to drive real quality improvement for the entire patient population.
  
  Date: October 5, 2011
• Potential Problems with the Use of Antidepressants among Older Veterans Residing in VA Nursing Homes
  This study examined the prevalence and patient/site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants among Veterans aged 65 years and older that were admitted to any one of 133 VA Community Living Centers (CLC, previously called Nursing Home Care Units). Findings suggest potential problems with the use of antidepressants in older Veterans that reside in VA CLCs. Overall, only 18% of antidepressant use was optimal. Of the 877 Veterans with depression, 25% did not receive an antidepressant, suggesting potential underuse. Among depressed Veterans who received antidepressants, 43% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. In addition, of the 2,815 Veterans who did not have depression, 42% were prescribed one or more antidepressants; of these, only 4% had an FDA-approved labeled indication, suggesting potential overuse. Also, the co-prescribing of antipsychotics (in patients without schizophrenia) among those without depression was associated with an increased risk of antidepressant overuse.
  
  Date: August 1, 2011
• Excessive Caution in Prescribing to Veterans with Geriatric Conditions May Be Unnecessary
  This study evaluated whether common geriatric conditions were associated with risk of adverse drug events (ADEs). Findings show that over the one-year study period, 126 Veterans suffered a total of 167 ADEs, but there was no association between the presence of various geriatric conditions and ADEs. However, in exploratory analyses investigators found that the use of new medications (present at 12-month follow-up) was associated with a higher risk of ADEs. The authors suggest that while it is important to consider the unique circumstances of each patient, excessive caution in prescribing to elders with geriatric conditions may not be warranted.
  
  Date: April 1, 2011
• Aggression May Be Linked to Psychosis in Elderly Persons with Dementia
  This literature review examined the evidence on whether delusions or hallucinations contribute to the development of agitation or aggression in persons aged 65 and older with dementia. Most studies showed a statistically significant association between psychosis and aggression. Findings also showed that the use of antipsychotic medications in the setting of agitation/aggression and psychosis among patients with dementia is not uniformly supported. Authors note that given the multifactorial etiology of psychosis and aggression with other comorbid symptoms in dementia, it is important to understand the various contributing factors to facilitate more effective treatment interventions with least possible risk.
  
  Date: June 1, 2010
• All Antipsychotics May Not Increase Short-Term Risk for Mortality among Veterans with Dementia
  Commonly prescribed doses of haloperidol, olanzapine, and risperidone, but not quetiapine, were associated with short-term increases in mortality. During the first 30 days, there was a significant increase in mortality in subgroups prescribed a daily low dose of haloperidol, olanzapine, or risperidone, after adjusting for demographics, comorbidities, and medication history. However, increased mortality was not seen when quetiapine was prescribed. No antipsychotic was associated with increased mortality after the first 30 days. Therefore, the authors suggest that all antipsychotics might not pose the same degree of risk in all patient groups as implied by the general warnings that have been issued.
  
  Date: May 7, 2010
• Assessment Tool for Elderly Adults’ Capacity to Live Independently
  An interdisciplinary team of clinicians developed the Capacity Assessment and Intervention (CAI) model to evaluate vulnerable patients – and to assess their capacity for safe and independent living. Despite some challenges, the authors suggest that the CAI model provides a systematic approach to initiating, conducting, and following through an assessment of an older adult’s capacity to make and execute decisions regarding safe and independent living in the community.
  
  Date: May 1, 2010
• More than One-Quarter of Elderly Individuals Require Surrogate Decision-Making Near the End of Life
  Of the 3,746 elderly adults (non-Veterans) in this study, 26.8% required decision-making at the end of life and lacked decision-making capacity. Thus, surrogate decision-making was often required. Of those requiring surrogate decision-making, 67.6% had advance directives. Individuals who authored advance directives received care that was strongly associated with their preferences. And those who requested all care possible were far more likely to receive aggressive care compared to those who did not request it. Individuals with advance directives preferred limited and comfort care more than all care possible. Cognitive impairment, cerebrovascular disease, and nursing home status were associated with the need for decision-making and lost decision-making capacity before death; but these characteristics were so common (present in 65.3% of the study population) as to not be clinically useful risk factors.
  
  Date: April 1, 2010
• Nursing Homes’ Disaster Response Activities Following Hurricanes Katrina and Rita
  Hurricanes Katrina and Rita exposed significant flaws in the U.S. preparedness for catastrophic events – and in the nation’s capacity to respond to them. This article reviews VA’s response to these hurricanes, in regard to nursing home evacuation, and the literature on nursing home evacuation. Authors also propose a conceptual model to help guide decision-making for future evacuations.
  
  Date: March 24, 2010
• Older Elderly Patients Experience Poorer Outcomes Following Collaborative Depression Care
  This study examined the differences between young-old (age 60 to 74) and old-old (age 75 and older) patients who received collaborative depression care as part of the IMPACT (Improving Mood: Promoting Access to Collaborative Treatment) study, which include both VA and non-VA patients. Findings show that young-old and old-old patients who receive collaborative depression care have a similar initial clinical response, but old-old patients may have a lower rate of long-term treatment response and complete remission. For example, young-old and old-old patients randomized to the IMPACT intervention responded similarly to initial treatment at 3 months, but the old-old were less likely to respond to treatment at later follow-up intervals. Treatment response and remission rates peaked for both age groups at 6 months, although treatment response rates for the young-old were significantly higher than those for the old-old group (51% vs. 44%). Study findings also show that the process of care did not differ between young-old and old-old patients who received the IMPACT intervention.
  
  Date: December 1, 2009
• Implementing a Successful Fall Prevention Program for Elderly Veterans
  This article discusses the implementation of a Telecare fall prevention program at the VA Greater Los Angeles Healthcare System (VAGLAHS) that was designed to be sustainable. Findings show that leadership and workgroup meetings led to the development of a functional program. The Telecare fall prevention program screened its first Veteran in October 2008 and is ongoing. The program uses an existing telephone nurse advice line to: 1) place outgoing calls to Veterans at high risk of falling, 2) assess the Veterans’ risk factors, and 3) triage Veterans to the appropriate services. Because Telecare operates via the telephone, it can accept referrals from anywhere in VAGLAHS, thus reaching Veterans in geographically remote areas. The authors suggest that another potential advantage of the Telecare fall prevention program is the opportunity to unburden primary care providers of additional responsibilities by helping assess patients’ needs and arranging the appropriate services.
  
  Date: November 16, 2009
• Barriers to Dementia Diagnosis
  The goals of this study were to ascertain what is known about the prevalence of missed and delayed diagnosis of dementia in primary care, and to identify factors contributing to problems in diagnosis. While the findings did not definitively determine the prevalence of missed or delayed dementia diagnoses, estimates suggest that the number is substantial. Major barriers to diagnosing dementia included patient/provider communication (e.g., poor provider communication skills, language barriers), education deficits (e.g., belief that little or nothing can be done to treat dementia), and system resource constraints (e.g., time constraints for office visits). Attitude problems also were found; for example, among providers, a major barrier often noted was the attitude that diagnosis, particularly in the early stages of dementia, was more harmful than helpful, while patients often feared and/or denied cognitive problems.
  
  Date: October 1, 2009
• Improving Acute Care for Elders at Risk for Poor Hospital Outcomes
  For patients older than age 65, traditional hospital care frequently results in adverse outcomes that increase their risk of mortality, functional dependency, and institutionalization. There are several alternative models to traditional hospital care that have been shown to address these problems and improve outcomes for older patients. One such model is VA’s Geriatric Evaluation and Management (GEM) program, which was launched in 1976 to provide interdisciplinary, multi-dimensional evaluations for elderly Veterans in need of geriatric treatment, rehabilitation, health promotion, and social service interventions. However, alternative models are not widely disseminated. This Editorial challenges healthcare providers to think outside the traditional hospital box. They suggest broadening the implementation and availability of programs such as GEM and Hospital at Home (non-VA program providing hospital-level care of elders in their own homes) for those patients who would benefit from acute care outside a hospital setting.
  
  Date: September 28, 2009
• Appropriate Prescription of Proton-Pump Inhibitors among Elderly Veterans Using NSAIDs
  Using VA data, this observational study assessed VA provider awareness of NSAID gastro-protection and the therapeutic intent of proton-pump inhibitor (PPI) prescription among 1,491 elderly Veterans at one VAMC. In other words, investigators sought to better understand why VA physicians were prescribing these drugs. Findings show that among elderly Veterans who were prescribed a PPI, a therapeutic intent was documented in 71% of the cases, and of these prescriptions, 88.8% were considered appropriate. However, practitioner recognition of the need for gastro-protection in elderly patients was remarkably low (10%). Results also show that poor rates of appropriate therapeutic intent were noted when the PPI was initiated by the inpatient service, by certain sub-specialties (e.g., cardiology, otolaryngology), and for Veterans using the VA for medication refill only.
  
  Date: September 15, 2009
• Ethnic Disparities in the Treatment of Veterans with Dementia
  This study sought to determine if there were ethnic disparities in the evaluation and treatment of dementia among 410 Veterans treated at one VAMC between 4/05 and 6/05. Findings show that while laboratory and imaging workup (i.e., CT, MRI) did not differ between ethnic groups, there were significant differences in the treatment of dementia. For example, African American Veterans with dementia were 40% less likely than all other patients to receive acetylcholinesterase inhibitors. This treatment disparity did not appear to be due to differences in the evaluation of dementia, which was similar across groups, although significantly more Caucasian Veterans (43.8%) underwent neuropsychological testing compared to African American (24.8%) or Hispanic Veterans (32.4%).
  
  Date: September 1, 2009
• Drugs-to-Avoid Criteria for the Elderly have Limited Value
  Drugs-to-avoid criteria are lists of drugs considered to be potentially inappropriate for the elderly due to adverse effects, limited effectiveness, or both. For example, the Centers for Medicare and Medicaid Services use a version of the criteria of Beers et al. in nursing homes, and the National Committee for Quality Assurance uses the criteria of Zhan et al. to compare the quality of U.S. health plans. This study compared the Beers and Zhan criteria with individualized expert assessment of patients’ medications in 256 elderly Veterans from the Iowa City VAMC who were taking five or more medications. Findings show that the drugs-to-avoid criteria performed poorly when used as quality measures to assess the current state of a patient’s drug therapy. For example, half or more of the drugs flagged by the Beers and Zhan criteria were not considered problematic upon individualized expert review. In addition, the Beers and Zhan criteria identified only 8-15% of drugs that experts judged to be problematic. Therefore, authors suggest that while these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures for the quality of prescribing.
  
  Date: July 27, 2009
• Panel Reaches Consensus on Oral Dosing for Primarily Renally Cleared Medications in Older Adults
  Chronic kidney disease (CKD) is a growing public health problem that disproportionately affects older adults. Medications are the most frequently used therapy for the management of CKD-related problems in older adults, but they are often prescribed in inappropriate doses. This study sought to establish consensus dosing guidelines for primarily renally cleared oral medications commonly taken by older adults with renal insufficiency. An expert panel was able to reach consensus agreement on 18 oral medications that are primarily renally cleared, including anti-infectives and central nervous system medications.
  
  Date: February 1, 2009
• Providing Better Care for Vulnerable Elders in the Primary Care Setting
  Investigators identify three key processes of care needed to achieve better outcomes for vulnerable elder patients: communication, developing a personal care plan for each patient, and care coordination. They also describe two delivery models of primary care: co-management (e.g., primary care clinician shares patient responsibility with another clinician or care team with additional expertise in caring for vulnerable elders), and augmented primary care (e.g., enhanced decision support for clinicians, such as computerized clinical reminders).
  
  Date: December 1, 2008
• Cancer Treatment Rates Low among Elderly Veterans
  Cancer treatment was more common among younger elders (age 70-84) and the authors suggest that it is possible that an exaggerated level of trepidation regarding treatment ramifications among the elderly may be an obstacle to appropriate treatment in patients who could benefit from it.
  
  Date: September 1, 2008
• More Daytime Sleeping Predicts Less Functional Recovery among Elderly Undergoing Inpatient Post-Acute Rehabilitation
  More daytime sleep during the rehabilitation stay was associated with less functional recovery from admission to discharge, even after adjusting for other significant predictors (e.g., mental status, reason for admission, and hours of rehabilitation therapy). Further, more daytime sleep remained a predictor of less functional recovery at 3-month follow-up.
  
  Date: September 1, 2008
• Fall Prevention and Management for Older Adults
  This article describes fall prevention and management activities from a chronic care perspective that may help researchers, practitioners, and policymakers better understand existing programs and services. The authors propose a "no wrong door" approach to fall prevention and management, in which older adults at risk of falls are evaluated across three domains -- physical activity, medical risks, and home safety. Trained providers would then connect the patients and their caregivers to programs and services that address the identified risk in the most appropriate manner.
  
  Date: August 1, 2008

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 End of Life Care

• Unintended Consequences of Advance Directive Law
  This study sought to identify the unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences. Findings show that unintended negative consequences of advance directive legal restrictions may prevent all patients, vulnerable patients in particular, from making and communicating their end-of-life wishes and having them honored. Five overarching legal and content-related barriers were identified: poor readability (i.e., laws in all states were written above a 12th-grade reading level); restrictions on who may serve as a healthcare agent; execution requirements (steps needed to make forms legally valid); inadequate reciprocity (acceptance of advance directives between states); and religious, cultural, and social inadequacies. These restrictions have rendered advance directives less clinically useful. Advance directive statues meant to protect patients’ right of self-determination may instead better protect physicians from punitive action. For example, many states have provisions that enable physicians to presume the validity of an advance directive in the absence of actual knowledge that the directive is invalid. Author recommendations include improving readability (e.g., older persons read at a 5th-grade level), allowing oral advance directives, and eliminating witness or notary requirements. They also suggest that patients be allowed and encouraged to document their values, cultural traditions, and other socially or culturally important information.
  
  Date: January 18, 2011
• More than One-Quarter of Elderly Individuals Require Surrogate Decision-Making Near the End of Life
  Of the 3,746 elderly adults (non-Veterans) in this study, 26.8% required decision-making at the end of life and lacked decision-making capacity. Thus, surrogate decision-making was often required. Of those requiring surrogate decision-making, 67.6% had advance directives. Individuals who authored advance directives received care that was strongly associated with their preferences. And those who requested all care possible were far more likely to receive aggressive care compared to those who did not request it. Individuals with advance directives preferred limited and comfort care more than all care possible. Cognitive impairment, cerebrovascular disease, and nursing home status were associated with the need for decision-making and lost decision-making capacity before death; but these characteristics were so common (present in 65.3% of the study population) as to not be clinically useful risk factors.
  
  Date: April 1, 2010
• Patient/Provider Communication in Veterans with Terminal Illness
  When providers communicated to Veterans the life-limiting nature of their illness, Veterans were more likely to understand that aspect of their illness and to discuss care preferences with family members. Veterans who believed they had a life-limiting illness more frequently reported that their provider had communicated this to them than those who did not share that belief. More than half of the Veterans reported discussing care preferences with their providers, and 66% reported such discussions with their family. Findings underscore the need to promote effective communication and mutual understanding between Veterans, families, and providers regarding the patient’s illness and prognosis as part of improving patient-centered, late-life care.
  
  Date: March 1, 2010
• Disease-Specific Differences in End-of-Life Treatment of Seriously Ill Veterans of Different Ethnic and Racial Backgrounds
  Differences in the level of end-of-life treatments were disease-specific and not based on race and/or ethnicity. In addition, increased end-of-life care for minorities was most pronounced in veterans with dementia, and non-cancer patients received more invasive care than patients with cancer or dementia, independent of their race or ethnicity.
  
  Date: September 1, 2008

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 Heart Disease

• Increased Risk of Mortality Following Heart Attack for Veterans Insufficiently Treated for Major Depressive Disorder
  This study sought to determine if mortality following acute MI was associated with treatment-resistant depression (TRD). Findings show that all-cause mortality following an acute MI is greatest in Veterans with depression that is insufficiently treated – and is a risk in Veterans with treatment-resistant depression. Veterans who were insufficiently treated were 3.04 times more likely to die than those who received treatment. Veterans with TRD were 1.71 times more likely to die; however, this risk was partly explained by comorbid disorders.
  
  Date: January 12, 2012
• Investigators Provide Rationale for New LDL Guidelines
  Updated guidelines for cholesterol testing and management from the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults are due to be published in 2012. A primary focus of the previous version of the guidelines was treating patients to low-density lipoprotein (LDL) cholesterol level targets, with the primary goals of therapy and the cut-points for initiating treatment stated in terms of LDL. However, the authors of this commentary believe this reasoning diverges from clinical evidence and present three primary reasons that justify a major change in the next generation of guidelines: 1) There is no scientific basis to support treating to LDL targets, 2) The safety of treating to LDL targets has never been proven, and 3) Tailored treatment is a simpler, safer, more effective, and more evidence-based approach. This perspective is synergistic with recent activities in VA, in which a multidisciplinary group of leaders provided input that led to the suspension of VA’s Performance Measure that was strictly focused on achievement of lipid targets. They are now working to substitute a performance measure that emphasizes the prescription of statin medications.
  
  Date: January 1, 2012
• Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008
  This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care.
  
  Date: December 1, 2011
• Caregivers of Veterans with Chronic Illness
  This study sought to identify predictors of caregiver strain and satisfaction associated with caring for Veterans with chronic illness. Findings showed that although 76% of caregivers reported feeling very self-confident in their caregiving role, more than one-third (37%) reported high strain. Overall, the mean caregiving satisfaction score indicated a moderate level of satisfaction. Caregiver characteristics that predicted strain included having less support, having depressive symptoms, and using paid help. Veteran characteristics that predicted caregiver strain included greater need for caregiving assistance in IADL (instrumental activities of daily living), and greater levels of depression. Predictors of lower caregiver satisfaction included less social support, older age, depression, and poor Veteran health status. Predictors of higher caregiver satisfaction included helping the Veteran with medical equipment and the coping style of “taking medication.” Both caregivers and Veterans reported similar levels of assistance provided, which were relatively low for ADL (activities of daily living) and IADL. However, caregivers reported providing a mean of 43 hours per week in assistance. Investigators suggest this may be due to the higher percentage of spouse caregivers in this sample, who are available for caregiving around the clock. A majority of caregivers expressed a need to know more about the Veteran’s medication.
  
  Date: November 22, 2011
• Missed Opportunities for Providers to Discuss Advance Care Planning with Veterans with Heart Failure
  This study sought to identify and characterize potential opportunities for physicians to engage in advance care planning (ACP) discussions – and to examine their responses to opportunities during follow-up with Veterans recently hospitalized for heart failure. Findings showed that in 13 of 71 outpatient consultations, Veterans expressed concerns, questions, and thoughts regarding their future care that gave providers opportunities to engage in an ACP discussion. The majority of these opportunities (84%) were missed by physicians. Instead, physicians changed the subject back to the routine biomedical aspects of the visit; hedged their response about prognosis; denied or contradicted the patient’s expressed emotion or preference; or inadequately acknowledged the question or sentiment underlying the patient’s statement. In order to successfully leverage opportunities to engage in ACP discussions, authors suggest that communication training efforts should focus on helping physicians identify patient openers and providing a toolbox to encourage appropriate physician responses.
  
  Date: October 25, 2011
• Health of Gulf War Veterans Worsened in 10-Year Study
  Since the 1991 Gulf War, initial concerns regarding health consequences of participation in the war have turned to requests for longitudinal evaluation of how the health of Gulf War Veterans has changed over time. To help in this evaluation, investigators conducted health surveys of deployed and non-deployed Gulf War-era Veterans in 1995 and again in 2005. Findings showed that the health of deployed Gulf War Veterans worsened during the 10-year period from 1995 to 2005 in comparison with non-deployed Gulf War Veterans. Perceived health of fair or poor was more likely to persist among deployed Veterans, and relatively more deployed Veterans reported that their health status had worsened over the 10-year follow-up. Deployed Veterans were less likely to recover from any prior functional impairment, limitation of activities, or PTSD that they had in 1995 – and were more likely to report new onset of these adverse health outcomes in 2005 compared with non-deployed Veterans. Authors note that the extent to which any of the health problems experienced by Gulf War Veterans were due to the effects of military service in the Gulf War is difficult to detemine.
  
  Date: October 1, 2011
• Collaborative Care Intervention for Veterans with Ischemic Heart Disease Treated in VA Primary Care Setting
  The Collaborative Cardiac Care Project sought to determine whether a multi-faceted intervention using a collaborative care model ? directed through primary care providers ? would improve symptoms of angina, self-perceived health, and concordance with practice guidelines for managing chronic stable angina among Veterans with ischemic heart disease (IHD). Findings showed that the collaborative care intervention had no significant effects on symptoms or self-perceived health, but significantly improved receipt of guideline-concordant care in Veterans with stable angina. Although concordance with guidelines improved 4.5% more among Veterans receiving collaborative care than those receiving usual care, this was mainly due to increased use of diagnostic testing rather than recommended medications. The collaborative care model was well received by primary care providers, who implemented 92% of 701 recommendations made by collaborative care teams. Nearly half of the recommendations were related to medications, e.g., adjustments to beta blockers, long-acting nitrates, and statins.
  
  Date: September 12, 2011
• Veterans with Diabetes and Major Depressive Disorder at Significantly Increased Risk of Myocardial Infarction
  This study sought to determine if major depressive disorder (MDD) complicates the course of type 2 diabetes and is associated with increased risk of myocardial infarction (MI) and mortality. Findings showed that Veterans with comorbid MDD and type 2 diabetes were 82% more likely to experience a MI compared to Veterans without MDD and type 2 diabetes. Veterans with MDD alone were 29% more likely to have a MI, and Veterans with type 2 diabetes alone were at 33% increased risk of MI. The incidence of MI increased in a step-wise fashion, from unaffected Veterans (2.6% incidence of MI) to those with depression only (3.5%) to those with diabetes only (5.9%) to Veterans with both conditions (7.4%). Veterans with PTSD, anxiety, and panic disorder were more likely to have a MI, as were Veterans with hypertension, hyperlipidemia, obesity, and nicotine dependence.
  
  Date: August 1, 2011
• Nurse Case Management Decreases Cardiovascular Risk Factors among Veterans with Diabetes Compared to Usual Care
  This study sought to determine if nurse case management could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia among Veterans with diabetes compared to usual care. Findings showed that involving a nurse case manager in the care of patients with diabetes can significantly improve the number of individuals achieving target values for glycemia, lipids, and blood pressure compared to usual care. In this study, a greater number of Veterans in the intervention group had all three outcome measures under control compared to Veterans in the usual care group. In addition, a greater number of Veterans in the nurse case management group achieved individual treatment goals for blood pressure, lipids, and blood sugar compared to Veterans receiving usual care. Observed differences between groups were likely mediated both by enhanced lifestyle changes and a greater intensity of pharmacological treatment among Veterans in the intervention group.
  
  Date: June 2, 2011
• Newly FDA-Approved Dabigatran May Be Cost-Effective Alternative to Warfarin for Patients at Increased Risk of Stroke
  Atrial fibrillation (AF) is the second most common cardiovascular condition in the U.S. – and the second most common condition affecting Veterans. AF also increases the risk of ischemic stroke by five-fold. Research shows that anticoagulation therapy with warfarin and other vitamin K antagonists can reduce the relative risk of stroke in AF by two-thirds. Dabigatran – a newer anticoagulant and the first such drug approved by the FDA in 20 years – produces similar or reduced rates of ischemic stroke and hemorrhage compared with warfarin and requires no blood testing. This study evaluated the quality-adjusted survival, costs, and cost-effectiveness of dabigatran compared with warfarin for the prevention of ischemic stroke in patients >65 years with non-valvular AF. Findings show that dabigatran could be a cost-effective alternative to adjusted dose warfarin. High-dose dabigatran was the most effective and the most cost-effective therapy examined. The quality-adjusted life expectancy was 10.28 quality-adjusted life years (QALYs) with warfarin, 10.70 QALYs with low-dose dabigatran, and 10.84 QALYs with high-dose dabigatran. Thus, high-dose dabigatran yielded an additional half year of quality-adjusted life compared to warfarin. With dabigatran given at 150 mg twice daily – the approved dosage for most patients – the incremental cost compared with using warfarin is under the conventional cost-effectiveness threshold of $50,000 per QALY gained. Total costs were $143,193 for warfarin, $164,576 for low-dose dabigatran, and $168,398 for high-dose dabigatran.
  
  Date: January 4, 2011
• Risk-Adjusted Time in Therapeutic Range Can Be Used as Quality Indicator for Outpatient Oral Anticoagulation
  This study examined the suitability of risk-adjusted time in therapeutic range (TTR) as a potential quality indicator for anticoagulation therapy among VA patients. Findings show that TTR can be used to profile the quality of outpatient oral anticoagulation in a large, integrated healthcare system. Thus, this measure can serve as the basis for quality measurement and quality improvement efforts. TTR differed among VA anticoagulation clinics – from 38% to 69%, or from poor to excellent. Risk-adjustment did not alter performance rankings for many sites, but for other sites it made an important difference. For example, the anticoagulation clinic that was ranked 27th out of 100 before risk adjustment was ranked as one of the best (7th) after risk-adjustment. Risk-adjusted site rankings were consistent between the first and second years of the study, suggesting that risk-adjusted TTR measures a construct (quality of care) that is stable over time.
  
  Date: January 1, 2011
• Use of Automated External Defibrillators on Hospitalized Patients Not Associated with Improved Survival
  The use of automated external defibrillators (AEDs) has been proposed as a strategy to reduce times to defibrillation and improve survival from cardiac arrests that occur in the hospital setting. This study evaluated the association of AED use and survival for patients with cardiac arrests in general hospital wards. Findings show that the use of AEDs to assess and treat hospitalized patients with cardiac arrest was not associated with improved survival. Overall, the use of an AED in this study population was associated with a lower rate of survival after in-hospital cardiac arrest compared with no AED use (16% vs. 19%). Among cardiac arrests due to non-shockable heart rhythms (e.g., asystole, pulseless electrical activity), AED use was associated with lower survival (10% vs. 15%). In contrast, for cardiac arrests due to shockable heart rhythms (e.g., ventricular fibrillation, pulseless ventricular tachycardia), AED use was not associated with survival (38% vs. 40%).There were no differences by age or gender, but there was a slightly higher rate of AED use among African Americans.
  
  Date: November 17, 2010
• Model Used for Cholesterol Guidelines May Lead to Misclassification of Risk for Heart Attack and Coronary Death
  National cholesterol guidelines use the “Framingham model” to calculate a person’s 10-year risk of myocardial infarction or coronary death. Based on this risk, patients are categorized into different risk groups, which are used to guide treatment decisions. Both original and point-based versions of the model are in use and endorsed by national guidelines. Given that approximately 36 million persons in the U.S. are eligible for lipid-lowering therapy, differences in risk classification depending on which model is used could result in millions receiving different lipid-lowering therapy. This study compared differences in predicted risk between the original and point-based Framingham calculations. Findings show that compared with the original Framingham model, the point-based version of the tool misclassifies millions of Americans into different risk groups, with 25-46% of affected individuals experiencing potential impacts on drug treatment recommendations for cholesterol control.
  
  Date: November 1, 2010
• Using One Classification System for Estimates of Urban/Rural Impact on AMI Outcomes among Veterans May Not Be Adequate
  This study examined whether: 1) two different rural classification systems identify differential rates of Veterans admitted for AMI; 2) rural-urban disparities exist for risk-adjusted AMI outcomes (measured by mortality and receipt of coronary revascularization); and 3) whether hospital transfer rates differ for patients admitted with AMI. Findings showed no observed differences between rural-dwelling and urban-dwelling Veterans in risk-adjusted 30-day mortality, regardless of the urban-rural classification system used. However, rural-dwelling Veterans were less likely to receive revascularization compared to urban-dwelling Veterans, but risk estimations were dependent upon the urban-rural classification system used. Regardless of classification system, Veterans residing in rural settings were transferred more often and were more likely to be admitted to VA hospitals without revascularization facilities. This study demonstrates that using a single rural classification system for estimating the effects of living in a rural setting on AMI outcomes among Veterans may not be adequate.
  
  Date: September 1, 2010
• Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness
  This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains.
  
  Date: August 1, 2010
• Heart Failure Mortality Decreases While Rehospitalization Increases among Veterans
  Heart failure is the number one reason for admission among Veterans enrolled in the VA healthcare system. In order to improve care for this chronic disease, VA has incorporated the use of guideline-recommended treatments; however, it is unclear if the increased performance on process of care measures for hospitalized Veterans has led to improvements in outcomes. This study sought to determine if recent mortality and readmission rates have improved within VA. Findings show that mortality and rehospitalization rates for Veterans with a first hospitalization for heart failure in the VA healthcare system or in a non-VA hospital that was paid for by VA trended in opposite directions between 2002 and 2006. Mortality rates at 30 days decreased (7.1% to 5.0%), while rehospitalization rates for heart failure at 30 days increased (5.6% to 6.1%). Over the same time period, use of guideline recommended therapy increased. During the six months prior to hospital admission and during the three months following admission, there were large increases in the use of beta-blockers. The use of angiotensin-receptor blockers also increased. Examination of patient characteristics showed that most comorbid diagnoses increased significantly from 2002 to 2006, suggesting that Veterans hospitalized in 2006 were more ill. The authors suggest that the use of rehospitalization for heart failure as a marker of poor care may be flawed. Further studies to determine the reasons for the decline in mortality and the portion of hospitalizations that are preventable are recommended.
  
  Date: July 27, 2010
• Additional Evidence of Clustering of Cardiovascular Events Following Cessation of Clopidogrel in Patients with ACS
  In multivariable analysis, including adjustment for total duration of clopidogrel treatment, the 0-90 day interval after stopping clopidogrel was associated with significantly increased risk of death/MI compared to the 91-360 day interval among a non-VA population. There was a similar trend of increased adverse events after stopping clopidogrel for various subgroups (women vs. men, medical therapy vs. percutaneous coronary intervention, stent type, and = or <6 months of clopidogrel treatment). This clustering of adverse events was not present among patients stopping ACE-inhibitors, suggesting that the events are not a general effect of stopping medications. There was no association between the 91-360 day interval after stopping clopidogrel and adverse outcomes compared to patients remaining on clopidogrel.
  
  Date: May 1, 2010
• History of Depression Remains a Risk Factor for Heart Disease after Accounting for Other Contributing Factors among Twin Veterans
  A history of depression remained a risk factor for incident heart disease even after adjusting for numerous covariates including: sociodemographics, co-occurring psychopathology, smoking, obesity, diabetes, hypertension, and social isolation. Moreover, twins with both high genetic and phenotypic expression of depression were at greatest risk of ischemic heart disease (IHD). Results also show that twins with hypertension and twins with diabetes were more likely to have IHD, as were twins who reported no social support. Age, race, education, and marital status were not associated with IHD status.
  
  Date: May 1, 2010
• Lower Mortality Rates for African American Compared with White Patients Hospitalized for Heart Failure
  This study examined research reporting mortality by race after hospitalization for heart failure (HF), and combined the results using meta-analyses. Adjusted mortality rates were 32% lower in short-term follow-up (0-30 days) and 16% lower in long-term follow-up (after 30 days) for African American compared with white patients. Authors suggest that differences in mortality imply unmeasured differences by race in clinical severity of illness at hospital admission and may lead to biased hospital mortality profiles.
  
  Date: March 1, 2010
• Strategies to Reduce Sodium Intake Likely to Decrease Stroke and Heart Disease, and Save Billions in Costs
  Using a mathematical model, investigators examined the cost-effectiveness of two governmental strategies to reduce sodium intake in the U.S.: 1) government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience; and 2) a tax on sodium. Findings show that strategies to reduce sodium intake on a population level are likely to substantially reduce the incidence of stroke and myocardial infarction, saving billions of dollars in medical expenses.
  
  Date: March 1, 2010
• Relationship between Cost of Care and Quality of Care for Two Conditions in Non-VA Hospitals
  The relationship between (non-VA) hospitals’ cost of care and quality of care for a particular condition was small and differed by condition. However, evidence did not support the hypothesis that low-cost hospitals discharge patients with congestive heart failure (CHF) or pneumonia earlier, only to increase readmission rates and incur greater inpatient cost of care over time. Low-cost hospitals had similar or slightly higher 30-day readmission rates compared with high-cost hospitals. Hospitals in the highest-cost quartile for CHF care had higher quality-of-care scores and lower mortality. For pneumonia, the opposite was true: high-cost hospitals had lower quality-of-care scores and higher mortality. Risk-adjusted costs of care for CHF and pneumonia varied widely between hospitals, although hospital cost-of-care patterns seemed stable over time.
  
  Date: February 22, 2010
• Comparing Treat-to-Target Strategies to Tailored Approach for Statin Therapy
  This study examined how a simple Tailored Treatment strategy for statin therapy compared with a Treat-to-Target strategy based on National Cholesterol Education Program (NCEP) III treatment recommendations. Findings show that a simple Tailored Treatment strategy was more efficient and prevented substantially more coronary artery disease morbidity and mortality than any of the currently recommended Treat-to-Target approaches. The Tailored Treatment approach was predicted to save 520,000 more quality-adjusted life years among Americans aged 30-75 than the best NCEP III Treat-to-Target approach for every five years of treatment, even though fewer people were treated with high doses of statins. The authors indicate that these results suggest that a Tailored Treatment approach to medicine can substantially improve care, while also reducing unnecessary treatment and costs. Thus, they recommend that given its potential to better tailor treatments to individual patients, the principles underlying a Tailored Treatment approach should be considered during deliberations about guidelines and performance measures.
  
  Date: January 19, 2010
• Veterans with Psychosis More Likely to Die from Heart Disease
  This study assessed whether Veterans with mental disorders receiving care in the VA healthcare system were more likely to die from heart disease than Veterans without these disorders, and whether modifiable factors may explain mortality risks. Findings show that compared to Veterans without a mental health diagnosis, Veterans with psychosis (schizophrenia or other psychotic disorder diagnoses) were more likely to die from heart disease. Smoking and physical inactivity were the behavioral factors most strongly associated with mortality related to heart disease. Veterans with schizophrenia were the most likely to be current smokers, and those with bipolar disorder were the least likely to report adequate physical activity. Controlling for behavioral factors (e.g., smoking and physical inactivity) diminished but did not eliminate the impact of psychosis on mortality. The authors suggest that to reduce mortality related to heart disease, early interventions that promote smoking cessation and physical activity among Veterans with psychotic disorders are warranted.
  
  Date: November 1, 2009
• Mental Health Diagnoses Associated with Cardiovascular Risk Factors among OEF/OIF Veterans
  Studies of Veterans from prior wars found that those with PTSD are at increased risk of developing and dying from cardiovascular disease, but this risk had not yet been evaluated in OEF/OIF Veterans. This article discusses findings from a study on the association between mental health disorders, including PTSD, and cardiovascular risk factors. Findings show that OEF/OIF Veterans (male and female) with mental health diagnoses had a significantly higher prevalence of cardiovascular risk factors (e.g., hypertension, obesity, diabetes, tobacco use). The association between mental health diagnoses and cardiovascular risk factors remained after adjusting for demographics and military factors. The most common mental health diagnosis was PTSD (24%). The majority of Veterans with PTSD had comorbid mental health diagnoses: depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), as well as other psychiatric diagnoses (33%).
  
  Date: August 5, 2009
• Improving Adherence to Cardiovascular Medications
  This article focuses on cardiovascular medication adherence and discusses studies that address: 1) different methods of measuring adherence, 2) prevalence of non-adherence, 3) association between non-adherence and outcomes, 4) reasons for non-adherence, and 5) interventions to improve medication adherence. Findings show that while there are many different methods for assessing medication adherence, non-adherence to cardiovascular medications is common and associated with adverse outcomes. The authors also found that non-adherence is not solely a patient problem but is impacted by both providers and the healthcare system. To date, interventions targeting medication adherence have produced only modest success. Multi-modal interventions have shown the most promise in improving adherence, but require the clinical personnel to manage and coordinate multiple intervention components.
  
  Date: June 16, 2009
• Men and Women Veterans Receive Equal Care for AMI in VA Hospitals
  This study sought to describe the clinical characteristics, treatment, and survival in women Veterans compared with men admitted to VA hospitals for AMI between 10/03 and 3/05. Findings show that after adjusting for clinical characteristics, men and women Veterans treated for AMI in VA hospitals had similar levels of care and survival. There were no significant differences in the treatment provided to men and women Veterans, and cardiac catheterization was provided at equal rates (34.9% for men vs. 36.9% for women). Men did have higher mortality rates, but after adjusting for clinical characteristics this difference was no longer significant. In addition, significantly more men were prescribed aspirin and angiotensin-converting enzyme inhibitors, but there were no differences with regard to other platelet inhibitors, beta-blockers, or lipid-lowering medications.
  
  Date: May 1, 2009
• Neither Warfarin nor Clopidogrel Superior to Aspirin as Antiplatelet Therapy for Chronic Heart Failure
  The Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) Trial was conducted to determine the optimal anti-thrombotic agent for heart failure patients with reduced ejection fraction who are in sinus rhythm. WATCH Trial findings do not support the primary hypotheses that warfarin or clopidogrel is superior to aspirin. For the primary combined outcome of mortality, non-fatal MI, or non-fatal stroke, major differences between anticoagulation with warfarin and anti-platelet therapy with aspirin or clopidogrel are unlikely. Warfarin was associated with fewer non-fatal strokes than aspirin or clopidogrel, but also was associated with more frequent bleeding episodes compared to clopidogrel, and a non-significant excess of bleeding compared to aspirin.
  
  Date: March 31, 2009
• Study Compares PCI Strategies to Medical Therapy in Patients with Non-Acute CAD
  This study compared medical therapy (e.g., lifestyle modifications, medication) to various percutaneous coronary intervention (PCI) strategies in the treatment of patients with non-acute coronary artery disease (CAD). Findings show that while bare metal stents and drug-eluting stents yielded increased improvements in diminishing the need for revascularization, innovations in PCI technologies have not improved outcomes (i.e., incidence of myocardial infarction, mortality) compared to medical therapy.
  
  Date: March 14, 2009
• Concomitant Use of Clopidogrel and Proton-Pump Inhibitors after ACS is Associated with Higher Risk of Adverse Outcomes
  Proton-pump inhibitors (PPI) were frequently prescribed with clopidogrel (63.9%) for Veterans following hospitalization for acute coronary syndrome (ACS); the concomitant use of clopidogrel and PPI was associated with a higher risk of adverse outcomes compared to the use of clopidogrel alone. The combined primary outcome of mortality or re-hospitalization occurred in 20.8% of Veterans prescribed clopidogrel only, and in 29.8% of Veterans prescribed clopidogrel and PPI. Among secondary outcomes, Veterans taking clopidogrel and PPI also had a higher risk of recurrent hospitalization for ACS and revascularization procedures. Longer duration of clopidogrel plus PPI treatment was associated with adverse outcomes, suggesting that time on combination treatment is important. Pending further studies to confirm results and prospectively assess cardiovascular outcomes for Veterans taking clopidogrel and PPI versus clopidogrel alone, these results may suggest that PPIs should be used for patients with a clear indication for the medication, rather than prophylactically.
  
  Date: March 4, 2009
• Cardiovascular Risk Reduction Clinic for Veterans with Diabetes
  The Cardiovascular Risk Reduction Clinic (CRRC) is a pharmacist-coordinated clinic at the Providence VAMC designed to treat the four traditional cardiovascular risk factors (diabetes, dyslipidemia, hypertension, and smoking) to attain goals set forth by national guidelines for patients with diabetes or documented cardiovascular disease. Veterans are discharged from the CRRC when guideline-recommended goals for hemoglobin A1c, low-density lipoprotein cholesterol, blood pressure, and smoking are achieved or mostly achieved. This study evaluated the maintenance of these goals for two to three years after discharge from the CRRC. Findings show that Veterans who completed the program maintained two goals – HbA1c and LDL-C – over three years of observation. The effect on blood pressure was less durable, with half of the Veterans who were at target levels at discharge from the CRRC reaching systolic BP >130 within six months after discharge. Results also show that the most important factor to consider for risk of failure after successful attainment of a cardiovascular goal is how poorly controlled the goal was at baseline.
  
  Date: March 1, 2009
• Increase in VA Prescription Co-Pay Leads to Decrease in Adherence to Statins for Veterans at Risk of Heart Disease
  VA’s increase in drug co-payments from $2 to $7 adversely affected lipid-lowering medication adherence among Veterans, including those at high risk of coronary heart disease. After the increase in medication co-payments, the percent of Veterans who were adherent to lipid-lowering therapy declined significantly, even for Veterans with no co-pay. The co-payment increase was also accompanied by a significant increase in the likelihood of having continuous gaps in lipid-lowering medication use.
  
  Date: January 27, 2009
• Improving Treatment Adherence for Veterans with Coronary Artery Disease
  Nearly 40% of the veterans in this study did not keep their appointments for testing or treatment for coronary artery disease, indicating that non-attendance in this particular patient population is a significant problem. Several factors associated with non-attendance were: slightly younger age, lower income, unemployment, and longer wait times for appointments (136 vs. 54 days for non-attenders compared to attenders). Veterans who missed appointments also reported fewer cardiac symptoms and were more likely to attribute them to something other than heart disease. Other reasons given for non-attendance were fear of diagnostic procedures (22.3%), as well as dissatisfaction with VA care and lack of trust in the physicians or hospital (16.5%).
  
  Date: December 1, 2008
• Reducing Cardiovascular Risk for Veterans with Diabetes and Depression
  The Cardiovascular Risk Reduction Clinic (CRRC) is an ongoing clinical, multi-disciplinary, disease management program at the Providence VAMC. Veterans with and without a depression diagnosis had a significant improvement in cardiovascular risk reduction after participation in the CRRC program. Veterans with a diagnosis of depression had significantly higher cardiovascular risk than those with no mental health condition, but they had greater improvement after participating in the program.
  
  Date: October 1, 2008
• Early Invasive Strategy Associated with Improved Clinical Outcomes for Patients with STEMI after Fibrinolytic Therapy
  An early invasive strategy was associated with significant reductions in mortality and re-infarction for patients with ST-segment elevation myocardial infarction (STEMI) compared with ischemia-guided management. There were no significant differences in the risk of stroke or major bleeding.
  
  Date: September 1, 2008

^ top

 Hepatitis C

• Rates of Liver Cancer and Cirrhosis Increase Significantly among Veterans with Hepatitis C Virus
  This study identified all Veterans with hepatitis C virus (HCV) who visited any of 128 VA medical centers over a 10-year period to examine the prevalence of cirrhosis, hepatic decompensation, and hepatocellular cancer, as well as risk factors that may be associated with an accelerated progression to cirrhosis. The number of Veterans diagnosed with HCV increased over the ten years from 17,261 to 106,242. Over the same time period, among HCV patients, the prevalence of cirrhosis increased from 9% to 18.5%, while the prevalence of liver cancer increased approximately 19-fold (from 0.07% to 1.3%). Regarding risk factors among HCV-infected Veterans, the proportion of patients with co-existing diabetes increased from 12% in to 23%, while the number of patients with HIV, hepatitis B virus, or a diagnosis of alcohol use declined slightly.
  
  Date: December 22, 2010
• Patients with Hepatitis C Benefit from Collaborative Care
  This study evaluated the quality of healthcare that patients (non-Veterans) with Hepatitis C (HCV) receive and factors associated with receipt of quality care, using research data from one of the largest commercial health insurance carriers in the U.S. Findings show that collaboration between specialists and primary care physicians translates into better care for patients with HCV. Patients were less likely to receive any recommended care if they were being treated by specialists or generalists only, compared with being seen by both. Only about 19% of patients with HCV received all recommended care, and the proportion of patients who met quality indicators varied substantially. For example, most patients (79%) received a genotype test before treatment, whereas relatively few (25%) received recommended vaccinations.
  
  Date: August 17, 2010
• Self-Management Program for Veterans with Hepatitis C Improves Health, Independent of Antiviral Therapy
  This randomized controlled trial sought to examine the effects of a Hepatitis C (HCV) self-management intervention on the quality of life of Veterans with HCV who were not currently on or scheduled to start antiviral treatment. Findings show that the HCV Self-Management Program was well attended and produced significant improvements along a number of dimensions of quality of life and other outcomes six weeks later. When compared to the information-only group, Veterans who attended the self-management workshop improved more on HCV knowledge, self-efficacy, and had more energy and vitality.
  
  Date: May 31, 2010
• Chronic Kidney Failure Associated with Increased Mortality among Veterans with HIV and Hepatitis C Virus
  Compared with their mono-infected counterparts, Veterans with HIV who were co-infected with HCV had significantly higher rates of chronic kidney disease (14% vs. 11%) and mortality. HCV co-infection independently increased the likelihood of death by nearly 25%, after adjusting for other important HIV- and HCV-related factors. Co-infected Veterans also were less likely to have received highly active antiretroviral therapy (HAART) at baseline. Authors suggest that efforts should be targeted toward optimizing medical care for mono- and co-infected Veterans, including HAART therapy, HCV antiviral therapy, and treatment of comorbid medical conditions.
  
  Date: February 1, 2010
• Areas for Mental Health Intervention for Patients with Hepatitis C
  In addition to the physiological side effects of treatment for the hepatitis C virus (HCV), there also can be significant neuropsychiatric effects such as depression, anxiety, psychosis, and suicidality. Moreover, numerous studies have documented the high prevalence of pre-existing psychiatric disorders among patients with HCV. This article reviews the psychological and psychosocial issues that are relevant to patients with HCV and provides mental health treatment recommendations. Some of these issues include stigma (i.e., more than half diagnosed with HCV have experienced discrimination) and social support. The authors also identify areas in which clinicians can intervene, including adjustment to having a chronic medical illness, management of side effects, and implementing healthy lifestyle recommendations.
  
  Date: March 1, 2009
• Low Rates of Hepatitis Vaccination among Veterans with HCV
  Among veterans diagnosed with HCV between 2000 and 2005, approximately 8% overall received hepatitis vaccination and 7% of those with cirrhosis were vaccinated. In veterans with HCV who did not receive hepatitis vaccinations, 66%-96% had hepatitis A or B serology checked and about one-third had negative serology indicating susceptibility to co-infection and missed opportunity for vaccination.
  
  Date: November 1, 2008

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 HIT

• Majority of Veterans Interested in Sharing Personal Health Record Information with Caregivers and non-VA Healthcare Providers
  This study explored patient preferences regarding shared access to electronic health information by surveying individuals who used VA’s personal health record, My HealtheVet. Findings showed that a majority (79%) of My HealtheVet users were interested in sharing access to their personal health record with someone outside the VA healthcare system: 62% with a spouse/partner, 23% with a child, 15% with another family member, and 25% with a non-VA healthcare provider. Preferences regarding degree of access varied based on the type of information being shared, the type of activity being performed, and the respondent’s relationship with the person. Interest in sharing access to My HealtheVet was modestly, but significantly, greater among older Veterans and men, but did not vary by health status.
  
  Date: December 20, 2011
• Natural Language Processing with Electronic Medical Record Improves Identification of VA Post-Operative Complications
  This study evaluated a natural language processing (NLP) search approach to detect post-operative surgical complications within VA’s electronic medical record (EMR). Findings showed that, among Veterans undergoing inpatient VA surgery, NLP using the EMR greatly improved the identification of post-operative complications compared to an administrative-code based algorithm. NLP correctly identified 82% of acute renal failure cases compared with 38% for patient safety indicators; 59% vs. 46% for venous thromboembolism; 64% vs. 5% for pneumonia; 89% vs. 34% for sepsis; and 91% vs. 89% for post-operative MI. An accompanying Editorial states that NLP has the potential to greatly enhance the EMR with new applications, such as automated quality assessment to assist in the performance of comparative effectiveness research.
  
  Date: August 24, 2011
• Veterans in Favor of Internet-Provided HIV Screening Information
  This study examined patient and provider perceptions of Internet-based outreach to increase HIV screening among Veterans who use the VA healthcare system. Findings showed that both Veterans and providers thought that HIV screening outreach provided electronically via the personal health record (PHR – MyHealtheVet) would improve patient access to health information, with important educational value. Providers believed that it would reinforce messages they give to their patients. Veterans could envision instances in which information provided electronically might be better than verbal information from their doctor because it would be in lay language and readily available. Veterans also believed that electronic outreach would motivate them to be proactive about their health. Most felt that electronic messages would remind them to be screened, or at least contemplate getting screened. Regarding stigma attached to an electronic message about HIV, providers expressed substantially more concerns than Veterans. Providers also expected increased workload from the electronic outreach, and suggested adding primary care resources and devising methods to smooth the flow of patients getting screened.
  
  Date: August 15, 2011
• Electronic Record Intervention Improves Follow-Up of Veterans with Positive Colorectal Cancer Screening
  This randomized trial of eight VAMCs evaluated an electronic record intervention for follow-up of Veterans with a positive fecal occult blood test (FOBT). Findings show that a simple electronic intervention involving an automatic GI consult for Veterans with a positive FOBT result improved follow-up and reduced the time between a positive FOBT and GI evaluation, as well as complete diagnostic evaluation (CDE). The 30, 90, and 180 day GI consult rates improved 21% to 33% among intervention sites, but did not change in the usual care sites. Thirty, 90, and 180 day CDE rates improved 9% to 31% in intervention sites, but did not significantly change in usual care sites. Time to GI consult and CDE decreased significantly over time in the intervention sites, but remained unchanged in the usual care sites.
  
  Date: February 15, 2011
• Electronic Health Information’s Effect on Clinical Workflow
  This study sought to assess aspects of health information technology (HIT) that impact clinical workflow – and to identify a set of HIT characteristics that support patient care processes. Investigators identified many examples of how HIT affects workflow, but characteristics were strongest within four primary domains: 1) Trustworthy and reliable (e.g., inconsistent incomplete, incorrect information in the electronic health record (EHR); 2) Ubiquitous (e.g., poor accessibility due to lack of computer workstations or lengthy secure login processes, but good information availability ); 3) Effectively displayed (e.g., problems locating scanned documents in the EHR, lack of searchability , information not well-organized or prioritized); and 4) Adaptable to work demands (e.g., EHR is not portable or customizable, difficult to modify information). The findings from this study underscore the value of obtaining input from healthcare employees and may be used to enhance HIT design, clinical practice, and patient safety.
  
  Date: December 1, 2010
• Fixing an Electronic Communication Problem that Reduced Follow-Up of Positive Cancer Screens at One VAMC
  This study sought to determine if technical and/or workflow-related aspects of automated communication in VA’s electronic health record could lead to the lack of response to a positive fecal occult blood test (FOBT). A problem with software configuration at one VA medical center intended to alert VA primary care physicians about positive FOBT results led to breakdowns in transmission of a subset of test results. About one-third of the 490 positive FOBTs examined for this study were not directly reported to PCPs as CPRS alerts. Upon correction of the technical problem, lack of timely follow-up of test results decreased from 29.9% to 5.4% -- and was sustained for four months following the intervention. The authors recommend that electronic communication of positive FOBT results should be monitored to avoid limiting the benefits of colorectal cancer screening. They are currently investigating whether this problem exists in other VA facilities, or if this was an isolated event.
  
  Date: December 9, 2009
• “Rights” of Safe Electronic Health Record Use
  This JAMA Commentary proposes eight “Rights” of safe electronic health record (EHR) use, which are grounded in an engineering model that addresses work-system design for patient safety. The authors recommend the use of the eight “Rights,” in order to address the complex interaction of organizational, technical, and cognitive factors that affect the safety and effectiveness of EHRs.
  
  Date: September 9, 2009
• Federal Investment in Electronic Medical Records
  The American Recovery and Reinvestment Act (ARRA) includes $19 billion in incentives for the adoption of electronic medical records (EMRs) and $50 billion to promote health information technology. Medicare physicians adopting and making “meaningful use” of EMRs in 2011 and 2012 will be eligible for an initial payment of up to $18,000, with reduced payments in 2013 and 2014. However, current EMR systems’ inability to learn from aggregated health data has led to implementations and hospital information technology departments that can actually obstruct quality improvement. For example, much of the information contained in EMRs is formatted as unstructured free text – useful for essential individual communication but unsuitable for detecting quantifiable trends. This commentary suggests that the Department of Health and Human Services capitalize on the opportunity to mandate EMRs that have the potential to learn from data in the EMR system.
  
  Date: September 9, 2009
• Focus Groups Recommend Strategies to Decrease Missed Test Results
  This paper reports on the efforts of two focus groups that formed as part of the Diagnostic Error in Medicine – A National Conference, which was held by the American Medical Informatics Association in 2008. Clinicians who were part of the focus groups were asked to develop interventions that might decrease the risk of diagnostic delay due to missed test results in the future. The focus groups concluded that while the electronic medical record helps to improve access to test results, eliminating all missed test results would be difficult to achieve. However, they did recommend several strategies that might decrease the rates of missed test results, including: improving standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow-up of test results, and systems re-engineering to improve the management and presentation of data. They also suggest that healthcare organizations focus initial quality improvement efforts on specific tests that have been identified as high-risk for adverse impact on patient outcomes, such as tests associated with a possible malignancy or acute coronary syndrome.
  
  Date: September 1, 2009
• Costs and Benefits of Health Information Technology
  The use of health information technology (HIT) has been promoted as having tremendous promise in improving the efficiency, cost-effectiveness, quality, and safety of medical care delivery. Findings from this literature review show a proliferation of patient-focused HIT applications, many of which are designed for use by patients without significant oversight by healthcare providers. Investigators believe that accelerating the adoption of HIT will require greater public-private partnerships, new policies to address the misalignment of financial incentives, and a more robust evidence base regarding HIT implementation.
  
  Date: March 1, 2009

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 HIV

• Intervention to Increase HIV Testing Can Be Successfully Implemented by Non-Research Staff
  This study reports on the one-year results of implementing a program that doubled HIV testing rates in at-risk Veterans receiving care at two VAMCs in two other VA facilities where the research team played a much smaller part in the intervention implementation. Findings showed that the annual rate of HIV testing among at-risk Veterans increased by 6% and 16% after the end of the first year for the two sites to which the project was newly exported, and where non-research staff were responsible for implementation. In contrast, for the original two implementation sites where research staff played a major role, testing rates increased by 9% and 12%. There was no change in the rate of testing at the one control site that did not participate in the project. Authors note that even with differences between the original and “export” sites (e.g., strength of academic affiliations, emphasis on specialized services), the successful implementation and similar increases in HIV testing rates across patient and sub-facility levels provides further support for the generalizability of the intervention.
  
  Date: December 1, 2011
• Veterans in Favor of Internet-Provided HIV Screening Information
  This study examined patient and provider perceptions of Internet-based outreach to increase HIV screening among Veterans who use the VA healthcare system. Findings showed that both Veterans and providers thought that HIV screening outreach provided electronically via the personal health record (PHR – MyHealtheVet) would improve patient access to health information, with important educational value. Providers believed that it would reinforce messages they give to their patients. Veterans could envision instances in which information provided electronically might be better than verbal information from their doctor because it would be in lay language and readily available. Veterans also believed that electronic outreach would motivate them to be proactive about their health. Most felt that electronic messages would remind them to be screened, or at least contemplate getting screened. Regarding stigma attached to an electronic message about HIV, providers expressed substantially more concerns than Veterans. Providers also expected increased workload from the electronic outreach, and suggested adding primary care resources and devising methods to smooth the flow of patients getting screened.
  
  Date: August 15, 2011
• Routine, Oral, Rapid HIV Testing in VA Emergency Departments Financially Equivalent to Usual Care
  Using a dynamic decision analysis model, this study examined the budget impact of implementing a routine oral HIV rapid-testing program in a VA emergency department (ED) versus the impact of following ‘usual’ care. Findings show that a routine oral HIV screening program using a rapid testing approach is financially equivalent to following a usual care approach within the VA healthcare system. Assuming a 1% prevalence of the disease and an 80% acceptance of testing, the total cost of HIV rapid-testing was $1,418,088 versus $1,320,338 for ‘usual care.’ While the HIV rapid-testing program had substantial screening costs, they were offset by lower inpatient expenses associated with earlier identification of disease. The higher treatment costs for ‘usual care’ patients were largely due to inpatient stays, reflecting more hospitalizations for these patients due to opportunistic infections. Given that early detection of HIV and linkage to treatment is associated with better health outcomes – and non-targeted testing does not result in a greater budget impact than usual care – the authors suggest that this analysis provides support for the implementation of a routine oral rapid testing program within VA.
  
  Date: January 27, 2011
• Collaborative Care Intervention Improves Depression in Veterans with HIV
  The goal of this study was to adapt an evidence-based primary care model of depression collaborative care for HIV clinic settings (HIV Translating Initiatives for Depression into Effective Solutions [HITIDES])) – and to evaluate its effectiveness. Findings show that the HITIDES intervention was successfully implemented in HIV settings and improved both depression and HIV symptom outcomes. Veterans who participated in the intervention were more likely to report treatment response and remission compared to Veterans in usual care at 6-month follow-up but not at 12-month follow-up. Improved depression response and remission outcomes at 6 but not 12 months suggest that depression symptoms improved more rapidly in the intervention group compared to usual care. Intervention participants also reported more depression-free days over 12 months. Compared to usual care, significant intervention effects also were observed for lowered HIV symptom severity at 6 and 12 months. The authors suggest that the HITIDES intervention may serve as a model for collaborative care interventions in other specialty physical healthcare settings.
  
  Date: January 10, 2011
• Nurse-Initiated Rapid HIV Testing was Cost-Effective and Increased Screening Rates among Veterans
  Nurse-initiated routine screening (i.e. recommending HIV testing to all Veterans) with rapid HIV testing and streamlined counseling increased rates of testing and receipt of test results among Veterans – and was cost-effective compared with traditional risk-based HIV testing strategies. When benefits to sexual partners from reduced transmission was considered, rapid testing with streamlined counseling was even more favorable. Traditional risk-based HIV counseling and testing resulted in the lowest costs and effectiveness.
  
  Date: March 4, 2010
• Chronic Kidney Failure Associated with Increased Mortality among Veterans with HIV and Hepatitis C Virus
  Compared with their mono-infected counterparts, Veterans with HIV who were co-infected with HCV had significantly higher rates of chronic kidney disease (14% vs. 11%) and mortality. HCV co-infection independently increased the likelihood of death by nearly 25%, after adjusting for other important HIV- and HCV-related factors. Co-infected Veterans also were less likely to have received highly active antiretroviral therapy (HAART) at baseline. Authors suggest that efforts should be targeted toward optimizing medical care for mono- and co-infected Veterans, including HAART therapy, HCV antiviral therapy, and treatment of comorbid medical conditions.
  
  Date: February 1, 2010
• Predictors Associated with Use of Complementary/Alternative Medicine in Men with HIV
  This study sought to describe the types, frequency, and intensity of complementary/alternative medicine (CAM) use among men living with HIV infection in southern California and northern Florida/southern Georgia, and to identify predictors of CAM use and intensity. Findings show that the majority of men with HIV infection in this study (69%) reported some CAM use. The most frequently cited types of CAM use were drug or dietary supplements (71%) and spiritual therapies (66%). CAM use was almost three times higher in California compared to Florida/Georgia, and was also greater in men who reported depression or more health-promoting behaviors. The odds of CAM use intensity increased with greater symptom frequency and more health-promoting behaviors. In addition, vitamins, dietary supplements, and herbs were used by the majority of men in this study. The authors suggest that high levels of CAM use among men with HIV infection should alert healthcare providers to assess CAM use and to incorporate CAM-related patient education into their clinical practices.
  
  Date: November 1, 2009
• Improving Provider-Patient Communication about Routine HIV Testing in VA
  This study sought to understand patient and provider perspectives on the adoption of routine HIV testing within the VA healthcare system. Findings show that Veterans and providers agreed that the implementation of routine HIV testing, treating HIV like other chronic diseases, and removing requirements for written informed consent and pre-test counseling would benefit both Veterans and public health. Veterans wished to have HIV testing routinely offered by providers so that they could decide whether or not to be tested; they also believed that routine testing would help de-stigmatize HIV. Six steps for providers to use in communicating about routine testing also were identified, such as raising the topic of HIV testing, reassuring the Veteran that he/she is not showing clinical signs of the disease, and responding to Veteran questions about HIV.
  
  Date: October 1, 2009
• Low Rates of HIV Screening among Veterans with Substance Use Disorders
  This study sought to determine the rate of HIV screening among Veterans with substance use disorders. Findings show that among the 371,749 Veterans with substance use disorders in this study, only 20% had evidence of ever having been screened for HIV. HIV screening was lowest among Veterans with alcohol use disorders alone (11%), and highest among Veterans treated in substance use programs (28%) or receiving inpatient care (28%). Authors suggest that these findings support the need for more widespread interventions to expand routine voluntary HIV screening nationally – within and outside VA.
  
  Date: October 1, 2009
• Effective Clinical Decision Support Tool for HIV Symptom Management
  This pilot study produced a clinical decision support tool called TEMS that was developed to: elicit information about symptoms at routine clinic visits; organize information to emphasize what is most useful for clinical care; present information at the point-of-care; and recommend clinical responses based on that information. TEMS was implemented as part of VA’s electronic medical record at one VA medical center, to increase provider awareness of and response to common HIV symptoms. Investigators then studied the tool’s feasibility in routine care within a weekly HIV clinic, comparing a 4-week intervention period with a 4-week control period. Findings show that TEMS was accepted by Veterans and their providers and did not substantially impede workflow. In addition, there was a trend toward including a greater number of symptoms in the progress notes documented during the intervention period compared to the control period.
  
  Date: July 1, 2009
• Veterans with HIV Treated at Clinics with Integrated Specialty Services More Likely to Achieve Better Outcomes
  The most common way HIV clinics address patients with comorbidities is by integrating non-infectious disease providers (e.g., psychiatrists and social workers) into HIV primary care. This retrospective cohort study evaluated the association between Integrated HIV Care and patient outcomes among 1018 Veterans with HIV who received care at five VA facilities from 2000-2006. Findings show that Veterans who visited HIV clinics with more integrated specialty services were more likely to achieve viral suppression. In particular, Veterans visiting clinics that offered hepatitis, psychiatric, psychological, and social services in addition to primary care and HIV specialty services were three times more likely to achieve viral suppression than Veterans visiting clinics that offered only primary care and HIV specialty services. Results also showed that 93% of Veterans in this study had one or more comorbid conditions, with a mean of 3.2 comorbidities. Authors suggest that resources should be allocated to integrate sub-specialty services into HIV primary care clinics, and that providers should direct patients toward these clinics and retain them in care.
  
  Date: May 1, 2009
• Quality Indicators to Help Treat Veterans with HIV and Depression
  Quality indicators were developed based on a review of the existing clinical guidelines for depression, particularly depression related to HIV, in addition to a review of the literature. Authors suggest that quality indicators identified in this study provide a useful tool for measuring and informing the quality of HIV depression care.
  
  Date: October 1, 2008

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 Hypertension

• Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008
  This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care.
  
  Date: December 1, 2011
• Health of Gulf War Veterans Worsened in 10-Year Study
  Since the 1991 Gulf War, initial concerns regarding health consequences of participation in the war have turned to requests for longitudinal evaluation of how the health of Gulf War Veterans has changed over time. To help in this evaluation, investigators conducted health surveys of deployed and non-deployed Gulf War-era Veterans in 1995 and again in 2005. Findings showed that the health of deployed Gulf War Veterans worsened during the 10-year period from 1995 to 2005 in comparison with non-deployed Gulf War Veterans. Perceived health of fair or poor was more likely to persist among deployed Veterans, and relatively more deployed Veterans reported that their health status had worsened over the 10-year follow-up. Deployed Veterans were less likely to recover from any prior functional impairment, limitation of activities, or PTSD that they had in 1995 – and were more likely to report new onset of these adverse health outcomes in 2005 compared with non-deployed Veterans. Authors note that the extent to which any of the health problems experienced by Gulf War Veterans were due to the effects of military service in the Gulf War is difficult to detemine.
  
  Date: October 1, 2011
• Behavioral and Medication Management Interventions Improve Blood Pressure Control for Veterans
  This randomized clinical trial evaluated three nurse-led, home tele-monitoring interventions that were developed to improve blood pressure (BP) – and also tested which intervention was most effective among Veterans treated in VA primary care. Findings showed that overall, the behavioral and medication management intervention groups had a greater increase in the proportion of Veterans with BP measurements within target, relative to the usual care group, at 12 months. These findings were not sustained at 18 months; however, among Veterans with poor baseline BP control, the combined intervention significantly decreased blood pressure at both 12 and 18 months.
  
  Date: July 11, 2011
• Averaging Multiple Blood Pressure Measurements May Provide Optimal Assessment for Veterans with Hypertension
  This study compared home, clinic, and research systolic blood pressure (SBP) measurements in Veterans with hypertension – and estimated the certainty with which an individual’s true BP can be determined. Findings showed that clinicians who want to be certain that they are correctly classifying patients’ blood pressure control should average multiple measurements. Hypertension quality metrics based on a single clinic measurement potentially misclassify a large proportion of patients. The relationship between mean clinic and home SBP varied substantially, e.g., 52% had a mean clinic SBP that was at least 10 mm Hg greater than their mean home SBP. The within-individual variance declined markedly with increasing number of measurements and the relationship was similar across all three modes of measurement, with little added value of additional readings beyond 4-6 observed SBP measurements for all three modes. The proportion of patients with their SBP in control within the first 30 days (<140 mm Hg for clinic or research measurement; <135 mm Hg for home measurement) differed between mode of measurement: 28% were in control based on clinic measurement; 47% based on home measurement; and 68% based on research measurement.
  
  Date: June 21, 2011
• Racial and Ethnic Differences in Blood Pressure Control among Veterans with Type 2 Diabetes
  This study examined racial/ethnic differences in blood pressure control among Veterans with type 2 diabetes and uncontrolled BP at baseline. Findings showed that the adjusted proportion of Veterans with uncontrolled BP (>=140/90 mmHg) decreased in all groups over the study period. However, ethnic minority Veterans had significantly increased odds of poor BP control over a mean follow-up of 5 years compared to non-Hispanic White Veterans, independent of socio-demographic factors and comorbidity patterns. Compared to non-Hispanic Whites (45%), 54% of non-Hispanic Black Veterans, 48% of Hispanic Veterans, and 49% of Veterans with unknown race had poor blood pressure control. In using a more stringent BP cutoff (>=130/80 mmHg) to define poor BP control, 74% of non-Hispanic White Veterans had poor blood pressure control over the 5 years compared to 82% of non-Hispanic Black Veterans, 75% of Hispanic Veterans, and 79% of Veterans with unknown race/ethnicity. The presence of a hypertension diagnosis at the time of study entry appears to be associated with higher odds of achieving BP control over time. Among other comorbidities, cancer, coronary heart disease, congestive heart failure, and substance use disorders were all associated with increased odds of good BP control over time.
  
  Date: June 14, 2011
• Nurse Case Management Decreases Cardiovascular Risk Factors among Veterans with Diabetes Compared to Usual Care
  This study sought to determine if nurse case management could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia among Veterans with diabetes compared to usual care. Findings showed that involving a nurse case manager in the care of patients with diabetes can significantly improve the number of individuals achieving target values for glycemia, lipids, and blood pressure compared to usual care. In this study, a greater number of Veterans in the intervention group had all three outcome measures under control compared to Veterans in the usual care group. In addition, a greater number of Veterans in the nurse case management group achieved individual treatment goals for blood pressure, lipids, and blood sugar compared to Veterans receiving usual care. Observed differences between groups were likely mediated both by enhanced lifestyle changes and a greater intensity of pharmacological treatment among Veterans in the intervention group.
  
  Date: June 2, 2011
• Redefining “Normal” Blood Pressure
  This study examined the independent effects of diastolic (DBP) and systolic (SBP) blood pressure on mortality – and estimated the number of Americans affected by accounting for these effects in the definition of “normal.” Findings show that systolic blood pressure elevations are more important than diastolic blood pressure elevations in individuals older than age 50. The situation was reversed in individuals younger than age 50, in whom DBP was the more important predictor of mortality. For individuals older than age 50, the lowest and highest blood pressures were associated with the greatest rates of death. Without adjusting for SBP, the rate of death began to increase at a DBP of 90 or higher; however, adjusting for SBP made the relationship disappear. The mortality rate began to significantly increase at SBP >140 – independent of DBP. For individuals younger than age 50, a DBP above 100 was associated with significant increases in mortality, with or without adjustment for SBP. The current definition of normal BP (<120/80) leads an estimated 160 million adult Americans to be labeled abnormal. Redefining normal BP as one that does not confer an increased mortality risk (DBP <100 under age 50, SBP <140 over age 50) would reduce that number to less than 60 million.
  
  Date: March 15, 2011
• Hypertension Care Management Program Provided by Clinical Pharmacists Reduces Blood Pressure among Veterans
  This study evaluated the effectiveness of a hypertensive care management program provided by clinical pharmacists in collaboration with primary care physicians within four VA primary care teams at one urban Midwest VAMC. Findings show that Veterans referred to the hypertension care management program provided by VA clinical pharmacists had a significant reduction in blood pressure, and most met their BP treatment goals. Overall, the change in mean systolic BP at the final visit was –11.2 mm Hg from the initial visit, whereas the change in mean diastolic BP at the final visit was –4.6 mm Hg from the initial visit. By the final visit, 75% of Veterans had reached their BP treatment goals, which was 99.5% of the Veterans who completed the program. For Veterans with diabetes or chronic kidney disease (CKD), both systolic and diastolic BP measurements were significantly reduced from the initial pharmacist visit to the final pharmacist visit. Approximately 60% of all Veterans in the program with diabetes and 56% of those with CKD reached their BP goals.
  
  Date: January 1, 2011
• Possible Hypertension Medication Gaps in Veterans Switching Healthcare Systems
  This study sought to measure the relationship between switching healthcare systems (VA and Medicaid) when filling prescriptions and gaps in medication adherence for Veterans with a diagnosis of hypertension. Findings show a significant and positive relationship between switching healthcare systems where prescriptions are filled and medication gaps when all drug classes are combined. Veterans who switched between healthcare systems were predicted to significantly increase their percent of days without drugs by 7% compared to individuals who received their drugs in one system. The authors suggest that healthcare policymakers and providers pay particular attention to patients who are switching payers for drug coverage because their medication regime may be compromised.
  
  Date: January 1, 2011
• Rapid-Induction Group Clinic May Be Effective Method of Increasing Rates of Hypertension Control
  This report describes the process of care and outcomes of a QI initiative that used group clinics to rapidly induce hypertension control among Veterans in a VA primary care setting at one VAMC. Findings show that among Veterans with chronically treated but persistently uncontrolled hypertension, more than half (54%) were able to rapidly lower their blood pressures to controlled levels within six weeks using a group clinic quality improvement initiative. Moreover, Veterans maintained BP control over the follow-up period (10 months after QI protocol completion). Adherence to the QI protocol predicted hypertension control at follow-up, even after controlling for multiple baseline variables (e.g., diabetes, body mass index, medication compliance). Two-thirds of Veterans without diabetes achieved hypertension control, including more than 80% of those who adhered to the group-clinic protocol.
  
  Date: September 1, 2010
• Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness
  This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains.
  
  Date: August 1, 2010
• Article Suggests Achieving Blood Pressure Control within Three Months Should be New Therapy Goal
  The authors argue that to improve cardiovascular outcomes, evidence now indicates that a new paradigm emphasizing the rapid achievement of blood pressure control is required. Central to this paradigm is an explicit expectation of the timeframe in which blood pressure control should be achieved. Higher rates of control in shorter time periods have been seen in more recent clinical trials, and rapid blood pressure control is safe and associated with few side effects. Thus, the authors believe that the balance of the evidence supports changing the paradigm of hypertension treatment and implementing an expectation that blood pressure control should be achieved within three months of starting medication therapy.
  
  Date: May 1, 2010
• Strategies to Reduce Sodium Intake Likely to Decrease Stroke and Heart Disease, and Save Billions in Costs
  Using a mathematical model, investigators examined the cost-effectiveness of two governmental strategies to reduce sodium intake in the U.S.: 1) government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience; and 2) a tax on sodium. Findings show that strategies to reduce sodium intake on a population level are likely to substantially reduce the incidence of stroke and myocardial infarction, saving billions of dollars in medical expenses.
  
  Date: March 1, 2010
• Assessing New HEDIS Blood Pressure Quality Measure for Diabetes
  To encourage aggressive treatment of hypertension, the National Committee on Quality Assurance recently adopted a new HEDIS blood pressure performance measure of <130/80 mm Hg for patients with diabetes. Although there is nearly universal agreement on the benefits of aggressive BP treatment (3-4 BP medications) for those with diabetes, the new HEDIS performance measure has generated considerable controversy. This study examined BP levels and medication treatment intensity in patients with diabetes, in order to assess the reasons for failing to meet the new HEDIS measure. Findings suggest that the new diabetes BP measure may not accurately identify poor quality care and could promote overtreatment through its performance incentives. The new measure commonly mislabeled patients as being inadequately treated, especially elderly patients. Thus, the authors recommend that new BP measures be developed to encourage aggressive treatment of hypertension without unduly promoting overtreatment, especially among elderly patients.
  
  Date: January 1, 2010
• Team-Based Care Led by Pharmacists or Nurses Improves Blood Pressure Control
  Investigators in this study conducted a systematic review of the literature to evaluate the effectiveness of team-based BP care involving pharmacists and nurses. Findings indicate that team-based interventions involving nurses or pharmacists were associated with significantly improved blood pressure control, with community pharmacists having the greatest impact. In addition, counseling on lifestyle modification and providing free BP medications had a significant impact on lowering systolic BP. Results also show that intervention strategies that provided medication education were the most effective, but this strategy cannot be evaluated on its own merit because it was usually provided with additional strategies.
  
  Date: October 26, 2009
• Blood Pressure Telemonitoring Feasible for Most Veterans
  This article reports on the first six months of the Hypertension Intervention Nurse Telemedicine Study – an 18-month randomized clinical intervention to improve blood pressure (BP) control. Findings focus on the feasibility of using home BP telemonitoring devices to manage BP among Veterans. Technical alerts were generated if patients did not transmit their BP readings via the telemonitoring devices. Findings show that 75% of Veterans using the BP intervention were able to set up the telemonitoring devices and adhere to the study protocol. During the first six months of this study, 693 technical alerts were generated by 267 Veterans: 61% of the alerts were attributed to patient non-adherence, and 5% were attributed to a lack of patient knowledge (e.g., difficulty setting up the equipment, putting on the BP cuff). The authors suggest that despite the possibilities of improving health care using home BP telemonitoring equipment, there are groups who may require more support using this technology.
  
  Date: September 1, 2009
• Self-Management Intervention for Hypertension has Modest “Spill-Over” Effect on Diabetes Control
  This study evaluated the effect of a tailored hypertension self-management intervention that had been shown to have a modest effect on blood pressure control on the unintended targets of diabetes and cholesterol control. Findings show a modest difference in glycemic control between Veterans with diabetes who received the intervention compared to usual care: the mean HbA1c decreased by 0.28% among Veterans in the intervention, while increasing 0.18% for those in usual care. LDL-C decreased over the two-year period in both groups, but there was no significant difference between the intervention group and usual care. Similar to results found in the analysis of HbA1c, Veterans with higher LDL-C at baseline had steeper rates of improvement over the study period; however, there was no differential effect between the intervention and usual care groups. Thus, this study shows some evidence that a telephone administered, nurse self-management intervention targeting hypertension may have a modest “spill-over” effect on diabetes control.
  
  Date: July 1, 2009
• Standard-Based Method is Preferred Measure of Treatment Intensity for BP Control
  One possible measure of the quality of hypertension care is the intensity of clinical management when blood pressure (BP) is uncontrolled, thus there is increasing interest in measuring treatment intensification (TI). This study compared different TI measures in predicting BP control among 819 outpatients with hypertension. The three TI scores/measures evaluated were: 1) any/none score, which divides patients into those who had any therapy increase during the study vs. none; 2) Norm-Based Method (NBM), which scores each patient based on whether they received more or fewer medication increases than predicted at each visit; and 3) Standard-Based Method (SBM), which is similar to NBM but expects a medication increase whenever the BP is uncontrolled. Findings show that the SBM score was an excellent predictor of the final systolic blood pressure, thus the authors suggest that SBM serve as the basis for research and quality improvement efforts for better hypertension care. The any/none measure produced paradoxical results (therapy increases were associated with a higher final BP), while the NBM was not predictive of BP control.
  
  Date: July 1, 2009
• Veterans with Hypertension and Comorbidities Receive Better Care than Veterans with Hypertension Alone
  This study sought to determine the impact of different types of co-existing chronic diseases on quality of care for hypertension, as well as patient perceptions of quality. Findings show that Veterans with hypertension and comorbid conditions had greater odds of receiving good quality of care. Moreover, as the number of chronic conditions increased, so did the odds of receiving appropriate overall care for hypertension. No relationship was found between the provision of guideline-recommended care for hypertension and Veterans’ perception of quality of care, nor did Veterans’ assessment of quality of care vary by the presence of co-existing conditions.
  
  Date: June 16, 2009
• Physicians More Likely than Mid-Level Providers to Initiate Treatment Change for Veterans with Diabetes and Elevated Blood Pressure
  This study sought to examine whether treatment change for Veterans with diabetes and elevated blood pressure (BP) differed between physicians and mid-level providers (nurse practitioners, physician assistants), and to determine reasons for any observed differences. Findings show that mid-level providers were significantly less likely than physicians to change BP treatment for Veterans with diabetes and multiple chronic conditions, even after controlling for a number of patient, provider, and organizational characteristics. For example, after controlling for visit factors, provider practice style, measurement and organizational factors, mid-level providers were still less likely than physicians to initiate treatment change (37.5% vs. 52.5%) for elevated BP. Investigators also note that a fairly comprehensive set of potential explanatory variables did not account for any of the differences between physicians and mid-level providers.
  
  Date: June 1, 2009

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 Informed Consent

• New Concept Regarding Patient Autonomy When Coping with Multiple Chronic Conditions
  The clinical benchmark for evaluating patient autonomy in the acute care setting is patients’ capacity to participate in the informed consent process. However, this one-component concept of patient autonomy may be problematic in the context of multiple chronic conditions that require the patient to participate in their treatment plan beyond providing consent. Authors in this article call for a new two-component concept that includes both autonomous decision-making and the execution of the agreed upon treatment plan.
  
  Date: February 1, 2009
• Appreciation of Research Information in Patients with Bipolar Disorder
  Patients with bipolar disorder were able to weigh risk levels associated with various studies, and to appreciate that their participation was voluntary. However, patients demonstrated two misconceptions: their appreciation of research goals was flawed (a substantial proportion had difficulty distinguishing clinical research from clinical care), and they incorrectly applied concepts of 'double-blind' and 'randomization.' In addition, more than half believed that their primary mental health provider could convince them to participate in a study even if they did not want to.
  
  Date: July 1, 2008
• Conveying Risk Information Presented During the Informed Consent Process
  Whether numeric or word formats lead to better decisions about participation in research is largely unknown. A few small studies indicate that using numbers rather than words to communicate the likelihood of adverse outcomes can make a difference, and suggest that many people prefer the chances of adverse effects be expressed in numerical terms. The author recommends minimizing probabilistic words (e.g., rarely, possible) and encourages the use of simple frequencies with common denominators (e.g., one out of 100 people).
  
  Date: July 1, 2008

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 Kidney Disease

• Low Rate of Referral for Outpatient Nephrology Consultation for Veterans Hospitalized with Acute Kidney Injury
  This study examined the likelihood of nephrology referral among survivors of acute kidney injury (AKI) at risk for subsequent decline in kidney function. Findings showed that the majority of Veterans (56%) had persistent CKD (Stage III or IV) one year following their acute event. Consistent with non-VA cohorts, there was a low rate of outpatient referral for kidney specialist care among Veterans hospitalized with acute kidney injury. The cumulative incidence of nephrology referral before death, dialysis, or improvement in kidney function was 8.5%.
  
  Date: December 8, 2011
• Chronic Kidney Failure Associated with Increased Mortality among Veterans with HIV and Hepatitis C Virus
  Compared with their mono-infected counterparts, Veterans with HIV who were co-infected with HCV had significantly higher rates of chronic kidney disease (14% vs. 11%) and mortality. HCV co-infection independently increased the likelihood of death by nearly 25%, after adjusting for other important HIV- and HCV-related factors. Co-infected Veterans also were less likely to have received highly active antiretroviral therapy (HAART) at baseline. Authors suggest that efforts should be targeted toward optimizing medical care for mono- and co-infected Veterans, including HAART therapy, HCV antiviral therapy, and treatment of comorbid medical conditions.
  
  Date: February 1, 2010
• Panel Reaches Consensus on Oral Dosing for Primarily Renally Cleared Medications in Older Adults
  Chronic kidney disease (CKD) is a growing public health problem that disproportionately affects older adults. Medications are the most frequently used therapy for the management of CKD-related problems in older adults, but they are often prescribed in inappropriate doses. This study sought to establish consensus dosing guidelines for primarily renally cleared oral medications commonly taken by older adults with renal insufficiency. An expert panel was able to reach consensus agreement on 18 oral medications that are primarily renally cleared, including anti-infectives and central nervous system medications.
  
  Date: February 1, 2009
• Contrast-Induced Acute Kidney Injury (CIAKI) Following Computed Tomography
  Clinically significant CIAKI following non-emergent computed tomography is very uncommon among outpatients with mild kidney disease. CIAKI was not associated with need for post-procedure dialysis, hospital admission, or 30-day mortality.
  
  Date: September 1, 2008

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 Long-Term Care

• Unintended Consequences of Advance Directive Law
  This study sought to identify the unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences. Findings show that unintended negative consequences of advance directive legal restrictions may prevent all patients, vulnerable patients in particular, from making and communicating their end-of-life wishes and having them honored. Five overarching legal and content-related barriers were identified: poor readability (i.e., laws in all states were written above a 12th-grade reading level); restrictions on who may serve as a healthcare agent; execution requirements (steps needed to make forms legally valid); inadequate reciprocity (acceptance of advance directives between states); and religious, cultural, and social inadequacies. These restrictions have rendered advance directives less clinically useful. Advance directive statues meant to protect patients’ right of self-determination may instead better protect physicians from punitive action. For example, many states have provisions that enable physicians to presume the validity of an advance directive in the absence of actual knowledge that the directive is invalid. Author recommendations include improving readability (e.g., older persons read at a 5th-grade level), allowing oral advance directives, and eliminating witness or notary requirements. They also suggest that patients be allowed and encouraged to document their values, cultural traditions, and other socially or culturally important information.
  
  Date: January 18, 2011
• Physicians May Need More Education about Long-Term Care Options for Veterans
  The purpose of this study was to obtain information about VA long-term care (LTC) referrals that could be used to develop interventions that increase the likelihood of referrals to home and community-based services (HCBS) instead of institutional care. Findings indicate that physicians are often seen as having limited familiarity with HCBS options and tend to refer Veterans with LTC needs to nursing homes. Training physicians about LTC referral options, with particular focus on how HCBS can be used to meet Veteran and caregiver needs, may help to increase those referrals.
  
  Date: February 1, 2009
• Prescribing Discrepancies during Patient Transfer May Result in Adverse Drug Events
  The objective of this study was to examine medication discrepancies related to adverse drug events (ADEs) in nursing home patients transferred to and from the hospital. Findings show that less than 5% of discrepancies caused ADEs, which is consistent with reviews that suggest only a small fraction of errors result in harm. Authors note that information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients, and inform the development of decision-support tools at the time of patient transfer.
  
  Date: February 1, 2009
• Veterans Using Home Healthcare have Higher Rates of Outpatient, Inpatient, and Nursing Home Care
  Veterans receiving VA home health care in 2002 increased their absolute chance of using VA outpatient care by 3%, inpatient care by nearly 12%, and nursing home care by 5% in 2003. Moreover, although utilization rates were low, VA HHC users were about 10 times more likely to have used hospice, adult day health care, or respite care in the VA system than non-users.
  
  Date: October 1, 2008

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 Medication

• Few Veterans Receive Appropriate Thrombolysis Following Stroke
  This study examined the use and misuse of thrombolytic therapy with tissue plasminogen activator (tPA) in a national sample of Veterans with acute ischemic stroke who were admitted to one of 129 VA medical centers in FY07. Findings show that VA treatment of Veterans with acute ischemic stroke who are eligible for thrombolytic therapy is similar to that in non-stroke center hospitals in the private sector. Among the 532 Veterans with ischemic stroke presenting to VA within three hours of symptom onset, 33% were eligible for tPA, and 11% received it. Considering only the 135 Veterans who arrived within two hours of symptom onset (allowing adequate time for testing and evaluation), 14% received tPA. Among the 30 Veterans who received tPA (whether eligible to receive it or not), 17% received the wrong dose. Eligible Veterans receiving tPA were similar to eligible Veterans who did not receive tPA in terms of clinical conditions and time to brain imaging.
  
  Date: January 1, 2012
• Adverse Drug Reactions Associated with Polypharmacy are Common Cause of Unplanned Hospitalizations among Older Veterans
  This study sought to describe the prevalence of unplanned hospitalizations caused by adverse drug reactions (ADRs) among older Veterans. Findings showed that adverse drug reactions are a common cause of unplanned hospitalization among older Veterans, are frequently preventable, and are associated with polypharmacy (overall, 45% of Veterans took >9 outpatient medications and 35% took 5 to 8). The most common ADRs that occurred were bradycardia, hypoglycemia, falls, and mental status changes. Of the 678 unplanned hospitalizations that occurred during the study period, 70 ADRs involving 113 drugs occurred in 68 older Veterans, of which 37% were preventable. Extrapolating to a population of more than 2.4 million older Veterans receiving care during this time, 8,000 hospitalizations costing about $110 million (using FY04 dollars) may have been unnecessary. The most common reason for a preventable ADR was suboptimal prescribing (52%), followed by patient non-adherence (28%), and suboptimal monitoring (12%). In addition, 4 medication classes (cardiovascular, central nervous system, anti-thrombotic, and endocrine) accounted for almost 80% of all the drugs implicated in ADRs.
  
  Date: December 8, 2011
• Diabetes Managed More Intensively in Older Veterans with Dementia and Cognitive Impairment
  This study sought to examine and compare anti-glycemic medication use, glycemic control, and risk of hypoglycemia in older Veterans with and without dementia or cognitive impairment. Findings showed that diabetes was managed more intensively in older Veterans with dementia or cognitive impairment than in those with no impairment, with more patients on insulin (30% vs. 24%) among those with cognitive problems. These conditions were independently associated with a greater risk of hypoglycemia. Of all Veterans taking insulin, the incidence of hypoglycemia was higher among those with dementia (27%) or cognitive impairment (20%) than among those with neither condition (14%). Veterans with dementia or cognitive impairment also had a greater decline in HbA1c over the 2-year study period. These findings suggest that providers were less likely to pursue individualized glycemic goals, as recommended by VA-DoD clinical practice guidelines (updated in 2010), when patients had cognitive problems.
  
  Date: December 8, 2011
• Decreased Use of Benzodiazepines among Veterans with PTSD
  This study examined trends in benzodiazepine prescribing among Veterans with PTSD. Findings show that the overall proportion of Veterans receiving a benzodiazepine decreased from 37% in 1999 to 31% in 2009. In addition, the proportion of long-term users (>90 days) decreased from 69% to 64%, and the mean daily dose declined by nearly 15%. The likelihood of receiving benzodiazepines was influenced by time since first VA PTSD diagnosis. For example, in 2009, patients newly diagnosed with PTSD were the least likely to receive a benzodiazepine (21%) compared to patients with a history of three or more years of treatment (36%). Clonazepam was the most commonly prescribed benzodiazepine across all study years.Despite decreasing frequency of use, the absolute number of Veterans with PTSD who received benzodiazepines increased nearly 250% due to the increasing numbers of Veterans receiving care for PTSD in the VA healthcare system. Therefore, the authors suggest that minimizing benzodiazepine exposure will remain a vital policy issue.
  
  Date: November 29, 2011
• Majority of OEF/OIF Veterans with Chronic Non-Cancer Pain are Prescribed Opioids by VA Outpatient Providers
  This study sought to describe the prevalence of prescription opioid use, types and doses of opioids received, as well as factors associated with the prescription of opioids among OEF/OIF Veterans. Findings showed that about two-thirds of OEF/OIF Veterans with chronic non-cancer pain were prescribed opioids over a one-year timeframe. Of Veterans prescribed any opioids, 59% were prescribed opioids ‘short-term’ compared to 41% prescribed opioids ‘long-term’ (more than 90 days). The mean duration of opioid prescription was 61 days for Veterans in the short-term group and 285 days for Veterans in the long-term group. Several findings suggest a need for improvement in adherence to pain and opioid treatment guidelines. For example, among long-term opioid users, 51% were prescribed short-acting opioids only (guidelines recommend transitioning to long-acting opioids); only 31% were administered one or more urine drug screens (guidelines suggest more frequent drug screening); and 33% were also prescribed sedative-hypnotic medications (monitoring by prescribing physicians is recommended to prevent possible overdose or death). Diagnoses associated with an increased likelihood of receiving an opioid prescription included: low back pain, migraine headache, PTSD, and nicotine use disorder.
  
  Date: September 7, 2011
• Potential Problems with the Use of Antidepressants among Older Veterans Residing in VA Nursing Homes
  This study examined the prevalence and patient/site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants among Veterans aged 65 years and older that were admitted to any one of 133 VA Community Living Centers (CLC, previously called Nursing Home Care Units). Findings suggest potential problems with the use of antidepressants in older Veterans that reside in VA CLCs. Overall, only 18% of antidepressant use was optimal. Of the 877 Veterans with depression, 25% did not receive an antidepressant, suggesting potential underuse. Among depressed Veterans who received antidepressants, 43% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. In addition, of the 2,815 Veterans who did not have depression, 42% were prescribed one or more antidepressants; of these, only 4% had an FDA-approved labeled indication, suggesting potential overuse. Also, the co-prescribing of antipsychotics (in patients without schizophrenia) among those without depression was associated with an increased risk of antidepressant overuse.
  
  Date: August 1, 2011
• Quality Improvement Program for Oral Anticoagulation has Potential to Save Lives and Millions in VA Healthcare Costs
  Quality of anticoagulation can be measured by percent time in the therapeutic range (TTR). Because VA is considering a quality improvement program to increase TTR, this study sought to determine whether a "business case" could be made for such a program, including whether or not it has the potential to save money in the short term. Findings showed that even after considering the cost of implementing the program, a quality improvement program for oral anticoagulation therapy in Veterans with atrial fibrillation has the potential to save lives and millions in VA healthcare costs. In this study population, a modest improvement in TTR (5%) would be expected to avert 1,114 adverse events over two years, many of them fatal. Such an improvement would result in a savings of $15.9 million (minus the cost of the quality improvement program). Improving TTR by 10% prevented 2,087 events and saved $29.7 million (again, minus the cost of the quality improvement program).
  
  Date: July 1, 2011
• Medication Reconciliation Reduces Adverse Drug Events Related to Some Hospital Admission Prescribing Changes
  This study estimated the effectiveness of inpatient medication reconciliation at the time of hospital admission on adverse drug events (ADEs) caused by admission prescribing changes. Findings showed that medication reconciliation at the time of hospital admission reduced ADEs caused by admission prescribing changes that were classified as errors by 43%, but it did not reduce ADEs caused by all admission prescribing changes. Non-error-related ADEs would not be averted by one-time medication reconciliation on admission, but they might be averted by improved provider awareness and monitoring of admission prescribing changes during the hospital stay. The potential impact of such an intervention is large, as 50% of the ADEs in this study were caused by admission medication changes that were not errors.
  
  Date: May 9, 2011
• Veterans Receiving Higher-Dose Opioid Prescriptions for Pain at Increased Risk of Death from Overdose
  This study examined the association of maximum prescribed daily opioid dose and dosing schedule (“as needed,” regularly scheduled, or both) with risk of opioid overdose death among Veterans with cancer, chronic pain, acute pain, and substance use disorders. Findings showed that among Veterans receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of death from opioid overdose. The frequency of fatal overdose among Veterans treated with opioids was rare – estimated to be 0.04% - and was directly related to the maximum prescribed daily dose of opioid medication. There was no significant increased risk of opioid overdose among Veterans who were treated with both “as-needed” and regularly scheduled opioids – a strategy for treating pain exacerbations – after adjusting for maximum daily dose and patient characteristics. Veterans who died from opioid overdose were significantly more likely to have chronic or acute pain, substance use disorders, and other psychiatric disorders, but they were less likely to have cancer. This study highlights the importance of implementing strategies for reducing opioid overdose among patients being treated for pain, for example, ascertaining history of substance abuse, using treatment contracts, and scheduling frequent follow-up visits and toxicological screens for patients at special risk.
  
  Date: April 6, 2011
• Patient Self-Testing/Management May Decrease Mortality and Thromboembolic Events among Patients on Long-Term Anticoagulation
  This evidence review sought to determine whether patient self-testing (PST), either alone or in combination with self-dose adjustment (patient self-management, PSM), is associated with fewer thromboembolic complications and all-cause mortality – without an increase in major bleeding – compared to usual care. Findings showed that PST with or without PSM is associated with significantly fewer deaths and thromboembolic events – without an increased risk of serious bleeding – for a highly select group of motivated adult patients requiring long-term anticoagulation with Vitamin K antagonists. Patients randomized to PST/PSM had a 26% lower risk of death and a 42% reduction in major thromboembolism without any increased risk of major bleeding events. Whether or not this care model is cost-effective and can be implemented successfully in typical U.S. healthcare settings is unknown.
  
  Date: April 5, 2011
• Excessive Caution in Prescribing to Veterans with Geriatric Conditions May Be Unnecessary
  This study evaluated whether common geriatric conditions were associated with risk of adverse drug events (ADEs). Findings show that over the one-year study period, 126 Veterans suffered a total of 167 ADEs, but there was no association between the presence of various geriatric conditions and ADEs. However, in exploratory analyses investigators found that the use of new medications (present at 12-month follow-up) was associated with a higher risk of ADEs. The authors suggest that while it is important to consider the unique circumstances of each patient, excessive caution in prescribing to elders with geriatric conditions may not be warranted.
  
  Date: April 1, 2011
• Rates of Accidental Poisoning among VA Patients Higher than General Population
  This study describes the rate of accidental poisoning mortality among Veterans who used VA healthcare services, compares this rate to the general U.S. population, and describes the drugs/medications involved. Findings show that for FY05, VA patients had nearly twice the rate of fatal accidental poisoning compared to adults in the general population. Among VA patients who died from accidental poisoning, opioid medications (including methadone) made up 32% of the reported deaths; cocaine also was common at 23%. In both the VA and U.S. general populations, the rate of accidental poisoning mortality was higher for men than women, and higher for individuals ages 30 to 64 as compared to those ages 18 to 29, or ages 65 and older. Although VA patients have a greater risk of suicide than death by accidental poisoning, their risk for accidental poisoning death relative to the general population is larger than that of suicide.
  
  Date: April 1, 2011
• Newly FDA-Approved Dabigatran May Be Cost-Effective Alternative to Warfarin for Patients at Increased Risk of Stroke
  Atrial fibrillation (AF) is the second most common cardiovascular condition in the U.S. – and the second most common condition affecting Veterans. AF also increases the risk of ischemic stroke by five-fold. Research shows that anticoagulation therapy with warfarin and other vitamin K antagonists can reduce the relative risk of stroke in AF by two-thirds. Dabigatran – a newer anticoagulant and the first such drug approved by the FDA in 20 years – produces similar or reduced rates of ischemic stroke and hemorrhage compared with warfarin and requires no blood testing. This study evaluated the quality-adjusted survival, costs, and cost-effectiveness of dabigatran compared with warfarin for the prevention of ischemic stroke in patients >65 years with non-valvular AF. Findings show that dabigatran could be a cost-effective alternative to adjusted dose warfarin. High-dose dabigatran was the most effective and the most cost-effective therapy examined. The quality-adjusted life expectancy was 10.28 quality-adjusted life years (QALYs) with warfarin, 10.70 QALYs with low-dose dabigatran, and 10.84 QALYs with high-dose dabigatran. Thus, high-dose dabigatran yielded an additional half year of quality-adjusted life compared to warfarin. With dabigatran given at 150 mg twice daily – the approved dosage for most patients – the incremental cost compared with using warfarin is under the conventional cost-effectiveness threshold of $50,000 per QALY gained. Total costs were $143,193 for warfarin, $164,576 for low-dose dabigatran, and $168,398 for high-dose dabigatran.
  
  Date: January 4, 2011
• Possible Hypertension Medication Gaps in Veterans Switching Healthcare Systems
  This study sought to measure the relationship between switching healthcare systems (VA and Medicaid) when filling prescriptions and gaps in medication adherence for Veterans with a diagnosis of hypertension. Findings show a significant and positive relationship between switching healthcare systems where prescriptions are filled and medication gaps when all drug classes are combined. Veterans who switched between healthcare systems were predicted to significantly increase their percent of days without drugs by 7% compared to individuals who received their drugs in one system. The authors suggest that healthcare policymakers and providers pay particular attention to patients who are switching payers for drug coverage because their medication regime may be compromised.
  
  Date: January 1, 2011
• Risk-Adjusted Time in Therapeutic Range Can Be Used as Quality Indicator for Outpatient Oral Anticoagulation
  This study examined the suitability of risk-adjusted time in therapeutic range (TTR) as a potential quality indicator for anticoagulation therapy among VA patients. Findings show that TTR can be used to profile the quality of outpatient oral anticoagulation in a large, integrated healthcare system. Thus, this measure can serve as the basis for quality measurement and quality improvement efforts. TTR differed among VA anticoagulation clinics – from 38% to 69%, or from poor to excellent. Risk-adjustment did not alter performance rankings for many sites, but for other sites it made an important difference. For example, the anticoagulation clinic that was ranked 27th out of 100 before risk adjustment was ranked as one of the best (7th) after risk-adjustment. Risk-adjusted site rankings were consistent between the first and second years of the study, suggesting that risk-adjusted TTR measures a construct (quality of care) that is stable over time.
  
  Date: January 1, 2011
• Model Used for Cholesterol Guidelines May Lead to Misclassification of Risk for Heart Attack and Coronary Death
  National cholesterol guidelines use the “Framingham model” to calculate a person’s 10-year risk of myocardial infarction or coronary death. Based on this risk, patients are categorized into different risk groups, which are used to guide treatment decisions. Both original and point-based versions of the model are in use and endorsed by national guidelines. Given that approximately 36 million persons in the U.S. are eligible for lipid-lowering therapy, differences in risk classification depending on which model is used could result in millions receiving different lipid-lowering therapy. This study compared differences in predicted risk between the original and point-based Framingham calculations. Findings show that compared with the original Framingham model, the point-based version of the tool misclassifies millions of Americans into different risk groups, with 25-46% of affected individuals experiencing potential impacts on drug treatment recommendations for cholesterol control.
  
  Date: November 1, 2010
• VA Increases Prescriptions for Smoking Cessation Medications among Veterans
  Since 2002, VA has implemented a range of policies and programs to increase evidence-based treatment for smoking. This study examined the change in rates of dispensing cessation-related medications to Veterans in the VA healthcare system to assess the impact of these policy changes. Findings show that VA policy initiatives instituted since 2002 have greatly increased prescriptions for smoking cessation medications among Veterans, while decreasing costs. The number of Veterans filling a prescription for nicotine replacement therapy (NRT) increased 63% from FY04 through FY08. Thirty-day-equivalent NRT prescriptions rose nearly 50% over the same period. Bupropion prescribing also rose sharply; the four-year growth rate among Veterans also prescribed a NRT was 61% greater than the 35% growth rate among all Veterans receiving bupropion prescriptions. While prescriptions for NRT and bupropion rose, spending per treated patient fell by 39% for bupropion and by 24% across all NRT formats (e.g., patch, gum).
  
  Date: September 24, 2010
• Medication Management for Veterans with Schizophrenia
  This study examined medication management for a random sample of Veterans who received drug therapy for schizophrenia at any one of three VA mental health clinics in Southern California between 2002 and 2003. Overall, 67% of Veterans had inappropriate management at baseline: 32% had inappropriate management of psychotic symptoms, 45% had inappropriate management of weight, and 8% had inappropriate management of tardive dyskinesia (TD). Further, 11% had depression that was moderately severe or worse. At one year, the appropriateness of management for psychotic and depressive symptoms had not changed. The appropriateness of management of TD also did not change over time, but the management of elevated weight improved modestly. There were no significant differences between the three clinics in the prevalence of symptoms or side effects, or in the appropriateness of medication management. However, psychiatrists with more than 12 patients were significantly more likely to improve their patients’ care over time.
  
  Date: July 1, 2010
• Inappropriate Non-Steroidal Anti-Inflammatory Drug Use is Prevalent among Veterans
  This study examined the prevalence of inappropriate non-steroidal anti-inflammatory drug (NSAID) use among Veterans– and identified patient and clinical characteristics associated with inappropriate use. The inappropriate use of NSAIDs was prevalent and was associated with more GI symptoms and higher levels of pain. Of the 1,250 Veterans who reported NSAID use, approximately 32% used NSAIDs inappropriately, including taking two or more NSAIDs, exceeding the highest daily recommended dosage, or both. Veterans classified as using NSAIDs inappropriately were more likely to be non-white and were more likely to have an income of less than $20,000.
  
  Date: June 1, 2010
• All Antipsychotics May Not Increase Short-Term Risk for Mortality among Veterans with Dementia
  Commonly prescribed doses of haloperidol, olanzapine, and risperidone, but not quetiapine, were associated with short-term increases in mortality. During the first 30 days, there was a significant increase in mortality in subgroups prescribed a daily low dose of haloperidol, olanzapine, or risperidone, after adjusting for demographics, comorbidities, and medication history. However, increased mortality was not seen when quetiapine was prescribed. No antipsychotic was associated with increased mortality after the first 30 days. Therefore, the authors suggest that all antipsychotics might not pose the same degree of risk in all patient groups as implied by the general warnings that have been issued.
  
  Date: May 7, 2010
• Additional Evidence of Clustering of Cardiovascular Events Following Cessation of Clopidogrel in Patients with ACS
  In multivariable analysis, including adjustment for total duration of clopidogrel treatment, the 0-90 day interval after stopping clopidogrel was associated with significantly increased risk of death/MI compared to the 91-360 day interval among a non-VA population. There was a similar trend of increased adverse events after stopping clopidogrel for various subgroups (women vs. men, medical therapy vs. percutaneous coronary intervention, stent type, and = or <6 months of clopidogrel treatment). This clustering of adverse events was not present among patients stopping ACE-inhibitors, suggesting that the events are not a general effect of stopping medications. There was no association between the 91-360 day interval after stopping clopidogrel and adverse outcomes compared to patients remaining on clopidogrel.
  
  Date: May 1, 2010
• Article Suggests Achieving Blood Pressure Control within Three Months Should be New Therapy Goal
  The authors argue that to improve cardiovascular outcomes, evidence now indicates that a new paradigm emphasizing the rapid achievement of blood pressure control is required. Central to this paradigm is an explicit expectation of the timeframe in which blood pressure control should be achieved. Higher rates of control in shorter time periods have been seen in more recent clinical trials, and rapid blood pressure control is safe and associated with few side effects. Thus, the authors believe that the balance of the evidence supports changing the paradigm of hypertension treatment and implementing an expectation that blood pressure control should be achieved within three months of starting medication therapy.
  
  Date: May 1, 2010
• Pharmacotherapy May Be Underused for Veterans with Alcohol Addiction
  In FY06 and FY07, only about 3% of more than a quarter of a million VA patients with alcohol use disorders received treatment with one of four drugs specifically approved for treating alcohol dependence. [This apparent underutilization is not unique to VA, as utilization rates are within the range of rates reported in other settings.] Receipt of pharmacotherapy was more likely among Veterans receiving specialty addiction care, Veterans with alcohol dependence (vs. abuse), Veterans younger than 55 years old, and women. SSRI antidepressants were used about five times as often as alcohol use disorder medications in Veterans with an alcohol use disorder but without a psychiatric indication for SSRIs.
  
  Date: April 1, 2010
• Comparing Treat-to-Target Strategies to Tailored Approach for Statin Therapy
  This study examined how a simple Tailored Treatment strategy for statin therapy compared with a Treat-to-Target strategy based on National Cholesterol Education Program (NCEP) III treatment recommendations. Findings show that a simple Tailored Treatment strategy was more efficient and prevented substantially more coronary artery disease morbidity and mortality than any of the currently recommended Treat-to-Target approaches. The Tailored Treatment approach was predicted to save 520,000 more quality-adjusted life years among Americans aged 30-75 than the best NCEP III Treat-to-Target approach for every five years of treatment, even though fewer people were treated with high doses of statins. The authors indicate that these results suggest that a Tailored Treatment approach to medicine can substantially improve care, while also reducing unnecessary treatment and costs. Thus, they recommend that given its potential to better tailor treatments to individual patients, the principles underlying a Tailored Treatment approach should be considered during deliberations about guidelines and performance measures.
  
  Date: January 19, 2010
• Affective Disorders Strongest Predictor of Suicidal Behavior in Elderly Veterans Receiving Anti-Epileptic Medication
  In January 2008, the FDA issued an alert indicating that anti-epileptic drug (AED) treatment is associated with increased risk for suicidal ideation, attempt, and completion. This study sought to assess variation in suicide-related behaviors in a population not well-represented by the data used for the FDA analysis – individuals 66 years and older with new exposure to AEDs. Findings show that in older Veterans who were started on AED monotherapy, the strongest reliable predictor of suicide-related behaviors was the diagnosis of an affective disorder prior to AED treatment. Increased suicide-related behaviors were not associated with individual AEDs. However, while most Veterans in this study received AED prescriptions for gabapentin (76.8%), a trend for increased suicide-related behaviors was found among those prescribed levetiracetam or lamotrigine, but interpretation was difficult since few Veterans received either drug (0.6%). The associations between suicide-related behaviors and chronic pain or chronic disease burden were not statistically significant, but dementia was significantly associated with suicide-related behaviors (42.2% with dementia vs. 25.8% without).
  
  Date: January 11, 2010
• Costs and Outcomes Associated with Newer Medications for Glycemic Control in Type 2 Diabetes
  Investigators in this study conducted a cost-effectiveness analysis to better understand the value of adding either of two newer medications (exenatide and sitagliptin) as second-line therapy to glycemic control strategies, compared to an older medication (glyburide), for new-onset type 2 diabetes in persons 25 to 64 years of age. Findings show that newer medications offer more options for glycemic control; however, they come at considerable costs. Exenatide and sitagliptin conferred 0.09 and 0.12 additional quality-adjusted life years respectively, relative to glyburide as second-line therapy. Using sitagliptin as a second-line treatment is associated with additional costs of $20,213 per person over their lifetime compared to a baseline strategy using glyburide as second-line therapy. Using exenatide as a second-line treatment is associated with an additional cost of $23,849 per person over their lifetime compared to glyburide as second-line therapy.
  
  Date: January 7, 2010
• Increase in VA Drug Co-Payment Resulted in Decrease in Veterans’ Adherence to Some Medications
  This study examined the impact of the VA medication co-payment increase on adherence to diabetes, hypertension, and hyperlipidemic medications by Veterans with diabetes or hypertension at 4 VAMCs during a 35-month period (2/01--12/03). Findings showed that a medication co-payment increase from $2 to $7 adversely impacted adherence to statins and anti-hypertensives by Veterans subject to the co-payment, but the impact was greatest among Veterans taking oral hypoglycemic medication. Adherence to all medications increased in the short term for all Veterans (12 months after co-payment increase), but then declined in the longer term (subsequent 11-month period). The impact of the co-payment increase was particularly adverse for Veterans with diabetes who were responsible for co-payments. Their adherence to oral hypoglycemic medication in the period 13-23 months after the co-payment increase was 10.3% lower than their pre-period adherence – and 9% lower than comparable Veterans who were exempt from co-payments.
  
  Date: January 1, 2010
• Importance of Communicating Drug Information to Clinicians
  The most direct way that the Food and Drug Administration (FDA) communicates prescribing information to clinicians is through the drug label. However, critical information that the FDA has at the time of drug approval may not appear on the drug label or in relevant journal articles. This commentary reviews several instances of information not included on drug labels and suggests the importance of better communicating this information to clinicians.
  
  Date: October 29, 2009
• Delays in Initiating Antibiotic Therapy for Veterans Hospitalized with Pneumonia
  Time to first antibiotic dose (TFAD) is an important quality indicator for pneumonia care. Findings from this study, which included 20 VA hospitals, show that of the 82 survey participants, 72% perceived that ordering and performing chest X-ray was the most frequent step resulting in TFAD delays. Additional steps reported to cause TFAD delays were medical provider assessment, chest X-ray interpretation, ordering/obtaining blood cultures, and ordering/administering initial antibiotic therapy. The most commonly perceived barriers were patient and X-ray equipment transportation delays and communication delays between providers. The most frequently used strategies to reduce TFAD were stocking antibiotics in the emergency department and physician education. Focus groups emphasized the importance of multi-faceted quality improvement approaches and a top-down hospital leadership style to improve performance on this pneumonia quality measure.
  
  Date: October 1, 2009
• Effect of Medicare Pharmacy Benefit Coverage on VA Healthcare Users
  This study examined the influence of Medicare pharmacy benefit coverage on VA pharmacy use among Veterans using the VA healthcare system during 2002, who had diabetes mellitus, ischemic heart disease, or chronic heart failure. Overall, results showed that Veterans dually enrolled in VA and Medicare fee-for-service (FFS) were less likely to receive condition-related medications from VA compared with Veterans enrolled in HMOs with lower levels of prescription drug coverage. One implication of the overall study findings is that VA will become less the healthcare system of choice for Veteran beneficiaries if Medicare pharmacy services become more affordable. Moreover, Veterans with chronic conditions that require many medications and who hit a coverage gap in Medicare Part D or have difficulty making the Medicare co-payments may turn to VA as a safety net at intermittent times rather than using VA pharmacy services more steadily.
  
  Date: October 1, 2009
• Veterans Using VA Pharmacy Services are More Ill than their Counterparts
  This study compared users and non-users of VA pharmacy services separately by age group – Veterans ages 18-64 (non-elderly) vs. age 65 and older (elderly). Findings suggest that Veterans who use VA pharmacy services appear to be more ill than their counterparts who do not use the VA pharmacy benefit. Among younger Veterans, users of the VA pharmacy were more than twice as likely to report fair or poor general health status and more than three times as likely to report fair or poor mental health status. Moreover, both non-elderly and elderly users of VA pharmacy services reported more medical conditions and were more disabled. Overall results show a higher proportion of Veterans who use VA pharmacy services are African American and have no alternative insurance. Compared to non-users, VA pharmacy users also were more likely to be unemployed or out of the labor force, and living in a poor or low income family.
  
  Date: October 1, 2009
• Appropriate Prescription of Proton-Pump Inhibitors among Elderly Veterans Using NSAIDs
  Using VA data, this observational study assessed VA provider awareness of NSAID gastro-protection and the therapeutic intent of proton-pump inhibitor (PPI) prescription among 1,491 elderly Veterans at one VAMC. In other words, investigators sought to better understand why VA physicians were prescribing these drugs. Findings show that among elderly Veterans who were prescribed a PPI, a therapeutic intent was documented in 71% of the cases, and of these prescriptions, 88.8% were considered appropriate. However, practitioner recognition of the need for gastro-protection in elderly patients was remarkably low (10%). Results also show that poor rates of appropriate therapeutic intent were noted when the PPI was initiated by the inpatient service, by certain sub-specialties (e.g., cardiology, otolaryngology), and for Veterans using the VA for medication refill only.
  
  Date: September 15, 2009
• Toyota Production System Methodology Leads to Improved Peri-Operative Care in One VAMC
  In the Toyota Production System (TPS) industrial engineering approach, front-line work groups identify problems, experiment with possible solutions, measure the results, and implement strategies to improve quality, resulting in a “ground-up” rather than “top-down” approach to solving system problems. Beginning in 2001, one VAMC instituted TPS methods to reduce Methicillin Resistant Staphylococcus Aureus (MRSA) infections on a general surgical floor. The intervention then evolved to address other areas for QI on the surgical unit, such as increasing appropriate prophylactic peri-operative antibiotic therapy. The aims of this study were to determine: 1) whether the QI intervention for peri-operative antibiotic therapy was associated with improvements in selection and duration of prophylactic therapy; and 2) if the overall MRSA prevention initiative was associated with decreased hospital stay (LOS). Findings show that use of the TPS methodology resulted in a QI intervention that was associated with an increase in appropriate peri-operative antibiotic therapy among surgical patients. The proportion of all surgical admissions in this study (n=2,550) receiving appropriate peri-operative antibiotics was significantly higher in 2004 after initiation of the TPS intervention (44.0%) compared to the previous four years (range 23.4% to 29.8%). Results also showed no statistically significant decrease in LOS over time.
  
  Date: September 1, 2009
• Drugs-to-Avoid Criteria for the Elderly have Limited Value
  Drugs-to-avoid criteria are lists of drugs considered to be potentially inappropriate for the elderly due to adverse effects, limited effectiveness, or both. For example, the Centers for Medicare and Medicaid Services use a version of the criteria of Beers et al. in nursing homes, and the National Committee for Quality Assurance uses the criteria of Zhan et al. to compare the quality of U.S. health plans. This study compared the Beers and Zhan criteria with individualized expert assessment of patients’ medications in 256 elderly Veterans from the Iowa City VAMC who were taking five or more medications. Findings show that the drugs-to-avoid criteria performed poorly when used as quality measures to assess the current state of a patient’s drug therapy. For example, half or more of the drugs flagged by the Beers and Zhan criteria were not considered problematic upon individualized expert review. In addition, the Beers and Zhan criteria identified only 8-15% of drugs that experts judged to be problematic. Therefore, authors suggest that while these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures for the quality of prescribing.
  
  Date: July 27, 2009
• Improving Adherence to Cardiovascular Medications
  This article focuses on cardiovascular medication adherence and discusses studies that address: 1) different methods of measuring adherence, 2) prevalence of non-adherence, 3) association between non-adherence and outcomes, 4) reasons for non-adherence, and 5) interventions to improve medication adherence. Findings show that while there are many different methods for assessing medication adherence, non-adherence to cardiovascular medications is common and associated with adverse outcomes. The authors also found that non-adherence is not solely a patient problem but is impacted by both providers and the healthcare system. To date, interventions targeting medication adherence have produced only modest success. Multi-modal interventions have shown the most promise in improving adherence, but require the clinical personnel to manage and coordinate multiple intervention components.
  
  Date: June 16, 2009
• Factors Associated with Antibiotic Prescribing for Likely Non-Bacterial Respiratory Infections
  This study sought to identify patient and provider factors associated with prescribing antibiotics for emergency department (ED) outpatients with acute respiratory infections of likely non-bacterial etiology. Findings show that antibiotic use varied substantially between the two VAMCs studied and was particularly high for acute bronchitis (97% and 65%). Overall, 26% of the Veterans with upper respiratory infections (URIs) and/or acute bronchitis received antibiotics: 78% for acute bronchitis only, 57% for both infections, and 16% for URIs only. The following factors were associated with prescribing antibiotics for infections of likely non-bacterial etiology: presence of one or more comorbidities, fever, purulent sputum, shortness of breath, altered breath sounds, diagnosis of acute bronchitis, as well as non-internal medicine provider specialty and provider age older than 30.
  
  Date: June 1, 2009
• Physicians More Likely than Mid-Level Providers to Initiate Treatment Change for Veterans with Diabetes and Elevated Blood Pressure
  This study sought to examine whether treatment change for Veterans with diabetes and elevated blood pressure (BP) differed between physicians and mid-level providers (nurse practitioners, physician assistants), and to determine reasons for any observed differences. Findings show that mid-level providers were significantly less likely than physicians to change BP treatment for Veterans with diabetes and multiple chronic conditions, even after controlling for a number of patient, provider, and organizational characteristics. For example, after controlling for visit factors, provider practice style, measurement and organizational factors, mid-level providers were still less likely than physicians to initiate treatment change (37.5% vs. 52.5%) for elevated BP. Investigators also note that a fairly comprehensive set of potential explanatory variables did not account for any of the differences between physicians and mid-level providers.
  
  Date: June 1, 2009
• Inhaled Corticosteroids Associated with Higher Glucose Levels in Veterans with Diabetes, but Effect was Dose-Dependent
  This study examined the association between inhaled corticosteroids and glucose concentration among Veterans who received care at seven VA primary care clinics between 12/96 and 5/01. Of the 1,698 Veterans in this study, 19% also had self-reported diabetes. Findings show that after controlling for systemic corticosteroid use and other potential confounders, no association was found between inhaled corticosteroids and serum glucose for Veterans without diabetes. However, among Veterans with diabetes, every additional 100 mcg of inhaled corticosteroid dose was associated with increased glucose concentration. Given this association, authors suggest that clinicians anticipate an increase in serum glucose for patients with diabetes who are using inhaled corticosteroids and adjust serum glucose monitoring accordingly.
  
  Date: May 1, 2009
• Adapting Pharmaceutical Company Strategies to Improve Physician NSAID Prescribing Behaviors
  This study sought to describe the social and communicative strategies that pharmaceutical companies use to influence non-steroidal anti-inflammatory drug (NSAID) prescribing behaviors – and to elicit physicians’ perceptions and counterbalances to these strategies. Physicians described several strategies used by pharmaceutical companies to influence their NSAID prescribing behaviors, including detailing and direct contact with pharmaceutical representatives, requests from patients inspired by direct-to-consumer advertisements, and marketing during formative medical school and residency training. Practice guidelines and peer-reviewed evidence, as well as local physician experts were viewed as important counterbalances to the influence of pharmaceutical companies.
  
  Date: April 1, 2009
• Diffusion of New Drug Therapy for PTSD Lessens with Distance
  This study sought to evaluate the pace and reach of the passive dissemination of a novel, but as yet un-established treatment with the drug prazosin for post-traumatic stress disorder (PTSD) within the VA health care system. Investigators used geographic surveillance data to track the diffusion of prazosin to treat Veterans diagnosed with PTSD in the VA Puget Sound Healthcare System (where the treatment was developed), and at VAMCs ranging up to 2500 miles or farther from Puget Sound. Findings show that the passive diffusion of a new treatment can be rapid in the immediate area in which it is developed, but the geographic gradient of use seems to be steep and changed little during a two-year period, even when cost and organizational barriers were minimal. Veterans with PTSD treated in the area nearest to Puget Sound (<499 miles) were about 63% less likely in 2004 and about 49% less likely in 2006 to be prescribed prazosin than their counterparts treated within Puget Sound. These results suggest that if and when new treatments are definitively demonstrated to be effective, more active dissemination is likely to be needed, especially in geographically remote areas.
  
  Date: April 1, 2009
• Neither Warfarin nor Clopidogrel Superior to Aspirin as Antiplatelet Therapy for Chronic Heart Failure
  The Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) Trial was conducted to determine the optimal anti-thrombotic agent for heart failure patients with reduced ejection fraction who are in sinus rhythm. WATCH Trial findings do not support the primary hypotheses that warfarin or clopidogrel is superior to aspirin. For the primary combined outcome of mortality, non-fatal MI, or non-fatal stroke, major differences between anticoagulation with warfarin and anti-platelet therapy with aspirin or clopidogrel are unlikely. Warfarin was associated with fewer non-fatal strokes than aspirin or clopidogrel, but also was associated with more frequent bleeding episodes compared to clopidogrel, and a non-significant excess of bleeding compared to aspirin.
  
  Date: March 31, 2009
• Primary Care-Based Collaborative Care for Chronic Pain May Be More Effective than Usual Care
  A primary care-based collaborative care intervention for chronic pain was significantly more effective than usual care across a variety of outcome measures, including pain disability and intensity. However, these improvements were generally modest. Depression severity and pain disability and intensity improved among Veterans in the intervention group who reported both chronic pain and depression. Greater use of adjunctive pain medications and long-term opioids among the intervention group suggested that the intervention contributed to the delivery of guideline-concordant care.
  
  Date: March 25, 2009
• Concomitant Use of Clopidogrel and Proton-Pump Inhibitors after ACS is Associated with Higher Risk of Adverse Outcomes
  Proton-pump inhibitors (PPI) were frequently prescribed with clopidogrel (63.9%) for Veterans following hospitalization for acute coronary syndrome (ACS); the concomitant use of clopidogrel and PPI was associated with a higher risk of adverse outcomes compared to the use of clopidogrel alone. The combined primary outcome of mortality or re-hospitalization occurred in 20.8% of Veterans prescribed clopidogrel only, and in 29.8% of Veterans prescribed clopidogrel and PPI. Among secondary outcomes, Veterans taking clopidogrel and PPI also had a higher risk of recurrent hospitalization for ACS and revascularization procedures. Longer duration of clopidogrel plus PPI treatment was associated with adverse outcomes, suggesting that time on combination treatment is important. Pending further studies to confirm results and prospectively assess cardiovascular outcomes for Veterans taking clopidogrel and PPI versus clopidogrel alone, these results may suggest that PPIs should be used for patients with a clear indication for the medication, rather than prophylactically.
  
  Date: March 4, 2009
• Research Agenda for Oral Anticoagulation Quality Measurement
  Efforts to measure the quality of oral anticoagulation care have focused disproportionately on the identification of ideal candidates for warfarin therapy, with little effort in measuring the quality of oral anticoagulation once therapy has begun. To address this knowledge gap, investigators propose a research agenda to advance our understanding of how to measure the quality of care in oral anticoagulation. Authors propose that valid quality indicators will provide a framework for quality improvement that will maximize the effectiveness of therapy and minimize patient harm.
  
  Date: March 1, 2009
• Panel Reaches Consensus on Oral Dosing for Primarily Renally Cleared Medications in Older Adults
  Chronic kidney disease (CKD) is a growing public health problem that disproportionately affects older adults. Medications are the most frequently used therapy for the management of CKD-related problems in older adults, but they are often prescribed in inappropriate doses. This study sought to establish consensus dosing guidelines for primarily renally cleared oral medications commonly taken by older adults with renal insufficiency. An expert panel was able to reach consensus agreement on 18 oral medications that are primarily renally cleared, including anti-infectives and central nervous system medications.
  
  Date: February 1, 2009
• Prescribing Discrepancies during Patient Transfer May Result in Adverse Drug Events
  The objective of this study was to examine medication discrepancies related to adverse drug events (ADEs) in nursing home patients transferred to and from the hospital. Findings show that less than 5% of discrepancies caused ADEs, which is consistent with reviews that suggest only a small fraction of errors result in harm. Authors note that information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients, and inform the development of decision-support tools at the time of patient transfer.
  
  Date: February 1, 2009
• Increase in VA Prescription Co-Pay Leads to Decrease in Adherence to Statins for Veterans at Risk of Heart Disease
  VA’s increase in drug co-payments from $2 to $7 adversely affected lipid-lowering medication adherence among Veterans, including those at high risk of coronary heart disease. After the increase in medication co-payments, the percent of Veterans who were adherent to lipid-lowering therapy declined significantly, even for Veterans with no co-pay. The co-payment increase was also accompanied by a significant increase in the likelihood of having continuous gaps in lipid-lowering medication use.
  
  Date: January 27, 2009
• Lessons Learned from Deceptive Marketing of Neurontin™
  Recent lawsuits alleging injury from the illegal marketing of gabapentin (Neurontin™) have yielded remarkable discoveries about the structure and function of pharmaceutical marketing. This article summarizes the marketing tactics used and offers actions to prevent similar occurrences.
  
  Date: January 8, 2009
• Study Suggests Changes Needed in Warfarin Dosing
  The lack of evidence regarding optimal management strategies for warfarin probably contributes to limited success in maintaining patients within the target International Normalized Ratio (INR) range (system used to report testing for coagulation). Findings from this study show that providers vary widely in their dose change thresholds in similar clinical situations and that the INR value was by far the most important predictor of dose change. Authors suggest that in addition to offering warfarin to as many optimal candidates as possible, we also need to optimize warfarin dose management to fully realize the benefits of anticoagulation.
  
  Date: January 1, 2009
• ACE Inhibitors May Benefit Patients with Pneumonia
  Prior outpatient use of lipophilic, but not hydrophilic ACE inhibitors was associated with decreased 30-day mortality for patients hospitalized with community-acquired pneumonia. Study results also provide further support demonstrating that ACE inhibitor use, in general, is associated with decreased mortality for patients with pneumonia.
  
  Date: December 1, 2008
• Controlling Medicare Costs: Study Suggests VA-Administered Drug-Only Benefit for Veterans Enrolled in Medicare
  This article discusses the role of interest groups in drug-plan policy differences between Medicare and VA. Authors suggest a partnership between Medicare and VA that could provide access to the VA drug benefit to a large number of Medicare-enrolled veterans who do not currently have it.
  
  Date: December 1, 2008
• Treatments for Co-Occurring Schizophrenia and Substance Use Disorders
  While studies to date suggest better outcomes with second-generation antipsychotics (SGAs), for example, olanzapine and risperidone, the available evidence does not clearly demonstrate an advantage for any particular SGA; thus investigators recommend that clinicians select the medication that balances efficacy and side effects for each individual patient.
  
  Date: October 1, 2008
• Veteran Perceptions of In-Home Medication Dispensing Devices
  No significant differences were found across types of devices in the perceived likelihood that using the device would improve medication adherence. Moreover, even if VA paid for the devices, patient participants reported that they would be unlikely to use them.
  
  Date: July 1, 2008

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 Mental Health

• Increased Risk of Mortality Following Heart Attack for Veterans Insufficiently Treated for Major Depressive Disorder
  This study sought to determine if mortality following acute MI was associated with treatment-resistant depression (TRD). Findings show that all-cause mortality following an acute MI is greatest in Veterans with depression that is insufficiently treated – and is a risk in Veterans with treatment-resistant depression. Veterans who were insufficiently treated were 3.04 times more likely to die than those who received treatment. Veterans with TRD were 1.71 times more likely to die; however, this risk was partly explained by comorbid disorders.
  
  Date: January 12, 2012
• Majority of OEF/OIF Veterans with Traumatic Brain Injury also Diagnosed with Mental Illness and Head, Neck or Back Pain
  This study examined the prevalence and VA healthcare costs of TBI with and without comorbid psychiatric illness and pain among OEF/OIF Veterans who used VA healthcare services (inpatient or outpatient) during FY09. Findings showed that 7% of the Veterans who used VA healthcare received a diagnosis of TBI. Among this patient subgroup, the vast majority (89%) also had a psychiatric diagnosis (most frequently PTSD: 73%), and 70% had a diagnosis of head, neck or back pain. More than half had both PTSD and pain (54%). Overall, depression was the second most common (45%) mental health diagnosis. Annual costs for OEF/OIF Veterans with TBI were four times greater than for those without TBI ($5,831 vs. $1,547), and costs increased as clinical complexity increased. For example, Veterans with TBI, PTSD, and pain demonstrated the highest median cost per patient ($7,974).
  
  Date: January 4, 2012
• Gender Differences in Combat Exposure, Military Sexual Trauma, and Mental Health among Active Duty Soldiers
  This study examined gender differences in combat exposure, military sexual trauma (MST), and their associations with mental health outcomes among OEF/OIF active-duty personnel. Findings showed that although men reported greater exposure to high-intensity combat experiences than women, results indicate that women are experiencing combat at higher rates than observed in prior cohorts. For example, 7% of women reported injury in the war zone, and 4% reported killing in war, compared to 2% and 1%, respectively, for a Gulf War cohort. MST was a significant predictor of both PTSD and depression symptoms: 12% of women and less than 1% of men reported MST in the war zone. There were no gender differences in PTSD symptoms; however, there was a stronger assocation between injury in combat and PTSD symptoms for women than for men. Men were more likely to report hazardous alcohol use, while female gender was more likely to be associated with depression symptoms.
  
  Date: December 13, 2011
• Diabetes Managed More Intensively in Older Veterans with Dementia and Cognitive Impairment
  This study sought to examine and compare anti-glycemic medication use, glycemic control, and risk of hypoglycemia in older Veterans with and without dementia or cognitive impairment. Findings showed that diabetes was managed more intensively in older Veterans with dementia or cognitive impairment than in those with no impairment, with more patients on insulin (30% vs. 24%) among those with cognitive problems. These conditions were independently associated with a greater risk of hypoglycemia. Of all Veterans taking insulin, the incidence of hypoglycemia was higher among those with dementia (27%) or cognitive impairment (20%) than among those with neither condition (14%). Veterans with dementia or cognitive impairment also had a greater decline in HbA1c over the 2-year study period. These findings suggest that providers were less likely to pursue individualized glycemic goals, as recommended by VA-DoD clinical practice guidelines (updated in 2010), when patients had cognitive problems.
  
  Date: December 8, 2011
• History of Military Sexual Trauma Increases Risk of Sexual Health Diagnoses among OEF/OIF Veterans
  This study examined the prevalence rates of sexually transmitted infections (STIs) and sexual dysfunction disorders (SDDs) among OEF/OIF Veterans with and without reported military sexual trauma (MST). Investigators also explored whether the presence of a co-existing mental health diagnosis (e.g., PTSD, depression, substance use disorder) was associated with higher rates of STIs and SDDs among Veterans who screened positive for MST. Findings show that a number of STI and SDD diagnoses were more common among OEF/OIF Veterans who reported a history of MST compared to Veterans without a history of MST. There were no instances in which any of the sexual health diagnoses were significantly higher among Veterans who did not report a history of MST, even after controlling for age and length of time in VA healthcare. Moreover, among Veterans with a history of MST, the risk of having an STI or SDD increased in the presence of certain mental health diagnoses. Among women with a history of MST, those with a diagnosis of PTSD, depression, or a substance use disorder were significantly more likely to have an STI than women without these diagnoses. Among men with MST, only substance use disorder increased their risk for an STI. Among women with a history of MST, those with a diagnosis of depression were significantly more likely to have an SDD than women without a depressive disorder. Among men with MST, those with a diagnosis of PTSD or depression were more likely to have an SDD diagnosis than men without either disorder. This study emphasizes the importance of sexual health screening, particularly among Veterans with a history of MST.
  
  Date: December 5, 2011
• Telemedicine-Based Collaborative Care Intervention for Depression has Greater Effect on Minority vs. White Veterans
  The Telemedicine Enhanced Antidepressant Management (TEAM) study was a randomized trial of telemedicine-based collaborative care tailored for small, rural primary care practices. Investigators in the current study evaluated racial differences in clinical outcomes among 360 Veterans with depression who were randomized to usual care or the TEAM intervention. Findings showed that in the usual care group, minority Veterans had a lower treatment response rate (8%) than Caucasians (18%), but this was not significant. In contrast, minority Veterans in the TEAM intervention group had a significantly higher treatment response rate (42%) than Caucasians (19%) in the intervention group. Veterans in the minority group were significantly less likely to report that antidepressants were an acceptable form of treatment, and were significantly less likely to have had prior or current depression treatment. However, none of these variables were significantly related to treatment outcomes. Thus, the study was not able to determine why minorities responded better to the intervention than Caucasians.
  
  Date: November 1, 2011
• Survey-based vs. Chart-based Screening Yields Significantly Higher Rates of Depression among Veterans in Primary Care
  This study sought to characterize the yield of practice-based screening in 10 diverse VA primary care clinics (rural and urban), as well as the care needs of Veterans assessed as having depression. Findings showed that practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. Practice-wide depression screening yielded 20% positive depression screens and 12% probable major depression. This is substantially higher than most previously reported VA rates. In addition, comorbid medical and mental illness were highly prevalent.
  
  Date: October 6, 2011
• VA Mental Health Care Staff More Satisfied and Suffer Less Burnout Compared to Non-VA Community Mental Health Staff
  This study compared burnout and job satisfaction between VA staff and non-VA community mental health staff working in the same large Midwestern city in 2009. Findings show VA staff reported significantly greater job satisfaction and accomplishment, less emotional exhaustion, and lower likelihood of leaving their job. VA and non-VA community mental health clinic (CMHC) staff also differed significantly in two categories. CMHC staff were significantly more likely to report job-related aspects as being challenging, such as lack of flexibility in the schedule and little pay. VA staff were more likely than CMHC staff to report administrative issues as being challenging, e.g., bureaucracy, red tape, and policies. Authors suggest that while CMHC leadership may need to find ways to address concerns related to job responsibilities (e.g., pay, schedule), VA may need greater focus helping workers navigate administrative concerns.
  
  Date: October 5, 2011
• Depression and Race may Independently Affect Receipt of Some Surgeries
  This study examined race and ethnicity as factors potentially associated with surgeries experienced by Veterans with and without major depressive disorder (MDD). Findings show that Veterans with pre-existing MDD were less likely to undergo digestive, hip/knee, vascular, or CABG surgeries than Veterans without MDD. Minority Veterans were slightly less likely to receive vascular operations compared to white Veterans, but were more likely to undergo digestive system procedures. The effect of depression was independent of race and ethnicity; thus, depression and race would have an additive but not synergistic effect on the odds of receiving surgery. In addition, a gender effect was noted: women Veterans were more likely to have digestive procedures but were less likely to undergo CABG or vascular operations. Authors note that the lack of information regarding severity of illness makes it difficult to determine whether or not diagnostic differences explain differences in surgery.
  
  Date: October 1, 2011
• Military Sexual Trauma Associated with Increased Rate of Mental Health Disorders among Male and Female Veterans with Comorbid PTSD
  This study examined correlates of PTSD in OEF/OIF Veterans, as well as mental health comorbidities by gender among Veterans with PTSD – with and without military sexual trauma (MST). Findings showed that overall, MST was associated with a nearly three-fold increase in odds of PTSD in men, and more than a four-fold increase in women Veterans. Among women Veterans with PTSD, 31% screened positive for MST, and 1% of men with PTSD screened positive for MST. Among Veterans with PTSD, those with military sexual trauma also had more comorbid mental health diagnoses than those without MST. Three-quarters of women Veterans with PTSD and MST had comorbid depression, more than one-third had another anxiety disorder, and 4% were diagnosed with eating disorders. Male Veterans with PTSD and MST were more likely to have comorbid depression and substance use than male Veterans with PTSD, but without MST.
  
  Date: September 8, 2011
• Quality of VA Mental Health Care Following Psychiatric Hospitalization for Veterans with Depression
  This study sought to assess the quality of depression care (e.g., antidepressant treatment, psychotherapy) during the high-risk period following a psychiatric hospitalization. Findings show that less than half of Veterans hospitalized for major depression had outpatient mental health follow-up within 7 days of discharge (39%), which is similar to rates found in the general U.S. population among Medicare (38%) and Medicaid (43%) beneficiaries in 2008. Mental health follow-up within 30 days for Veterans in this study was substantially more common (76%). Many Veterans also received adequate psychopharmacologic treatment following a hospitalization for depression (59%), but relatively few received adequate psychotherapy post-discharge (13%).
  
  Date: September 1, 2011
• Study Suggests PTSD Associated with Cognitive Impairment
  This systematic review analyzed data from 21 articles published between 1968 and 2009 that examined memory and cognitive function in subjects with chronic PTSD compared to subjects who had been exposed to trauma but did not have PTSD. Eight of the studies that were analyzed included Veterans. Findings showed that chronic post-traumatic stress disorder is associated with cognitive impairment, particularly in Veterans, when compared to individuals with a history of trauma but no PTSD. The severity of PTSD is positively correlated with cognitive impairment. Strong evidence, especially in studies of Veterans, refugees, and war victims, suggests that individuals with PTSD have a poorer ability to sustain attention compared with individuals who have a history of exposure to trauma.
  
  Date: September 1, 2011
• Co-Location of Primary Care in VA Mental Health Clinics Associated with Better Processes of Care for Veterans with Serious Mental Illness
  This study sought to determine the association between the co-location of primary care services and quality of medical care for patients with serious mental illness (SMI) receiving care in VA mental health clinics. Findings showed that the co-location of primary care services within VA mental health clinics was associated with better quality of care for Veterans with serious mental illness, particularly for key processes of care. After adjusting for organizational and patient-level factors, Veterans from co-located clinics were more likely to receive diabetes foot exams and screening for colorectal cancer and alcohol misuse (process measures), and to have satisfactory blood pressure control (outcome measure). Co-location was not associated with better outcomes for hemoglobin A1C levels among Veterans with diabetes. Observed quality of care in this sample exceeded national averages. Overall, integrated medical care may potentially provide an effective medical home model that can improve processes of medical care for Veterans with SMI.
  
  Date: August 1, 2011
• Potential Problems with the Use of Antidepressants among Older Veterans Residing in VA Nursing Homes
  This study examined the prevalence and patient/site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants among Veterans aged 65 years and older that were admitted to any one of 133 VA Community Living Centers (CLC, previously called Nursing Home Care Units). Findings suggest potential problems with the use of antidepressants in older Veterans that reside in VA CLCs. Overall, only 18% of antidepressant use was optimal. Of the 877 Veterans with depression, 25% did not receive an antidepressant, suggesting potential underuse. Among depressed Veterans who received antidepressants, 43% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. In addition, of the 2,815 Veterans who did not have depression, 42% were prescribed one or more antidepressants; of these, only 4% had an FDA-approved labeled indication, suggesting potential overuse. Also, the co-prescribing of antipsychotics (in patients without schizophrenia) among those without depression was associated with an increased risk of antidepressant overuse.
  
  Date: August 1, 2011
• Veterans with Diabetes and Major Depressive Disorder at Significantly Increased Risk of Myocardial Infarction
  This study sought to determine if major depressive disorder (MDD) complicates the course of type 2 diabetes and is associated with increased risk of myocardial infarction (MI) and mortality. Findings showed that Veterans with comorbid MDD and type 2 diabetes were 82% more likely to experience a MI compared to Veterans without MDD and type 2 diabetes. Veterans with MDD alone were 29% more likely to have a MI, and Veterans with type 2 diabetes alone were at 33% increased risk of MI. The incidence of MI increased in a step-wise fashion, from unaffected Veterans (2.6% incidence of MI) to those with depression only (3.5%) to those with diabetes only (5.9%) to Veterans with both conditions (7.4%). Veterans with PTSD, anxiety, and panic disorder were more likely to have a MI, as were Veterans with hypertension, hyperlipidemia, obesity, and nicotine dependence.
  
  Date: August 1, 2011
• Differences in Communication between Providers in VA Mental Health Clinics and General Medical Providers in Treating Veterans with Serious Mental Illness
  Integrated care for co-occurring substance use and general medical disorders is considered essential for improving quality of care for individuals with serious mental illness (SMI), and is one of VA’s priority goals. This study sought to describe the barriers and facilitators of integrated care (from the perspective of mental health providers) for nearly 20,000 Veterans with SMI. Findings show that mental health providers from VA mental health clinics with high versus low quality of care scores differed in their ability to communicate with general medical providers regarding care for Veterans with SMI. Among mental health providers from low-performing sites, lack of communication with primary care providers was a key barrier. Barriers to communication included lack of opportunities to interact on a face-to-face basis and lack of opportunities to have team meetings. In addition, they were concerned that primary care providers did not want to see patients with SMI because of the perception that they were difficult to treat. Stigma was not mentioned as a problem for providers among the high-performing sites, with general medical providers viewed as sensitive to the needs of Veterans with SMI. The authors suggest that these findings indicate that efforts to improve communication between mental health and primary care providers, as well as delineating roles and responsibilities across both types of providers may potentially facilitate integrated medical care for Veterans with serious mental illness.
  
  Date: July 7, 2011
• Integrated Primary Care Clinic Improves Access to Mental Health and Social Services for OEF/OIF Veterans
  In April 2007, an OEF/OIF Integrated Care (IC) Clinic was established at the San Francisco VAMC, as part of VA primary care system-wide priorities for improving mental health screening and treatment for OEF/OIF Veterans. This study evaluated whether an initial IC clinic visit improved mental health and social services use among OEF/OIF Veterans entering primary care at the San Francisco VAMC, compared to Veterans who received usual care. Findings showed that OEF/OIF Veterans seen in the IC clinic were significantly more likely to have had initial mental health and social work evaluations within 30 days. Moreover, IC clinic patients were significantly more likely than usual care patients to have had at least one follow-up specialty mental health visit within 90 days of initiating primary care. Women Veterans, younger Veterans, and those with positive mental health and TBI screens were significantly more likely to have had mental health and social service evaluations if seen in the IC versus the usual care clinic. While the Integrated Clinic increased initial mental health evaluations, there was no significant increase in longer-term retention in specialty mental health services among Veterans who screened positive for mental health problems.
  
  Date: June 7, 2011
• Women as Resilient to Combat-Related Stress as Men in the First Year Following Return from OEF/OIF Deployment
  This study examined gender differences in various dimensions of combat-related stress and associated consequences for post-deployment mental health in a nationally representative sample of male and female OEF/OIF Veterans. Study results suggest that women OEF/OIF service members may be as resilient to combat-related stress as men in the first year following deployment. There were no significant interactions between combat-related stressors and gender in the prediction of post-traumatic stress symptomatology, mental health functioning, or depression. Women reported slightly less exposure than men to most combat-related stressors, but higher exposure to other stressors (i.e., prior life stress, deployment sexual harassment). There were no differences between men and women in reports of perceived threat in the war zone.
  
  Date: May 30, 2011
• Telemedicine-Based Collaborative Care Does Not Increase Total Workload for Primary Care or Mental Health Providers
  This study examined patterns of healthcare utilization and cost associated with telemedicine-based collaborative care for depression among Veterans who received care in seven VA community-based outpatient clinics (CBOCs). Findings suggest that telemedicine-based collaborative care does not increase total workload for primary care or mental health providers; therefore, there is no disincentive for mental health providers to offer telemedicine-based care ? or for primary care providers to refer Veterans to telemedicine care. There was no significant difference in the total number or cost of primary care encounters between Veterans in the intervention group and those in the usual care group. Between the two groups, there also were no statistically significant differences in total mental health encounters or cost; however, Veterans in the intervention group did have significantly more cost and encounters in specialty physical health clinics. In addition, Veterans in the intervention group had a significantly greater total outpatient cost compared to Veterans in usual care. These differences were likely due to the high levels of physical and mental health comorbidities in this study population.
  
  Date: May 26, 2011
• Book Examines Social and Cultural Factors Contributing to Combat-Related PTSD among OEF/OIF Veterans
  This book follows a group of OEF/OIF Veterans and tells their personal stories of war, trauma, and recovery as they re-enter civilian life while dealing with combat-related PTSD. Written from an anthropologist’s perspective, the author examines the cultural, political, and historical influences that shape individual experiences of PTSD – and how Veterans with PTSD are perceived by the military, medical personnel, and society at large. Despite widespread media coverage and public controversy over the military’s response to wounded and traumatized service members, debate continues about how best to provide treatment and compensation for service-related disabilities. At the same time, new and highly effective treatments are revolutionizing how VA provides trauma care, and redefining the way PTSD is understood. Fields of Combat discusses real-life issues related to living with PTSD, and suggests recommendations to improve PTSD care.
  
  Date: May 19, 2011
• Effect of Housing Vouchers on Homeless Veterans with Mental Illness
  This study examined how homeless Veterans with mental illness obtain housing without a voucher, and whether greater employment earnings or better clinical outcomes were associated with such housing success. Findings showed that Veterans who obtained independent housing without a voucher worked more days and had higher employment income than those with a voucher, but they were less satisfied with their housing. Veterans who used vouchers lived in housing with the highest rent, but paid less of their own income toward rent because of their vouchers. They also reported the highest quality of life with respect to their living situation, higher satisfaction with their housing, and higher safety scores. About one-third of Veterans who obtained independent housing without a voucher lived with others, most often with a family member, and reported lower total rent costs, but paid the greatest share of the rent themselves. Approximately 80% of participants were diagnosed with alcohol or drug dependency. There were no differences in psychiatric, substance abuse, or legal outcomes between groups at three months; however, data over all three years shows that Veterans who were not housed had higher psychiatric, substance abuse, and work problems over time than all other groups.
  
  Date: May 1, 2011
• Veterans Reporting a History of Military Sexual Trauma are Treated in a Variety of VA Outpatient Mental Health Settings
  This study sought to determine the VA mental health outpatient settings in which patients with military sexual trauma (MST) are most likely to be treated, which might help set priorities for targeted MST-related education and training. Findings showed that more than one-third of female Veterans (36%) and 2% of male Veterans seen in VA outpatient mental healthcare settings during FY08 reported a history of military sexual trauma. Both women and men with MST were more likely to use more than one type of mental health clinic setting, compared to those without MST. A significantly larger proportion of women seen in MST specialty clinics reported MST as compared to all other settings (81% vs. 34%). However, there was a wide range of clinic visit settings for female Veterans with MST, including: MST specialty clinics, PTSD specialty clinics, psychosocial rehabilitation, and substance use disorder clinics. Male Veterans represented a small proportion of patients seen in all clinics, and a larger proportion of men seen in MST specialty clinics reported MST as compared to other settings (56% vs. 2%). These findings indicate that mental health providers who treat women Veterans, even if they work in settings that do not traditionally incorporate interventions focused on traumatic stress, may encounter issues related to MST. Therefore the authors suggest that training in how to respond to sexual trauma disclosure be an important component in all VA mental healthcare settings.
  
  Date: May 1, 2011
• Less than One-Quarter of Veterans who Complete Suicide Access VA Healthcare in Year Prior to Death
  This study sought to determine the number of Veterans who completed suicide and who had accessed VA healthcare in the Pacific Northwest Region in the year prior to death. Findings show that of the 968 Veterans in this study who completed suicide, less than one-quarter (22%) accessed VA healthcare in the year prior to death, and a minority of those Veterans visited mental health providers. These numbers are consistent with current estimates of the number of Veterans accessing care at VA hospitals and clinics, and suggest that Veterans who go on to complete suicide may access VA healthcare at similar rates as Veterans who do not commit suicide. Of those Veterans who completed suicide, 57% did not have a mental health diagnosis, and 58% had not seen a mental health professional, suggesting that it is perhaps equally important to understand patients with general medical conditions who also may be likely to complete suicide. Of those who completed suicide, 55 were hospitalized during the year prior to death. Of these, 39% with a psychiatric hospitalization and 22% with a medical/surgical hospitalization completed suicide within 30 days. A large number of Veterans (73% of men; 36% of women) completed suicide by use of a firearm, supporting concerns from earlier studies over firearm access as a key risk factor in Veteran suicide.
  
  Date: April 4, 2011
• Initial Implementation of VA Primary Care Mental Health Not Associated with Differences in Specialty Mental Health Clinic Use by Veterans
  This study sought to determine whether the implementation of primary care mental health services is associated with differences in specialty mental health clinic use within the VA healthcare system. Findings show that the initial implementation of primary care mental health within VA is not associated with substantial differences in mental health clinic use – or diagnoses received in specialty mental health clinics by primary care patients. Facilities with primary care mental health – compared to those without – had similar rates of primary care patients initiating specialty mental health treatment (5.6% vs. 5.8%), and their primary care patients averaged similar total specialty mental health clinic visits (7.0 vs. 6.3). After adjusting for facility characteristics and multiple comparisons, there were no statistically significant differences with regard to diagnoses for Veterans who initiated specialty mental health clinic treatment at primary care mental health facilities. The authors note that primary care mental health may impact mental health clinic use over longer periods of time as these programs mature.
  
  Date: April 1, 2011
• Successful Translation of Behavioral Intervention for Caregivers of Veterans with Dementia
  This study assessed the translation of the NIA/NINR Resources for Enhancing Alzheimer’s Caregivers Health (REACH II) intervention into REACH VA – a behavioral intervention for caregivers of Veterans with dementia that ran from 9/07 through 8/09. Findings show that the REACH VA intervention provided clinically significant benefits for caregivers of Veterans with progressive dementia. Caregivers reported significantly decreased burden, depression, impact of depression on daily life, frustrations associated with caregiving, and number of troubling dementia-related behaviors. Also, a decrease of two hours per day “on duty” trended toward significance. Of the caregivers who participated in the REACH VA intervention, 96% believed that the program should be provided by VA to caregivers.
  
  Date: February 28, 2011
• Using Administrative Data to Measure Treatment for Veterans with PTSD May Overestimate Delivery of Psychotherapy
  This study sought to determine whether using administrative data to determine the number of psychotherapy sessions Veterans receive is equivalent to manual record review. Manually-classified notes were used to develop an automated coding protocol using the Automated Retrieval Console (ARC), a VA-developed natural language processing program. ARC was then used to independently code the notes, and the performance of the automated coding program was compared to manual coding. Findings showed that, of the notes that were administratively coded as individual psychotherapy for PTSD, 57% were coded as individual psychotherapy after manual review of records. Thus, nearly half of the encounters that would have been counted as the provision of psychotherapy in large administrative studies appeared to be records of services other than psychotherapy (e.g., intakes, psychological testing). Findings suggest that using counts of administrative codes over-estimates the amount of psychotherapy delivered to Veterans with PTSD. This suggests a potential limitation in current studies of the quality of care for PTSD in VA. The ARC program replicated the performance of the manual coders in classifying psychotherapy notes very well. This suggests that ARC may help bridge the gap between the accuracy of manual coding and the scope of administrative coding.
  
  Date: February 14, 2011
• Study Evaluates Workshop to Assist OEF/OIF Veterans with Reintegration and Resiliency
  Few programs to promote healthy reintegration exist that are evidence-based and designed for individuals who are not receiving formal mental health care. In response to this need, a two-hour workshop, Life Guard, was developed for the Arkansas National Guard. This pilot study evaluated the effectiveness of the Life Guard workshop for OEF/OIF National Guard Veterans. Findings show that Veterans who participated in the workshop reported significant declines in symptoms of depression, anxiety, and PTSD, in addition to increased satisfaction with relationships. Results also show high levels of exposure to traumatic events, physical injury, and symptoms of psychosocial distress. The authors suggest that these findings support the continued evaluation of Life Guard as a valuable tool to help service members with reintegration and resiliency.
  
  Date: February 1, 2011
• Rates of PTSD and Depression Highly Prevalent among OEF/OIF Veterans with Alcohol and/or Drug Use Disorders
  This study sought to determine the prevalence and independent correlates of alcohol use disorders (AUD) and drug use disorders (DUD) among OEF/OIF Veterans who were first-time users of VA healthcare. Findings show that, overall, 11% of the OEF/OIF Veterans in this study received diagnoses of AUD, DUD, or both; 10% received AUD diagnoses and 5% received DUD diagnoses. Post-deployment AUD and DUD diagnoses were more prevalent in particular sub-groups of OEF/OIF Veterans and were highly comorbid with PTSD and depression. Among Veterans diagnosed with AUD, DUD, or both, 55% to 75% also received a diagnosis of PTSD or depression. AUD, DUD, or both diagnoses were 3 to 4.5 times more likely among Veterans with PTSD and depression. AUD and DUD diagnoses were more prevalent among Veterans younger than age 25, men, and Veterans who were more likely to have had greater exposure to combat, e.g., Veterans who were enlisted versus officers, and those who served in the Army and Marines.
  
  Date: January 28, 2011
• Suicide Risk Factors for OIF Veterans
  This study examined combat and mental health as risk factors for suicidal ideation among OIF Veterans. Findings show that, overall, 2.8% of the OIF Veterans in the study reported suicidal thinking, the desire for self-harm, or both. Post-deployment depression symptoms were associated with suicidal thoughts, while post-deployment PTSD symptoms were associated with current desire for self-harm. Post-deployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while post-deployment PTSD symptoms mediated the association between killing in combat and the desire for self-harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning Veterans.
  
  Date: January 22, 2011
• Telephone-based Care Coordination Intervention Complements Care for Veterans with Dementia and Supports their Caregivers
  This article provides a detailed description of a telephone-based care coordination intervention – Partners in Dementia Care (PDC) – developed for Veterans with dementia and their family caregivers across all stages of the disease. Findings show that, overall, the PDC intervention addresses the diverse needs of Veterans with dementia and their caregivers, including non-medical care issues such as understanding VA benefits, accessing community resources, and addressing caregiver strain. The authors also note that the PDC intervention incorporates several unique features that distinguish it from most other services and programs for dementia caregiving, such as the delivery of the intervention through formal partnerships between VAMCs and local Alzheimer’s Association Chapters, the inclusion of family caregivers, and the breadth of issues addressed for both Veterans and their caregivers. The consumer-directed philosophy of the program enabled Care Coordinators to serve a large number of families in a cost-efficient way, since Veterans and families were taking action on their own with support and guidance from both VA and Alzheimer’s Association care coordinators.
  
  Date: January 17, 2011
• Collaborative Care Intervention Improves Depression in Veterans with HIV
  The goal of this study was to adapt an evidence-based primary care model of depression collaborative care for HIV clinic settings (HIV Translating Initiatives for Depression into Effective Solutions [HITIDES])) – and to evaluate its effectiveness. Findings show that the HITIDES intervention was successfully implemented in HIV settings and improved both depression and HIV symptom outcomes. Veterans who participated in the intervention were more likely to report treatment response and remission compared to Veterans in usual care at 6-month follow-up but not at 12-month follow-up. Improved depression response and remission outcomes at 6 but not 12 months suggest that depression symptoms improved more rapidly in the intervention group compared to usual care. Intervention participants also reported more depression-free days over 12 months. Compared to usual care, significant intervention effects also were observed for lowered HIV symptom severity at 6 and 12 months. The authors suggest that the HITIDES intervention may serve as a model for collaborative care interventions in other specialty physical healthcare settings.
  
  Date: January 10, 2011
• Peer-Support Interventions May Reduce Symptoms of Depression Better than Usual Care
  Investigators in this study conducted a meta-analysis of published randomized clinical trials (RCTs) to determine whether peer-support interventions resulted in a greater reduction of depression symptoms compared to either usual care or psychotherapy (group cognitive behavioral therapy only). Seven RCTs comparing peer support vs. usual care for depression showed a significantly greater reduction in mean depression scores with peer support. Seven RCTs comparing a peer-support intervention to group cognitive behavioral therapy (CBT) showed no statistically significant difference between group CBT and peer interventions. These findings suggest that peer-support interventions have the potential to be effective components of depression care.
  
  Date: January 1, 2011
• Pregnancy and Mental Health Conditions among Female OEF/OIF Veterans Using VA Healthcare
  This study sought to determine the prevalence of mental health problems among 43,078 OEF/OIF women Veterans who received a pregnancy diagnosis in the VA healthcare system over a five-year study period (2003-2008). Although a relatively small proportion of OEF/OIF women Veterans received VA healthcare related to pregnancy (7%), a substantial proportion of these women (32%) received one or more mental health diagnoses compared with 21% of women without a pregnancy-related condition. Compared with all women Veterans enrolled in VA healthcare, Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, PTSD, bipolar disorder, or schizophrenia than those without a pregnancy. The most common mental health diagnoses among Veterans with a pregnancy were anxiety (43%), depression (36%), and PTSD (21%), followed by bipolar disorder (3%), and alcohol abuse/dependence (3%). [Sum is greater than 100% due to comorbidity.] Veterans with a pregnancy were significantly more likely to have a service-connected disability than those without a pregnancy. 71% of Veterans with a pregnancy were either never married or no longer married. On average, women Veterans experienced their index pregnancy nearly two years after returning from their last deployment.
  
  Date: December 1, 2010
• Veterans who Commit Suicide May Not Show Apparent Emotional Distress During Last Healthcare Contact
  This retrospective study examined VA healthcare contacts (by phone or in person) by Veterans in the year prior to their deaths by suicide. The majority of Veterans in this study were seen for routine VA medical care in the year prior to committing suicide, and did not show apparent signs of emotional distress at their last healthcare visit. In the year prior to death, nearly 50% of the Veterans had one or more mental health contacts, and 63% had one or more primary care contacts. Just over half of the Veterans received care in the 30 days prior to death, with 20% receiving mental health care and 15% receiving primary care. Forty percent of these Veterans were assessed for suicidal ideation during the year prior to death, and 16% were assessed during their last contact. Nearly three-quarters of those who were specifically asked about thoughts of suicide in the year prior to death denied having such thoughts. The median number of days between final VA healthcare contact and date of death was 42. Of the 26 Veterans whose final contacts were with mental health, 87% were assessed for depression, substance use disorder, or PTSD, and 54% were assessed for suicidal ideation. Of the 22 Veterans whose final contacts were with primary care, 55% were assessed for depression, substance use disorder, or PTSD, and 9% were assessed for suicidal ideation.
  
  Date: December 1, 2010
• Differences in Mental Health Diagnoses among OEF/OIF Soldiers Transitioning from DoD to VA Care
  This study assessed the transition of healthcare from DoD to VA for service members traumatically injured in OEF/OIF, and their subsequent psychiatric care. Findings show that although none of the 994 DoD inpatients received a diagnosis of PTSD, 21% (209) had other mental health diagnoses, primarily drug abuse (12%). Of the 216 service members who transitioned to VA care, 71% (153) subsequently had at least one psychiatric diagnosis, with PTSD (52%) and depression (40%) the most common. OEF/OIF service members who were discharged from DoD care in FY06 were more likely to transition into VA care (31%) than were patients discharged in earlier years. Of service members who sought VA care, 38% did so within six months of DoD discharge, and 75% within one year of discharge. Nearly 88% of those service members who transitioned to VA healthcare were still using VA care in the final year of the study, FY09. Treatment retention was significantly greater for those receiving psychiatric care: 98% vs. 62% for those not receiving psychiatric care.
  
  Date: November 2, 2010
• Link between Psychiatric Diagnosis and Higher Risk of Suicide among Veterans
  As part of VA’s ongoing evaluation of suicide risk among Veterans being treated in VA facilities, this study examined the impact of different psychiatric diagnoses on the risk of suicide. Findings show that a clinical diagnosis of a psychiatric disorder increased the risk of subsequent suicide by 160%. Psychiatric diagnoses were an especially strong risk factor for suicide among women, increasing their risk of suicide more than 5-fold. Bipolar disorder was the least common diagnosis (only 3% of all Veterans studied), but was diagnosed in approximately 9% of all Veterans who died by suicide. A diagnosis of bipolar disorder increased the risk of suicide nearly 3-fold in men and 6-fold in women. Authors suggest this makes bipolar disorder particularly appropriate for targeted interventions (e.g., improving medication adherence). Overall, suicides were more than three times as common in men than in women and were 37% to 77% more common in Veterans ages 30 and older than among those ages 18 to 29.
  
  Date: November 1, 2010
• Providing Free Care for Veterans with Military Sexual Trauma Does Not Result in Major Income Loss to VA
  Since 2002 there have been no co-payments for VA healthcare related to military sexual trauma (MST), defined by VA as sexual assault or harassment that took place during military service. However, eliminating co-payments reduces income for the VA healthcare system. This retrospective study estimated the loss in outpatient co-payment revenue for VA due to the mandate for free care related to MST. Findings show that about 95% of Veterans who received outpatient care for military sexual trauma would have had no co-payment, even in the absence of a free-care mandate. The estimated co-payment revenue foregone by the free-care mandate for MST was modest, totaling about $418,000 in FY06, $517,000 in FY07, and $455,000 in FY08. These totals represented only .04-.05% of first-party co-payment revenues for outpatient care. These results suggest that VA can continue to provide free care for patients who have experienced military sexual trauma without major income loss.
  
  Date: November 1, 2010
• Substantial Gaps in Processes of Care for Veterans with Bipolar Disorder
  This study applied a comprehensive set of process of care measures that reflect the integration of psychosocial, patient preference, and continuum of care approaches to mental health – and evaluated whether Veterans with bipolar disorder received care concordant with these practices. Findings show substantial gaps in care for Veterans with bipolar disorder, especially for patient-centered processes such as symptom assessment and treatment experience. Only half of the patients received care in accordance with clinical practice guidelines. Moreover, only 17% had documented assessment of psychiatric symptoms, 28% had documented patient treatment preferences, 56% had documented assessment of substance abuse and psychiatric comorbidity, and 62% had documented assessment of cardiometabolics. Monitoring of weight gain was noted in 54% of the patient charts, and no-show visits were followed up only 20% of the time. However, 72% of the patients received appropriate anti-manic medication, and all patients were assessed for suicidal ideation. Overall, results suggest that in order to present a more patient-centered view of quality, processes of care for bipolar disorder cannot be distilled into a single measure; but rather, a series of patient-centered composite indicators.
  
  Date: November 1, 2010
• Gender Differences in Mental Health Diagnoses among OEF/OIF Veterans
  This study examined differences in socio-demographic, military service, and mental health characteristics between female and male OEF/OIF Veterans. Findings show that female OEF/OIF Veterans who were new users of VA healthcare were younger, more often African-American, and more frequently diagnosed with depression. In addition, older age was associated with a higher prevalence of PTSD and depression diagnoses among female Veterans. Male OEF/OIF Veterans who were new users of VA healthcare were more frequently diagnosed with PTSD and alcohol use disorder. Among male Veterans, younger age indicated greater risk for PTSD. Both female and male OEF/OIF Veterans with higher combat exposure were more likely to receive a diagnosis of PTSD.
  
  Date: October 21, 2010
• PTSD Associated with Poorer Couple Adjustment and Increased Parenting Challenges among Male OIF National Guard Troops
  This study examined associations among combat-related PTSD symptoms, parenting behaviors, and couple adjustment among male National Guard troops who had served in Iraq (OIF). Findings show that increases in PTSD symptoms were associated with poorer couple adjustment and greater perceived parenting challenges one year post-deployment. Further, PTSD symptoms predicted parenting challenges independently of their impact on couple adjustment. PTSD was associated with higher levels of alcohol use, but alcohol use was not significantly associated with couple adjustment or parenting. Deployment injury also was independently associated with increased PTSD symptoms. Findings suggest that symptoms of PTSD may exert their influence at multiple levels within the family, making transitions from combat to home life even more complicated. This highlights the importance of investigating and intervening to support parenting and couple-adjustment among combat-affected National Guard families, who often lack the support available to active duty families via the military base community.
  
  Date: October 1, 2010
• Dementia More Prevalent among Older Veterans with PTSD
  This study sought to determine the association between PTSD and dementia in older Veterans. Findings show that older Veterans with PTSD had twice the incidence and prevalence of dementia diagnoses, even after accounting for confounding illnesses, combat-related trauma (measured by receipt of a Purple Heart), and number of primary care visits. Rates of TBI were highest in the group with PTSD and a Purple Heart, while rates of stroke were slightly higher among all groups with PTSD (regardless of Purple Heart receipt). The prevalence of drug dependence and abuse and the rates of alcohol dependence and abuse were highest in the group with PTSD, but without a Purple Heart. The mechanism for the observed increased incidence and prevalence of dementia among Veterans with PTSD is unknown. Possibilities include a common risk factor underlying PTSD and dementia, or PTSD being a risk factor for dementia. Regardless, the authors suggest that veterans over 65 years of age with PTSD be considered for dementia screening.
  
  Date: September 1, 2010
• Measuring the Quality of Mental Healthcare: Barriers and Strategies
  This article discusses the barriers to mental health quality measurement – and identifies strategies to enhance the development and use of quality measures in order to improve outcomes for people with mental health disorders. The authors suggest that key reasons for the lag in mental health performance measurement include: lack of sufficient evidence regarding appropriate mental health care, poorly defined quality measures, limited descriptions of mental health services from existing clinical data, and lack of linked electronic health information. The refinement of quality measures and, ultimately, enhanced outcomes in mental health will require investment in information technology, additional studies to support the evidence base, and the development of a culture of measurement-based care. Sustaining efforts to improve mental health performance measurement will require rethinking how quality measurement is used to promote the uptake of evidence-based mental healthcare across systems of care. In addition, measurement systems should cut across mental health disorders, physical disorders, and substance use disorders, which often co-occur.
  
  Date: September 1, 2010
• Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness
  This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains.
  
  Date: August 1, 2010
• Medication Management for Veterans with Schizophrenia
  This study examined medication management for a random sample of Veterans who received drug therapy for schizophrenia at any one of three VA mental health clinics in Southern California between 2002 and 2003. Overall, 67% of Veterans had inappropriate management at baseline: 32% had inappropriate management of psychotic symptoms, 45% had inappropriate management of weight, and 8% had inappropriate management of tardive dyskinesia (TD). Further, 11% had depression that was moderately severe or worse. At one year, the appropriateness of management for psychotic and depressive symptoms had not changed. The appropriateness of management of TD also did not change over time, but the management of elevated weight improved modestly. There were no significant differences between the three clinics in the prevalence of symptoms or side effects, or in the appropriateness of medication management. However, psychiatrists with more than 12 patients were significantly more likely to improve their patients’ care over time.
  
  Date: July 1, 2010
• Most VA Patients with Substance Use Disorders Who Die from Suicide Use Violent Means
  Most VA patients with substance use disorders (SUDs) who died from suicide used violent means (70%, n=600), and the majority were carried out with firearms. No specific SUD was associated with increased risks of violent suicide, but several SUD diagnoses (e.g., cocaine use and opiate use) were associated with a higher risk of non-violent suicide. Alcohol use was associated with a lower likelihood of non-violent suicide. While many psychiatric disorders (e.g., major depression, PTSD, schizophrenia) were associated with increased risk of both violent and non-violent suicide, the strength of the association between the disorder and type of suicide was greater for non-violent than violent suicide. The authors suggest that by linking data on risk factors to information about the specific methods used, future interventions designed to decrease access to lethal means could be tailored to focus on those at greatest risk of dying by specific means.
  
  Date: July 1, 2010
• Military Sexual Trauma: Important Mental Health Issue for OEF/OIF Veterans
  Of the 125,729 OEF/OIF Veterans who received VA primary care or mental health services between 10/01 and 9/07, 15% of women and 0.7% of men reported military sexual trauma (MST) based on results of universal screening that asks about sexual assault or harassment. Women and men who reported a history of MST were significantly more likely than those who did not to be diagnosed with mental health conditions, including PTSD, other anxiety disorders, depression, and substance use disorders. This finding remained consistent after adjusting for demographics, healthcare use, and military service characteristics. The relationship of MST to PTSD was stronger among women compared to men, suggesting that MST may be a particularly relevant issue for women Veterans seeking care for PTSD. There were high rates of post-deployment mental health conditions among all OEF/OIF patients.
  
  Date: June 17, 2010
• Majority of National Guard Soldiers Recently Returned from Combat in Iraq Did Not Meet Criteria for Mental Health Disorder
  This study provides the first known report of rates of mental health disorders and comorbidities diagnosed by structured clinical interviews, as opposed to self-report, in a sample of 348 National Guard troops who returned from Iraq. Findings show that a majority (62%) did not meet criteria for a mental health disorder. However, the soldiers had slightly higher rates than community and non-deployed military samples across all mental health diagnoses, with the exception of drug use disorders. Depressive disorders were the most common, followed by non-PTSD anxiety disorders. Mental health diagnoses were associated with poorer functioning and quality of life, with PTSD having the strongest negative relationship with social functioning and quality of life. Results also show that more than 85% of soldiers with a diagnosis of PTSD had at least one additional mental health diagnosis, with depressive disorders being the most common. In addition, female soldiers were significantly more likely to have a mental health diagnosis than male soldiers. Specifically, women were diagnosed with PTSD, depressive disorders, and non-PTSD anxiety disorders at twice the rate of men.
  
  Date: June 9, 2010
• Aggression May Be Linked to Psychosis in Elderly Persons with Dementia
  This literature review examined the evidence on whether delusions or hallucinations contribute to the development of agitation or aggression in persons aged 65 and older with dementia. Most studies showed a statistically significant association between psychosis and aggression. Findings also showed that the use of antipsychotic medications in the setting of agitation/aggression and psychosis among patients with dementia is not uniformly supported. Authors note that given the multifactorial etiology of psychosis and aggression with other comorbid symptoms in dementia, it is important to understand the various contributing factors to facilitate more effective treatment interventions with least possible risk.
  
  Date: June 1, 2010
• Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings
  Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and quality.
  
  Date: May 11, 2010
• All Antipsychotics May Not Increase Short-Term Risk for Mortality among Veterans with Dementia
  Commonly prescribed doses of haloperidol, olanzapine, and risperidone, but not quetiapine, were associated with short-term increases in mortality. During the first 30 days, there was a significant increase in mortality in subgroups prescribed a daily low dose of haloperidol, olanzapine, or risperidone, after adjusting for demographics, comorbidities, and medication history. However, increased mortality was not seen when quetiapine was prescribed. No antipsychotic was associated with increased mortality after the first 30 days. Therefore, the authors suggest that all antipsychotics might not pose the same degree of risk in all patient groups as implied by the general warnings that have been issued.
  
  Date: May 7, 2010
• History of Depression Remains a Risk Factor for Heart Disease after Accounting for Other Contributing Factors among Twin Veterans
  A history of depression remained a risk factor for incident heart disease even after adjusting for numerous covariates including: sociodemographics, co-occurring psychopathology, smoking, obesity, diabetes, hypertension, and social isolation. Moreover, twins with both high genetic and phenotypic expression of depression were at greatest risk of ischemic heart disease (IHD). Results also show that twins with hypertension and twins with diabetes were more likely to have IHD, as were twins who reported no social support. Age, race, education, and marital status were not associated with IHD status.
  
  Date: May 1, 2010
• Predictors of Veterans’ Use of Mental Health Services
  Findings show that being older, female, having greater clinical need, lack of enabling resources (e.g., employment, stable housing, social support), and fewer problems with access to treatment significantly predicted increased mental health services use over the three-month follow-up period. Results also show that fewer outpatient mental health visits did not adversely affect clinical outcomes. Findings support VA’s ongoing commitment to provide special programs and initiatives focused on easing access to mental health services, vocational rehabilitation, and housing assistance.
  
  Date: April 1, 2010
• Rates of Depression Rise among VA Nursing Home Residents
  Prevalence rates for dementia and schizophrenia fluctuated moderately from 1990 to 2006, but rates for depression were substantially higher in 2006 than in 1998. Results also show that PTSD was more prevalent, while the prevalence of alcohol use disorders declined. The prevalence of serious mental illness (e.g., schizophrenia, bipolar and manic disorders) was relatively stable over this time period, except for increases among the oldest residents. Understanding recent changes in the prevalence of mental health disorders among VA nursing home residents can contribute to optimal planning to meet their treatment needs.
  
  Date: April 1, 2010
• Aggression is Common among Veterans with Dementia
  Findings showed that 41% of Veterans with newly diagnosed dementia became aggressive within 24 months, corroborating the findings of previous studies that aggression is common in persons with dementia. The use of antipsychotic medications increased significantly in Veterans after they became aggressive, and this group also had a ten-fold greater occurrence of injuries. In addition, almost twice as many aggressive Veterans were admitted to nursing homes. There were no differences in rates of restraint use or in- and outpatient visits between Veterans who became aggressive and those who did not.
  
  Date: March 1, 2010
• Interactive Communication between Primary Care and Specialty Care Improves Patient Outcomes
  This meta-analysis showed that interactive communications between collaborating PCPs and specialists were associated with improved patient outcomes. Interactive communication methods included: initial joint patient consultations, regular specialist attendance at primary care team meetings, telepsychiatry with primary care physicians, scheduled phone discussions, and shared electronic progress notes. The studies in this review all involved collaborations with psychiatrists for management of depression and other mental health disorders and with endocrinologists for management of diabetes; however, the consistency of the effects across different primary care-specialty collaborations, healthcare conditions, and study designs suggests the potential for improvement across other specialties and conditions. Effectiveness was enhanced by interventions to improve the quality of information exchange (e.g., needs assessment, joint care planning).
  
  Date: February 16, 2010
• Male OEF/OIF Veterans with PTSD More Likely to Perpetrate and Experience Aggressive Behavior toward/from Female Partners
  This study examined the nature and frequency of self-reported partner aggression among three male cohorts recruited from one large VAMC outpatient PTSD clinic: OEF/OIF Veterans with PTSD, OEF/OIF Veterans without PTSD, and Vietnam Veterans with PTSD. Findings show that OEF/OIF Veterans with PTSD were significantly more likely to report psychologically abusing their partners than OEF/OIF Veterans without PTSD. Although other comparisons did not reach significance, results suggested that OEF/OIF Veterans with PTSD were about two to three times more likely than the other two groups to report perpetrating or sustaining violence. OEF/OIF Veterans with PTSD also were six times more likely to report sustaining injury from their female partners than OEF/OIF Veterans without PTSD. Significant correlations among reports of violence perpetrated and sustained suggest many men may have been in mutually violent relationships. In terms of family functioning, 63% of OEF/OIF Veterans with PTSD reported having children in the home. These results emphasize the importance of assessing partner aggression in VA clinical settings in order to provide a more complete psychological picture of Veterans and their families’ potential treatment considerations.
  
  Date: February 2, 2010
• Mental Health Treatment Seeking among OIF National Guard Soldiers
  This study sought to determine the rate of reported mental health treatment-seeking in 424 returning OIF National Guard soldiers – and to examine potential barriers to and facilitators of treatment-seeking. Findings show that approximately one-third of the soldiers in this study reported post-deployment mental health treatment through military, VA, or other sources; however, 51% of soldiers who screened positive for PTSD and 40% who screened positive for depression did not report involvement in mental health treatment. Of the 34.7% who reported receiving mental health services, 22.9% had received psychotherapy only, 4.5% received psychiatric medications only, and 7.3% had received both. Reported treatment-seeking was more common among soldiers who screened positive for either PTSD or depression. Injury in-theater, illness-based need (e.g. presence and severity of mental illness), and mental health treatment in-theater were significantly associated with both self-reported psychotherapy and medication treatment-seeking. More positive attitudes regarding mental health treatment were associated with greater reported utilization of both psychotherapy and medication. Findings also indicate that while concerns about stigma were present, they were not associated with reported treatment-seeking behavior.
  
  Date: February 1, 2010
• Minority of OEF/OIF Veterans Receive Recommended Treatment for PTSD
  This study examined OEF/OIF Veterans use of VA mental health services within the first year of receiving new mental health diagnoses. Only a minority of OEF/OIF Veterans with newly diagnosed PTSD received a recommended number and intensity of VA mental health treatment sessions within the first year of diagnosis. Of the 49,425 OEF/OIF Veterans with newly diagnosed PTSD, only 9.5% attended >9 VA mental health treatment sessions in 15 weeks or less in the first year of diagnosis. Overall, two-thirds of OEF/OIF Veterans who received new mental health diagnoses from any VA outpatient clinic had at least one follow-up VA mental health visit in the first year of diagnosis, including 80% of OEF/OIF Veterans with a new PTSD diagnosis and nearly 50% with mental health diagnoses other than PTSD. Among the 35,547 OEF/OIF Veterans with new mental health diagnoses other than PTSD, 42.3% were diagnosed with a depressive disorder and 34.1% with an adjustment disorder. Overall, 60.3% received two or more new mental health diagnoses.
  
  Date: February 1, 2010
• Prior Violence Associated with Greater Risk of Suicidal Thoughts and Attempts in Patients Seeking SUD Treatment
  Even after accounting for other known risk factors, such as symptoms of depression or childhood victimization, a history of violent behavior was consistently associated with a higher likelihood of lifetime suicidal thoughts and behaviors. Suicidal thoughts and attempts are common in those with substance use disorders (SUD): more than 43% of the participants in this study reported either prior suicide attempts or suicidal ideation at some point in their lives. A history of either suicidal ideation or suicide attempt(s) was more common among substance users who were female and those with a history of depression or childhood abuse.
  
  Date: February 1, 2010
• Taking a Life in War Associated with Higher Rates of PTSD and Behavioral/Adjustment Problems in OIF Soldiers
  This study examined the relationship between killing and mental health among 2,797 soldiers returning from Operation Iraqi Freedom (OIF). Overall, 40% of the soldiers in this study reported direct killing or being responsible for killing during their deployment. Taking another life in war was an independent predictor of multiple mental health symptoms. Even after controlling for combat exposure, killing was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems. In addition, 22% of soldiers met threshold screening criteria for PTSD, 32% for depression, and 25% for alcohol abuse. The authors suggest a comprehensive evaluation of Veterans returning from combat should include an assessment of direct and indirect killing and reactions to killing. This information could be part of a treatment plan, including specific interventions targeted at the impact of taking a life.
  
  Date: February 1, 2010
• Veterans Diagnosed with Traumatic Brain Injury Significantly More Likely to Experience Mental Illness
  In April 2007, VA implemented national screening for symptomatic TBI resulting from combat exposure. Using VA data for 13,201 OEF/OIF Veterans who were screened for TBI in VISN 23, investigators examined rates of psychiatric disorders in relation to both TBI screening results and post-screening confirmation of TBI status. Findings show that among 836 Veterans with confirmed TBI, 85% had at least one psychiatric diagnosis, and 64% had two or more distinct diagnoses. Compared to Veterans with negative TBI screens, those with positive screens but without confirmed TBI were three times more likely to have PTSD – and were two times more likely to have depression and substance-related diagnoses. Veterans with clinically confirmed TBI were more likely than those with positive screens but no confirmed TBI to have diagnoses of PTSD, anxiety, and adjustment disorders. Nearly half of all OEF/OIF Veterans screened for TBI in VISN 23 had at least one psychiatric disorder, with PTSD (25.9%) and depression (25.6%) being the most common.
  
  Date: February 1, 2010
• Therapy via Video-Teleconference as Effective as In-Person Treatment in Reducing Anger Problems in Veterans with PTSD
  Cognitive behavioral therapy (CBT) anger management conducted via video-teleconference was as effective as in-person delivery of the same treatment in reducing anger problems among Veterans with PTSD who live in rural settings. Moreover, mean improvements in the video-teleconferencing group were actually slightly larger than in the in-person treatment group. Veterans in both treatment groups benefited from anger management therapy (AMT), making this one of the few large randomized controlled trials to show meaningful benefits for reducing anger problems in Veterans with PTSD. Veterans in both treatment groups reported high rates of treatment credibility, satisfaction with care, homework adherence, and high alliance with the therapist.
  
  Date: January 26, 2010
• Affective Disorders Strongest Predictor of Suicidal Behavior in Elderly Veterans Receiving Anti-Epileptic Medication
  In January 2008, the FDA issued an alert indicating that anti-epileptic drug (AED) treatment is associated with increased risk for suicidal ideation, attempt, and completion. This study sought to assess variation in suicide-related behaviors in a population not well-represented by the data used for the FDA analysis – individuals 66 years and older with new exposure to AEDs. Findings show that in older Veterans who were started on AED monotherapy, the strongest reliable predictor of suicide-related behaviors was the diagnosis of an affective disorder prior to AED treatment. Increased suicide-related behaviors were not associated with individual AEDs. However, while most Veterans in this study received AED prescriptions for gabapentin (76.8%), a trend for increased suicide-related behaviors was found among those prescribed levetiracetam or lamotrigine, but interpretation was difficult since few Veterans received either drug (0.6%). The associations between suicide-related behaviors and chronic pain or chronic disease burden were not statistically significant, but dementia was significantly associated with suicide-related behaviors (42.2% with dementia vs. 25.8% without).
  
  Date: January 11, 2010
• Cost/Benefit of Collaborative Care Intervention for Veterans with Chronic Pain and Depression
  This study reports on the incremental benefit (pain disability-free days – PDFDs) and incremental health services costs of the Study of the Effectiveness of a Collaborative Approach to Pain (SEACAP) intervention from a VA healthcare perspective. Findings show that the collaborative care intervention resulted in more pain-free days for Veterans with chronic pain and depression, but was more expensive than usual care. Veterans in the intervention group experienced an average of 16 additional PDFDs over the 12 month follow-up period compared to Veterans in the treatment as usual group, with a cost per PDFD of $364 (overall, about $2300 per patient during the study year). Study results also show that important predictors of costs were baseline medical comorbidities, depression severity, and prior year treatment costs.
  
  Date: January 1, 2010
• Lower Quality of Care for Cardiometabolic Disease among Veterans with Mental Disorders, Regardless of Rural or Urban Dwelling
  Mental disorders (MD) were associated with a decreased likelihood of obtaining quality cardiometabolic care. When compared to those without MD, Veterans with MD were less likely to receive diabetes sensory foot exams, retinal exams, and renal tests. Rural residence was not associated with differences in quality measures. Primary care visit volume was associated with a greater likelihood of obtaining diabetic retinal exam and renal testing, but did not explain disparities among patients with MD.
  
  Date: January 1, 2010
• Validity of Mental Health Diagnosis Using VA Administrative Data
  This study estimated the validity of eight ICD9-based algorithms for the identification of mental health disorders in administrative data among 124,716 Veterans with diabetes who used the VA healthcare system in 1998, and also participated in the 1999 Large Health Survey of Veteran Enrollees, which included questions about history of mental health diagnoses. Findings show that many Veterans with a diagnosed mental health disorder can be identified through VA administrative data; however, the choice of algorithm influenced conclusions. Since the limitations of administrative data cannot be fully eliminated with any algorithm, the authors suggest that investigators and quality improvement programs also consider conducting sensitivity analyses in which they vary the algorithm, in order to indicate how different assumptions affect conclusions.
  
  Date: January 1, 2010
• Effectiveness of Residential Substance Use Disorder Programs in Treating Veterans with SUDs and Mental Illness
  This study compared processes and outcomes for alcohol-dependent Veterans with and without comorbid psychiatric illness at one and five years following treatment in 15 residential substance use disorder (SUD) treatment programs affiliated with VA. Findings show that dually-diagnosed (DD) Veterans did not perceive SUD programs as positively as Veterans with SUD alone, and DD Veterans had worse proximal outcomes at discharge from treatment. For example, DD patients saw fewer benefits to quitting and had less self-efficacy in regard to staying abstinent. Results also showed that dually-diagnosed Veterans did as well as SUD patients on 1-year and 5-year substance use outcomes but had worse psychiatric outcomes. Veterans from both groups who perceived treatment more positively and had better outcomes at discharge had better longer-term outcomes; however, DD patients perceived the programs to be less supportive and clear, and were less satisfied with treatment. The authors suggest that SUD programs either need to add resources directed toward treating psychiatric problems, or that DD Veterans need to be treated in sequential or integrated programs. They note, however, that standard SUD programs may offer more components of integrated treatment than standard psychiatric programs do.
  
  Date: December 1, 2009
• Older Elderly Patients Experience Poorer Outcomes Following Collaborative Depression Care
  This study examined the differences between young-old (age 60 to 74) and old-old (age 75 and older) patients who received collaborative depression care as part of the IMPACT (Improving Mood: Promoting Access to Collaborative Treatment) study, which include both VA and non-VA patients. Findings show that young-old and old-old patients who receive collaborative depression care have a similar initial clinical response, but old-old patients may have a lower rate of long-term treatment response and complete remission. For example, young-old and old-old patients randomized to the IMPACT intervention responded similarly to initial treatment at 3 months, but the old-old were less likely to respond to treatment at later follow-up intervals. Treatment response and remission rates peaked for both age groups at 6 months, although treatment response rates for the young-old were significantly higher than those for the old-old group (51% vs. 44%). Study findings also show that the process of care did not differ between young-old and old-old patients who received the IMPACT intervention.
  
  Date: December 1, 2009
• Veteran Minorities Equally Likely to Receive PTSD Treatment
  This study sought to determine the rates of mental health use in the six months after Veterans received a PTSD diagnosis – and to examine whether service use varied by race or ethnicity. Findings show that minority Veterans were similar to Whites in the likelihood of receiving VA mental health treatment in the six months following a diagnosis of PTSD. Of the 20,284 Veterans with PTSD in this study, 50% received psychotropics, 39% received counseling, and 64% received at least one of these forms of treatment. However, only 24% who received any counseling had at least eight sessions, and most had only one session. These findings indicate that possible treatment preferences exist. The authors suggest that incorporating preferences into treatment planning may facilitate treatment retention and help to maximize treatment outcomes for all Veterans with PTSD.
  
  Date: December 1, 2009
• Mental Illness and Substance Use Disorders Highly Prevalent Among Veterans with Spinal Cord Injury
  Using VA and Medicare data, this study sought to estimate the prevalence of mental illness and substance use disorders (SUDs) among 8,338 Veterans with spinal cord injury (SCI) who used outpatient or hospital care in VA or Medicare facilities between FY00 and FY01. Findings show that mental illness and SUDs are highly prevalent among Veterans with SCI. Overall, 47% of the Veterans in this study had either a mental illness or SUD. The most common mental illness was depression (27%), followed by anxiety (10%) and PTSD (6%). Tobacco use also was prevalent (19%), followed by alcohol (9%) and illicit drugs (8%). Moreover, mood and anxiety disorders were highly prevalent among those with chronic physical conditions such as diabetes, hypertension, and COPD. Results also showed that women Veterans had higher rates of mental illness and lower rates of SUD, and were significantly more likely to have mental illness only. In addition, as the duration of SCI increased, the likelihood of mental illness or SUD alone or in combination decreased.
  
  Date: November 1, 2009
• Substance Abuse is Strongest Predictor of Suicide among Veterans with Depression
  This study was an analysis designed to derive an empirically-based set of interactions related to rates of suicide in a national sample of VA patients diagnosed with depression. Findings show that among Veterans with depression those at highest risk for suicide have the combined risk factors of a substance use disorder (SUD), non-African American race, and a psychiatric inpatient stay in the past 12 months. Substance use disorder was also identified as the strongest single risk factor for suicide. Among Veterans without a substance use disorder, gender was the strongest predictor of suicide risk – rates were significantly higher for men than for women. Ethnicity also was related to suicide risk in this group. African American Veterans without an SUD were less likely to die by suicide compared to non-African American Veterans. The authors suggest that providers treating patients with these characteristics should be aware of these risks and consider target strategies to screen for current suicidal ideation.
  
  Date: November 1, 2009
• Veterans with Psychosis More Likely to Die from Heart Disease
  This study assessed whether Veterans with mental disorders receiving care in the VA healthcare system were more likely to die from heart disease than Veterans without these disorders, and whether modifiable factors may explain mortality risks. Findings show that compared to Veterans without a mental health diagnosis, Veterans with psychosis (schizophrenia or other psychotic disorder diagnoses) were more likely to die from heart disease. Smoking and physical inactivity were the behavioral factors most strongly associated with mortality related to heart disease. Veterans with schizophrenia were the most likely to be current smokers, and those with bipolar disorder were the least likely to report adequate physical activity. Controlling for behavioral factors (e.g., smoking and physical inactivity) diminished but did not eliminate the impact of psychosis on mortality. The authors suggest that to reduce mortality related to heart disease, early interventions that promote smoking cessation and physical activity among Veterans with psychotic disorders are warranted.
  
  Date: November 1, 2009
• Aggressive Behavior Prevalent in Veterans with Dementia
  This study examined aggressive behavior in 400 community-dwelling Veterans, 60 years or older and newly diagnosed with dementia at one VAMC, who were non-aggressive at the beginning of the study. Findings show that 40.9% of initially non-aggressive Veterans with dementia became aggressive within the 24-month study period, and most aggression was verbal. Verbal aggression was associated with the highest levels of disruptiveness, with 69.3% of verbally aggressive behaviors considered moderately or extremely disruptive, while 39.8% of physically aggressive behaviors and 12.5% of sexually aggressive behaviors were considered moderately or extremely disruptive. Results also show that most caregivers were women (94%), and there were no significant differences found in aggressive vs. non-aggressive Veterans with dementia in terms of demographics.
  
  Date: October 1, 2009
• Barriers to Dementia Diagnosis
  The goals of this study were to ascertain what is known about the prevalence of missed and delayed diagnosis of dementia in primary care, and to identify factors contributing to problems in diagnosis. While the findings did not definitively determine the prevalence of missed or delayed dementia diagnoses, estimates suggest that the number is substantial. Major barriers to diagnosing dementia included patient/provider communication (e.g., poor provider communication skills, language barriers), education deficits (e.g., belief that little or nothing can be done to treat dementia), and system resource constraints (e.g., time constraints for office visits). Attitude problems also were found; for example, among providers, a major barrier often noted was the attitude that diagnosis, particularly in the early stages of dementia, was more harmful than helpful, while patients often feared and/or denied cognitive problems.
  
  Date: October 1, 2009
• Determinants of Veteran Treatment-Seeking for PTSD
  This study explored determinants of PTSD treatment initiation among 21 treatment-seeking and 23 non-treatment-seeking Veterans who had served in Vietnam, or the current conflicts in Afghanistan and Iraq (14 of the 44 participants were women Veterans). Findings show that both Veterans who were and were not in treatment for PTSD described similar factors that hindered their help-seeking, including their own values and priorities (e.g., pride in self reliance), treatment-discouraging beliefs (e.g., providers would not believe them, or would treat them as if they were “crazy”), and trauma-related avoidance (e.g., avoiding discussion of the traumatic event). They also cited an invalidating post-trauma environment as a detriment to seeking treatment; for example, some women cited a military culture that silenced the reporting of sexual assault. But for some participants, facilitators located within the healthcare system and Veterans’ social networks led to help-seeking despite individual-level barriers. In some cases, it was a trusting relationship with the primary care provider that led the Veteran to follow the provider’s recommendation to seek mental health care. This suggests that factors outside the individual can promote mental health service use for PTSD, even when the Veteran is reluctant.
  
  Date: October 1, 2009
• Use of Medicare and VA Healthcare among Veterans with Dementia
  This study sought to characterize healthcare use among Veterans with dementia over a four-year period (1998-2001), and to determine predictors of whether a Veteran will be a VA-only, dual, or Medicare-only user. Findings show that during the four-year study period, Medicare-only use increased while VA-only use decreased. Results also show that an increased likelihood of some Medicare use was associated with being older, white, married, and having higher education, private insurance or Medicaid, and low VA priority level. Further, the number of functional limitations was associated with an increased likelihood of Medicare-only use and a decreased likelihood of VA-only use, while higher comorbidities were associated with a higher likelihood of dual use as opposed to any single system use. The authors suggest that these results imply that different aspects of Veterans’ needs have differential effects on where Veterans seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure patients receive high quality care, particularly among those with multiple comorbidities.
  
  Date: October 1, 2009
• OEF/OIF Veterans with Mental Health Diagnoses, Particularly PTSD, Use More Non-Mental Health VA Services
  Using national data from all returning OEF/OIF Veterans (N=249,440) who used VA healthcare between 10/01 and 3/07, this study sought to examine the association of PTSD and other mental disorders with non-mental health outpatient, inpatient, and emergency services utilization. Findings show that OEF/OIF Veterans diagnosed with mental health disorders had significantly greater utilization of all types of non-mental health care services than OEF/OIF Veterans with no mental health diagnoses. In adjusted analyses, compared with OEF/OIF Veterans without mental disorders, those with mental disorders other than PTSD had 55% greater utilization of all non-mental health outpatient services; Veterans with PTSD had 91% higher utilization. Results also showed that female gender and lower rank were independently associated with greater utilization. The authors suggest that as more Veterans return home, many with mental and physical injuries, evaluating the capacity of VA and other healthcare systems to meet their needs will be increasingly important.
  
  Date: September 29, 2009
• Ethnic Disparities in the Treatment of Veterans with Dementia
  This study sought to determine if there were ethnic disparities in the evaluation and treatment of dementia among 410 Veterans treated at one VAMC between 4/05 and 6/05. Findings show that while laboratory and imaging workup (i.e., CT, MRI) did not differ between ethnic groups, there were significant differences in the treatment of dementia. For example, African American Veterans with dementia were 40% less likely than all other patients to receive acetylcholinesterase inhibitors. This treatment disparity did not appear to be due to differences in the evaluation of dementia, which was similar across groups, although significantly more Caucasian Veterans (43.8%) underwent neuropsychological testing compared to African American (24.8%) or Hispanic Veterans (32.4%).
  
  Date: September 1, 2009
• Mental Health Diagnoses Associated with Cardiovascular Risk Factors among OEF/OIF Veterans
  Studies of Veterans from prior wars found that those with PTSD are at increased risk of developing and dying from cardiovascular disease, but this risk had not yet been evaluated in OEF/OIF Veterans. This article discusses findings from a study on the association between mental health disorders, including PTSD, and cardiovascular risk factors. Findings show that OEF/OIF Veterans (male and female) with mental health diagnoses had a significantly higher prevalence of cardiovascular risk factors (e.g., hypertension, obesity, diabetes, tobacco use). The association between mental health diagnoses and cardiovascular risk factors remained after adjusting for demographics and military factors. The most common mental health diagnosis was PTSD (24%). The majority of Veterans with PTSD had comorbid mental health diagnoses: depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), as well as other psychiatric diagnoses (33%).
  
  Date: August 5, 2009
• Regular Primary Care Associated with Better Survival Rates for Veterans with Schizophrenia and Diabetes
  Medical comorbidity among aging people with schizophrenia is common and many patients with schizophrenia have difficulty managing their medical healthcare needs, which may result in delayed treatment and poor outcomes. This retrospective cohort study assessed whether patterns of VA primary care use among Veterans with diabetes, schizophrenia , or both were a significant predictor of mortality over the study period (FY02-FY05). Findings show that regular primary care and high levels of primary care were associated with better survival for patients with chronic illness, whether psychiatric or medical. For example, increasing use of primary care was least common among Veterans with schizophrenia only (4%) compared with Veterans with diabetes only (7%), or those with both conditions (8%), – and was associated with improved survival. This suggests that innovations in treatment retention targeting at-risk groups can offer significant promise of improving outcomes.
  
  Date: July 26, 2009
• Mental Health Diagnoses among OEF/OIF Veterans Increased Rapidly Following Invasion of Iraq
  This study sought to investigate longitudinal trends and risk factors for mental health diagnoses among OEF/OIF Veterans. Findings show that the prevalence of new mental health diagnoses among OEF/OIF Veterans using VA healthcare increased rapidly following the Iraq invasion. Among the 289,328 Veterans in this study, new mental health diagnoses increased 6-fold from 6.4% in April 2002 to 36.9% by March 2008. 21.8% of Veterans were diagnosed with post-traumatic stress disorder (PTSD), and 17.4% with depression. Two-year prevalence rates of PTSD increased 4-7 times after the invasion of Iraq. The youngest active duty OEF/OIF Veterans (< 25 years) were at nearly twice the risk for PTSD, more than twice the risk for alcohol use disorders, and at a nearly 5-fold risk for drug use disorders than older active duty Veterans (> 40 years). Among National Guard/Reserve Veterans, those older than age 40 were at greater risk for PTSD and depression. Women Veterans from both service components (active duty and Guard/Reserve) were at higher risk for depression, while male Veterans were at greater risk for drug use disorders. Authors suggest that early targeted interventions may prevent chronic mental illness.
  
  Date: July 16, 2009
• Smoking Cessation Services for Veterans in VA Psychiatric Facility
  This study had two goals: 1) determine staff characteristics that are associated with attitudes about providing smoking cessation services to Veterans who are psychiatric patients, and 2) seek suggestions from staff about what would be important to include in a tobacco cessation program. Findings show that nearly 75% of staff in this study thought that VA should do more to assist Veterans to quit smoking, yet only about 25% said that they personally provide cessation services. However, more than 50% felt moderately, very, or extremely confident in providing cessation services. Interestingly, nurses were less likely than other staff to feel that it was important to provide cessation services, which could be because of competing job demands. The most common reasons given by all respondents for not providing services were not enough time and lack of training. When asked how VA could best assist smokers to quit, most responses focused on educating Veterans about tobacco use and how they can quit, as well as providing tobacco cessation medications.
  
  Date: June 1, 2009
• High Rate of Suicidal Ideation among Veterans with Bipolar Disorder
  Some suicidal ideation within the past two weeks was reported in 49% of Veterans with bipolar disorder in this study. Approximately 32% of the Veterans reported suicidal ideation for several days, 9% reported suicidal ideation more than half of the days, and 8% reported experiencing it nearly every day. Elevated rates of suicidal ideation were found in Veterans who reported drug use, poorer mental health status, and poorer general functioning. After accounting for current mood state and other risk factors, even minimal increases in the extent to which Veterans perceived their therapeutic relationship as collaborative were associated with a reduction in the risk of suicidal ideation.
  
  Date: May 1, 2009
• Strong Association between Homelessness and Incarceration among Veterans with Bipolar Disorder
  This study assessed the association between homelessness and incarceration in 435 Veterans with bipolar disorder who received inpatient or outpatient care at one large, urban VAMC from 7/04 to 7/06. Findings show that homelessness and incarceration are common among Veterans with bipolar disorder, and share many risk factors. Among Veterans with bipolar disorder, 12% reported having been homeless in the previous four weeks, and 55% reported ever having been homeless or incarcerated. Results also show that lifetime experience of homelessness was associated with 4-fold increased odds of lifetime experience of incarceration. Moreover, recent homelessness was strongly related to recent incarceration. Programs that better coordinate psychiatric and drug treatment with housing programs may reduce the cycle of incarceration, homelessness, and treatment disruption among this vulnerable patient population.
  
  Date: May 1, 2009
• Suicide Risk Significantly Higher for VHA Patients Compared to the General Population
  Suicide rates among the Veterans enrolled in the VA healthcare system during FY00 and FY01 were found to be significantly higher than those in the general population. However, the differentials between suicide rates for VA patients and the general population were less than what might be expected given previous comparisons. Overall, for men and women combined, suicide risks among Veterans were 66% higher than those observed in the general population. Among male Veterans, suicide rates were highest for those aged 30-49 years and lowest among Veterans aged 18-29 and 60-69. Among women Veterans, suicide rates were highest among those aged 50-59 years. It is important to emphasize that this study compares a general population to users of a health care system where the prevalence of all conditions would be expected to be higher. Also, the study population precedes current conflicts in Iraq and Afghanistan.
  
  Date: April 15, 2009
• Access to Healthcare among Veterans with Bipolar Disorder
  Findings from this study show that despite the fact that all Veterans were currently receiving VA treatment for bipolar disorder, 15%-20% experienced trouble obtaining different aspects of healthcare when needed. Compared with accessing psychiatric care, Veterans with bipolar disorder reported greater difficulty accessing general medical services. Veterans experiencing current bipolar symptoms more frequently avoided psychiatric care due to cost, and perceived greater problems accessing medical specialists. As with mental healthcare services, the dominant influences predicting limitations in obtaining needed general medical care included living alone, an inpatient stay, homelessness, and current bipolar symptoms. The authors suggest that current VA efforts to expand mental healthcare access should be coupled with efforts to ensure adequate access to medical services for Veterans with chronic mental illness.
  
  Date: April 1, 2009
• Primary Care-Based Collaborative Care for Chronic Pain May Be More Effective than Usual Care
  A primary care-based collaborative care intervention for chronic pain was significantly more effective than usual care across a variety of outcome measures, including pain disability and intensity. However, these improvements were generally modest. Depression severity and pain disability and intensity improved among Veterans in the intervention group who reported both chronic pain and depression. Greater use of adjunctive pain medications and long-term opioids among the intervention group suggested that the intervention contributed to the delivery of guideline-concordant care.
  
  Date: March 25, 2009
• Areas for Mental Health Intervention for Patients with Hepatitis C
  In addition to the physiological side effects of treatment for the hepatitis C virus (HCV), there also can be significant neuropsychiatric effects such as depression, anxiety, psychosis, and suicidality. Moreover, numerous studies have documented the high prevalence of pre-existing psychiatric disorders among patients with HCV. This article reviews the psychological and psychosocial issues that are relevant to patients with HCV and provides mental health treatment recommendations. Some of these issues include stigma (i.e., more than half diagnosed with HCV have experienced discrimination) and social support. The authors also identify areas in which clinicians can intervene, including adjustment to having a chronic medical illness, management of side effects, and implementing healthy lifestyle recommendations.
  
  Date: March 1, 2009
• Assessing Healthcare Utilization among Veterans with Depression
  Nearly half of VA primary care patients with significant depressive symptoms also used non-VA care. Among dual users, 94.9% used both VA and non-VA care for physical health problems, but only 20.3% used both for emotional health problems. Lower levels of alcohol use and the presence of PTSD were associated with the use of non-VA outpatient care for emotional health services. Authors suggest that care management strategies for Veterans with depression should include communication and coordination with non-VA providers.
  
  Date: March 1, 2009
• Costs Associated with Providing Depression Care in the Primary Care Setting
  This study reports on organizational costs associated with depression care quality improvement, specifically introducing an evidence-based depression model – Translating Initiatives in Depression into Effective Solutions (TIDES) Project – into VA primary care settings. Findings show that organizational costs for the TIDES project (in the locations studied) were significant, and should be accounted for in planning the implementation of evidence-based depression care.
  
  Date: February 1, 2009
• Hybrid Quality Improvement Approach May Be Best
  There is a growing consensus that a hybrid of two common approaches to quality improvement (QI) – local participatory QI and central expert QI – might be the best method for achieving quality care across a variety of conditions. This study examined preferences of frontline staff and managers participating in HSR&D’s Translating Initiatives for Depression into Effective Solutions (TIDES) project regarding how to engage in QI dialogue and provide practical suggestions for implementation. Many study participants believed that a hybrid of participatory and expert QI models might provide the best formula for improving the quality of care.
  
  Date: February 1, 2009
• Investigators Develop Diagnostic Guidelines for Post-Traumatic Stress Disorder
  Diagnosing mental disorders is often challenging, but may be especially difficult in post-traumatic stress disorder (PTSD) due to the high rates of comorbidity between PTSD and other psychiatric disorders. As a result of this study, investigators offer guidelines for the differential diagnosis of Veterans with PTSD. Clinicians should be aware that those suffering from PTSD might present with symptoms that initially point to other diagnoses, and that mistaken diagnoses can have detrimental effects. Investigators believe that the guidelines they offer can lead to greater reliability in the diagnosis of PTSD and related comorbid conditions.
  
  Date: February 1, 2009
• Sexual Harassment has Negative Effects on Men and Women Marines’ Mental Health
  This study is the first to examine the role of post-traumatic stress symptoms (PSS) in the relationship between sexual harassment in the military and perceived physical health. Findings show that both men and women who experienced sexual harassment had increased PSS. For men, higher levels of sexual harassment were associated with worse perceived physical health; whereas for women, lower levels of sexual harassment were associated with worse perceived health.
  
  Date: February 1, 2009
• Successful Strategy that Engages Veterans and Families in Psychoeducation to Improve Treatment for Mental Illness
  Recently, VA funded 19 initiatives to implement family psychoeducation, an evidence-based practice in the treatment of psychotic disorders that results in reduced risk of relapse, remission of residual psychotic symptoms, and enhanced social and family functioning, but the implementation of such programs requires engaging mental health clinicians, consumers, and families. This paper discusses the engagement strategies used in the Reaching out to Educate and Assist Caring, Healthy Families (REACH) program, a 9-month family psychoeducation program for Veterans with serious mental illness or post-traumatic stress disorder (PTSD). Findings show that REACH has had notable success in engaging Veterans and their families, with participation rates that are comparable to those for programs requiring a much shorter commitment than 9 months, and suggest that the REACH engagement strategy may be a promising tool in recruiting Veterans and their families into family psychoeducation.
  
  Date: February 1, 2009
• Study Suggests Additional Interventions for Veterans with SUD and History of Abuse
  Men with a history of physical or sexual abuse had more severe drug problems at intake, but by six months there were no group differences in drug use. However, veterans with a history of sexual abuse had more severe psychiatric problems at all time points and were more likely to report significant suicidality at intake and 6 month follow-up. This suggests that additional interventions may be warranted for veterans with SUD and a history of sexual abuse. Also, routine screening for suicidality in SUD treatment programs may be warranted given the prevalence of lifetime sexual abuse among SUD patients and the relationship between sexual abuse and attempted suicide.
  
  Date: December 1, 2008
• Using VA Medical Data Alone May Underestimate Post-Stroke Depression and Geographic Variation in this Condition
  When VA medical data alone were used, investigators found no significant geographic variation in the detection of post-stroke depression (PSD). But when VA medical data were used along with Medicare and VA pharmacy data, significant geographic variation (nearly double – 39.1% vs. 20.0%) was observed. This suggests that to gain a comprehensive view of PSD detection in VA patients, investigators must evaluate non-VA data sources because 70% of VA stroke patients were multiple health program users.
  
  Date: December 1, 2008
• Consumer-Providers Improve Care for Veterans with Serious Mental Illness
  In 2005, VA began funding a number of positions for consumer-providers (CPs) – veterans with personal experience of serious mental illness who provide support services to other veterans suffering from the same condition. Findings from this study suggest that hiring and employing CPs within VA has been feasible, beneficial, and acceptable to a majority of clinical teammates. However, CPs reported experiencing some role confusion and resistance and fears among professional staff about how CPs would fit in.
  
  Date: November 1, 2008
• Program Improves Access to Mental Health Care for Veterans
  This article discusses the implementation and outcomes for the first four years of the “Primary Mental Health Care Clinic” (PMHC) program, an innovative program developed at one VA medical center that shifted specialized staffing into an existing mental health clinic in primary care and added advanced clinical access in primary care. Waiting time for new appointments was shortened from a mean of 33 days to 19 minutes. Clinician productivity and evaluations of new referrals more than doubled. In addition, the program has reduced the number of veterans referred into the specialized mental health clinic, thus conserving resources.
  
  Date: November 1, 2008
• Quality Indicators to Help Treat Veterans with HIV and Depression
  Quality indicators were developed based on a review of the existing clinical guidelines for depression, particularly depression related to HIV, in addition to a review of the literature. Authors suggest that quality indicators identified in this study provide a useful tool for measuring and informing the quality of HIV depression care.
  
  Date: October 1, 2008
• Reducing Cardiovascular Risk for Veterans with Diabetes and Depression
  The Cardiovascular Risk Reduction Clinic (CRRC) is an ongoing clinical, multi-disciplinary, disease management program at the Providence VAMC. Veterans with and without a depression diagnosis had a significant improvement in cardiovascular risk reduction after participation in the CRRC program. Veterans with a diagnosis of depression had significantly higher cardiovascular risk than those with no mental health condition, but they had greater improvement after participating in the program.
  
  Date: October 1, 2008
• Treatments for Co-Occurring Schizophrenia and Substance Use Disorders
  While studies to date suggest better outcomes with second-generation antipsychotics (SGAs), for example, olanzapine and risperidone, the available evidence does not clearly demonstrate an advantage for any particular SGA; thus investigators recommend that clinicians select the medication that balances efficacy and side effects for each individual patient.
  
  Date: October 1, 2008
• Psychotherapy Administered via Telephone Reduces Depression
  Findings show a significant reduction in depressive symptoms for patients enrolled in telephone-administered psychotherapy as compared to those in control conditions (e.g. treatment as usual). Moreover, attrition rates were considerably lower than rates reported in face-to-face psychotherapy.
  
  Date: September 1, 2008
• Advances in Couple Therapy for Returning Soldiers and their Spouses
  The authors of this article present a case study about a service member who suffers from PTSD and his wife, who are treated with an adaptation of integrative behavioral couple therapy (IBCT). At the end of the 13 weeks of treatment, this couple reported that their relationship was considerably stronger.
  
  Date: August 1, 2008
• Improving the Environment of Care to Reduce Inpatient Suicide and Suicide Attempts in VA Facilities
  Authors provide 5 recommendations for reducing environmental hazards for suicide on inpatient psychiatric units.
  
  Date: August 1, 2008
• Panic Control Treatment Proves Effective in Veterans with Panic Disorder and PTSD
  Panic control treatment appeared to be superior in reducing the frequency, severity, and distress associated with panic disorder and suggests that brief cognitive-behavioral therapy for panic is effective for veterans with PTSD.
  
  Date: August 1, 2008
• Appreciation of Research Information in Patients with Bipolar Disorder
  Patients with bipolar disorder were able to weigh risk levels associated with various studies, and to appreciate that their participation was voluntary. However, patients demonstrated two misconceptions: their appreciation of research goals was flawed (a substantial proportion had difficulty distinguishing clinical research from clinical care), and they incorrectly applied concepts of 'double-blind' and 'randomization.' In addition, more than half believed that their primary mental health provider could convince them to participate in a study even if they did not want to.
  
  Date: July 1, 2008
• Mental Illness and Substance Use Costs among Veteran Clinic Users with Diabetes
  Alcohol and drug use among veterans with diabetes increased healthcare costs due to greater use of inpatient services, regardless of the presence or severity of mental illness.
  
  Date: July 1, 2008
• Veterans with Spinal Cord Injury Report Frequent Physical and Mental Health Concerns
  Overall, veterans with spinal cord injury (SCI) were much more likely to experience frequent physically and mentally unhealthy days, and frequent days with depression than what has been reported for the general population. In addition, both chronic illnesses and smoking had a substantial effect on health-related quality of life for persons with SCI.
  
  Date: July 1, 2008

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 Nursing

• Evidence-Based Staffing Methodology to Predict Nurse Staffing Needs
  This article describes a process used to identify indicators of nursing workload and develop an evidence-based nurse-staffing methodology that could be used to predict staffing needs and eventually link to nursing outcomes in the VA healthcare system. The final set of indicators included: 1) average length of stay (surrogate marker for patient severity of illness); 2) average number of medication doses administered daily; 3) percentage of patients with age >70; 4) percentage of patients with a BMI >25; 5) top three diagnostic categories on the unit (surrogate for complexity/scope of care required); 6) average daily census (patient volume and nursing workload); and 7) daily patient turnover (admissions, transfers, discharges). Following successful evaluation, the Office of Nursing Services introduced a national VA policy that directed all facilities to implement the new evidence-based, nationally standardized staffing methodology by September 2011. A formal evaluation will begin in October 2011.
  
  Date: October 1, 2011
• Nurse Case Management Decreases Cardiovascular Risk Factors among Veterans with Diabetes Compared to Usual Care
  This study sought to determine if nurse case management could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia among Veterans with diabetes compared to usual care. Findings showed that involving a nurse case manager in the care of patients with diabetes can significantly improve the number of individuals achieving target values for glycemia, lipids, and blood pressure compared to usual care. In this study, a greater number of Veterans in the intervention group had all three outcome measures under control compared to Veterans in the usual care group. In addition, a greater number of Veterans in the nurse case management group achieved individual treatment goals for blood pressure, lipids, and blood sugar compared to Veterans receiving usual care. Observed differences between groups were likely mediated both by enhanced lifestyle changes and a greater intensity of pharmacological treatment among Veterans in the intervention group.
  
  Date: June 2, 2011
• Pain Screening Implementation for Veterans Falls Short
  This study included surveys of Veteran outpatients and nursing staff who screened for pain during normal vital sign intake. Investigators compared pain levels documented by the nursing staff with those reported by Veterans during the study survey. Findings show that despite a longstanding mandate, pain screening implementation falls short, and informal screening is common. Although pain was evaluated in all patient encounters, less than half of the Veterans reported that the nursing staff formally rated their pain. However, the majority of the time the nursing staff’s pain documentation matched the Veteran’s subsequent report within one point on the rating scale. When differences did occur, the nursing staff under-estimated pain in 25% of the cases, and overestimated pain in 7% of the cases. Veterans with PTSD or another anxiety disorder were almost twice as likely to report higher pain levels than those documented by the nursing staff. Additionally, nursing staff were less likely to underestimate pain when the patient self-reported excellent, very good, or good health status (relative to fair or poor health status).
  
  Date: August 6, 2010
• Addressing Psychosocial Needs of Cancer Patients
  This Commentary discusses the nursing challenges of assessing and managing cancer-related distress, in addition to recommending assessment tools and further research. Measurement tools are available that are both well-established and feasible for nurses working within time-constrained environments.
  
  Date: April 1, 2010
• Nursing’s Role in Healthcare and Advancement in Evolving Healthcare Environment
  In a recent national survey, although 77% of nurses reported that they were satisfied with their jobs, only 18% of nurses reported that they were actively engaged (defined as psychological commitment to job and workplace) in their work. Therefore, efforts to improve the clinical work environment, the safety culture, and the nursing education infrastructure are necessary. This article explores the opportunity for change by: 1) examining nursing’s history in professional practice and its journey as an evolving profession, and 2) mapping the growth of hospitals and the advancement of nursing’s role in the US, specifically in the context of the healthcare organization.
  
  Date: January 1, 2010
• Association between Nurse Staffing Levels and Patient Mortality in VA Hospitals
  RN staffing was not significantly associated with in-hospital mortality for veterans with an ICU stay; however, increased RN staffing was significantly associated with decreased mortality among non-ICU patients. Continuing to estimate the effect of RN staffing and skill mix on patient outcomes using hospital-level data will provide poor estimates of outcome associations, such as in-hospital mortality.
  
  Date: September 1, 2008
• VA Nurse Burnout and Patient Safety Outcomes
  Among VA nurses at one Midwestern location, burnout was associated with perceptions of a less safe environment. While burnout was not associated with event-reporting behavior, it was negatively associated with reporting of near misses (mistakes that did not lead to adverse events). The finding that higher burnout was associated with lower incidence of near-miss reports is of concern because these reports are essential to addressing safety concerns in the environment.
  
  Date: August 1, 2008

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 Obesity

• Bariatric Surgery Does Not Decrease Mortality among Obese Veterans
  This study sought to determine whether bariatric surgery is associated with reduced mortality among Veterans, who are older and predominantly male compared to prior studies. Findings showed that in a matched cohort of obese, high-risk, predominantly male Veterans (847 who underwent surgery and 847 non-surgical controls), bariatric surgery was not significantly associated with a survival benefit during a median of 6.7 years of follow-up. In unmatched comparisons of 850 Veterans who underwent bariatric surgery and 41,244 Veterans who did not, those in the surgical group were significantly younger, had higher BMIs, and had greater comorbidity burden. Surgical patients also were more likely to be super-obese. However, analyses after matching reduced the significant differences in characteristics between surgical and control patients. These analyses also controlled more closely for time of follow-up and showed that the protection conferred by surgery was small and not statistically significant after 6.7 years.
  
  Date: June 15, 2011
• Obese and Overweight Patients Receive Equal or Better Care than Patients of Normal Weight
  Among Medicare and VA patients, there was no evidence across eight quality performance measures that obese and overweight patients received worse care than normal weight patients. In fact, obese and overweight patients received marginally better care on certain measures.
  
  Date: April 7, 2010
• VA Care for Obese Veterans
  Of those Veterans identified as obese, only 27.7% had an obesity diagnosis in FY02; by 2006, 53.5% had an obesity diagnosis. Although suboptimal, these rates are comparable or better than those recently reported in the public sector. Results also show that an obesity diagnosis, and not BMI per se, was the strongest predictor of receiving obesity-related education. Only about 10-13% of obese Veterans received individual or group outpatient education in nutrition, exercise, or weight management on an annual basis, and only about one-third received any obesity-related education over the five-year study period. Obese Veterans who were older than 65 years, prescribed fewer types of medications, or lacking an EMR diagnosis of obesity or diabetes were less likely to have outpatient obesity-related education. Investigators also found limited utilization of weight loss medications and bariatric surgery, which may be partially due to system barriers such as access to surgery and medications.
  
  Date: February 24, 2010
• Comparing Two Weight Loss Therapies in Overweight/Obese Veterans
  This study compared a low-carbohydrate, ketogenic diet (LCKD) to orlistat combined with a low-fat, reduced-calorie diet (O+LFD). Findings show that a low-carbohydrate diet led to similar improvements as O+LFD for weight, serum lipid, and glycemic parameters – and was more effective for lowering blood pressure. While weight loss was significant and similar for both diet interventions, and decrease in waist circumference also was similar, the LCKD had a more beneficial impact than the O+LFD on systolic (-5.9 vs. 1.5 mm Hg) and diastolic (-4.5vs. 0.4 mm Hg) blood pressure. Study results also show that participants who attended 80% or more of the group counseling sessions lost considerably more weight, regardless of treatment assignment. The authors suggest that efforts be made to incorporate similarly intensive weight loss programs into medical practice.
  
  Date: January 25, 2010
• “Super-obesity” Associated with Risk of Death Among Veterans Following Bariatric Surgery
  This retrospective study of 856 bariatric surgical cases conducted in 12 VAMCs between 2000 and 2006 sought to define the risk of death among Veterans with a body mass index (BMI) of 40 or greater – and to identify patient-level factors associated with mortality. Findings show that Veterans classified as “super-obese” (BMI of 50 or higher) and those with a higher chronic disease burden appear more likely to die within one year of having bariatric surgery. Authors recommend that the risks of bariatric surgery in patients with significant comorbidities should be carefully weighed against potential benefits in older male Veterans and those with super-obesity.
  
  Date: October 1, 2009
• Financial Incentives to Reduce Weight among Obese and Overweight Veterans
  Veterans participating in two weight loss strategies based on financial incentives lost significantly more weight than veterans in the control group. Incentive participants weighed significantly less at seven months than at the study start compared to veterans participating in the control group.
  
  Date: December 10, 2008

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 OEF/OIF

• Majority of OEF/OIF Veterans with Traumatic Brain Injury also Diagnosed with Mental Illness and Head, Neck or Back Pain
  This study examined the prevalence and VA healthcare costs of TBI with and without comorbid psychiatric illness and pain among OEF/OIF Veterans who used VA healthcare services (inpatient or outpatient) during FY09. Findings showed that 7% of the Veterans who used VA healthcare received a diagnosis of TBI. Among this patient subgroup, the vast majority (89%) also had a psychiatric diagnosis (most frequently PTSD: 73%), and 70% had a diagnosis of head, neck or back pain. More than half had both PTSD and pain (54%). Overall, depression was the second most common (45%) mental health diagnosis. Annual costs for OEF/OIF Veterans with TBI were four times greater than for those without TBI ($5,831 vs. $1,547), and costs increased as clinical complexity increased. For example, Veterans with TBI, PTSD, and pain demonstrated the highest median cost per patient ($7,974).
  
  Date: January 4, 2012
• Prevalence and Risk Factors for Non-Fatal Injuries among Veterans with TBI – Post-Discharge from VA Polytrauma Care
  This study examined the prevalence of, and potential risk factors for, non-fatal injuries among Veterans with TBI after discharge from VA inpatient polytrauma rehabilitation programs. Caregivers reported that nearly one-third (32%) of Veterans discharged from VA Polytrauma Rehabilitation Centers had incurred subsequent, medically treated injuries; most were associated with falls (49%) and motor vehicles (37%). Factors associated with Veterans’ increased odds of subsequent injury included poor or fair general health and requiring assistance with activities of daily living or instrumental activities of daily living. A number of caregiver-reported ongoing symptoms/health problems among Veterans (e.g., depression, vision loss, hearing loss) were also associated with greater injury odds. Moreover, the odds of subsequent injury increased as the number of reported symptoms/comorbid health problems increased. Compared to male Veterans, the small proportion of female Veterans (n=23) had approximately four and a half times the odds of sustaining subsequent injury. Caregivers who reported their own health as poor or fair were more likely to report subsequent injuries for Veterans compared to caregivers who reported their own health as excellent, very good, or good. Caregivers with higher than average or average depressive or anxiety symptoms, or lower than average physical functioning scores, also were more likely to report injuries among Veterans compared to caregivers without these symptoms.
  
  Date: January 1, 2012
• Gender Differences in Combat Exposure, Military Sexual Trauma, and Mental Health among Active Duty Soldiers
  This study examined gender differences in combat exposure, military sexual trauma (MST), and their associations with mental health outcomes among OEF/OIF active-duty personnel. Findings showed that although men reported greater exposure to high-intensity combat experiences than women, results indicate that women are experiencing combat at higher rates than observed in prior cohorts. For example, 7% of women reported injury in the war zone, and 4% reported killing in war, compared to 2% and 1%, respectively, for a Gulf War cohort. MST was a significant predictor of both PTSD and depression symptoms: 12% of women and less than 1% of men reported MST in the war zone. There were no gender differences in PTSD symptoms; however, there was a stronger assocation between injury in combat and PTSD symptoms for women than for men. Men were more likely to report hazardous alcohol use, while female gender was more likely to be associated with depression symptoms.
  
  Date: December 13, 2011
• History of Military Sexual Trauma Increases Risk of Sexual Health Diagnoses among OEF/OIF Veterans
  This study examined the prevalence rates of sexually transmitted infections (STIs) and sexual dysfunction disorders (SDDs) among OEF/OIF Veterans with and without reported military sexual trauma (MST). Investigators also explored whether the presence of a co-existing mental health diagnosis (e.g., PTSD, depression, substance use disorder) was associated with higher rates of STIs and SDDs among Veterans who screened positive for MST. Findings show that a number of STI and SDD diagnoses were more common among OEF/OIF Veterans who reported a history of MST compared to Veterans without a history of MST. There were no instances in which any of the sexual health diagnoses were significantly higher among Veterans who did not report a history of MST, even after controlling for age and length of time in VA healthcare. Moreover, among Veterans with a history of MST, the risk of having an STI or SDD increased in the presence of certain mental health diagnoses. Among women with a history of MST, those with a diagnosis of PTSD, depression, or a substance use disorder were significantly more likely to have an STI than women without these diagnoses. Among men with MST, only substance use disorder increased their risk for an STI. Among women with a history of MST, those with a diagnosis of depression were significantly more likely to have an SDD than women without a depressive disorder. Among men with MST, those with a diagnosis of PTSD or depression were more likely to have an SDD diagnosis than men without either disorder. This study emphasizes the importance of sexual health screening, particularly among Veterans with a history of MST.
  
  Date: December 5, 2011
• Unique Culture of Modern Military Family
  This article discusses challenges faced by military couples, as well as strengths inherent to the military culture (e.g., community environment and camaraderie) that clinicians can use in helping families develop resiliency. Couple-based interventions also are described.
  
  Date: December 1, 2011
• Military Sexual Trauma Associated with Increased Rate of Mental Health Disorders among Male and Female Veterans with Comorbid PTSD
  This study examined correlates of PTSD in OEF/OIF Veterans, as well as mental health comorbidities by gender among Veterans with PTSD – with and without military sexual trauma (MST). Findings showed that overall, MST was associated with a nearly three-fold increase in odds of PTSD in men, and more than a four-fold increase in women Veterans. Among women Veterans with PTSD, 31% screened positive for MST, and 1% of men with PTSD screened positive for MST. Among Veterans with PTSD, those with military sexual trauma also had more comorbid mental health diagnoses than those without MST. Three-quarters of women Veterans with PTSD and MST had comorbid depression, more than one-third had another anxiety disorder, and 4% were diagnosed with eating disorders. Male Veterans with PTSD and MST were more likely to have comorbid depression and substance use than male Veterans with PTSD, but without MST.
  
  Date: September 8, 2011
• Majority of OEF/OIF Veterans with Chronic Non-Cancer Pain are Prescribed Opioids by VA Outpatient Providers
  This study sought to describe the prevalence of prescription opioid use, types and doses of opioids received, as well as factors associated with the prescription of opioids among OEF/OIF Veterans. Findings showed that about two-thirds of OEF/OIF Veterans with chronic non-cancer pain were prescribed opioids over a one-year timeframe. Of Veterans prescribed any opioids, 59% were prescribed opioids ‘short-term’ compared to 41% prescribed opioids ‘long-term’ (more than 90 days). The mean duration of opioid prescription was 61 days for Veterans in the short-term group and 285 days for Veterans in the long-term group. Several findings suggest a need for improvement in adherence to pain and opioid treatment guidelines. For example, among long-term opioid users, 51% were prescribed short-acting opioids only (guidelines recommend transitioning to long-acting opioids); only 31% were administered one or more urine drug screens (guidelines suggest more frequent drug screening); and 33% were also prescribed sedative-hypnotic medications (monitoring by prescribing physicians is recommended to prevent possible overdose or death). Diagnoses associated with an increased likelihood of receiving an opioid prescription included: low back pain, migraine headache, PTSD, and nicotine use disorder.
  
  Date: September 7, 2011
• Profile of Caregivers and Care Provided for OEF/OIF Veterans Following Acute Rehabilitation for TBI and Polytrauma
  The Family and Caregiver Experience Study (FACES) sought to describe the care and support needs of OEF/OIF Veterans with moderate to severe polytrauma after they received acute rehabilitation – and to describe the providers of that care. Findings showed that a significant portion of caregivers provide time-consuming, unpaid care for Veterans, years after injury. Policymakers may need to target additional resources to meet the long-term needs of caregivers who may not be eligible for support mandated by the Caregivers and Veterans Omnibus Health Services Act of 2010.
  
  Date: August 25, 2011
• Many Risk Factors for Post-Traumatic Stress Symptomatology among OEF/OIF Veterans have Pre-Deployment Origins
  This study sought to identify the mechanisms through which previously documented risk factors (among Vietnam Veterans) contribute to post-traumatic stress symptomatology (PTSS) in a national sample of OEF/OIF Veterans exposed to combat operations who had returned from deployment in the 12 months preceding the study. Findings showed that PTSS appears to be accounted for by multiple chains of risk, many of which originate in pre-deployment experiences (e.g., history of trauma, troubled family backgrounds) that put both female and male OEF/OIF Veterans at risk for additional stress exposure. Moreover, earlier experiences of stress may lead to the depletion of resources over time, as well as greater risk of subsequent stress exposure. The majority of previously documented risk pathways in Vietnam Veterans held for both women and men in this sample of OEF/OIF Veterans, providing support for the generalizability of mechanisms of risk for PTSS across Veteran populations. Relationship concerns during deployment increased risk for PTSS, especially among female Veterans. Warfare exposure had a direct effect on PTSS, suggesting that those who experience high levels of objective events of combat, even those who don’t report experiencing high levels of threat or fear, appear to be at risk for PTSS.
  
  Date: June 27, 2011
• Painful Musculoskeletal Conditions More Prevalent among Female Compared to Male OEF/OIF Veterans
  This study sought to describe gender differences in the prevalence of painful musculoskeletal conditions in male and female OEF/OIF Veterans. Findings showed that the prevalence of back pain, musculoskeletal conditions, and joint disorders increased significantly in years 1-7 after deployment among both female and male Veterans using VA care. Moreover, the odds of having back pain, a musculoskeletal condition, or a joint disorder was higher for female compared to male Veterans and increased over time.
  
  Date: June 14, 2011
• Integrated Primary Care Clinic Improves Access to Mental Health and Social Services for OEF/OIF Veterans
  In April 2007, an OEF/OIF Integrated Care (IC) Clinic was established at the San Francisco VAMC, as part of VA primary care system-wide priorities for improving mental health screening and treatment for OEF/OIF Veterans. This study evaluated whether an initial IC clinic visit improved mental health and social services use among OEF/OIF Veterans entering primary care at the San Francisco VAMC, compared to Veterans who received usual care. Findings showed that OEF/OIF Veterans seen in the IC clinic were significantly more likely to have had initial mental health and social work evaluations within 30 days. Moreover, IC clinic patients were significantly more likely than usual care patients to have had at least one follow-up specialty mental health visit within 90 days of initiating primary care. Women Veterans, younger Veterans, and those with positive mental health and TBI screens were significantly more likely to have had mental health and social service evaluations if seen in the IC versus the usual care clinic. While the Integrated Clinic increased initial mental health evaluations, there was no significant increase in longer-term retention in specialty mental health services among Veterans who screened positive for mental health problems.
  
  Date: June 7, 2011
• Women as Resilient to Combat-Related Stress as Men in the First Year Following Return from OEF/OIF Deployment
  This study examined gender differences in various dimensions of combat-related stress and associated consequences for post-deployment mental health in a nationally representative sample of male and female OEF/OIF Veterans. Study results suggest that women OEF/OIF service members may be as resilient to combat-related stress as men in the first year following deployment. There were no significant interactions between combat-related stressors and gender in the prediction of post-traumatic stress symptomatology, mental health functioning, or depression. Women reported slightly less exposure than men to most combat-related stressors, but higher exposure to other stressors (i.e., prior life stress, deployment sexual harassment). There were no differences between men and women in reports of perceived threat in the war zone.
  
  Date: May 30, 2011
• Book Examines Social and Cultural Factors Contributing to Combat-Related PTSD among OEF/OIF Veterans
  This book follows a group of OEF/OIF Veterans and tells their personal stories of war, trauma, and recovery as they re-enter civilian life while dealing with combat-related PTSD. Written from an anthropologist’s perspective, the author examines the cultural, political, and historical influences that shape individual experiences of PTSD – and how Veterans with PTSD are perceived by the military, medical personnel, and society at large. Despite widespread media coverage and public controversy over the military’s response to wounded and traumatized service members, debate continues about how best to provide treatment and compensation for service-related disabilities. At the same time, new and highly effective treatments are revolutionizing how VA provides trauma care, and redefining the way PTSD is understood. Fields of Combat discusses real-life issues related to living with PTSD, and suggests recommendations to improve PTSD care.
  
  Date: May 19, 2011
• Low Follow-Up Rates for Positive TBI Screens
  This retrospective study evaluated VA’s TBI screening program in terms of predictors of screening and positive-screen follow-up. Findings show that almost 90% of Iraq and Afghanistan war Veterans in this study were offered TBI screening, and 17% screened positive; 52% of those screening positive had subsequent appointments in a TBI/polytrauma specialty clinic during the 18-month study period. Of 1,185 patients evaluated in a TBI/polytrauma clinic following a positive screen, 55% were given a TBI diagnosis, and of 92 patients not evaluated in a TBI/polytrauma clinic following a positive screen, 8.5% were given a TBI diagnosis. Screening likelihood increased with time since implementation of the TBI screening program and was greater at the first clinic encounter. There was considerable variation by facility; for example, Veterans seen in a VAMC were more likely to be screened than those seen in a CBOC. Screening was particularly likely to occur during TBI/polytrauma and primary care clinic appointments. Younger, male, Army Veterans without psychiatric diagnoses were more likely to be screened compared with women Veterans, Iraq/Afghanistan Veterans from other branches of the military, and those who were at least 40 years old.
  
  Date: February 11, 2011
• National Guard Soldiers Prefer Family-Based Interventions for PTSD and Co-Occurring Family Problems
  This is the first study that has examined Army National Guard soldiers’ interest in and preference for various treatment approaches for post-deployment reintegration problems. Findings show that, among a sample of Army National Guard soldiers recently returned from OEF/OIF combat deployment, a majority showed a preference for couples or family counseling over individual counseling. The percentage of soldiers willing to consider couples counseling was significantly greater than the percentage willing to consider individual counseling. Among soliders who also were parents, 80% preferred family counseling, while 75% reported they would consider individual counseling.
  
  Date: February 1, 2011
• Study Evaluates Workshop to Assist OEF/OIF Veterans with Reintegration and Resiliency
  Few programs to promote healthy reintegration exist that are evidence-based and designed for individuals who are not receiving formal mental health care. In response to this need, a two-hour workshop, Life Guard, was developed for the Arkansas National Guard. This pilot study evaluated the effectiveness of the Life Guard workshop for OEF/OIF National Guard Veterans. Findings show that Veterans who participated in the workshop reported significant declines in symptoms of depression, anxiety, and PTSD, in addition to increased satisfaction with relationships. Results also show high levels of exposure to traumatic events, physical injury, and symptoms of psychosocial distress. The authors suggest that these findings support the continued evaluation of Life Guard as a valuable tool to help service members with reintegration and resiliency.
  
  Date: February 1, 2011
• Rates of PTSD and Depression Highly Prevalent among OEF/OIF Veterans with Alcohol and/or Drug Use Disorders
  This study sought to determine the prevalence and independent correlates of alcohol use disorders (AUD) and drug use disorders (DUD) among OEF/OIF Veterans who were first-time users of VA healthcare. Findings show that, overall, 11% of the OEF/OIF Veterans in this study received diagnoses of AUD, DUD, or both; 10% received AUD diagnoses and 5% received DUD diagnoses. Post-deployment AUD and DUD diagnoses were more prevalent in particular sub-groups of OEF/OIF Veterans and were highly comorbid with PTSD and depression. Among Veterans diagnosed with AUD, DUD, or both, 55% to 75% also received a diagnosis of PTSD or depression. AUD, DUD, or both diagnoses were 3 to 4.5 times more likely among Veterans with PTSD and depression. AUD and DUD diagnoses were more prevalent among Veterans younger than age 25, men, and Veterans who were more likely to have had greater exposure to combat, e.g., Veterans who were enlisted versus officers, and those who served in the Army and Marines.
  
  Date: January 28, 2011
• Suicide Risk Factors for OIF Veterans
  This study examined combat and mental health as risk factors for suicidal ideation among OIF Veterans. Findings show that, overall, 2.8% of the OIF Veterans in the study reported suicidal thinking, the desire for self-harm, or both. Post-deployment depression symptoms were associated with suicidal thoughts, while post-deployment PTSD symptoms were associated with current desire for self-harm. Post-deployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while post-deployment PTSD symptoms mediated the association between killing in combat and the desire for self-harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning Veterans.
  
  Date: January 22, 2011
• Concussion/mild TBI During Deployment Does Not Result in Significant Post-Deployment Health Effects Separate from PTSD
  This study assessed the longitudinal associations between concussion/mild TBI (mTBI) and PTSD symptoms reported in-theater and longer-term psychosocial outcomes in 953 combat-deployed National Guard soldiers. Findings show that the rate of self-reported concussion/mTBI was 9% at Time 1 (one month before returning home from Iraq) and 22% at Time 2 (one year later). Differences may be explained by recall bias and/or poor reliability of the TBI screening instrument. Prevalence of probable PTSD at Times 1 and 2 was 8% and 14%, respectively; and for probable depression was 9% and 18%, respectively. At Time 2, 42% screened positive for problematic drinking and 29% endorsed clinically-significant non-specific somatic complaints. Self-reported post-concussive symptoms at Time 2 were common. For example, among those who reported neither mTBI nor PTSD, 23% reported balance problems, 57% reported tinnitus, 60% reported memory problems, and 64% reported concentration problems and irritability. Post-concussive symptom prevalences were even higher among those who reported mTBI and/or PTSD. The increased post-concussive symptoms reported by soldiers who also reported concussion/mTBI were no longer statistically significant after adjusting for post-deployment PTSD symptoms, suggesting that post-concussion symptoms may be largely explained by PTSD. Findings suggest that early identification and evidence-based treatment of PTSD may be important to the management of post-concussive symptoms following deployment.
  
  Date: January 1, 2011
• Pregnancy and Mental Health Conditions among Female OEF/OIF Veterans Using VA Healthcare
  This study sought to determine the prevalence of mental health problems among 43,078 OEF/OIF women Veterans who received a pregnancy diagnosis in the VA healthcare system over a five-year study period (2003-2008). Although a relatively small proportion of OEF/OIF women Veterans received VA healthcare related to pregnancy (7%), a substantial proportion of these women (32%) received one or more mental health diagnoses compared with 21% of women without a pregnancy-related condition. Compared with all women Veterans enrolled in VA healthcare, Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, PTSD, bipolar disorder, or schizophrenia than those without a pregnancy. The most common mental health diagnoses among Veterans with a pregnancy were anxiety (43%), depression (36%), and PTSD (21%), followed by bipolar disorder (3%), and alcohol abuse/dependence (3%). [Sum is greater than 100% due to comorbidity.] Veterans with a pregnancy were significantly more likely to have a service-connected disability than those without a pregnancy. 71% of Veterans with a pregnancy were either never married or no longer married. On average, women Veterans experienced their index pregnancy nearly two years after returning from their last deployment.
  
  Date: December 1, 2010
• Differences in Mental Health Diagnoses among OEF/OIF Soldiers Transitioning from DoD to VA Care
  This study assessed the transition of healthcare from DoD to VA for service members traumatically injured in OEF/OIF, and their subsequent psychiatric care. Findings show that although none of the 994 DoD inpatients received a diagnosis of PTSD, 21% (209) had other mental health diagnoses, primarily drug abuse (12%). Of the 216 service members who transitioned to VA care, 71% (153) subsequently had at least one psychiatric diagnosis, with PTSD (52%) and depression (40%) the most common. OEF/OIF service members who were discharged from DoD care in FY06 were more likely to transition into VA care (31%) than were patients discharged in earlier years. Of service members who sought VA care, 38% did so within six months of DoD discharge, and 75% within one year of discharge. Nearly 88% of those service members who transitioned to VA healthcare were still using VA care in the final year of the study, FY09. Treatment retention was significantly greater for those receiving psychiatric care: 98% vs. 62% for those not receiving psychiatric care.
  
  Date: November 2, 2010
• Gender Differences in Mental Health Diagnoses among OEF/OIF Veterans
  This study examined differences in socio-demographic, military service, and mental health characteristics between female and male OEF/OIF Veterans. Findings show that female OEF/OIF Veterans who were new users of VA healthcare were younger, more often African-American, and more frequently diagnosed with depression. In addition, older age was associated with a higher prevalence of PTSD and depression diagnoses among female Veterans. Male OEF/OIF Veterans who were new users of VA healthcare were more frequently diagnosed with PTSD and alcohol use disorder. Among male Veterans, younger age indicated greater risk for PTSD. Both female and male OEF/OIF Veterans with higher combat exposure were more likely to receive a diagnosis of PTSD.
  
  Date: October 21, 2010
• PTSD Associated with Poorer Couple Adjustment and Increased Parenting Challenges among Male OIF National Guard Troops
  This study examined associations among combat-related PTSD symptoms, parenting behaviors, and couple adjustment among male National Guard troops who had served in Iraq (OIF). Findings show that increases in PTSD symptoms were associated with poorer couple adjustment and greater perceived parenting challenges one year post-deployment. Further, PTSD symptoms predicted parenting challenges independently of their impact on couple adjustment. PTSD was associated with higher levels of alcohol use, but alcohol use was not significantly associated with couple adjustment or parenting. Deployment injury also was independently associated with increased PTSD symptoms. Findings suggest that symptoms of PTSD may exert their influence at multiple levels within the family, making transitions from combat to home life even more complicated. This highlights the importance of investigating and intervening to support parenting and couple-adjustment among combat-affected National Guard families, who often lack the support available to active duty families via the military base community.
  
  Date: October 1, 2010
• Greater Burden of Medical Illness among OEF/OIF Veterans with PTSD
  This study sought to determine whether the burden of medical illness is higher in OEF/OIF Veterans with PTSD who used VA outpatient care compared to OEF/OIF Veterans with no mental health conditions. Findings show that among women and men OEF/OIF Veterans who used VA outpatient care between FY06 and FY07, the burden of medical illness (measured as a count of diagnosed conditions) was greater for those with PTSD than for those with no mental health conditions. The median number of medical conditions for women Veterans was 7.0 for those with PTSD versus 4.5 for those with no mental health conditions; for men, the rates were 5.0 versus 4.0. For Veterans with PTSD, the most frequent conditions among women were lumbosacral spine disorders, headache, and lower extremity joint disorders; among men, the most frequent were lumbosacral spine disorders, lower extremity joint disorders, and hearing problems. These high-frequency conditions were more common in those with PTSD than in those with no mental health conditions.
  
  Date: September 18, 2010
• Negative Emotionality May Contribute to Worse Post-Deployment PTSD and Poorer Intimate Relationships among National Guard Iraq War Soldiers
  This study examined the contribution of the pre-existing personality trait of negative emotionality (NEM) and comorbid problem drinking to the association between post-deployment PTSD symptoms and relationship distress among combat-exposed OIF National Guard soldiers. Findings show that NEM predisposes combat-exposed soldiers to more severe PTSD symptoms, which, in turn, contribute to poorer intimate relationships. Higher levels of pre-existing NEM predicted higher levels of post-deployment PTSD symptoms. Soldiers with probable PTSD were more likely to experience relationship distress than those without probable PTSD. Soldiers with positive hazardous drinking screens were more likely to screen positive for PTSD than those with negative drinking screens, however, those with positive drinking screens were no more likely to experience relationship distress than those with negative drinking screens.
  
  Date: September 16, 2010
• Military Sexual Trauma: Important Mental Health Issue for OEF/OIF Veterans
  Of the 125,729 OEF/OIF Veterans who received VA primary care or mental health services between 10/01 and 9/07, 15% of women and 0.7% of men reported military sexual trauma (MST) based on results of universal screening that asks about sexual assault or harassment. Women and men who reported a history of MST were significantly more likely than those who did not to be diagnosed with mental health conditions, including PTSD, other anxiety disorders, depression, and substance use disorders. This finding remained consistent after adjusting for demographics, healthcare use, and military service characteristics. The relationship of MST to PTSD was stronger among women compared to men, suggesting that MST may be a particularly relevant issue for women Veterans seeking care for PTSD. There were high rates of post-deployment mental health conditions among all OEF/OIF patients.
  
  Date: June 17, 2010
• Majority of National Guard Soldiers Recently Returned from Combat in Iraq Did Not Meet Criteria for Mental Health Disorder
  This study provides the first known report of rates of mental health disorders and comorbidities diagnosed by structured clinical interviews, as opposed to self-report, in a sample of 348 National Guard troops who returned from Iraq. Findings show that a majority (62%) did not meet criteria for a mental health disorder. However, the soldiers had slightly higher rates than community and non-deployed military samples across all mental health diagnoses, with the exception of drug use disorders. Depressive disorders were the most common, followed by non-PTSD anxiety disorders. Mental health diagnoses were associated with poorer functioning and quality of life, with PTSD having the strongest negative relationship with social functioning and quality of life. Results also show that more than 85% of soldiers with a diagnosis of PTSD had at least one additional mental health diagnosis, with depressive disorders being the most common. In addition, female soldiers were significantly more likely to have a mental health diagnosis than male soldiers. Specifically, women were diagnosed with PTSD, depressive disorders, and non-PTSD anxiety disorders at twice the rate of men.
  
  Date: June 9, 2010
• JRRD Single-Topic Issue Reports on Results of First National Survey of Veterans with Traumatic Limb Loss
  This issue of JRRD reports the results of the first nationally representative survey of Vietnam Veterans and service members and Veterans from OEF/OIF who sustained major traumatic limb loss while serving. Members of a Prosthetics Expert Panel, which included 27 professionals from academic and clinical settings, clinicians and researchers from VA and DoD, and three Veterans with limb loss, analyzed Survey findings. Panel members then wrote articles based on the Survey data, presenting survey findings as well as Expert Panel recommendations.
  
  Date: June 1, 2010
• Majority of OEF/OIF Veterans Interested in Interventions/Information to Help with Community Readjustment
  An estimated 40% of OEF/OIF combat Veterans who used VA medical services perceived some to extreme overall difficulty readjusting to civilian life within the past 30 days. Between 25% and 56% of the participants had some to extreme difficulty in specific areas related to social functioning, productivity, community involvement, and self-care. For example, 31% reported more alcohol and drug use, and 57% reported more anger control problems since returning from Iraq or Afghanistan. Almost all Veterans (96%) expressed interest in services to help them readjust to civilian life. Veterans with probable PTSD (n=291) reported more reintegration problems and expressed interest in more kinds of services for these problems than did Veterans without probable PTSD (n=463). The most commonly preferred ways to receive reintegration services or information were at a VA facility, through the mail, and via the Internet. Almost all OEF/OIF Veterans in this study had access to the Internet and used it regularly.
  
  Date: June 1, 2010
• Male OEF/OIF Veterans with PTSD More Likely to Perpetrate and Experience Aggressive Behavior toward/from Female Partners
  This study examined the nature and frequency of self-reported partner aggression among three male cohorts recruited from one large VAMC outpatient PTSD clinic: OEF/OIF Veterans with PTSD, OEF/OIF Veterans without PTSD, and Vietnam Veterans with PTSD. Findings show that OEF/OIF Veterans with PTSD were significantly more likely to report psychologically abusing their partners than OEF/OIF Veterans without PTSD. Although other comparisons did not reach significance, results suggested that OEF/OIF Veterans with PTSD were about two to three times more likely than the other two groups to report perpetrating or sustaining violence. OEF/OIF Veterans with PTSD also were six times more likely to report sustaining injury from their female partners than OEF/OIF Veterans without PTSD. Significant correlations among reports of violence perpetrated and sustained suggest many men may have been in mutually violent relationships. In terms of family functioning, 63% of OEF/OIF Veterans with PTSD reported having children in the home. These results emphasize the importance of assessing partner aggression in VA clinical settings in order to provide a more complete psychological picture of Veterans and their families’ potential treatment considerations.
  
  Date: February 2, 2010
• Mental Health Treatment Seeking among OIF National Guard Soldiers
  This study sought to determine the rate of reported mental health treatment-seeking in 424 returning OIF National Guard soldiers – and to examine potential barriers to and facilitators of treatment-seeking. Findings show that approximately one-third of the soldiers in this study reported post-deployment mental health treatment through military, VA, or other sources; however, 51% of soldiers who screened positive for PTSD and 40% who screened positive for depression did not report involvement in mental health treatment. Of the 34.7% who reported receiving mental health services, 22.9% had received psychotherapy only, 4.5% received psychiatric medications only, and 7.3% had received both. Reported treatment-seeking was more common among soldiers who screened positive for either PTSD or depression. Injury in-theater, illness-based need (e.g. presence and severity of mental illness), and mental health treatment in-theater were significantly associated with both self-reported psychotherapy and medication treatment-seeking. More positive attitudes regarding mental health treatment were associated with greater reported utilization of both psychotherapy and medication. Findings also indicate that while concerns about stigma were present, they were not associated with reported treatment-seeking behavior.
  
  Date: February 1, 2010
• Minority of OEF/OIF Veterans Receive Recommended Treatment for PTSD
  This study examined OEF/OIF Veterans use of VA mental health services within the first year of receiving new mental health diagnoses. Only a minority of OEF/OIF Veterans with newly diagnosed PTSD received a recommended number and intensity of VA mental health treatment sessions within the first year of diagnosis. Of the 49,425 OEF/OIF Veterans with newly diagnosed PTSD, only 9.5% attended >9 VA mental health treatment sessions in 15 weeks or less in the first year of diagnosis. Overall, two-thirds of OEF/OIF Veterans who received new mental health diagnoses from any VA outpatient clinic had at least one follow-up VA mental health visit in the first year of diagnosis, including 80% of OEF/OIF Veterans with a new PTSD diagnosis and nearly 50% with mental health diagnoses other than PTSD. Among the 35,547 OEF/OIF Veterans with new mental health diagnoses other than PTSD, 42.3% were diagnosed with a depressive disorder and 34.1% with an adjustment disorder. Overall, 60.3% received two or more new mental health diagnoses.
  
  Date: February 1, 2010
• Taking a Life in War Associated with Higher Rates of PTSD and Behavioral/Adjustment Problems in OIF Soldiers
  This study examined the relationship between killing and mental health among 2,797 soldiers returning from Operation Iraqi Freedom (OIF). Overall, 40% of the soldiers in this study reported direct killing or being responsible for killing during their deployment. Taking another life in war was an independent predictor of multiple mental health symptoms. Even after controlling for combat exposure, killing was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems. In addition, 22% of soldiers met threshold screening criteria for PTSD, 32% for depression, and 25% for alcohol abuse. The authors suggest a comprehensive evaluation of Veterans returning from combat should include an assessment of direct and indirect killing and reactions to killing. This information could be part of a treatment plan, including specific interventions targeted at the impact of taking a life.
  
  Date: February 1, 2010
• Veterans Diagnosed with Traumatic Brain Injury Significantly More Likely to Experience Mental Illness
  In April 2007, VA implemented national screening for symptomatic TBI resulting from combat exposure. Using VA data for 13,201 OEF/OIF Veterans who were screened for TBI in VISN 23, investigators examined rates of psychiatric disorders in relation to both TBI screening results and post-screening confirmation of TBI status. Findings show that among 836 Veterans with confirmed TBI, 85% had at least one psychiatric diagnosis, and 64% had two or more distinct diagnoses. Compared to Veterans with negative TBI screens, those with positive screens but without confirmed TBI were three times more likely to have PTSD – and were two times more likely to have depression and substance-related diagnoses. Veterans with clinically confirmed TBI were more likely than those with positive screens but no confirmed TBI to have diagnoses of PTSD, anxiety, and adjustment disorders. Nearly half of all OEF/OIF Veterans screened for TBI in VISN 23 had at least one psychiatric disorder, with PTSD (25.9%) and depression (25.6%) being the most common.
  
  Date: February 1, 2010
• Geographic Access to Rehabilitation for OEF/OIF Veterans
  This study sought to ascertain specific geographic areas where the need for VHA rehabilitation services appears greatest and potential access gaps may exist. Findings show that VA provides access to rehabilitation care for the majority of traumatically injured OEF/OIF Veterans; however, more than 10% of Veterans may have potential access barriers due to excessive travel time. For the combined cohort, the median distance to Level I, Level II, and Level III facilities was 411 miles, 121 miles, and 64 miles respectively, and the median distance to the closest VA facility was 22 miles. Clark County, Nevada, and El Paso County, Texas had the highest number of patients with potential access gaps due to excessive travel times.
  
  Date: October 1, 2009
• Special Issue of Pain Medicine Highlights VA Research on Pain among OEF/OIF Veterans
  This publication is in follow-up to a Pain Research Summit held in September 2007 by VA’s Rehabilitation R&D Service and VA/HSR&D’s Polytrauma and Blast-Related Injury Quality Enhancement Research Initiative (PT/BRI-QUERI). This Special Issue begins with four articles that build on the growing epidemiological literature on the prevalence and correlates of pain among OEF/OIF Veterans, and considers the evidence for the assessment and management of pain in this population. The Issue also includes several original articles that provide a sample of the relatively large and growing body of research on pain, including research that focuses on the most prevalent and challenging of pain conditions observed among OEF/OIF Veterans, such as neuropathic pain, chronic widespread pain, musculoskeletal/joint pain, and pain secondary to spinal cord injury.
  
  Date: October 1, 2009
• OEF/OIF Veterans with Mental Health Diagnoses, Particularly PTSD, Use More Non-Mental Health VA Services
  Using national data from all returning OEF/OIF Veterans (N=249,440) who used VA healthcare between 10/01 and 3/07, this study sought to examine the association of PTSD and other mental disorders with non-mental health outpatient, inpatient, and emergency services utilization. Findings show that OEF/OIF Veterans diagnosed with mental health disorders had significantly greater utilization of all types of non-mental health care services than OEF/OIF Veterans with no mental health diagnoses. In adjusted analyses, compared with OEF/OIF Veterans without mental disorders, those with mental disorders other than PTSD had 55% greater utilization of all non-mental health outpatient services; Veterans with PTSD had 91% higher utilization. Results also showed that female gender and lower rank were independently associated with greater utilization. The authors suggest that as more Veterans return home, many with mental and physical injuries, evaluating the capacity of VA and other healthcare systems to meet their needs will be increasingly important.
  
  Date: September 29, 2009
• Demands on VHA for Post-Deployment Healthcare Needs of OEF/OIF Veterans will be Overshadowed by the Needs of Older Veterans
  This article discusses the implications for the Veterans healthcare system of the demand for healthcare services from OEF/OIF Veterans. Findings show that although the pressing needs of newly discharged Veterans require immediate attention, especially in the areas of TBI, PTSD, and physical disability services, the demand for immediate post-deployment VA healthcare services by OEF/OIF Veterans will be overshadowed by the demands of aging Korean and Vietnam War Veterans (and, eventually, aging OEF/OIF Veterans), in terms of the number of patients and the average cost of their care. Thus, the major demand on VA healthcare services will be from aging Veterans whose usage and needs for services will be relatively stable and predictable; however, it is the extra cost for OEF/OIF Veterans that is difficult to quantify because of the unknowns (e.g., nature, severity, and number of PTSD and TBI cases).
  
  Date: September 1, 2009
• Emerging Issues Related to PTSD for OEF/OIF Women Veterans
  The goal of this review was to highlight emerging issues relevant to the development of PTSD among women deployed to Iraq and Afghanistan. Investigators reviewed the literature on topics including: gender differences in combat experiences and in PTSD following combat exposure; sexual assault, sexual harassment, and other interpersonal stressors experienced during deployment; women Veterans’ experiences of pre-military trauma exposure; and unique stressors faced by women Veterans during the homecoming readjustment period. Findings show that combat deployments are not associated with a higher risk of mental health problems for women compared to men. However, women are more likely than men to meet criteria for PTSD following a range of traumatic experiences. In addition, studies published between 2002 and 2007 suggest that more than half of women Veterans experienced pre-military physical or sexual abuse, and there is some evidence that pre-military trauma increases women Veterans’ risk of developing PTSD following combat exposure. Further, concerns about family/relationship disruptions are more strongly associated with post-deployment mental health for female than male service members.
  
  Date: August 24, 2009
• Mental Health Diagnoses Associated with Cardiovascular Risk Factors among OEF/OIF Veterans
  Studies of Veterans from prior wars found that those with PTSD are at increased risk of developing and dying from cardiovascular disease, but this risk had not yet been evaluated in OEF/OIF Veterans. This article discusses findings from a study on the association between mental health disorders, including PTSD, and cardiovascular risk factors. Findings show that OEF/OIF Veterans (male and female) with mental health diagnoses had a significantly higher prevalence of cardiovascular risk factors (e.g., hypertension, obesity, diabetes, tobacco use). The association between mental health diagnoses and cardiovascular risk factors remained after adjusting for demographics and military factors. The most common mental health diagnosis was PTSD (24%). The majority of Veterans with PTSD had comorbid mental health diagnoses: depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), as well as other psychiatric diagnoses (33%).
  
  Date: August 5, 2009
• Mental Health Diagnoses among OEF/OIF Veterans Increased Rapidly Following Invasion of Iraq
  This study sought to investigate longitudinal trends and risk factors for mental health diagnoses among OEF/OIF Veterans. Findings show that the prevalence of new mental health diagnoses among OEF/OIF Veterans using VA healthcare increased rapidly following the Iraq invasion. Among the 289,328 Veterans in this study, new mental health diagnoses increased 6-fold from 6.4% in April 2002 to 36.9% by March 2008. 21.8% of Veterans were diagnosed with post-traumatic stress disorder (PTSD), and 17.4% with depression. Two-year prevalence rates of PTSD increased 4-7 times after the invasion of Iraq. The youngest active duty OEF/OIF Veterans (< 25 years) were at nearly twice the risk for PTSD, more than twice the risk for alcohol use disorders, and at a nearly 5-fold risk for drug use disorders than older active duty Veterans (> 40 years). Among National Guard/Reserve Veterans, those older than age 40 were at greater risk for PTSD and depression. Women Veterans from both service components (active duty and Guard/Reserve) were at higher risk for depression, while male Veterans were at greater risk for drug use disorders. Authors suggest that early targeted interventions may prevent chronic mental illness.
  
  Date: July 16, 2009
• OEF/OIF Veterans with Spinal Cord Injury and Additional Problems Require Timely Intervention to Avoid Rehabilitation Delays
  Soldiers returning from Iraq and Afghanistan with spinal cord injury often have additional medical and psychosocial problems that require timely intervention to avoid significant delays in rehabilitation. Rehabilitation was often delayed because other problems needed to be addressed first.
  
  Date: March 1, 2009
• Advances in Couple Therapy for Returning Soldiers and their Spouses
  The authors of this article present a case study about a service member who suffers from PTSD and his wife, who are treated with an adaptation of integrative behavioral couple therapy (IBCT). At the end of the 13 weeks of treatment, this couple reported that their relationship was considerably stronger.
  
  Date: August 1, 2008

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 Pain

• Majority of OEF/OIF Veterans with Traumatic Brain Injury also Diagnosed with Mental Illness and Head, Neck or Back Pain
  This study examined the prevalence and VA healthcare costs of TBI with and without comorbid psychiatric illness and pain among OEF/OIF Veterans who used VA healthcare services (inpatient or outpatient) during FY09. Findings showed that 7% of the Veterans who used VA healthcare received a diagnosis of TBI. Among this patient subgroup, the vast majority (89%) also had a psychiatric diagnosis (most frequently PTSD: 73%), and 70% had a diagnosis of head, neck or back pain. More than half had both PTSD and pain (54%). Overall, depression was the second most common (45%) mental health diagnosis. Annual costs for OEF/OIF Veterans with TBI were four times greater than for those without TBI ($5,831 vs. $1,547), and costs increased as clinical complexity increased. For example, Veterans with TBI, PTSD, and pain demonstrated the highest median cost per patient ($7,974).
  
  Date: January 4, 2012
• Complementary and Alternative Medicine Options for Veterans with Chronic Pain
  As part of the “Study of the Effectiveness of a Collaborative Approach to Pain,” investigators surveyed Veterans with chronic (non-cancer) pain about their prior use of, and their willingness to try four complementary/alternative medicine (CAM) treatments: massage, chiropractic care, herbal medicines, and acupuncture. Investigators also examined whether demographic characteristics, VA treatment satisfaction, common pain-related characteristics (i.e., pain intensity, disability, depression), or overall disease burden distinguished CAM users from non-users. Findings showed that 82% of Veterans reported previously trying CAM therapy, and nearly all were willing to try one or more of the four CAM treatment options in the study survey. Chiropractic care was the least preferred CAM therapy, whereas massage was the most preferred option. Compared to Veterans who did not use CAM therapy, CAM users were less likely to have service-connected disabilities, and reported having spent a larger percentage of their lives in pain. Investigators detected few differences between Veterans who had tried CAM therapy and those who had not, suggesting CAM may have broad appeal among Veterans with chronic pain. Moreover, study results did not show differences in treatment satisfaction or pain treatment effectiveness ratings between the two groups. This suggests that Veteran patients with chronic pain may use CAM as an additional tool in pain management, rather than as a reaction to perceived inadequacies of conventional care.
  
  Date: December 1, 2011
• Majority of OEF/OIF Veterans with Chronic Non-Cancer Pain are Prescribed Opioids by VA Outpatient Providers
  This study sought to describe the prevalence of prescription opioid use, types and doses of opioids received, as well as factors associated with the prescription of opioids among OEF/OIF Veterans. Findings showed that about two-thirds of OEF/OIF Veterans with chronic non-cancer pain were prescribed opioids over a one-year timeframe. Of Veterans prescribed any opioids, 59% were prescribed opioids ‘short-term’ compared to 41% prescribed opioids ‘long-term’ (more than 90 days). The mean duration of opioid prescription was 61 days for Veterans in the short-term group and 285 days for Veterans in the long-term group. Several findings suggest a need for improvement in adherence to pain and opioid treatment guidelines. For example, among long-term opioid users, 51% were prescribed short-acting opioids only (guidelines recommend transitioning to long-acting opioids); only 31% were administered one or more urine drug screens (guidelines suggest more frequent drug screening); and 33% were also prescribed sedative-hypnotic medications (monitoring by prescribing physicians is recommended to prevent possible overdose or death). Diagnoses associated with an increased likelihood of receiving an opioid prescription included: low back pain, migraine headache, PTSD, and nicotine use disorder.
  
  Date: September 7, 2011
• Painful Musculoskeletal Conditions More Prevalent among Female Compared to Male OEF/OIF Veterans
  This study sought to describe gender differences in the prevalence of painful musculoskeletal conditions in male and female OEF/OIF Veterans. Findings showed that the prevalence of back pain, musculoskeletal conditions, and joint disorders increased significantly in years 1-7 after deployment among both female and male Veterans using VA care. Moreover, the odds of having back pain, a musculoskeletal condition, or a joint disorder was higher for female compared to male Veterans and increased over time.
  
  Date: June 14, 2011
• Veterans Receiving Higher-Dose Opioid Prescriptions for Pain at Increased Risk of Death from Overdose
  This study examined the association of maximum prescribed daily opioid dose and dosing schedule (“as needed,” regularly scheduled, or both) with risk of opioid overdose death among Veterans with cancer, chronic pain, acute pain, and substance use disorders. Findings showed that among Veterans receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of death from opioid overdose. The frequency of fatal overdose among Veterans treated with opioids was rare – estimated to be 0.04% - and was directly related to the maximum prescribed daily dose of opioid medication. There was no significant increased risk of opioid overdose among Veterans who were treated with both “as-needed” and regularly scheduled opioids – a strategy for treating pain exacerbations – after adjusting for maximum daily dose and patient characteristics. Veterans who died from opioid overdose were significantly more likely to have chronic or acute pain, substance use disorders, and other psychiatric disorders, but they were less likely to have cancer. This study highlights the importance of implementing strategies for reducing opioid overdose among patients being treated for pain, for example, ascertaining history of substance abuse, using treatment contracts, and scheduling frequent follow-up visits and toxicological screens for patients at special risk.
  
  Date: April 6, 2011
• Overuse of Diagnostic Imaging for Chronic Low Back Pain
  This article discusses evidence-based recommendations for the use of imaging tests in patients with low back pain, factors that promote the overuse of imaging, as well as how physicians can reduce overuse. The American College of Physicians and the American Pain Society call for imaging only for patients with low back pain who have severe or progressive neurologic deficits – or signs or symptoms that suggest a serious or specific underlying condition. Patient expectations and preferences about diagnostic testing can affect clinical decisions, e.g., wanting diagnostic testing is a frequent reason for repeated office visits for chronic back pain. The number of MRI scanners in the U.S. tripled from 2000 to 2005, and studies suggest that greater availability of imaging resources correlates with their increased use. To be most effective, efforts to reduce the use of diagnostic imaging should be multi-focal and should address clinician behaviors, patient expectations, and financial incentives.
  
  Date: February 1, 2011
• Telephone-Based Self-Management Program Improves Pain among Veterans with Osteoarthritis
  This study examined the effectiveness of a one-year, telephone-based self-management support intervention for 461 Veterans with symptomatic hip and/or knee osteoarthritis who received VA primary care at the Durham VAMC. Findings show that the telephone-based self-management program produced moderate improvements in pain among Veterans with osteoarthritis, particularly compared with a general health education intervention. The self-management group also had greater improvement on the walking and bending subscale measure.
  
  Date: November 2, 2010
• Pain Screening Implementation for Veterans Falls Short
  This study included surveys of Veteran outpatients and nursing staff who screened for pain during normal vital sign intake. Investigators compared pain levels documented by the nursing staff with those reported by Veterans during the study survey. Findings show that despite a longstanding mandate, pain screening implementation falls short, and informal screening is common. Although pain was evaluated in all patient encounters, less than half of the Veterans reported that the nursing staff formally rated their pain. However, the majority of the time the nursing staff’s pain documentation matched the Veteran’s subsequent report within one point on the rating scale. When differences did occur, the nursing staff under-estimated pain in 25% of the cases, and overestimated pain in 7% of the cases. Veterans with PTSD or another anxiety disorder were almost twice as likely to report higher pain levels than those documented by the nursing staff. Additionally, nursing staff were less likely to underestimate pain when the patient self-reported excellent, very good, or good health status (relative to fair or poor health status).
  
  Date: August 6, 2010
• Article Helps Identify Patients Prone to Persistent and Disabling Low Back Pain
  Findings show that the most helpful components for predicting persistent, disabling low back pain were maladaptive pain coping behaviors (e.g., avoidance of work), nonorganic signs (e.g., suggests strong psychological component of pain), functional impairment, general health status, and presence of psychiatric comorbidities. In addition, baseline functional impairment showed an increasing likelihood of poor outcomes at three to six months and at one year. However, patients’ age, sex, education level, smoking status, and overweight status consistently failed to predict worse outcomes.
  
  Date: April 7, 2010
• Cost/Benefit of Collaborative Care Intervention for Veterans with Chronic Pain and Depression
  This study reports on the incremental benefit (pain disability-free days – PDFDs) and incremental health services costs of the Study of the Effectiveness of a Collaborative Approach to Pain (SEACAP) intervention from a VA healthcare perspective. Findings show that the collaborative care intervention resulted in more pain-free days for Veterans with chronic pain and depression, but was more expensive than usual care. Veterans in the intervention group experienced an average of 16 additional PDFDs over the 12 month follow-up period compared to Veterans in the treatment as usual group, with a cost per PDFD of $364 (overall, about $2300 per patient during the study year). Study results also show that important predictors of costs were baseline medical comorbidities, depression severity, and prior year treatment costs.
  
  Date: January 1, 2010
• Ethnic Disparities in Treatment for Chronic Pain
  This study sought to identify racial and ethnic differences in patient-reported rates of treatment for chronic pain and ratings of pain-treatment effectiveness among 255,522 Veterans who were treated at more than 800 VA healthcare facilities in FY05. Findings show that 35% of male Veterans and 44% of female Veterans reported receiving treatment for chronic pain. Male and female Veterans who were Hispanic or non-Hispanic black were more likely to report receiving treatment for chronic pain compared to non-Hispanic white Veterans. Among the Veterans who received treatment for chronic pain, non-Hispanic black men were one-fifth less likely to rate pain treatment effectiveness as very good or excellent compared to non-Hispanic white male Veterans.
  
  Date: October 1, 2009
• Special Issue of Pain Medicine Highlights VA Research on Pain among OEF/OIF Veterans
  This publication is in follow-up to a Pain Research Summit held in September 2007 by VA’s Rehabilitation R&D Service and VA/HSR&D’s Polytrauma and Blast-Related Injury Quality Enhancement Research Initiative (PT/BRI-QUERI). This Special Issue begins with four articles that build on the growing epidemiological literature on the prevalence and correlates of pain among OEF/OIF Veterans, and considers the evidence for the assessment and management of pain in this population. The Issue also includes several original articles that provide a sample of the relatively large and growing body of research on pain, including research that focuses on the most prevalent and challenging of pain conditions observed among OEF/OIF Veterans, such as neuropathic pain, chronic widespread pain, musculoskeletal/joint pain, and pain secondary to spinal cord injury.
  
  Date: October 1, 2009
• Primary Care-Based Collaborative Care for Chronic Pain May Be More Effective than Usual Care
  A primary care-based collaborative care intervention for chronic pain was significantly more effective than usual care across a variety of outcome measures, including pain disability and intensity. However, these improvements were generally modest. Depression severity and pain disability and intensity improved among Veterans in the intervention group who reported both chronic pain and depression. Greater use of adjunctive pain medications and long-term opioids among the intervention group suggested that the intervention contributed to the delivery of guideline-concordant care.
  
  Date: March 25, 2009
• Racial Differences in Coping with Chronic Osteoarthritis Pain
  Compared to white veterans, African American veterans were much more likely to perceive prayer as helpful (85% vs. 66%) and were more likely to have tried it for hip or knee pain (73% vs. 55%). Race was not associated with arthritis pain self-efficacy, arthritis function self-efficacy, or any other coping strategies.
  
  Date: December 1, 2008
• Pain among Veterans with Spinal Cord Injury
  Veterans reported higher rates of pain-related catastrophizing (exaggerated negative interpretations of pain, e.g., “my pain is unbearable and will never get better”). Authors suggest that in clinical settings it may be important to assess and manage catastrophizing as a factor important to the experience of pain and especially the impact of pain on functioning.
  
  Date: October 1, 2008

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 Parkinson's Disease

• Parkinson Disease: Caregiver Needs and Experiences
  While most caregivers felt prepared for their role, one-third or more were unprepared for the stress and physical strain they encountered. Typical caregivers were older female spouses who rated tasks involving physical effort the most difficult.
  
  Date: July 1, 2008

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 Patient Safety

• Patient Safety Indicators Do Not Always Identify True Safety Events in VA Hospitals
  This study examined the positive predictive value (PPV: proportion of flagged cases confirmed by chart review to have PSI event) of 12 selected PSIs using data from VA’s electronic medical record as the gold standard. Findings showed that despite evidence on the accuracy and completeness of VA data, all PSIs misidentified true events to some extent, with considerable PPV variation across PSIs. PPVs ranged from 28% for post-operative hip fracture to 87% for post-operative wound dehiscence. This variation was due to coding inaccuracies or limitations (e.g., lack of precise or meaningful codes, poor documentation). PSI rates were generally low. Ulcer and respiratory failure were the most commonly flagged PSIs, suggesting clinical areas for targeting and opportunities for hospital improvement. VA PSI rates will be reported on both the VA and CMS Hospital Compare websites in the near future. However, results suggest that additional coding improvements are needed before the PSIs evaluated in this study are used for hospital reporting or pay-for-performance.
  
  Date: January 1, 2012
• Article Recommends Role of “Patient Safety Professional” to Increase Patient Safety
  This article recommends consideration of a new type of clinical role in the hospital setting – the Patient Safety Professional (PSP) – to ensure that each patient receives individualized prevention strategies to minimize the hazards of hospitalization. Authors suggest the PSP be an advanced practice registered nurse, who would: 1) assess assigned patients for hospital-acquired complications (e.g., pressure ulcers, falls, pain) following explicit protocols relevant to a short list of safety targets; 2) prioritize identified complications based on morbidity, mortality, and hospital costs; and 3) develop and implement plans to decrease hospital-acquired complications, in consultation with physicians and staff nurses. The PSP might also provide additional benefits to the organization, i.e., he/she could serve as an educational resource or consultant to other clinicians and take responsibility for staying up to date on new advances and recommendations in the area of patient safety.
  
  Date: September 8, 2011
• Medication Reconciliation Reduces Adverse Drug Events Related to Some Hospital Admission Prescribing Changes
  This study estimated the effectiveness of inpatient medication reconciliation at the time of hospital admission on adverse drug events (ADEs) caused by admission prescribing changes. Findings showed that medication reconciliation at the time of hospital admission reduced ADEs caused by admission prescribing changes that were classified as errors by 43%, but it did not reduce ADEs caused by all admission prescribing changes. Non-error-related ADEs would not be averted by one-time medication reconciliation on admission, but they might be averted by improved provider awareness and monitoring of admission prescribing changes during the hospital stay. The potential impact of such an intervention is large, as 50% of the ADEs in this study were caused by admission medication changes that were not errors.
  
  Date: May 9, 2011
• Patient-Centered Medical Homes Could Reduce Medical Errors
  The patient-centered medical home (PCMH) can potentially address many current safety concerns in primary care, including what is likely the leading type of error – diagnostic error (i.e., missed, delayed, or wrong diagnosis). Integral to the PCMH concept are electronic medical records (EHRs), which can enhance access to data and advanced decision support to reduce diagnostic error. However, as currently envisioned, many PCMH models may not address other systems and cognitive problems that cause diagnostic errors. In this Commentary, authors recommend five “rights” for reducing diagnostic errors in future patient-centered medical homes within and outside VA. The five “Rights” include: Right Teamwork, Right Information Management, Right Measurement and Monitoring, Right Patient Empowerment, and Right Safety Culture.
  
  Date: July 28, 2010
• Checklist Successfully Identifies VA Environmental Hazards for Inpatient Suicide
  This is the first study to examine the implementation and effectiveness of the Mental Health Environment of Care Checklist to improve patient safety. Findings show that between 2007 and 2008, 7,642 environmental suicide hazards had been identified and 5,834 (76.3%) had been abated. Approximately 2% of these suicide hazards were identified as critical, and another 27% were rated as serious. The most common hazard was anchor points for hanging (44%); anchor points also presented the greatest risk level, followed by suffocation and poison. High-risk locations included bedrooms and bathrooms.
  
  Date: February 1, 2010
• Computerized Patient Hand-Off Tool Shows Promise in Increasing Patient Safety
  Clinicians at the Indianapolis VAMC use a computerized patient hand-off tool (PHT) that extracts information from the electronic health record to populate a form that is printed and given to the cross-over physician. This study sought to: 1) evaluate the rate at which data were extracted from VA’s electronic medical record into the PHT; 2) assess the frequency for needing information beyond that contained in the PHT; and 3) assess physicians’ perceptions of the PHT, as well as opportunities for improvement. Overall, findings show that the PHT reliably extracts information from the electronic health record. However, while patient identifiers and medications were reliably extracted (>98%), other types of information were more variable (e.g., allergies and code status, <50%). Residents preferred PHT content that included: patient medication list, assessment and plan from the most recent physician note, and list of anticipated problems and recommendations for treatment. The primary suggestion for improving the PHT form was that it be organized by patient location (e.g., ward patients grouped together). Authors suggest that the PHT, which is marked for dissemination to other VAMCs, has considerable potential for improving patient safety.
  
  Date: July 1, 2009
• Resident Duty Hour Reform has No Systematic Impact on Patient Safety in Teaching Hospitals
  This observational study focused on patients admitted to VA and Medicare acute-care hospitals, examining changes in patient safety events in more vs. less teaching-intensive hospitals before (2000-2003) and after (2003-2005) duty hour reform. Findings show that the implementation of duty hour regulations did not have an overall systematic impact on potential safety-related events in either VA or non-VA (Medicare) hospitals of different teaching intensity. In the few cases where there were statistically significant increases in the relative odds of developing a patient safety event, the increases were too small to be clinically meaningful.
  
  Date: July 1, 2009
• Application of Aviation Duty-Hour Restrictions to the U.S. Healthcare System would be Cost-Prohibitive
  Restricting resident work hours has been identified as a potential mechanism to improve patient safety. One approach to reform has been to model guidelines and standards after the aviation industry. This study sought to evaluate the cost and workforce implications of applying aviation duty-hour restrictions to the entire practicing physician workforce. Findings show that the application of aviation duty-hour restrictions to the U.S. health care system would be cost-prohibitive. Adopting aviation guidelines would create a deficit of 166,835 residents at a cost of approximately $6.45 billion per year. The application of aviation standards for duty-hour restrictions and rest time requirements to actively practicing physicians creates even larger deficits. To correct the work-hours deficit created through widespread adoption of aviation industry standards would require 459,198 physicians at a cost of approximately $80.4 billion per year. Implementing a mandatory retirement age would cost an additional $10.5 billion.
  
  Date: June 1, 2009
• Improving Patient Safety in Teaching Hospitals by Modifying Residents' Work Hours
  The authors propose 8 guiding principles and note that work schedule reform should use the best scientific evidence to devise an optimal system.
  
  Date: September 10, 2008
• Improving the Environment of Care to Reduce Inpatient Suicide and Suicide Attempts in VA Facilities
  Authors provide 5 recommendations for reducing environmental hazards for suicide on inpatient psychiatric units.
  
  Date: August 1, 2008
• VA Nurse Burnout and Patient Safety Outcomes
  Among VA nurses at one Midwestern location, burnout was associated with perceptions of a less safe environment. While burnout was not associated with event-reporting behavior, it was negatively associated with reporting of near misses (mistakes that did not lead to adverse events). The finding that higher burnout was associated with lower incidence of near-miss reports is of concern because these reports are essential to addressing safety concerns in the environment.
  
  Date: August 1, 2008

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 Performance Measures

• Investigators Provide Rationale for New LDL Guidelines
  Updated guidelines for cholesterol testing and management from the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults are due to be published in 2012. A primary focus of the previous version of the guidelines was treating patients to low-density lipoprotein (LDL) cholesterol level targets, with the primary goals of therapy and the cut-points for initiating treatment stated in terms of LDL. However, the authors of this commentary believe this reasoning diverges from clinical evidence and present three primary reasons that justify a major change in the next generation of guidelines: 1) There is no scientific basis to support treating to LDL targets, 2) The safety of treating to LDL targets has never been proven, and 3) Tailored treatment is a simpler, safer, more effective, and more evidence-based approach. This perspective is synergistic with recent activities in VA, in which a multidisciplinary group of leaders provided input that led to the suspension of VA’s Performance Measure that was strictly focused on achievement of lipid targets. They are now working to substitute a performance measure that emphasizes the prescription of statin medications.
  
  Date: January 1, 2012
• Unintended Consequences of Local Implementation of VA Performance Measures
  This study explored the possible relationships between a centralized primary care clinical performance measurement (PM) system, facility-level practices to implement the PM system into daily care, and unintended negative consequences for Veterans. Findings showed that primary care staff described several ways in which PMs may lead to inappropriate care (e.g., over-prescribing of medication), decrease focus on Veterans’ concerns and patient service (e.g., inconveniencing patients for little benefit), and may make it more difficult for Veterans to make informed, value-consistent decisions (e.g., performance system doesn’t acknowledge when a patient makes an informed refusal of a recommended intervention). Staff also described unintended consequences on primary care team dynamics, e.g., requiring nurses to check on providers to be sure they completed and documented PMs, and providing performance bonuses based on PMs to physicians, but not to nurses. In many instances, problems originated from local implementation strategies developed in response to national PM definitions and policies. Some noted benefits of PMs included feedback from the system helping some clinic staff feel more confident that their care was thorough, and performance scores as a source of pride and positive competition. VA is currently making changes to the national PM system based on this and other research, e.g., developing new PMs that reward clinically appropriate action, even if the patient has not achieved specific targets, and developing clinical reminders that facilitate patient-centered decisions.
  
  Date: October 13, 2011
• Effect of Active versus Passive Monitoring of VA Quality Performance Measures
  This study compared the nature and rate of change in hospital outpatient clinical performance as a function of VA performance measures’ status (active vs. passive), and examined the mean time to stability of performance after changing status. Findings showed that performance measure monitoring status (active vs. passive) did not significantly impact performance over time. Structural organizational characteristics, including facility size, academic mission, and primary care structure, had no impact on this finding. There was variability in whether or not measures stabilized after a status change, suggesting the possibility that some measures may take more than two years to stabilize. However, performance scores for measures with short stability times were no higher or lower than scores for measures with longer stability times. All measures that stabilized did so immediately after the status change (e.g., time to stability was one quarter). Of the 6 measures that did not stabilize, 5 suggested continued improvement after the change.
  
  Date: October 1, 2011
• Article Challenges Process for Disseminating Diabetes Performance Measures
  Pressure to develop more stringent measures for “optimal” control of risk factors in patients with diabetes has accelerated, despite the absence of new evidence from 1998 to 2008, and results from recent trials have cast new doubt on the benefits of achieving these “optimal” measures in many patients. This editorial suggests that an examination of Toyota, often portrayed as a leader in quality, may provide some answers as to how diabetes performance measures got ahead of the evidence.
  
  Date: February 16, 2011
• Threshold for Glycemic Control among Veterans with Diabetes
  In 2009, the National Committee for Quality Assurance (NCQA) – Healthcare Employer Information Data Set (HEDIS) measure for good (<7% A1c) glycemic control for individuals with diabetes was revised to apply only to persons younger than 65 years without cardiovascular disease, end-stage diabetes complications, or dementia. However, multiple guidelines recommend that glycemic control targets be individualized, especially in the presence of comorbid medical and mental health conditions. This retrospective study used the NCQA <7% measure to compare overall VA facility rankings with a subset of Veterans receiving complex glycemic treatment regimens (CGR). Findings show that the assessment of the quality of good glycemic control among VA facilities differs using the NCQA-HEDIS measure for the overall study population compared to a subset of patients receiving CGR. For example, the overall top 10% performing facilities achieved a rate of 57% at the <7% A1c threshold compared to 34% for Veterans on CGR using the same measure. Therefore, the authors suggest that reliance upon a <7% A1c threshold measure as the “quality standard” for public reporting or pay-for-performance could have the unintended consequence of adversely impacting patient safety. Moreover, they propose that rather than assessing “good glycemic control” by an all-or-none threshold, developers of measures should provide credit for an A1c result within an acceptable range (e.g. incremental credit for improvement between 7.9% and <7%) in order to balance the trade-offs of benefits, harms, and patient preferences.
  
  Date: October 1, 2010
• VA’s Brief Alcohol Intervention Strategy Successful
  This study evaluated the prevalence of documented brief interventions among VA outpatients with alcohol misuse before, during, and after implementation of a national performance measure linked to incentives and dissemination of an electronic clinical reminder for brief interventions. Findings show that VA’s strategy of implementing brief alcohol interventions with a performance measure supported by a clinical reminder meaningfully increased documentation of brief interventions over a one-year period. Among Veteran outpatients with alcohol misuse, the prevalence for brief interventions increased significantly over successive phases of implementation – from 5.5% at baseline – to 7.6% after announcement of the brief intervention performance measure – to 19.1% following implementation of the measure – to 29% following dissemination of the clinical reminder. Brief interventions increased among patients without prior alcohol use disorders or addictions treatment, as well as those with recognized drinking problems, with proportionately greater increases among the former group after clinical reminder dissemination.
  
  Date: September 28, 2010
• Risk Related to Serious Hypoglycemia among Diabetics is Under-stated by Current Guidelines and Performance Measurements
  Rapidly evolving evidence from clinical trials and observational studies indicates that serious hypoglycemia is frequent among individuals with type 2 diabetes. Notwithstanding the absence of proven causality between hypoglycemia and mortality, the risks and consequences of hypoglycemia are significant. Despite the significant health burden associated with hypoglycemia, its risks appear to be understated by guideline and performance measurement groups. To increase public and professional awareness about this risk – and to decrease its occurrence, several recommendations are suggested.
  
  Date: May 26, 2010
• Veterans with Hypertension and Comorbidities Receive Better Care than Veterans with Hypertension Alone
  This study sought to determine the impact of different types of co-existing chronic diseases on quality of care for hypertension, as well as patient perceptions of quality. Findings show that Veterans with hypertension and comorbid conditions had greater odds of receiving good quality of care. Moreover, as the number of chronic conditions increased, so did the odds of receiving appropriate overall care for hypertension. No relationship was found between the provision of guideline-recommended care for hypertension and Veterans’ perception of quality of care, nor did Veterans’ assessment of quality of care vary by the presence of co-existing conditions.
  
  Date: June 16, 2009
• Continuity of Care Performance Measure Not Associated with Improved Outcomes for Veterans with Substance Use Disorders
  The Continuity of Care (CoC) performance measure specifies that patients should receive at least two substance use disorder (SUD) outpatient visits in each of the three consecutive 30-day periods after they qualify as new SUD patients. Findings from this study show that meeting the CoC performance measure was not associated with patient-level improvements in the Addiction Severity Index (ASI) alcohol or drug composites, days of alcohol intoxication, or days of substance-related problems. Higher facility-level rates of CoC were negatively associated with improvements in ASI alcohol and drug composites – and were not associated with follow-up abstinence rates.
  
  Date: April 1, 2009
• New Process for Quality Improvement Suggests Local Focus on Improving, in Addition to Measuring Quality
  Authors suggest reforming quality improvement (QI) so that instead of a focus on measures with national benchmarks, there is a focus on rewarding local actions that improve quality of care using local norms to guide progress. Quality improvement efforts should be tied to local actions and local results rather than national norms, acknowledging that QI efforts are not generalizable – one size does not fit all. Measures would be tailored to each institution to reflect local core causes. Measurement could remain a key part of local QI initiatives, however, the measurement of core causes and incentives to improve would be conducted at the local sites.
  
  Date: April 1, 2009
• Evaluating Profiling Program and New Quality Indicators for Diabetes Care
  This study evaluated the addition of new quality indicators to an ongoing clinician feedback initiative that profiles diabetes care and suggests that rather than relying on benchmarks with high and consistent attainment, profiling programs may want to target indicators that demonstrate low and variant performance to better differentiate care across sites.
  
  Date: March 1, 2009
• Transparency Standards for Diabetes Performance Measures
  The development and adoption of performance measures must be transparent. Transparency has been defined as “a process by which information about existing conditions, decisions and actions is made accessible, visible and understandable.” This JAMA Commentary discusses several examples of transparency that might help guide the development of hemoglobin A1c performance measures in the future. Authors suggest that, considering the potential effect on millions of patients and the high cost of antiglycemic medications alone, the upfront investment in ensuring evidence-based, transparently developed performance measures would be worthwhile to protect the public health and restore public and professional confidence.
  
  Date: January 14, 2009
• Clinically Complex Veterans have Higher Rates of Performance Measurement and Higher Satisfaction with Care
  Veterans with higher clinical complexity had higher measured performance on common process measures used to assess the quality of outpatient care. In addition, satisfaction with care was higher among clinically complex patients with high measured performance, suggesting that compliance with performance measures does not crowd out unmeasured care.
  
  Date: November 1, 2008

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 Prevention

• Systematic Review Shows Most Current Readmission Risk Prediction Models have Poor Predictive Ability
  This systematic review was performed to synthesize the available literature on validated readmission risk prediction models, describe their performance, and assess their suitability for clinical or administrative use. Findings showed that most current readmission risk prediction models that were designed for either comparing hospital performance or clinical purposes have poor predictive ability. Although in certain settings such models may prove useful, better approaches are needed to assess hospital performance in discharging patients, as well as to identify patients at greater risk of preventable readmission. Most models incorporated variables for medical comorbidity and use of prior medical services, but few examined variables associated with overall health and function, illness severity, or social determinants of health. The variable performance of predictive models in different populations suggests that the best choice of a model may depend on the setting and population in which it is being used. Even though the overall predictive ability of the clinical models was poor, investigators found that high- and low-risk scores were associated with a clinically meaningful gradient of readmission rates. Thus, even limited ability to identify a proportion of patients at highest risk for readmission could increase the cost-effectiveness of hospital interventions aimed at improving the discharge process and post-hospital follow-up.
  
  Date: October 19, 2011
• Long-Term Outcomes Following Positive Colorectal Screening
  Despite persistently low rates of follow-up colonoscopy in older adults with positive fecal occult blood test (FOBT) results, the long-term outcomes of screening and follow-up practices have not been described. This study examined outcomes following a positive screening FOBT result for 212 Veterans ages 70 years or older at four VA facilities in 2001. Both Veterans who did receive a follow-up colonoscopy and Veterans who did not were followed through 2008. Findings showed that, over a 7-year period, a little more than half of the older Veterans in this study received a follow-up colonoscopy after a positive FOBT. Among Veterans who received follow-up colonoscopy, more than 25% had significant adenomas or cancer detected, were treated, and survived for more than five years. Approximately 59% of Veterans who received follow-up colonoscopy had no significant findings, and 10% experienced complications from colonoscopy or cancer treatment. Among Veterans who did not receive follow-up colonoscopy, 57% underwent some form of follow-up other than colonoscopy (e.g., repeat FOBT or sigmoidoscopy) and 59% had more than one non-colonoscopy follow-up test. Nearly half of the non-colonoscopy group died of other causes within five years, and 3% ultimately died of colorectal cancer. Veterans with the best predicted life expectancy were less likely to experience net burden from screening than Veterans with the worst predicted life expectancy. These findings support guidelines that recommend using life expectancy to guide colorectal cancer screening decisions in older adults, and argue against one-size-fits-all interventions that simply aim to increase overall screening and follow-up rates.
  
  Date: May 9, 2011
• Targeting Infection Prevention: JAMA Commentary on Methods for Comparative Effectiveness Research
  This Commentary focuses on three complementary methods for comparative effectiveness research in infection prevention: cluster randomized trials, quasi-experimental studies, and mathematical models. The authors suggest that the focused and coordinated use of well-designed quasi-experiments, cluster-randomized trials, and mathematical models offer significant potential opportunities for targeting infection prevention efforts.
  
  Date: April 13, 2011
• Targeted Cost-Saving Method for MRSA and VRE Surveillance in VA Hospitals
  Emerging antibiotic-resistant bacteria, including MRSA (methicillin-resistant Staphylococcus aureus) and VRE (vancomycin-resistant enterococcus), are leading causes of infections in hospitalized patients that result in significant costs, morbidity, and mortality. This prospective study investigated alternative methods for targeted active surveillance (using a prediction rule to identify a group of patients at high risk for MRSA or VRE among general hospital admissions) among 585 Veterans admitted to the medical and surgical wards of one VA hospital between 8/07 and 10/09 (non-ICU patients only). Findings show that antibiotic exposure documented by VA’s electronic medical record (EMR) in the year prior to admission was the best prediction rule for MRSA and VRE infections, identifying 84% of MRSA exposure risk and 98% of VRE exposure risk, while culturing only 51% of inpatients. During the 26-month study period, active surveillance for MRSA (culturing all patients at hospital admission) on all non-ICU inpatients would cost $86,773. Targeted active surveillance with EMR documentation of antibiotics would cost $45,255, resulting in a 48% savings. Active surveillance for VRE would cost $77,275 compared to $42,468 for targeted active surveillance, resulting in a 45% savings. An overall cost savings of 47% would result if targeted surveillance for both MRSA and VRE were included.
  
  Date: December 1, 2010
• Prostate Screening Does Not Reduce Prostate Cancer or All-Cause Mortality
  In a 2006 review of the evidence, authors identified insufficient evidence to either support or refute the use of routine screening for prostate cancer. This article presents findings from their updated study, in which investigators sought to determine whether population-based screening reduces prostate cancer-specific mortality and/or all-cause mortality. They also examined its impact on quality of life, including adverse events (e.g., harms of screening from false-positive or false-negative results). Findings show that prostate cancer screening did not result in a statistically significant reduction in prostate cancer-specific or all-cause mortality. One of the studies in this review showed a marginally significant benefit for prostate cancer screening among a subgroup of men aged 55 to 69. Among this group, it was reported that 1,410 men would need to be screened, with 48 men needing prostate cancer treatment, to prevent one additional death from prostate cancer during a 9-year period. Any benefits from prosate cancer screening may take up to 10 years to accrue; therefore, the authors suggest that men with a life expectancy of less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. None of the studies reviewed provided detailed assessment of the effect of screening on quality of life or costs associated with screening.
  
  Date: September 1, 2010
• Responding to Decline in MRSA Infection
  This JAMA Editorial reports on the current status of MRSA (methicillin-resistant S aureus) infection rates – and what it may mean for the future. Using data from 2005-2008, the CDC’s surveillance system showed a continuous decline of invasive MRSA disease. This includes an estimated 9.4% annual decrease in hospital onset and an estimated 5.7% annual decrease in healthcare-associated community-onset infections. There are a variety of theories for these decreases, such as general infection control efforts (e.g., wider use of alcohol-based hand rubs). However, it may be presumptuous to assume that hospital-based prevention efforts have a major effect on the natural history of such a wide-spread pathogen. Natural biologic trends are likely to override the best-laid attempts at infection control. Therefore, only by improving existing surveillance and prevention research programs can clinicians and infection control researchers begin to explain the decrease in MRSA disease.
  
  Date: August 11, 2010
• Surveillance Colonoscopy is Cost-Effective for Patients at High Risk for Developing Colorectal Cancer
  A modeling study examining different surveillance strategies for patients who have adenomas on their initial screening colonoscopy found that costs and benefits differed widely depending on the characteristics of the adenomas and the surveillance intervals. Performing routine screening colonoscopies every ten years in patients at low risk of developing colorectal cancer and surveillance colonoscopy every three years in patients at high risk was more costly, but also more effective than a “no surveillance” strategy where everyone got routine screening every ten years. Compared to no surveillance, this “3/10” strategy was highly cost-effective. Compared to the 3/10 strategy, a “3/5”strategy which conducted surveillance every 5 years on low-risk patients was considerably more costly, but only marginally more effective. A “3/3” strategy was cost-ineffective and potentially harmful in comparison to less intensive surveillance. Based on these results, the authors suggest that the 3/10 strategy is the optimal strategy under the vast majority of clinical circumstances for patients with adenomas on screening colonoscopy.
  
  Date: March 10, 2010
• Implementation of a VA Quality Improvement Initiative Improves Knowledge and Perceptions Regarding MRSA Prevention
  Implementation of the initiative at 17 VAMCs was associated with temporal improvements in knowledge and perceptions regarding MRSA prevention. Between baseline and follow-up, there were increases in the number of respondents who: correctly identified that alcohol-based hand rub is more effective at inactivating MRSA than soap and water, reported cleaning their hands when entering and exiting a patient room in the past 30 days, reported using alcohol-based hand rub over soap and water when cleaning their hands, and felt comfortable reminding others about proper hand hygiene.
  
  Date: February 3, 2010
• Comparing Treat-to-Target Strategies to Tailored Approach for Statin Therapy
  This study examined how a simple Tailored Treatment strategy for statin therapy compared with a Treat-to-Target strategy based on National Cholesterol Education Program (NCEP) III treatment recommendations. Findings show that a simple Tailored Treatment strategy was more efficient and prevented substantially more coronary artery disease morbidity and mortality than any of the currently recommended Treat-to-Target approaches. The Tailored Treatment approach was predicted to save 520,000 more quality-adjusted life years among Americans aged 30-75 than the best NCEP III Treat-to-Target approach for every five years of treatment, even though fewer people were treated with high doses of statins. The authors indicate that these results suggest that a Tailored Treatment approach to medicine can substantially improve care, while also reducing unnecessary treatment and costs. Thus, they recommend that given its potential to better tailor treatments to individual patients, the principles underlying a Tailored Treatment approach should be considered during deliberations about guidelines and performance measures.
  
  Date: January 19, 2010
• Implementing a Successful Fall Prevention Program for Elderly Veterans
  This article discusses the implementation of a Telecare fall prevention program at the VA Greater Los Angeles Healthcare System (VAGLAHS) that was designed to be sustainable. Findings show that leadership and workgroup meetings led to the development of a functional program. The Telecare fall prevention program screened its first Veteran in October 2008 and is ongoing. The program uses an existing telephone nurse advice line to: 1) place outgoing calls to Veterans at high risk of falling, 2) assess the Veterans’ risk factors, and 3) triage Veterans to the appropriate services. Because Telecare operates via the telephone, it can accept referrals from anywhere in VAGLAHS, thus reaching Veterans in geographically remote areas. The authors suggest that another potential advantage of the Telecare fall prevention program is the opportunity to unburden primary care providers of additional responsibilities by helping assess patients’ needs and arranging the appropriate services.
  
  Date: November 16, 2009
• Electronic Reminder Increases Follow-Up Rates for Positive Fecal Occult Blood Tests
  Screening with fecal occult blood tests (FOBT) reduces colorectal cancer mortality by 15-33% and decreases the incidence of the disease by 20%; however, as many as 46-66% of patients with an abnormal FOBT do not receive proper diagnostic testing (e.g., follow-up colonoscopy). This study sought to determine the impact of an electronic reminder on the timeliness and proportion of Veterans referred to gastroenterology (GI) for evaluation after a positive FOBT. Findings show that the electronic reminder was associated with a significant improvement in the proportion and timeliness of follow-up for Veterans with a positive FOBT. The intervention was associated with a 20.3% increase in GI consultations within 14 days, and the median time to colonoscopy decreased by 38 days (105 vs. 143 days).
  
  Date: September 1, 2009
• Strategies to Improve Follow-Up for Positive Colorectal Cancer Screening
  In 2006, VA launched a national effort to increase the proportion of patients receiving a colonoscopy within 60 days of a positive fecal occult blood test (FOBT). This study sought to determine the proportion of VA patients with a positive FOBT between March and June of 2007 that received a colonoscopy within 60 days. Investigators also examined data from a 2007 web-based survey that was completed by 132 VAMCs on their FOBT follow-up quality improvement strategies. Results show that only 1 in 4 Veterans received follow-up colonoscopies within 60 days of a positive FOBT for colorectal cancer screening. Findings also show that developing QI infrastructure appears to be an effective strategy for improving FOBT follow-up, when this work is followed by process improvements (e.g., strategies to decrease cancellations, revise colonoscopy prep education protocols). On average, facilities indicated that they had fully implemented 6.84 of 16 improvement strategies. The number of strategies fully implemented was positively associated with 60-day follow-up. The most commonly cited barriers to improvement involved capacity constraints, e.g., sites listing insufficient gastroenterology staff as a barrier had a lower percentage of Veterans receiving timely follow-up. However, none of the improvement strategies designed to address gastroenterology capacity constraints were associated with timely follow-up, suggesting that this barrier may be more difficult or take more time to address than process inefficiencies.
  
  Date: August 1, 2009
• Need for Better Self-Management Education to Address Cultural Differences among Veterans with Diabetes
  Although non-white Veterans have documented disparities in the quality of some diabetes care processes and intermediate outcome measures, racial disparities in foot care examinations have not been widely explored. Findings from this study show that there are significant differences in self-reported foot care and education across racial and ethnic groups among Veterans with diabetes. Authors suggest the need for better self-management education to address culture, knowledge, preferences, and unique barriers to care.
  
  Date: January 1, 2009
• Low Rates of Hepatitis Vaccination among Veterans with HCV
  Among veterans diagnosed with HCV between 2000 and 2005, approximately 8% overall received hepatitis vaccination and 7% of those with cirrhosis were vaccinated. In veterans with HCV who did not receive hepatitis vaccinations, 66%-96% had hepatitis A or B serology checked and about one-third had negative serology indicating susceptibility to co-infection and missed opportunity for vaccination.
  
  Date: November 1, 2008
• Fall Prevention and Management for Older Adults
  This article describes fall prevention and management activities from a chronic care perspective that may help researchers, practitioners, and policymakers better understand existing programs and services. The authors propose a "no wrong door" approach to fall prevention and management, in which older adults at risk of falls are evaluated across three domains -- physical activity, medical risks, and home safety. Trained providers would then connect the patients and their caregivers to programs and services that address the identified risk in the most appropriate manner.
  
  Date: August 1, 2008

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 Provider Education

• VA Physicians Involved with Research have Higher Job Satisfaction
  This study examined whether VA physicians who were involved with research had greater job satisfaction and more positive job characteristics perceptions. Findings showed that VA physicians who spend part of their time involved with research activities are more likely to report favorable job characteristics ratings. They are also more likely to be satisfied with their job. Physicians who were involved with research activities provided higher ratings on all dimensions, the largest differences being autonomy and skill development opportunities. For overall job satisfaction, 78% of physicians involved with research reported a favorable rating compared to 72% of physicians not involved with research. The organizational research funding level was significantly related to higher ratings for all job characteristics; as the level of funding increased, the estimates for favorable responses increased. Physicians working in VAMCs with academic affiliates reported less favorable ratings for skill development opportunities, as well as work and family balance. However, when the academic affiliate was located within walking distance, these ratings were significantly more favorable.
  
  Date: June 20, 2011
• Education Intervention Decreases Inappropriate Prostate Cancer Screening among Veterans
  This study tested an e-mail-based intervention called “spaced education” (SE) that was developed to reduce clinicians’ inappropriate screening for prostate cancer. Findings show that during the intervention period (36 weeks), clinicians who received the spaced education intervention ordered significantly fewer inappropriate PSA screening tests than clinicians in the control group. Over the 72-week follow-up period, SE clinicians continued to order fewer inappropriate tests compared to controls, representing a 40% relative reduction in inappropriate screening. The impact of the intervention was unaffected by clincians’ age, gender, or provider type.
  
  Date: November 1, 2010
• Study Assesses Knowledge Gains for SGIM Meeting Attendees
  This pilot study assessed the feasibility of surveys to measure the impact of continuing medical education provided at the 2006 Society of General Internal Medicine (SGIM) Annual Meeting on both short- and long-term educational outcomes. Investigators assessed responses to a brief questionnaire administered to SGIM meeting participants who attended one research pre-course, one research methods workshop, and/or one clinical workshop. Findings show that all three sessions showed initial gains in knowledge: the research pre-course gain was large; the clinical workshop gain was moderate; and the research methods workshop gain was modest. Two of the three sessions showed a decrease in knowledge over the subsequent 9 months: the research pre-course decrease was moderate; the clinical workshop’s decrease was small; while the research workshop had a large gain in knowledge levels over the subsequent 9 months.
  
  Date: May 1, 2009
• Spaced Education May Improve Teaching by Surgical Residents
  This randomized trial investigated whether feedback given by surgery residents to students could improve using a spaced-education program delivering succinct weekly e-mails. Findings show that succinct e-mails using spaced education methods are an effective tool to significantly improve both the frequency and quality of feedback given by surgical residents to medical students. Authors suggest that spaced-education techniques may help educate busy residents, for whom service and education responsibilities are often at odds with effective teaching strategies.
  
  Date: February 1, 2009
• Spaced Education May Improve Learning for Medical Students
  ‘Spaced education’ refers to online educational programs that are structured to present information in small increments and reinforce learning by repetition. Medical students in this study who received spaced education e-mails demonstrated significant, topic-specific increases in pre-test scores for both prostate cancer/PSA knowledge and BPH/erectile dysfunction knowledge. However, students demonstrated a substantial decline in their urology knowledge in between the post-test and delayed test in both topic areas. Thus, while prospective spaced education can improve learning and retention, it does not appear to be enough to shift urology learning into long-term memory.
  
  Date: January 1, 2009

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 PTSD

• Decreased Use of Benzodiazepines among Veterans with PTSD
  This study examined trends in benzodiazepine prescribing among Veterans with PTSD. Findings show that the overall proportion of Veterans receiving a benzodiazepine decreased from 37% in 1999 to 31% in 2009. In addition, the proportion of long-term users (>90 days) decreased from 69% to 64%, and the mean daily dose declined by nearly 15%. The likelihood of receiving benzodiazepines was influenced by time since first VA PTSD diagnosis. For example, in 2009, patients newly diagnosed with PTSD were the least likely to receive a benzodiazepine (21%) compared to patients with a history of three or more years of treatment (36%). Clonazepam was the most commonly prescribed benzodiazepine across all study years.Despite decreasing frequency of use, the absolute number of Veterans with PTSD who received benzodiazepines increased nearly 250% due to the increasing numbers of Veterans receiving care for PTSD in the VA healthcare system. Therefore, the authors suggest that minimizing benzodiazepine exposure will remain a vital policy issue.
  
  Date: November 29, 2011
• Factors Associated with Veterans Seeking PTSD Service Connection
  This study sought to describe the reasons Veterans seek PTSD disability benefits and examined differences between those who served in different military service eras. Findings show five inter-related categories of reasons for seeking PTSD service connection: 1) tangible need (e.g., financial, healthcare), 2) need for problem identification or clarification (getting a thorough, official PTSD evaluation), 3) justification/legitimization of disability status (e.g., recognition of military trauma), 4) encouragement from trusted others (e.g., clinician, commanding officer, family), and 5) professional assistance (e.g., Veterans advocate). For Vietnam Veterans, reasons for applying for PTSD service-connection were affected by changes associated with aging, as well as decades of difficulty understanding and coping with post-deployment difficulties. In comparison, OEF/OIF Veterans wanted to avoid the problems Vietnam Veterans had in obtaining needed services and benefits by being more proactive.
  
  Date: November 22, 2011
• Low Rates of Screening for Intimate Partner Violence among Veterans with PTSD
  This study sought to determine how many Veterans’ records showed documentation of screening for intimate partner violence (IPV) perpetration – and to assess the total number of screenings, and whether an initial screening affected future screenings. Findings show a low rate of screening and assessment for IPV perpetration in male, treatment-seeking Veterans with PTSD – a population believed to have high rates of relationship conflict. While most patient records did not show documentation of a screening or assessment for IPV perpetration, many provided rich descriptions of relationships, indicating that Veterans gave VA staff opportunities to ask about IPV. Authors suggest that documenting IPV screening and perpetration can alert other providers, offering an opportunity for further assessment of its impact on the Veteran and his family members.
  
  Date: November 1, 2011
• Cognitive Processing Therapy Improves PTSD Symptoms More than Usual Care among Veterans in Residential Rehabilitation Program
  This study examined one VA PTSD Residential Rehabilitation Program and compared clinical outcomes for two cohorts of male Veterans with PTSD that were treated with either cognitive processing therapy (CPT) or trauma-focused group treatment as usual (TAU). Findings showed that Veterans treated with CPT experienced more improvement of PTSD and depression symptoms, psychological quality of life, coping, and psychological distress than Veterans who received TAU. In the CPT cohort, more Veterans reported PTSD symptoms that were classified as recovered or improved, compared to the TAU cohort.
  
  Date: October 1, 2011
• Health of Gulf War Veterans Worsened in 10-Year Study
  Since the 1991 Gulf War, initial concerns regarding health consequences of participation in the war have turned to requests for longitudinal evaluation of how the health of Gulf War Veterans has changed over time. To help in this evaluation, investigators conducted health surveys of deployed and non-deployed Gulf War-era Veterans in 1995 and again in 2005. Findings showed that the health of deployed Gulf War Veterans worsened during the 10-year period from 1995 to 2005 in comparison with non-deployed Gulf War Veterans. Perceived health of fair or poor was more likely to persist among deployed Veterans, and relatively more deployed Veterans reported that their health status had worsened over the 10-year follow-up. Deployed Veterans were less likely to recover from any prior functional impairment, limitation of activities, or PTSD that they had in 1995 – and were more likely to report new onset of these adverse health outcomes in 2005 compared with non-deployed Veterans. Authors note that the extent to which any of the health problems experienced by Gulf War Veterans were due to the effects of military service in the Gulf War is difficult to detemine.
  
  Date: October 1, 2011
• Veterans Receiving PTSD Disability Benefits May Experience Fewer Symptoms, Less Poverty and Homelessness over Long Term
  This study sought to examine long-term outcomes associated with receiving and not receiving VA disability benefits for PTSD. Findings showed that compared to Veterans not receiving VA PTSD disability benefits, Veterans receiving benefits continued to report more severe PTSD symptoms 10 years after applying for benefits, but were more likely to have had a clinically meaningful reduction in PTSD symptoms. Beneficiaries also had reduced odds of poverty and homelessness compared to denied claimants. Employment was low in both groups, and mortality was similar. On average, Veterans who had been awarded PTSD benefits and Veterans who had been denied them both experienced meaningful improvements of similar magnitude in work, role, and social functioning; however, overall functioning remained poor nonetheless. Findings counter common concerns that PTSD disability benefits impede recovery by incentivizing Veterans to remain ill, and suggest that such benefits may be helpful.
  
  Date: October 1, 2011
• Treating Comorbid Substance Use Disorder and PTSD
  This trial sought to determine whether male Veterans with a substance use disorder (SUD) and co-occurring PTSD symptoms in a VA outpatient SUD clinic would benefit from a specialized treatment program for these comorbid disorders. Findings show that Seeking Safety, a manualized treatment approach for substance use disorder, was well received and associated with better drug use outcomes than treatment as usual (TAU) in male Veterans with PTSD. Compared to TAU, Seeking Safety also was associated with increased treatment attendance, client satisfaction, and active coping through treatment. Although these factors may be beneficial for promoting recovery more broadly, neither they – nor reduction in PTSD severity that occurred during treatment – accounted for reductions in drug use among Veterans during the study.
  
  Date: September 16, 2011
• Variation in Attitudes and Practices among VA Clinicians Conducting Disability Assessment for PTSD
  This study examined the beliefs and practices of VA mental health professionals performing PTSD examinations as part of VA’s Compensation and Pension (C&P) Program. Findings showed that there was wide variation in the beliefs and practices of individuals conducting PTSD examinations, primarily in two areas: 1) preferences and practices related to psychological assessment, and 2) beliefs related to symptom under-reporting and exaggerating. In a high percentage of cases, attitudes and practices conflicted with recommended best practices. For example, 59% of clinicians reported rarely or never using testing, and only 17% indicated routinely using standardized clinical interviews. Less than 1% of clinicians reported using functional assessment scales. [Note: VA does not require use of standardized testing; it is an option.] Standardized interviews were seldom employed, with 85% and 90% reporting that they “never” or “rarely” used the Clinician Administered PTSD Scale or the Structured Clinical Interview for DSM IV Axis I Disorders, respectively. Less than half of clinicians reported having received training in administering diagnostic interviews for PTSD. Nearly all clinicians (96%) believed that they were qualified in the skills needed to conduct a PTSD examination. On the other hand, clinicians held varying opinions about the authenticity of Veterans’ psychiatric conditions. For example, 25% of respondents reported that at least 15% of Veterans exaggerate PTSD symptoms, while 25% of respondents also reported that at least 15% of Veterans minimize or under-report their symptoms.
  
  Date: September 12, 2011
• Military Sexual Trauma Associated with Increased Rate of Mental Health Disorders among Male and Female Veterans with Comorbid PTSD
  This study examined correlates of PTSD in OEF/OIF Veterans, as well as mental health comorbidities by gender among Veterans with PTSD – with and without military sexual trauma (MST). Findings showed that overall, MST was associated with a nearly three-fold increase in odds of PTSD in men, and more than a four-fold increase in women Veterans. Among women Veterans with PTSD, 31% screened positive for MST, and 1% of men with PTSD screened positive for MST. Among Veterans with PTSD, those with military sexual trauma also had more comorbid mental health diagnoses than those without MST. Three-quarters of women Veterans with PTSD and MST had comorbid depression, more than one-third had another anxiety disorder, and 4% were diagnosed with eating disorders. Male Veterans with PTSD and MST were more likely to have comorbid depression and substance use than male Veterans with PTSD, but without MST.
  
  Date: September 8, 2011
• Study Suggests PTSD Associated with Cognitive Impairment
  This systematic review analyzed data from 21 articles published between 1968 and 2009 that examined memory and cognitive function in subjects with chronic PTSD compared to subjects who had been exposed to trauma but did not have PTSD. Eight of the studies that were analyzed included Veterans. Findings showed that chronic post-traumatic stress disorder is associated with cognitive impairment, particularly in Veterans, when compared to individuals with a history of trauma but no PTSD. The severity of PTSD is positively correlated with cognitive impairment. Strong evidence, especially in studies of Veterans, refugees, and war victims, suggests that individuals with PTSD have a poorer ability to sustain attention compared with individuals who have a history of exposure to trauma.
  
  Date: September 1, 2011
• Most Veterans with New PTSD Diagnoses Who Attend PTSD Clinics May Not Receive Minimally Adequate Treatment
  This study sought to assess receipt of PTSD specialty treatment among Veterans newly diagnosed with PTSD – and to identify predictors of receiving minimally adequate specialty treatment (MAST), which is defined as 9 or more visits over 12 months to a VA PTSD specialty clinic. Findings showed that only 33% of Veterans in this study who began VA PTSD specialty care received minimally adequate specialty treatment. OEF/OIF Veterans were less likely to receive MAST (29% vs. 36%) and attended fewer clinic visits (mean 8.2 vs. 9.9) than non-OEF/OIF Veterans. However, they were more likely to have an initial PTSD visit within 30 days of a positive PTSD screen.
  
  Date: August 1, 2011
• Many Risk Factors for Post-Traumatic Stress Symptomatology among OEF/OIF Veterans have Pre-Deployment Origins
  This study sought to identify the mechanisms through which previously documented risk factors (among Vietnam Veterans) contribute to post-traumatic stress symptomatology (PTSS) in a national sample of OEF/OIF Veterans exposed to combat operations who had returned from deployment in the 12 months preceding the study. Findings showed that PTSS appears to be accounted for by multiple chains of risk, many of which originate in pre-deployment experiences (e.g., history of trauma, troubled family backgrounds) that put both female and male OEF/OIF Veterans at risk for additional stress exposure. Moreover, earlier experiences of stress may lead to the depletion of resources over time, as well as greater risk of subsequent stress exposure. The majority of previously documented risk pathways in Vietnam Veterans held for both women and men in this sample of OEF/OIF Veterans, providing support for the generalizability of mechanisms of risk for PTSS across Veteran populations. Relationship concerns during deployment increased risk for PTSS, especially among female Veterans. Warfare exposure had a direct effect on PTSS, suggesting that those who experience high levels of objective events of combat, even those who don’t report experiencing high levels of threat or fear, appear to be at risk for PTSS.
  
  Date: June 27, 2011
• Book Examines Social and Cultural Factors Contributing to Combat-Related PTSD among OEF/OIF Veterans
  This book follows a group of OEF/OIF Veterans and tells their personal stories of war, trauma, and recovery as they re-enter civilian life while dealing with combat-related PTSD. Written from an anthropologist’s perspective, the author examines the cultural, political, and historical influences that shape individual experiences of PTSD – and how Veterans with PTSD are perceived by the military, medical personnel, and society at large. Despite widespread media coverage and public controversy over the military’s response to wounded and traumatized service members, debate continues about how best to provide treatment and compensation for service-related disabilities. At the same time, new and highly effective treatments are revolutionizing how VA provides trauma care, and redefining the way PTSD is understood. Fields of Combat discusses real-life issues related to living with PTSD, and suggests recommendations to improve PTSD care.
  
  Date: May 19, 2011
• Intervention Targeting Trauma-Specific Sleep Disturbances Reduces PTSD Symptoms and Insomnia Severity among Veterans
  This pilot study sought to determine whether or not the combined effects of cognitive behavioral therapy (CBT) for insomnia and imagery rehearsal therapy (IRT) for nightmares would produce significantly greater improvements in sleep disturbance than usual care alone. Findings show that the sleep intervention produced large short-term effects, including substantial reductions in PTSD symptoms, such as the frequency of nightmares and insomnia severity. In contrast, none of the participants in the usual care group responded or remitted from insomnia or PTSD, and did not improve from baseline on sleep quality.
  
  Date: February 15, 2011
• Using Administrative Data to Measure Treatment for Veterans with PTSD May Overestimate Delivery of Psychotherapy
  This study sought to determine whether using administrative data to determine the number of psychotherapy sessions Veterans receive is equivalent to manual record review. Manually-classified notes were used to develop an automated coding protocol using the Automated Retrieval Console (ARC), a VA-developed natural language processing program. ARC was then used to independently code the notes, and the performance of the automated coding program was compared to manual coding. Findings showed that, of the notes that were administratively coded as individual psychotherapy for PTSD, 57% were coded as individual psychotherapy after manual review of records. Thus, nearly half of the encounters that would have been counted as the provision of psychotherapy in large administrative studies appeared to be records of services other than psychotherapy (e.g., intakes, psychological testing). Findings suggest that using counts of administrative codes over-estimates the amount of psychotherapy delivered to Veterans with PTSD. This suggests a potential limitation in current studies of the quality of care for PTSD in VA. The ARC program replicated the performance of the manual coders in classifying psychotherapy notes very well. This suggests that ARC may help bridge the gap between the accuracy of manual coding and the scope of administrative coding.
  
  Date: February 14, 2011
• National Guard Soldiers Prefer Family-Based Interventions for PTSD and Co-Occurring Family Problems
  This is the first study that has examined Army National Guard soldiers’ interest in and preference for various treatment approaches for post-deployment reintegration problems. Findings show that, among a sample of Army National Guard soldiers recently returned from OEF/OIF combat deployment, a majority showed a preference for couples or family counseling over individual counseling. The percentage of soldiers willing to consider couples counseling was significantly greater than the percentage willing to consider individual counseling. Among soliders who also were parents, 80% preferred family counseling, while 75% reported they would consider individual counseling.
  
  Date: February 1, 2011
• Rates of PTSD and Depression Highly Prevalent among OEF/OIF Veterans with Alcohol and/or Drug Use Disorders
  This study sought to determine the prevalence and independent correlates of alcohol use disorders (AUD) and drug use disorders (DUD) among OEF/OIF Veterans who were first-time users of VA healthcare. Findings show that, overall, 11% of the OEF/OIF Veterans in this study received diagnoses of AUD, DUD, or both; 10% received AUD diagnoses and 5% received DUD diagnoses. Post-deployment AUD and DUD diagnoses were more prevalent in particular sub-groups of OEF/OIF Veterans and were highly comorbid with PTSD and depression. Among Veterans diagnosed with AUD, DUD, or both, 55% to 75% also received a diagnosis of PTSD or depression. AUD, DUD, or both diagnoses were 3 to 4.5 times more likely among Veterans with PTSD and depression. AUD and DUD diagnoses were more prevalent among Veterans younger than age 25, men, and Veterans who were more likely to have had greater exposure to combat, e.g., Veterans who were enlisted versus officers, and those who served in the Army and Marines.
  
  Date: January 28, 2011
• Suicide Risk Factors for OIF Veterans
  This study examined combat and mental health as risk factors for suicidal ideation among OIF Veterans. Findings show that, overall, 2.8% of the OIF Veterans in the study reported suicidal thinking, the desire for self-harm, or both. Post-deployment depression symptoms were associated with suicidal thoughts, while post-deployment PTSD symptoms were associated with current desire for self-harm. Post-deployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while post-deployment PTSD symptoms mediated the association between killing in combat and the desire for self-harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning Veterans.
  
  Date: January 22, 2011
• Concussion/mild TBI During Deployment Does Not Result in Significant Post-Deployment Health Effects Separate from PTSD
  This study assessed the longitudinal associations between concussion/mild TBI (mTBI) and PTSD symptoms reported in-theater and longer-term psychosocial outcomes in 953 combat-deployed National Guard soldiers. Findings show that the rate of self-reported concussion/mTBI was 9% at Time 1 (one month before returning home from Iraq) and 22% at Time 2 (one year later). Differences may be explained by recall bias and/or poor reliability of the TBI screening instrument. Prevalence of probable PTSD at Times 1 and 2 was 8% and 14%, respectively; and for probable depression was 9% and 18%, respectively. At Time 2, 42% screened positive for problematic drinking and 29% endorsed clinically-significant non-specific somatic complaints. Self-reported post-concussive symptoms at Time 2 were common. For example, among those who reported neither mTBI nor PTSD, 23% reported balance problems, 57% reported tinnitus, 60% reported memory problems, and 64% reported concentration problems and irritability. Post-concussive symptom prevalences were even higher among those who reported mTBI and/or PTSD. The increased post-concussive symptoms reported by soldiers who also reported concussion/mTBI were no longer statistically significant after adjusting for post-deployment PTSD symptoms, suggesting that post-concussion symptoms may be largely explained by PTSD. Findings suggest that early identification and evidence-based treatment of PTSD may be important to the management of post-concussive symptoms following deployment.
  
  Date: January 1, 2011
• PTSD Associated with Poorer Couple Adjustment and Increased Parenting Challenges among Male OIF National Guard Troops
  This study examined associations among combat-related PTSD symptoms, parenting behaviors, and couple adjustment among male National Guard troops who had served in Iraq (OIF). Findings show that increases in PTSD symptoms were associated with poorer couple adjustment and greater perceived parenting challenges one year post-deployment. Further, PTSD symptoms predicted parenting challenges independently of their impact on couple adjustment. PTSD was associated with higher levels of alcohol use, but alcohol use was not significantly associated with couple adjustment or parenting. Deployment injury also was independently associated with increased PTSD symptoms. Findings suggest that symptoms of PTSD may exert their influence at multiple levels within the family, making transitions from combat to home life even more complicated. This highlights the importance of investigating and intervening to support parenting and couple-adjustment among combat-affected National Guard families, who often lack the support available to active duty families via the military base community.
  
  Date: October 1, 2010
• Greater Burden of Medical Illness among OEF/OIF Veterans with PTSD
  This study sought to determine whether the burden of medical illness is higher in OEF/OIF Veterans with PTSD who used VA outpatient care compared to OEF/OIF Veterans with no mental health conditions. Findings show that among women and men OEF/OIF Veterans who used VA outpatient care between FY06 and FY07, the burden of medical illness (measured as a count of diagnosed conditions) was greater for those with PTSD than for those with no mental health conditions. The median number of medical conditions for women Veterans was 7.0 for those with PTSD versus 4.5 for those with no mental health conditions; for men, the rates were 5.0 versus 4.0. For Veterans with PTSD, the most frequent conditions among women were lumbosacral spine disorders, headache, and lower extremity joint disorders; among men, the most frequent were lumbosacral spine disorders, lower extremity joint disorders, and hearing problems. These high-frequency conditions were more common in those with PTSD than in those with no mental health conditions.
  
  Date: September 18, 2010
• Negative Emotionality May Contribute to Worse Post-Deployment PTSD and Poorer Intimate Relationships among National Guard Iraq War Soldiers
  This study examined the contribution of the pre-existing personality trait of negative emotionality (NEM) and comorbid problem drinking to the association between post-deployment PTSD symptoms and relationship distress among combat-exposed OIF National Guard soldiers. Findings show that NEM predisposes combat-exposed soldiers to more severe PTSD symptoms, which, in turn, contribute to poorer intimate relationships. Higher levels of pre-existing NEM predicted higher levels of post-deployment PTSD symptoms. Soldiers with probable PTSD were more likely to experience relationship distress than those without probable PTSD. Soldiers with positive hazardous drinking screens were more likely to screen positive for PTSD than those with negative drinking screens, however, those with positive drinking screens were no more likely to experience relationship distress than those with negative drinking screens.
  
  Date: September 16, 2010
• Dementia More Prevalent among Older Veterans with PTSD
  This study sought to determine the association between PTSD and dementia in older Veterans. Findings show that older Veterans with PTSD had twice the incidence and prevalence of dementia diagnoses, even after accounting for confounding illnesses, combat-related trauma (measured by receipt of a Purple Heart), and number of primary care visits. Rates of TBI were highest in the group with PTSD and a Purple Heart, while rates of stroke were slightly higher among all groups with PTSD (regardless of Purple Heart receipt). The prevalence of drug dependence and abuse and the rates of alcohol dependence and abuse were highest in the group with PTSD, but without a Purple Heart. The mechanism for the observed increased incidence and prevalence of dementia among Veterans with PTSD is unknown. Possibilities include a common risk factor underlying PTSD and dementia, or PTSD being a risk factor for dementia. Regardless, the authors suggest that veterans over 65 years of age with PTSD be considered for dementia screening.
  
  Date: September 1, 2010
• Mild Traumatic Brain Injury and PTSD: A Synthesis of the Evidence
  HSR&D’s Evidence-based Synthesis Program (ESP) recently produced an important report on TBI and PTSD. This article summarizes that report, in which investigators examined data from 32 studies published between 1980 and June 2009, in addition to a large survey of OEF/OIF Veterans conducted by the RAND Corporation. Findings show that the prevalence of comorbid traumatic brain injury and PTSD in published studies varies widely, ranging from 0% to 89%. However, in three large studies evaluating OEF/OIF Veterans, the prevalence of probable mild TBI ranged from 5% to 7%; among Veterans with probable mild TBI, the prevalence of probable PTSD ranged from 33% to 39%. There were no published studies addressing the relative accuracy of diagnostic tests used for assessing history or symptoms of mild TBI or PTSD when one condition co-occurs with the other. There also were no published studies that evaluated the effectiveness and harms of therapies in adults with these comorbid conditions. Future efforts are needed to improve the evidence on which the assessment and treatment of mild TBI and PTSD are based.
  
  Date: July 13, 2010
• Male OEF/OIF Veterans with PTSD More Likely to Perpetrate and Experience Aggressive Behavior toward/from Female Partners
  This study examined the nature and frequency of self-reported partner aggression among three male cohorts recruited from one large VAMC outpatient PTSD clinic: OEF/OIF Veterans with PTSD, OEF/OIF Veterans without PTSD, and Vietnam Veterans with PTSD. Findings show that OEF/OIF Veterans with PTSD were significantly more likely to report psychologically abusing their partners than OEF/OIF Veterans without PTSD. Although other comparisons did not reach significance, results suggested that OEF/OIF Veterans with PTSD were about two to three times more likely than the other two groups to report perpetrating or sustaining violence. OEF/OIF Veterans with PTSD also were six times more likely to report sustaining injury from their female partners than OEF/OIF Veterans without PTSD. Significant correlations among reports of violence perpetrated and sustained suggest many men may have been in mutually violent relationships. In terms of family functioning, 63% of OEF/OIF Veterans with PTSD reported having children in the home. These results emphasize the importance of assessing partner aggression in VA clinical settings in order to provide a more complete psychological picture of Veterans and their families’ potential treatment considerations.
  
  Date: February 2, 2010
• Minority of OEF/OIF Veterans Receive Recommended Treatment for PTSD
  This study examined OEF/OIF Veterans use of VA mental health services within the first year of receiving new mental health diagnoses. Only a minority of OEF/OIF Veterans with newly diagnosed PTSD received a recommended number and intensity of VA mental health treatment sessions within the first year of diagnosis. Of the 49,425 OEF/OIF Veterans with newly diagnosed PTSD, only 9.5% attended >9 VA mental health treatment sessions in 15 weeks or less in the first year of diagnosis. Overall, two-thirds of OEF/OIF Veterans who received new mental health diagnoses from any VA outpatient clinic had at least one follow-up VA mental health visit in the first year of diagnosis, including 80% of OEF/OIF Veterans with a new PTSD diagnosis and nearly 50% with mental health diagnoses other than PTSD. Among the 35,547 OEF/OIF Veterans with new mental health diagnoses other than PTSD, 42.3% were diagnosed with a depressive disorder and 34.1% with an adjustment disorder. Overall, 60.3% received two or more new mental health diagnoses.
  
  Date: February 1, 2010
• Taking a Life in War Associated with Higher Rates of PTSD and Behavioral/Adjustment Problems in OIF Soldiers
  This study examined the relationship between killing and mental health among 2,797 soldiers returning from Operation Iraqi Freedom (OIF). Overall, 40% of the soldiers in this study reported direct killing or being responsible for killing during their deployment. Taking another life in war was an independent predictor of multiple mental health symptoms. Even after controlling for combat exposure, killing was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems. In addition, 22% of soldiers met threshold screening criteria for PTSD, 32% for depression, and 25% for alcohol abuse. The authors suggest a comprehensive evaluation of Veterans returning from combat should include an assessment of direct and indirect killing and reactions to killing. This information could be part of a treatment plan, including specific interventions targeted at the impact of taking a life.
  
  Date: February 1, 2010
• Therapy via Video-Teleconference as Effective as In-Person Treatment in Reducing Anger Problems in Veterans with PTSD
  Cognitive behavioral therapy (CBT) anger management conducted via video-teleconference was as effective as in-person delivery of the same treatment in reducing anger problems among Veterans with PTSD who live in rural settings. Moreover, mean improvements in the video-teleconferencing group were actually slightly larger than in the in-person treatment group. Veterans in both treatment groups benefited from anger management therapy (AMT), making this one of the few large randomized controlled trials to show meaningful benefits for reducing anger problems in Veterans with PTSD. Veterans in both treatment groups reported high rates of treatment credibility, satisfaction with care, homework adherence, and high alliance with the therapist.
  
  Date: January 26, 2010
• Veteran Minorities Equally Likely to Receive PTSD Treatment
  This study sought to determine the rates of mental health use in the six months after Veterans received a PTSD diagnosis – and to examine whether service use varied by race or ethnicity. Findings show that minority Veterans were similar to Whites in the likelihood of receiving VA mental health treatment in the six months following a diagnosis of PTSD. Of the 20,284 Veterans with PTSD in this study, 50% received psychotropics, 39% received counseling, and 64% received at least one of these forms of treatment. However, only 24% who received any counseling had at least eight sessions, and most had only one session. These findings indicate that possible treatment preferences exist. The authors suggest that incorporating preferences into treatment planning may facilitate treatment retention and help to maximize treatment outcomes for all Veterans with PTSD.
  
  Date: December 1, 2009
• Determinants of Veteran Treatment-Seeking for PTSD
  This study explored determinants of PTSD treatment initiation among 21 treatment-seeking and 23 non-treatment-seeking Veterans who had served in Vietnam, or the current conflicts in Afghanistan and Iraq (14 of the 44 participants were women Veterans). Findings show that both Veterans who were and were not in treatment for PTSD described similar factors that hindered their help-seeking, including their own values and priorities (e.g., pride in self reliance), treatment-discouraging beliefs (e.g., providers would not believe them, or would treat them as if they were “crazy”), and trauma-related avoidance (e.g., avoiding discussion of the traumatic event). They also cited an invalidating post-trauma environment as a detriment to seeking treatment; for example, some women cited a military culture that silenced the reporting of sexual assault. But for some participants, facilitators located within the healthcare system and Veterans’ social networks led to help-seeking despite individual-level barriers. In some cases, it was a trusting relationship with the primary care provider that led the Veteran to follow the provider’s recommendation to seek mental health care. This suggests that factors outside the individual can promote mental health service use for PTSD, even when the Veteran is reluctant.
  
  Date: October 1, 2009
• OEF/OIF Veterans with Mental Health Diagnoses, Particularly PTSD, Use More Non-Mental Health VA Services
  Using national data from all returning OEF/OIF Veterans (N=249,440) who used VA healthcare between 10/01 and 3/07, this study sought to examine the association of PTSD and other mental disorders with non-mental health outpatient, inpatient, and emergency services utilization. Findings show that OEF/OIF Veterans diagnosed with mental health disorders had significantly greater utilization of all types of non-mental health care services than OEF/OIF Veterans with no mental health diagnoses. In adjusted analyses, compared with OEF/OIF Veterans without mental disorders, those with mental disorders other than PTSD had 55% greater utilization of all non-mental health outpatient services; Veterans with PTSD had 91% higher utilization. Results also showed that female gender and lower rank were independently associated with greater utilization. The authors suggest that as more Veterans return home, many with mental and physical injuries, evaluating the capacity of VA and other healthcare systems to meet their needs will be increasingly important.
  
  Date: September 29, 2009
• Emerging Issues Related to PTSD for OEF/OIF Women Veterans
  The goal of this review was to highlight emerging issues relevant to the development of PTSD among women deployed to Iraq and Afghanistan. Investigators reviewed the literature on topics including: gender differences in combat experiences and in PTSD following combat exposure; sexual assault, sexual harassment, and other interpersonal stressors experienced during deployment; women Veterans’ experiences of pre-military trauma exposure; and unique stressors faced by women Veterans during the homecoming readjustment period. Findings show that combat deployments are not associated with a higher risk of mental health problems for women compared to men. However, women are more likely than men to meet criteria for PTSD following a range of traumatic experiences. In addition, studies published between 2002 and 2007 suggest that more than half of women Veterans experienced pre-military physical or sexual abuse, and there is some evidence that pre-military trauma increases women Veterans’ risk of developing PTSD following combat exposure. Further, concerns about family/relationship disruptions are more strongly associated with post-deployment mental health for female than male service members.
  
  Date: August 24, 2009
• Mental Health Diagnoses Associated with Cardiovascular Risk Factors among OEF/OIF Veterans
  Studies of Veterans from prior wars found that those with PTSD are at increased risk of developing and dying from cardiovascular disease, but this risk had not yet been evaluated in OEF/OIF Veterans. This article discusses findings from a study on the association between mental health disorders, including PTSD, and cardiovascular risk factors. Findings show that OEF/OIF Veterans (male and female) with mental health diagnoses had a significantly higher prevalence of cardiovascular risk factors (e.g., hypertension, obesity, diabetes, tobacco use). The association between mental health diagnoses and cardiovascular risk factors remained after adjusting for demographics and military factors. The most common mental health diagnosis was PTSD (24%). The majority of Veterans with PTSD had comorbid mental health diagnoses: depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), as well as other psychiatric diagnoses (33%).
  
  Date: August 5, 2009
• Mental Health Diagnoses among OEF/OIF Veterans Increased Rapidly Following Invasion of Iraq
  This study sought to investigate longitudinal trends and risk factors for mental health diagnoses among OEF/OIF Veterans. Findings show that the prevalence of new mental health diagnoses among OEF/OIF Veterans using VA healthcare increased rapidly following the Iraq invasion. Among the 289,328 Veterans in this study, new mental health diagnoses increased 6-fold from 6.4% in April 2002 to 36.9% by March 2008. 21.8% of Veterans were diagnosed with post-traumatic stress disorder (PTSD), and 17.4% with depression. Two-year prevalence rates of PTSD increased 4-7 times after the invasion of Iraq. The youngest active duty OEF/OIF Veterans (< 25 years) were at nearly twice the risk for PTSD, more than twice the risk for alcohol use disorders, and at a nearly 5-fold risk for drug use disorders than older active duty Veterans (> 40 years). Among National Guard/Reserve Veterans, those older than age 40 were at greater risk for PTSD and depression. Women Veterans from both service components (active duty and Guard/Reserve) were at higher risk for depression, while male Veterans were at greater risk for drug use disorders. Authors suggest that early targeted interventions may prevent chronic mental illness.
  
  Date: July 16, 2009
• Review Suggests PTSD Negatively Impacts Physical Health but More Research Needed
  In this systematic review, investigators searched case reports, comparative studies, meta-analyses, and review articles that examined the relationship between PTSD and specific physical-health diagnoses. Findings suggest that PTSD can have negative effects on physical health, but evidence regarding its association with specific physical disorders is lacking. Evidence suggests a significant association between PTSD and musculoskeletal disorders, especially participant report of arthritis, in the general population – but not in Veterans. There also was an association between PTSD and digestive disorders, particularly ulcers, among non-Veterans. The rest of the associations were either found in single studies or are conflicting, particularly in regard to diabetes, congestive heart failure, and stroke. Authors suggest that large, prospective epidemiological trials are needed to examine the relationship between PTSD and physical illness.
  
  Date: June 1, 2009
• Diffusion of New Drug Therapy for PTSD Lessens with Distance
  This study sought to evaluate the pace and reach of the passive dissemination of a novel, but as yet un-established treatment with the drug prazosin for post-traumatic stress disorder (PTSD) within the VA health care system. Investigators used geographic surveillance data to track the diffusion of prazosin to treat Veterans diagnosed with PTSD in the VA Puget Sound Healthcare System (where the treatment was developed), and at VAMCs ranging up to 2500 miles or farther from Puget Sound. Findings show that the passive diffusion of a new treatment can be rapid in the immediate area in which it is developed, but the geographic gradient of use seems to be steep and changed little during a two-year period, even when cost and organizational barriers were minimal. Veterans with PTSD treated in the area nearest to Puget Sound (<499 miles) were about 63% less likely in 2004 and about 49% less likely in 2006 to be prescribed prazosin than their counterparts treated within Puget Sound. These results suggest that if and when new treatments are definitively demonstrated to be effective, more active dissemination is likely to be needed, especially in geographically remote areas.
  
  Date: April 1, 2009
• Investigators Develop Diagnostic Guidelines for Post-Traumatic Stress Disorder
  Diagnosing mental disorders is often challenging, but may be especially difficult in post-traumatic stress disorder (PTSD) due to the high rates of comorbidity between PTSD and other psychiatric disorders. As a result of this study, investigators offer guidelines for the differential diagnosis of Veterans with PTSD. Clinicians should be aware that those suffering from PTSD might present with symptoms that initially point to other diagnoses, and that mistaken diagnoses can have detrimental effects. Investigators believe that the guidelines they offer can lead to greater reliability in the diagnosis of PTSD and related comorbid conditions.
  
  Date: February 1, 2009
• Successful Strategy that Engages Veterans and Families in Psychoeducation to Improve Treatment for Mental Illness
  Recently, VA funded 19 initiatives to implement family psychoeducation, an evidence-based practice in the treatment of psychotic disorders that results in reduced risk of relapse, remission of residual psychotic symptoms, and enhanced social and family functioning, but the implementation of such programs requires engaging mental health clinicians, consumers, and families. This paper discusses the engagement strategies used in the Reaching out to Educate and Assist Caring, Healthy Families (REACH) program, a 9-month family psychoeducation program for Veterans with serious mental illness or post-traumatic stress disorder (PTSD). Findings show that REACH has had notable success in engaging Veterans and their families, with participation rates that are comparable to those for programs requiring a much shorter commitment than 9 months, and suggest that the REACH engagement strategy may be a promising tool in recruiting Veterans and their families into family psychoeducation.
  
  Date: February 1, 2009
• Advances in Couple Therapy for Returning Soldiers and their Spouses
  The authors of this article present a case study about a service member who suffers from PTSD and his wife, who are treated with an adaptation of integrative behavioral couple therapy (IBCT). At the end of the 13 weeks of treatment, this couple reported that their relationship was considerably stronger.
  
  Date: August 1, 2008
• Panic Control Treatment Proves Effective in Veterans with Panic Disorder and PTSD
  Panic control treatment appeared to be superior in reducing the frequency, severity, and distress associated with panic disorder and suggests that brief cognitive-behavioral therapy for panic is effective for veterans with PTSD.
  
  Date: August 1, 2008

^ top

 Quality

• Relationship between Resources and Quality of VA Primary Care
  This study examined the relationship between resource use and care quality in VA primary care clinics using the concept of organizational slack, which is defined as extra organizational resources (i.e., staff, budget, equipment) available to meet a given level of demand. Findings showed that Veterans seen in VA primary care clinics where staffing was below the recommended level were more likely to experience lower quality of care. Although some level of organizational slack resource for staffing was associated with better quality of care, additional staffing – beyond guideline recommendations – exhibited diminished returns. Thus, the addition of staffing resources in primary care clinics contributed to higher levels of quality, but only to a point, at which more staff appeared to make only minimal contributions to quality. Findings are relevant to understanding the cost and benefits of adding staff to new models of primary care, such as panel management and the Patient-Aligned Care Team (PACT). Also, staff cost and quality trade-off issues may be an increasingly important issue in future policy discussions.
  
  Date: December 20, 2011
• Access to Healthcare and Framework for Reducing Hospital Readmissions
  This Commentary discusses how a patient’s level of access to healthcare can influence readmission risk, and proposes a broader framework that can be used to identify alternative strategies to reduce readmissions – a framework in which readmission rates are determined by access, social determinants of health, and regulatory policies.
  
  Date: October 26, 2011
• Systematic Review Shows Most Current Readmission Risk Prediction Models have Poor Predictive Ability
  This systematic review was performed to synthesize the available literature on validated readmission risk prediction models, describe their performance, and assess their suitability for clinical or administrative use. Findings showed that most current readmission risk prediction models that were designed for either comparing hospital performance or clinical purposes have poor predictive ability. Although in certain settings such models may prove useful, better approaches are needed to assess hospital performance in discharging patients, as well as to identify patients at greater risk of preventable readmission. Most models incorporated variables for medical comorbidity and use of prior medical services, but few examined variables associated with overall health and function, illness severity, or social determinants of health. The variable performance of predictive models in different populations suggests that the best choice of a model may depend on the setting and population in which it is being used. Even though the overall predictive ability of the clinical models was poor, investigators found that high- and low-risk scores were associated with a clinically meaningful gradient of readmission rates. Thus, even limited ability to identify a proportion of patients at highest risk for readmission could increase the cost-effectiveness of hospital interventions aimed at improving the discharge process and post-hospital follow-up.
  
  Date: October 19, 2011
• Quality Indicators may Lead to Unintended Harm in Elderly Patients with Complex Health Issues
  This article highlights two ways that current quality indicators may lead to unintended harms for older patients with complex medical problems and proposes ways to improve quality indicators by minimizing or preventing those harms. For example, current quality indicators are unbalanced, with many encouraging more appropriate care but few indicators discouraging inappropriate care, such as mammography screening for patients with pre-existing advanced cancer or advanced dementia, who are unlikely to benefit. The authors suggest that quality indicators be refined and improved to drive real quality improvement for the entire patient population.
  
  Date: October 5, 2011
• Adherence to National Prevention Measures for Surgical Site Infection Does Not Impact VA Surgical Outcomes
  This study evaluated whether the Surgical Care Improvement Project (SCIP) improved surgical site infection (SSI) rates at the VA patient or hospital level. Findings showed that none of the 5 SCIP infection prevention measures were significantly associated with lower odds of SSI among Veterans after adjusting for variables known to predict SSI and procedure type. Individual hospital SCIP performance also was not associated with hospital SSI rates. While adherence to SCIP measures improved, risk-adjusted SSI rates remained stable. For Veterans with all measures assessed, the composite rate of adherence was 81%. Although SCIP measures are best practices and should continue, they may not discriminate hospital quality. Mandatory SCIP reporting without improvement in care may lead to health professional skepticism and fatigue with quality improvement measures.
  
  Date: September 1, 2011
• Quality of VA Mental Health Care Following Psychiatric Hospitalization for Veterans with Depression
  This study sought to assess the quality of depression care (e.g., antidepressant treatment, psychotherapy) during the high-risk period following a psychiatric hospitalization. Findings show that less than half of Veterans hospitalized for major depression had outpatient mental health follow-up within 7 days of discharge (39%), which is similar to rates found in the general U.S. population among Medicare (38%) and Medicaid (43%) beneficiaries in 2008. Mental health follow-up within 30 days for Veterans in this study was substantially more common (76%). Many Veterans also received adequate psychopharmacologic treatment following a hospitalization for depression (59%), but relatively few received adequate psychotherapy post-discharge (13%).
  
  Date: September 1, 2011
• Most Veterans with Military Sexual Trauma Report High Satisfaction with VA Outpatient Care
  This study examined the association of military sexual trauma (MST) to patient satisfaction with VA outpatient care. Findings showed that Veterans’ ratings of overall satisfaction with VA outpatient care (regardless of MST status) were high. The proportion of patients reporting very good or excellent overall satisfaction was 79% for male Veterans and 72% for female Veterans. After adjusting for patient characteristics, male and female Veterans’ MST status was not associated with satisfaction ratings of overall VA healthcare. However, female Veterans with a history of MST rated the patient satisfaction dimensions of overall coordination, as well as education and information, less favorably than female Veterans without a history of MST.
  
  Date: July 6, 2011
• Quality Improvement Program for Oral Anticoagulation has Potential to Save Lives and Millions in VA Healthcare Costs
  Quality of anticoagulation can be measured by percent time in the therapeutic range (TTR). Because VA is considering a quality improvement program to increase TTR, this study sought to determine whether a "business case" could be made for such a program, including whether or not it has the potential to save money in the short term. Findings showed that even after considering the cost of implementing the program, a quality improvement program for oral anticoagulation therapy in Veterans with atrial fibrillation has the potential to save lives and millions in VA healthcare costs. In this study population, a modest improvement in TTR (5%) would be expected to avert 1,114 adverse events over two years, many of them fatal. Such an improvement would result in a savings of $15.9 million (minus the cost of the quality improvement program). Improving TTR by 10% prevented 2,087 events and saved $29.7 million (again, minus the cost of the quality improvement program).
  
  Date: July 1, 2011
• Despite Improved Quality of VA Healthcare, Racial Disparity Persists for Important Clinical Outcome
  This article reports on trends in the quality of care and racial disparities in relation to 10 VA clinical performance measures that assessed cancer screening, cardiovascular care, and diabetes care from 2000 to 2009. Findings show that in the decade following VA’s organizational transformation, quality of care improved and racial disparities were minimal for most process measures, such as glucose and LDL screening. However, these were not accompanied by meaningful reductions in racial disparity for important clinical outcomes, such as blood pressure, glucose, and cholesterol control. A gap in clinical outcomes of as much as nine percentage points was observed between African-American and white Veterans. Almost all of the disparity in outcomes was explained by within-facility disparity, which suggests that VA medical centers will need to measure and address racial gaps in care for their patient populations. Of the five performance measures with an absolute racial disparity of 5 percentage points or more in the initial year of the study, there were statistically significant reductions in racial disparity for three: glucose control, BP control, and CRC screening. However, the reductions in disparity were modest, and none were reduced by more than 2 percentage points.
  
  Date: April 1, 2011
• Positive Effect of Pay-for-Performance May Not be Long Term
  The Affordable Care Act of 2010 establishes a pay-for-performance program for hospitals. This program, which will take effect in 2013, includes all U.S. acute care hospitals and will be similar to an ongoing hospital pay-for-performance demonstration project sponsored by the Centers for Medicare and Medicaid Services (CMS). This study examined the results of the CMS demonstration project in non-VA hospitals in order to inform efforts to implement pay-for-performance across all U.S. hospitals through the Affordable Care Act. Findings showed that although hospital performance improved under the pay-for-performance demonstration project, the effect was short-lived. By the end of the five-year study period, performance in control hospitals matched that in pay-for-performance hospitals. Over the first three years of the pay-for-performance demonstration project, participating hospitals had better average overall performance than hospitals that did not participate for all three conditions (acute myocardial infarction, heart failure, pneumonia). However, non-pay-for-performance hospitals caught up by the fourth and fifth years of this study. Performance scores were highest among hospitals that were eligible for larger bonuses, were well-financed, or operated in less competitive markets.
  
  Date: April 1, 2011
• VA Healthcare Outperforms Private-Sector, Medicare-Managed Care among Older Patients
  This study compared clinical performance between VA and Medicare-managed care plans, known as Medicare Advantage (MA). Findings show that VA outperformed MA health plans on 10 out of 11 widely used clinical performance indicators assessing diabetes, cardiovascular, and cancer screening care among patients ages 65 and older in the initial study year – and on all 12 measures by the final year. Moreover, for 10 of the 12 measures studied, even the best-performing MA plans lagged behind the lowest-performing VAMCs. The performance advantage for VA was substantial. For example, in 2006 and 2007, adjusted differences between VA and MA ranged from 4.3 percentage points for cholesterol testing in coronary heart disease to 30.8 percentage points for colorectal cancer screening. VA delivered care that was less variable by site, geographic region, and socioeconomic status. For 9 of the 12 measures, socioeconomic disparities were lower in VA than in MA.
  
  Date: March 18, 2011
• Concepts for Evaluating High-Value, Cost-Conscious Healthcare
  This article discusses three key concepts for understanding how to assess the value of healthcare interventions: 1) assessing the benefits, harms, and costs; 2) identifying the cost of the intervention as well as any potential downstream costs that will occur as a result of performing the intervention; and 3) estimating the incremental cost-effectiveness ratio. The authors suggest that the first step toward providing high-value healthcare is to reduce or eliminate the use of interventions that provide no benefit. A second step is to ensure that we provide interventions that are both effective and reduce costs. Finally, for interventions that provide additional benefit at additional cost, cost-effectiveness analysis is recommended, but should not be the sole determinant of use.
  
  Date: February 1, 2011
• Risk-Adjusted Time in Therapeutic Range Can Be Used as Quality Indicator for Outpatient Oral Anticoagulation
  This study examined the suitability of risk-adjusted time in therapeutic range (TTR) as a potential quality indicator for anticoagulation therapy among VA patients. Findings show that TTR can be used to profile the quality of outpatient oral anticoagulation in a large, integrated healthcare system. Thus, this measure can serve as the basis for quality measurement and quality improvement efforts. TTR differed among VA anticoagulation clinics – from 38% to 69%, or from poor to excellent. Risk-adjustment did not alter performance rankings for many sites, but for other sites it made an important difference. For example, the anticoagulation clinic that was ranked 27th out of 100 before risk adjustment was ranked as one of the best (7th) after risk-adjustment. Risk-adjusted site rankings were consistent between the first and second years of the study, suggesting that risk-adjusted TTR measures a construct (quality of care) that is stable over time.
  
  Date: January 1, 2011
• Substantial Gaps in Processes of Care for Veterans with Bipolar Disorder
  This study applied a comprehensive set of process of care measures that reflect the integration of psychosocial, patient preference, and continuum of care approaches to mental health – and evaluated whether Veterans with bipolar disorder received care concordant with these practices. Findings show substantial gaps in care for Veterans with bipolar disorder, especially for patient-centered processes such as symptom assessment and treatment experience. Only half of the patients received care in accordance with clinical practice guidelines. Moreover, only 17% had documented assessment of psychiatric symptoms, 28% had documented patient treatment preferences, 56% had documented assessment of substance abuse and psychiatric comorbidity, and 62% had documented assessment of cardiometabolics. Monitoring of weight gain was noted in 54% of the patient charts, and no-show visits were followed up only 20% of the time. However, 72% of the patients received appropriate anti-manic medication, and all patients were assessed for suicidal ideation. Overall, results suggest that in order to present a more patient-centered view of quality, processes of care for bipolar disorder cannot be distilled into a single measure; but rather, a series of patient-centered composite indicators.
  
  Date: November 1, 2010
• VA Performs Better than Non-VA Healthcare on Quality Measures for Processes of Care
  Since VA’s organizational transformation in the 1990’s, there have been both favorable and unfavorable reports of the quality of VA care published in the peer-reviewed literature and lay media. In order to better understand the totality of the evidence, this systematic review compared the quality of medical and other non-surgical care in VA and diverse non-VA healthcare settings. Findings show that VA outperforms non-VA healthcare on quality measures assessing adherence to recommended processes of care. For example, studies of care processes after an acute myocardial infarction found greater rates of evidence-based drug therapy in VA settings. In addition, more VA patients than Medicare patients received beta-blockers, angiotensin-converting-enzyme inhibitors, or aspirin at discharge. Studies of diabetes care processes also demonstrated a performance advantage for VA; one study reported that VA outperformed commercial managed care plans on all seven measures of care processes examined. Most studies found no significant differences in mortality rates between VA and non-VA care.
  
  Date: October 18, 2010
• Threshold for Glycemic Control among Veterans with Diabetes
  In 2009, the National Committee for Quality Assurance (NCQA) – Healthcare Employer Information Data Set (HEDIS) measure for good (<7% A1c) glycemic control for individuals with diabetes was revised to apply only to persons younger than 65 years without cardiovascular disease, end-stage diabetes complications, or dementia. However, multiple guidelines recommend that glycemic control targets be individualized, especially in the presence of comorbid medical and mental health conditions. This retrospective study used the NCQA <7% measure to compare overall VA facility rankings with a subset of Veterans receiving complex glycemic treatment regimens (CGR). Findings show that the assessment of the quality of good glycemic control among VA facilities differs using the NCQA-HEDIS measure for the overall study population compared to a subset of patients receiving CGR. For example, the overall top 10% performing facilities achieved a rate of 57% at the <7% A1c threshold compared to 34% for Veterans on CGR using the same measure. Therefore, the authors suggest that reliance upon a <7% A1c threshold measure as the “quality standard” for public reporting or pay-for-performance could have the unintended consequence of adversely impacting patient safety. Moreover, they propose that rather than assessing “good glycemic control” by an all-or-none threshold, developers of measures should provide credit for an A1c result within an acceptable range (e.g. incremental credit for improvement between 7.9% and <7%) in order to balance the trade-offs of benefits, harms, and patient preferences.
  
  Date: October 1, 2010
• VA Residency Training Program Rankings May Predict Cost of Care but not Hospital Readmission or Mortality Rates
  Investigators in this natural experiment analyzed data from nearly 30,000 Veterans from one large, urban VA hospital who had been randomly assigned by standard hospital procedure to teams comprised of physicians affiliated with one of two medical/surgical residency training programs. One program was affiliated with one of the higher-ranked medical schools in the U.S., while the other program ranked lower. Findings show that Veterans treated by a team of VA physicians affiliated with a higher-ranked medical/surgical residency training program had 10% lower healthcare costs compared to Veterans at the same hospital who were treated by a team of VA physicians affiliated with a lower-ranked training program – and up to 25% lower costs for more complicated conditions (e.g., heart failure, COPD). Differences in cost largely were the result of diagnostic-testing rates: the physician team affiliated with the lower-ranked program took longer to order tests, and ordered more of them. Hospital readmission rates and mortality were unrelated to the physicians’ training program.
  
  Date: October 1, 2010
• VA’s Brief Alcohol Intervention Strategy Successful
  This study evaluated the prevalence of documented brief interventions among VA outpatients with alcohol misuse before, during, and after implementation of a national performance measure linked to incentives and dissemination of an electronic clinical reminder for brief interventions. Findings show that VA’s strategy of implementing brief alcohol interventions with a performance measure supported by a clinical reminder meaningfully increased documentation of brief interventions over a one-year period. Among Veteran outpatients with alcohol misuse, the prevalence for brief interventions increased significantly over successive phases of implementation – from 5.5% at baseline – to 7.6% after announcement of the brief intervention performance measure – to 19.1% following implementation of the measure – to 29% following dissemination of the clinical reminder. Brief interventions increased among patients without prior alcohol use disorders or addictions treatment, as well as those with recognized drinking problems, with proportionately greater increases among the former group after clinical reminder dissemination.
  
  Date: September 28, 2010
• Validated Alcohol Screening Questionnaire Not Enough to Ensure Quality of Screening
  This study evaluated the quality of clinical alcohol screening among VA outpatients by comparing Alcohol Use Disorders Identification Test - Consumption Questions (AUDIT-C) results documented during routine clinical care to AUDIT-C results from a confidential mailed survey completed within 90 days of the clinical screen. Of the national sample, 61% of VA outpatients who screened positive for alcohol misuse with the AUDIT-C on mailed surveys screened negative during the same time period with the AUDIT-C in VA outpatient clinical settings. Overall, 11% of Veterans screened positive on the survey screen vs. only 6% on the clinical screen. Patients who screened positive on the AUDIT-C survey were much more likely to have discordant clinical screening results, e.g., among patients whose clinical screens indicated no alcohol use in the past year, 22% reported drinking on the survey screens. Discordance was significantly increased among African American Veterans compared with white Veterans. There were also differences across VA networks: the proportion of Veterans with positive survey screens who had negative clinical screens varied from 43% to 100% across different networks.
  
  Date: September 22, 2010
• Measuring the Quality of Mental Healthcare: Barriers and Strategies
  This article discusses the barriers to mental health quality measurement – and identifies strategies to enhance the development and use of quality measures in order to improve outcomes for people with mental health disorders. The authors suggest that key reasons for the lag in mental health performance measurement include: lack of sufficient evidence regarding appropriate mental health care, poorly defined quality measures, limited descriptions of mental health services from existing clinical data, and lack of linked electronic health information. The refinement of quality measures and, ultimately, enhanced outcomes in mental health will require investment in information technology, additional studies to support the evidence base, and the development of a culture of measurement-based care. Sustaining efforts to improve mental health performance measurement will require rethinking how quality measurement is used to promote the uptake of evidence-based mental healthcare across systems of care. In addition, measurement systems should cut across mental health disorders, physical disorders, and substance use disorders, which often co-occur.
  
  Date: September 1, 2010
• Patients with Hepatitis C Benefit from Collaborative Care
  This study evaluated the quality of healthcare that patients (non-Veterans) with Hepatitis C (HCV) receive and factors associated with receipt of quality care, using research data from one of the largest commercial health insurance carriers in the U.S. Findings show that collaboration between specialists and primary care physicians translates into better care for patients with HCV. Patients were less likely to receive any recommended care if they were being treated by specialists or generalists only, compared with being seen by both. Only about 19% of patients with HCV received all recommended care, and the proportion of patients who met quality indicators varied substantially. For example, most patients (79%) received a genotype test before treatment, whereas relatively few (25%) received recommended vaccinations.
  
  Date: August 17, 2010
• Heart Failure Mortality Decreases While Rehospitalization Increases among Veterans
  Heart failure is the number one reason for admission among Veterans enrolled in the VA healthcare system. In order to improve care for this chronic disease, VA has incorporated the use of guideline-recommended treatments; however, it is unclear if the increased performance on process of care measures for hospitalized Veterans has led to improvements in outcomes. This study sought to determine if recent mortality and readmission rates have improved within VA. Findings show that mortality and rehospitalization rates for Veterans with a first hospitalization for heart failure in the VA healthcare system or in a non-VA hospital that was paid for by VA trended in opposite directions between 2002 and 2006. Mortality rates at 30 days decreased (7.1% to 5.0%), while rehospitalization rates for heart failure at 30 days increased (5.6% to 6.1%). Over the same time period, use of guideline recommended therapy increased. During the six months prior to hospital admission and during the three months following admission, there were large increases in the use of beta-blockers. The use of angiotensin-receptor blockers also increased. Examination of patient characteristics showed that most comorbid diagnoses increased significantly from 2002 to 2006, suggesting that Veterans hospitalized in 2006 were more ill. The authors suggest that the use of rehospitalization for heart failure as a marker of poor care may be flawed. Further studies to determine the reasons for the decline in mortality and the portion of hospitalizations that are preventable are recommended.
  
  Date: July 27, 2010
• Processes of Care to Improve Stroke Outcomes
  After adjusting for patient characteristics and other processes of care, three processes of care were independently associated with a reduction in the combined outcome: 1) swallowing evaluation, 2) deep vein thrombosis (DVT) prophylaxis, and 3) treating all episodes of hypoxia with supplemental oxygen. Two of the three processes (swallowing evaluation, DVT prophylaxis) are similar to existing stroke quality measures, but the treatment of hypoxia is not a current performance measure. Thus, authors recommend that organizations that establish national performance measures add treatment of hypoxia to their assessment of stroke care quality, and continue to measure DVT prophylaxis and swallowing assessment among stroke patients.
  
  Date: May 10, 2010
• Obese and Overweight Patients Receive Equal or Better Care than Patients of Normal Weight
  Among Medicare and VA patients, there was no evidence across eight quality performance measures that obese and overweight patients received worse care than normal weight patients. In fact, obese and overweight patients received marginally better care on certain measures.
  
  Date: April 7, 2010
• Relationship between Cost of Care and Quality of Care for Two Conditions in Non-VA Hospitals
  The relationship between (non-VA) hospitals’ cost of care and quality of care for a particular condition was small and differed by condition. However, evidence did not support the hypothesis that low-cost hospitals discharge patients with congestive heart failure (CHF) or pneumonia earlier, only to increase readmission rates and incur greater inpatient cost of care over time. Low-cost hospitals had similar or slightly higher 30-day readmission rates compared with high-cost hospitals. Hospitals in the highest-cost quartile for CHF care had higher quality-of-care scores and lower mortality. For pneumonia, the opposite was true: high-cost hospitals had lower quality-of-care scores and higher mortality. Risk-adjusted costs of care for CHF and pneumonia varied widely between hospitals, although hospital cost-of-care patterns seemed stable over time.
  
  Date: February 22, 2010
• Implementation of a VA Quality Improvement Initiative Improves Knowledge and Perceptions Regarding MRSA Prevention
  Implementation of the initiative at 17 VAMCs was associated with temporal improvements in knowledge and perceptions regarding MRSA prevention. Between baseline and follow-up, there were increases in the number of respondents who: correctly identified that alcohol-based hand rub is more effective at inactivating MRSA than soap and water, reported cleaning their hands when entering and exiting a patient room in the past 30 days, reported using alcohol-based hand rub over soap and water when cleaning their hands, and felt comfortable reminding others about proper hand hygiene.
  
  Date: February 3, 2010
• Assessing New HEDIS Blood Pressure Quality Measure for Diabetes
  To encourage aggressive treatment of hypertension, the National Committee on Quality Assurance recently adopted a new HEDIS blood pressure performance measure of <130/80 mm Hg for patients with diabetes. Although there is nearly universal agreement on the benefits of aggressive BP treatment (3-4 BP medications) for those with diabetes, the new HEDIS performance measure has generated considerable controversy. This study examined BP levels and medication treatment intensity in patients with diabetes, in order to assess the reasons for failing to meet the new HEDIS measure. Findings suggest that the new diabetes BP measure may not accurately identify poor quality care and could promote overtreatment through its performance incentives. The new measure commonly mislabeled patients as being inadequately treated, especially elderly patients. Thus, the authors recommend that new BP measures be developed to encourage aggressive treatment of hypertension without unduly promoting overtreatment, especially among elderly patients.
  
  Date: January 1, 2010
• Lower Quality of Care for Cardiometabolic Disease among Veterans with Mental Disorders, Regardless of Rural or Urban Dwelling
  Mental disorders (MD) were associated with a decreased likelihood of obtaining quality cardiometabolic care. When compared to those without MD, Veterans with MD were less likely to receive diabetes sensory foot exams, retinal exams, and renal tests. Rural residence was not associated with differences in quality measures. Primary care visit volume was associated with a greater likelihood of obtaining diabetic retinal exam and renal testing, but did not explain disparities among patients with MD.
  
  Date: January 1, 2010
• Candidate Quality Measures for VA Alcohol Use Disorder Treatment
  The goal of this study was to identify patterns of VA care that are associated with both facility- and patient-level outcomes in order to develop a new process-of-care measure for VA outpatient alcohol use disorder (AUD) treatment quality. Findings show that nine candidate process measures of outpatient AUD treatment quality can predict facility-level and patient-level improvement. The candidate measures with the strongest association with improvement in outcomes focused on Veterans who received 3 to 6 outpatient visits in the first month of care. Results also showed that while the literature indicates that longer duration of care should produce better patient outcomes, the investigators found no such link with overall outcomes.
  
  Date: December 1, 2009
• Delays in Initiating Antibiotic Therapy for Veterans Hospitalized with Pneumonia
  Time to first antibiotic dose (TFAD) is an important quality indicator for pneumonia care. Findings from this study, which included 20 VA hospitals, show that of the 82 survey participants, 72% perceived that ordering and performing chest X-ray was the most frequent step resulting in TFAD delays. Additional steps reported to cause TFAD delays were medical provider assessment, chest X-ray interpretation, ordering/obtaining blood cultures, and ordering/administering initial antibiotic therapy. The most commonly perceived barriers were patient and X-ray equipment transportation delays and communication delays between providers. The most frequently used strategies to reduce TFAD were stocking antibiotics in the emergency department and physician education. Focus groups emphasized the importance of multi-faceted quality improvement approaches and a top-down hospital leadership style to improve performance on this pneumonia quality measure.
  
  Date: October 1, 2009
• “Rights” of Safe Electronic Health Record Use
  This JAMA Commentary proposes eight “Rights” of safe electronic health record (EHR) use, which are grounded in an engineering model that addresses work-system design for patient safety. The authors recommend the use of the eight “Rights,” in order to address the complex interaction of organizational, technical, and cognitive factors that affect the safety and effectiveness of EHRs.
  
  Date: September 9, 2009
• Federal Investment in Electronic Medical Records
  The American Recovery and Reinvestment Act (ARRA) includes $19 billion in incentives for the adoption of electronic medical records (EMRs) and $50 billion to promote health information technology. Medicare physicians adopting and making “meaningful use” of EMRs in 2011 and 2012 will be eligible for an initial payment of up to $18,000, with reduced payments in 2013 and 2014. However, current EMR systems’ inability to learn from aggregated health data has led to implementations and hospital information technology departments that can actually obstruct quality improvement. For example, much of the information contained in EMRs is formatted as unstructured free text – useful for essential individual communication but unsuitable for detecting quantifiable trends. This commentary suggests that the Department of Health and Human Services capitalize on the opportunity to mandate EMRs that have the potential to learn from data in the EMR system.
  
  Date: September 9, 2009
• Chronic Care Model Improves VA Care, with Opportunities for More Progress within and Outside VA
  The Chronic Care Model (CCM) has been embraced by many healthcare systems including VA, whose reorganization in 1995 encouraged the type of organizational commitment that the CCM views as vital to providing high quality care for patients with chronic illness. The return on VA’s investment in the CCM is reflected in significant improvements in quality of care. Comparisons of the quality of chronic illness and preventive care between VA and the private sector generally show that VA provides superior quality of care. Looking ahead, the American Recovery and Reinvestment Act (ARRA) contains several provisions with the potential to support the widespread adoption of CCM processes throughout the US healthcare system.
  
  Date: September 1, 2009
• Focus Groups Recommend Strategies to Decrease Missed Test Results
  This paper reports on the efforts of two focus groups that formed as part of the Diagnostic Error in Medicine – A National Conference, which was held by the American Medical Informatics Association in 2008. Clinicians who were part of the focus groups were asked to develop interventions that might decrease the risk of diagnostic delay due to missed test results in the future. The focus groups concluded that while the electronic medical record helps to improve access to test results, eliminating all missed test results would be difficult to achieve. However, they did recommend several strategies that might decrease the rates of missed test results, including: improving standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow-up of test results, and systems re-engineering to improve the management and presentation of data. They also suggest that healthcare organizations focus initial quality improvement efforts on specific tests that have been identified as high-risk for adverse impact on patient outcomes, such as tests associated with a possible malignancy or acute coronary syndrome.
  
  Date: September 1, 2009
• Guideline Concordant Care Improves Outcomes for Veterans with Venous Ulcers
  Using VA data, investigators identified 155 Veterans with 400 venous ulcers who were treated in the VA Puget Sound Healthcare system between 10/03 and 9/07. Using the 2006 Wound Healing Society guidelines for venous ulcers, guideline-concordant care was defined as adherence during at least 80% of patient visits with the use of: dressings creating a moist wound-healing environment, use of a multi-layer compression device (excluding monolayer devices like ace wraps and compression stockings), and ulcer debridement. Findings show that guideline concordant venous ulcer care was significantly associated with venous ulcer healing, when provided at 80% or more of patient visits. The likelihood of ulcer healing increased when compression therapy or a moist wound-healing environment were provided during at least 80% of the visits; debridement alone was not significantly associated with ulcer healing. Veterans who received all three treatments during at least 80% of their visits were more likely to heal than those who received less than 80%. For this cohort of Veterans, a majority of ulcers (n=362) healed, with an average time to healing of 18.1 weeks, which is much better than the reported average of 36 weeks.
  
  Date: September 1, 2009
• Toyota Production System Methodology Leads to Improved Peri-Operative Care in One VAMC
  In the Toyota Production System (TPS) industrial engineering approach, front-line work groups identify problems, experiment with possible solutions, measure the results, and implement strategies to improve quality, resulting in a “ground-up” rather than “top-down” approach to solving system problems. Beginning in 2001, one VAMC instituted TPS methods to reduce Methicillin Resistant Staphylococcus Aureus (MRSA) infections on a general surgical floor. The intervention then evolved to address other areas for QI on the surgical unit, such as increasing appropriate prophylactic peri-operative antibiotic therapy. The aims of this study were to determine: 1) whether the QI intervention for peri-operative antibiotic therapy was associated with improvements in selection and duration of prophylactic therapy; and 2) if the overall MRSA prevention initiative was associated with decreased hospital stay (LOS). Findings show that use of the TPS methodology resulted in a QI intervention that was associated with an increase in appropriate peri-operative antibiotic therapy among surgical patients. The proportion of all surgical admissions in this study (n=2,550) receiving appropriate peri-operative antibiotics was significantly higher in 2004 after initiation of the TPS intervention (44.0%) compared to the previous four years (range 23.4% to 29.8%). Results also showed no statistically significant decrease in LOS over time.
  
  Date: September 1, 2009
• Strategies to Improve Follow-Up for Positive Colorectal Cancer Screening
  In 2006, VA launched a national effort to increase the proportion of patients receiving a colonoscopy within 60 days of a positive fecal occult blood test (FOBT). This study sought to determine the proportion of VA patients with a positive FOBT between March and June of 2007 that received a colonoscopy within 60 days. Investigators also examined data from a 2007 web-based survey that was completed by 132 VAMCs on their FOBT follow-up quality improvement strategies. Results show that only 1 in 4 Veterans received follow-up colonoscopies within 60 days of a positive FOBT for colorectal cancer screening. Findings also show that developing QI infrastructure appears to be an effective strategy for improving FOBT follow-up, when this work is followed by process improvements (e.g., strategies to decrease cancellations, revise colonoscopy prep education protocols). On average, facilities indicated that they had fully implemented 6.84 of 16 improvement strategies. The number of strategies fully implemented was positively associated with 60-day follow-up. The most commonly cited barriers to improvement involved capacity constraints, e.g., sites listing insufficient gastroenterology staff as a barrier had a lower percentage of Veterans receiving timely follow-up. However, none of the improvement strategies designed to address gastroenterology capacity constraints were associated with timely follow-up, suggesting that this barrier may be more difficult or take more time to address than process inefficiencies.
  
  Date: August 1, 2009
• Study Questions Validity of HEDIS Quality Measures for Substance Use Disorder Specialty Care
  Healthplan Employer Data and Information Set (HEDIS) is the most widely used set of quality measures, thus many healthcare systems now track HEDIS measures of Initiation and Engagement in Alcohol and Other Drug Dependence Treatment. Using VA data, this study identified 320,238 Veterans who received at least one of the HEDIS-specified substance use disorder (SUD) diagnoses during FY06. Investigators then developed a model to determine their progression through Initiation and Engagement, with a focus on clinical setting and care specialty. Findings show that Veterans who have contact with SUD specialty treatment have higher rates of advancing from diagnosis to Initiation – and from Initiation to Engagement – compared to Veterans who are diagnosed with substance use disorders in psychiatric or other medical locations. For example, outpatients who were diagnosed in SUD specialty treatment settings were much more likely to “initiate” than those who were diagnosed in psychiatric and other specialty settings. Results also showed that 85% of the Veterans who received an SUD diagnosis in FY06 did so first in an outpatient setting, and that more than 40% of “engagement” occurred outside of SUD specialty care. Therefore, the usual combining of inpatient and outpatient performance on these measures into overall facility scores may affect measurement and interpretation. The authors suggest that these particular quality measures be considered measures of facility performance rather than measures of the quality of SUD specialty care.
  
  Date: August 1, 2009
• Significant Proportion of New Abdominal Aortic Aneurysms are not Recorded in VA’s Electronic Medical Record
  This study examined the frequency with which newly identified abdominal aortic aneurysms were accompanied by evidence of clinician recognition of the abnormality in VA’s electronic medical record. Of the 91 Veterans with abdominal aortic aneurysms newly identified by CT, 60% lacked documentation in their VA electronic medical record within three months of CT detection, and 18% were never documented during an average follow-up of more than three years. Radiologists infrequently notified the clinical teams of aortic abnormalities, and notification did not appear more common for larger as opposed to smaller abnormalities. More than 40% of Veterans with new aortic aneurysms identified on CT scan had no follow-up contact with the provider who ordered the test, suggesting a potential mechanism for missed results. There was no evidence that any of the aneurysms ruptured or that deaths resulted from the delayed follow-up.
  
  Date: July 7, 2009
• Resident Duty Hour Reform has No Systematic Impact on Patient Safety in Teaching Hospitals
  This observational study focused on patients admitted to VA and Medicare acute-care hospitals, examining changes in patient safety events in more vs. less teaching-intensive hospitals before (2000-2003) and after (2003-2005) duty hour reform. Findings show that the implementation of duty hour regulations did not have an overall systematic impact on potential safety-related events in either VA or non-VA (Medicare) hospitals of different teaching intensity. In the few cases where there were statistically significant increases in the relative odds of developing a patient safety event, the increases were too small to be clinically meaningful.
  
  Date: July 1, 2009
• Veterans with Hypertension and Comorbidities Receive Better Care than Veterans with Hypertension Alone
  This study sought to determine the impact of different types of co-existing chronic diseases on quality of care for hypertension, as well as patient perceptions of quality. Findings show that Veterans with hypertension and comorbid conditions had greater odds of receiving good quality of care. Moreover, as the number of chronic conditions increased, so did the odds of receiving appropriate overall care for hypertension. No relationship was found between the provision of guideline-recommended care for hypertension and Veterans’ perception of quality of care, nor did Veterans’ assessment of quality of care vary by the presence of co-existing conditions.
  
  Date: June 16, 2009
• HSR&D Investigators Propose New Measure to Assess Diabetes Care Quality
  This article discusses a conceptual framework for assessing the efficiency of pharmacologic control of three important risk factors for diabetes (glucose, blood pressure, and cholesterol) because of their central role in diabetes management, and policy implications related to higher medication costs. The authors note that a growing body of evidence indicates a need for more flexible measures of diabetes quality of care. Thus, rather than a single optimal threshold approach, they suggest a new framework for measuring quality of care that incorporates the benefit of incremental improvement among multiple populations that differ by age, diabetes duration, and co-existing illness. The new paradigm would assess pharmaceutical efficiency using quality-adjusted life years (QALYs), calculated separately within multiple age/risk categories, as the output (numerator) and acquisition costs of medications as the input (denominator). The QALYs/cost ratio will provide an assessment of the efficiency of pharmacologic utilization. Therefore, measuring efficiency in the treatment of glucose, blood pressure, and cholesterol in persons with diabetes would incorporate the evaluation of a future healthcare benefit that is “purchased” by direct pharmaceutical costs, linking expected healthcare benefits to actual costs.
  
  Date: June 1, 2009
• Comparative Effectiveness Research Initiatives Fall Short without Commitment to Implementation
  President Obama recently signed into law an initiative providing $1.1 billion to support research on the comparative effectiveness of drugs, medical devices, surgical procedures, and other treatments for various conditions. Although comparative effectiveness research (CER) funding has increased, the translation of this investment into practice is very slow, and little attention has been paid to a critical question: Will CER results significantly improve the quality and safety of the healthcare received by the average patient? This Editorial focuses on the issue of translating evidence into practice, as well as existing programs that can serve as models for achieving important implementation research objectives. Authors note that Federal (CER) initiatives will fall short unless they include a commitment to implementation research to help translate findings into high-quality health care. An implementation research and development program could fulfill three important objectives: 1) accelerate the translation of evidence into everyday care; 2) enhance opportunities for healthcare providers and patients to define value (balancing expected benefits with costs); and 3) provide the means for providers and patients to communicate with researchers and policymakers about clinically important issues earlier in the research process. Three programs already exist as models for achieving the aforementioned objectives: 1) VA’s Quality Enhancement Research Initiative (QUERI), 2) VA’s Center for Implementation Practice and Research Support, and 3) the Agency for Healthcare Research and Quality’s (AHRQ) John M. Eisenberg Clinical Decisions and Communications Science Center.
  
  Date: May 7, 2009
• Establishing Appropriate Peer Group Method for Comparing Healthcare Quality
  Measuring and reporting healthcare facility performance via clinical measures of quality has become a major strategic initiative in improving the quality of healthcare. Establishing appropriate peer groups can help make equitable comparisons across hospital or healthcare systems. This study sought to develop a new methodology for constructing customized peer groups for VA medical centers by identifying the “nearest neighbor” medical centers, according to distance from each other and selected characteristics for comparison. Findings show that one of the advantages of the nearest-neighbor method is that the peer groups are more refined, reflecting the multi-dimensional diversity of healthcare providers. Moreover, the nearest-neighbor method incorporates the practical consideration that healthcare facilities or systems may have structural and patient-based differences that cannot be changed, but do affect financial or quality outcomes. Authors suggest that nearest-neighbor peer groups may be more appealing to some researchers and administrators than standard cluster analysis, and thus may strengthen organizational buy-in for financial and quality comparisons.
  
  Date: April 1, 2009
• Multi-faceted Quality Improvement Intervention Improves Follow-up Colonoscopy for Veterans with Positive Colorectal Cancer Screening Test
  Inadequate follow-up of abnormal fecal occult blood test (FOBT) screening for colorectal cancer (CRC) may be related to patient, provider, or system-level factors. Thus, in calendar years 2004 and 2005 the Houston VAMC implemented multi-faceted quality improvement (QI) activities to improve follow-up of positive FOBT results. This study examined the effects of these activities on timeliness and appropriateness of positive-FOBT follow-up for 800 Veterans, and also identified factors that affect colonoscopy performance. Findings show that in cases where a colonoscopy was indicated, the proportion of Veterans who received timely referral and performance was significantly higher after the implementation of the QI activities. In addition, there was a significant decrease in median times to colonoscopy referral and performance. However, colonoscopy was not indicated in more than one-third of Veterans with positive FOBTs, raising concerns about current screening practices and the appropriate performance measures related to CRC screening.
  
  Date: April 1, 2009
• New Process for Quality Improvement Suggests Local Focus on Improving, in Addition to Measuring Quality
  Authors suggest reforming quality improvement (QI) so that instead of a focus on measures with national benchmarks, there is a focus on rewarding local actions that improve quality of care using local norms to guide progress. Quality improvement efforts should be tied to local actions and local results rather than national norms, acknowledging that QI efforts are not generalizable – one size does not fit all. Measures would be tailored to each institution to reflect local core causes. Measurement could remain a key part of local QI initiatives, however, the measurement of core causes and incentives to improve would be conducted at the local sites.
  
  Date: April 1, 2009
• Quality Enhancement Research Initiative Advances Implementation Science
  This Editorial offers a perspective from implementation researchers outside the U.S. about VA/HSR&D’s Quality Enhancement Research Initiative (QUERI) and its impact on and contributions to implementation science.
  
  Date: March 6, 2009
• Taking Stock: Quality Enhancement Research Initiative and Implementation Science
  The Quality Enhancement Research Initiative (QUERI) program and implementation research emerged at the same time – about 10 years ago. This Editorial takes stock of how much both QUERI and implementation science have grown in the intervening decade, and reflects on the opportunities and challenges ahead.
  
  Date: March 6, 2009
• Improving Audit and Feedback Strategies
  Audit and feedback (A&F) furnishes providers with summaries of clinical performance over a specified period of time, offering providers current information and motivation to improve. This study found that A&F has a modest but significant positive effect on quality outcomes. A&F reports containing specific suggestions for performance improvements – delivered in writing, rather than verbally or graphically, and delivered frequently – can noticeably improve the effectiveness of audit and feedback. Also, providing combined group- and individual-level feedback appeared to positively impact feedback effectiveness; however, definitive conclusions could not be made.
  
  Date: March 1, 2009
• Research Agenda for Oral Anticoagulation Quality Measurement
  Efforts to measure the quality of oral anticoagulation care have focused disproportionately on the identification of ideal candidates for warfarin therapy, with little effort in measuring the quality of oral anticoagulation once therapy has begun. To address this knowledge gap, investigators propose a research agenda to advance our understanding of how to measure the quality of care in oral anticoagulation. Authors propose that valid quality indicators will provide a framework for quality improvement that will maximize the effectiveness of therapy and minimize patient harm.
  
  Date: March 1, 2009
• Costs Associated with Providing Depression Care in the Primary Care Setting
  This study reports on organizational costs associated with depression care quality improvement, specifically introducing an evidence-based depression model – Translating Initiatives in Depression into Effective Solutions (TIDES) Project – into VA primary care settings. Findings show that organizational costs for the TIDES project (in the locations studied) were significant, and should be accounted for in planning the implementation of evidence-based depression care.
  
  Date: February 1, 2009
• Hybrid Quality Improvement Approach May Be Best
  There is a growing consensus that a hybrid of two common approaches to quality improvement (QI) – local participatory QI and central expert QI – might be the best method for achieving quality care across a variety of conditions. This study examined preferences of frontline staff and managers participating in HSR&D’s Translating Initiatives for Depression into Effective Solutions (TIDES) project regarding how to engage in QI dialogue and provide practical suggestions for implementation. Many study participants believed that a hybrid of participatory and expert QI models might provide the best formula for improving the quality of care.
  
  Date: February 1, 2009
• Hospital Readmission More Likely Following VA vs. non-VA Hospitalization for Older Veterans Living in Rural and Urban Settings
  Regardless of where veterans lived (urban or rural setting), readmission after a VA hospitalization was more common than readmission after a non-VA hospitalization (20.7% vs. 16.8% for rural veterans; 21.2% vs. 16.1% for urban veterans). Authors suggest that VA consider using unplanned 30-day readmission rates as a component of quality assessment.
  
  Date: January 1, 2009
• Clinically Complex Veterans have Higher Rates of Performance Measurement and Higher Satisfaction with Care
  Veterans with higher clinical complexity had higher measured performance on common process measures used to assess the quality of outpatient care. In addition, satisfaction with care was higher among clinically complex patients with high measured performance, suggesting that compliance with performance measures does not crowd out unmeasured care.
  
  Date: November 1, 2008
• Healthcare Providers Should Adopt Principles of Both Patient Centeredness and Cultural Competence to Meet the Needs of All Patients
  Authors suggest that healthcare organizations and providers should adopt principles of both patient centeredness and cultural competence so that services are aligned to meet the needs of all patients. Moreover, health services researchers should develop measures of cultural competence and patient centeredness and explore the impact of their unique and overlapping components on patient outcomes.
  
  Date: November 1, 2008
• Quality Improvement Collaborative Improves ICU Care for Veterans
  This study focused on two “bundles” (ventilator bundle and central line insertion bundle) – tools designed to facilitate the application of best practices and evidence-based care at the bedside. Using these bundles, the goals were to increase adherence with specific evidence-based ICU practices, and to determine whether this would promote additional and sustained quality improvement across VISN 23. Adherence with all five elements of the ventilator bundle improved to 82% in the final three months of the intervention. The use of a central line insertion checklist to monitor adherence with the central line bundle increased to 74% in the final three months of the intervention. In addition, the implementation of the ventilator and central line bundles was associated with a reduction in rates of ventilator-associated pneumonias and catheter-related blood stream infections, respectively.
  
  Date: November 1, 2008
• Quality Indicators to Help Treat Veterans with HIV and Depression
  Quality indicators were developed based on a review of the existing clinical guidelines for depression, particularly depression related to HIV, in addition to a review of the literature. Authors suggest that quality indicators identified in this study provide a useful tool for measuring and informing the quality of HIV depression care.
  
  Date: October 1, 2008

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 Rehabilitation

• JRRD Single-Topic Issue Reports on Results of First National Survey of Veterans with Traumatic Limb Loss
  This issue of JRRD reports the results of the first nationally representative survey of Vietnam Veterans and service members and Veterans from OEF/OIF who sustained major traumatic limb loss while serving. Members of a Prosthetics Expert Panel, which included 27 professionals from academic and clinical settings, clinicians and researchers from VA and DoD, and three Veterans with limb loss, analyzed Survey findings. Panel members then wrote articles based on the Survey data, presenting survey findings as well as Expert Panel recommendations.
  
  Date: June 1, 2010
• Better Outcomes for Veteran Amputees Receiving Specialized Rehabilitation Compared to Consultative Services
  Veterans who receive specialized rehabilitation can be expected to make comparatively higher gains than Veterans who receive consultative services, regardless of timing and clinical complexity. Advanced age, trans-femoral amputation, paralysis, serious nutritional compromise, and psychosis were associated with lower gains in physical function. Most Veterans (89.1%) received early rehabilitation occurring directly after surgery vs. late rehabilitation beginning during a separate hospitalization after discharge from the index surgical stay. Authors suggest that clinicians consider adjusting prognostic expectations to both clinical severity and the type of rehabilitation patients receive.
  
  Date: April 1, 2010

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 Spinal Cord Injury

• Veterans with Spinal Cord Injury and Pressure Ulcers have More Hospitalizations and Higher Costs of Care
  This study compared the annual healthcare utilization and costs of Veterans with spinal cord injury/disorder (SCI/D), with and without pressure ulcers, who used the VA healthcare system. Findings show that among Veterans with SCI/D, pressure ulcers were associated with greater rates of hospitalization and higher healthcare costs. After adjusting for patient demographics, comorbidities, and other characteristics, total annual healthcare costs per patient were $73,021 higher for Veterans with pressure ulcers and annual hospitalizations were nearly 52 days longer. This represents more than $89 million in total additional costs to the VA healthcare system. Higher total costs were due primarily to higher total inpatient costs for Veterans with pressure ulcers compared to Veterans without pressure ulcers. Factors associated with more total inpatient days included: older age, hospitalization within the 12-month period prior to the index date, and a history of depression.
  
  Date: April 15, 2011
• Mental Illness and Substance Use Disorders Highly Prevalent Among Veterans with Spinal Cord Injury
  Using VA and Medicare data, this study sought to estimate the prevalence of mental illness and substance use disorders (SUDs) among 8,338 Veterans with spinal cord injury (SCI) who used outpatient or hospital care in VA or Medicare facilities between FY00 and FY01. Findings show that mental illness and SUDs are highly prevalent among Veterans with SCI. Overall, 47% of the Veterans in this study had either a mental illness or SUD. The most common mental illness was depression (27%), followed by anxiety (10%) and PTSD (6%). Tobacco use also was prevalent (19%), followed by alcohol (9%) and illicit drugs (8%). Moreover, mood and anxiety disorders were highly prevalent among those with chronic physical conditions such as diabetes, hypertension, and COPD. Results also showed that women Veterans had higher rates of mental illness and lower rates of SUD, and were significantly more likely to have mental illness only. In addition, as the duration of SCI increased, the likelihood of mental illness or SUD alone or in combination decreased.
  
  Date: November 1, 2009
• Bloodstream Infections in Veterans with Spinal Cord Injury May Require Different Treatment Strategies
  Bloodstream infections (BSIs) are a common type of infection in people with spinal cord injury. Bloodstream infections that occur in healthcare settings (e.g., acute care, long-term care) have been traditionally classified as community-acquired, but recent evidence suggests that these infections are distinct and may have a unique epidemiology. This retrospective review assessed characteristics associated with bloodstream infections that were: hospital-acquired (HA BSI), from healthcare contact outside the hospital (HCA BSI), or were community-acquired (CA BSI). Results show that HCA bloodstream infections accounted for 25% of all BSIs in hospitalized Veterans with spinal cord injury. Antibiotic resistance was more common in Veterans with HA BSI (65.5%) compared to those with HCA (49.1%) and CA BSI (22.2%). Methicillin-resistance in Staphylococcus aureus (MRSA) was highly prevalent: 84.5% in Veterans with HA BSI, 60.6% in Veterans with HCA BSI, and 33.3% in Veterans with CA BSI. Because several differences in medical characteristics and causal micro-organisms were found, the authors suggest that treatment and management strategies for HCA and CA infections may need to vary.
  
  Date: August 1, 2009
• Improving Wheelchair Appropriateness for Adults with Spinal Cord Injury
  This study integrated and expanded upon previously published models of wheelchair service delivery to provide a preliminary framework for developing more comprehensive, descriptive models for adults with spinal cord injury (SCI). In this article, ‘wheelchair service delivery’ includes the process of justifying wheelchair selection, approving the selected wheelchair, delivering it to the client, fitting and customizing the wheelchair, and providing follow-up care and consultation. Findings show that most experts stress the importance of having both patients and providers play a key role in the process. For example, the primary patient factors identified were: wheelchair funding source, ability to pay out of pocket, decision-making capacity, self-awareness of needs, familiarity with products, and family influences. Suppliers also play an integral role and may significantly influence the appropriateness of the wheelchair provided. In addition, the authors identified a number of system-level factors (e.g., facility standards, policies, and regulations) that influence wheelchair service delivery.
  
  Date: June 1, 2009
• OEF/OIF Veterans with Spinal Cord Injury and Additional Problems Require Timely Intervention to Avoid Rehabilitation Delays
  Soldiers returning from Iraq and Afghanistan with spinal cord injury often have additional medical and psychosocial problems that require timely intervention to avoid significant delays in rehabilitation. Rehabilitation was often delayed because other problems needed to be addressed first.
  
  Date: March 1, 2009
• Spinal Cord Injury and Alcohol Use are Risk Factors for Osteoporosis Hospitalization
  Spinal cord injury (SCI) is associated with severe osteoporosis, increasing the risk of low-impact fractures that occur in the absence of trauma. Findings from this study show that hospitalization for low-impact fractures was more common in motor complete SCI (no motor function below the neurological level of injury) and was associated with greater alcohol use after injury. Osteoporosis diagnosis, prevention, and management were not included in the treatment plans for any of the Veterans hospitalized with fractures. These findings suggest that future studies should address prevention and treatment of bone loss among Veterans with motor complete SCI.
  
  Date: March 1, 2009
• Barriers to Bone Density Testing for Patients with Spinal Cord Injury
  Several barriers to routine bone mineral density assessment among the SCI population were identified, e.g., scanner design that limits accessibility, and increased scanning time that requires additional staff. To help lessen these barriers, investigators recommend several changes, such as: installing ceiling-mounted hydraulic lifts and grab bars to facilitate transfers in the screening room, increasing staff during scans, and partnering with administrators and staff to raise awareness of access issues faced by individuals with spinal cord injury.
  
  Date: January 1, 2009
• Pain among Veterans with Spinal Cord Injury
  Veterans reported higher rates of pain-related catastrophizing (exaggerated negative interpretations of pain, e.g., “my pain is unbearable and will never get better”). Authors suggest that in clinical settings it may be important to assess and manage catastrophizing as a factor important to the experience of pain and especially the impact of pain on functioning.
  
  Date: October 1, 2008
• Veterans with Spinal Cord Injury Report Frequent Physical and Mental Health Concerns
  Overall, veterans with spinal cord injury (SCI) were much more likely to experience frequent physically and mentally unhealthy days, and frequent days with depression than what has been reported for the general population. In addition, both chronic illnesses and smoking had a substantial effect on health-related quality of life for persons with SCI.
  
  Date: July 1, 2008

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 Substance Use

• Treating Comorbid Substance Use Disorder and PTSD
  This trial sought to determine whether male Veterans with a substance use disorder (SUD) and co-occurring PTSD symptoms in a VA outpatient SUD clinic would benefit from a specialized treatment program for these comorbid disorders. Findings show that Seeking Safety, a manualized treatment approach for substance use disorder, was well received and associated with better drug use outcomes than treatment as usual (TAU) in male Veterans with PTSD. Compared to TAU, Seeking Safety also was associated with increased treatment attendance, client satisfaction, and active coping through treatment. Although these factors may be beneficial for promoting recovery more broadly, neither they – nor reduction in PTSD severity that occurred during treatment – accounted for reductions in drug use among Veterans during the study.
  
  Date: September 16, 2011
• Male Veterans Reporting Sexual Assault are More Likely to Engage in Unsafe Drinking than Veterans with No History of Sexual Assault
  This study explored the rates of sexual assault in male Veterans reporting alcohol misuse – and the potential differences in alcohol use patterns and alcohol-related characteristics in those with and without a history of sexual assault. Findings showed that male Veterans reporting sexual assault are more likely to engage in increased alcohol consumption, experience more lifetime alcohol-related consequences, and have more risk factors for unsafe drinking when compared with their peers who have no history of sexual assault. In addition, the odds of using any illicit substance in the last 90 days were three times higher in the sexual assault group. There also was a two-to-four times greater likelihood of almost all risk factors for unsafe drinking in the sexual assault group. Authors note that SUD treatment settings may be a context in which a history of sexual assault is high and that it may interact with core indicators of treatment success (e.g., psychiatric and physical comorbidities). Therefore, universal sexual assault screening, like the approach in VA, may be relevant for men presenting to SUD treatment settings.
  
  Date: September 1, 2011
• Differences in Communication between Providers in VA Mental Health Clinics and General Medical Providers in Treating Veterans with Serious Mental Illness
  Integrated care for co-occurring substance use and general medical disorders is considered essential for improving quality of care for individuals with serious mental illness (SMI), and is one of VA’s priority goals. This study sought to describe the barriers and facilitators of integrated care (from the perspective of mental health providers) for nearly 20,000 Veterans with SMI. Findings show that mental health providers from VA mental health clinics with high versus low quality of care scores differed in their ability to communicate with general medical providers regarding care for Veterans with SMI. Among mental health providers from low-performing sites, lack of communication with primary care providers was a key barrier. Barriers to communication included lack of opportunities to interact on a face-to-face basis and lack of opportunities to have team meetings. In addition, they were concerned that primary care providers did not want to see patients with SMI because of the perception that they were difficult to treat. Stigma was not mentioned as a problem for providers among the high-performing sites, with general medical providers viewed as sensitive to the needs of Veterans with SMI. The authors suggest that these findings indicate that efforts to improve communication between mental health and primary care providers, as well as delineating roles and responsibilities across both types of providers may potentially facilitate integrated medical care for Veterans with serious mental illness.
  
  Date: July 7, 2011
• Journal Section Focuses on Implementing Evidence-Based Interventions for Substance Use Disorders
  This article introduces a special section of Psychology of Addictive Behaviors, which provides an overview of conceptual frameworks for and research on the implementation of evidence-based practices and treatments for substance use disorders (SUDs). The types of treatments that are examined range from brief interventions to psychological treatments and continuing care to pharmacological treatment. The settings in which treatments are implemented range from primary care to specialty SUD care settings.
  
  Date: June 1, 2011
• Women Veterans with History of Sexual Abuse at Higher Risk for Substance Use Disorder
  This study examined the associations between rape history and substance use disorders among women Veterans (age <51 years) who received care at two Midwestern VAMCs. Findings showed that lifetime substance abuse disorder was higher for women Veterans with a history of rape. Two-thirds (62%) of study participants reported lifetime sexual assault, including 11% reporting attempted rape and 51% reporting at least one completed rape. Women with women as sex partners had significantly higher rates of rape and lifetime substance use disorder (73% of women with women as sex partners reported lifetime rape vs. 48% of exclusively heterosexual women). Women with lifetime rape were more likely to report abstinence from drinking (50%) than women with no rape (41%). Women reported the highest rates of rape during childhood and military service (51% and 25%, respectively), and those reporting rape in any period of their lives were significantly more likely to report rape in other periods. For example, women Veterans reporting in-military rape were significantly more likely to report post-military rape (18% vs. 9%).
  
  Date: June 1, 2011
• Rates of Accidental Poisoning among VA Patients Higher than General Population
  This study describes the rate of accidental poisoning mortality among Veterans who used VA healthcare services, compares this rate to the general U.S. population, and describes the drugs/medications involved. Findings show that for FY05, VA patients had nearly twice the rate of fatal accidental poisoning compared to adults in the general population. Among VA patients who died from accidental poisoning, opioid medications (including methadone) made up 32% of the reported deaths; cocaine also was common at 23%. In both the VA and U.S. general populations, the rate of accidental poisoning mortality was higher for men than women, and higher for individuals ages 30 to 64 as compared to those ages 18 to 29, or ages 65 and older. Although VA patients have a greater risk of suicide than death by accidental poisoning, their risk for accidental poisoning death relative to the general population is larger than that of suicide.
  
  Date: April 1, 2011
• Complications Following Total Joint Arthroplasty Significantly Related to Pre-Operative Alcohol Misuse among Veterans
  This study evaluated the association between a standardized, pre-operative alcohol screening score (AUDIT-C [Alcohol Use Disorders Identification Test – Consumption]) and the risk of post-operative complications in Veterans who underwent total joint arthroplasty at one VA facility between 2004 and 2007. Findings show that complications following total joint arthroplasty were significantly related to alcohol misuse. Of the 185 Veterans in this study, 32 had alcohol screening scores suggestive of alcohol misuse, and 12 Veterans had at least one post-operative complication. Therefore, AUDIT-C scores signified a 29% increase in the expected mean number of complications with every additional AUDIT-C point above 1. The authors suggest that pre-operative alcohol misuse screening, and perhaps pre-operative counseling or referral to treatment for heavy drinkers, may be indicated for patients undergoing total joint arthroplasty.
  
  Date: February 1, 2011
• Rates of PTSD and Depression Highly Prevalent among OEF/OIF Veterans with Alcohol and/or Drug Use Disorders
  This study sought to determine the prevalence and independent correlates of alcohol use disorders (AUD) and drug use disorders (DUD) among OEF/OIF Veterans who were first-time users of VA healthcare. Findings show that, overall, 11% of the OEF/OIF Veterans in this study received diagnoses of AUD, DUD, or both; 10% received AUD diagnoses and 5% received DUD diagnoses. Post-deployment AUD and DUD diagnoses were more prevalent in particular sub-groups of OEF/OIF Veterans and were highly comorbid with PTSD and depression. Among Veterans diagnosed with AUD, DUD, or both, 55% to 75% also received a diagnosis of PTSD or depression. AUD, DUD, or both diagnoses were 3 to 4.5 times more likely among Veterans with PTSD and depression. AUD and DUD diagnoses were more prevalent among Veterans younger than age 25, men, and Veterans who were more likely to have had greater exposure to combat, e.g., Veterans who were enlisted versus officers, and those who served in the Army and Marines.
  
  Date: January 28, 2011
• Alcohol Screening Results Up to One Year Prior to Surgery Associated with Increased Post-Operative Complications for Veterans
  This study evaluated whether results of alcohol screening with the AUDIT-C (Alcohol Use Disorders Identification Test – Consumption), administered up to one year before surgery, were associated with the risk of post-operative complications in Veterans undergoing major non-cardiac surgery in VA. Findings showed that AUDIT-C scores of 5 or higher up to one year before surgery were associated with increased post-operative complications. Overall, 16% of the total study population screened positive for alcohol misuse with AUDIT-C scores >5, and 8% had post-operative complications. There also was a dose-response relationship between AUDIT-C scores and post-operative complications, with complications increasing from 6% among low-risk drinkers to 14% among Veterans with the highest AUDIT-C scores. The authors suggest that AUDIT-C scores could be electronically loaded into surgery consults, surgery clinic notes, or pre-operative templates in VA’s computerized patient record system in order to alert clinicians to alcohol misuse at the time of referral to surgery.
  
  Date: September 28, 2010
• VA’s Brief Alcohol Intervention Strategy Successful
  This study evaluated the prevalence of documented brief interventions among VA outpatients with alcohol misuse before, during, and after implementation of a national performance measure linked to incentives and dissemination of an electronic clinical reminder for brief interventions. Findings show that VA’s strategy of implementing brief alcohol interventions with a performance measure supported by a clinical reminder meaningfully increased documentation of brief interventions over a one-year period. Among Veteran outpatients with alcohol misuse, the prevalence for brief interventions increased significantly over successive phases of implementation – from 5.5% at baseline – to 7.6% after announcement of the brief intervention performance measure – to 19.1% following implementation of the measure – to 29% following dissemination of the clinical reminder. Brief interventions increased among patients without prior alcohol use disorders or addictions treatment, as well as those with recognized drinking problems, with proportionately greater increases among the former group after clinical reminder dissemination.
  
  Date: September 28, 2010
• Validated Alcohol Screening Questionnaire Not Enough to Ensure Quality of Screening
  This study evaluated the quality of clinical alcohol screening among VA outpatients by comparing Alcohol Use Disorders Identification Test - Consumption Questions (AUDIT-C) results documented during routine clinical care to AUDIT-C results from a confidential mailed survey completed within 90 days of the clinical screen. Of the national sample, 61% of VA outpatients who screened positive for alcohol misuse with the AUDIT-C on mailed surveys screened negative during the same time period with the AUDIT-C in VA outpatient clinical settings. Overall, 11% of Veterans screened positive on the survey screen vs. only 6% on the clinical screen. Patients who screened positive on the AUDIT-C survey were much more likely to have discordant clinical screening results, e.g., among patients whose clinical screens indicated no alcohol use in the past year, 22% reported drinking on the survey screens. Discordance was significantly increased among African American Veterans compared with white Veterans. There were also differences across VA networks: the proportion of Veterans with positive survey screens who had negative clinical screens varied from 43% to 100% across different networks.
  
  Date: September 22, 2010
• Negative Emotionality May Contribute to Worse Post-Deployment PTSD and Poorer Intimate Relationships among National Guard Iraq War Soldiers
  This study examined the contribution of the pre-existing personality trait of negative emotionality (NEM) and comorbid problem drinking to the association between post-deployment PTSD symptoms and relationship distress among combat-exposed OIF National Guard soldiers. Findings show that NEM predisposes combat-exposed soldiers to more severe PTSD symptoms, which, in turn, contribute to poorer intimate relationships. Higher levels of pre-existing NEM predicted higher levels of post-deployment PTSD symptoms. Soldiers with probable PTSD were more likely to experience relationship distress than those without probable PTSD. Soldiers with positive hazardous drinking screens were more likely to screen positive for PTSD than those with negative drinking screens, however, those with positive drinking screens were no more likely to experience relationship distress than those with negative drinking screens.
  
  Date: September 16, 2010
• Homelessness Affects Substance Use Treatment Outcomes and Costs among Veterans
  This analysis evaluated homelessness among Veterans who had entered VA outpatient substance use disorder treatment, and also explored associations between housing status, treatment outcomes, and use of VA services over one year. Findings suggest that the problem of homelessness among Veterans with substance use disorders remains large, with 65% of 622 Veterans in this study spending at least one night homeless at some point during the study period. Veterans experiencing homelessness during the six months prior to treatment admission had more severe alcohol, medical, employment, legal, and psychiatric problems than Veterans with housing. Abstinence rates did not differ between the homeless and housed groups, and about 65% of participants in each group remained engaged in treatment for 90 days. In addition, results showed that homeless Veterans used more services and had higher total costs than housed Veterans, e.g., homeless Veterans had more inpatient admissions and were more likely to use the emergency room.
  
  Date: July 1, 2010
• Most VA Patients with Substance Use Disorders Who Die from Suicide Use Violent Means
  Most VA patients with substance use disorders (SUDs) who died from suicide used violent means (70%, n=600), and the majority were carried out with firearms. No specific SUD was associated with increased risks of violent suicide, but several SUD diagnoses (e.g., cocaine use and opiate use) were associated with a higher risk of non-violent suicide. Alcohol use was associated with a lower likelihood of non-violent suicide. While many psychiatric disorders (e.g., major depression, PTSD, schizophrenia) were associated with increased risk of both violent and non-violent suicide, the strength of the association between the disorder and type of suicide was greater for non-violent than violent suicide. The authors suggest that by linking data on risk factors to information about the specific methods used, future interventions designed to decrease access to lethal means could be tailored to focus on those at greatest risk of dying by specific means.
  
  Date: July 1, 2010
• Pharmacotherapy May Be Underused for Veterans with Alcohol Addiction
  In FY06 and FY07, only about 3% of more than a quarter of a million VA patients with alcohol use disorders received treatment with one of four drugs specifically approved for treating alcohol dependence. [This apparent underutilization is not unique to VA, as utilization rates are within the range of rates reported in other settings.] Receipt of pharmacotherapy was more likely among Veterans receiving specialty addiction care, Veterans with alcohol dependence (vs. abuse), Veterans younger than 55 years old, and women. SSRI antidepressants were used about five times as often as alcohol use disorder medications in Veterans with an alcohol use disorder but without a psychiatric indication for SSRIs.
  
  Date: April 1, 2010
• Prior Violence Associated with Greater Risk of Suicidal Thoughts and Attempts in Patients Seeking SUD Treatment
  Even after accounting for other known risk factors, such as symptoms of depression or childhood victimization, a history of violent behavior was consistently associated with a higher likelihood of lifetime suicidal thoughts and behaviors. Suicidal thoughts and attempts are common in those with substance use disorders (SUD): more than 43% of the participants in this study reported either prior suicide attempts or suicidal ideation at some point in their lives. A history of either suicidal ideation or suicide attempt(s) was more common among substance users who were female and those with a history of depression or childhood abuse.
  
  Date: February 1, 2010
• Candidate Quality Measures for VA Alcohol Use Disorder Treatment
  The goal of this study was to identify patterns of VA care that are associated with both facility- and patient-level outcomes in order to develop a new process-of-care measure for VA outpatient alcohol use disorder (AUD) treatment quality. Findings show that nine candidate process measures of outpatient AUD treatment quality can predict facility-level and patient-level improvement. The candidate measures with the strongest association with improvement in outcomes focused on Veterans who received 3 to 6 outpatient visits in the first month of care. Results also showed that while the literature indicates that longer duration of care should produce better patient outcomes, the investigators found no such link with overall outcomes.
  
  Date: December 1, 2009
• Effectiveness of Residential Substance Use Disorder Programs in Treating Veterans with SUDs and Mental Illness
  This study compared processes and outcomes for alcohol-dependent Veterans with and without comorbid psychiatric illness at one and five years following treatment in 15 residential substance use disorder (SUD) treatment programs affiliated with VA. Findings show that dually-diagnosed (DD) Veterans did not perceive SUD programs as positively as Veterans with SUD alone, and DD Veterans had worse proximal outcomes at discharge from treatment. For example, DD patients saw fewer benefits to quitting and had less self-efficacy in regard to staying abstinent. Results also showed that dually-diagnosed Veterans did as well as SUD patients on 1-year and 5-year substance use outcomes but had worse psychiatric outcomes. Veterans from both groups who perceived treatment more positively and had better outcomes at discharge had better longer-term outcomes; however, DD patients perceived the programs to be less supportive and clear, and were less satisfied with treatment. The authors suggest that SUD programs either need to add resources directed toward treating psychiatric problems, or that DD Veterans need to be treated in sequential or integrated programs. They note, however, that standard SUD programs may offer more components of integrated treatment than standard psychiatric programs do.
  
  Date: December 1, 2009
• Mental Illness and Substance Use Disorders Highly Prevalent Among Veterans with Spinal Cord Injury
  Using VA and Medicare data, this study sought to estimate the prevalence of mental illness and substance use disorders (SUDs) among 8,338 Veterans with spinal cord injury (SCI) who used outpatient or hospital care in VA or Medicare facilities between FY00 and FY01. Findings show that mental illness and SUDs are highly prevalent among Veterans with SCI. Overall, 47% of the Veterans in this study had either a mental illness or SUD. The most common mental illness was depression (27%), followed by anxiety (10%) and PTSD (6%). Tobacco use also was prevalent (19%), followed by alcohol (9%) and illicit drugs (8%). Moreover, mood and anxiety disorders were highly prevalent among those with chronic physical conditions such as diabetes, hypertension, and COPD. Results also showed that women Veterans had higher rates of mental illness and lower rates of SUD, and were significantly more likely to have mental illness only. In addition, as the duration of SCI increased, the likelihood of mental illness or SUD alone or in combination decreased.
  
  Date: November 1, 2009
• Subjective Reactions to Cannabis Use Associated with Use and Dependence
  Using data from VA’s Vietnam Era Twin Registry (VETR), investigators in this study were able to adjust for genetic and environmental factors while assessing the effects of cannabis use on 464 VETR offspring (adolescents and young adults age 12-32). These offspring were then categorized into four classes (or subsets) of cannabis responders: high (39%), positive (28%), mixed/relaxed (22%), and low (11%). Findings show that cannabis use, abuse, and dependence is associated with the type of subjective response even after adjusting for genetic influence and environmental factors, as well as demographic and psychiatric variables. For example, compared to mixed/relaxed responders and positive responders, high responders were more likely to have cannabis abuse and dependence. In addition, compared to low responders, members of the other three classes were heavier users of cannabis. Among sociodemographic variables, only male gender was associated with subjective response, as evidenced by a lower prevalence of males in mixed/relaxed and low responder classes as compared to high and positive responder classes.
  
  Date: November 1, 2009
• Substance Abuse is Strongest Predictor of Suicide among Veterans with Depression
  This study was an analysis designed to derive an empirically-based set of interactions related to rates of suicide in a national sample of VA patients diagnosed with depression. Findings show that among Veterans with depression those at highest risk for suicide have the combined risk factors of a substance use disorder (SUD), non-African American race, and a psychiatric inpatient stay in the past 12 months. Substance use disorder was also identified as the strongest single risk factor for suicide. Among Veterans without a substance use disorder, gender was the strongest predictor of suicide risk – rates were significantly higher for men than for women. Ethnicity also was related to suicide risk in this group. African American Veterans without an SUD were less likely to die by suicide compared to non-African American Veterans. The authors suggest that providers treating patients with these characteristics should be aware of these risks and consider target strategies to screen for current suicidal ideation.
  
  Date: November 1, 2009
• Low Rates of HIV Screening among Veterans with Substance Use Disorders
  This study sought to determine the rate of HIV screening among Veterans with substance use disorders. Findings show that among the 371,749 Veterans with substance use disorders in this study, only 20% had evidence of ever having been screened for HIV. HIV screening was lowest among Veterans with alcohol use disorders alone (11%), and highest among Veterans treated in substance use programs (28%) or receiving inpatient care (28%). Authors suggest that these findings support the need for more widespread interventions to expand routine voluntary HIV screening nationally – within and outside VA.
  
  Date: October 1, 2009
• Study Questions Validity of HEDIS Quality Measures for Substance Use Disorder Specialty Care
  Healthplan Employer Data and Information Set (HEDIS) is the most widely used set of quality measures, thus many healthcare systems now track HEDIS measures of Initiation and Engagement in Alcohol and Other Drug Dependence Treatment. Using VA data, this study identified 320,238 Veterans who received at least one of the HEDIS-specified substance use disorder (SUD) diagnoses during FY06. Investigators then developed a model to determine their progression through Initiation and Engagement, with a focus on clinical setting and care specialty. Findings show that Veterans who have contact with SUD specialty treatment have higher rates of advancing from diagnosis to Initiation – and from Initiation to Engagement – compared to Veterans who are diagnosed with substance use disorders in psychiatric or other medical locations. For example, outpatients who were diagnosed in SUD specialty treatment settings were much more likely to “initiate” than those who were diagnosed in psychiatric and other specialty settings. Results also showed that 85% of the Veterans who received an SUD diagnosis in FY06 did so first in an outpatient setting, and that more than 40% of “engagement” occurred outside of SUD specialty care. Therefore, the usual combining of inpatient and outpatient performance on these measures into overall facility scores may affect measurement and interpretation. The authors suggest that these particular quality measures be considered measures of facility performance rather than measures of the quality of SUD specialty care.
  
  Date: August 1, 2009
• Mental Health Diagnoses among OEF/OIF Veterans Increased Rapidly Following Invasion of Iraq
  This study sought to investigate longitudinal trends and risk factors for mental health diagnoses among OEF/OIF Veterans. Findings show that the prevalence of new mental health diagnoses among OEF/OIF Veterans using VA healthcare increased rapidly following the Iraq invasion. Among the 289,328 Veterans in this study, new mental health diagnoses increased 6-fold from 6.4% in April 2002 to 36.9% by March 2008. 21.8% of Veterans were diagnosed with post-traumatic stress disorder (PTSD), and 17.4% with depression. Two-year prevalence rates of PTSD increased 4-7 times after the invasion of Iraq. The youngest active duty OEF/OIF Veterans (< 25 years) were at nearly twice the risk for PTSD, more than twice the risk for alcohol use disorders, and at a nearly 5-fold risk for drug use disorders than older active duty Veterans (> 40 years). Among National Guard/Reserve Veterans, those older than age 40 were at greater risk for PTSD and depression. Women Veterans from both service components (active duty and Guard/Reserve) were at higher risk for depression, while male Veterans were at greater risk for drug use disorders. Authors suggest that early targeted interventions may prevent chronic mental illness.
  
  Date: July 16, 2009
• Alcohol Screening Scores Predict Fracture Risk
  The Alcohol Use Disorder Identification Test – Consumption (AUDIT-C) is a three-item screen that can be routinely administered to primary care patients and has been widely adopted for alcohol screening. Research is needed to determine whether it might be valid for purposes other than screening, such as predicting alcohol-related health problems such as osteoporotic and other bone fractures. This study examined the association between AUDIT-C scores and the risk for fractures among Veterans who received care at seven VA primary care clinics across the country. Findings show that after adjusting for comorbidities and demographics, having an AUDIT-C score of 10 or greater was associated with doubling the risk of an osteoporotic fracture compared to AUDIT-C scores of 1 to 3, while an AUDIT-C of 6 or greater was associated with about a 1.5-fold increase in the risk of a fracture that was not typical of osteoporosis. This suggests that alcohol screening scores could help clinicians quickly assess and provide feedback to patients on their alcohol-related fracture risks, much the way other screening tests (e.g. blood pressure or lipids) are used.
  
  Date: July 1, 2009
• High Rates of Violence among Substance Abusers
  This study examined violence related to SUD, as well as potential violence prevention treatment needs for men and women patients (non-Veterans) in SUD treatment settings. Investigators looked specifically at violence resulting in injury toward partners and non-partners, as well as against individuals in treatment. Findings show that rates of injury across relationship types were substantial, with more than 54.8% reporting injuring another person, and 55.4% reporting being injured. Further, there was a strong association between injuring others and being injured. Overall, those reporting injuring others had significant psychosocial challenges in terms of low rates of employment, low household income, relatively few prior SUD treatment visits on average, and most participants did not have prior “anger-management/domestic violence” treatment. Moreover, those injuring or reporting injury by others had higher rates of problems (e.g., binge drinking, opiate use, depression) than those in the non-injury groups.
  
  Date: July 1, 2009
• Smoking Cessation Services for Veterans in VA Psychiatric Facility
  This study had two goals: 1) determine staff characteristics that are associated with attitudes about providing smoking cessation services to Veterans who are psychiatric patients, and 2) seek suggestions from staff about what would be important to include in a tobacco cessation program. Findings show that nearly 75% of staff in this study thought that VA should do more to assist Veterans to quit smoking, yet only about 25% said that they personally provide cessation services. However, more than 50% felt moderately, very, or extremely confident in providing cessation services. Interestingly, nurses were less likely than other staff to feel that it was important to provide cessation services, which could be because of competing job demands. The most common reasons given by all respondents for not providing services were not enough time and lack of training. When asked how VA could best assist smokers to quit, most responses focused on educating Veterans about tobacco use and how they can quit, as well as providing tobacco cessation medications.
  
  Date: June 1, 2009
• VA Treatment for Drinking Problems in Primary Care vs. Referral-Based Management
  Relying upon the Chronic Care Model, this study identified organizational factors that distinguish primary care (PC) practices using PC-based approaches versus referral-based management of Veterans with drinking problems in the VA healthcare system. Findings show that PC- and referral-based practices did not differ on the sufficiency of their structural resources, physician staffing, or on the availability of specialty services. However, PC-based practices were found to take more responsibility for managing Veterans’ chronic conditions and had more staff for decision support activities.
  
  Date: June 1, 2009
• Alcohol Misuse and Counseling among Minority Veterans
  This study sought to describe alcohol consumption across race and ethnicity groups among Veterans treated in VA during FY05, and examine associations between race and ethnicity and receipt of alcohol-related advice by clinicians. Findings show that overall, less than one-third of patients who drank at all and one-third of patients with positive alcohol misuse screens reported receiving alcohol-related advice. After adjusting for demographics, health status, and alcohol consumption, Veterans who self-identified as black, Hispanic, or American Indian/Alaska Native were more likely to report receiving alcohol-related advice from their VA healthcare providers compared to non-Hispanic whites. In addition, women and older Veterans were less likely to receive alcohol-related advice than their male and younger counterparts, respectively.
  
  Date: May 1, 2009
• Continuity of Care Performance Measure Not Associated with Improved Outcomes for Veterans with Substance Use Disorders
  The Continuity of Care (CoC) performance measure specifies that patients should receive at least two substance use disorder (SUD) outpatient visits in each of the three consecutive 30-day periods after they qualify as new SUD patients. Findings from this study show that meeting the CoC performance measure was not associated with patient-level improvements in the Addiction Severity Index (ASI) alcohol or drug composites, days of alcohol intoxication, or days of substance-related problems. Higher facility-level rates of CoC were negatively associated with improvements in ASI alcohol and drug composites – and were not associated with follow-up abstinence rates.
  
  Date: April 1, 2009
• Study Suggests Additional Interventions for Veterans with SUD and History of Abuse
  Men with a history of physical or sexual abuse had more severe drug problems at intake, but by six months there were no group differences in drug use. However, veterans with a history of sexual abuse had more severe psychiatric problems at all time points and were more likely to report significant suicidality at intake and 6 month follow-up. This suggests that additional interventions may be warranted for veterans with SUD and a history of sexual abuse. Also, routine screening for suicidality in SUD treatment programs may be warranted given the prevalence of lifetime sexual abuse among SUD patients and the relationship between sexual abuse and attempted suicide.
  
  Date: December 1, 2008
• Is Music Therapy Efficacious in Treating Patients with Addictions?
  Investigators reviewed the literature to evaluate the evidence that music therapy improves outcomes of patients with addictions. Findings show that few descriptions of music therapies, and even fewer studies reporting outcomes of music therapies exist for the treatment of patients with addiction. Investigators found only 19 articles that either described music therapy or were music therapy studies. Moreover, of the existing literature there was no consensus regarding the effects of music therapy on outcomes for patients with addictions.
  
  Date: November 1, 2008
• Factors that Contribute to Cannabis Abuse and/or Dependence among Young Adults
  Using data from a study of twin members of the Vietnam Era Twin Registry, their biological offspring, and mothers, findings show that cannabis abuse and dependence (CAD) was significantly more likely among male offspring. Offspring cannabis use/dependence was associated with siblings’ use of illicit drugs (with or without cannabis, but not cannabis only), as well as friends’ and peers’ use of drugs. Female gender was associated with reduced risk of young adult CAD.
  
  Date: October 1, 2008
• Treatments for Co-Occurring Schizophrenia and Substance Use Disorders
  While studies to date suggest better outcomes with second-generation antipsychotics (SGAs), for example, olanzapine and risperidone, the available evidence does not clearly demonstrate an advantage for any particular SGA; thus investigators recommend that clinicians select the medication that balances efficacy and side effects for each individual patient.
  
  Date: October 1, 2008
• Continuity of Care Improves Abstinence among Veterans with Substance Use Disorder
  The use of outpatient mental health services in the year prior to treatment and the staff's continuity of care practices were the most important factors for increasing abstinence rates, while engagement in continuing care was a key post-treatment factor. Veterans also were more likely to be abstinent when staff provided continuing care appointments prior to discharge, developed discharge plans that called for patients to attend continuing care at least once a week, and arranged drug-free and sober living arrangements.
  
  Date: September 1, 2008
• Mental Illness and Substance Use Costs among Veteran Clinic Users with Diabetes
  Alcohol and drug use among veterans with diabetes increased healthcare costs due to greater use of inpatient services, regardless of the presence or severity of mental illness.
  
  Date: July 1, 2008

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 Surgery

• Depression and Race may Independently Affect Receipt of Some Surgeries
  This study examined race and ethnicity as factors potentially associated with surgeries experienced by Veterans with and without major depressive disorder (MDD). Findings show that Veterans with pre-existing MDD were less likely to undergo digestive, hip/knee, vascular, or CABG surgeries than Veterans without MDD. Minority Veterans were slightly less likely to receive vascular operations compared to white Veterans, but were more likely to undergo digestive system procedures. The effect of depression was independent of race and ethnicity; thus, depression and race would have an additive but not synergistic effect on the odds of receiving surgery. In addition, a gender effect was noted: women Veterans were more likely to have digestive procedures but were less likely to undergo CABG or vascular operations. Authors note that the lack of information regarding severity of illness makes it difficult to determine whether or not diagnostic differences explain differences in surgery.
  
  Date: October 1, 2011
• Adherence to National Prevention Measures for Surgical Site Infection Does Not Impact VA Surgical Outcomes
  This study evaluated whether the Surgical Care Improvement Project (SCIP) improved surgical site infection (SSI) rates at the VA patient or hospital level. Findings showed that none of the 5 SCIP infection prevention measures were significantly associated with lower odds of SSI among Veterans after adjusting for variables known to predict SSI and procedure type. Individual hospital SCIP performance also was not associated with hospital SSI rates. While adherence to SCIP measures improved, risk-adjusted SSI rates remained stable. For Veterans with all measures assessed, the composite rate of adherence was 81%. Although SCIP measures are best practices and should continue, they may not discriminate hospital quality. Mandatory SCIP reporting without improvement in care may lead to health professional skepticism and fatigue with quality improvement measures.
  
  Date: September 1, 2011
• Adverse Post-Operative Events More Common among Current Veteran Smokers Compared with Prior or Non-Smokers
  This study assessed the attributable risk and potential benefits of smoking cessation on surgical outcomes for Veterans who underwent non-cardiac, elective surgery in a VA hospital between 2002 and 2008. Findings showed that compared with both never and prior smokers – and controlling for patient and procedure risk factors – Veterans who were current smokers had significantly more post-operative pneumonia and surgical-site infection, despite being younger and having fewer comorbidities. Moreover, current smokers had increased odds of dying up to one year after surgery compared with prior smokers or Veterans who had never smoked. There was a dose-dependent increase in pulmonary complications based on pack-year exposure (one pack-year equals smoking 20 cigarettes a day for one year), with greater than 20 pack-years leading to a significant increase in smoking-related surgical complications. Previous literature suggests that pre-operative quit smoking interventions may reduce the risk of post-operative complications. Authors suggest that smoking cessation intervention be considered for Veterans who are current smokers, with greater than 20 pack-years of exposure, who undergo major surgical procedures.
  
  Date: August 24, 2011
• Natural Language Processing with Electronic Medical Record Improves Identification of VA Post-Operative Complications
  This study evaluated a natural language processing (NLP) search approach to detect post-operative surgical complications within VA’s electronic medical record (EMR). Findings showed that, among Veterans undergoing inpatient VA surgery, NLP using the EMR greatly improved the identification of post-operative complications compared to an administrative-code based algorithm. NLP correctly identified 82% of acute renal failure cases compared with 38% for patient safety indicators; 59% vs. 46% for venous thromboembolism; 64% vs. 5% for pneumonia; 89% vs. 34% for sepsis; and 91% vs. 89% for post-operative MI. An accompanying Editorial states that NLP has the potential to greatly enhance the EMR with new applications, such as automated quality assessment to assist in the performance of comparative effectiveness research.
  
  Date: August 24, 2011
• Excess Cost Associated with Post-Operative Complications among Veterans in VA Hospitals
  This study estimated excess costs associated with post-operative complications among inpatients treated in VA hospitals. Findings showed that among Veterans who survived to discharge, excess costs associated with post-operative complications were found to be considerable. Veterans experiencing complications had inpatient costs that ranged from 3% to 120% higher (for “cardiac arrest requiring CPR” and “failure to wean,” respectively) than those without complications. Among the 16 complications that were significantly related to cost, the estimated excess costs ranged from $8,234 for “progressive renal insufficiency” to $28,779 for “failure to wean from ventilator within 48 hours.” Results suggest that directing efforts toward reducing complications such as cerebral vascular accidents, sepsis, acute renal failure, and failure to wean, each of which incurred excess costs of greater than $20,000, might have high value.
  
  Date: August 1, 2011
• Bariatric Surgery Does Not Decrease Mortality among Obese Veterans
  This study sought to determine whether bariatric surgery is associated with reduced mortality among Veterans, who are older and predominantly male compared to prior studies. Findings showed that in a matched cohort of obese, high-risk, predominantly male Veterans (847 who underwent surgery and 847 non-surgical controls), bariatric surgery was not significantly associated with a survival benefit during a median of 6.7 years of follow-up. In unmatched comparisons of 850 Veterans who underwent bariatric surgery and 41,244 Veterans who did not, those in the surgical group were significantly younger, had higher BMIs, and had greater comorbidity burden. Surgical patients also were more likely to be super-obese. However, analyses after matching reduced the significant differences in characteristics between surgical and control patients. These analyses also controlled more closely for time of follow-up and showed that the protection conferred by surgery was small and not statistically significant after 6.7 years.
  
  Date: June 15, 2011
• Increased Wait Times for Surgical Cancer Treatment, Particularly at VA Medical Centers and NCI Cancer Centers
  This study sought to assess changes in wait times for initial cancer treatment over a decade (1995 - 2005) and to identify patient, tumor, and hospital factors associated with prolonged wait times, using data from National Cancer Institute (NCI)-designated cancer centers, VA medical centers, academic hospitals, and community hospitals. Findings show that wait times for cancer treatment progressively increased at all four hospital center types over the 10-year study period. The median time from diagnosis to treatment was significantly longer at VA medical centers and NCI-designated cancer centers compared to community hospitals for all eight cancers studied. For patients who were diagnosed and treated at the same hospital, the median time from diagnosis to treatment was longest at VA medical centers, and shortest at community hospitals. Patients were significantly more likely to undergo initial treatment more than 30 days following diagnosis if they were: older, African American, had more comorbidities, had Stage I disease, or were treated at NCI cancer centers or VA medical centers.
  
  Date: February 25, 2011
• Complications Following Total Joint Arthroplasty Significantly Related to Pre-Operative Alcohol Misuse among Veterans
  This study evaluated the association between a standardized, pre-operative alcohol screening score (AUDIT-C [Alcohol Use Disorders Identification Test – Consumption]) and the risk of post-operative complications in Veterans who underwent total joint arthroplasty at one VA facility between 2004 and 2007. Findings show that complications following total joint arthroplasty were significantly related to alcohol misuse. Of the 185 Veterans in this study, 32 had alcohol screening scores suggestive of alcohol misuse, and 12 Veterans had at least one post-operative complication. Therefore, AUDIT-C scores signified a 29% increase in the expected mean number of complications with every additional AUDIT-C point above 1. The authors suggest that pre-operative alcohol misuse screening, and perhaps pre-operative counseling or referral to treatment for heavy drinkers, may be indicated for patients undergoing total joint arthroplasty.
  
  Date: February 1, 2011
• VA Patient-Provider Communication Does Not Contribute to Racial Disparities in Use of Total Joint Replacement
  This study examined whether there were racial differences in patient-provider communication about treatment of chronic knee/hip osteoarthritis in African American and white Veterans referred to two VA orthopedic clinics over a 3-year period. Findings show that communication between VA orthopedic surgeons and patients regarding the management of chronic knee/hip osteoarthritis did not, for the most part, vary by patient race. No racial differences were observed with regard to length of visit, overall amount of dialogue, discussion of psychosocial issues, Veteran activation/engagement statements, physician verbal dominance, display of positive affect by Veterans or providers, or discussion related to informed decision-making. However, visits with African American Veterans contained less discussion of biomedical topics and more rapport-building statements than visits with white Veterans. These findings diminish the potential role of communication in VA orthopedic settings as an explanation for racial disparities in the use of total joint replacement.
  
  Date: January 10, 2011
• Alcohol Screening Results Up to One Year Prior to Surgery Associated with Increased Post-Operative Complications for Veterans
  This study evaluated whether results of alcohol screening with the AUDIT-C (Alcohol Use Disorders Identification Test – Consumption), administered up to one year before surgery, were associated with the risk of post-operative complications in Veterans undergoing major non-cardiac surgery in VA. Findings showed that AUDIT-C scores of 5 or higher up to one year before surgery were associated with increased post-operative complications. Overall, 16% of the total study population screened positive for alcohol misuse with AUDIT-C scores >5, and 8% had post-operative complications. There also was a dose-response relationship between AUDIT-C scores and post-operative complications, with complications increasing from 6% among low-risk drinkers to 14% among Veterans with the highest AUDIT-C scores. The authors suggest that AUDIT-C scores could be electronically loaded into surgery consults, surgery clinic notes, or pre-operative templates in VA’s computerized patient record system in order to alert clinicians to alcohol misuse at the time of referral to surgery.
  
  Date: September 28, 2010
• Patient Treatment Preferences Play Important Role in Racial Disparities in Knee/Hip Total Joint Replacement
  Overall, 10.3% of Veterans treated for knee/hip osteoarthritis at two VA orthopedic clinics underwent total joint replacement (TJR) within six months of study enrollment. TJR was less likely for African-American Veterans compared to white Veterans of similar age and disease severity, but this difference was not significant after adjusting for whether patients had received a recommendation for the procedure from their orthopedic surgeon. African-American Veterans were less likely to receive a recommendation for TJR than white Veterans of similar age and disease severity. However, this difference was not significant after controlling for Veterans’ willingness to undergo TJR, as assessed prior to the visit with their surgeon. This suggests that the observed race differences in recommendations about joint replacement may result from orthopedic surgeons being responsive to patient preferences regarding the procedure.
  
  Date: May 28, 2010
• “Super-obesity” Associated with Risk of Death Among Veterans Following Bariatric Surgery
  This retrospective study of 856 bariatric surgical cases conducted in 12 VAMCs between 2000 and 2006 sought to define the risk of death among Veterans with a body mass index (BMI) of 40 or greater – and to identify patient-level factors associated with mortality. Findings show that Veterans classified as “super-obese” (BMI of 50 or higher) and those with a higher chronic disease burden appear more likely to die within one year of having bariatric surgery. Authors recommend that the risks of bariatric surgery in patients with significant comorbidities should be carefully weighed against potential benefits in older male Veterans and those with super-obesity.
  
  Date: October 1, 2009
• African Americans and Whites Equally Appropriate Candidates for Total Joint Arthroplasty
  This study sought to determine if racial differences in clinical appropriateness for surgery existed among a sample of primary care patients (425 whites and 260 African Americans) with moderate to severe symptomatic knee or hip osteoarthritis (OA) treated at one VA hospital and one county hospital between 3/03 and 9/06. Findings show that African Americans and whites were equally appropriate candidates for total joint arthroplasty (TJA). There were no significant ethnic differences found between the proportion of those deemed appropriate for TJA and those deemed inappropriate.
  
  Date: September 1, 2009
• Toyota Production System Methodology Leads to Improved Peri-Operative Care in One VAMC
  In the Toyota Production System (TPS) industrial engineering approach, front-line work groups identify problems, experiment with possible solutions, measure the results, and implement strategies to improve quality, resulting in a “ground-up” rather than “top-down” approach to solving system problems. Beginning in 2001, one VAMC instituted TPS methods to reduce Methicillin Resistant Staphylococcus Aureus (MRSA) infections on a general surgical floor. The intervention then evolved to address other areas for QI on the surgical unit, such as increasing appropriate prophylactic peri-operative antibiotic therapy. The aims of this study were to determine: 1) whether the QI intervention for peri-operative antibiotic therapy was associated with improvements in selection and duration of prophylactic therapy; and 2) if the overall MRSA prevention initiative was associated with decreased hospital stay (LOS). Findings show that use of the TPS methodology resulted in a QI intervention that was associated with an increase in appropriate peri-operative antibiotic therapy among surgical patients. The proportion of all surgical admissions in this study (n=2,550) receiving appropriate peri-operative antibiotics was significantly higher in 2004 after initiation of the TPS intervention (44.0%) compared to the previous four years (range 23.4% to 29.8%). Results also showed no statistically significant decrease in LOS over time.
  
  Date: September 1, 2009
• Intra-Operative Reading during Anesthesia Care
  What is considered acceptable or professional behavior and activities during periods of low clinical workload during anesthesia care are controversial. This study sought to ascertain the incidence of intra-operative reading and measure its effects on clinicians’ workload and vigilance. Findings show that anesthesia providers read during 60 of the 172 cases observed (35%). Reading was observed during the maintenance period, not during induction or emergence, thus it occurred when workload was low and did not appear to affect vigilance. However, when reading, anesthesia providers spent less time conversing with others, performing manual tasks, and record-keeping.
  
  Date: February 1, 2009
• Study Suggests Changes Needed in Warfarin Dosing
  The lack of evidence regarding optimal management strategies for warfarin probably contributes to limited success in maintaining patients within the target International Normalized Ratio (INR) range (system used to report testing for coagulation). Findings from this study show that providers vary widely in their dose change thresholds in similar clinical situations and that the INR value was by far the most important predictor of dose change. Authors suggest that in addition to offering warfarin to as many optimal candidates as possible, we also need to optimize warfarin dose management to fully realize the benefits of anticoagulation.
  
  Date: January 1, 2009
• Most Elderly Veterans Obtain High-Risk Surgeries in Non-VA Hospitals
  Regardless of where they live (rural vs. suburban vs. urban), most elderly veterans obtain high-risk procedures such as heart, vascular, and cancer surgeries in non-VA hospitals. Veterans generally traveled about as long to get to higher performance hospitals as to reach lower performance hospitals. Authors suggest that veterans might benefit from an effort to direct them to higher performance hospitals for these high-risk surgeries, and that this effort might best be initiated by focusing on veterans living beyond urban areas.
  
  Date: October 1, 2008
• Demographic and Clinical Factors Affect Ostomy Complications
  Demographic factors (age) and clinical factors (marking the stoma pre-operatively and provider explanation of the ostomy prior to surgery) are potential risk factors for the development of ostomy complications. In addition, the four quality of life domains measured in this study (physical, psychological, social, and spiritual) were strongly related to all three ostomy complications evaluated.
  
  Date: September 1, 2008

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 Telemedicine

• Telemedicine-Based Collaborative Care Intervention for Depression has Greater Effect on Minority vs. White Veterans
  The Telemedicine Enhanced Antidepressant Management (TEAM) study was a randomized trial of telemedicine-based collaborative care tailored for small, rural primary care practices. Investigators in the current study evaluated racial differences in clinical outcomes among 360 Veterans with depression who were randomized to usual care or the TEAM intervention. Findings showed that in the usual care group, minority Veterans had a lower treatment response rate (8%) than Caucasians (18%), but this was not significant. In contrast, minority Veterans in the TEAM intervention group had a significantly higher treatment response rate (42%) than Caucasians (19%) in the intervention group. Veterans in the minority group were significantly less likely to report that antidepressants were an acceptable form of treatment, and were significantly less likely to have had prior or current depression treatment. However, none of these variables were significantly related to treatment outcomes. Thus, the study was not able to determine why minorities responded better to the intervention than Caucasians.
  
  Date: November 1, 2011
• Telemedicine-Based Collaborative Care Does Not Increase Total Workload for Primary Care or Mental Health Providers
  This study examined patterns of healthcare utilization and cost associated with telemedicine-based collaborative care for depression among Veterans who received care in seven VA community-based outpatient clinics (CBOCs). Findings suggest that telemedicine-based collaborative care does not increase total workload for primary care or mental health providers; therefore, there is no disincentive for mental health providers to offer telemedicine-based care ? or for primary care providers to refer Veterans to telemedicine care. There was no significant difference in the total number or cost of primary care encounters between Veterans in the intervention group and those in the usual care group. Between the two groups, there also were no statistically significant differences in total mental health encounters or cost; however, Veterans in the intervention group did have significantly more cost and encounters in specialty physical health clinics. In addition, Veterans in the intervention group had a significantly greater total outpatient cost compared to Veterans in usual care. These differences were likely due to the high levels of physical and mental health comorbidities in this study population.
  
  Date: May 26, 2011
• Telemedicine ICU Coverage Lowers ICU Mortality but Not In-Hospital Mortality
  Because many hospitals lack the patient volume or financial resources to hire dedicated specialists trained to care for critically ill patients (intensivists) – and because of a shortage of these trained specialists – hospitals are increasingly adopting telemedicine ICU (tele-ICU) coverage. This systematic review of the literature examined the impact of tele-ICU coverage on mortality and length of stay in non-VA hospitals. Findings showed that tele-ICU coverage was associated with a significant 20% reduction in ICU mortality, but did not significantly reduce in-hospital mortality for patients admitted to an ICU. Tele-ICU coverage was associated with a 1.26 day mean reduction in ICU length of stay, which translates into a 10%-30% relative reduction in ICU length of stay. Tele-ICU was not associated with a reduction in the patient’s length of stay in the hospital.
  
  Date: March 28, 2011
• Telephone-based Care Coordination Intervention Complements Care for Veterans with Dementia and Supports their Caregivers
  This article provides a detailed description of a telephone-based care coordination intervention – Partners in Dementia Care (PDC) – developed for Veterans with dementia and their family caregivers across all stages of the disease. Findings show that, overall, the PDC intervention addresses the diverse needs of Veterans with dementia and their caregivers, including non-medical care issues such as understanding VA benefits, accessing community resources, and addressing caregiver strain. The authors also note that the PDC intervention incorporates several unique features that distinguish it from most other services and programs for dementia caregiving, such as the delivery of the intervention through formal partnerships between VAMCs and local Alzheimer’s Association Chapters, the inclusion of family caregivers, and the breadth of issues addressed for both Veterans and their caregivers. The consumer-directed philosophy of the program enabled Care Coordinators to serve a large number of families in a cost-efficient way, since Veterans and families were taking action on their own with support and guidance from both VA and Alzheimer’s Association care coordinators.
  
  Date: January 17, 2011
• Telephone-Based Self-Management Program Improves Pain among Veterans with Osteoarthritis
  This study examined the effectiveness of a one-year, telephone-based self-management support intervention for 461 Veterans with symptomatic hip and/or knee osteoarthritis who received VA primary care at the Durham VAMC. Findings show that the telephone-based self-management program produced moderate improvements in pain among Veterans with osteoarthritis, particularly compared with a general health education intervention. The self-management group also had greater improvement on the walking and bending subscale measure.
  
  Date: November 2, 2010
• Evidence Review Suggests Clinic Dermatology Provides Better Accuracy than Teledermatology
  This systematic review of the scientific literature sought to compare teledermatology and clinic dermatology in several key areas: diagnostic accuracy/concordance, management accuracy/concordance, clinical outcomes, and costs. Of the 78 studies included in this review, about two-thirds comparing teledermatology and clinic dermatology found better diagnostic accuracy with clinic dermatology. Diagnostic concordance between store-and-forward and clinic dermatology was fair. Concordance rates between real-time or live teledermatology compared to clinic dermatology were higher, but were based on fewer patients. Overall rates of management accuracy were equivalent, but teledermatology was inferior to clinic dermatology for malignant lesions. Management concordance was fair to excellent. There was insufficient evidence to evaluate clinical course outcomes, but patient satisfaction and preferences were comparable. Teledermatology did reduce time to treatment and clinic visits, and it was cost-effective – if certain assumptions were met (i.e., patient travel distance, costs of clinic dermatology).
  
  Date: October 29, 2010
• Therapy via Video-Teleconference as Effective as In-Person Treatment in Reducing Anger Problems in Veterans with PTSD
  Cognitive behavioral therapy (CBT) anger management conducted via video-teleconference was as effective as in-person delivery of the same treatment in reducing anger problems among Veterans with PTSD who live in rural settings. Moreover, mean improvements in the video-teleconferencing group were actually slightly larger than in the in-person treatment group. Veterans in both treatment groups benefited from anger management therapy (AMT), making this one of the few large randomized controlled trials to show meaningful benefits for reducing anger problems in Veterans with PTSD. Veterans in both treatment groups reported high rates of treatment credibility, satisfaction with care, homework adherence, and high alliance with the therapist.
  
  Date: January 26, 2010
• Long-Term Impact of Home Telehealth on Preventable Hospitalizations for Veterans with Diabetes
  This study assessed the longitudinal effect of a VA Care Coordination Home Telehealth (CCHT) program on preventable hospitalizations for Veterans with diabetes. Findings showed a statistically significant reduction in preventable hospitalizations for Veterans enrolled in the CCHT program during the initial 18 months of follow-up compared to Veterans in the control group, even after adjusting for potential socio-demographic and clinical risk factors. However, the program did not demonstrate a significant impact after the initial 18 months, which may largely be due to the fact that the control group had more deaths than the CCHT group during those 18 months, likely resulting in the control group’s decreased use of preventable hospitalizations during the remainder of the study period. Over the entire four-year study period, the CCHT group had a lower death rate and longer survival time than the control group, while the control group had much higher frequency in all diabetes-related ambulatory care sensitive conditions such as lower-extremity amputations, uncontrolled diabetes, and bacterial pneumonia.
  
  Date: October 1, 2009
• Blood Pressure Telemonitoring Feasible for Most Veterans
  This article reports on the first six months of the Hypertension Intervention Nurse Telemedicine Study – an 18-month randomized clinical intervention to improve blood pressure (BP) control. Findings focus on the feasibility of using home BP telemonitoring devices to manage BP among Veterans. Technical alerts were generated if patients did not transmit their BP readings via the telemonitoring devices. Findings show that 75% of Veterans using the BP intervention were able to set up the telemonitoring devices and adhere to the study protocol. During the first six months of this study, 693 technical alerts were generated by 267 Veterans: 61% of the alerts were attributed to patient non-adherence, and 5% were attributed to a lack of patient knowledge (e.g., difficulty setting up the equipment, putting on the BP cuff). The authors suggest that despite the possibilities of improving health care using home BP telemonitoring equipment, there are groups who may require more support using this technology.
  
  Date: September 1, 2009
• In-Person Dermatology More Accurate than Teledermatology for Skin Lesions
  Due to improved digital photography and Internet availability, at least two-thirds of teledermatology programs use store-and-forward technology – still images of skin viewed by remote dermatologists. This study compared the accuracy of store-and-forward teledermatology for non-pigmented skin lesions with in-person dermatology among 728 Veterans with a skin lesion diagnosed at one VA dermatology clinic. Findings show that the diagnostic accuracy of teledermatology was inferior to in-person dermatology, but the accuracy of treatment plans was equivalent. The addition of polarized light dermatoscopy (PLD) to macro images (standard method used in teledermatology) yielded significantly better diagnostic accuracy for teledermatology overall, but there remained no significant difference in the accuracy of treatment plans. Although the diagnostic accuracy of teledermatology was inferior to standard clinical dermatology, this study confirms the clinical utility of teledermatology for management of non-pigmented lesions and underscores the important role of PLD images for diagnosis of malignant non-pigmented lesions.
  
  Date: April 1, 2009
• Teledermatology – Promising Technique for Improving Access to Care
  In this study, teledermatology demonstrated good performance in comparison to clinic-based consultation for diagnostic agreement and diagnostic accuracy. Regarding diagnosis, teledermatologists agreed with each other and with clinic-based dermatologists at a rate comparable to group agreement among clinic dermatologists. Regarding accuracy, when compared to the gold standard of histology, rates ranged from 30% to 92% for clinic dermatologists and from 19% to 95% for teledermatologists.
  
  Date: April 1, 2009
• Psychotherapy Administered via Telephone Reduces Depression
  Findings show a significant reduction in depressive symptoms for patients enrolled in telephone-administered psychotherapy as compared to those in control conditions (e.g. treatment as usual). Moreover, attrition rates were considerably lower than rates reported in face-to-face psychotherapy.
  
  Date: September 1, 2008

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 Women's Health

• Barriers to Healthcare Access for Women Veterans
  This study examined the association of general and Veteran-specific barriers on access to healthcare among women Veterans. Findings showed that overall, almost 1 in 5 women Veterans (19%) delayed healthcare or went without needed care in the prior 12 months, including 14% of insured and 55% of uninsured women Veterans. VA healthcare users comprised 21% of those with and 13% of those without delayed healthcare or unmet needs. Younger age groups were associated with a higher prevalence of delayed care or unmet need. Among women Veterans delaying or going without care, barriers that varied by age group were: unaffordable healthcare; inability to take time off work; and transportation difficulties. A higher percentage of women with delayed care or unmet need, compared to those without, were racial/ethnic minorities, lacked a regular source or provider of healthcare, were uninsured, had low income, fair or poor health status, were disabled, and had mental health diagnoses. With respect to Veteran-related factors, women Veterans with delayed care or unmet need were more likely than those without to be OEF/OIF Veterans, in a high-priority group for VA enrollment, and to have experienced military sexual assault.
  
  Date: November 1, 2011
• Growing VA Research Agenda for Women Veterans
  This paper reports on the 2010 VA Women’s Health Services Research Conference, as well as the resulting research agenda for moving forward on behalf of women who have served in the military. Recommendations for the future VA women’s health research agenda, resulting from this conference, included, to name a few: Address gaps in women Veterans’ knowledge and use of VA services (e.g., outreach/education, social marketing, telemedicine); Evaluate and improve quality of transitions from military to VA care; Assess gender differences in the presentation and outcomes of chronic diseases; Determine reproductive health needs of women Veterans; Examine the structure and care models that support patient-aligned care teams; Evaluate variations in mental healthcare needs; Assess and reduce the risk of homelessness among women Veterans; Conduct research on post-deployment reintegration and readjustment among women Veterans; and Develop combat exposure measure(s) that reflect women Veterans’ experiences.
  
  Date: July 6, 2011
• Most Veterans with Military Sexual Trauma Report High Satisfaction with VA Outpatient Care
  This study examined the association of military sexual trauma (MST) to patient satisfaction with VA outpatient care. Findings showed that Veterans’ ratings of overall satisfaction with VA outpatient care (regardless of MST status) were high. The proportion of patients reporting very good or excellent overall satisfaction was 79% for male Veterans and 72% for female Veterans. After adjusting for patient characteristics, male and female Veterans’ MST status was not associated with satisfaction ratings of overall VA healthcare. However, female Veterans with a history of MST rated the patient satisfaction dimensions of overall coordination, as well as education and information, less favorably than female Veterans without a history of MST.
  
  Date: July 6, 2011
• Updated Literature Review Examines Research and Findings on Women Veterans’ Health
  Investigators conducted a systematic review of the scientific literature published from 2004-2008 and summarized major findings, as well as advancements and gaps in comparison to literature from an original synthesis (more research was published in this 5-year review than in the 25-year period of the previous review). High rates of PTSD symptoms and other mental health disorders (e.g., depression) were found among returning OEF/OIF military women. Also, as the number of OIF deployments increases, screening positive for mental health problems appears to increase. Military sexual trauma (MST) combined with combat exposure was associated with doubled rates of new onset PTSD in both women and men, and MST was associated with more readjustment difficulties in civilian life. In addition, the literature suggests the need for repeated PTSD/mental health screening in returning OEF/OIF Veterans. Local organizational culture and quality of leadership support for women’s health were key factors in fostering gender-sensitive VA programs for women Veterans. Within VA healthcare, women Veteran’s satisfaction is positively affected by access to women’s clinics, gynecological services, and overall continuity of care. Women Veterans who do not use VA healthcare lack understanding of VA care and services. Among VA users, women and men had similar outpatient satisfaction ratings; however, women had consistently lower ratings for inpatient care (e.g., physical comfort, courtesy). While successes are evident in the breadth and depth of publications, remaining gaps in the literature include: post-deployment readjustment for women Veterans and their families, and quality of care interventions/outcomes for physical and mental conditions affecting women Veterans.
  
  Date: July 6, 2011
• Women’s Health Issues Journal Focuses on Women Veterans
  This special issue of Women’s Health Issues includes 18 peer-reviewed manuscripts summarizing health services research findings about women Veterans and women in the military, framed in the context of informing evidence-based practice and policy. Highlights include: VA has tailored primary care to women through the use of designated providers or separate women’s clinics. VA’s with these clinics were rated higher on most dimensions of care. These findings are particularly important to VA’s current implementation of patient-aligned care teams (PACTs). More than half of VA facilities now offer one or more mental healthcare services specifically for women Veterans, including services embedded within women’s primary care clinics, designation of women’s healthcare providers within general mental health clinics, and/or separate women’s mental health clinics. Recent data on VA care among men and women Veterans with histories of military sexual trauma (MST) show high satisfaction with care. Authors suggest that VA’s system-wide monitoring of MST-related care may be contributing to these positive results. PTSD among women Veterans is associated with poorer occupational functioning and satisfaction, but not employment status. Symptoms of depression have substantial effects across all components of work-related quality of life, independent of PTSD symptoms. PTSD is the most common psychiatric condition among both women and men with traumatic brain injury (TBI). However, women with TBI are less likely than men to have a PTSD diagnosis, but more likely to have a depression or anxiety disorder diagnosis.
  
  Date: July 6, 2011
• Women Veterans with History of Sexual Abuse at Higher Risk for Substance Use Disorder
  This study examined the associations between rape history and substance use disorders among women Veterans (age <51 years) who received care at two Midwestern VAMCs. Findings showed that lifetime substance abuse disorder was higher for women Veterans with a history of rape. Two-thirds (62%) of study participants reported lifetime sexual assault, including 11% reporting attempted rape and 51% reporting at least one completed rape. Women with women as sex partners had significantly higher rates of rape and lifetime substance use disorder (73% of women with women as sex partners reported lifetime rape vs. 48% of exclusively heterosexual women). Women with lifetime rape were more likely to report abstinence from drinking (50%) than women with no rape (41%). Women reported the highest rates of rape during childhood and military service (51% and 25%, respectively), and those reporting rape in any period of their lives were significantly more likely to report rape in other periods. For example, women Veterans reporting in-military rape were significantly more likely to report post-military rape (18% vs. 9%).
  
  Date: June 1, 2011
• Women as Resilient to Combat-Related Stress as Men in the First Year Following Return from OEF/OIF Deployment
  This study examined gender differences in various dimensions of combat-related stress and associated consequences for post-deployment mental health in a nationally representative sample of male and female OEF/OIF Veterans. Study results suggest that women OEF/OIF service members may be as resilient to combat-related stress as men in the first year following deployment. There were no significant interactions between combat-related stressors and gender in the prediction of post-traumatic stress symptomatology, mental health functioning, or depression. Women reported slightly less exposure than men to most combat-related stressors, but higher exposure to other stressors (i.e., prior life stress, deployment sexual harassment). There were no differences between men and women in reports of perceived threat in the war zone.
  
  Date: May 30, 2011
• Veterans Reporting a History of Military Sexual Trauma are Treated in a Variety of VA Outpatient Mental Health Settings
  This study sought to determine the VA mental health outpatient settings in which patients with military sexual trauma (MST) are most likely to be treated, which might help set priorities for targeted MST-related education and training. Findings showed that more than one-third of female Veterans (36%) and 2% of male Veterans seen in VA outpatient mental healthcare settings during FY08 reported a history of military sexual trauma. Both women and men with MST were more likely to use more than one type of mental health clinic setting, compared to those without MST. A significantly larger proportion of women seen in MST specialty clinics reported MST as compared to all other settings (81% vs. 34%). However, there was a wide range of clinic visit settings for female Veterans with MST, including: MST specialty clinics, PTSD specialty clinics, psychosocial rehabilitation, and substance use disorder clinics. Male Veterans represented a small proportion of patients seen in all clinics, and a larger proportion of men seen in MST specialty clinics reported MST as compared to other settings (56% vs. 2%). These findings indicate that mental health providers who treat women Veterans, even if they work in settings that do not traditionally incorporate interventions focused on traumatic stress, may encounter issues related to MST. Therefore the authors suggest that training in how to respond to sexual trauma disclosure be an important component in all VA mental healthcare settings.
  
  Date: May 1, 2011
• Pregnancy and Mental Health Conditions among Female OEF/OIF Veterans Using VA Healthcare
  This study sought to determine the prevalence of mental health problems among 43,078 OEF/OIF women Veterans who received a pregnancy diagnosis in the VA healthcare system over a five-year study period (2003-2008). Although a relatively small proportion of OEF/OIF women Veterans received VA healthcare related to pregnancy (7%), a substantial proportion of these women (32%) received one or more mental health diagnoses compared with 21% of women without a pregnancy-related condition. Compared with all women Veterans enrolled in VA healthcare, Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, PTSD, bipolar disorder, or schizophrenia than those without a pregnancy. The most common mental health diagnoses among Veterans with a pregnancy were anxiety (43%), depression (36%), and PTSD (21%), followed by bipolar disorder (3%), and alcohol abuse/dependence (3%). [Sum is greater than 100% due to comorbidity.] Veterans with a pregnancy were significantly more likely to have a service-connected disability than those without a pregnancy. 71% of Veterans with a pregnancy were either never married or no longer married. On average, women Veterans experienced their index pregnancy nearly two years after returning from their last deployment.
  
  Date: December 1, 2010
• Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness
  This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains.
  
  Date: August 1, 2010
• Predictors Associated with Homelessness among Women Veterans
  Among women Veterans, being unemployed, disabled, or unmarried were the strongest predictors of homelessness. Homeless women Veterans also were significantly more likely than housed women Veterans to have low incomes, to have experienced military sexual assault (53%), to be in fair to poor health, to have diagnosed medical conditions, and to screen positive for anxiety disorder and/or PTSD. Homeless women Veterans were significantly less likely than housed women Veterans to be college graduates or to have health insurance, but were more likely to have used mental health services, VA health care, or been hospitalized in the prior 12 months. Homeless Veterans had an average of four entries into and exits out of homelessness, and the median length of time they spent being homeless (over lifetime) was 2.1 years. Of the homeless women Veterans, 16% had children under the age of 18 living with them in the prior 12 months.
  
  Date: February 1, 2010
• Emerging Issues Related to PTSD for OEF/OIF Women Veterans
  The goal of this review was to highlight emerging issues relevant to the development of PTSD among women deployed to Iraq and Afghanistan. Investigators reviewed the literature on topics including: gender differences in combat experiences and in PTSD following combat exposure; sexual assault, sexual harassment, and other interpersonal stressors experienced during deployment; women Veterans’ experiences of pre-military trauma exposure; and unique stressors faced by women Veterans during the homecoming readjustment period. Findings show that combat deployments are not associated with a higher risk of mental health problems for women compared to men. However, women are more likely than men to meet criteria for PTSD following a range of traumatic experiences. In addition, studies published between 2002 and 2007 suggest that more than half of women Veterans experienced pre-military physical or sexual abuse, and there is some evidence that pre-military trauma increases women Veterans’ risk of developing PTSD following combat exposure. Further, concerns about family/relationship disruptions are more strongly associated with post-deployment mental health for female than male service members.
  
  Date: August 24, 2009
• Men and Women Veterans Receive Equal Care for AMI in VA Hospitals
  This study sought to describe the clinical characteristics, treatment, and survival in women Veterans compared with men admitted to VA hospitals for AMI between 10/03 and 3/05. Findings show that after adjusting for clinical characteristics, men and women Veterans treated for AMI in VA hospitals had similar levels of care and survival. There were no significant differences in the treatment provided to men and women Veterans, and cardiac catheterization was provided at equal rates (34.9% for men vs. 36.9% for women). Men did have higher mortality rates, but after adjusting for clinical characteristics this difference was no longer significant. In addition, significantly more men were prescribed aspirin and angiotensin-converting enzyme inhibitors, but there were no differences with regard to other platelet inhibitors, beta-blockers, or lipid-lowering medications.
  
  Date: May 1, 2009
• Outpatient Healthcare Use for American Indian and Alaska Native Women Veterans
  American Indian and Alaska Native (AIAN) women are among the growing number of female Veterans who now seek VA healthcare. In 2003, VA and the Indian Health Service (IHS) executed a Memorandum of Understanding (MOU) to improve access and health outcomes for AIAN Veterans by encouraging cooperation and resource sharing. In order to inform inter-agency planning and coordination, this study reports on the demographic characteristics and healthcare utilization patterns of AIAN women Veterans at the outset of the MOU agreement. Findings show that regardless of group, the medical needs of female AIAN Veterans were similar to other Veterans, including other female Veterans. On average, Veteran dual-users received two-thirds of their healthcare at VA facilities, while non-Veteran dual-users received most of their healthcare at IHS facilities. The lowest outpatient utilization rate was for IHS-only users. Results also show that three of the most frequent diagnoses were hypertension, diabetes, and depression.
  
  Date: March 1, 2009
• Improving Care for Female Veterans
  Findings from this study show significant improvements in sensitivity and knowledge for VA healthcare providers who used a computerized educational program that enhanced gender awareness compared to those who did not.
  
  Date: July 1, 2008

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