1999 HSR&D Annual Meeting Abstracts
1. Are We Improving the Quality of Nursing Home
Care: The Case of Pressure Ulcers?
DR Berlowitz, MD, MPH. HSR&D Field Program CHQOER,
Bedford, MA. HQ, Bezerra, GH Brandeis, JJ Anderson
Objectives: Despite recent initiatives to improve nursing
home care, widespread concerns regarding nursing home quality persist and it is unknown
whether care is improving. Large databases describing nursing home residents are now
becoming available. We use two such databases to determine whether risk-adjusted rates of
pressure ulcer development have changed over time in two large, national providers of
nursing home care, the VA and a private, for profit chain.
Methods: We used the Patient Assessment File (PAF) to study VA
nursing homes from 1990 through 1997, and the Minimum Data Set (MDS) to study the private
nursing home chain from 1991 to 1995. Information from after 1995 was unavailable due to
the switch to version 2 of the MDS. Rates of pressure ulcer development were calculated
for successive six-month periods by determining the proportion of initially ulcer-free
residents having a stage 2 or larger pressure ulcer on subsequent assessments. Rates were
risk-adjusted for patient characteristics using previously developed models specific to
each setting. The proportion of new ulcers that were deep (stages 3 or 4) were also
calculated for each period.
Results: We examined risk-adjusted rates of pressure ulcer
development based on 274,919 observations of VA nursing home residents, and 144,379
observations of residents from the private chain. Between 1990 and 1995, rates of pressure
ulcer development declined by over 25% in both systems (p<0.05). Additionally, the
proportion of new ulcers that were deep declined in the private chain from 30% to 22%
(p<0.01). Beginning in 1996, though, VA risk-adjusted rates of ulcer development
increased to levels similar to those in 1990. The proportion of new ulcers that were deep
also increased from 40% before 1996, to 45% afterwards (p=0.01).
Conclusions: Significant improvements have occurred in the
quality of nursing home care between 1990 and 1995. Further studies are required to
understand why these improvements were not sustained in the VA.
Impact: These results demonstrate how large databases may be
used to monitor the quality of nursing home care over time. Despite concerns over nursing
home quality, our results are reassuring in that improvements have occurred. However,
pressure ulcer preventive care in the VA should be reexamined.
HSR&D Funded: IIR 95-031
2. Variations in Condition-Specific Health Status
Among VA General Internal Medicine Clinics
Stephan Fihn, MD, MPH, and Mary McDonell, MS. Northwest
Center for Outcomes Research in Older Adults, Seattle, WA.
Objectives: Recent efforts to improve quality of care and
productivity have involved measurements of patients' general health status to adjust
for case-mix and assess outcomes. Measures of health status, such as the SF-36, however,
may be too general to identify important differences in health and function among patients
with specific medical conditions. We compared variability in general and
condition-specific measures of health status among patients from a geographically diverse
sample of VA primary care clinics.
Methods: As part of the Ambulatory Care Quality Improvement
Project, we surveyed 38,642 active, eligible patients in 7 VA General Internal Medicine
Clinics. Baseline data collected on respondents included an inventory of active medical
conditions, including a depression screen (MHI5), and a demographic survey. Respondents
were then mailed the SF-36 and condition-specific health status measures for any of six
target conditions reported. Measures included the Seattle Angina Questionnaire (SAQ) and
the Seattle Obstructive Lung Disease Questionnaire (SOLQ). Patients with a positive MHI-5
were mailed the SCL-20, a measure of depression.
Results: Sixty-six percent of patients responded to the baseline
inventory. The mean age was 64 years, and 96% were male. Of the 24,287 patients who were
mailed follow-up SF-36 and condition-specific surveys, 15,007 (62%) responded.
Statistically and clinically significant differences among sites were observed on all
SF-36 scales including Physical Function (range 38.9 to 58.6), General Health (36.1 to
54.4), Vitality (33.8 to 50.5); Bodily Pain (44.7 to 61.3). Significant but smaller
variation was observed on scales of social and mental health. The relative differences
among sites were consistent across scales and approximated a full standard deviation
comparing the highest and lowest sites. Of 9004 patients who reported angina on the
initial questionnaire, 5697 (63%) returned the SAQ. Highly significant differences among
sites were also observed for scores on all SAQ scales including Anginal Frequency (69.4 to
80.5), Anginal Stability (50.6 to 64.4) and Physical Function (43.5 to 55.6). Of 5553
patients who reported COPD, 3302 (59%) returned the SOLQ. Again, highly significant
differences among sites were present for all scales including Coping (59.8 to 70.7),
Emotional function (51.1 to 65.5) and Physical Function (51.8 to 61.6).
Conclusions: Although potentially limited by response bias,
these results suggest there are clinically important differences among primary care
patients in different geographic locations with regard to both general and
condition-specific health status for chronic stable angina and COPD.
Impact: Differences in health status among primary care patients
in different locations must be taken into account when comparing outcomes and quality of
care. These results indicate that substantially more research is required to understand
and address these differences.
HSR&D Funded: SDR 96-002
3. Patient Preferences in PSA Screening: The Impact
of Shared Decision-Making Videos
EG Wilkins, MD, JC Lowery, MHSA, PhD, and JB Hamill, MPH. VA
Center for Practice Management and Outcomes Research, Ann Arbor, MI.
Objectives: VHA has recognized the need for a more
patient-oriented approach to the delivery of healthcare, including sharing responsibility
for medical decisions between providers and patients. Previous research has shown that
shared decision-making (SDM) may result in a variety of benefits, including improvements
in patient satisfaction and clinical outcomes. SDM programs have involved the use of
educational materials, primarily videotapes, to encourage patients to actively participate
in their healthcare. Although initial assessments of these approaches have been
encouraging, randomized clinical trials (RCTs) are lacking for most SDM interventions. Our
study used an RCT design to assess the impact of a standardized video program for patients
considering Prostate Specific Antigen (PSA) screening.
Methods: Male patients eligible for PSA testing were recruited
from five VA outpatient clinics and randomized to either SDM video or non-video groups.
Prior to meeting with their primary care provider, those in the SDM group viewed a PSA
video from the Foundation for Shared Medical Decision-Making. The control group received
information (verbally and in writing) traditionally used by the participating centers for
PSA test candidates. Following the provider meeting, patients in both groups were
administered written questionnaires ascertaining their decisions to undergo or decline PSA
testing. Consisting largely of previously validated instruments, the surveys also
evaluated patients' overall satisfaction with care; knowledge about PSA testing;
decision-making and information-seeking preferences; and decisional conflict. Comparisons
of categorical variables between the two groups were performed using chi-square analysis,
while continuous variables were analyzed using t-tests.
Results: A total of 91 patients were randomized to either SDM
(n=43) or control (n=48) groups. While no significant differences between the two groups
were noted in age, race, or marital status, the control group reported a significantly
higher educational level than the SDM group (p=0.04). Fewer SDM patients chose to undergo
testing (59.5%) compared with controls (80.4%) (p=0.099). SDM patients were more satisfied
with both the information received (p=0.08) and their levels of input into the testing
decision (p=0.07). Furthermore, the SDM group demonstrated significantly greater knowledge
about PSA testing compared to the control patients (p=0.0001). Both groups expressed a
strong desire for information; but SDM patients expressed significantly greater
preferences for active participation in the PSA decision (p=0.0075). Finally, in spite of
assuming larger roles in medical decision-making, SDM patients did not report
significantly higher levels of anxiety or uncertainty surrounding their decisions.
Conclusions: VA patients want information to help them make
decisions about their healthcare. Implementation of a video-based SDM protocol for
patients considering PSA screening appears to result in significantly greater knowledge
and preferences for active decision-making roles. These findings contradict reports by
Ende and others (1989) who found that older, less educated patients prefer less
information and participatory roles.
Impact: Our findings have important implications for designing
and implementing patient-centered care in VHA. Patients want and need information to help
them make decisions about their healthcare. SDM videos offer a means of conveying the
results of outcomes research in a way that patients can understand and use to make
decisions consistent with their preferences and values.
4. Effectiveness of VA Primary Care Firm Systems:
Elizabeth Yano, PhD, Mingming Wang, MPH, Lisa Rubenstein, MD,
MSPH. Center for the Study of Healthcare Provider Behavior, Sepulveda, CA.
Objectives: As a healthcare delivery model, firm systems have
been associated with improved prevention, continuity and coordination. By 1996, many VA
facilities had launched firm "like" primary care delivery models, with little
information about the relative effectiveness of the variations being used. We assessed the
relative performance of VA firm systems in contrast with non-firms in terms of preventive
and chronic disease care and patients' satisfaction with continuity and coordination.
Methods: In 1996, a national VA expert panel operationally
defined a VA firm system through a modified Delphi process that examined the relative
importance and contribution to the suggested effects of firms of each of 30 proposed
features. Survey items based on these features were incorporated into a 50-item
organizational survey, pilot tested and fielded in June 1996 among all VAMCs nationwide. A
VAMC was classified as having a firm system if they had 1+ interdisciplinary primary care
teams with patients indefinitely assigned to a primary care provider who was responsible
for care from clinic-to-ward. We used these survey results (100% response rate) to
evaluate the performance associated with VA firm systems using baseline chart-based data
from the VHA External Peer Review Program and 1996 VHA National Customer Feedback Center
patient satisfaction data. We compared performance associated with firms vs. non-firms and
among alternate firm system specifications using the Kruskal-Wallis test.
Results: Overall, 35 (21.9%) VAMCs had firm systems. Compared to
non-firms, VA firms served fewer patients (p<.05), but achieved higher proportions of
patients who reported having a primary care provider (76.4% vs. 71.3%, p<.05).
Preventive practices were higher in firms vs. non-firms (Prevention Index .79 vs. .74,
p<.05), with specific benefits in alcohol counseling and colon-cancer screening
(p<.05). The Chronic Disease Index scores were also higher among firms (.87 vs. .82,
p<.05), with higher performance of sensation exams and foot pulse checks among
diabetics, and exercise counseling among hypertensives and obese patients (each p<.05).
On average, patients reported slightly fewer problems with continuity (.24+/-.12 vs.
.28+/-.10, p=.08). VA firms were more likely to have specialty referral and notification
policies (p<.01). The subset of firms with randomized patients and providers and the
larger set of firms without inpatient-outpatient continuity had few performance benefits
Conclusions: VA healthcare facilities adopting firm systems as
their primary care delivery model have higher proportions of patients who report having a
primary care provider, provide more preventive care, and higher quality of care for
selected chronic conditions. Patients were only marginally more satisfied with their
continuity of care. More research is needed to understand the key ingredients of effective
delivery models to support the continued growth and development of VA primary care
delivery systems, including the adoption of managed care practices, especially as they
relate to interdisciplinary teams of providers.
Impact: This work will support the planning and design of VA
primary care delivery systems that are associated with higher facility performance.
HSR&D Funded: MPC 97-012
5. Do Patients with Mental Disorders
"Unnecessarily" Use More Medical Services? Policy Implications for Mental Health
CS Hankin, PhD, A Spiro III,PhD, and D Miller. Bedford VA
Medical Center, Bedford, MA. D Mansell,MD, MPH. Assistant Professor, Birmingham, AL LE Kazis, ScD, Bedford VA Medical Center, Bedford, MA.
Objectives: It is commonly believed that patients with mental
disorders "unnecessarily" use high rates of medical services; the objective of
the present study was to explore this assumption. We examined patterns of medical services
use among VA ambulatory care patients who screened positive for depressive,
alcohol-related, or posttraumatic stress (PTSD) disorders. We hypothesized that even with
adjustment for age and medical disease comorbidity, patients who screened positive for
targeted mental disorders would have higher rates of medical services use that those who
did not screen positive.
Methods: Baseline data were obtained from the Veterans Health
Study, a longitudinal investigation of the health of 2,425 Boston-area, male VA ambulatory
care patients. Screening measures were CES-D for depression, CAGE for alcohol-related
disorder, and PCL-C for PTSD. Prior medical services use (number of inpatient stays in the
prior 12 months, and emergency room visits, outpatient visits, or telephone contact with
medical personnel in the prior 3 months) was assessed by self-report. The Disease Burden
Index (DBI; Kazis et. al., 1998) was used to adjust for medical comorbidity. We compared
unadjusted means between groups using t-tests. We then used general linear modeling to
compare means, adjusting for age and DBI.
Results: In unadjusted analyses, patients screening positive for
depression reported significantly more inpatient stays (1.86 vs. 1.53), outpatient visits
(4.80 vs. 3.15), and telephone contacts (2.53 vs. 1.83); following adjustment for age and
medical comorbidity, only the significant difference in number of inpatient stays (1.78
vs. 1.58) remained. Prior to adjustment, patients screening positive for alcohol-related
disorder reported significantly more inpatient stays (2.16 vs. 1.57), fewer emergency room
visits (1.20 vs. 2.12), outpatient visits (3.36 vs. 3.78), and telephone contacts (2.05
vs. 2.15); however, with adjustment, differences in number of inpatient stays (2.02 vs.
1.58) and outpatient visits (2.56 vs. 3.85) remained significant, but differences in
number of emergency room visits and telephone contacts no longer met statistical
significance. Prior to adjustment, patients screening positive for PTSD reported
significantly more inpatient stays (1.82 vs. 1.59), emergency room visits (2.47 vs. 1.66),
outpatient visits (4.76 vs. 3.46), and telephone contact (2.88 vs.1.88); following
adjustment, differences in medical services use were no longer significant.
Conclusions: Although unadjusted analyses of medical services
use revealed clear effects of the screening presence of mental disorders on most outcomes,
after adjusting for age and medical comorbidity, many of these effects no longer met
Impact: Our findings have particular relevance for private
sector managed care organizations, where restrictions on mental health benefits
("capitation") serve to reduce adverse selection of patient with mental
disorders who are assumed to be poor risk because they "unnecessarily" use high
rates of medical services. Our findings do not support the notion of such a discrete or
direct relationship between mental disorders and medical services use. Results suggest
that capitation strategies which are based upon the presumed relationship between mental
disorders and medical services use should reconsider the important contributions of age,
comorbid medical disorders, and specific mental disorder diagnoses.
HSR&D Funded: SDR 91-006
6. A Comparison of VA to Public Sector Mental Health
Patients: the Connecticut Outcomes Study
Rani Hoff, PhD, Robert Rosenheck, MD, M Sernyak, J Steiner, S Atkins.
VA Connecticut Healthcare System, West Haven, CT.
Objectives: This paper presents results from a study comparing
mental health service delivery to seriously mentally ill patients at three institutions: a
VA hospital and two local community mental health centers operated by the State Mental
Health Agency (SMHA). The objective was to compare mental health care delivered in VA to
those services delivered to a socio-demographically similar population in community mental
Methods: A random sample of 600 patients with serious mental
illness were taken from the three institutions (200 at each) and interviewed about their
clinical status, service use, satisfaction with services, and needs and barriers to care.
Results: VA patients were older, less likely to be non-white,
had higher incomes both from entitlements and other sources, had fewer problems with
housing, and were more satisfied with their housing. They also received significantly more
medical care, particularly outpatient medical care, than did SMHA patients, even after
controlling for age and medical conditions. There were no differences in the severity of
mental health symptoms or use of inpatient mental health care across the three sites.
However, VA was less community oriented in its outpatient mental health care: VA patients
were less likely to have received case management and rehabilitation services, were more
likely to be receiving individual therapy and medication management from a psychiatrist,
and were less likely to be taking atypical antipsychotics. These differences persisted
after controlling for severity of symptoms, age, race, marital status, income, and
Conclusions: We conclude that the integrated medical system in
VA affords veterans better access to needed medical services; that the VA in Connecticut
has successfully moved away from a focus on inpatient mental health care; but that VA has
not made a complete transition to community oriented mental health care.
Impact: The impact of this research highlights the advantages of
an integrated medical system in ensuring veterans' access to all types of health care.
However, it also indicates that mental health treatment in VA has not been completely
translated to a community-oriented model.
HSR&D Funded: PPR 94-002
7. Comparing Quality of Mental Health Care in Public
Sector and Privately Insured Populations: First Efforts and Methodological Challenges
Douglas Leslie, PhD and Robert Roseheck, MD. VA Connecticut
Healthcare System, West Haven, CT.
Objectives: Comparing quality of care between large health care
systems is methodologically difficult, but is an important challenge to health care system
management. This study demonstrates methods for measuring quality of mental health care
and compares a sample of VA and privately insured patients using these measures.
Methods: Using discharge abstracts, we identified individuals
receiving inpatient mental health care in VA during the first six months of each fiscal
year 1993 to 1995. A similar cohort of privately insured individuals was identified using
MEDSTAT's MarketScan database. These individuals were tracked for six months following
discharge and length of stay, readmission rates, and access to outpatient services were
calculated. Means of these variables, adjusted for patient characteristics, were compared
over time and between the two populations.
Results: The private sector outperformed VA with respect to most
of the quality measures, although these differences were modest in magnitude and are
likely explained by the fact that VA patients are generally more severely ill and far more
socially disadvantaged. However, readmission rates increased considerably over time in the
private sector, whereas they declined among VA patients. The outpatient measures improved
in both systems, with VA improving more on the number of outpatient visits after discharge
and the private sector improving more with respect to the number of days to the first
outpatient visit after discharge. VA outperformed the private sector with respect to the
continuity of care measure in each year. Quality measures varied by diagnosis, with VA
performing better relative to the private sector in treating patients diagnosed with
substance abuse and mental health disorders not elsewhere classified, but performing
relatively worse in treating patients belonging to the depression diagnostic groups.
Unfortunately, variables describing income, disability and homelessness were not available
to adjust for major differences between patients treated in the two systems.
Conclusions: Although the private sector outperformed VA to a
modest degree with respect to these quality measures (with the exception of continuity of
care), VA improved markedly over time compared to the private sector, especially with
respect to the inpatient quality measures, and treats a more troubled population for which
adjustment was not possible.As these systems continue to adopt strategies to reduce the
costs of care and as government systems are increasingly compared to their private sector
counterparts, methods for comparing and evaluating the quality of care delivered become
increasingly important, although methodological challenges, as illustrated here, are
Statements: This study provides a benchmark for quality of
mental health care in VA as efforts are made to reduce costs. Although similarities in
these quality measures between VA and the private sector are impressive (especially given
the fact that VA treats a more severely ill population), this study shows that there is
room for improvement.
8. Comparing Reimbursement Models for VA Mental
Douglas Leslie, PhD, Robert Rosenheck, MD, Rani Hoff, WD White. VA Connecticut Healthcare System, West Haven, CT.
Objectives: VA funding mechanisms have historically relied on
previous utilization as a basis for distributing funds, and have been criticized as
rewarding inefficient provision of care. In response to such criticisms, there is a desire
to base these funding mechanisms entirely on patient characteristics. This study explores
the impact of using various reimbursement models based on two patient classification
schemes - a functional assessment measure (the GAF) and clinical diagnosis - to distribute
funds for VA mental health care across VISNs.
Methods: We identify a cross-sectional sample of veterans
treated in specialty mental health clinics during a two-week period in fiscal year (FY)
1991. Data from the Patient Treatment File, Outpatient Care File, and the Cost
Distribution Report were combined to calculate total utilization and costs for this sample
during FY 1991. We then simulate hypothetical reimbursement amounts for these patients
based on five different reimbursement models: 1) reimbursement based on average total cost
per capita (average cost), 2) reimbursement based on average total cost by GAF score
(GAF-based), 3) reimbursement based on average total cost by diagnosis (diagnosis-based),
4) outpatient care reimbursed based on average overall outpatient costs and inpatient care
reimbursed based on average inpatient costs by GAF score (GAF-based inpatient), and 5)
outpatient care reimbursed based on average overall outpatient costs and inpatient care
reimbursed based on average inpatient costs by diagnosis (diagnosis-based inpatient).
Total simulated reimbursement by VISN for each of these models was then compared to actual
Results: The distribution of funds nationally across VISNs
changes substantially as a result of our reimbursement models compared to actual
expenditures. The percentage of total VA expenditures redistributed across VISNs as a
result of our models ranges from 6.86% for the diagnosis-based reimbursement model to
8.29% for the simple average cost reimbursement model. However, using functional or
diagnostic measures resulted in only small changes from simple average cost capitation.
The effects on individual VISNs were substantial and consistent across reimbursement
models, with some VISNs experiencing an increase in funding of over 30% and others
experiencing a decrease of almost 22% in some simulations.
Conclusions: Reimbursement mechanisms based on functional
measures could have a substantial impact on funding patterns compared to current regimes,
although they make only minor changes compared to a simple average cost capitation rate.
Ideally, one would like to base the distribution of funds on the inherent costs of
treating patients in the VA system. Our use of GAF scores and diagnoses is a step in the
right direction, but these measures are probably imperfect bases for classification and
predicting costs because they are based on clinician judgement and are vulnerable to rater
Impact: These preliminary analyses demonstrate the application
of simple, readily available clinical classification schemes to reimbursing VA mental
health care. Further analyses are underway to elucidate the strengths and weaknesses of
9. Impact of Primary Care Satellite Clinics on
Access to General Health Care Services and Mental Health Services
Robert Rosenheck, MD. VA Connecticut Healthcare System, West
Objectives: This study sought to determine whether the
establishment of community-based primary care clinics (CBOCs) facilitate access to general
health care and/or mental health care services, in both the general population and among
people with disabling mental illness.
Methods: From the last quarter of FY 1995 through the third
quarter of FY 1997, the Department of Veterans Affairs established thirty-four new
community-based primary care clinics in underserved areas. Data were obtained from the
1990 Census on the number of veterans residing in each US county. Data were also obtained
from VA's computerized workload data bases (the Patient Treatment File and the Outpatient
Care File) on the number of veterans residing in each US County who used VA health and
mental health services In FY 1995, before the clinics were established and FY 1997 and
used to determine the proportion of veterans in each county who used VA health and mental
health services. Analysis of Covariance was used to compare changes from FY 1995 - FY 1997
in use of VA services in counties in which new primary care clinics were located and in
other US counties, adjusting for potentially confounding factors such age distribution,
race and gender composition, and income distribution.
Results: Counties in which new clinics were established in late
1995-6 showed an increase in the proportion of veterans who used general VA health care
services that was almost twice as large as that observed in comparison counties (2.3% vs
1.3%; F=4.94; df=1,3117; p=.03). However, introduction of these clinics was not associated
with greater use of specialty VA mental health services in the general veteran population;
or of either general health care services or mental health services among veterans who
received VA compensation for psychiatric disorders. Interaction analysis showed that CBOCs
had their greatest impact on VA service use in counties with larger proportions of low
income veterans (beta = 0.006; F=2.11; df=1,3019; p=.03) and had less of an impact in
counties with a high proportion of hispanics (beta=-.35; F=2.20; df=1,3019; p=.02).
Conclusions: Community-base primary care clinics successfully
improve access to general health care services but do not improve access to specialty
mental health care for either the general population or for people with serious mental
Impact: In part as a result of this study, the Under Secretary's
Special Committee on Treatment of Seriously Mentally Ill Veterans recommended that
specialty mental health staff be included in planning of future CBOCs and the
Undersecretary has approved the recommendation.
HSR&D Funded: PPR 94-002
10. Corticosteroid Utilization and Outcomes in HIV
Associated Pneumocystis Carinii Pneumonia: Three-fold Higher Mortality among Severely Ill
Patients when Corticosteroids given by CDC Guidelines
Charles Bennett, MD, PhD and TC,Ilraith. Chicago VA
Hospital, Chicago, IL.
Objectives: Experience with the management of Pneumocystis
carinii pneumonia (PCP) exploded with the onset of the AIDS epidemic. Anecdotal reports of
improved outcome when steroids were used as adjuncts to appropriate anti-microbial therapy
led to controlled trials demonstrating their efficacy.[Bozette S, NEJM] The CDC created
guidelines supporting adjunctive therapy with corticosteroids. PCP management during 1995
to 1997 was evaluated for variations in guideline adherence and outcomes.
Methods: Chart reviews from 7 states, 74 hospitals (66 non-VA
and 8 VA), and 1,660 empirically diagnosed or confirmed PCP cases.
Results: 735 (44.2%) met CDC guidelines for adjunctive steroids
(Aa oxygen gradient > 35 mm Hg or p02 < 70 mm Hg) and 606 (82.4%) received steroids
as directed by the guidelines (w/in 3 days of anti-PCP medications). Higher rates of
appropriate steroid use were associated with African-American race/ethnicity (84%) versus
white (81%) or Hispanics (73%) (p=0.02), younger age (p=0.002), or receiving care in
Chicago or Seattle (90%) vs NY, Miami, or LA (71%) (p=0.001). Among severely ill patients
with Aa oxygen gradient > 53 mm Hg, 73% were confirmed PCP cases and 82% received
corticosteroids per the CDC guidelines. Among these patients, mortality rates were
three-fold higher for those who DID receive steroids (18% vs 6%, p=0.02). Similar findings
were noted for severely ill persons with confirmed PCP (17% vs 6%). In addition, receiving
PCP prophylaxis was associated with higher mortality rates (30% vs 16%, p=.001).
Conclusions: Adherence to CDC guidelines for adjunctive
corticosteroid use varied according to city and patient sociodemographics. More
importantly, improved outcomes seen in randomized controlled trials were not realized in
practice. Among severely ill PCP patients, mortality was three-fold higher when
corticosteroids were given according to CDC guidelines. Our findings suggest that the
utility of adjunctive corticosteroids in severe PCP needs to be revisited.
Impact: There was a three-fold higher mortality among severely
ill patients with associated Pneumocystis carinii pneumonia when corticosteroids were
given by CDC guidelines.
11. Use of Centralized VA Data Registry to Assess
Quality of HIV Care
Samuel Bozzette, MD, PhD and the HIV-QUERI Executive Committee.
Center for the Study of Healthcare Provider Behavior, San Diego, CA.
Objectives: To demonstrate the feasibility of extracting Quality
of Care data from the comprehensive longitudinal VA Immunology (HIV) Case Registry (ICR)
by assessing the use of newer "highly active" antiretroviral therapies among the
HIV-infected under VHA care.
Methods: The HIV-QUERI Coordinating Center was provided with
copies of the ICR. We identified unique patients and constructed ratios of the number of
patients and of total outpatient visits and hospital discharges, and prescriptions for
protease inhibitors or non-nucleoside reverse transcriptase inhibitors (PI-NNRTI). We
compared these values with national data on the population of adults under care from the
HIV Cost and Service Utilization Study (HCSUS).
Results: Approximately 11,000 unique HIV-infected patients were
seen at VA facilities each quarter from the 1st quarter of 1996 (1Q96), when PI-NNRTIs
were licensed, to the 4th quarter of 1997 (4Q97). Outpatient visits/100 patients
fluctuated from 769 in 1Q96 to 715 in 4Q96 to 851 in 4Q97. However, discharges/100
patients declined monotonically from 30 in 1Q96 to 24 in 4Q96 to 18 in 4Q97. The patterns
of use accompanied the rapid adoption of PI-NNRTI therapy in the VA as the percentage of
unique patients having at least one prescription written for a PI-NNRTI reached 62% by
4Q96 and 71% by 4Q97. The former compares favorably with estimates that 52 to 61% of all
HIV-infected adults under care in the US received the newer drugs in 12/96.
Conclusions: Newer antiretroviral therapies were adopted by VHA
providers and patients at least as quickly as by the general population. Increasing use of
these agents was accompanied by a dramatic decline in inpatient but not outpatient care.
Impact: Initial comparisons suggest that access of VHA patients
to newer HIV therapies is similar to that of other American adults, and that use of these
therapies is associated with a reduction in inpatient stays. The VA ICR database contains
important information on care for HIV. Improving the validity and accessibility of this
database is a high priority for the HIV-QUERI.
HSR&D Funded: HIV 98-000
12. The Prevalence of Hepatitis C in a Sample of
Severely Mentally Ill Veterans
Andrew Muir, MD and M Butterfield,. Duke University Medical
Center, Durham, NC. KG Meador, Hayden Bosworth, PhD. Durham VA Medical Center,
Durham, NC. K Stechuchak, and R Frothingham.
Objectives: There is a pressing need to study Hepatitis C
prevalence and risks in veterans including those with severe mental illness. The goal of
this study is to establish a prevalence estimate of Hepatitis C in severely mentally ill
Methods: From March 1 1998- October 15, 1998 consecutive
patients admitted to the Durham VAMC inpatient psychiatric unit with a severe mental
illness (SMI) diagnosis were serotested for Hepatitis C. SMI diagnoses were defined as
meeting Diagnostic and Statistical Manuel of Mental Disorders fourth edition, (DSM-IV)
criteria for schizophrenia, schizoaffective disorder, bipolar disorder, or posttraumatic
stress disorder (PTSD).
Results: 146 SMI veterans were serotested during the study
period. Among these patients, 92.5% were male, 58.9% were African-American. The overall
proportion of hepatitis C in this sample of severely mentally ill patients was 17.8% (26
of 146). There was a trend for SMI African-Americans to have significantly higher
prevalence rates of Hepatitis C than for SMI Caucasians (24.42% vs. 9.62%). Among those
who tested positive for Hepatitis C, 42.3% were diagnosed with schizophrenia, 3.9% with
schizoaffective disorder, 7.7% with bipolar disorder, and 46.2% with PTSD.
Conclusion: SMI patients have substantially higher levels of
Hepatitis C than what has been reported in community samples. There is a significant trend
for SMI African-American patients to have higher Hepatitis C prevalence rates than
Caucasian persons with SMI. Positive Hepatitis C was most prevalent among veterans
suffering from schizophrenia or PTSD.
Implications: Hepatitis C is a potential epidemic among
veterans, including those with severe mental illnesses. Veterans with severe mental
illness who are infected with Hepatitis C may increasingly rely on the VA health system
for care with substantial cost implications. Further studies are necessary to determine
potential Hepatitis C risk factors for SMI persons who are particularly vulnerable to
Hepatitis C. Racial differences in Hepatitis C among SMI veterans may exist and warrant
further exploration. Increased risk behaviors (intravenous drug and alcohol use) and
increased social/contextual risks (community violence poverty, and trauma) have been
associated with race/ethnicity and may impact on Hepatitis C and associated risks.
Research directed toward understanding Hepatitis C prevalence, transmission, risks, and
progression in severely mentally ill veterans is essential.
CSP Funded: EPP 97-022 "HIV Seroprevalence and Risks in
Veterans with Severe Mental Illness
13. Management of Hepatitis C at the VA Puget
Sound Health Care System
Therese Dawson, BMED. VA Puget Sound Health Care System
Objectives: Hepatitis C virus (HCV) infection is emerging as a
major health concern in the veteran population. Reports suggest up to 85% of those
infected will develop chronic hepatitis and 20% of these will develop cirrhosis. While the
prevalence in the VA patient population is estimated to be 10 times that of the general
community there appears to be no uniform approach to the management of HCV. Although
recent guidelines may help clarify HCV treatment several factors may impede their
implementation. The aims of this study were to review the management of patients diagnosed
with HCV at the VA Puget Sound Health Care System (VAPSHCS) in 1996 and identify factors
influencing this management.
Methods: A retrospective, systematic analysis was made of
medical, pathology and pharmacy records of all patients diagnosed with HCV in 1996 at the
VAPSHCS. Patients were followed through to May, 1998. Data collected included
demographics; diagnostic tests for HCV; history of drug and alcohol abuse; history of HIV,
HAV and HBV (testing and status); frequency and results of liver function tests; the
presence of concomitant liver disease; HCV notation in discharge summaries; hospital
attendances; Gastroenterology referrals; liver biopsies and alpha interferon treatment.
Descriptive statistics were performed where appropriate.
Results: One hundred and twenty seven patients were diagnosed
with HCV in 1996, 125 males and 2 females (mean age 46 years). Four died during the study,
3 from liver disease. Infection with HCV was detected by ELISA in 119 (94%) and confirmed
by PCR in 15 (12%), (RIBA not available). Eight patients (6%) had only PCR results
recorded. A history of intravenous and alcohol abuse was recorded in 89 (70%) and 68
(53%), respectively. Thirty-nine patients were tested for HIV (2 positive), 93 for HAV IgM
(all negative) and 110 for HBV (70 previous exposure, 3 chronic disease). Liver function
tests were performed at HCV diagnosis in 121 patients (95%) of which 63 (52%) were
abnormal. Of these, 42/121 (33%) had no subsequent LFTs. Hepatic cirrhosis was recorded in
10 (13%) and hepatocellular carcinoma in 2. Of 149 admissions among 84 patients HCV was
recorded in 98 (66%) of their discharge summaries. Twenty-seven patients (21%) have been
referred to Gastroenterology and 11 have undergone liver biopsy. Treatment with alpha
interferon was commenced in 9 patients.
Conclusions: This review provides an insight into current
managementpractices of HCV in our veteran population. Although it is limited by the
accuracy and completeness of records and data extraction some conclusions may be drawn.
The diagnosis and management of HCV infection at the VAPSHCS lacks uniformity and
direction with only 12% of patients receiving confirmatory PCRs. Even once diagnosed, 5%
of patients did not have LFTs performed and despite a high incidence of abnormality, a
further 33% have not had LFTs repeated. Few patients are referred to Gastroenterology and
fewer receive alpha interferon treatment. That HCV has a low profile among health care
providers is demonstrated by its lack of inclusion in the discharge summaries of 34% of
Impact: Hepatitis C infection is over represented in the veteran
population. Despite its associated morbidity and mortality HCV appears to have a low
profile at the VAPSHCS. Although new treatment guidelines have been proposed it is
unlikely that these will have significant impact on patient care if an active program for
raising the profile of HCV and organizing and centrally implementing them is not
14. Hepatitis C Virus Infection and Addiction
Disorders in Department of Veterans Affairs Facilities Nationwide
Gary Roselle, MD, and Marta RENDER, MD. VA Medical Center,
Cincinnati, OH. SM Kralovic, LH Danko, and LA Simbart.
Objectives: An association exists between Hepatitis C Virus
(HCV) infection and addiction disorders (AD), such as illicit injection drug use,
inhalation of cocaine, and alcohol ingestion. Alcohol use is of special importance since
data suggest an accelerated progression to cirrhosis, and perhaps, hepatocellular
carcinoma. This investigation was designed to quantify the extent of comorbidities of
documented AD in persons testing positive for HCV antibody (HCVAb).
Methods: The DVA has implemented a national automated electronic
surveillance tool (Emerging Pathogens Initiative [EPI]) to extract information from VHA
local facility computer systems. The EPI program first identifies persons with a
laboratory test positive for HCVAb. Once identified, data are automatically extracted,
including demographics such as age, gender, era served, race/ethnicity, and ICD-9-CM coded
diagnoses for inpatients. At the Austin Automation Center data are converted to SAS format
for analysis by the Infectious Diseases Program Office. Each patient was only counted
once, even if the HCVAb test was positive on multiple occasions. AD for inpatients were
defined by ICD-9-CM codes and included: Alcohol Only, Cocaine Only, Tobacco Only, Other
Drugs Only (including barbiturates, amphetamines, narcotics, etc.), and combinations of
these diagnoses. Data were collected from 9/97 - 7/98 (11 months). Statistical analysis
used the chi-square test.
Results: Over 11-months, 22,676 persons were identified with a
positive test for HCVAb. Mean age was 48.51 (+9.03 SD); 2,021 (8.9%) were noted as
homeless; 21,811 (96.5%) were male. 15,981 (70.5%) were outpatients, 6,695 (29.5%) were
inpatients; 41% were identified as White, 28.6% Black, and 6.6% Hispanic; 2.6% of
inpatients with HCVAb died. 54.2% of inpatients with HCVAb had an ICD-9-CM code for an
alcohol-related diagnosis. Any cocaine and any other drug ICD-9-CM diagnoses were seen in
30.5% and 35% of patients who had HCVAb, respectively. 27.9% of persons who were HCVAb
positive had no documented AD. HIV infection was seen in 3.7% of inpatients with HCVAb.
81.6% of HCVAb positive persons were from the Vietnam or post-Vietnam era.
Conclusions: 54.2% of inpatients with a positive test for HCVAb
had an ICD-9-CM diagnosis related to intemperate use of alcohol, a substance associated
with greater severity of HCV-related liver disease. The AD seen in approximately 72% of
the patients are often associated with risk behavior for transmission, such as sharing
equipment for illicit injection drug use or inhalation of cocaine, and sexual risk
behavior. AD in patients with HCV infection will be challenging to provision of the
continuum of care; treatment regimen will require complex drug combinations with the need
for close follow-up, presenting major obstacles to mitigation of disease.
Impact: The VHA has identified a large population of HCVAb
positive persons, creating an inevitable patient care (>22,000 patients to date) and
financial (up to 750 million dollars) burden. AD were common, including intemperate
alcohol use. Intervention strategies must include VHA data driven targeted screening of
risk populations (IL 10-98-013), providing treatment and education for those currently
infected, and, most importantly, emphasize prevention of risk behavior that leads to
HSR&D Funded: DEV 97-032
15. Mortality after Cardiac Bypass Surgery:
Prediction from Administrative versus Clinical Data
Jane Geraci, MD, MPH, Howard Gordon, MD, ML Johnson, Nancy
Petersen, PhD, L Shroyer, Nelda Wray, MD, MPH. Houston Center for Quality of Care and
utilization Studies, Houston, TX.
Objectives: To determine whether the administrative data
contained in the VA Patient Treatment File (PTF) can adjust for patient severity and
identify hospital mortality outliers identical to severity adjustment and outlier
identification using clinical data from a primary data collection, the Continuous
Improvement in Cardiac Surgery Program (CICSP).
Methods: We developed logistic regression models to predict
operative mortality following cardiac bypass surgery (BYPASS) in 15,288 veterans who
underwent bypass from 10/93-3/96. Two models were developed: one from PTF data and one
from the CICSP data. Observed-to-expected (O/E) ratios for operative mortality in each of
43 hospitals performing BYPASS were calculated, and hospitals were identified as outliers
if the 90% confidence interval for their O/E ratios did not include 1.0. Hospital outlier
status was compared for the O/E ratios calculated from each of the 2 logistic models.
Because the PTF model and CICSP models did not identify the same hospitals as outliers,
clinical variables from the CICSP data set were added, in stepwise fashion (entry
criterion pï¿½0.1), to the PTF model to determine whether it could be "enriched"
to equal the CICSP model in outlier assignment. Both the PTF and the CICSP models were
developed on 2/3 of the study population and validated on the remaining 1/3.
Results: The PTF and CICSP models had comparable predictive
power (c statistics=0.767 and 0.760, respectively). The PTF model identified 3 of 6 CICSP
high outliers and 1 of 4 CICSP low outliers, plus 2 unique high and 3 unique low outliers.
Two additional CICSP variables added to the PTF model resulted in identification of 4 of 6
high and 2 of 4 low outlier hospitals; addition of other CICSP variables increased the PTF
model's predictive power (final c statistic=0.811) but did not further improve outlier
Conclusions: PTF data have predictive power for BYPASS operative
mortality. Addition of a few clinical variables improved the PTF model's hospital outlier
assignment, but differences between the PTF and the CICSP model in this performance
Impact: Administrative data have an ability to predict operative
death following BYPASS that is comparable in predictive power to that of clinical data.
The comparable predictive power yet unique hospital outlier identification suggests that
the PTF model and CICSP model adjust for different things. The addition of a small number
of clinical variables not currently available in the PTF improved its ability to detect
hospital outliers, as measured against the CICSP data.
HSR&D Funded: 95-005
16. The Houston Approach to Optimal Risk-Adjustment
Using Administrative Data
Howard Gordon, MD, Jane Geraci, MD, MPH, ML Johnson, Nancy
Petersen, PhD, L Shroyer, and Nelda Wray. Houston Center for Quality of Care and
Utilization Studies, Houston, TX.
Objectives: To develop a comprehensive risk adjustment that
takes full advantage of the data available in an administrative database.
Methods: We analyzed 15,288 veterans who underwent cardiac
bypass surgery (BYPASS) in the Department of Veterans Affairs (VA) between 10/93-3/96,
using data from the Patient Treatment File (PTF), the administrative data base on
inpatient hospitalizations maintained by the VA. Data included death within 30 days of
BYPASS, age, date of surgery (weekend versus other), ancillary procedure performance
before or on the day of surgery (coronary angioplasty or intraortic balloon pump (IABP)),
and the ICD-9-CM principal and up to 9 comorbid diagnosis codes. Diagnoses identified as
possible complications of BYPASS were not used for risk-adjustment. The frequency of
post-operative death for principal and comorbid diagnoses was ascertained in a
developmental set of FY92-93 BYPASS cases. Principal diagnoses that occurred in 30 or more
cases were coded individually. Less frequent principal diagnoses were grouped together
into a "rare principal" variable. Comorbid diagnoses were ranked in five groups
by risk of death, for codes occurring in at least 30 cases. Less frequent comorbid
diagnoses were grouped together into a "rare" group. Patients without any
comorbid diagnosis codes were placed into another group. Stepwise logistic regression was
used to choose important independent predictors of death within 30 day of BYPASS. In
addition, we explored whether a count of comorbid conditions had independent predictive
power, and whether a count within each of the comorbidity groups was predictive. The model
was developed on 2/3 of the study sample and validated on the remaining 1/3. Data are
presented from the full study sample.
Results: Eight independent predictors of postoperative death
were identified: age, weekend surgery, angioplasty on the day of surgery, IABP before or
on the day of surgery, and 4 variables representing principal or comorbid diagnoses. Two
principal diagnosis codes were protective against operative death: angina pectoris (413)
and "other forms of chronic ischemic heart disease" (414). A count of the
comorbidities within the group having the lowest mortality rate in the developmental set
also was protective. Having any comorbidity from the rare group increased the risk of
postoperative death. The model c statistic=0.767, Hosmer-Lemeshow goodness-of-fit
Conclusions: Administrative data have moderate ability to
predict operative death following BYPASS. Even in a homogenous group of patients
undergoing the same surgical procedure the principal medical diagnosis influenced the risk
of death, and should be handled separately from comorbid conditions. Some comorbid
conditions were more influential than others in predicting death, illustrating that a
unit-weighting of them does not accurately reflect their risk.
Impact: Administrative data have moderate ability to predict
operative death following BYPASS. Even in a homogenous group of patients undergoing the
same surgical procedure the principal medical diagnosis influenced the risk of death, and
should be handled separately from comorbid conditions. Some comorbid conditions were more
influential than others in predicting death, illustrating that a unit-weighting of them
does not accurately reflect their risk.
HSR&D Funded: 95-005
17. A Markov Model of Severity of Illness States
and Hospital Mortality
ML Johnson, W Chan, DH Kuykendall, and Carol Ashton, MD, MPH. Houston Center for Quality of Care and Utilization Studies, Houston, TX.
Objectives: To model the course of hospitalization from
admission to discharge or death using a Markov model of illness severity states derived
from laboratory data.
Methods: Laboratory data was collected using the Health Summary
component of VISTA for 476 consecutive patients admitted with non-psychiatric principal
diagnoses to the general medicine section of the Houston VAMC. Laboratory test results
were scored to create APACHE-L severity of illness measures for each day of the hospital
stay that laboratory tests were conducted. Patients were classified into Low, Medium, or
High severity states based on the APACHE-L scores. A Markov chain is proposed to model the
transition of patients between severity states over the course of the hospital stay, until
reaching states of discharge or hospital death, defined as death in the hospital or within
30 days of discharge. A total of 12 possible transitions can occur from day to day: from
Low to Medium (LM), Low to High (LH), Low to Discharge (Ldisch), or Low to Dead (Ldead);
and similarly four each from Medium and High. A split sample technique was employed to
validate predictions of transition rates between severity states, and from severity states
to discharge or death.
Results: In the development sample, 44.5% of patients were
admitted in severity state Low (106/238), 46.2% in Medium (110/238) and 9.2% in High
(22/238). The overall hospital mortality rate was 9.2% (22/238), with a 3.8% mortality
rate occurring in patients admitted in Low state (4/106), 9.1% in Medium (10/110) and
36.4% in High (8/22). Median waiting times were 4 days in a Low state, 2 days in Medium
and 1 day in High. Example transition rates were: Ldisch 8.7%, meaning patients in a Low
state had a 8.7% probability of discharge the next day; Hdead 6.25%, meaning patients who
ever reach a High severity state faced a 6.25% chance of dying before the next day. Rates
were applied to the validation sample and accurate predictions were found, including:
149.55 expected discharges from Low state with 149 observed; 9.6 expected Hdead
transitions, 6 observed; and 5.8 Ldead transitions, 6 observed. Stationary transition
probabilities obtained from the limiting probability distribution were 6.1% deaths from
Low state, 9.0% Medium and 21.6% High for an entire course of hospitalization.
Conclusions: A Markov model can be constructed from laboratory
data to accurately predict transitions between severity of illness states and from
severity states to discharge or death. Waiting times indicate relatively quick departure
from High and Medium severity states, but relatively long stays in a Low severity state
before being discharged, with risk of becoming more ill or even dying.
Impact: Further research is needed to explore methods to use
results of Markov modeling as quality of care indicators. In addition to hospital
mortality rates, performance could be monitored on rates of improvement or worsening
during the course of hospitalization. To improve quality of patient care, a computerized
system could track severity states of patients daily to provide a synthesis of laboratory
data and risk of mortality to physicians.
18. Hospital Profiles of Mortality from Cardiac
Bypass Surgery: Effect of Definition of Outcome based on Administrative versus Clinical
ML Johnson, JM Geraci, NP Wray, HS Gordon, MJ Petersen, AL Shroyer. Houston Center for Quality of Care and Utilization Studies, Houston, TX.
Objectives: To determine whether using a definition of
post-operative mortality based on administrative data from the Patient Treatment File
(PTF) affects identification of hospital mortality outliers derived from a model of
post-operative mortality based on clinical data from a primary data collection the
Continuous Improvement in Cardiac Surgery Program (CICSP).
Methods: A sample of 15,288 patients from the CICSP data
collection who underwent cardiac bypass surgery from 10/93 to 3/96 were studied. The CICSP
defined post-operative mortality as any death occurring within 30 days of the operation,
or any post-surgical death attributable to surgical complication by medical peer review.
Post-operative death was defined using administrative data as any death occurring within
30 days of surgery. Agreement of the outcome variables defined by administrative data
versus clinical data was assessed. A logistic regression model was constructed to predict
the dependent variable, operative mortality, as defined by CICSP, using the CICSP clinical
data as independent variables in a backward stepwise selection (Model 1).
Observed-to-expected (O/E) ratios for operative mortality in each of 43 hospitals
performing bypass were calculated, and hospitals were identified as outliers if the 90%
confidence interval for their O/E ratios did not include 1.0. A second logistic model was
constructed using the same independent variables from Model 1, but substituting the
dependent variable with post-operative mortality as defined by the PTF to determine the
unique effect of the definition of outcome on hospital profiles (Model 2).= Hospital
outlier status was compared for the O/E ratios calculated from each of the 2 logistic
Results: CICSP classified 557 patients as post-operative deaths,
and the PTF classified 498 as post-operative deaths. Sensitivity of the PTF definition to
the CICSP was 89.4% and specificity was 100%. Model 1 identified 6 hospitals as high
outliers and 4 hospitals as low outliers. Model 2 identified 5 high outliers, 3 of which
were original outliers, and 3 low outliers, 2 of which were outliers originally.
Conclusions: Agreement of classifications of post-operative
death was very high between administrative data and clinical data. However, using the
definition of death from administrative data resulted in 10.6% fewer patients classified
as a post-operative mortality, due to the inability of the administrative data to capture
post-30 day deaths attributed to the surgery by medical review. This discrepancy in the
definition of death further resulted in different hospitals being identified as outliers
than originally derived from clinical data alone.
Impact: Further research to examine the sensitivity of hospital
profiles to changes in outcome definition is needed to determine best use of both
administrative and clinical data. The PTF is a highly accurate source of identifying
post-operative death from cardiac bypass surgery overall; however, the administrative
database does not contain the clinical information to identify which post-30 day deaths
are due to surgical complications. Hospital profiles developed from clinical or
administrative models may differ because of differences in the definition of outcome even
when the independent variables are identical.
HSR&D Funded: IIR 95-005
19. Accuracy of Computer Identified Diagnoses in a
VA General Medicine Clinic
Herbert Szeto, MD, MPH and Mary Goldstein, MD. VA Palo Alto,
Palo Alto, CA.
Objectives: Many existing and proposed critiques of medical care
rely on DHCP diagnoses. Whereas the accuracy of VA inpatient diagnoses in VISTA/DHCP
versus charts have been well studied, little is known about the accuracy of outpatient
diagnoses. This study sought to examine the accuracy of diagnoses for
hypertension-relevant disorders recorded in DHCP when compared to the outpatient medical
Methods: We undertook a cross-sectional chart review to assess
the accuracy of common medical diagnoses that may affect the choice of anti-hypertensive
therapy. Eight clinical conditions, asthma/COPD , atrial fibrillation, BPH, congestive
heart failure, coronary artery disease, diabetes mellitus, gastroesphogeal reflux disease
(GERD), hyperlipidemia, and hypertension were assessed in the general medical clinic at VA
Palo Alto. Charts of patients scheduled to one of the half-day clinics of 16 residents, 5
nurse practitioners (NPs) and 5 attending physicians (MDs) were reviewed for the week of
May 18-22, 1998. A half-day clinic schedule was chosen by convenience for MDs and NPs who
had more than one general medicine clinic that week. Clinic charts of 137 of the 148
scheduled established patients were available for review. A diagnosis was considered to be
present if it was listed either in the past medical history or as part of the problem list
for any past note in the clinic record. A list of diagnoses for each patient was then
obtained through DHCP and compared to diagnoses listed in the chart.
Results: The prevalence of the conditions varied from 5.1% for
CHF to 51.1% for hypertension. Using the outpatient record as the gold standard, the
sensitivity/specificity of DHCP for the conditions are as follows: asthma/COPD (.43/.96),
atrial fibrillation (.89/.97), BPH (.3/.95), congestive heart failure (.57/.97), coronary
artery disease (.57/.98), diabetes mellitus (.77/.95), GERD (.58/.97), hyperlipidemia
(.73/.88), and hypertension (.74/.79). The specificity of DHCP was generally greater than
.95, but was as low as .79 for hypertension. The positive predictive value for a diagnosis
listed in DHCP varied from .50 for BPH to .89 for CAD. One of the limitations of this
study is that patients were chosen through scheduled appointments with specific providers.
As is typical of university affiliated VA clinics, our clinics are staffed by resident and
staff physicians. Since resident physicians have clinic scheduled only once a week, the
sample was disproportionately shifted toward patients cared for by residents. Moreover,
the patient population may be biased toward patients with a greater number of medical
problems, who seek medical attention more frequently. Coding of diagnoses for these
patients may be less complete since providers are less likely to list secondary diagnoses
related to any one visit.
Conclusions: This pilot study suggests that significant
discrepancies may exist between clinic records and the DHCP system. Diagnoses were often
omitted from DHCP, and some diagnoses present in DHCP were not present in the clinic
Impact: As we move into an era where electronic clinical
databases may be used to assess quality, risk adjust, or as a basis for automated
treatment recommendations, careful attention must be paid to the accuracy of such data.
20. Prostate Cancer Quality of Life and Outcomes
Research among Patients with Low Socioeconomic Status: An Overview of the VA Cancer
of the Prostate Outcomes Study (VA CaPOS)
Simon Kim, MPH. Chicago, VA Hospital. SJ Knight, E Moran, CN
Robertson, and JE Smith. Charles Bennett, MD, PhD. Chicago VA Hospital, Chicago, IL.
Objectives: Outcomes assessment for prostate cancer are
important, because of debates over the benefits and costs of alternate treatments and
outcomes. Because of a lack of evidence of survival benefits with specific therapies,
quality of life (QOL) evaluations have taken on increased importance. QOL is rarely
assessed among racial/ethnic minorities and men of lower socioeconomic status, who make up
a disproportionately large part of the prostate cancer burden. We have initiated the first
multi-center QOL outcomes study of lower socioeconomic status men, the VA Cancer of the
Prostate Outcomes Study (VA CaPOS).
Methods: VA CaPOS QOL information is collected from prostate
cancer patients, spouses, and physicians at six VA medical centers. Because of low rates
of literacy, interviewers assess QOL, involvement in care, and the relative importance of
likely outcomes following alternative treatments. Spouses provide proxy ratings of patient
QOL. Physicians provide information on patients' performance status and the
patients' perceived preferences for alternate outcomes. Medical records and
electronic databases are reviewed for sociodemographic characteristics and relevant
Results: Currently, 601 men with prostate cancer are included in
the VA CaPOS, over half of whom are African American. The mean time since diagnosis was
1.4 month for newly diagnosed patients and over 4 years for the rest. QOL responses were
most favorable for newly diagnosed, intermediate for stable metastatic disease, and
poorest for progressive metastatic disease patients, most of whom had been followed for
several years. Spouse emotional well-being assessments were significantly worse than those
of individual patients. While patients were not able to provide reliable estimates of
their own preferences for future QOL states, they were able to respond reliably to
questions phrased as a comparison of the preferences of two hypothetical patients. While
African American prostate cancer patients were more likely to have advanced stage disease
at the time of diagnosis, after adjustment for differences in health literacy, race was no
longer a significant predictor of having advanced prostate cancer.
Conclusions: The VA CaPOS provides useful information on health
status, QOL, and low literacy for VA prostate cancer patients. Our results indicate that
valid and reliable assessments in low literacy populations are feasible, but that
long-term evaluations are needed to detect clinically meaningful information on QOL as the
disease progresses. Alternative sources of QOL information, such as spouses, provided
results that had poor concordance for emotional and social functioning, but were generally
valid for other dimensions of health. The reliability of patient ratings of future QOL
states was increased when questions were based on two hypothetical friends rather than
consideration by the patients themselves of two potential, but different, future health
states. Observational database efforts are potential sources of important information for
lower socioeconomic status patients who are faced with difficult therapeutic decisions,
limited financial resources, and concerns over both quantity and quality of life outcomes
with alternative therapies.
Impact: VA CaPOS provides useful information on health status,
QOL, and low literacy for VA prostate cancer patients. It also provides useful information
about spouse proxy ratings of patient QOL.
21. Prevalence of Lower Urinary Tract Symptoms and
Associated Resource Utilization among VA Primary Care Patients
Elizabeth Yano, PhD, MSPH. VA Greater Los Angeles Healthcare
System, Sepulveda, CA. AB Lanto. Timothy Wilt, MD, MPH. VA Medical Center,
Minneapolis, MN. Lisa Rubenstein, MD MSPH. VA Greater Los Angeles Healthcare
System, Sepulveda, CA.
Objectives: In 1997, nearly 750,000 male veterans had outpatient
diagnoses of benign and malignant prostate disease, yet little is known about their
presenting symptoms in primary care or associated resource utilization, information that
would be useful in the design of programs to systematically screen and treat them. We
assessed the prevalence of lower urinary tract symptoms consistent with the presentation
of prostate disease among VA primary care patients and assessed their VA healthcare
Methods: These data were drawn from a longitudinal cohort of
randomly sampled male veterans in no acute distress who were visiting the Primary
Ambulatory Care and Education (PACE) Center from March-June 1993. Using the Survey of
Health and Medical Care designed for the evaluation of PACE, a primary care firm system,
we conducted a telephone survey of 1,849 veterans with 3+ primary care visits regarding
their health status and symptoms. Lower urinary symptoms (e.g., nocturia) were queried
using items developed by a national panel of academic urologists. Cutpoints were selected
to identify the most clinically meaningful symptom burden. Survey data were linked with VA
administrative data to evaluate general medicine and subspecialty outpatient visits
(particularly urology), and admission rates during the following year. We used logistic
regression to evaluate the predictors of symptom burden among primary care patients.
Results: For specific symptoms, 24.4% of men reported
sometimes-to-frequently having urinary urgency (11.2% frequently), 12.1% reported
sometimes-to-often having problems urinating in the previous month (4.0% often), and 24.1%
reported urinating 1+ times/hour (4.4% >2 times/hour). Nearly half of those surveyed
(47.5%) reported that they urinated 2+ times/night (22.2% with 3+ trips), while over half
(56.2%)reported moderate-to-slow streams (11.2% slow and strained). Taking the most severe
category for each symptom, we found that 32.9% had 1+ clinically meaningful lower urinary
tract symptoms (21.0% with 1, 6.7% with two symptoms). As clinically expected,
hypertensives were 53% more likely to report 1+ symptoms (1.53, 95%CI 1.18-1.98),
diabetics were 75% more likely (1.75, 95%CI 1.32-2.31), and men reporting
shortness-of-breath at rest (1.80, 95%CI 1.28-2.52) or on exertion (2.03, 95%CI 1.49-2.77)
were more likely to report 1+ lower urinary tract symptoms (p<.0001). Adjusting for
these comorbid conditions, men with 1+ symptoms had significantly more general medicine
(p<.01) and urology visits (p<.00001) in the following year compared to men without
urinary symptoms. The more symptoms reported, the higher the general medicine (p<.005),
subspecialty (p<.0001) and urology (p<.0001) visit rates, as well as
medical-and-surgical admission rates (p<.0001).
Conclusions: Male primary care patients have a significant lower
urinary tract symptom burden consistent with underlying prostate disease that is
associated with significantly higher utilization of VA healthcare resources. Clinical
guidelines and pathways that address the optimal role of primary care practitioners and
urologists in a coordinated system of care are needed.
Impact: VHA has identified prostate disease as a high impact
target condition for QUERI. These analyses are helpful in quantifying the needs of
veterans and in assessing how to manage patients in primary and specialty care.
22. Relative Effectiveness of Androgen Suppressive
Therapies for Advanced Prostate Cancer
Timothy Wilt, MD, MPH. VA Medical Center, Minneapolis, MN. N
Aronson, J Seidenfeld, D Samson, V Hasselblad, and P Albertsen. Charles Bennett,
MD, Chicago, IL. PhD Alan Garber, MD. PhD. Center for Health Care Evaluation,
Palo Alto, CA.
Objectives: To determine the relative effectiveness of
alternative strategies for androgen suppression as treatment of advanced prostate cancer.
Methods: We conducted a systematic review of the evidence from
randomized controlled trials Options included monotherapy with surgical or medical
orchiectomy (diethlystibesterol, [DES], luteinizing hormone-releasing hormone [LHRH]
agonist, or antiandrogens) or combination therapy with additional suppression of adrenal
androgens (Combined Androgen Blockade) [CAB]. Three issues were addressed: (1) the
relative effectiveness of monotherapy (orchiectomy, DES, LHRH agonists, and
antiandrogens); (2) the effectiveness of CAB compared to monotherapy; (3) the
effectiveness of immediate androgen suppression for PSA rise compared to androgen
suppression deferred until clinical progression. Outcomes included overall,
cancer-specific, and progression-free survival; time to treatment failure; adverse effects
and quality of life.
Results: There are wide differences in costs of androgen
suppression: annual costs were DES = $109; LHRH agonists = $5,000; antiandrogens = $3500;
CAB = $8500; surgical orchiectomy per operation = $3000. Survival after treatment with an
LHRH agonist is equivalent to survival after orchiectomy or DES (Hazard ratio [HR] = 1.11;
95% CI= 0.89,1.39). The available LHRH agonists are equally effective regarding survival
and no LHRH agonist is superior to others when considering adverse effects. Survival may
be lower with use of a nonsteroidal antiandrogen (hazard ratio relative to orchiectomy =
1.22; 95% CI = 0.97, 1.54). There is no statistically significant difference in survival
at 2 years between patients treated with CAB or monotherapy (HR = 0.97; 95% CI=0.87,1.09).
Meta-analysis of the limited data available show a statistically significant difference in
survival at 5 years that favors CAB but this is of questionable clinical significance (HR
= 0.91; 95% CI = 0.85,0.99). Data suggest that monotherapy has fewer adverse events and
results in improved quality life. More men randomized to CAB (10%) withdrew from therapy
due to adverse events than men randomized to monotherapy (4%). There is no evidence from
randomized trials to compare early androgen suppression initiated upon PSA rise to
androgen suppression deferred until clinical progression. There was a significant
difference in 5-year overall survival in favor of androgen suppression initiated at the
time of radiation compared to radiation alone followed by androgen suppression initiated
at clinical progression (HR = 0.63; 95% CI = 0.48, 0.83; NNT at 5 years = 12).
Conclusions: Androgen suppression with orchiectomy or DES
provides equivalent survival at lower cost than LHRH agonist, antiandrogens or CAB.
Adverse events and quality of life favored monotherapy.
Impact: Androgen suppression for advanced prostate cancer with
orchiectomy or DES provides equivalent survival and quality of life compared to LHRH
agonists, antiandrogens or CAB. Treatment with orchiectomy or DES would result in
considerable cost savings. Despite widespread practice of initiating androgen suppression
for rising PSA levels in the absence of clinical signs or symptoms there is no evidence
from randomized trials comparing this strategy to androgen suppression deferred until
clinical evidence of disease progression. Patients who undergo immediate treatment will
have a longer duration of therapy in which they experience the adverse effects and
increased costs of androgen suppression.
23. Men's Beliefs about the Benefits of and
Professional Recommendations for PSA Screening
Judith Zemencuk MA, and Rodney Hayward MD. Center for Practice
Management and Outcomes Research, Ann Arbor, MI. SJ Katz
Objectives: Despite the many uncertainties surrounding
screening for prostate cancer, few published studies have examined men's beliefs about the
pros and cons of prostate-specific antigen (PSA) testing. This study assesses and
describes the beliefs men hold with regard to the benefits of, controversies about, and
professional recommendations for screening for prostate cancer by PSA testing.
Methods: Using a self-administered questionnaire developed to
measure men's knowledge and understanding regarding PSA testing, we collected data from a
sample of men seeking care at a VA medical center general medicine outpatient clinic or at
one of two primary care sites of its university affiliate. Of 390 consecutive men, 45
years or older, at the VA medical center site, 270 (69%) consented to participate and
returned completed questionnaires. At its university affiliate sites, 119 of the 162 (73%)
eligible patients completed questionnaires.
Results: Over 42% of all men reported that they had had a PSA
test, while 16% were unsure. Nearly 77%, however, indicated a desire for PSA testing
within the next year or two, including 75% of men 70 years and older (for whom the test is
not generally recommended even by screening advocates). In general, most men believed
regular PSA testing to be highly beneficial. For example, over 80% of all men thought that
medical studies have shown that regular PSA testing can reduce a man's chance of dying
from prostate cancer by 50% or more. Most men were unaware of the uncertainties
surrounding the use of PSA as a screening test. For example, although nearly half of men
reported reading or hearing reports about PSA testing, nearly two-thirds were unsure as to
whether there was a controversy among medical professionals concerning when and how often
a man should get regular PSA testing. Beliefs regarding recommendations for PSA screening
for men their age were inconsistent. For example, while 62% of all men thought that the
medical profession in general recommends that men their age get regular PSA testing, 46%
were unsure as to whether their own physician endorsed a similar recommendation. There
were no significant differences in responses at the VA vs. non-VA clinics.
Conclusions: Most men were uncertain as to whether screening for
prostate cancer by PSA testing is controversial, while a majority believed that PSA
testing is recommended by the medical profession in general. A substantial proportion of
men were uncertain as to whether their own physician recommended PSA testing. Still, a
large majority believed PSA testing to be substantially beneficial and wanted PSA
Impact: Uncertainties concerning the benefits of screening for
prostate cancer using prostate-specific antigen (PSA) have led many to suggest that men be
involved in the decision to screen. Indeed, the VA has mandated documentation of PSA
counseling. Our study's findings indicate that men may not have sufficient information to
make an informed decision regarding screening for prostate cancer by PSA testing and
highlight the need to improve men's knowledge and understanding of this screening test.
24. Preventing Urinary Tract Infection using
Urinary Catheters Coated with Silver Alloy: A Cost-Effectiveness Analysis
Sanjay Saint, MD, MPH. Center for Practice Management and
Outcomes Research, Ann Arbor, MI. DL Veenstra, SD Sullivan, C Chenoweth, and AM
Objectives: Up to 25% of hospitalized patients have a
urinary catheter placed at some time during their stay. The overall incidence of
nosocomial urinary tract infection (UTI) among patients with an indwelling catheter is
about 5% per day. UTIs account for up to 40% of nosocomial infections, with bacteremia
complicating nosocomial UTI in about 4% of cases. A recent meta-analysis indicated that
silver alloy urinary catheters were efficacious in preventing UTI compared with standard
urinary catheters; however, providers must decide whether the efficacy of such catheters
is worth the extra cost of approximately $5 per catheter. We performed an analysis to
determine the incremental cost and the incremental incidence of catheter-related UTI,
bacteremia, and death associated with the use of silver alloy urinary catheters versus
standard urinary catheters.
Methods: The decision analytic model, performed from the
healthcare payer=92s perspective, was based on patients admitted to acute care hospitals
on general medical, surgical and urological services requiring indwelling urethral
catheterization between three and six days. Three interventions were compared: 1)
universal silver alloy catheter use; 2) silver alloy catheter use only in those at high
risk for catheter-related UTI, defined as patients not on systemic antimicrobials; and 3)
standard (non-coated) urinary catheter use in all patients. Outcome estimates were derived
from several quantitative syntheses of published reports. Cost estimates were based on
University of Michigan Health System costs and literature review. Sensitivity analyses
were performed and included scenarios in which estimates were set to favor either the
universal use of silver catheters or the universal use of standard catheters.
Results: In the base-case analysis, the strategy of universal
silver catheter use resulted in an expected cost savings of almost $6 per catheter
compared with universal standard catheter use and a 45% relative decrease in the incidence
of symptomatic UTI, bacteremia, and death. The strategy of targeted silver catheter use
resulted in cost savings of $3.75 per catheter used compared to universal standard
catheter use and an expected 20% relative decrease in symptomatic UTI, bacteremia, and
death. Sensitivity analyses across the reasonable range of outcome and cost estimates did
not dramatically alter these findings.
Conclusions: The results of our analysis indicate that
strategies using either universal silver catheters or targeted silver catheters in
patients requiring urinary catheterization between three and six days are cost-saving
compared to standard catheters and should reduce the incidence of symptomatic UTI,
bacteremia, and death. The appropriate use of silver catheters in patients requiring
catheterization for less than three days or more than six days remains unclear.
Impact: The universal use of silver alloy-coated urinary
catheters in patients requiring catheterization between three and six days should be
strongly considered. The base-case analysis suggests that for approximately every 1000
silver-alloy catheters used, an average of $6500 will be saved overall, and 9.7 cases of
symptomatic UTI, 1.7 cases of bacteremia and .2 deaths will be avoided.
25. HSR&D Development Center Workshop
Douglas D. Bradham, DrPH. HSR&D
Developmental Center, Capital VISN (5), Baltimore, MD.
Purpose: To provide an open discussion (from the trenches) of
key issues facing these Centers as they mature into HSR&D
infrastructure for their VISNs.
Objective A: To encourage interchange among the current (10)
HSR&D Developmental Centers by discussing their approaches to
several key issues including:
a) Attracting a critical mass of clinician investigators.
b) Training and mentoring these investigators toward successful LOIs
c) Hiring talented staff in critical areas of:
i) VA Database extraction and programming.
ii) Biostatistics and methodologists.
iii) Health economists.
d) Acquiring and holding on to space!
e) Maintaining linkage with R&D and VISN-level operational
f) Gaining VISN-level financial support.
Objective B: To improve the next round of HSR&D Developmental
Center applications by discussing the current Centers' approaches to issues including:
i) Critical items in the proposals.
ii) Critical items in the organizational phase.
iii) Critical items in the implementation phase.
iv) Other critical items for success.
Approach: Each topic will be examined by the 10 directors along
a) What works and why?
b) What does not work?
c) Who is helpful and why?
Activities: Each Developmental Center
Director will be asked to participate. Modifications in the issues listed above will be
generated. Prior to the Annual Meeting, each Director will be asked to lead a posting of
ideas for group contributions for a particular topic. The posting of ideas will be
recorded and a summary report will be assembled. That report will be made available for
the attendees and for HSR&D Headquarters staff for use in encouraging new applicant's
Audience: Current and future of applicants for developmental
Audience Familiarity: Individuals who are considering
application for Developmental Center funding should attend.
26. Internet-Based Education for Epidemiology
Michel A. Ibrahim, MD, University of
North Carolina at Chapel Hill, Chapel Hill, NC .
Abstract: This workshop is intended to
demonstrate the utility of Internet-based courses in basic and continuing education of
epidemiology. As an illustration, one module for an outbreak investigation will showcase
the technology and demonstrate the interactive and stimulating nature of this mode of
learning. A module is a self-contained unit of study that requires advanced readings and
consists of an audio tutorial and a review of a case study with a set of questions and
answers. An entire course consists of several related modules. You
need not to bring anything with you to benefit from this demonstration. However, if you
want to have a hands-on experience by actual participation you should bring a laptop with
Windows95, Intel Pentium, floppy drive, 16Mb of RAM, 16-bit sound card with headphones,
Netscape Navigator version 3.x or 4.x, RealAudio Player and CD-Rom drive. You may download
Netscape from http://home.netscape.com/ and RealAudio Player from http://www.real.com -
both these programs are free and are needed for the demonstration. No Internet link is
necessary during the demonstration. In order to be able to use the
technology effectively to complete an actual module or an entire course, the
"student" must have the skills and understanding of Internet jargon, Internet
navigation, discussion forums, listservs, and other related topics.
Target: The target audience includes The
Veterans Administration clinicians, researchers and administrators. The educational
offerings would vary in terms of the nature of topics covered as well as the degree of
complexity of content from the introductory to the advanced, depending on the particular
27. Using National VA Data in health Services and
Reiber, Gayle, PhD, MPH, and Jennifer MAYFIELD, MD, MPH. VA
Puget Sound Health Care System, Seattle, WA. Charles Maynard. Michael Chapko,
PhD, VA Puget Sound Health Care System, Seattle,
Objective: To describe and illustrate
basic considerations and strategies for use of national VA data in health services and
Activities: In this workshop, participants
will have an opportunity to follow the steps involved in procuring data from national VA
databases. Two clinical examples will provide participants with an overview of the process
and specific methods used to obtain the data. The first example is
ï¿½ what was the prevalence of esophageal cancer in the VA from
1993-1997 and what was the survival experience of these patients? ï¿½ The
second example is ï¿½ how many lower limb bypass and amputation
procedures were performed in VA hospitals between 1992 and 1996? Participants
will receive information on administrative and human subjects clearance, database
considerations, downloading strategies, sample programs for data extraction, and file
linkage and data quality considerations.
Target: Health services researchers with
no prior experience using national VA databases.
28. Continuity of Care as a Determinant of Patient
Satisfaction. Results from the ACQUIP Study
Marcia Burman, MD, Mary McDonell, MS, and Stephan Fihn, MD, MPH. VA Puget Sound Health Care System, Seattle, WA.
Objectives: Patient satisfaction has been positively associated
with improved patient compliance and improved clinical outcomes and negatively associated
with malpractice claims. Factors that have been found to be related to patient
satisfaction include sociodemographic factors, payment source, both patient and physician
rated health status and utilization measures. We examined relationship between continuity
of care and patient satisfaction.
Methods: We surveyed 38,642 General Internal Medicine Clinic
(GIMC) patients followed at 7 VAs. Data gathered included demographics, active medical
problems and satisfaction with care using the Seattle Outpatient Satisfaction
Questionnaire (SOSQ) which measures satisfaction with humanistic and organization aspects
of care. Patients who reported angina, COPD, diabetes or hypertension also received
condition-specific questionnaires (e.g. the Seattle Angina Questionnaire and the Seattle
Obstructive Lung Disease Questionnaire) which include measures of condition-specific
satisfaction. All scales were scored from 0 (worst) to 100 (best). Patients were also
asked to rate their continuity of care.
Results: 14,865 patients responded with 11,711 reporting one or
more of the following disease conditions: angina (n=5544), COPD (n=3189), diabetes
(n=3249) or hypertension (n=8059). The percent of patients reporting seeing the same
provider "always", "most of the time", "sometimes", and
"rarely or never" were 38, 39, 14 and 6 respectively. There was no difference in
the distribution of continuity scores between the disease conditions. Mean scores on both
the SOSQ humanistic scale and condition-specific scales were strongly related to perceived
continuity of care with satisfaction scores ranging from 86.7 to 61.4 among veterans who
reported "always" seeing the same provider. Satisfaction scores among veterans
who reported "rarely or never" seeing the same provider ranged from 69.5 to 41.9
(p<.001). These findings persisted after adjusting for age, education, race, income, VA
facility, and length of time receiving care at the VA and SF-36 scores.
Conclusions: Continuity with the same provider is highly related
to Patients' general and condition-specific satisfaction.
Impact: Since higher patient satisfaction has been associated
with improved outcomes in chronic disease and improved medical compliance efforts to
improve patient satisfaction might be reasonable interventions for improving outcomes.
Further studies are needed to evaluate the contribution of various components of
continuity of care (for example convenience, access, ease of negotiating the system, etc)
to patient satisfaction.
HSR&D Funded: SDR 96-002
30. A Disease-Targeted Measure of Health-Related
Quality of Life (HRQOL) for Patients with Chronic Liver Disease the LDQOL 1.0.
Ian Gralnek,MD, MSHS. West Los Angeles VA Medical Center,
Los Angeles, CA. RD Hays, HR Rosen, EB Keeffee, DM Jensen, and P Martin.
Objectives: The development and validation of a
patient-centered HRQOL outcomes measure is timely and needed for individuals with chronic
liver disease. Disease-targeted measures can capture small, yet clinically meaningful
changes in patients' health status due to an intervention or disease progression that a
generic instrument may fail to detect. Therefore, the objective of this study is to
evaluate the psychometric properties (reliability and validity) of a newly developed
disease-targeted HRQOL instrument (the LDQOL 1.0) for individuals with chronic liver
Methods: Disease-targeted items in the LDQOL 1.0 were developed
from focus groups of patients with chronic liver disease awaiting liver transplantation,
expert hepatology panel input, and an extensive review of the literature. Cognitive
interviews were conducted to detect potential problems with instrument design or wording
of items. The HRQOL instrument was then constructed consisting of 36 generic items (SF-36)
supplemented with 77 disease-targeted items. A multicenter, cross-sectional field test was
Results: 221 consecutive ambulatory adult patients being
evaluated for liver transplantation participated in this field test (64.1% male; median
age = 51 years (range 23-78 years); 68.9% white, 6.8% Asian/Pacific Islander, 3.9%
frican-American, 1.9% Native American, 18.5% other or multiracial). The LDQOL 1.0 is a
self-report measure that includes 21 multi-item scales (number of items): physical
functioning (10), role limitations-physical (4), pain (2), liver disease-related symptoms
(19), emotional well-being (7), role imitations-emotional (3), energy (4), cognitive
function (6), memory (4), concentration 3), hopelessness (7), loneliness (6), stigma of
liver disease (8), social function (2), quality of social interaction (5), sexual function
(3), sleep 6), general health perceptions (7), health distress (4), effects of liver
disease 9), and impact of liver disease (4). Internal consistency reliabilities
(Cronbach's alpha) ranged from 0.67 to 0.95 (median=0.86); 20/21 reliability estimates
were excellent, alpha >= 0.70. All 21 scales were significantly (p<0.05) associated
with self-reported severity of symptoms and 4 scales with duration of liver disease
(better HRQOL related to less severity and shorter duration of liver disease). Role
limitations-physical was most strongly related to severity of symptoms (p<0.01); sleep
was most strongly associated with duration of disease (p<0.05). Worse physical
functioning (p<0.01), worse sexual functioning among males (p<0.01), role
limitations-physical (p<0.01), more liver disease-related symptoms (p<0.05), and
greater negative effects of liver disease (p<0.05) were all significantly associated
with higher Child-Pugh class.
Conclusions: This multicenter study demonstrates the high degree
of reliability and construct validity of the LDQOL 1.0 for individuals with chronic liver
disease. This HRQOL outcomes instrument is able to measure significant impairment of daily
functioning not detected by more traditional clinician-rated methods (e.g., Child-Pugh
classification). The LDQOL 1.0 is now ready for implementation into prospective,
Impact: 1. The LDQOL 1.0 will allow for a better understanding
of HRQOL in patients with chronic liver disease. 2. The LDQOL 1.0 fits well with the VHA's
initiative to build a system of data collection that will integrate both generic and
disease-targeted functional status instruments into a routine process of HRQOL data
collection. 3. HRQOL data collection in chronic liver disease will allow for case mix
comparisons, evaluation of changes in patient functional status over time and its
potential relationship to processes of care, and generation of patient summary information
for the clinician in their care of patients with chronic liver disease. 4. The LDQOL 1.0
may provide important information on resource utilization within the VA health care system
such as response to therapeutic interventions (e.g., therapies for chronic viral hepatitis
and liver transplantation).
31. Measuring the Job Satisfaction of Providers in
VA Primary Care: the Seattle Provider Satisfaction Questionnaire (SPSQ)
Mary McDonell, MS. VA Puget Sound Health Care System,
Seattle, WA. J Marshall. Stephan Fihn, MD, MPH. VA Puget Sound Health Care
System, Seattle, WA. KE Kilpatrick, and DS Lessler.
Objectives: Determining the satisfaction of health care
providers is critical given continual changes in organization and expectations that often
dramatically affect providers and influence their perceptions about their ability to
deliver high quality care. We developed and validated a survey to measure multiple
dimensions of job satisfaction among VA primary care providers.
Methods: Open-ended interviews designed to elicit provider
perceptions of organizational characteristics that contributed to work satisfaction were
conducted with 20 providers from a large group practice and VAPSHCS. Interviews and
published questionnaires were used to generate a prototype 78-item questionnaire. As part
of the Ambulatory Care Quality Improvement Project (ACQUIP) pilot study, the survey was
tested among 236 general internists at 8 facilities (VA and non-VA) and condensed to 50
items. The 50-item questionnaire has now been administered to 220 providers at 7 ACQUIP
sites and 792 providers at 56 VA facilities participating in the PRIME program. We
performed exploratory (EFA) and confirmatory factor analyses (CFA) to analyze
dimensionality of the SPSQ. Convergent and discriminate validity of the SPSQ were assessed
using CFA as an approximation of the multitrait-multimethod approach. ANOVA and linear
regression were used to examine subscale and global satisfaction scores and to adjust for
demographic characteristics. Scales were scored from 0 (least satisfied) to 100 (most
Results: The sample of 1012 providers was comprised of
physicians (69%), nurse practitioners (NPs) (22%) and physician assistants (PAs) (9%). 49%
were female. Ages ranged from 20-65 years; 40% were between 36 and 45. 77% were Caucasian,
12% Asian, and 4% African American. 44% had been at their jobs for >5 years. Six
dimensions (subscales) emerged from factor analysis and all demonstrated high internal
consistency: clinical staff communication (Cronbach's alpha=.86); relationships with
specialists (.89); hassle-free work environment (.89); patient characteristics (.77);
philosophy of practice (.84); and colleagues (.84). The CFA also demonstrated both
convergent and discriminant validity (p<.001). Mean scores for all scales were low:
staff communication (38.6); specialists (41.5); assle-free (37.7); patient characteristics
(49.3); philosophy (66.4); and colleagues (58.4). Subscale and global satisfaction scores
did not differ significantly according to gender, age, ethnicity, time on the job or
provider type (resident, staff MD, PA, NP). Comparing different VA facilities, there were
significant differences for all scales that were most dramatic (i.e., >25 points) for
philosophy and colleagues. When the six domains were entered into a regression model
predicting global satisfaction, the philosophy domain (belief in organization's philosophy
and ability to practice according to personal standards) accounted for 57% of the variance
(p < .001). Clinic organization and clinical staff communication were also
significantly related to overall satisfaction (p< .001).
Conclusions: The SPSQ is a reliable, valid measure of multiple
domains of provider satisfaction. The extent to which a provider's practice standards and
philosophy are aligned with the organizations is a key determinant of overall
Impact: The SPSQ is potentially useful for monitoring outcomes
and evaluating changes in clinic organization.
HSR&D Funded: SDR 96-002
32. Patient Characteristics and Patterns of use of
Lumbar Spine Radiographs: Results from the Veterans Health Study
Alfredo Selim,, MD, MPH. Boston VA Medical Center, Boston,
MA. G Fincke. X Ren, PhD. Edith Nourse Rogers Memorial Veterans Hospital,
Bedford, MA. A Lee, and C Skinner. Lewis Kazis, ScD. Edith Nourse Rogers
Memorial Veterans Hospital, Bedford, MA.
Objectives: Understanding patient factors that affect patterns
of use of lumbar spine films is essential for clinicians, hospital administrators, and
managers in order to adopt the best and most effective practice of x-ray utilization. Very
little is known about patient factors that affect patterns of x-ray use such as no use and
repeat lumbar spine films. In this study, we examined a number of patient characteristics
in groups of low back pain patients as defined by their pattern of x-ray use after 12
months of prospective follow-up.
Methods: We analyzed longitudinal data from the Veterans Health
Study, an observational study of patients receiving ambulatory care. Five hundred and
seventy four patients with LBP were identified through self-report of ever having had LBP
that began more than three months ago and a health care visit for LBP in the past year.
Four hundred and one of these patients were available for follow-up 12 months after the
initial study visit. Participants were mailed a health-related quality of life
questionnaire (HRQoL), and had an interview that included a LBP questionnaire and a
straight leg raising test. We defined four groups based on the patterns of use of lumbar
spine films (new, repeat, no repeat, and no use of lumbar spine films. We compared these
groups in terms of sociodemographics, comorbid conditions, low back pain intensity,
radiating leg pain, straight leg raising, HRQoL, and low back disability. We examined
predictors of repeat lumbar spine radiographs during the 12 months of prospective
follow-up and no use of lumbar spine films.
Results: Patients with new lumbar spine films showed worse
physical impairment and psychological distress than the other groups. Compared to other
groups, patients with no lumbar spine films reported minor physical impairment. Patients
with repeat lumbar spine films showed evidence of psychological distress which can not be
explained by the small differences in physical health between these patients and those who
had no have repeat films. Using regression models, straight leg raising, radiating leg
pain, and mental health were found to be independent predictors of repeat use of lumbar
spine radiographs (c-statistic of 0.73). We found that low back pain intensity, vitality,
and mental health were independent predictors of no use of lumbar spine films (c-statistic
Conclusions: This study found that the use of lumbar spine film
is strongly influenced by patient characteristics. Given the physical and emotional toll
that low back pain takes on these patients, our data illustrated that physicians rely
primarily on the degree of physical impairment to request initial roentgenographic
evaluations. Physicians appear to give the benefit of the doubt to patient in
psychological distress in considering repeat lumbar spine films. However for many of these
patients, education is needed instead of lumbar spinal films.
Impact: Careful consideration of both physical and psychological
characteristics of patients with LBP is essential when evaluating and comparing use of
lumbar spine films.
HSR&D Funded: SDR 91-006
34. Measuring Patient Expectations: Does the
Measurement Instrument Affect the Number of Expectations Elicited and Patient
Bob Peck, MS. Durham VA Medical Center, Durham, NC. DA
Asch, MD, MBA. Leonard Davis Institute of Health Economics, Philadelphia, PA. SD
Goold, and D Roter. Peter Ubel, MD. Philadelphia VA Medical Center. James
Tulsky, MD. Durham VA Medical Center, Durham, NC.
Objectives: Fulfillment of patient expectations can be used as
an indicator of quality of care, and may influence health care utilization and costs.
Previous research has shown that the number of expectations fulfilled is positively
associated with medical visit satisfaction. However, research also suggests that how
expectations are measured may create expectations for care. We conducted this study to
examine the relationship between the type of instrument used to measure patients'
expectations, the method of eliciting expectations, and patient satisfaction. In
particular, we sought to determine whether instruments that elicit different numbers of
expectations create bias by yielding different patient satisfaction.
Methods: We randomly assigned patients in a single VA outpatient
clinic to one of three methods of expectation assessment. One group received a
questionnaire that asked only about 3 specific expectations for care: tests, referrals,
and new medications. A second group received a questionnaire that asked about the same
three expectations; however, they were nested within a longer list of expectations. The
third group received no pre-visit measure of expectations. All patients were interviewed
after the clinic visit to assess whether expectations were met and to assess satisfaction
with the visit using the ABIM and Ware Visit Specific Questionnaire (VSQ).
Results: 409 consecutive patients in the outpatient clinics were
approached to participate. 291 (71%) patients completed both the pre- and post-visit
interviews. The remaining 118 patients either refused (20%), did not complete the
post-visit interview (8%), or failed the enrollment criteria (1%). The mean patient age
was 60, 99% were male, 69% were white and, on average, the patients had completed 12 years
of education. The treatment groups did not differ significantly by any demographic
variables. The type of instrument used to measure expectations for care was significantly
related to the number of expectations reported. The group receiving the specific
questionnaire reported an average of 0.74 expectations for tests, referrals, and new
medications. The group receiving the nested questionnaire reported an average of 1.65
expectations for the same items (p<0.001). Despite the differences in expectations
elicited, reported satisfaction did not differ among the groups. The mean ABIM
satisfaction scores for the three groups (specific, nested, control) were 13.86, 13.83,
14.42 respectively (p=.660). The mean Ware VSQ scores for the three groups were 16.09,
16.57, 16.42 (p=.897).
Conclusions: The type of instrument used to measure patient
expectations affects key outcome variables. A questionnaire with more expectations to
choose from generates more expectations than a questionnaire with fewer expectations.
Different measurement instruments, however, do not affect patient satisfaction.
Impact: Investigators studying patient expectations must contend
with an "instrument" effect when measuring the number of expectations. However,
they need not worry that the instrument will affect patient satisfaction with the medical
HSR&D Funded: MCV 97-011
35. Barriers to Walking for Exercise in Elderly
Primary Care Patients
Patricia Dubbert, PhD. GU "Sonny" Montgomery VA
Medical Center, Jackson, MS. DE Bilbrew, KM Cooper, and ER Meydrech.
Objectives: Walking is a good exercise recommendation for
many older patients, but not all are able or willing to adopt a regular walking habit.
Interventions to increase physical activity in older patients at risk for increased
disability require understanding of potential barriers to regular activity. The purpose of
this study was to identify barriers to unsupervised walking for exercise as viewed from
two perspectives: the health care provider and the patient.
Methods: Participants were patients being screened for the
Seniors Telephone Exercise Primary Care Study (STEPS), which is designed to test the
effectiveness of nurse telephone counseling to increase walking for exercise. To determine
the relative frequency of medical exclusion barriers identified by health care providers,
medical records of 658 veterans aged 60-80 and enrolled in VA primary care clinics were
selected randomly on the day of clinic visits and reviewed by a nurse researcher.
Conditions which would exclude the patient from counseling for an unsupervised walking
program ere recorded. Subsequently, patients who passed the medical record prescreen and
attended a research clinic visit completed an instrument listing 18 potential barriers to
exercise. Patients indicated the degree to which they agreed or disagreed with each
potential barrier. Responses were ranked within patients and analysis of variance used to
identify the most highly ranked barriers.
Results: 217 (33%) of the 658 medical records reviewed by the
research nurse over a period of several months revealed one or more medical exclusions for
nurse counseling for unsupervised walking. The most frequent were: severe cardiovascular
disease (41%), severe orthopedic problem/joint disease (21%), and severe pulmonary disease
(15%).. Ratings by patients of the potential barriers revealed 8 were most endorsed.
Ranked in order these were: 1) no good place to exercise; 2) exercise makes me tired; 3)
too much exercise could be bad for my heart; 4) exercise makes me hurt more; 5) exercise
is hard work for me; 6) family members don't encourage exercise; 7) too much exercise
could make me sick; 8) persons close to me don't encourage exercise. Rankings of barriers
were not associated with age, ethnicity, or urban vs. rural home location.
Conclusions: The STEPS program was designed to provide nurse
counseling for physical activity for patients with chronic medical conditions, but we
found that one-third of elderly primary care patients had to be excluded from
consideration due to health barriers to unsupervised exercise or inability to walk. Among
eligible patients who attended a screening visit, health concerns were highly ranked as
perceived barriers to exercise
Implications: Although the majority of elderly primary care
patients could be eligible for nurse counseling for home-based exercise, a substantial
minority (1/3 in our sample) could not be referred for a walking program. Future
prevention efforts need to include consideration of appropriate physical activity designed
to maintain functional status and the psychosocial benefits of activity for those who
cannot engage in a walking program. Effective methods of addressing patientsï¿½ perceived
barriers, including concerns about health risks of exercise, are needed to optimize
prevention counseling for those patients who can walk for exercise.
HSR&D Funded: NRI 95-022
36. Validity of Physical Activity Recall in Urban and Rural Elderly
Patricia Dubbert, PhD. GU "Sonny" Montgomery VA Medical Center,
Jackson, MS. KE Kerr, DE Bilbrew, KA Kirchner, EF Meydrech, B Shaw.
Objectives: To evaluate the impact of low levels of physical
activity (PA) on health and the effects of interventions to increase PA, investigators
must often rely on self-report measures such as the 7 day physical activity recall (PAR).
The reliability and validity of this measure has not been established in older and rural
populations. The purpose of the study was to evaluate the temporal stability and the
validity of PAR in elderly urban and rural dwelling elderly men.
Methods: 142 men, average age 68.7 (S.D. 4.6) years, 27%
minority, 54% rural, 46% < HS education, who were being screened for the Seniors
Telephone Exercise Primary Care Study (STEPS) completed the PAR; a subset of 97 of these
subsequently completed a submaximal treadmill test. 138 completed a second PAR 2 to 4
weeks after the first. PARs were administered and scored by trained interviewers using
standardized protocols. Energy expenditure (EE) was estimated for several intensity levels
of PA. Temporal stability was estimated with Pearson correlations of EE at different
intensities of PA across the 2 occasions. Validity coefficients were the Pearson
correlations of estimated EE with cardiorespiratory fitness as measured by the submaximal
treadmill performance (METs).
Results: Most participants reported little or no hard intensity
PA. Temporal stability was 0.45 (P<.01) for total weekly EE; 0.44 (P<.01) for
moderate PA; and 0.65 (P<.01) for light-moderate PA; comparing favorably with results
of previous studies with young, healthy, active
samples. In urban participants, total EE (0.33, P<.03), hard PA
(0.36, P=.02), and moderate PA (0.31, P=.04) were each significantly correlated with
treadmill performance with validity coefficients similar to those observed in previous
research with younger samples. In rural participants, however, only estimated EE for
light-moderate PA was significantly correlated with treadmill performance (0.29, P=.03).
Total EE estimates and submaximal treadmill performance were similar for both groups.
Validity coefficients were improved by coding specifically for both light-moderate and
Conclusions: Stability of moderate and light-moderate PA was
similar in urban and rural dwelling elderly men and stability of moderate and
light-moderate PA recall in both groups was similar to results from previous research. In
our sample, the performance of the PAR against treadmill fitness as a validation standard
was better in urban men. It may be more difficult to accurately estimate duration and
intensity (and EE) of the variety of PA described by rural men.
Impact: Measurement of the effectiveness of preventive
counseling to promote healthful PA requires measures which are reliable and valid in the
diverse populations served. Failure to accurately assess the health behaviors of elderly
and rural dwelling populations will make it
difficult to evaluate effectiveness of interventions to decrease health
risks. Future research should examine differences in types of PA which could account for
the findings as well as evaluate the accuracy of EE estimates by using motion sensor and
other approaches for measuring PA which do not depend.
37. Multidisciplinary Rehabilitation Versus Medical
Care use of Meta-Analysis to Determine the Clinical Effectiveness of Physical Medicine
Ron Evans, MSW. VA Puget Sound Health Care System, Seattle,
Objectives: Research studies in physical medicine have not
demonstrated the effectiveness of inpatient rehabilitation services, primarily due to
differences in methodological approaches which have led to inconsistent findings. To
address this problem, research studies comparing the clinical effects of rehabilitation
with medical care were evaluated for 3 uniformly available outcomes: survival, functional
ability, and discharge location. Published trials were obtained from citations in Medline
and Nursing and Allied Health Abstracts covering the period from 1974 to 1995 using the
descriptors: rehabilitation, physical medicine, activities of daily living, and functional
Methods: We used meta-analysis of completed clinical trials to
test the hypotheses that rehabilitation results in better health care outcomes. To be
included studies had to prospectively evaluate a multidisciplinary program of physical
rehabilitation by comparing outcomes with a control group and report results in a manner
that allowed quantitative analysis of uniformly available variables: e.g., mortality,
function, and residence. Eleven studies met this rather stringent criteria.
Results: Results indicated that rehabilitation services are
significantly associated with better rates of short term survival (86% versus 81%,
Chi-square=7.30, p < 0.01) and improved function during hospital stay (Fisher Combined
Test, Chi-square=67.12, p < 0.01), but significance was not observed at one year. Also,
rehabilitation patients returned home and remained there more frequently than controls
(Odds ratio=2.08, Chi-square=40.15, p< 0.001).
Conclusions: We concluded that patients who participate in
rehabilitation: 1] function better at hospital discharge, 2] have a better chance of short
term survival, and 3] return home more frequently than non-participants. Contrarily, long
term survival and function were unaffected by the relatively short term treatment [3-5
Impact: The sustaining benefit of returning home may justify
provision of inpatient rehabilitation. However, the lack of other long term benefits
suggests that services may need to be continued at home or in subacute care settings to
optimize their effectiveness. Future clinical research might include social and behavioral
outcomes so that results of rehabilitation research can be applied to clinical settings
and can more accurately reflect psychosocial objectives.
HSR&D Funded: IIR 94-125
38. Racial Variation in Congestive Heart Failure
Mortality among the Elderly
Said Ibrahim, MD. University Hospitals of Cleveland and
Cleveland VA Medical Center, Cleveland, OH. EF Cook C. Kent Kwoh, MD and Gary
Rosenthal, MD. Cleveland VA Medical Center. DW Baker.
Objectives: Prior studies have suggested a significant
difference between blacks and whites in in-hospital mortality from congestive heart
failure (CHF). Whether this difference is sustained in the long-term and what clinical
factors account for this difference remain unclear. The objective of this study was to
compare risk-adjusted, post-hospitalization short-term and long-term mortality from
congestive heart failure in elderly black and white patients. This is a 2-year follow-up
of a cohort for whom an in-hospital mortality was reported in a published study in 1996.
Methods: The study sample consists of 12,991 patients with the
principal discharge diagnosis of congestive heart failure (CHF) following an admission to
one of 30 hospitals in Northeast Ohio between 1991 and 1993. All patients were Medicare
enrollees 65 years of age or older.
Data Collection: This data comes from the Cleveland Health
Quality Choice Program (CHQC). The reliability of data collection for CHQC has been
confirmed in prior studies. The database includes information on demographics, comorbid
conditions, laboratory test results and detailed clinical information abstracted from
patients' hospital records. Analysis: Crude and adjusted 30-day and 2-year survival curves
were compared for black and white patients using Kaplan-Meier method. Multivariate
analysis was performed using Cox Proportional Hazard models to determine adjusted hazard
ratios for the relationship between race and 30-day, 90-day and 2-year mortality.
Important clinical variables such as age, gender, comorbid medical conditions, ejection
fraction, albumin level, creatinine level and serum sodium level were included in the
Results: Black and white patients in this cohort were comparable
with respect to age, and gender. Blacks were more likely to have hypertension ( blacks
47%, whites 31% ), and less likely to have Ischemic Heart Disease (blacks 30%, whites
58%). Other comorbidities were comparable. In the one third of the cohort who had ejection
fraction recorded, blacks were just as likely to have left ventricular systolic
dysfunction compared with whites. During the first 30 days, blacks showed better survival
compared to whites (adjusted hazard ratio 0.7 95% CI 0.60-0.83). However, over time the
survival advantage for blacks diminished, although it remained significant. During the
first 90 days the adjusted hazard ratio for blacks was 0.80 (95% CI 0.60-0.90), and during
the first 2 years it was 0.90 (95% CI 0.83-0.97).
Conclusions: This study is one of the first to compare short
term and long-term CHF mortality between blacks and whites. Although in the short-term
elderly blacks have lower mortality, in the long-term their mortality approaches that of
whites. However, because the majority of patients did not have left ventricular ejection
fraction measured, further studies are necessary to understand whether racial differences
in survival are explained by differences in left ventricular function.
Impact: This study adds to our understanding of the racial
variations in outcomes of chronic medical conditions. As the minority patient population
in the VA health system increases, understanding racial variations in outcomes will help
us devise approaches that will reduce black and white disparities in health outcomes.
39. African American Veterans with Coronary Artery
Disease Report Worse Health and Less Satisfaction with Care than Whites: Results
from the ACQUIP Survey
Catarina Kiefe, Mary McDonell, MS, Donald Martin, PhD, and
Stephan Fihn, MD, MPH. VA Puget Sound Health Care System, Seattle, WA.
Objectives: Racial differences in management of coronary artery
disease (CAD) are well known but poorly understood. Several studies document less intense
management of African Americans (AA) compared to Whites, even within the Department of
Veteran Affairs (DVA). We examined AA vs. White differences in self-reported health status
and satisfaction among veterans with CAD.
Methods: Cross-sectional analysis of surveys mailed to 38,642
General Internal Medicine Clinic patients at 7 VAs. Survey information included
socioeconomic factors and a checklist of medical conditions, including CAD. Patients
reporting CAD received follow-up surveys including: the Seattle Angina Questionnaire
(SAQ); the Seattle Outpatient Satisfaction Questionnaire (SOSQ) which measures
satisfaction with humanistic and organizational aspects of care; and the Medical Outcomes
Study SF36. All scales were scored from 0 (worst) to 100 (best).
Results: 66% of patients responded to the baseline surveys;
4,204 (16.4%) classified themselves as AA, and 15,391 (63.5%) as White. AAs compared to
Whites were younger (58.9 vs. 62.8 years, p < .001), less likely to use non -VA health
care (27.9% vs. 37.2%, p < .001) or to be married (44.8% vs. 59.2%, p < .001); more
likely to have income below $10,000 (39.9% vs. 24.8%, p < .001), to smoke (33.6% vs.
25.6%, p < .001), and to screen positive for drinking problems (39.2% vs. 30.4%, p <
.001). AAs were also more likely to report diabetes (25.8% vs. 20.2%, p < .001) and
hypertension (65.4% vs. 52.0%, p < .001), but less likely to report CAD (26.6% vs.
37.9%, p < .001). CAD was reported by 9,287 patients (36%); 1,118 AAs, 5,836 Whites and
4,642 other. The differences between Whites and AAs reported above were also present in
CAD patients. Among CAD patients, 61.3% returned the SAQ, SOSQ, and SF36. AAs scored lower
than Whites on the Exertional Capacity (48.6 vs. 52.4, p=.003) , Disease Perception (58.8
vs. 64.1, p<.001) and Satisfaction (77.1 vs. 84.4, p<.001) domains of the SAQ (p
< .01), but did not differ on Angina Frequency and Stability. AAs were also less
satisfied than Whites with humanistic (65.6 vs. 74.3, p < .001) and organizational
(58.7 vs. 64.2, p < .001) aspects of care. AAs scored higher than Whites on the
Vitality scale of SF36 (40.9 vs. 35.2, p < .001) and lower on Emotional Function (50
vs. 54.7, p < .001); AAs tended to score lower on the other SF36 scales but differences
were not significant at p<0.01. Differences persisted after adjustment for age, income,
education, and marital status.
Conclusions: Compared to Whites, AAs in this DVA sample had
poorer socioeconomic circumstances. Among those with CAD, there were no racial differences
in overall health or severity of angina symptoms. Yet, even after adjustment for
socioeconomic factors, AAs had worse scores on exertional capacity, disease perception,
and satisfaction, both general and related to their CAD.
Impact: Racial differences in health status and satisfaction
parallel differences in treatment observed in other studies. Longitudinal analyses should
explore potential causal relationships between these different instances of racial
HSR&D Funded: SDR 96-002
40. Racial Variation in Mortality Following
Elective Surgery for Vascular Disease
Tracie Collins, MD, MPH, Howard Gordon, MD. Houston VA
Medical Center, Houston, TX. M Johnson. Jennifer Daley, MD. Brockton, MA. W
Henderson, and SF Khuri.
Objectives: Racial variation in mortality for common medical
interventions such as elective surgery has not been well investigated. The purpose of this
study is to assess differences in 30-day postoperative mortality between whites and blacks
after elective surgery for vascular disease.
Methods: Data from the National VA Surgical Quality Improvement
Program were used. A prospective, multicenter observational study of risk adjusted
surgical outcomes after major surgery. Race was defined as black, not of Hispanic origin
or white, not of Hispanic origin as identified by the physician, physician assistant, or
clinical nurse specialist. Cases involving other races were excluded. The following
elective surgeries were evaluated: abdominal aortic aneurysm repair (AAA; n=1401;94.2%
white and 5.8% black), and lower extremity revascularization surgery (LEVS;n=2773;81.7%
white and 18.3% black), and lower extremity amputations (AMP;n=2336;70.7% white and 29.3%
black). The outcome of interest was all cause mortality within 30 days of the index
surgery. For each surgery, the independent relationship of race and mortality was examined
with multivariable logistic regression models. Models were adjusted for co-existing
illnesses and markers of baseline health that were univariately significantly associated
with 30-day mortality and/or clinically relevant.
Results: The overall 30-day mortality was 4.0% for AAA, 2.1% for
LEVS, and 7.0% for AMP. The 30-day unadjusted mortality rate in black compared to white
patients was higher (9.5 vs. 3.5%;p=.013) for AAA, and was similar for other vascular
disease related surgeries (1.7 vs. 2.2,p=.517, LEVS;8.0 vs. 6.6%,p=.253,AMP). The
multivariable odds ratio for mortality in blacks compared with white patients undergoing
AAA was 2.6 (95% CI 1.11-6.05) after adjusting for age, hypertension, dyspnea, creatinine
>= 1.2, history of cerebrovascular accident, diabetes, and ASA-class.
Conclusions: For black patients who undergo elective AAA, there
is a higher rate of both unadjusted and adjusted mortality compared to white patients.
Following LEVS and AMP, there were no statistically significant increased risks of
mortality among blacks. The increased risk of mortality following AAA could not be
accounted for by co-morbidities. Further research is needed to address issues of access to
care, unmeasured risk factors specific to African Americans, and/or process of care, which
could account for the increased 30-day mortality following elective AAA.
Impact: Understanding the factors related to increased 30-day
mortality for a minority population following an elective medical intervention can help to
improve health care within the Veterans Administration.
HSR&D Funded: NSQIP
41. Antimicrobial Prophylaxis for Urinary Tract
Infection in Persons with Spinal Cord Dysfunction
Sally Morton, PhD. Rand Statistics Group, Santa Monica, CA. Paul
Shekelle, MD. West Los Angeles VA Medical Center, Los Angeles, CA. JL Adams. Charles
Bennett, MD, PhD. Chicago VA Medical Center, Chicago, IL. B Dobkin and BG Vickrey.
Objectives: Recurrent urinary tract infections (UTIs) occur
frequently in persons with neurogenic bladders due to spinal cord dysfunction, resulting
in increased morbidity and cost. To assess the potential benefits and possible harms of
antimicrobial prophylaxis to prevent recurrent UTI, we conducted a meta-analysis of
Methods: MEDLINE and EMBASE were searched from 1966 and 1974
respectively to January 1998, and CINAHL was searched from 1982 to July 1998 using a broad
and inclusive strategy with no language restriction. Additional articles were identified
by experts and via a hand-search of reference lists. All controlled trials of prophylaxis
of UTI that included bacteriuria or UTI as an outcome were included; two reviewers were
used. Nineteen trials were identified. Two reviewers abstracted data. Studies were graded
according to the quality criteria of Jadad and Schulz. Effect sizes of differences in
weekly infection rates (treatment minus control) were pooled using a random effects model.
Specific subgroup analyses (asymptomatic versus symptomatic infections; acute versus
non-acute patients; high quality, defined as a Jadad score greater than or equal to three,
versus low quality) were identified a priori. Sensitivity analyses were also conducted.
Results: Antimicrobial prophylaxis is associated with a
reduction in asymptomatic bacteriuria among patients in the acute phase (less than 90
days) following spinal cord injury. The difference in weekly infection rates was equal to
-0.27 (95% confidence interval of -0.40 to -0.15; p < 0.05). This means that one
patient would require 3.7 weeks of treatment on average to prevent one infection. For
non-acute patients the reduction in asymptomatic infections was -0.06 (95% confidence
interval of -0.12 to 0.00; p = 0.06). However, antimicrobial prophylaxis did not
significantly decrease symptomatic infections among any patients. For acute patients, the
difference was -0.03 (95% confidence interval of -0.08 to 0.02; p > 0.05), while for
non-acute patients, the difference was -0.04 (95% confidence interval of -0.11 to 0.04; p
> 0.05). The study quality subgroup analyses showed no differences from the overall
pooled results. In addition, antimicrobial prophylaxis resulted in a two-fold increase in
the proportion of antimicrobial-resistant bacteria.
Conclusions: The regular use of antimicrobial prophylaxis
for reducing symptomatic infections in most patients with neurogenic bladder due spinal
cord dysfunction cannot be supported.
Impact: Routine antimicrobial prophylaxis should not be given to
patients with neurogenic bladder due to spinal cord dysfunction. Future research to
identify subgroups of patients who might benefit from antimicrobial prophylaxis is needed.
Such research should focus on randomized controlled trials that employ rigorous methods;
have adequate statistical power; define the study population and outcomes carefully;
measure cost and quality-of-life outcomes; and measure potential harms, particularly the
development of antimicrobial resistant organisms.
42. Predictors of Outcomes in Patients with Type 2
Virginia Baldwin, PhD, RPL. Portland VA Medical Center,
Portland, OR. SK Joos and DH Hicham
Objectives: Quality improvement programs for the management
of diabetes mellitus (DM) often emphasize the importance of regularly assessing hemoglobin
A1c (HgA1c) and maintaining good glycemic control, but there is only limited evidence that
HgA1c accurately predicts outcomes for patients with type 2 DM. The purpose of this study
was to investigate the relationships among HgA1c, severity of disease, and outcome
measures for a group of patients with type 2 DM.
Methods: In 1994-96, 212 veterans with confirmed type 2 DM were
enrolled in the study and followed for an average of 3.2 years. Patients were recruited
during regularly scheduled visits to a general medicine clinic at the Portland VAMC. Upon
study entry, subjects completed the Diabetes Severity Index (DSI) Questionnaire, the
SF-36, the GHAA Consumer Satisfaction Survey, and a series of demographic questions. In
September 1998, information on death from all causes, medication use, and HgA1c lab values
was downloaded from VISTA. A DSI score, composed of five subscales (Visual, Renal,
Vascular, Neurological, and Metabolic), SF-36 scores, and satisfaction scores were
calculated for each patient. Based on mean HgA1c values, patients were classified as
well-controlled (WC) (HgA1c<=7.0), moderately controlled (MC) (HgA1c>7.0 and
<9.0), or poorly controlled (PC) (HgA1c>=9.0).
Results: The patients' mean age was 64.4 years, and 95% were
male. Forty-two (19.8%) died during the follow-up period. Sixteen percent of patients were
classified as WC, 59% as MC, and 25% as PC. WC patients had significantly shorter duration
of DM than did MC or PC patients (5.7 vs. 10.2 and 10.7 years, respectively) and tended to
be treated with oral diabetic agents (40%) or diet alone (50%). PC patients more often
were treated with oral medications (64%) and/or insulin (68%). Mean HgA1c values were not
significantly associated with death, any of the eight SF-36 subscales, any of the seven
GHAA patient satisfaction measures, or any of the DSI disease severity subscales with the
exception of the metabolic subscale, which consists primarily of glycemic control
variables. Several DSI measures of disease severity were significantly associated with
patient functional status (SF-36) and satisfaction. The overall DSI score and the
neurological and vascular subscales were significantly and negatively associated with all
eight SF-36 subscales (Spearman's rho [r] ranged -0.20 to -0.40) and nearly all of the
seven patient satisfaction subscales (r -0.15 to -0.22) , and positively associated with
death (p<0.05). However, the metabolic subscale was not associated with any
satisfaction or functional status measures, or death.
Conclusions: HgA1c measures were poorly associated with severity
of disease and patient outcomes, such as functional status, satisfaction with care, and
mortality. Other measures of diabetes severity were much more strongly associated with
outcomes for these patients with type 2 DM.
Impact: In these older type 2 diabetic patients with relatively
low functional status, glycemic control as measured by HgA1c appears to be unrelated to
patient outcomes. However, a multidimensional measure of severity of diabetes does predict
outcomes. Quality improvement efforts for type 2 DM should focus more attention on
clinical factors other than glycemic control.
43. Variations in Institutional Review Board (IRB)
Approvals for Allowing Third Party Medical Record Reviews of HIV-infected Individuals
without Patient Consent. The Multicity PCP Quality of Care Study.
Alison Sipler, BA. Chicago VA Medical Center, Chicago, IL
Objectives: Evaluation of medical care depends on record reviews
and Institutional Review Board (IRB) approval. There is increasing concern about medical
record confidentiality, especially among HIV-infected individuals. We evaluated variations
in IRB decisions for access to medical records of HIV-infected individuals as part of a
multi-city study of quality of HIV care.
Methods: The research setting was a random sample of VA and
non-VA hospitals in New York, Miami, Chicago, Los Angeles, Raleigh-Durham, Seattle, and
Arizona in 1990 (n=109) and 1997 (n=84). IRB decisions were evaluated in response to a
single protocol requesting permission for third party reviewers to abstract medical record
information for patients with HIV-related Pneumocystis carinii pneumonia (PCP) without
Results: In New York, IRB approval rates increased from 74% in
1990 to 100% in 1997. In Chicago, Los Angeles, and Miami, IRB approval rates in 1990 were
high (80%, 89%, and 92%), but decreased by 18% to 47% in 1997. In Seattle, Raleigh-Durham,
and Arizona and in all 14 VA hospitals in the study, IRB acceptance rates were 100% in
both time periods. Over half of the IRBs expedited approval. Of 67 IRBs that received
requests for collaboration in both periods, 70% approved the project twice, 24% approved
the study in 1990 and rejected the study in 1997, and 6% rejected the study in 1990 and
approved the study in 1997.
Conclusions: Despite assurances of confidentiality, IRB
decisions varied markedly for permission for the same study protocol. While legislation
that addresses confidentiality of medical record information is currently being proposed,
proposals that require written consent before medical information could be disclosed to
third party researchers would virtually end the ability to conduct large scale health
services and epidemiologic research studies.
Impact: Concerns over medical privacy for persons with
HIV-infection are widespread. Inappropriate disclosure of confidential medical information
by medical researchers or providers, similar to that which has already occurred with
electronic data bases, can affect the employability, insurability, and social situation of
large numbers of individuals. Despite legislative progress in the area for HIV-infected
individuals and in IRB practices in the first two decades of the AIDS epidemic, more
uniformity is needed to assure patient, physician, and hospital confidentialty and to
enable large scale health services and epidemiologic research studies to be continued.
44. Tailoring Smoking Cessation Treatments Based on
Nicotine Dependence Level and Depression Status of Patients
Arthur Garvey, PhD. Harvard School of Dental Medicine,
Bedford, MA. Pantel Vokonas, MD. Boston VA Medical Center, Boston, MA.
Objectives: Cigarette smoking is highly prevalent in the VA
patient population. In an attempt to improve the delivery of smoking cessation
interventions for Veteran patients, we conducted a study with a 1-year follow-up period
which involved delivery of different degrees of nicotine replacement for low- and
high-dependence smokers, and for smokers who were depressed or nondepressed.
Methods: The Fagerstrom Tolerance Questionnaire was used to
classify subjects by level of dependence, and the Center for Epidemiological Studies
Depression Scale (CES-D) was used to assess depression status. Subjects were randomly
assigned to placebo, 2 mg, or 4 mg nicotine gum treatment. We collected both objective and
self-reported indices of withdrawal, and we also collected saliva samples which were
assessed for cotinine content by radioimmunoassay procedures so that we could determine
the percent of nicotine replacement achieved by each subject. Survival analyses, logistic
regression analysis, and repeated measures analysis of variance were used to assess
Results: Major differences in outcomes were found for patients
with different characteristics. Highly- dependent smokers had significantly better success
rates at 1-year post-cessation with the 4 mg gum, while low-dependence smokers were
benefited equally by either the 2 mg or 4 mg gum. Either dose resulted in significantly
better outcomes than did placebo gum. Depressed smokers given placebo gum had
exceptionally high relapse rates (94%), but depressed smokers given nicotine gum (either 2
mg or 4 mg) had significantly better outcomes (30% abstinent at 3-months post-cessation).
A higher proportion of nicotine replacement was also significantly related to better
cessation rates, and significantly reduced objective signs of withdrawal such as heart
rate decline and weight gain.
Conclusions: Our findings strongly suggest that smoking
cessation outcomes will be significantly improved if treatment is tailored, or
individualized based on specific patient characteristics. Highly- dependent smokers need
greater nicotine replacement, while those low on dependence can succeed using a lower dose
of nicotine. Depressed smokers, a major sub-population among VA patients, must receive
greater nicotine replacement if they are to quit smoking successfully.
Impact: Results from our study clearly demonstrate that the
"one size fits all" model of smoking cessation treatment simply will not succeed
in helping smokers quit successfully. Smoking cessation interventions need to be tailored
to smokers based on at least two critical dimensions: (a) their nicotine dependence level,
and (b) their depression status. Highly dependent patients must receive a higher dose of
nicotine replacement, and depressed smokers clearly need nicotine replacement therapy if
they are to be helped to stop smoking.
45. The Effectiveness of Bupropion vs. Bupropion
plus Nicotine Patch in a Smoking Cessation Clinic.
Scott Sherman, MD, MPH. VA Greater Los Angeles Healthcare
System, Sepulveda, CA. S Takayesu, P West, and A Chapman.
Objectives: Several research trials have examined the
efficacy of bupropion. While efficacy studies such as these are helpful, they
unfortunately often do not translate into effectiveness in actual clinical practice. We
examined the effectiveness of bupropion vs. bupropion plus nicotine patch in the routine
practice of a smoking cessation clinic.
Methods: The Sepulveda VA Smoking Cessation Clinic was
established in 1992 and has consistently received approximately 60 referrals/month.
Patients attend seven visits over two months and receive individual counseling in a group
setting from both a health educator and a clinical pharmacist. Compliance is assessed by
carbon monoxide meter at each visit, and patients with repeated high readings are dropped
from the clinic. Since April, 1998, we have randomly assigned all new patients to either
bupropion or bupropion plus nicotine patch ("combined therapy"). Patients were
assigned to only nicotine patches if they had a history of seizures or refused bupropion.
We assessed how patients were doing at each visit and whether or not they were tolerating
their therapy. We also determined the percent of patients who successfully completed the
two-month program. No extra resources or funding were used, so that we were comparing
these two regimens in routine practice. We calculated approximate direct costs of the
medication and counseling for each regimen.
Results: During the first four months, 231 patients were
referred, of whom 140 (61%) attended at least one session. 62 patients were assigned to
bupropion, 54 to combined therapy, and 22 to nicotine patches. Two patients chose not to
use any pharmacologic therapy. Side effects were noted in 21 people taking bupropion
(34%), 14 people taking combined therapy (26%), and 3 people taking nicotine patches
(14%). 18% of patients started on bupropion were switched to another regimen (10 to
nicotine patches, 1 to combined therapy), compared to 15% of patients started on combined
therapy (6 to nicotine patches, 2 to bupropion), and 0% of patients started on nicotine
patches. The rate of successfully completing the two-month program (by initial treatment
assignment) was as follows: bupropion 13/62 (21%), combined therapy 21/54 (39%), and
nicotine patch 5/22 (23%). The cost of medication and counseling for one complete
two-month course was $190 for bupropion and $310 for combined therapy. Factoring in the
unsuccessful patients, the cost/successful completer was approximately $447 for bupropion
and $513 for combined therapy.
Conclusions: We conclude that in routine practice, patients
taking combined therapy tolerate it as well (when measured by side effects or treatment
switching) as patients taking bupropion. The success rate appears to be higher in patients
initially assigned to combined therapy, making the cost/successful completer just slightly
higher for combined therapy.
Impact: These data are helpful in determining what regimen to
use within a smoking cessation clinic, especially since there are so few trials of
combination therapy. We are continuing to accrue approximately 40 patients/month, which
will allow us to more precisely compare these two regimens. We do not yet have data on
long-term abstinence to determine whether the relapse rate differs by initial treatment
46. Reliability and Accuracy of
Dermatologists' Digital Image Consultations
John Whited MD, MHS. Center for Health Services Research in
Primary Care, Durham, NC. DL Simel, RP Hall, ME Foy, and KM Stechuchak. Ronnie
Horner PhD, Center for Health Services Research in Primary Care, Durham, NC
Objectives: Teledermatology, using digital imaging technology,
is a potentially important alternative means of dermatologic health care delivery. While
teledermatology consultations are technically feasible, they have not been critically
evaluated against traditional clinic-based consultations comparing diagnostic and
management outcomes. Our study asked the question, how reliable and accurate are
dermatologists' diagnoses and treatment plans generated from digital image
consultations when compared to clinic-based consultations?
Methods: Patients with skin lesions being referred for a
diagnostic question to the dermatology consult service from ambulatory care clinics at the
Durham VAMC were included in the study. Each patient underwent a standardized history
assessment and digital imaging of the referred condition. Two dermatologists independently
evaluated the patients in a traditional clinic setting. Three different dermatologists
independently reviewed the standardized histories and digital images. Examiners were asked
to provide a single most likely diagnosis and differential diagnoses and suggest a
management plan (medications, diagnostic testing, and therapeutic interventions). We
compared diagnostic reliability, management plan reliability, and diagnostic accuracy
between clinic-based examiners and digital image examiners.
Results: One-hundred sixty-eight lesions found on 129 patients
were included in the study. A comparable level of diagnostic reliability was found among
the different examiners. The simple proportion agreement between the clinic-based examiner
pair for their single most likely diagnosis was 0.54 (95% CI 0.46-0.61), and was 0.92 (95%
CI 0.88-0.96) when both the single most likely and differential diagnoses were considered.
Only one pairing that compared the reliability of clinic-based examiners' diagnoses
with digital image examiners' diagnoses (in the category that included single most
likely and differential diagnoses) resulted in a lower level of agreement (0.79, 95% CI
0.72-0.85) than that found between the two clinic-based examiners. Additionally, the
diagnoses offered by different digital image examiners were equally reliable with each
other and did not differ from the diagnostic reliability of the clinic-based examiner
pair. Recommendations for medical therapy were also found to be reliable. Therapeutic
recommendations were less reliable than diagnoses and medical therapy recommendations, and
diagnostic testing decisions were unreliable. Accuracy of the single most likely diagnosis
did not differ among the five examiners (p = 0.21).
Conclusions: Compared to traditional clinic-based consultations,
dermatologic consultations that use digital imaging technology provide reliable diagnostic
outcomes. Management recommendations were not as reliable which may reflect, in view of
diagnostic reliability, the different practice settings of the dermatologist examiners.
Our study also suggests that diagnostic accuracy does not differ by consult modality.
Impact: This study may have a considerable impact on the future
of teledermatology and telemedicine health care delivery and research in the VA. With the
knowledge that digital imaging results in reliable and accurate diagnostic outcomes in
dermatology, the clinical utility of digital imaging as a consult modality can be
justified. This essential information allows for further investigations into the health
services implications of functioning telemedicine consult systems.
HSR&D Funded: 95-045
47. Use of VA Services by Medicare HMO Enrollees
Steven Wright PhD. VA Medical Center, West Roxbury, MA. ES
Fisher, R Lamkin, C Cagan, D Hults.
Objectives: It is well established that HMO plans receive
capitated payments intended for the comprehensive care of Medicare enrollees at the same
time those enrollees receive care from other federal providers such as the VA. Regional
studies in Florida and California have found that a high proportion of Medicare-eligible
VA patients were enrolled in Medicare HMOs at the same time they received VA care. The
objective of this study was to determine time trends and patterns of health care
utilization by all veteran patients of the VA according to their enrollment status in
Methods: HCFA Medicare enrollment files were linked with a
denominator file Of all veterans who used the VA for inpatient or outpatient services
between 1992 and 1996. We identified VA patients 65 and older who were eligible for
Medicare during this period. Enrollment in Medicare risk-contract HMOs was then determined
using the monthly enrollment indicator on the Medicare enrollment files. The proportion of
Medicare-eligible patients who were enrolled in Medicare HMOs were calculated for each
year. We used VA PTF and OPC administrative files to determine VA resource use and the
national CDR (Cost Distribution Report) to calculate costs for patients who enrolled in
HMOs throughout FY1996.
Results: The proportion of VA patients who were in Medicare HMOs
increased from 3.5% in 1992 to 10.2% in 1996. In FY 96, there were 56,776 VA patients over
65 who were enrolled in Medicare HMOs throughout the year and an additional 32,415 who
enrolled at some point during the year. In several states, the proportion of
Medicare-eligible VA patients enrolled in Medicare HMOs exceeds 20%; in other states the
rates of enrollment doubled between 1994 and 1996. In FY 96 rates of outpatient visits
were similar between HMO enrollees compared to HMO non-enrollees (10.8 vs 10.6 per
capita). Hospitalization rates in the VA were lower for HMO enrollees compared to
non-enrollees (150 vs 310 per 1,000). For VA patients covered by HMOs throughout FY 96,
the total costs to the VA for their care was approximately $177 million.
Conclusions: There was rapid national growth in Medicare HMO
enrollment by VA patients between 1992 and 1996. There was also marked geographic
variation In patterns of HMO enrollment by states. VA patients enrolled in HMOs receive a
substantial amount of VA care at significant cost to the federal government.
Impact: Rates of HMO enrollment in the general Medicare
Population have continued to increase suggesting that the rates for VA patients have
continued to increase. These patients will likely also continue to use VA care under the
current federal system. These trends have implications for the coordination, continuity,
and cost of care to VA patients. Further research will be required to determine why
veterans enrolled in Medicare HMOs continue to seek care in the VA.
48. Validating Ascertainment of Mortality Using
Multiple Administrative Data Sources
Steven Wright, PhD. VA Medical Center, West Roxbury, MA. R
Lamkin, LA Petersen
Objectives: The VA conducts research on cardiovascular disease
using large administrative databases. Ascertainment of veteran deaths is accomplished
using the Beneficiary Identification and Record Locator Sub-system(BIRLS), the national VA
index of all deaths. In-hospital deaths are also coded in the PTF, the national VA
inpatient utilization database. The objective is to examine the validity of BIRLS for
Health Services Research.
Methods: We created a cohort of 43,514 veterans age 65
hospitalized with AMI in the VA or under Medicare financing from 1992-95. Site of initial
hospitalization classified veterans as VA index or Medicare index. We compared 30 day and
1 year mortality rates using BIRLS and/or PTF files against mortality rates obtained from
combining BIRLS, PTF and HCFA Medicare Denominator Files (all source, gold standard). We
examined sensitivity and specificity of the BIRLS and PTF stratified by index
hospitalization and patient characteristics.
Results: Sensitivity of BIRLS for VA index cases was 93% for 30
day Mortality and 92% for 1 year mortality. Sensitivity of BIRLS for Medicare index cases
was 79% for 30 day mortality and 81% for 1 year mortality. Sensitivity in the VA index
group improved to 98% for 30 day mortality and 95% for 1 year mortality when both BIRLS
and PTF were used. Specificity of BIRLS was 100% for both groups. A greater percentage of
Medicare index cases coded as dead from all sources but alive in BIRLS were from the
western region of the country (22 vs 16%). There were no differences in the sensitivity of
BIRLS by age or race.
Conclusions: Sensitivity of BIRLS data in ascertaining death is
not equivalent among all VA patients. Sensitivity of BIRLS was lower for patients
hospitalized with AMI in Medicare-financed hospitals compared to patients hospitalized
with AMI in VA hospitals.
Impact: BIRLS death status is obtained directly from funeral
home directors. Differences in the reporting of deaths for our index groups raises concern
about the validity of BIRLS for different patient subsets. We encourage researchers to use
multiple sources for ascertaining mortality in veterans.
49. Veterans' Preferences for Transfer of Primary
Care to Community Based Outpatient Clinics (CBOC): Association with Health Status,
Satisfaction with VA Care, and Prior Use of VA Care
Steven Borowsky MD, MPH. Center for Chronic Disease Outcomes
Research, Minneapolis, MN. DB Nelson, SM Nugent, PR Hamann, CJ Stolee, and JL Bradley. Hanna Rubins, MD, MPH. Center for Chronic Disease Outcomes Research, Minneapolis,
Objectives: CBOCs are a national VHA initiative intended to
enhance access to care. This study examines whether veterans' preferences to transfer
primary care to a CBOC are associated with health status, satisfaction with VA care, and
prior utilization of VA care.
Methods: We surveyed 1469 veterans in March 1998. Included with
the first of two survey mailings was an application to transfer primary care to a contract
CBOC. Veterans located in southern Minnesota (n=784) were offered a consortium of 23
clinics; veterans in northern Minnesota (n=685) were offered a CBOC consisting of 2
clinics. The sample included all veterans who lived within 50 miles of either CBOC area
and had >= 1 primary care visit at any of three Network 13 facilities during the
preceding year. The dependent variable was whether or not veterans requested transfer to a
CBOC. We used bivariate analyses and multivariate logistic regression to evaluate
associations between preference for CBOC and health status (SF36-V), VA Customer
Satisfaction Survey (CSS) scales, inpatient and outpatient VA utilization during the
preceding 12 months (data from Austin Automation Center), demographics, and service
connected status. Variable selection for the multivariate analysis used a model score
Results: 1246 (85%) responded to the survey. Of these, 53%
requested transfer of primary care to a CBOC. On bivariate analyses, compared to veterans
not requesting CBOC, those who chose CBOC had fewer prior VA outpatient encounters (19.9
vs. 26.2, p<.0001), and had higher CSS scores (lower satisfaction with VA care) on 7 of
8 scales (p values ranging from <.0001 to < .05). CBOC preference was greater in the
north than south (59.5% vs. 47.4%, p< .001), and a possible association was seen
between CBOC preference and SC status (55.4 % NSC, 52.7% 0-50% SC, 45.2% 50-100% SC,
p=.08). Seven of 8 SF36-V scales did not differ between veterans who did and did not
request CBOC. Multivariate analysis confirmed that preference for CBOC varied by CBOC area
(south vs. north OR=0.61 95%CI 0.47-0.79) and SC status (50-100% SC vs NSC OR=0.57 95%CI
0.38-0.85). Number of prior VA outpatient encounters was negatively associated with
preference for CBOC (OR 0.98 95%CI 0.97-0.99). Three satisfaction scales were retained in
the final model, each demonstrating an association between lower satisfaction and
preference for CBOC (for 0.1 increase on 0-1 scale, higher=less satisfied:
"access" OR 1.11 95%CI 1.01-1.23, "coordination" OR 1.11 95%CI
1.01-1.22, "preferences" OR 1.19, 95%CI 1.02-1.38). Three SF36V scales were
retained in the model but did not indicate a strong association between health
status and CBOC preference.
Conclusions: Preference for contract CBOCs is associated with
less prior VA use, lower satisfaction with VA, and lower SC status but is not strongly
related to self-reported health status.
Impact: Contract CBOCs may attract patients who use less VA care
and who are less satisfied with VA care. CBOCs are an alternative that may improve access
and satisfaction for this subpopulation. Comparisons of CBOC vs. VA-based care may not be
confounded by large differences in patient health status.
HSR&D Funded: CDA 98-309
50. Effect of Facility-Level Characteristics on
Primary Care Enrollment and Bed-days of Care
Margaret Byrne, PhD, Carol Ashton, MD, PhD, and Laura Hechtel, PhD. Houston VA Medical Center, Houston, TX.
Objectives: Performance standards (e.g. reducing bed days of
care [BDOC], increasing enrollment in primary care [PCE]) have been established for all VA
network and hospital facility directors. To the degree that these parameters are
determined by facility characteristics, their use to estimate management performance may
be biased. Therefore, we undertook this study to assess the extent to which PCE and acute
BDOC are determined by station-level characteristics such as facility type (free-standing
outpatient clinics [FSCs], hospitals), facility size (number of beds and users), focus of
care (GM&S, psychiatric, long term care), or hospital complexity (acute, intermediate,
Methods: The study was conducted on FY 1997 data. Patients' care
and outcomes are assumed to be the responsibility of the predominant outpatient care
provider. Therefore, using the Outpatient Clinic database, all patients were assigned to a
unique station (5-digit identifier code) where they received the plurality of visits to
primary care clinics or the plurality of total visits for those veterans without any
primary care stop. Veterans were classified as "enrolled in PC" if they had any
PC clinic stop. Acute BDOC rates were determined from the Patient Treatment File as the
total acute VA bed days for veterans assigned to that station, regardless of which VA
hospital was used.
Results: Over all stations providing ambulatory care (n=391),
70% of veterans were enrolled in primary care; 72.8% enrollment for hospitals (n=158), 68%
for FSCs (n=231), 87% for independent outpatient clinics (n=3), and 99% for mobile clinics
(n=4). Larger FSCs (more than 100 assigned users), however, had a 86.2% PCE rate. This was
significantly greater than for hospitals (p<0.0001). Hospital complexity was associated
with PCE; both acute (p<0.01) and intermediate (p<0.001) hospitals had higher PCE
than tertiary hospitals. Hospitals which focus on psychiatric care had higher PCE than did
general hospitals (p<0.02). The acute BDOC rate (per 1000 assigned users) over all VHA
stations was 2,143. Overall, patients of FSCs had significantly fewer BDOC than hospitals
(p<0.003), although small FSCs had higher BDOC (3,070) than did larger FSCs (1,267).
Patients of psychiatric hospitals had higher BDOC (3,563) than other hospitals (2,352)
(p<0.001). Regression analyses, controlling for characteristics found significant in
bivariate analyses, showed that station size was predictive of BDOC. Patients of stations
with more assigned users (p<0.003) and hospitals with more total beds (p<0.01) had
higher BDOC rates.
Conclusions: We have shown that station characteristics (type,
complexity, focus of care, and size) are important predictors of PCE and acute BDOC rates.
This finding suggests stations may have structural characteristics that provide an
advantage or disadvantage in meeting standards, regardless of management effectiveness.
This brings into question the practice of using these indicators, unadjusted for hospital
characteristics, to assess performance.
Impact: Currently, unadjusted PCE and BDOC rates are being used
to judge facility managers' proficiency. Our study suggests that this may lead to invalid
conclusions due to important effects of facility level characteristics. Future standards
should take into account the effect of these facility characteristics before judgements
HSR&D Funded: LFP 98-001