1999 HSR&D Annual Meeting Abstracts
101. One-year Mortality Rates for all Users of the
VA Medical Care System
J Souchek, PhD, NJ Petersen, CM Ashton, and TJ Menke, HJ Yu. Houston VA Medical Center, Houston, TX.
Objective: In the face of changes in the VA medical care system,
it is important to monitor outcomes of care. The purpose of this study was to estimate the
one-year mortality rate for all users of the VA medical care system for three fiscal
years, FY95, FY96, and FY97. Unadjusted, age-specific, and age-adjusted rates were
computed for the 22 Networks and VA-wide.
Methods: Users of the VA medical system were identified for each
year from the patient treatment file, the outpatient file, extended care file and the
fee-basis file. Vital status of patients was obtained from the VA's Beneficiary
Identification and Records Locator Subsystem death file. A file prepared by the VA
Planning Systems Support Group was used to assign the county of residence of each patient
to the Network responsible for his care. We used several methods to compute the mortality
estimates: ratio estimates were used initially, but were replaced by product limit
(Kaplan-Meier) estimates because the ratios underestimated the death rates. All mortality
rates (unadjusted, age-specific, and age-adjusted) were based on the Kaplan-Meier
estimates. Because of the large number of system users (almost 3 million), it was not
feasible to use Cox-regression to age-adjust the Network rates.
Results: The number of system users increased by 5.4% from
2,843,534 in FY95 to 2,996,640 in FY97. The VA-wide death rate decreased from 3.05 per 100
VA users in FY95 to 2.78 per 100 in FY97. Age-standardized rates varied among the
networks; in FY97 the range was 2.11% to 3.42%. As expected, the mortality rates increased
with age from 0.42% in the <45 age group to 10.60% in the 85 or older group.
Conclusions: The all-cause mortality rate per year gives a broad
view of the status of users of VA medical care over time and location, and allows
comparison of age-specific rates with those in the private sector. Of continuing interest
are the methodologies for estimating and comparing mortality rates over time, and within
the hierarchical system of hospitals within networks within the VA system.
Impact: These mortality rates allow comparison of the VA with
other health care systems and indicate areas where death rates are high in order that
efforts, medical or social, may be made to lower the rates in these areas.
HSR&D Funded: SDR 98-001
103. Defining the Attributes of the Quality of
Dying: Perspectives of Patients, Families and Health Care Providers.
K Steinhauser, PhD, EC Clipp, M McNeilly, N Christakis, L McIntyre,
PhD, and J Tulsky, MD. Durham VA Medical Center, Durham, NC.
Objectives: Health care providers and the public have targeted
considerable resources towards improving the quality of dying through such interventions
as hospice care, education of medical personnel, and promotion of advance directives.
However, despite these efforts, no well-established standardized tools exist to assess the
quality of dying. In particular, no tools explicitly acknowledge the variability in
patients' and families' perspectives. Consequently, attempts to evaluate the effectiveness
of hospice care have suffered. Our primary objective was to gather definitions of a
"good death" from the perspectives of patients, families, and health care
professionals. These data will be used in subsequent research to develop an instrument to
assess the quality of dying.
Methods: We convened focus groups to define the key domains of
experience for those involved in the process of dying including patients, recently
bereaved family members, physicians, nurses, social workers, chaplains, and hospice
volunteers. Focus groups were stratified by participant type and ethnicity. Following each
focus group we conducted in-depth interviews with two group members to clarify our
interpretations and gather a deeper level of specificity about the issues raised in the
Results: We conducted twelve focus groups with a total of
seventy-five participants. Participants ranged in age from 26-77 years with an average age
of 46.8. Women comprised 64 percent of our sample, men 36 percent. Seventy percent of
focus group participants were Caucasian, 28 percent were African-American and 3 percent
were Asian-American. Sixty one percent of the sample were Protestant, 18 percent were
Roman Catholic and 8 percent identified as Jewish. Eleven percent were unaffiliated. The
most prominent distinctions in definition of a "good death"occurred between
groups of health care professionals. These professional role distinctions appeared to
override differences by gender or ethnicity. For example, discussions with physicians'
centered primarily on issues of pain control. Non-physician providers tended to discuss
patients' and families' psychosocial and spiritual needs in addition to the importance of
managing physical symptoms. Groups also identified new domains of the quality of dying
including being known by providers as a "whole person," preparation for dying,
the opportunity to contribute to others' well-being, and the opportunity to develop a
sense of completion. Finally, participants stressed the very individual nature of the
dying experience. "Good deaths" are crafted through a process of communication
about patients' and families' values and preferences regarding care at the end of life.
Conclusions: Control of physical symptoms at the end of life is
important but only a point of departure for improving the quality of dying. Participants
suggested a "good death" also includes attention to psychosocial and spiritual
issues. Instruments designed to assess the quality of dying must include these multiple
Impact: We hope to use the results of this study to develop an
instrument to measure the quality and effectiveness of interventions to improve
end-of-life care, such as palliative care units or hospice programs. These data will allow
us to create instruments that focus on aspects of care patients and families consider most
HSR&D Funded: 96-006
104. Integrating VA Medical Centers
C VanDeusen Lukas, EdD. Boston VA Medical Center, Boston,
MA. B Mittman, PhD J Hernandez, J Macdonald, E Yano, PHD, MSPH, and B Simon, MA. VA
Greater Los Angeles Healthcare System, Los Angeles, CA.
Objectives: There is a strong trend in the VHA, as in the
private sector, to integrate healthcare facilities. This multi-year study was designed to
analyze 14 VHA integrated systems in order to develop management lessons for other VHA
systems. Drawing from the first phase of the study, this paper examines: 1) the effects of
facility characteristics on integration structures; 2) the planning and change processes
used by the integrating systems; and 3) the perceived impact of integration on operations,
patient care and staff morale in different integration settings.
Methods: Qualitative and quantitative data for 14 integrating
systems were drawn from four sources: 1) face-to-face interviews with top leadership,
middle managers, and representative staff and clinicians; 2) a survey of all system
department heads and service chiefs (91% response rate); 3) documents provided by the
systems and 4) VA administrative and research databases. Descriptive analyses identified
patterns in characteristics, processes and structures of integrating systems. Systems were
clustered by patterns and compared to assess differences in effectiveness on selected
Results: 1) Systems with one clearly dominant partner - an
affiliated tertiary facility paired with a smaller community or specialty facility -- were
more likely than systems with equal partners to be structurally integrated two years after
integration approval - particularly in clinical departments - and to have consolidated
acute care services to one campus. Equal-partner systems - with facilities similar in
size, complexity and academic affiliation -- were less likely consolidate services to one
campus and/or combine departments across campuses. Equal-partner systems on average
reported lower impacts of integration on department operations and lower perceived staff
moral. 2) Systems differed in the speed of appointment of new managers and in the roles
management and staff played in the early planning processes. Systems that appointed the
director immediately and used a model of shared leadership were more effective in terms of
a shorter integration process, higher staff satisfaction with the p rocess and higher
perceived staff morale.
Conclusions: 1) The characteristics of the participating
facilities strongly influence the structure of the integrated system. Equal-partner
systems tend to take longer and/or result in less complete clinical integration.
Integration among equal partners is often more difficult than in dominant partner systems
because more issues have to be negotiated extensively. 2) Effective planning processes
balance strong leadership with early involvement of middle managers. Staff are most
satisfied when they have an opportunity to participate within a clear structure - after
key decisions are made about the organizational structure, and when they are given clear
guidelines for planning. 3) Clinical integration is a key aspect of VHA integrations. In
most of the systems studied, the majority of clinical services are integrated. These
patterns are consistent with VHA goals of creating integrated delivery systems, not simply
joining hospitals for administrative purposes.
Impact: The first phase report has been distributed to all VISNs
and medical centers to inform their efforts in integrating services and facilities, and
more broadly creating integrated delivery systems. Study investigators have presented
their findings in VHA systems beginning the integration process.
HSR&D Funded: MRR96-022
105. Characteristics and Outcomes of Women
Undergoing Hysterectomies in VA Facilities
F Weaver, PhD and D Hynes, PhD, RN. Hines VA Medical Center,
Hines, IL. D Ippolito, W Cull, B Thakkar, and J Gibbs.
Objectives: The objectives of this research are to: describe
the patient sociodemographic, preoperative risk, structure and process characteristics and
outcomes of women undergoing selected procedures at VAMCs; and examine the relationship
between sociodemographic, preoperative risk, structure and process characteristics and
outcomes for women undergoing select procedures (i.e., hysterectomy, mastectomy, total
joint replacement) using multivariate modeling techniques.
Methods: This study is a secondary analysis of the National
Surgical Quality Improvement Program (NSQIP) database. For the present analyses, all
hysterectomy procedures (vaginal, abdominal and laproscopic-assisted) collected by the
NSQIP between FY92 and FY97 were selected. The NSQIP contains data on 62 preoperative risk
and demographic characteristics, four process, and 23 outcome variables. We supplemented
the NSQIP with data from the VA's Patient Treatment File for readmission data, pathology
reports from sites, and facility characteristic data. Data from these sources were merged
on patient identifiers and procedure date. Any hospitalizations that occurred within one
year of the procedure were captured. Outcomes of interest include: post-operative length
of stay, morbidity within 30 days (i.e., one or more of 21 complications monitored by the
NSQIP), and any readmissions that occurred as a result of a complication of the procedure
within one year post surgery. Complications were defined by an expert panel of surgeons
who identified relevant diagnostic codes and assigned a time period within which the
diagnosis would be considered a complication.
Results: Over a six year period, VA performed 1,758
hysterectomies. The majority were for abdominal hysterectomies (75%), whereas 22% were
vaginal, and less than 4% were laproscopic-assisted. The most frequent indications for
surgery included leioyomas of the uterus (31%), bleeding problems (16%), and endometriosis
(10%). Women were predominately white (64%), with an average age of 42.8 years, and a
minority were married (37%). Preoperatively, 40% of these women were smokers, 14% had a
history of hypertension requiring medications, and 5% were frequent alcohol users. The
mean length of stay was 4.2 days (sd=3.7) and almost 9% experienced one or more of the 21
complications defined by the NSQIP within 30 days of the procedure. Logistic regression
modeling of 30-day morbidity identified 6 significant predictors. Preoperative patient
variables, including impaired functional status, current smoker, alcohol use within two
weeks of admission, dyspnea, and infection, as well as, longer operation times were
associated with greater probability of morbidity (c-index=0.670). Modeling of
postoperative length of stay and readmissions due to complications is in process.
Conclusions: Research on hysterectomy outcomes have focused on
single outcomes and limited examination of preoperative characteristics. This work
examining multiple preoperative characteristics and outcomes indicates that risky health
behaviors and poorer health status prior to surgery were significant predictors of 30-day
Impact: Women veterans account for less than 5% of all VA health
care users. The rate of female-specific procedures at any one facility is very low. Given
these infrequent events, this study will help to inform the system as to the types of
women who undergo procedures within VA and their outcomes and how this compares to the
non-VA health care sector.
HSR&D Funded: GEN 97-016
106. Depression, Falls, and Risk of Fracture in
Mary Whooley, MD, KE Kip, JA Cauley, KE Ensrud, MC Nevitt, and
WS Browner, San Francisco VA Medical Center, San Francisco, CA.
Objective: Previous studies have suggested that depression is
associated with falls and with low bone density, but it is not known whether depression
leads to an increased risk of fracture.
Methods: We conducted a prospective cohort study in elderly
white women who were recruited from population-based listings in the U.S. At their second
visit (1988-90), 7414 participants completed the 15-item Geriatric Depression Scale (GDS),
and were considered depressed if they reported 6 or more symptoms of depression. We
measured bone mineral density (BMD) in the spine and hip using dual energy x-ray
absorptiometry, and askedparticipants about incident falls (yes/no) at 4 follow-up visits.
Nonvertebral fractures were ascertained for an average of 6 years
following the depression measure, and verified radiologically.
Wedetermined incident vertebral fractures by comparing lateral spine films obtained at the
first visit (1986-88) with repeat films obtained an average of 3.7 years later (1991-92).
Results: The prevalence of depression (GDS >= 6) was 6.3%
(467 of 7414). We found no difference in mean BMD of the hip and lumbar spine in depressed
compared with nondepressed women. Depressed women were more likely to experience
subsequent falls than nondepressed women [70% vs. 59%; age-adjusted odds ratio (OR) 1.6,
95% CI, 1.3 - 1.9; p<0.001], an association that persisted after adjusting for
potential confounding variables (OR 1.4, 95% CI, 1.1 - 1.8; p=0.004). Women with
depression had a 40% [age-adjusted hazard ratio (HR) 1.4, 95% CI, 1.2 - 1.7; p<0.001]
increased rate of nonvertebral fracture (124 fractures in 3,805woman-years of follow-up)
compared with nondepressed women (1367 fractures in 59,503 woman-years of follow-up). This
association remained strong after adjusting for potential confounding variables, including
neuromuscular function and use of antidepressant medication (HR 1.3, 95% CI, 1.1 - 1.6;
p=0.008). Further adjustment for subsequent falls appeared to explain part of the
association between depression and nonvertebral fracture (HR 1.2, 95% CI, 1.0 - 1.5;
p=0.06). Depressed women were also more likely to suffer vertebral fractures than
nondepressed women, adjusting for history of vertebral fracture, history of falling,
arthritis, diabetes, steroid use, estrogen use, supplemental calcium use, cognitive
function, and hip BMD (OR 2.1, 95% CI, 1.4 - 3.2; p<0.001).
Conclusions: Depression is a significant risk factor for
fracture in older women. The greater frequency of falls among depressed persons partially
explains this finding.
Impact: If treatment for depression were effective in reducing
the associated risk of falls and fracture, then better diagnosis and treatment of
depression could substantially decrease fracture-related morbidity and mortality.
107. Comparing Approaches to Predict Decline in
Functional Status in the VA Long-Term Care Population
J Wu, A Rosen, PhD, B Chang, ScD, D Berlowitz, MD, MPH, Lewis
Kazis, ScD. Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA. A Ash Mark
Moskowitz, MD. Boston University School of Medicine.
Objectives: Outcome measures, such as decline in functional
status (FS), have been shown to be useful when assessing quality in the Medicare
population. To replicate this approach in the VA setting, we developed a risk-adjustment
model to predict decline in FS in VA long-term care. Decline in FS is operationalized by
measuring the change in the sum of activities of daily living (ADLs) scores between two
time periods. However, there is no consensus on the best method of using baseline ADLs to
distinguish residents at different levels of risk for decline in FS. This study compares
approaches to using initial ADLs to model decline in FS.
Methods: Our sample consisted of 16,998 residents who resided in
VA long-term care facilities between 4/1/96 and 10/1/96. The Patient Assessment File (PAF)
was used to evaluate changes in residents' FS. Baseline and outcome FS were measured using
3 ADLs: eating, transferring, and toileting (each rated on a 1-5 scale). Decline in FS was
defined dichotomously as an increase (worsening) of two or more in the summed ADL scores
(ADLSUM) between baseline and semi-annual assessments. Patient characteristics related to
decline (e.g., age, medical conditions, and length of stay) were used as risk factors,
along with baseline ADLs, to predict decline in FS. Logistic regression models were
developed using each of the 3 ADLs individually as well as ADLSUM. ADL variables were
modeled continuously (i.e., linearly), categorically and quadratically. We also developed
a classification tree (using CART) based on ADLSUM, each of the 3 ADLs, and a fourth ADL,
Results: Decline in FS was not linearly associated with baseline
ADLs. The model that regressed decline in FS on baseline ADLSUM performed least well;
chi-square for covariates, p-value and c-statistic were 608.6 with 5 df, 0.0001 and 0.659,
respectively. The regression model that used the categorical groupings from CART and the
one which included both ADLSUM and (ADLSUM)2 terms had similar, better performance. For
example, the analogous performance figures for the CART model were 909.7 with 11 df,
0.0001 and 0.685, respectively.
Conclusions: Since model performance is affected by the method
used in modeling baseline ADLs, we suggest that to capture the full complexity of the
relationship between baseline ADLs and decline in FS, models that use baseline ADLs
non-linearly, such as CART, are the most appropriate for predicting decline.
Impact: Health services researchers need to use independent
variables which are clinically valid and statistically robust in modeling in order to make
comparisons across facilities on their quality of care.
HSR&D Funded: IIR 96-065
108. ACI-TIPI Intervention in the Triage of Urgest
Care Patients with Chest Pain
Robert Zalenski, MD. Wayne State University and John D.
Dingle Veteran's Hospital, Detroit, MI. FH Shamsa, D Waselewsky
Objectives: Although the ACI-TIPI score has been shown to
reduce unnecessary admissions to CCU, its effect on processes of care outcomes, such as
length of stay and resource utilization has never been examined.
Methods: We examined the effect of introducing the ACI-TIPI,
which provides a valid and reliable estimation of the probability of acute cardiac
ischemia (ACI) on process of care outcomes in Urgent Care setting (UC) of a VA hospital.
We used a pre-post study design, where no ACI-TIPI was used for 8 weeks followed by the
providing of instrument to all UC physicians with the initial ECG. Patients with chest
pain were studied, unless they were unstable. Primary outcomes were hospital admissions,
the use of diagnostic testing, cardiac consultation, length of stay, admission to CCU, and
hospital admission. Outcomes were analyzed considering patients with and without ACI.
Results: The study group of 203 patients has a mean age of 56.6
yrs with a 96.6% males and a racial distribution: 73.9% blacks, 20.2% whites, and 5.9%
others. In the 181 (89.1%) patients without a final diagnosis of ACI, there was no
difference comparing the control versus the ACI-TIPI periods in the proportions of
hospital admissions, the use of diagnostic testing (Chest X-ray, Cardiac enzymes, and IV
insertion). But, the rate of cardiac consultation (24.21%)in the control period was
significantly lower than that of the ACI-TIPI period (39.53%) with p=.02. Study groups
were also not different in the mean time to IV or aspirin, ED length of stay, admission to
CCU, and hospital admission.
Conclusions: In this study, ACI-TIPI did not appear to reduce
resource utilization or decrease the length of stay but was associated with increased rate
of cardiac consultation
Impact: In patients with chest pain, treated in an Urgent Care
setting, the ACI-TIPI was not associated with the decrease of resource utilization.
HSR&D Funded: LIP
109. Improving the Quality of Interdisciplinary
Team Meetings: The use of In-Depth Qualitative Research to Understand Team Processes.
Barbara Bokhour, PhD. Edith Nourse Rogers Memorial Veterans
Hospital, Bedford, MA.
Objectives: JCAHO mandates individualized treatment plans in
long term care. Team meetings are essential to the coordination of multidisciplinary
treatment teams in creating these plans. However, the manner in which meetings actually
produce consensus and coordinate activities is poorly understood, while professionals
often complain that they are inefficient and ineffective. Through the use of in-depth
qualitative methods, this study sought to describe how team meetings work, characterize
effective and ineffective interactions, and identify potential targets for improving the
Methods: Two interdisciplinary teams in a long-term care unit
for patients with Alzheimer's disease were observed. Teams included nurses,
physicians, recreational and occupational therapists, kinesiotherapists, dentists,
pharmacists, and social workers. Qualitative data include videotapes of seven meetings,
in-depth interviews with 16 team members, and participant observations of the staff and
patients on the units. All data were transcribed and analyzed using sociolinguistic and
activity analysis of the discourse of team meetings and thematic analysis of interviews.
Activities performed in the meeting were analyzed for their function in relation to the
members' goals of planning and coordinating patient care, with analyses guided by the
members' own reflections on their team interaction.
Results: In interviews, team members stated that the primary
goal of the meetings was collaborative treatment planning in order to insure good,
coordinated patient care. Team meetings proceeded in a ritualized fashion with little room
for variation. They included three primary activities: 1) Giving report: team members
state each listed problem, a goal and a plan for intervention, 2) Writing report: the team
determines how this information is to be written on the care plan, and 3) Discussion:
members openly exchange ideas about an individual patient's particular problem.
"Giving report" and "writing report" were found to be most productive
in terms of the administrative goal of "getting the paper done" ï¿½ that is
generating the written treatment plan. "Discussion" was more productive in
creating truly interdisciplinary decisions and coordinated plans for individual patient
care. The process emphasized "giving report" which imposed limited categories
for discussion discordant with team members' knowledge of patients' social and
Conclusions: Although the goal of team meetings is to produce
unique individualized treatment plans for patients, the ritualized quality of the
interactions, oriented towards producing a report, effectively eliminates dialogue about
individuals and their unique qualities. Hence, much information regarding personal and
psychosocial histories are omitted from the process, and discussions are often cut short
in order to complete the administrative function of the meetings.
Impact: Through the use of intensive observation and
sociolinguistic analysis of team meetings, this study was able to produce a detailed
description of the process, and identify specific practices that contribute to the goal of
creating individualized treatment plans. Interventions to improve the quality of team
meetings might include refocusing the team on current and crucial problems for each
individual at the start of each meeting, encouraging team members to discuss all
psychosocial and background knowledge about patients, and eliminate the ritualistic
presentation of information well known to the team members.
110. Gender Differences in Addiction Severity,
Health Status, and Psychosocial Functioning in Veterans with Substance Use DisordersC
Chun, PhD, P Ouimette, PhD, R Kimerling, and R Moos, Ph.D. VA Palo Alto Healthcare
System, Menlo Park, CA.
Objectives: The objectives of the present study were (a) to
examine gender differences in characteristics of VA substance abuse patients and (b) to
assess the impact of gender on the severity of addiction to alcohol and drugs as well as
on physical and mental health problems and social functioning. This effort is part of the
first large-scale study on veterans that used the Fifth Edition of the Addiction Severity
Index (ASI), which is part of the standard intake assessment battery in many VA substance
Methods: The sample was composed of 23,724 VA patients (97% men
and 3% women) with a primary diagnosis of substance abuse who obtained inpatient or
outpatient treatment in one of 150 VA facilities in September 1997. The ASI assesses
problem severity in seven areas: Alcohol use, drug use, psychiatric symptoms, medical
problems, family and social problems, legal problems, and employment problems.
Results: The results identified important gender differences. In
terms of substance use problems, men reported having recently used more alcohol than
women. The men also reported experiencing greater trouble with alcohol problems and
expressed greater need for treatment for their alcohol problems. However, the opposite was
true for drug use problems, with the women using more drugs, experiencing more drug
problems, and expressing greater need for drug treatment. In terms of physical and mental
health problems, although a large majority of both men and women reported experiencing
many medical and psychiatric symptoms and needing treatment, overall women reported more
medical and psychiatric problems compared to men. The women also consistently reported
experiencing greater conflict with their spouse, parents, children, and friends and
expressed greater need for treatment for family problems. There were no significant gender
differences in patients' legal and employment problems. The results of hierarchical
multiple regression analyses show that gender was a significant predictor of six of the
seven ASI composite scores after controlling for age, education, income, marital status,
and race. The women had less alcohol, legal, and employment problems than the men but had
more psychiatric, medical, and family/social problems. The gender effect on drug use
composite score disappeared when the sociodemographic variables were controlled, whereas a
gender effect on legal and employment composite scores emerged after the control variables
were entered into the analysis.
Conclusion: Most of our findings on veterans are consistent with
past findings on gender and substance abuse. Particularly important are the findings that
suggest that women with substance use disorders, whether they are veterans or not, tend to
have more comorbid medical and psychiatric conditions compared to men. Furthermore, the
women appear to have fewer social resources than the men.
Impact: The clinical implication of our findings is that
treatment for veteran women with substance use disorders will need to be comprehensive,
addressing not only their addiction problems but also their psychosocial problems and
111. Seeking Care in the VA: What Differentiates
Level of VA Use for Women Veterans?
Shelia R. Cotton, PhD. Edith Nourse Rogers Veterans Memorial
Hospital, Bedford, MA.
Objectives: The numbers of women veterans are increasing, but
little is known about factors that influence their use of the VA system for health care
services. The objective of this study is to understand characteristics of women veterans
that account for their decisions to seek care in the VA.
Methods: A national sample of women veterans (n=3632) who had at
least one VA out-patient visit during a one year time period completed self-administered
mailed questionnaires (58.4% response rate). Use of health care was measured through
responses to a question asking which of the following best described their use of VA
health care services: they use the VA (1) for all their medical care, (2) for most of
their medical care, and (3) for little of their care or as a "back-up" for
health care. Based upon this question, three self-identified groups of VA users were
defined and compared on demographic, VA access, resource, and health status (SF-36)
characteristics through the use of ANOVAS and logistic regression.
Results: The respondents were equally divided across the three
groups of users. Bivariate analyses reveal that women who obtained all their care at the
VA were significantly older, less educated, less likely to be currently married, and less
likely to have private health insurance than were women veterans from the other two user
groups (p<.05 for each). Average income for the all care at VA group ($20,128) was
significantly lower than for most care ($26,107) and "back-up" care ($35,215)
groups. They also had lower levels of social support and they lived alone more often than
their counterparts. The "back-up" group had significantly better health status
than the other two user groups. Logistic regression results indicate that being married
(p<.01), having higher income (p<.001), and having private health insurance
(p<.001) are associated with use of VA for "back-up" health care. Women
veterans who have lower levels of social support (p<.01), live alone (p<.05), rate
convenience of VA location (p<.001) and VA access factors (p<.001) more favorably,
report feeling welcome as a woman receiving treatment at a VA hospital (p<.001), and
have lower levels of physical functioning (p<.01) are more likely to use the VA for
most or all of their health care needs.
Conclusions: The results suggest that women veterans who use the
VA for most or all of their health care needs are different from women veterans who use
the VA as a "back-up" for care. It is apparent that economic resources, social
resources, and perceptions of the VA discriminate those who use the VA for most or all of
their care from those who use it only for "back-up" care.
Impact: These results suggest that the VA should focus attention
on the decision-making processes of women veterans who use the VA as a "back-up"
for health care. These women have more economic and social resources which may lead them
to seek care outside the VA. Issues surrounding access, location, and satisfaction with
services may be key to drawing these women into the VA for more health care services. In
addition, results suggest that the VA should pay particular attention to the lower levels
of social and economic resources of women who use the VA for substantial amounts of their
health care. This may impact how health care providers develop and implement patient
education and treatment plans.
HSR&D Funded: SDR 93-101
112. Depression Post Alcohol Treatment and
Drinking Outcomes: Implications for Clinical Intervention and Research Design
Geoffrey Curran, PhD, Jo Ann Kirchner, MD, and Brenda Booth,
PhD, HSR&D Center for Mental Healthcare and Outcomes Research, North Little Rock,
Objectives: This study examines the association between
continued abstinence and depressive symptomology measured during inpatient treatment for
alcohol disorder and three-months post-treatment.
Methods: Data were obtained from 298 males with alcohol use
disorders who completed 21-day inpatient treatment at a Midwestern VA Alcoholism Treatment
Unit. Three-, six-, nine-, and twelve-month follow-up interviews were conducted, with 271
subjects completing all phases of the study (91%). Multiple logistic regression was used
to assess the association between continued abstinence and baseline/three months
post-treatment measures of depression (Beck inventory), controlling for various
demographic and other treatment outcome relevant variables (ASI composite scores during
treatment; age, education, participation in a domiciliary aftercare program, number of
previous alcohol treatments, and baseline social support).
Results: Depressive symptomology at baseline was not associated
with abstinence at any follow up, but depression severity at three months post-treatment
was strongly negatively associated with abstinence at each follow up. Further analysis of
three-month depression with dummy coded variables representing mild-to-moderate
(Beck=14-19) and severe depression (Beck=20+) indicated that 1) the mild-to-moderately
depressed were on average 2.9 times less likely as those not depressed to be abstinent at
each follow-up, and 2) the severely depressed were on average 4.9 times less likely to be
abstinent at each follow-up. In comparison to those subjects with depressive symtomatology
(Beck >= 14) at baseline and 3 month follow-up, the never depressed were on average 2.6
times more likely to remain abstinent at each follow-up; subjects who were depressed at
baseline but not at follow-up were on average 4 times more like to remain abstinent across
Conclusions: The data support our hypothesis that the presence
of depressive symptomology following a treatment/abstinent period is a better predictor of
abstinence/relapse than depressive symptoms presenting during the initial phase of
treatment. In addition, our data suggest the presence of depressive symptomology
post-alcohol treatment is a high risk factor for relapse which needs to be identified and
addressed in aftercare planning. Further, our results indicate the need for more focused
research on depressive symptomatology both during and following treatment for alcohol/drug
Impact: Our research is important to the development of
interventions for the treatment of comorbid depression in patients seeking substance use
113. Efficacy and Safety of Medical Interventions
for Male Erectile Dysfunction: a Systematic Review
HA Fink, MD. Minneapolis VA Medical Center, Minneapolis, MN. R
MacDonald, IR Rutks, and D Schow. TJ Wilt, MD, MPH. Minneapolis VA Medical
Center, Minneapolis, MN.
Objectives: Erectile dysfunction (ED) is a common condition
which reduces quality of life. We conducted a technology assessment to evaluate the
efficacy and safety of medical treatments for ED in men with acquired ED of primarily
organic etiology, excluding that secondary to gonadal dysfunction.
Methods: To update a 1996 American Urological Association report
on ED treatments, we performed a systematic review of the literature on treatment for ED
published from January 1995-August 1998. We looked at oral sildenafil, yohimbine,
phentolamine and trazodone; intraurethral alprostadil; and the intracavernosal treatments
of alprostadil, phentolamine/papaverine and alprostadil/phentolamine/papaverine. Studies
were eligible if they were randomized and controlled. Only multiple dose studies using
clinically relevant outcomes (e.g. "successful intercourse" as opposed to penile
rigidity) were considered, except for intracavernous treatments where no studies met these
criteria. For included studies, information on study characteristics and outcomes was
extracted in a standardized fashion. Data was pooled using a fixed effects model unless
there was evidence of heterogeneity. A modified intention to treat analysis was utilized.
Results: Sildenafil produced "erections sufficient for
intercourse" in 48% of intercourse attempts (compared with placebo, RR = 2.7; 95%CI =
2.1, 3.5; NNT = 3.4) and "successful intercourse during treatment" in 84% of
subjects (RR = 1.6; 95%CI = 1.4, 1.8; NNT = 3.4). Adverse events included headaches (20%)
and visual disturbances (5%). Through August 1998, 69 confirmed deaths have been
associated with sildenafil. Yohimbine provided "response to treatment" in 48% of
subjects compared to 25% with placebo (RR = 1.9; 95%CI = 1.3, 2.8; NNT = 3.9). Adverse
events, including hypertension and anxiety, occurred in 17%. Neither trazodone nor oral
phentolamine were superior to placebo, though clinically important effects could not be
ruled out. In studies limited to responders (66% of subjects screened), intraurethral
alprostadil produced "erections sufficient for intercourse" in 51% of
intercourse attempts (compared with placebo, RR = 5.0; 95%CI = 4.6, 5.5; NNT = 2.5) and
"successful intercourse during treatment" in 61% of subjects (RR = 3.6; 95%CI =
3.0, 4.3; NNT = 2.3). Intracavernous alprostadil produced "erections adequate for
intercourse," in 22-56% of in-clinic administrations. Mean percent successful
self-injections was 61% in unblinded at-home use. Comparative studies suggested that
intracavernous combination therapies may be as effective as alprostadil with fewer adverse
Conclusions: Effective medical treatments for male ED include
oral sildenafil and yohimbine; intraurethral alprostadil; and intracavernous
alprostadil/phentolamine/papaverine, phentolamine/papaverine or alprostadil alone.
Randomized trials directly comparing treatments have not been performed, making evaluation
of relative treatment efficacy and safety difficult. Treatment options have marked
differences in costs, contraindications, side effects, and patient acceptability profiles.
Impact: ED is common and the number of men seeking evaluation
and treatment is likely to increase with enhanced awareness and increased treatment
options, especially with the availability of oral medications like sildenafil. If one
fifth of current VA users received sildenafil drug costs would approach $100,000,000 per
year. Cost estimates for treatment with intraurethral or intracavernosal therapy are
higher, but these treatments are unlikely to be as widely utilized.
HSR&D Funded: MTA 98-016
114. The Effect of Electrical Stimulation on
Chronic Wound Healing: A Meta-Analysis
S Gardner, PhD(C), MA, RN. Iowa City VA Medical Center, Iowa
City, IA. RA Frantz and FL Schmidt
Objectives: Electrical Stimulation (ES) is a largely unknown
and poorly understood treatment modality for chronic wounds. The problem is that the
collective body of evidence has not been considered in examining the merits of ES. The
purpose of this meta-analytic review was to determine if there is sufficient evidence to
support ES as an adjunctive therapy for chronic wound healing. Specific objectives were
to:1) Estimate the rate of healing of chronic wounds treated with ES and compare this rate
to controls using findings of multiple human studies. 2) Estimate the rate of healing of
chronic wounds treated with ES according to type of ES device and type of chronic wound.
Methods: Studies of ES and chronic wound healing were identified
from computerized and printed indices. 28 studies were identified with 15 meeting the
inclusion criteria. These 15 studies contained 24 independent ES samples and 15
independent control samples. Mean rate of healing was calculated for both the ES and
control samples using percent healing per week as the measure of healing. The net
effectiveness of ES was determined by subtracting the control rate of healing from the ES
rate. 95% confidence intervals were also calculated and compared for width and overlap.
The studies were then subgrouped and analyzed by type of ES device (continuous direct,
pulsed direct, and TENS) and type of chronic wound (pressure ulcers, venous ulcers, mixed
chronic wounds, and chronic wounds mixed with acute wounds).
Results: There were 591 ulcers in the ES samples and 212 in the
control samples. The mean rate of healing was 22 percent per week for ES and 9 percent per
week for control samples. The net effect was 13 percent per week, an increase of 144% over
the control rate. The 95% confidence intervals of the ES samples (18 to 26 percent per
week) and control samples (3.8 to 14 percent per week) did not overlap. The net increase
in rate of healing was 11 percent per week for TENS, 13 percent per week for continuous
direct, and 16 percent per week for pulsed direct. However the confidence substantially
overlapped. ES was most effective on pressure ulcers with a net effect of 13 percent
healing per week and no overlap of confidence intervals.
Conclusions: ES is an effective adjunctive therapy for chronic
wounds, especially pressure ulcers. However, further research is needed in order to
delineate the most effective ES device and optimal dose-responses.
Impact: Evidence of effectiveness is an appropriate standard
from which to base reimbursement policies. Both the effect and cost of ES compare
favorably with other adjunctive therapies used to manage chronic wounds. In the absence of
the findings of this meta-analysis, the Health Care Financing Administration has taken
action to deny reimbursement of ES for wound treatment. Without reimbursement, patients
will be unable to access an efficacious treatment and studies needed to ascertain the most
effective utilization of ES will be abandoned.
115. Predictors of Quality of Life in AIDS
JK Kemppainen, PhD, RN. VA Palo Alto Health Care System,
Palo Alto, CA.
Objectives: While many studies examine quality of life in
persons with HIV/AIDS, these studies tend to focus on assessment and measurement. Little
research attention has been directed toward identifying factors which influence quality of
life. This present study examined whether variables relating to demographic
characteristics, severity of illness, psychological status, or level of engagement in
nursing care could predict quality of life scores in patients with advanced or late stage
Methods: Questionnaires were administered to a representative
sample of hospitalized patients with AIDS. The total of 162 patients, including 65% males
(N=102) and 35% females (n=60), completed the following assessment measures: 1) HIV
symptom checklist, 2) Beck Depression Inventory (BDI), 3) the HIV/QAM (a measure of
physical status), and 4) two measures of engagement in nursing care, the Patient
Participation Scale and the Patient Anger Scale. The Living with HIV Scale was used as the
measure of quality of life.
Results: Stepwise multiple regression analyses were conducted
employing 6 factors: depression, patient demographics, symptoms, severity of illness,
psychological status, and two measures of patient engagement with nurses. Depression
proved to be the strongest predictor of quality of life, accounting for 23% of the
variance of scores in the quality of life measure. Symptoms accounted for 9.7% and female
gender accounted for 8% of the variance in the quality of life scores. Two measures of
engagement with nursing care providers contributed a total of 13.44% of the variance in
quality of life scores. Demographic variables did not significantly predict quality of
Conclusions: Multiple regression analyses revealed that
depression, the presence of symptoms, and female gender predicted quality of life scores.
Study findings also suggest that quality of life for an acutely ill hospitalized patient
with HIV/AIDS is enhanced through more active involvement in the process of nursing care.
The association in this study between patient level of engagement with nurses and quality
of life adds increased emphasis to the importance of the nurse-patient relationship in
acute care settings. The findings in this study also emphasize the importance of
recognizing and treating depression in patients with HIV/AIDS. It is noteworthy that at
least half of the patients scored moderate to severe depression on the Beck Depression
Inventory. Findings in this study are consistent with previous work which suggests that
the reporting of symptoms and the frequency have a profound effect on quality of life.
Impact: As care givers learn more about the issues affecting
quality of life for patients with HIV/AIDS, more focused interventions can be undertaken
to improve this important outcome of patient care.
116. Variations and Conflicts in Clinical Practice
Guideline Recommendations: Sources and Implications
E Licht, MD, B Vickrey, B Simon, MA, and BS Mittman, PhD. VA
Greater Los Angeles Healthcare System, Sepulveda, CA.
Objectives: Development and dissemination of clinical practice
guidelines represents an important strategy for medical societies, government agencies and
other public and private bodies seeking to improve the quality of healthcare and to
enhance uniformity of clinical practice. In recent years, the number of published
guidelines has expanded considerably, resulting in the availability of multiple,
overlapping guidelines in many clinical areas. Although redundancy and duplication are not
necessarily harmful, guideline users and others often note inconsistencies and conflicts
in guideline recommendations, suggesting problems in their development methods, evidence
base, or other features. Such conflicts may lead to inconsistencies and gaps in healthcare
delivery, particularly for patient populations care for by multiple specialties. We sought
to assess and explain conflicting recommendations and other variations in guidelines for a
single chronic illness in patients often treated by physicians in multiple
specialties--women with epilepsy of child bearing age--for whom consistency of
recommendations and coordination of care can be critical.
Methods: We identified ten relevant guidelines through Medline
searches and by contacting medical specialty organizations and public and private agencies
involved with issues of reproductive health. Guidelines were rated and classified on
several dimensions related to (1) guideline content and format (e.g., breadth of clinical
issues, patient populations addressed, specific recommendations included), (2) guideline
development agency characteristics (e.g., public/private, medical specialty) and (3)
guideline development process (e.g., nature and mode of evidence use, development
committee composition, external review). We used qualitative methods (due to sample size
limitations) to assess guideline conflicts and inconsistencies and to test hypotheses
regarding causal relationships linking guideline development and agency characteristics
with guideline content and format.
Results: Marked differences in general areas of coverage and
specific recommendations were common, and areas of direct conflict were identified. A
major area of inconsistency related to dosages of folate to reduce risk of neural tube
defects: suggestions ranged from 0.4- 5 mg/day of folic acid, and one agency failed to
recommend any specific dose. Guidelines from neurology-oriented organizations addressed
issues often excluded from guidelines developed by primary care and obstetric groups
(e.g., risk of neonatal hemorrhage from anticonvulsants); guidelines created by public
agencies (governmental and not-for-profit, public service agencies) also differed
significantly from those developed by private specialty societies and other organizations.
Conclusions: Inconsistencies in clinical practice guidelines may
undermine physician confidence and acceptance. Interactions between physicians with
different knowledge bases and different areas of clinical emphasis are more likely to
produce fragmented care when each group relies on separate and conflicting practice
guidelines. Greater cooperation between organizations developing guidelines is needed,
particularly when large, shared patient populations are involved, to produce
recommendations more likely to be accepted by physicians and more likely to unify rather
than fragment clinical practices across disciplines.
Impact: Results of this study should facilitate more effective
guideline development, by focusing attention on potential conflicts and other problems in
guideline content and format.
117. A Population-Based Survey of Tuberculosis
Symptoms: Insight into the Utility of Symptom-Based Screening for Active Disease
LG Miller, EI Yu, and SM Asch
Objectives: There have been few population-based case series
published on tuberculosis (TB) symptoms and none from the United States. Population-based
surveys are advantageous because they capture non-hospitalized cases that would have been
omitted in previous case series. The Centers for Disease Control and Prevention recommends
that screening programs that evaluate persons at risk for TB (such as health care workers
and persons entering long-term communal living facilities) should include questions about
symptoms. However the effectiveness of such screening has never been evaluated. Finally,
we wished to identify persons who present with less classic symptoms of TB, potentially
delaying their diagnosis.
Methods: We prospectively identified 526 consecutive cases of TB
reported between April and September 1993 to Los Angeles County Tuberculosis Control and
administered questionnaires to 313. Persons had significant symptoms if they had at least
1 of the following: cough >2 weeks, fever >2 weeks, hemoptysis, or weight loss. We
pre-selected 20 items from the County Registry and our questionnaire which we felt might
be associated with significant symptoms. We also surveyed physicians' perceptions of TB
Results: Our population was predominantly male (64%) and
nonwhite (90%). 73% (48% > for 2 weeks) had cough and 52% had fever (29% > for 2
weeks). 60% had fatigue, 45% had weight loss, and 21% had hemoptysis. 71% of patients had
significant symptoms. In bivariate analysis using Chi-squared analysis and t-testing,
significant symptoms were associated with (p<0.05)= positive smears, negative
tuberculin skin tests (TST),= alcoholism, drug use, HIV co-infection, homelessness, lack
of insurance, not being diagnosed during a screening program, American-born, and younger
age. Additionally, race was significantly associated with significant symptoms. In a=
multiple logistic regression model negative TST= (OR=3D12.5,p=3D0.02), not being diagnosed
in a screening program (OR=3D6.2,p<0.0001) and lack of health insurance
(OR=3D3.5,p=3D0.002)= was found to be associated with significant symptoms. Additionally,
Asian race (OR=3D0.16,p<0.0001) was associated with lacking significant symptoms of TB.
Physicians estimates of the percentage of patients with > 2 weeks of cough and fever
significantly exceeded measured rates. A commonly used screening program would have
identified 75% of cases, and 99% of cases when used in conjunction with a positive TST.
However missed cases included those with contagious pulmonary disease.
Conclusions: Fever and cough were less common symptoms of TB
than expected by physicians and lower than previously reported. Currently employed symptom
screening significantly augments the sensitivity of TST during screening of high-risk
populations. However, our data suggests that more effective questionnaires can be
developed. In a multiple regression model, persons with TB who lacked insurance or had a
negative TST were more likely to have significant symptoms from TB. Additionally, persons
of Asian descent with TB were less likely to report significant symptoms.
Impact: Rates of prolonged cough and fever may not be as
frequent in TB as commonly believed. Questionnaires used in TB screening appear to
complement skin testing but should be revised to enhance sensitivity. Clinicians should
have a higher degree of suspicion for TB in Asians when presented with an undiagnosed
syndrome compatible with TB.
118. Consistency of Self-Administered ASI
Composites with the Interview ASI
CS Rosen, PhD. VA Palo Alto Health Care System, Menlo Park,
CA. B Henson, and J Finney, RH Moos, PhD. VA Palo Alto Health Care System, Menlo
Objectives: To determine the viability of using a patient
self-report instrument as an alternative to the clinician-administered Addiction Severity
Index (ASI, McLellan et al., 1980; 1985; 1992) in monitoring outcomes of addiction
Methods: Eighty-five substance abuse patients at the VA Palo
Alto Health Care System completed both the standard semi-structured ASI interview, a
measure previously validated with VA patients, and a self-report questionnaire including
items used to calculate ASI composite scores. Composite scores (ranging from 0 to 1.0)
were calculated for seven domains of functioning: alcohol use, drug use, psychological
distress, family/social conflict, medical problems, employment, and legal problems. The
consistency of responses between the self-report and interview formats was assessed with
Pearson correlations and paired t-tests for continuous variables, and kappa coefficients
for dichotomous variables.
Results: For six of the seven ASI composites, scores obtained
from the self-report
instrument correlated .60 to .89 with the interview ASI. The most
consistent composite scores were alcohol use (r = .89), employment (r = .78), legal
problems (r = .77), and drug use (r = .73). Family/social conflict (r = .62) and
psychological distress (r = .60) were also highly correlated across both formats. The
least consistent composite score across the two formats was medical problems (r = .49).
Patients endorsed higher absolute levels of drug use, psychological distress, legal
problems, and family/social conflict by self-report than in the face-to-face ASI
interview. It is unclear whether patients tended to minimize problems in the face-to-face
interview or overstate problems on the self-report questionnaire. Exclusion of two
subjective questions (perceived distress and desire for treatment) from calculation of the
self-report composite scores did not significantly reduce the consistency of the
self-report alcohol, psychological, and family/social composites with the corresponding
composites in the interview ASI. Exclusion of these subjective items did reduce the
consistency of the self-reported drug use composite with the interview ASI composite.
Conclusions: The self-report instrument provided information on
patient functioning that was generally consistent with information obtained from the
clinician-administered ASI interview. The present study confirms similar findings by
Cacciola, McLellan, Alterman, and Mulvaney (1998) with substance abuse patients at the
Philadelphia VA Medical Center. Further research is need to determine whether a tendency
to endorse more pathology on a self-report questionnaire than in an interview, found in
the present study but not by Cacciola et al. (1998), is a generalizeable finding.
Impact: Results of the present study and previous research by
Cacciola et al. (1998) support using a patient self-report version of the ASI to assess
substance abuse patients' functioning. A self-report administration of the ASI enhances
its use for monitoring patient outcomes and gauging the performance of substance abuse
119. Rediscovering the Patient's Role in Receiving
Health Promotion Services
Laurence Branch PhD and D Rabiner, VA National Center for
Health Promotion and Disease Prevention, Durham, NC.
Objectives: This study examined differences in the odds of
receiving U.S. Preventive Services Task Force recommended health promotion/disease
prevention services among four subgroups of patients. We tested the hypotheses that those
most uninvolved in their own health (as exemplified by the lack of knowledge of blood
pressure and cholesterol levels despite having been tested) would receive fewer services,
and those being treated for both high blood pressure and hyperlipidemia would receive the
Methods: A mail survey was sent to a random sample of 68,422
veterans who obtained primary care from any of the 153 VA facilities in 1996. The adjusted
response rate was 68%. Subgroup analyses were performed on four subgroups who reported
being tested for both hypertension and hyperlipidemia: 1) those undergoing treatment for
both conditions (TREATED; n=4,944), 2) those with elevated blood levels for both
conditions but not undergoing treatment (HIGH RISK; n=534), those with normal or low blood
levels for both conditions (NORMAL; n=10,147), and those who did not know their blood
levels despite having been tested for both hypertension and hyperlipidemia (UNINVOLVED;
n=1,988). Three sets of analyses were conducted. First, prevalence rates for each of the
four mutually-exclusive subgroups were reported for 11 USPSTF-recommended health promotion
services. Second, multivariate logistic regression models were conducted to examine the
relationship between blood pressure/cholesterol status and the odds of receiving 11 other
USPSTF-recommended services after controlling for age and gender. Third, patient
characteristics and VA system characteristics were examined for the uninvolved subgroup of
veterans indicating that they did not know their blood pressure and cholesterol levels.
Results: The two main hypotheses were supported. Uninvolved
patients were the least likely subgroup to obtain other recommended health promotion
services and the dually treated were most likely. The uninvolved subgroup was
significantly more likely to be female, physically inactive, current smokers, heavy
alcohol drinkers, to report having a problem with alcohol, and significantly less likely
to be 50 years of age or older, overweight, almost always wear seat belts, and obtain at
least 90% of their health care at the VA.
Conclusions: Clinicians need to encourage all patients to
receive health promotion services but in particular should be aware that those who do not
know their last hypertension and cholesterol levels despite having been tested are
particularly in need of attention. Fortunately, busy clinicians can identify this
undertreated subgroup very easily; they just need to ask their patients if they remember
whether their last hypertension and cholesterol tests were high, normal, or low.
Impact: The new managed care paradigm requires that health care
providers become more proactive in the education and clinical management of their patients
to ensure that patients both become more motivated to seek out and obtain all
USPSTF-recommended services, and become better able to understand what the results of
these health promotion/disease prevention services mean for their health status over time.
Given the results reported here, health care providers need to refocus their health
promotion efforts on this important, relatively undertreated uninvolved subgroup.
120. The Accuracy of Physical Examination to
Detect Abdominal Aortic Aneurysm
Howard Fink MD, FA Lederle, CS Roth, CA Bowles, DB Nelson, and
MA Haas. VISN 13, Center for Chronic Disease Outcomes Research, Minneapolis, MN.
Objective: Abdominal palpation to detect abdominal aortic
aneurysm (AAA) has been recommended by some authors for the periodic health examination of
older men, but its accuracy remains uncertain. Previous studies in which the examiner was
unaware of the diagnosis were limited by low numbers of subjects with AAA. The purpose of
the present study was to better determine the operating characteristics of abdominal
palpation to detect AAA.
Methods: 200 subjects with and without AAA, as documented by
recent ultrasound, were invited to participate. 99 had AAA, of which 41 were 3.0-3.9 cm in
diameter, 44 were 4.0-4.9 cm, and 14 were > 5.0 cm. Each subject was examined by two
internists, who were blinded to each other's findings and to the ultrasound findings.
Examiners were to define AAA as pulsatile mass >= 3 cm in greatest transverse diameter
and were given brief instruction on AAA palpation prior to the study. For each of their
first 25 exams, after documenting their findings, the examiners were informed of the
ultrasound results as a means of feedback. Examiners rated each examination as definite or
suggestive for AAA (considered together as 'positive'), or as no AAA. In
addition, for each subject, the first examiner characterized the abdomen as
"obese" or " non-obese" and measured the girth. The examination was
used as the unit of analysis with repeated measures logistic regression used to control
for dependence of exams within each subject.
Results: Subject mean age was 73 years (range 51-88). 97
subjects were rated "obese" and 118 had abdominal girth >= 100 cm (Kappa for
"obese" vs. girth >= 100 cm - 0.78). Agreement between examiners
regarding presence of AAA was 77% (kappa = 0.53). For all examinations, sensitivity of
abdominal palpation for AAA was 67% and specificity was 75% (LR + = 2.7, LR - = 0.43).
Sensitivity for the first 10 exams by each examiner was 76%, higher than overall
sensitivity and suggesting absence of an important training effect. When abdominal girth
was < 100 cm, sensitivity was 91% and specificity was 64% (LR + = 2.5, LR - = 0.14),
whereas when girth was >= 10 cm, sensitivity was 53% and specificity was 83% (LR + =
3.2, LR - = 0.56). Results for "non-obese" vs. "obese" were similar to
those for girth. Sensitivity also increased with AAA diameter, ranging from 61% for AAA
3.0-3.9 cm, to 69^ for AAA 4.0-4.9 cm, and 82% for AAA >= 5.0 cm. In 12 exams on
subjects with girth <100 cm and AA >=5.0 cm sensitivity was 100%.
Conclusions: In this study, abdominal palpation demonstrated
moderate sensitivity for detection of AAA and fair-to-good interobserver agreement. For
larger AAA, especially in non-obese subjects, sensitivity was high. Sensitivity was higher
and specificity lower in this study that in previous studies, presumably reflecting the
examiners' increased vigilance due to the high prevalence of AAA in this series.
Implications: These results, considered along with previous
screening and cost-effectiveness studies, suggest that case-finding with abdominal
palpation in non-obese older men may be worthwhile.
121. The Risk of Gastrointestinal Complications
from Nonsteroidal Antiinflammatory Drugs: a Meta-analysis
Catherine MacLean, MD. Santa Monica, CA. J Ofman, MD,
MSHS. Director, Pharmacoeconomics and Technology Assessment, Beverly Hills, CA. Sally
Morton, PhD. RAND Statistics Group, Santa Monica, CA. Walter Straus Paul
Shekelle, MD. West Los Angeles VA Medical Center, Los Angeles, CA.
Objectives: Nonsteroidal antiinflammatory drugs (NSAIDs) are
mong the most commonly prescribed drugs in the VA. Past reviews of the gastrointestinal
(GI) complications of NSAIDs are limited by their reliance on only some of the relevant
study designs, and/or have focussed solely on the serious complication of perforations,
ulcers, and bleeds (PUB, and not dealt with the most common complication, dyspepsia. Our
goal with this meta-analysis was to review the evidence from all relevant study designs
published in any language on both PUBs and dyspepsia.
Methods: We searched MEDLINE, EMBASE, HEALTHSTAR, and BIOSIS
from 1966-1997 for studies of NSAIDs which reported original data on gastrointestinal
complications, regardless of study design or language. Potentially relevant abtracts were
selected, retrieved and reviewed against preset criteria for rejection. Each accepted
abstract had the full article retrieved, which was screened for relevancy. Relevant
articles were reviewed for study quality according to criteria developed by Jadad. All
work was done in duplicate by physician reviewers, with consensus to resolve
disagreements. Nonenglish language articles were reviewed by physicians fluent in the
language, with assistance from members of the study team. After data abstraction, studies
were assessed for clinical heterogeneity, and those deemed sufficiently clinically
homogenous were pooled using the DerSimonian and Laird random effects model.
Results: 4849 titles were identified of which 2145 were
potentially relevant and had abstracts reviewed. This resulted in selecting 1768 articles
(514 non-english), of which all but 70 (4%) were retrieved and reviewed. We identified 54
RCT's of an NSAID vs a placebo, of which 35, comprising 9396 patients, reported data on
dyspepsia. We identified an additional 84 RCT's of an NSAID vs.another NSAID (sample size
>49), and 24 studies reporting GI complications in a population of sample size >1000
all taking NSAIDs (large exposure series). Data from these two types of studies were used
to better estimate the rate of dyspepsia in the NSAID-treated group. We identified 27 case
control studies and 8 cohort studies, of which 19 (encompassing 26,103 patients) and 5
(representing 126,902 person-years of NSAID exposure), respectively, were judged
sufficiently clinically similar to pool. The quality of RCT's was generally good, with
more than 60% of studies scoring >3 according the the Jadad criteria. The rate of
dyspepsia in persons receiving NSAIDs increased from 5.5% to 7.5% to 10.9%, respectively,
in the NSAID vs. placebo, the NSAID vs. NSAID, and the large exposure studies. The rate of
dyspepsia in the placebo group was 2.2%. The pooled odds ratio for PUBs in the case
control studies was 2.9. The relative risk for PUBs in the cohort studies was 2.2, with an
absolute magnitude of 1% in the NSAID group and 0.44% in the no NSAID group.
Conclusions: The use of NSAIDs increases the rate of dyspepsia
from 2-3% to 6-10%, and increases the rate of GI perforations, ulcers, and bleeds from
0.5% to 1%.
Impact: These data provide the best evidence-based estimates to
date of GI complications and should be helpful to clinicians and policy makers when
weighing the benefits and harms of NSAIDs.
122. Depression, Self-Care, and Glycemic Control
in Patients with Diabetes Mellitus
DM Nachtigall, BA and MA Whooley, for the Ambulatory Care
Improvement Project. San Francisco VA Medical Center, San Francisco, CA.
Objectives: Previous studies have suggested that depression
leads to poor glycemic control in diabetic patients, but the reasons for this association
have not been determined. This study examined whether depressed patients have reduced
self-care, and whether lack of self-care is responsible for poor glycemic control among
patients who have diabetes mellitus.
Methods: We evaluated 24,671 patients who were recruited from 6
Veterans Affairs Medical Centers for the Ambulatory Care Quality Improvement Project. All
participants completed the Mental Health Inventory (MHI-5) and were considered depressed
if they scored at least 17 on a 30-point scale. Those with self-reported diabetes mellitus
were asked to complete an additional questionnaire regarding frequency of self-care (how
often they checked their blood sugar, checked their feet, and followed a meal plan) and
frequency of elevated blood sugar (>240 mg/dL) within the past 4 weeks. Results are
reported as odds ratios (OR) with 95% confidence intervals (CI) based on logistic
Results: Of the 3184 participants who completed the diabetes
questionnaire, 759 (24%) were depressed (MHI-5 >= 17). Compared with nondepressed
patients, depressed patients were equally likely to check their blood sugar (OR 1.0, 95%
CI, 0.8 - 1.2; p=0.96), but less likely to follow a meal plan (OR 0.7, 95% CI, 0.6 - 0.9;
p<0.001), and somewhat less likely to check their feet on a daily basis (OR 0.9; 95% CI
0.7-1.0; p=0.12). These results were not affected by adjusting for age, sex, ethnicity,
marital status, education, income, employment, smoking, alcohol, or comorbid illnesses.
Among participants who tested their blood sugar at least once per week (n=2189), those who
were depressed were more likely to report having a blood sugar > 240 mg/dL within the
past 4 weeks (OR 1.5, 95% CI, 1.2 - 1.9; p<0.001) than nondepressed patients. This
association was unchanged by adjusting for not following a meal plan.
Conclusions: Depression is associated with reduced self-care,
and with poorer self reported glycemic control. However, lack of self-care does not appear
to explain why depression leads to poor metabolic control in patients with diabetes
Impact: Better recognition and treatment of depression may
improve both self-care and glycemic control in diabetic patients.
HSR&D Funded: 96-002
123. Colorectal Cancer: Risk Factors for Advanced
Disease - Comparison of Stage at Diagnosis with SEER Cancer Statistics
Dawn Provenzale, MD, SC Murray, TD Schmidt, CF Martin, CM Rose,
and RS Sandler. Durham VA Medical Center, Durham, NC.
Objective: Colorectal cancer is the second leading cause of
cancer death in the United States each year. It has been estimated
that approximately one million veterans aged 50 and older, will develop colorectal
cancer over the remainder of their lives and approximately 433,000 will die from it. The mortality rate of nearly 50% associated with colorectal cancer
is a consequence of most cancers being diagnosed after local or regional spread. If
modifiable risk factors for presentation at advanced stages of cancer (e.g., physician and
patient delay in diagnosis, or poverty) could be identified, interventions that should
reduce mortality from colorectal cancer could be implemented. Our study of
"Colorectal Cancer: Risk Factors for Advanced Disease" among veterans, (ERIC
Study 97-023) will enroll 800 patients aged 40-79 in a four year period, and will examine
demographic and access to care factors as risks for presentation with advanced disease.
The objectives of this report are:
1) To summarize the demographic characteristics of the 110 patients for
whom we have complete data in the ERIC study.
2) To compare the stage at diagnosis with the Surveillance and
Epidemiology End Results (SEER) cancer statistics.
Methods: We determined age at diagnosis, race and stage at
presentation. Because most of our patients were white males, we compared their stage at
diagnosis with the SEER data (stage at diagnosis) for white males. We used original
pathology reports (TNM Staging) to classify our patients as having localized, or
non-localized (regional or distant) cancer, according to SEER notation. The Pearson's
chi-square test for independence was used to compare the proportion with localized cancer
in our data to that in the SEER population.
Results: The median age of the study population is 68 years
(range 45-78 years old), and 96.4% are white. Eighty-five and one-half percent of study
patients are white, 10% are African American and 4.5% are Hispanic. Thirty-three percent
of white males presented with localized disease (associated with a 92% five-year
survival), while 67% presented with regional or distant spread of disease (5-year survival
9%-66%). Forty percent of patients reported in SEER cancer statistics have localized
disease and 60% have evidence of regional or distant spread at the time of diagnosis,
which was not significantly different from our results.
1) Our preliminary results suggest that most veteran patients
present with evidence of regional or distant spread of their colorectal cancer.
2) There was no significant difference in stage at presentation among
veterans and the population-based SEER patients.
3) Fewer VA patients presented with localized disease (33% vs. 40%),
and although not statistically significant, could suggest a trend toward presentation at a
more advanced stage, which might become apparent as more patients are enrolled.
Impact: Colorectal cancer is curable if diagnosed
early. Our results suggest that most veterans present with evidence of regional or distant
spread of their cancer. If modifiable factors such as physician and patient delay in
diagnosis, or poverty, explain the increased mortality among veterans, interventions that
improve the process of care associated with screening and diagnosis can be instituted.
CSP Funded: EPP 97-023 "Colorectal Cancer: Risk Factors for
124. Epidemiology Education Preferences of VA
Administrators, Clinicians and Researchers
GE Reiber, PhD, MPH, TD Koepsell. VA Puget Sound Health Care
System, Seattle, WA. EJ Boyko.
Objective: To determine epidemiologic and research methods
courses of greatest continuing education interest to VA administrators, clinicians and
Methods: In 1997 the VA funded three Epidemiology Research and
Information Centers (ERICs), one in Seattle, Durham and Boston. A collective ERIC goal is
to promote the use of epidemiology by administrators and policy makers, clinicians, and
researchers. To learn the preferences of our target audience, a stratified random sample
of 2,346 VA administrators, clinicians and researchers received a questionnaire requesting
information on their educational background, length of time and primary role with the VA,
preferred learning strategies and interest in 28 potential epidemiology and research
methods courses. For each of the 28 course topics, participants rated their interest on a
scale ranging from no interest to high interest and indicated whether they already knew
the content. Participants completed either a hardcopy or WWW version of the survey.
Results: The survey response rate is 58% with additional surveys
still being received. The primary role of respondents was 17% administration, 67% clinical
care and 16% research. These participants had been in their present jobs a mean of 8 years
and employed by the VA a mean of 12 years. When asked to select all the educational
formats they found acceptable 41% identified
teleconference courses, 52% preferred travel to ERIC sites or DC, 26%
were interested in Internet courses with no travel involved, and 33% wanted combined
onsite and Internet courses involving travel. The three content areas of greatest interest
to administrators were: use of epidemiologic data in VA quality improvement programs,
epidemiologic methods for planning and evaluating health services, and quantitative
assessment of guidelines and their implementation. Highest interest areas for clinicians
were: improving clinical decision-making, use and interpretation of diagnostic and
screening tests, and evidence-based medicine/critical reading of medical literature.
Researchers' highest priorities were: clinical decision making, outcomes and
effectiveness research, and utilizing national VA data in research. Based on these results
the Seattle ERIC will host the first of the VA's Summer Epidemiology Sessions in
Seattle during June 1999.
Conclusions: Many administrators, clinicians and researchers
have identified an interest in additional epidemiologic and research methods training.
Onsite, teleconference and distance learning courses are being designed to address these
Impact: VA specific continuing education on epidemiology can
provide methodology that will assist administrators, clinicians and researchers in their
various VA roles.
125. Impact of a Low-cost Intervention on the
Cholesterol Awareness of Older Veterans Enrolled in an Ambulatory Care Clinic
M Murdoch, MD, MPH. Minneapolis VA Medical Center,
Minneapolis, MN. Sheridan and M Lavin. TJ Wilt, MD, MPH and HB Rubins, MD, MPH. Minneapolis VA Medical Center, Minneapolis, MN.
Background: Improving the public's cholesterol awareness is a
cornerstone of the National Cholesterol Education Panel's (NCEP) population-based approach
to cholesterol risk-reduction. Both the NCEP and American College of Physicians agree that
measuring individuals' serum cholesterol levels may help ensure their subsequent
compliance with Step I diets. However, previous work at our institution showed that only
two-thirds of patients screened by physicians for high cholesterol knew they had received
such screening, only half said they had been told their test results, and less than
one-fifth knew their cholesterol number.
Objective: 1) Develop a low-cost, sustainable intervention that would
improve veterans' cholesterol awareness, and 2) Improve resident physicians' compliance
with the NCEP population-based guidelines.
Methods: Quasi-experimental, pre- and post-intervention survey
of patients screened for high cholesterol. Survey results were correlated to laboratory
Setting: A large, Mid-Western, primary care clinic located within a
university-affiliated VA medical center.
Interventions: Provision of an automated feedback letter to
patients screened for high cholesterol and an educational program directed at internal
medicine residents assigned to the primary care clinic.
Results: Response rates to the pre- and post-intervention
surveys were 89% and 80%, respectively. Respondents were 99% male, and their mean age was
69 years (SD = 9.4). They reported, on average, 4.5 risk factors for coronary heart
disease (SD = 1.2). Compliance with some of the NCEP population-based guidelines improved
after the intervention. The percentage of subjects who remembered having their cholesterol
level tested increased from 88% to 94% (p = .04); the percentage who remembered being told
their cholesterol test results increased from 67% to 76% (p = .04); and the percentage who
remembered receiving general dietary information increased from 60% to 67% (p = .16).
However, subjects' cholesterol awareness and ability to recall their serum cholesterol
numbers were low at baseline (50% and 23%, respectively) and did not change significantly
after the intervention (to 51% and 17%, respectively; p = .17 and .86). On logistic
regression, cholesterol awareness was significantly and negatively associated with age [OR
= .97, 95% CI = (.95, .99)], and it was positively associated with a college education [OR
= 2.09, 95% CI = (1.26, 3.45)], with subjects' remembering being told their cholesterol
test results [OR= 3.16, 95% CI = (1.89, 5.30)], and with subjects' remembering being
provided general dietary information [OR = 1.93, 95% CI = (1.19, 3.14). These 4 parameters
accounted for only 4% of the total variance in cholesterol awareness.
Conclusions: The intervention successfully improved compliance
with some of the NCEP population-based guidelines but did not improve veterans'
Impact: Other programs successful in improving subjects' cholesterol
awareness have generally been conducted in younger and healthier populations, and the
subjects who became cholesterol-aware also took steps to modify other risk factors for
coronary heart disease. Older, male veterans may have unique barriers to becoming
cholesterol-aware that are not yet understood. Before these individuals can enjoy the
potential benefits of cholesterol awareness, barriers to and other, mutable
characteristics associated with cholesterol awareness will need to be identified.
126. Measuring the Validity of Chart Abstraction:
Should We Use It as a Quality Improvement Tool?
J Luck, MBA, PhD. Assistant Professor, UCLA School of Public
Health, Los Angeles, CA. JW Peabody, MD. West Los Angeles, VA Medical Center, Los
Angeles, CA. T Dresselhaus, MD. PA Glassman, MD,. West Los Angeles, VA Medical
Center, Los Angeles, CA. ML Lee, PhD and MM Wang, MPH. Sepulveda Campus/Southern
California System of Clinics, Sepulveda, CA.
Objectives: Improvements in clinical practice depend on a
reliable measure of quality. Chart abstraction is the usual method but many feel that it
is subject to biases, varies significantly within a single provider and has a low
generalizability across common conditions. The objective of this study was to measure the
criterion validity of medical record abstraction in the outpatient setting.
Methods: In a prospective study, we compared physician
performance as measured by standardized patients (SPs) to medical records derived during
the same SP visits. We introduced the SPs unannounced into two VA primary care outpatient
clinics. Each randomly selected physician saw 8 SPs with four common conditions-two cases
each of coronary artery disease, diabetes, low back pain and chronic obstructive pulmonary
disease. A total of 160 SP encounters were carried out yielding 320 scores for comparison.
The analytic model for comparison was a three way crossed one way nested ANOVA. The main
effect of the model compared the two measurement methods for overall score and for
clinical domain (history, physical examination, diagnosis and treatment). We also included
site, level of training and clinical case as random effects in our analysis.
Results: Chart abstraction consistently underreports the quality
of care across several dimensions as reported by SPs. Performance, as defined by national
guidelines and local exert panels, showed that history taking scores were 26% lower and
diagnostic accuracy was 17% lower. Overall scores were 10% lower and this was consistent
across sites, clinical conditions and case complexity. When we measured reports of
unnecessary care, however, charts consistently over reported quality by about 10%.
Conclusions: The criterion validity of charts as a measure of
quality in the outpatient setting may be limited. Underestimation is a variable problem
depending on whether the history, the physical, diagnostic accuracy or appropriateness of
treatment are being measured. If charts are used to measure case mix in a population they
might seriously underestimate the prevalence, incidence or severity of disease.
Impact: Quality measurement programs that rely on chart
abstraction, such as the External Peer Review Program used by the VA, may severely
underreport the quality of care actually provided to patients. A more reliable quality
measure that is less expensive than standardized patients would provide a better basis for
quality improvement initiatives.
HSR&D Funded: IIR 95-014
127. Validation of a Computerized Adaption of the
Charlson Index Using the SF-36 among VA Outpatients
MB McDonell, MS, DM Martin, PhD, and SD Fihn, MD, MPH. VA
Puget Sound Health Care System, Seattle, WA. SK Mirza
Objectives: When comparing patient outcomes, it is essential
that results be adjusted for severity of illness, including comorbid conditions. Charlson
et al. described a method of classifying and scoring comorbidities according to prognostic
significance. Deyo and colleagues adapted this index for use with an ICD-9-CM coded
administrative database. Using diagnostic codes extracted from a VA hospital database,
this study examines the effect of comorbid conditions (as measured by the adapted Charlson
Index) on functional status of patients followed in the Seattle VA General Internal
Methods: We conducted a cross-sectional analysis of 4,222
patients who were mailed the SF-36 as part of the Ambulatory Care Quality Improvement
Project (ACQUIP). All inpatient and outpatient ICD-9-CM diagnoses for the past two years
were extracted from a centralized data warehouse developed for the VA Northwest Region.
These data were then merged with SF-36 and demographic data collected as part of the
ACQUIP study. Patients were grouped according to their comorbidity scores; 0, 1-3, and
>3. SF-36 domains were correlated to the Charlson score, and group differences were
examined using ANOVA with adjustment for multiple comparisons and age. To assess the
accuracy of computer generated comorbidity scores, 200 charts were reviewed by physicians
and manually scored.
Results: Sixty-three percent (2,460/4,222) of patients (63%)
responded to the SF36. The mean age was 65 years, and 96% were male. The three comorbidity
groups differed in age; those with higher Charlson scores were older. The mean age was 62,
66, and 69 for patients scoring 0, 1-3 and >3 respectively (p < .001). Correlations
between the Charlson score and SF36 scores were significant for 7 of 8 domains; physical
function, general health, vitality, social function, role physical, emotional, and bodily
pain (p < .001). The Mental Health domain was not significantly correlated. Similarly,
group means differed for all domains except Mental Health with SF36 scores decreasing as
the comorbidity index increased (p <.001). These differences persisted after adjusting
for multiple comparisons and age. The domain means for the three groups (0, 1-3, >3)
were: Physical Function (57.7, 46.6, 36.1); Role Emotional (60.3, 57.7, 48.8); General
Health (53.8, 45.6, 36.7); Vitality (46.2, 41.6, 33.3); Bodily Pain (53.6, 51.6, 45.8);
Social Function (64.8, 61.3,52.5); Role Physical (40.7,29.5, 18.2); and Mental Health
(66.2, 67.7, 64.5). The analysis of discrepancies between computer and manually generated
scores showed no overall bias and no differential bias between high and low scores. A
graphical analysis failed to show any systematic change in variance over the range.
Conclusions: Comorbidity, as measured by the Charlson Index, was
significantly related to functional status, as measured by SF-36 scores, independent of
age. The results support the validity of the computerized, adapted Charlson Index when
applied to VA outpatients.
Impact: The adapted Charlson index may be a useful tool for
severity adjustment in outcomes research. The ability to compute this index from an
administrative database makes this approach appealing for health services research and
quality improvement efforts
HSR&D Funded: SDR 96-002
128. Appropriateness of Quinidine use at a
Veterans Affairs Medical Center
A Niakan, MD. Memphis VA Medical Center, Memphis, TN. LM
Objectives: The results of the Cardiac Arrhythmia
Suppression Trials in 1989 heightened our awareness of the potentially dangerous effects
of class I antiarrhythmics. Quinidine is one of the oldest prescribed agents in this drug
class. The manufacturer's package insert recommends quinidine's use for several
indications including preventing recurrences of paroxysmal ventricular and
supraventricular arrhythmias and maintaining sinus rhythm after cardioversion of atrial
fibrillation and flutter. However, the results of several studies have raised concern of
increased mortality associated with quinidine's use, particularly in patients with heart
failure or a history of myocardial infarction. In this study we evaluated the
appropriateness of quinidine use, dosing, and follow-up at our medical center and tried to
identify patients who may be at increased risk for mortality with quinidine.
Methods: A computer search identified all outpatients receiving
quinidine from the Memphis Veteran Affairs Medical Center (VAMC) as of February 1998. We
retrospectively reviewed the complete medical records for these patients To determine the
indication, dose, and duration of quinidine therapy, contraindications to quinidine
treatment, cardiac disease history, concomitant drug therapy, ambulatory
electrocardiography results, and laboratory and electrocardiographic data.
Results: Over 30 percent of patients were receiving quinidine
inappropriately or for unspecified reasons such as PVC's or palpitations. In addition,
forty percent of patients on quinidine had left ventricular systolic dysfunction or a
history of myocardial infarction. Although serum chemistries were routinely performed in
the majority of patients, quinidine levels and electrocardiographs were monitored much
less frequently. The most recently checked qunidine levels were below 2 mg/L in 54% of
Conclusions: This study demonstrates that quinidine is
frequently prescribedfor patients inappropriately, often for unspecified or questionable
indications, and with inadequate follow-up. Quinidine is frequently used in patients with
cardiac disease which place them at an increased risk for mortality.
Impact: We hypothesize that other practice sites have similar
patient care issues related to the inappropriate prescribing and patient follow-up with
quinidine therapy. The challenge for practitioners is to confirm and document the presence
of arrhythmias then treat with the most appropriate therapy available with necessary
follow-up and monitoring.
129. Testing the Performance of VHA's 1997
Ambulatory Care Survey Instrument
AE Sales, PhD, RNC. VA Puget Sound Health Care System,
Seattle, WA. O Yu. M McDonell, MS, and S Fihn, MD, MPH. VA Puget Sound
Health Care System, Seattle, WA. J Tuchschmidt
Objectives: The aim of this project was to determine if
items could be eliminated on the VHA's 1997 Ambulatory Care Survey. One of the corporate
aims of VHA is to achieve levels of customer satisfaction comparable with those in the
private sector. Customer satisfaction has been measured annually by the National Customer
Feedback Center (NCFC), a unit of the Office of Performance and Quality (OPQ) using the
Ambulatory Care Survey. Some items are borrowed from private sector satisfaction
instruments, and have some items tailored to VHA, as well as incorporating some health
status questions. The result is a relatively long instrument which may constitute a
significant patient burden. Response rates are typically around 50%.
Methods: Data from the 1997 Ambulatory Care Survey for VISN 20
(Northwest Network) were received from the NCFC. The number of respondents, sampled from
all eight VISN 20 facilities, was 1216 overall. We recoded variables that included logical
skips as legitimately missing values. We checked for inter-item reliability using
Cronbach's alpha on each of the seven domains. We used factor analysis with varimax
rotation to examine which items in each scale were responsible for the preponderance of
the information in each scale, including only items with eigenvalues greater than 1.00 in
the analysis and restricting the factor analysis to one factor. We then performed
confirmatory regression analyses where possible to check to see if the results from the
factor analysis were confirmed.
Results: Cronbach's alphas ranged from below .15 (Emotional
Support) to .735 (Courtesy). If Cronbach's alpha was below .40, we did not proceed with
factor analysis. We did not conduct further analysis on the Emotional, Preference and
Overall Coordination scales. The Courtesy scale consisted of only two items, obviating the
need for further analysis. Of the remaining three scales, consisting of 17 items, we were
able to identify two items per scale that explained most of the variance in the scale,
suggesting that these six items could replace the 17 items, shortening the instrument
Conclusions: The 1997 Ambulatory Care Survey demonstrates
questionable reliability on three of its seven scales, based on 1997 VISN 20 data. Of the
three scales amenable to factor analysis, dominant items emerge, allowing the instrument
to be shortened. However, focusing on improving the reliability of the other scales, and
determining the relative importance of including a large number of health status related
questions would have a greater impact in terms of shortening the instrument in its current
Impact: The results of this study are likely to be of interest
to Network Directors, facility directors, and national leadership in the Office of
Performance and Quality. Some of the scales in the current instrument perform very poorly,
suggesting the need for further evaluation. Others can be predicted with fewer items, thus
reducing patient burden and increasing the ability of facilities to add their own items,
relevant to local initiatives more under control of local managers, which potentially
could increase customer satisfaction more than responses to items not under local control.
130. Patient-Level and Facility-Level Factors
Affecting Patient Satisfaction Ratings of VA Care
Gary Young, JD, PhD, M Meterko, and Kamal Desai, PhD. Boston
VA Medical Center, Boston, MA.
Objectives: To examine whether and to what degree a
patient's satisfaction ratings of VA care are related to his/her demographic
characteristics as well as selected characteristics of the facility where care was
received. To assess the relative contribution of patient-level versus facility-level
characteristics to explaining variation in patient satisfaction ratings. To examine
whether a facility's involvement in total quality improvement activities (TQI) affects
patient satisfaction ratings.
Methods: We used several sources of data to construct
patient-level data sets for inpatient medicine, inpatient surgery, and outpatient care.
Our primary source of data consisted of the 1997 inpatient and outpatient patient
satisfaction surveys conducted by the VHA National Customer Feedback Center. This data
source provided satisfaction ratings for inpatient care from approximately 20,000 patients
and for outpatient care from approximately 24,000 patients. This data source also included
the demographic characteristics and self-reported health status of the patients who
provided satisfaction ratings. We used internal VA files to obtain data on facility-level
structural characteristics (e.g. size). Data on facility- level TQI involvement came from
our own 1997 VHA-wide survey of quality improvement practices. For the dependent variable
we created a composite measure of patient satisfaction that was the average of a patient's
satisfaction ratings (i.e., problem scores) across the subscales comprising the survey
questionnaire. Patient-level characteristics consisted of age (continuous), self-reported
health status (five-point scale), sex, and race (white versus nonwhite). Facility-level
characteristics consisted of size (number of FTE), whether or not a major teaching
hospital (based on membership in the Council of Teaching Hospitals), urban/rural status,
geographic location (east, west, central, and south), and TQI involvement (five-point
scale). Because of the multi-level nature of the data, we used random-effects regression
models. We conducted separate analyses for each type of setting (e.g., inpatient
Results: Among patient-level characteristics, advancing age and
better health status were consistently associated with higher satisfaction ratings.
Nonwhite patients were consistently less satisfied with their care than were white
patients. Among the facility-level characteristics, hospital size was consistently
associated with lower ratings. TQI involvement was associated with higher ratings for both
inpatient medicine and ambulatory surgery. Patient-level characteristics explained only a
small amount of sample Variation (between 8 and 14 percent). Facility level
characteristics contributed little additional explanatory power to the models.
Conclusions: Age, health status, and race appear to be important
proxies for patient expectations about service quality. Facility size is a possibly
important marker for processes that affect patient experiences with satisfaction. Facility
involvement in TQI appears to have potential in improving processes that ultimately result
in greater patient satisfaction.
Impact: Comparisons of facilities based on patient satisfaction
data need to take into account differences in the patient population. Accounting for
differences in age, health status, and race is particularly important. Larger facilities
appear to be at a disadvantage in terms of patient satisfaction. More research is needed
to understand the nature of the size effect. VHA should assess whether opportunities exist
to strengthen TQI training and education for VA managers and clinicians.
HSR&D Funded: 94-085
131. Comparing Faclities on Functional Status
Decline: a Hierarchical Bayes Linear Modeling Approach
BH Chang, ScD, J Wu, and AK Rosen, PhD. Edith Nourse Rogers
memorial Veterans Hospital, Bedford, MA.
Objectives: Decline in functional status is considered an
important outcome measure for making comparisons across facilities on quality of care.
Variation among facilities on decline rates can be attributed to various factors: patient
attributes, facility characteristics, and random error. We compare facilities on decline
rates which are case-mix adjusted using patient attributes. A Hierarchical Bayes Linear
Modeling (HBLM) approach is used for the comparison. Results from HBLM are compared with a
non-Bayesian approach. We also investigate the effect of a single facility level
characteristic, geographic region, on decline using HBLM.
Methods: Administrative inpatient and long-term care databases
(FY'96) from the Department of Veterans Affairs (VA) were used for analyses. To have
reliable estimates of decline rates, we included only those long-term care facilities
which had at least 50 residents (n=95). Decline in functional status was measured by a
worsening of 2 points in the activities of daily living (ADLs) summed score between
residents' baseline and semi-annual assessments. Facility case-mix adjusted decline rates
were estimated by a logistic regression model which included residents' medical
conditions, diagnoses, and demographic characteristics. The difference between observed
(O) and expected (E) or case-mix adjusted decline rates was used as the outcome measure.
We modeled this outcome and estimated its posterior distribution using HBLM. This method
compares facilities on the "true" outcome which does not include random error,
while a typical non-Bayesian method uses the observed outcome which generally includes
random error. HBLM takes into account the variance of the random error when estimating the
posterior mean of the true (O-E) rates. The uncertainty about the variance of the true
(O-E) is also incorporated into the estimation of both the mean and variance of the true
(O-E). Another feature of HBLM is that it can estimate the effects of the facility level
Results: HBLM estimated the standard deviation (S.D.) of the
true outcome to be .028 which was around half of the S.D. of the observed outcome (.054) .
Two facilities were identified as outliers by HBLM since they had significant non-zero
posterior means of the true "O-E" rates. The non-Bayesian method identified 4
more outliers in addition to the two identified by HBLM. Geographic region was not
significantly associated with decline.
Conclusions: Facility comparison using HBLM, which is based on
the posterior mean and variance of the true (O-E), is more appropriate than comparison
based on the observed (O-E) and its variance. As a result fewer outliers were identified
when HBLM was used compare to the non-Bayesian approach. Although the facility level
characteristic, geographic region, was not related to decline, future studies should
include additional facility characteristics, such as clinician to patient ratio, in the
Impact: With increasing interest in facility comparison in the
VA, it is important to have a sound statistical method for making such comparisons. HBLM
is a promising method because it models random error appropriately and thus avoids
identifying spurious outliers.
HSR&D Funded: IIR 96-065
132. Cost Effectiveness of Team Managed Home Based
Susan Hughes, DSW and FM Weaver, PhD. Hines VA Hospital,
Hines, IL. A Giobbie-Hurder. JD Kubal, MA. Hines VA Hospital, Hines, IL A
Ulasevich and TO Sindowski
Objectives: This study examined the cost-effectiveness of a
new ï¿½team managedï¿½ model of Hospital Based Primary Care (TM/HBPC). A previous test of
TM/HBPC at Hines VA Hospital demonstrated a net cost savings of 10% that was attributable
to a 29% reduction in hospital readmission costs. The TM/HBPC model emphasized targeting
patients at high risk of repeat hospital admission and active participation of the home
care physician in ongoing patient primary care management. The current study sought to
determine whether the model was generalizable and the cost savings replicable throughout
the VA health care system.
Methods: We used an RCT with pretest and multiple posttests to
examine cost-effectiveness. Pairs of patients and informal caregivers were recruited at 16
VA hospitals, stratified by age, disease (2 or more ADL impairments, terminal illness,
CHF, or COPD) and by site and randomly assigned to TM/HBPC or to customary care. Primary
outcomes tracked over 12 months were total health care costs, including inpatient and
outpatient VA and private sector costs. Secondary outcomes obtained at baseline, one, six
and 12 months included patient functional status, patient and informal caregiver
health-related quality of life, satisfaction with care and caregiver burden. Results were
analyzed using intent to treat analyses.
Results: Study investigators were only recently unblinded to
outcomes. Analyses are still on going but will be finalized by January in time for a
scheduled February 11-12, 1999 close-out meeting. 1,967 patients were randomized to the
study over four years. The primary reason for exclusion among patients screened was
residence outside the area served by HBPC(38%). Of persons who met the inclusion criteria,
40% refused to participate in the study. Inclusion criteria suceeded in identifying a high
risk patient group. At baseline 75% of study enrollees had severe disabilities, 20% were
terminally ill, and 5% had CHF or COPD. At baseline, patients had a mean age of 71, 3.2
ADL impairments on average and a mean SF-36 physical function score of 20. Close to 90% of
patients were recruited to the study during an index hospital admission and 88% had been
hospitalized at least once during the six months prior to enrollment. No significant
differences were observed between groups on demographics or baseline measures of study
outcomes. Attrition from secondary outcome measurement was low at 6% for treatment
subjects vs. 8 % for controls. Twelve-month mortality rates were similar at 37% and 36%,
respectively. Primary outcome data based on VA administrative databases, HCFA Medicare
charge data, and self reports confirmed with providers were obtained on close to 100% of
Conclusions: Preliminary findings based on repeated measures
ANOVA indicate significant treatment group benefits in patient and caregiver satisfaction
with care at one, six, and 12 months and in objective caregiver burden at 6 months. Cost
analyses are still ongoing but findings will
be available by February and will be presented.
Impact: The advisability of adopting this new home care
management model throughout the VA health care system will be discussed.
HSR&D Funded: CSP-003
133. Cost Effectiveness of a Primary Care
Intervention: Results from a VA Cooperative Study
DM Hynes, RN, PhD. Hines VA Hospital, Hines, IL. E
Oddone, MS, MHS. Durham VA Medial Center, Durham, NC. M Weinberger, PhD. Indianapolis VA Medical Center, Indianapolis, IN. A Giobbe-Hurder and W Henderson.
Objectives: We examined the cost effectiveness of a primary
care intervention in VA hospitals in a multi-site randomized clinical trial. We focused
specifically on marginal costs relative to a key patient centered outcome: improvement in
Methods: This multi-site RCT was conducted at nine
geographically and academically diverse VA Medical Centers to ascertain whether enhanced
access to a primary care intervention reduced hospital use of chronically ill veterans
over a six month period. Eligible patients with a diagnosis of diabetes mellitus, chronic
obstructive pulmonary disease, or congestive heart failure at or before the time of their
index admission were enrolled during an admission to the General Medicine Service.
Following enrollment, 1,396 eligible patients were randomized to receive their usual care
or the intervention. The intervention, delivered by a registered nurse and primary care
physicians, contained an inpatient and outpatient component. The inpatient component
included discharge planning with the nurse and physician, disease education, and
scheduling of a follow-up visit within 7 days to that primary care physician and nurse.
The outpatient component comprised follow-up telephone contact by the nurse,
post-discharge outpatient appointment within a week after discharge and a monitoring of
the treatment plan by the nurse and physician. Patients were followed for six months and
utilization data were tracked for one year after randomization. Costs were measured using
information from VA (Patient Treatment File, Outpatient File and Cost Distribution Report)
and non-VA sources (Medicare claims data and validated patient self-report) about the use
and costs of inpatient and outpatient care for the intervention and usual care group.
Patient satisfaction was measured using the Patient Satisfaction Questionnaire (PSQ) at
baseline and at the completion of the intervention for the intervention and the usual care
Results: VA hospital and outpatient visit costs were
significantly greater in the intervention group (Mean hospital: $5,438 _ 12,356 versus
$4,079 _ 9,108; p=0.02; Mean outpatient: $1,036 _ 832 versus $927 _ 1,269). While use of
non-VA inpatient and outpatient care accounted for less than 10% of health care use,
non-VA outpatient costs for the usual care group were significantly greater than for the
intervention group. Mean level of patient satisfaction for the intervention group
increased by 6% from baseline compared to no change in the usual care group (p=0.0001).
Marginal cost effectiveness ratios will be forthcoming.
Conclusions: With increasing emphasis on managed care principles
in VHA, the impact of patient care interventions must be examined relative to patient
Impact: As the VHA strives to compete for patient enrollment in
an increasingly competitive health care market, it must consider approaches for reducing
costs while maintaining quality of care. Strategies that demonstrate cost effectiveness in
terms of patient centered outcomes such as satisfaction with care, will have the most
likelihood of proving successful. This study provides a method that can be used to examine
the cost effectiveness of a wide range of health care interventions in VHA.
HSR&D Funded: CSHS ##8
134. Cost-Savings Associated with Limited Academic
Detailing to Promote Hypertension (HTN) Clinical Practice Guidelines
Joy Meier, PharmD. VANCHCS, Martinez, CA. JR Lopez and D
Objectives: VA clinical practice guidelines for HTN
recommend the use of beta-blockers and thiazide diuretics as first-line therapy for
hypertension, depending on co-morbidities, but do not recommend calcium antagonists as
first-line therapy with any co-morbidity. Prior analysis revealed an overuse of calcium
antagonists in our system.
To determine: 1) baseline antihypertensive prescribing patterns for
hypertensives with or without co-morbid conditions and 2) changes in antihypertensive
prescribing patterns following initiation of limited academic detailing.
Methods: Researchers used ICD-9 codes from encounter forms to
identify patients with HTN, DM, CHF, coronary artery disease (CAD), chronic obstructive
pulmonary disease (COPD) and asthma between 10/1/96 and 8/1/97, and between 4/1/97 and
3/31/98. Researchers determined prescribing patterns for HTN with and without co-morbid
conditions by relating the ICD-9 code database to prescriptions for beta-blockers, alpha-1
blockers, calcium antagonists, thiazide diuretics (alone or in combination with a
potassium sparing diuretic), loop diuretics, angiotensin converting enzyme (ACE)
inhibitors, and angiotensin II antagonists over a six month period (1/1/97 to 6/30/97 for
baseline and 12/1/97 to 5/31/98 for follow-up) using Access (TM) and Excel(TM).
Interventions included lectures, distribution of educational materials, profiling of
provider prescribing patterns, and individualized meetings with providers to promote the
guideline. Researchers calculated cost savings as the differences in expenditures for The
two study periods. In order to avoid changes in expenditures attributable to increases or
decreases in drug acquisition cost, researchers calculated the average cost per patient in
the follow-up period using the average cost per patient for each drug class at baseline
times the number of patients receiving drugs in that class.
Results: Of 7526 hypertensives at baseline, the percentage
receiving a drug class included: calcium antagonist (55%), ACE inhibitor (50%),
beta-blockers (20%), thiazide +/- potassium sparing diuretic (21%), alpha-1 blocker (22%),
loop diuretic (16%), angiotensin II antagonist (3%). Of 2426 hypertensives with DM, and of
970 hypertensives with CHF, 65% of both groups received an ACE inhibitor. Of hypertensives
with CAD who did not also have COPD, asthma, DM, or CHF, 38% received a beta-blocker. At
follow-up, of 8901 hypertensives, the percentage receiving a drug class included: calcium
antagonists (49%), ACE inhibitor (49%), thiazide +/- potassium sparing diuretic (25%),
alpha-1 blocker (23%), loop diuretic (16%), angiotensin II antagonist (4%). There was no
change in the proportion of hypertensives with either DM or CHF who received an ACE
inhibitor. Of hypertensives with CAD who did not also have COPD, asthma, DM, or CHF, 42%
received a beta-blocker. Over the six month follow-up period, $36,596 was saved.
Conclusions: Prescribing patterns following limited academic
detailing more closely followed VA and JNC VI recommendations and resulted in significant
Impact: Following VA and JNC VI guidelines for the treatment of
HTN will result in considerable cost savings nationwide.
135. The Impact of Per-Episode Payment for
Medicare Home Health Care on the Use of Non-Medicare Services: A Randomized Control Trial
BR Phillips, PhD. VA San Diego Healthcare System, San Diego,
Objectives: The use of Medicare home health services has
increased dramatically over the last decade, much of increase involves care to long-term
patients, who might have otherwise been served by Medicaid, VA, and other public programs.
Partly in response to these changes, Congress has mandated a prospective payment system
for Medicare home health by the turn of the century. The Health Care Financing
Administration (HCFA) has been implementing demonstrations of prospective payment for
Medicare home health care, including a demonstration of a lump-sum payment for an episode
of care. This payment system creates incentives for providers to reduce their own costs,
perhaps by shifting costs to other payers, such as VA, Medicaid, and Administration on
Aging programs, or shifting burden to relatives and friends of patients. The objective of
this study was to evaluate the impact of lump-sum payment on the use of non-Medicare
services, such as VA services.
Methods: Ninety-one home health agencies in five states enrolled
in the demonstration and were randomly assigned to receive per-episode payments or to
continue under cost-reimbursement. During their second year of demonstration operations, a
random sample of patients was selected at home health admission. These patients were
interviewed by telephone at the end of the 120-day period covered by the lump-sum payment
about their use of non-Medicare services. Logistic regression and Tobit models were
estimated, adjusting for the design effect of the clustering of the sampled patients in
Results: Lump-sum payment for Medicare home health care reduced
the likelihood of admission to assisted living facilities by about 25 percent (p = .02)
and may have reduced the likelihood of admission to nursing homes (p - .07). It did not
affect the likelihood of receipt of non-residential services, such as personal care aide
and adult day care. Nor did it affect the likelihood of receipt of care from relatives or
Conclusions: Lump-sum payment for home health care does not
increase the costs borne by payers other than Medicare. Rather, such payment reduces the
use of residential non-Medicare services, perhaps as a by-product of home health agencies
stressing patient self-care and independence.
Impact: This study impacts the VA in two major ways. First, it
indicates that use of VA personal assistance and long term care programs should not
increase as Medicare moves to prospective payment for home health care. Second, it
buttresses other evidence that per-episode payment is a cost-effective approach to
provider payment for home health care--one that the VA should consider for its home health
136. Cost-Effectiveness of Antiseptic-Impregnated
Central Venous Catheters in the Critically Ill
S Saint, MD, MPH. Ann Arbor VA Medical Center, Ann Arbor,
MI. DL Veenstra. SD Sullivan.
Objectives: Central venous vascular catheters, commonly used
in caring for critically ill patients, are associated with significant infectious
complications. Catheter-related bloodstream infection occurs in over 250,000 patients per
year in the United States and is associated with increased morbidity, mortality, and
costs. Central venous catheters impregnated with chlorhexidine/silver sulfadiazine have
recently been introduced for the prevention of catheter-related bloodstream infection. A
recently completed meta-analysis indicated these catheters are efficacious in reducing the
incidence of catheter-related bloodstream infection; however, antiseptic-coated catheters
cost about $25 more than standard catheters and have recently been associated with several
hypersensitivity reactions in Japan. We thus performed a formal economic analysis to
answer the question, "Compared with standard non-impregnated central venous
catheters, are antiseptic-impregnated central venous catheters cost-effective?"
Methods: We utilized decision-analytic techniques to evaluate
the incremental medical and economic outcomes associated with short-term use
(approximately 1 week) of antiseptic-impregnated versus standard central venous catheters
in critically ill patients from the perspective of a healthcare payer. The clinical
outcomes evaluated were catheter-related bloodstream infection and death. The probability
of catheter-related bloodstream infection was based on a meta-analysis of eleven
randomized controlled trials comparing standard central venous catheters to
chlorhexidine/silver sulfadiazine impregnated central venous catheters. Medical costs were
derived from literature review and the University of Washington Medical Center. In
addition to the base-case scenario, we analyzed scenarios in which all of the model
parameters were set to favor either standard or antiseptic-impregnated catheters.
Results: In the base-case analysis, use of an
antiseptic-impregnated catheter compared to a standard catheter resulted in expected cost
$233 per catheter used. The expected incidence of catheter-related
bloodstream infection decreased from 5.2% for standard catheters to 3.0% for
antiseptic-impregnated catheters. The expected incidence of death due to catheter-related
bloodstream infection or hypersensitivity reaction decreased from 1.30% to 0.76%. The
scenario with all parameters set to favor use of the standard catheter still resulted in a
slight cost-savings per catheter used of $4, a 0.6% absolute decrease in the incidence of
catheter-related bloodstream infection, and a 0.08% absolute decrease in the incidence of
Conclusions: The results of our analysis indicate that the use
of antiseptic-impregnated catheters in the critically ill is likely to result in cost
savings, a reduction in the incidence of catheter-related bloodstream infection, and an
overall decrease in the incidence of death compared to use of standard, non-impregnated
catheters. These results hold true over a wide range of assumptions and variation in
outcome and cost parameters.
Impact: The use of antiseptic-impregnated central venous
catheters in patients at high risk for catheter-related bloodstream infection e.g., the
critically ill) should be strongly considered as part of a comprehensive nosocomial
infection control program. Use of these catheters in high-risk patients should lead to
improved patient outcomes and decreased healthcare costs. The base-case analysis suggests
that for approximately every 200 antiseptic-impregnated catheters used, an average of
$47,000 will be saved overall and 4 cases of catheter-related bloodstream infection and 1
death will be avoided.
137. Depressive Symptoms and Three-Year Mortality
in Hospitalized Elders
KE Covinsky, MD, MPH. San Francisco VA Medical, San
Francisco, CA. E Kahana, MH Chin, RM Palmer, and RH Fortinsky. CS Landefeld, MD. San Francisco VA Medical Center, San Francisco, CA.
Objectives: Depressive symptoms are common in hospitalized
elders. However, their relationship to long-term mortality is unclear because few studies
have rigorously considered potential confounders of the relationship between depression
and mortality such as comorbidity, functional impairment, and cognitive impairment. Our
objective was to measure the association between depressive symptoms and long-term
mortality after controlling for these potential confounders.
Methods: This was a prospective cohort study of 573 hospitalized
elders (age >= 70) admitted to the general medical service of a teaching hospital. We
measured depressive symptoms with the Geriatric Depression Scale at the time of admission.
We also measured acute illness severity (APACHE II scores), comorbidity (Charlson scores),
physical function (nurse assessed dependence in 6 activities of daily living), and
cognitive function (modified mini-mental state examination) on admission. Mortality over
the three years following admission was determined from the National Death Index. We
compared mortality rates in patients with 6 or more depressive symptoms to those with 5 or
Results: The mean age of the patients was 80 and 68% were women.
Patients with 6 or more depressive symptoms had greater levels of comorbid illness,
functional impairment, and cognitive impairment at the time of admission than patients
with fewer depressive symptoms. Three year mortality was higher in patients with six or
more depressive symptoms (56% vs 40%, p<.001, hazard ratio= 1.56, 95% CI=1.22-2.00).
After adjustment for acute illness severity, comorbidity, functional impairment, and
cognitive impairment at the time of admission, patients with six or more depressive
symptoms continued to have a higher risk of death during the three years after admission
(hazard ratio=1.34, 1.03-1.73).
Conclusions: Depressive symptoms are associated with long-term
mortality in older patients hospitalized with medical illnesses. This association is not
fully explained by greater levels of comorbidity, functional impairment, and cognitive
impairment in patients with more depressive symptoms.
Impact: Screening for depressive symptoms will identify a group
of hospitalized elders at high risk for mortality. This study has important implications
for hospitalized Veterans given previous research demonstrating high rates of depressive
illnesses in Veterans hospitalized on medical services.
138. Conflicts in Values for Health Outcomes in
LA Lenert, MD, MS. VA San Diego Healthcare System, San
Diego, CA. J Ziegler, T Le, and R Mahmoud.
Objectives: Evaluate the potential for differences in values
among stakeholders groups to confound therapeutic decision making in schizophrenia.
Methods: A convenience sample of 148 Patients, 92 family
members, and 99 clinicians (nurses, psychologists, doctors of pharmacy and doctors of
medicine) drawn from geographically and clinically diverse environments were interviewed
to study their preferences. Participants viewed multimedia depictions of health states
with symptomatic schizophrenia with and without pseudo-parkinsonism (one of the most
common adverse effects of anti-psychotic drugs) and rated the desirability of life with
these conditions using standard gamble and visual analog scale methods. Assessments were
performed using a computer program that could detect and help correct many of subjects'
errors in preference measurements. Results were compared using analysis of variance
methods for multiple observations.
Results: Clinicians placed greater importance control of disease
symptoms than patients as shown by a greater difference in standard gamble utilities
(scaled 0 to 1.0) for states with mild and moderate symptoms (0.097 vs. 0.056,
p<0.001). Patients placed greater importance on the loss of in quality of life with
drug side-effects as shown by greater differences in utilities between states with an
without such symptoms (0.104 vs. 0.05, P0.016 and 0.07 vs. 0.032, p=0.014). Patients
preferred states with moderate symptoms from schizophrenia to states with mild symptoms
complicated by pseudo-parkinsonism; clinicians had the opposite preference (p<0.001).
Visual analog scale ratings supported findings seen with the standard gamble. Family
members had preferences that were intermediate between patients and clinicians. There are
systematic differences in values for health outcomes between patients and other
stakeholders that may underlay patient non-adherence with anti-psychotic drug regimens.
Impact: Schizophrenia is a high resource use area for the VA.
Results of this study illustrate the importance of directing therapy based on patients'
preferences and illustrate how patients and clinicians might work together to improve
adherence and patients' quality of life.
The World Wide Web-based technologies for preference measurement used
to collect data for this study potentially have broad applicability within the VA. These
tools could readily be adapted to conduct nationwide surveys of veterans' health
preferences for other medical domains for cost-effectiveness analysis and used as part of
systems that facilitate shared decision making by measurement of patients preferences.
139. Evaluating the Effectiveness of Telemedicine
for Enhancing Compliance in the Treatment of Schizophrenia
G Linn, PhD. Alvin C. York VA Medical Center,
Murfreesboro,TN. J St. Onge, R Harris-Turner, H Meltzer, R Prakash, and R Levine.
Objectives: The purpose of this study is to collect data on
compliance with atypical antipsychotic medications compared to typical antipsychotics and
conduct a randomized, comparison group (i.e. usual care) study to assess the clinical
effectiveness of a Telephone Medication Management (TMM) for veterans with Schizophrenia.
Methods: One hundred and forty patients with schizophrenia and
schizoaffective disorder were recruited at the Alvin C. York Medical Center over a
one-year period. Patients were randomized, in equal numbers, to either the TMM condition
or non-TMM condition. Research participants assigned to the TMM intervention met with a
nurse to discuss medication attitudes, develop strategies for taking medication on a
consistent basis post-discharge, and provide psychoeducation about side effects. A nurse
had telephone contact with the subject approximately once per week and conducted a brief
psychiatric and cognitive assessment, inquired about medication use, side effects, and
non-prescription substance use and provided psychoeducation about medication use. The
nurse initiated appropriate interventions (e.g., schedule appointment with a physician) to
combat increased symptoms and significant side effects, and to enhance treatment
compliance. Controls went through normal discharge procedures and received traditional
outpatient services. Cognitive and psychopathology measures, the Brief Psychiatric Rating
Scale (BPRS), as well as the Lehman Quality of Life Scale were administered to all
participants, Adherence to the medication regimen was assessed using self-report measures,
pill counts, and prescription refills. Side effects were examined using the Simpson-Angus
Rating Scale and the Abnormal Involuntary Movement Scale (AIMS). The Wisconsin Care Sort
was administered to assess the patient's problem solving and abstract reasoning skills and
the WAIS-III Subtest Letter Number Span was used to assess working memory capacity.
Research interviews were conducted at baseline (prior to randomization), 6-weeks,
6-months, and 12-months post-discharge. Pill counts were obtained at the time of the
interviews. Prescription refills and utilization data were obtained from research
participants' medical records at the end of the study. Regression, hierarchical linear
modeling, covariate analyses (e.g. ANCOVA, MANCOVA), and analysis of variance were used
for hypothesis testing.
Results: TMM was found to increase the effectiveness and
compliance of both typical and atypical antipsychotic drugs. Recall memory was observed to
be a predictor of non-compliance. Non-compliance was found to be inversely related to
efficacy and extra pyramidal symptoms. Compliance with atypical antipsychotic drugs was
better than that with typical neuroleptics due to enhanced cognitive abilities, increased
efficacy, and decreased side effects.
Conclusions: Telephone medication management is a valuable
intervention strategy for efficiently and effectively enhancing the effectiveness of
schizophrenia treatment in veterans.
Statements: The results from this study are being used to
improve the quality and cost-effectiveness of services offered to veterans with psychoses
at the Alvin C. York VA Medical Center and other medical centers in the network. We have
gained an understanding of the usefulness of telephone medication management for enhancing
clinical outcomes, quality of life, and compliance, and for decreasing hospitalization
140. Validity of a Alcohol Severity Measure in
Ambulatory Patients with Alcohol Disorders
Darcas Mansell, MD, MPH. Birmingham, AL. A Spiro III,
PhD, and A Lee, L Kazis, ScD. Bedford VA Medical Center, Bedford, MA.
Objectives: Existing measures of severity of alcohol disorders
were developed for use in alcohol treatment settings and are labor intensive to
administer. We describe the validation of a patient based assessment of alcohol severity
for patients seen in ambulatory care settings and describe the effect of the severity of
alcohol disorders on summary measures of health related quality of life.
Methods: The Veterans Health Study is a prospective study of
ambulatory patients in the greater Boston area; 286 (12%) of 2425patients were identified
as having an alcohol disorder (defined as answering "yes" to two or more CAGE
questions and having had a drink in the past year. Patients completed a self-report
measure of health related quality of life (SF-36) and a short form of the Diagnostic
Interview Survey (QDIS) for alcohol abuse and dependence. They were also administered a
measure of alcohol related severity (TyPEsm Specification) and a medical history
interview. From these latter two, three scales were developed to assess different aspects
of alcohol severity: Phys-Sum, a measure of medical complications of alcohol, Phys-With, a
measure of alcohol tolerance and withdrawal, and Behavior, a measure of behavioral
consequences of alcohol. Higher scores denote greater severity. T-tests were used to
compare mean scores on the three scales for those with and without alcohol
abuse/dependence, and ordinary least squares regression was used to examine the
association of the three scales with PCS and MCS from the SF-36. The PCS (physical
component scale) and MCS (mental component scale) are two summary scales expressed as
linear T score transformations with a mean of 50 and a standard deviation of 10 in a
normal population. Higher scores denote better function.
Results: 245(85%) completed the QDIS; of these 80.6% had alcohol
abuse or dependence. Patients with alcohol abuse/dependence had higher severity on all
three severity measures (p<0.001). Ordinary least squares regression revealed that age,
Phys-Sum, Phys-With and Behavior explained 14.1% of the variance in PCS and 15.7% of the
variance in MCS. After controlling for age, Phys-Sum was negatively associated with PCS
(p<0.0001) and Phy-Sum (p<0.001) and Behavior (p<0.05)were negatively associated
Conclusions: Medical consequences of alcohol are associated with
both poorer physical and mental health status, while behavioral consequences of alcohol
are associated with poorer mental health status. Although alcohol withdrawal was not
associated with health status, it may predict utilization of alcohol detoxification and
treatment services. Multidimensional patient based assessments of alcohol severity for
ambulatory care patients are associated with health related quality of life.
Impact: We expect that these relatively brief patient based
assessments for alcohol disorders, which are related to well validated measures of health
status, will predict use of health care services by ambulatory patients with alcohol
HSR&D Funded: SDR 91-006
141. Guideline-Concordant Antipsychotic Dose and
Outcomes of Routine Care for Schizophrenia
RR Owen, MD, EP Fischer, PhD, CRN Thrush, M Zhang, PhD, and JE
Kirchner, MD. North Little Rock VA Medical Center, North Little Rock, AR.
Objectives: The publication of clinical practice guidelines for
schizophrenia by VHA and other organizations provides an opportunity to develop measures
to assess guideline concordance and examine their relationship to patient outcomes. This
study examines the association between guideline-concordant antipsychotic doses and
symptom and functioning outcomes in a sample of patients who were receiving routine care
Methods: This study involves a secondary analysis of data
collected during a longitudinal outcomes study of routine care for patients with
schizophrenia. In this study, patients with a diagnosis of schizophrenia confirmed by
structured interview were enrolled during an acute psychiatric hospitalization. The Brief
Psychiatric Rating Scale (BPRS) and Short-Form 36 were administered at baseline and
six-month follow-up to assess symptom severity and functioning, respectively. Medical
records were abstracted to determine antipsychotic doses at discharge, which were
converted to chlorpromazine equivalent doses (CPZE) for comparison to the
guideline-recommended dose range, 300-1,000 CPZE. For all patients prescribed oral
antipsychotics (n=87), linear regression models were developed to test the association
between patient outcomes and two methods of classifying guideline on-concordant doses,
dichotomous (< or >= 300 CPZE) and trichotomous (below, within and above the
300-1000 CPZE range). Outcomes of interest included follow-up BPRS total score and SF-36
social functioning score. Analyses controlled for the baseline value for outcomes
measures, substance abuse, medication compliance, and the interaction between medication
compliance and dose level.
Results: The interaction between medication compliance and the
dichotomous dose range variable was significantly associated with both BPRS total score at
follow-up (F(1 df)=4.1, p<0.05) and follow-up SF-36 social functioning score (F(1
df)=3.89, p=0.05). Adjusted means for symptom severity were signifcantly higher for
noncompliant patients who were prescribed doses < 300 CPZE than for noncomplant
patients in the higher dose category (BPRS totals 45.5 versus 35.7, p<0.05). Similarly,
the low-dose, noncompliant group had significantly lower social functioning scores than
patients prescribed >= 300 CPZE (32.9 versus 56.0-62.1, p<0.05). In contrast, the
trichotomous guideline-concordant dose variable was significantly associated only with
follow-up symptom severity (F(1 df)=4.65, p<0.05). Patients prescribed
guideline-concordant doses of 300-1,000 CPZE had lower adjusted mean BPRS scores (36.2)
than patients prescribed >1,000 CPZE (45.1, p<0.01), and than patients prescribed
<300 CPZE (42.8, p<0.07).
Conclusions: The interpretation of our findings is limited by
potential differences in unmeasured patient characteristics that could affect patients'
response to treatment. Nevertheless, our study is among the first to find dose-outcome
relationships for patients with schizophrenia undergoing outine treatment. These findings
suggest that quality improvement programs could measure guideline-concordance of
antipsychotic doses and use this as an explicit criterion for the quality of medication
management for schizophrenia.
Impact: With the planned implementation of clinical practice
guidelines for schizophrenia in VHA, quality managers and administrators will need to
implement straightforward performance measures to monitor guideline implementation. This
research suggests that guideline-derived explicit criteria for antipsychotic dose are
related to patient outcomes. Because this measure can be readily extracted from
computerized pharmacy data, it can be widely used for quality improvement and for
monitoring clinical practice as part of the Quality Enhancement Research Initiative.
HSR&D Funded: IIR 95-020
142. Gender Differences in VA Disability Benefits
for PTSD after Controlling for Combat Exposure
Maureen Murdoch, MD, MPH. Minneapolis VA Medical Center,
Minneapolis, MN. L Fortier
Background: Although standardized protocols exist to
determine claimants' eligibility for Posttraumatic Stress Disorder (PTSD)-related
disability benefits, the granting of such benefits has historically varied across regions.
More recently, concerns have been raised that PTSD claims for men and women are processed
differently, perhaps because men and women cite different causative exposures. OBJECTIVES:
Examine gender and regional differences in PTSD claims approval rates after adjusting for
Methods: Historical cohort study using the Special Interest
Resources System (SIRS) database. SIRS contains data on all veterans who have filed a
claim for PTSD since 1980, the first year PTSD was recognized as a separately compensable
diagnosis. RESULTS: 191,701 men and 5,249 women have filed disability claims for PTSD
since 1980. Among male claimants, 67% served in the Army, 17% in the Marine Corps, 10% in
the Navy, and 5% in the Air Force. Of women, 55% served in the Army, 6% in the Marine
Corps, 20% in the Navy, and 17% in the Air Force. 19.6% of men and 2.4% of women reported
combat-related disabilities, and men were more likely than women to report either the loss
of an anatomical part (0.4% v. 0) or the loss of its use (0.5% v. 0.1%). Rating
specialists deemed 6% of men and 4% of women unemployable. Since 1980, 55% of male
veterans' claims for PTSD have been approved versus 43% of women's claims. Men's
combined degree of service connection is slightly higher, 46.6% v. 41.6% for women, which
translates into an additional annual benefit of $1,020 for men. Five percent of men and 2%
of women appealed denied claims, but men's appeals succeeded more often: 63% were
ultimately granted versus 42% of the women's. Men were older than women when they first
filed a claim (49.4 v. 37.1 years) and, from the date of military separation, waited
nearly twice as long to file (25.4 v. 11.1 years). Combat exposure was the
strongest predictor of an approved disabilityclaim (OR = 6.52) after adjusting for gender,
age, service branch, year and VISN in which claim was filed, employability, and either the
loss of an anatomical body part or the loss of its use. Unemployability was the second
strongest predictor (OR = 2.04). After adjustment, men were 1.15 times more likely than
women to be granted service connection for PTSD; regional differences in claims approval
rates were also confirmed. Across VISN's, the odds of claims approval ranged from 0.74 to
Conclusions: Small, but important, gender differences in PTSD
claims approval rates persisted after adjusting for combat exposure and other covariates.
Likewise, important regional differences remained, with the odds of claim approval varying
as much as 2-fold across particular VISN's.
Impact: A welfare loss may exist for women veterans who file
disability claims for PTSD and for veterans filing within specific VISN's. However, SIRS
data has limited clinical information, and unmeasured factors may explain the gender and
regional differences found here. Additional research using primary data collection is
required to confirm or deny our findings.
HSR&D Funded: GEN 97-002
143. Using Focus Group Methodology in the VA
Constance Captain, PhD and Donna Gladstone, Med, MSHP, RN.
South Texas Veterans Healthcare System, San Antonio, TX.
Abstract: "Prescription for Change" specifically
identified the use of focus groups to evaluate VHA's customer and stakeholder needs and
satisfaction with services. Study findings have helped VA better understand its customers,
their perceptions about healthcare and what was needed to further improve services.
However, there are special considerations when using focus groups to study customer
Objectives: This workshop will explore several of these issues
and present an overview of focus groups for those unfamiliar with this approach. Specific
objectives are to enable participants to understand: 1) the value and use of focus groups
to improve customer satisfaction, 2) key concepts of focus group methodology as a
qualitative research tool, 3) strategies and techniques for conducting effective focus
groups, and 5) how to analyze and use focus group data.
Target: Researchers interested in using focus groups to evaluate
customer satisfaction as well as, managers and clinicians who need to use the data from
focus groups to improve services. Participants with little to no experience with focus
groups will obtain overview-level knowledge.
Activities: The two presenters will share their experiences in
conducting focus groups with a variety of 'customer' groups to highlight the workshop
content; a 'lessons learned' format. Key concepts and techniques will be demonstrated and
144. Evaluating Health Care Organizational Change:
Benefits and Limitations of Hierarchical and Structural Equation Modeling
Martin Lee, PhD. Center for the Study
of Healthcare Provider Behavior, Sepulveda, CA.
Abstract: To review the strengths and limitations of statistical
approaches for controlling the effects of hierarchical relationships embedded in models
evaluating health care organizational change, including hierarchical (nested) analysis of
variance, multiple regression, non and semi-parametric corrections such as those suggested
by Huber, and other multivariate adjustment techniques, including structural equation
modeling. Activities: A multidisciplinary panel of methodologists (statistician,
epidemiologist, organizational theorist, and clinician-health services researcher) will
present the basic tenets of evaluating health care organizational change through
statistical models, followed by presentation of the approaches and basic issues faced by
users of each approach. Organizational case studies will be used to characterize
particular strengths and limitations based on previous and current studies evaluating the
effects of VA integrations and the economic and clinical performance of alternative VA
primary care delivery systems.
Target: Health services researchers interested in adding
hierarchical and structural equation modeling to their methodologic toolkits and those
generally interested in the issues involved in evaluating the effects of organizational
Familiarity: The workshop is designed for the broad health
services research audience, with low to moderate levels of statistical and modeling
understanding and familiarity needed.
145. VA National Guidelines, Strategies for
Implementation, Local Modifications, and Ways to Quantitatively Assess Guidelines Impact
Jacqueline A. Pugh, MD. Audie L. Murphy Memorial Veterans
Hospital, San Antonio, TX and Gayle E. Reiber, PhD, MPH. VA Puget Sound Healthcare
System, Seattle, WA.Ojective: To discuss VA national guidelines, strategies for
implementation, local modifications, and ways to quantitatively assess guideline impact.
Activities: Practice guidelines attempt to
summarize the available scientific data regarding diagnosis of treatment of a particular
medical disorder and to suggest a course of action for the provider. Evidence suggests
guidelines offer potential for improved quality of care, reduced practice variation,
improved outcomes and better cost containment at an organizational level. The VA has
supported development of national guidelines for many conditions that are prevalent among
veterans. This workshop will discuss strategies to target and reach users, recommendations
for adapting guidelines to local facilities, and focus on strategies in three areas that
are important in guideline implementation:
1) Strategies for individual providers
2) Strategies for individual patients
3) Strategies for organizational changes
Limitations of guidelines will also be discussed, including
appropriateness, infrastructure and fiscal realities, and ceiling and floor effects. Existing VA guidelines will be used as examples.
Target: Clinicians and health services
researchers interested in guidelines and quality of care initiatives.