Health Services Research & Development

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Improving Healthcare for Aging Veterans

In 2016 the number of people age 65 and older in the United States was over 48 million. This group accounted for approximately 15% of the total population1 and is estimated to double in the next 25 years, accounting for roughly 20% of the U.S. population.2 According to the 2012 U.S Census, more than 12.4 million of those 65 and older were Veterans.3 That number is estimated to be over 19 million in 2017.4 Thus, people 65 and older are a large and growing percentage of Americans, and Veterans represent a fair fraction – one quarter or more – of that population.

According to the National Council on Aging, “Approximately 92% of older adults have at least one chronic disease, and 77% have at least two.”5 Chronic health issues affecting elderly Veterans, such as heart disease, arthritis, dementia, and cancer, require considerable and varied clinical care, with the goals of improving functionality and quality of life, and preventing secondary conditions.6 Following is a cross-section of VA HSR&D research on issues affecting aging Veterans aiming to meet those goals, and which, with few limitations, can be generalized to apply to the larger population of aging Americans.



GRACE Decreases VA Healthcare Utilization

Older Veterans using VA healthcare have higher rates of functional and cognitive impairment, and higher rates of multi-morbidity than non-Veterans of the same age. Geriatric Resources for Assessment and Care of Elders (GRACE) uses the patient-centered medical home model in collaboration with primary care to provide home-based care that focuses on geriatric and psychological issues commonly affecting older adults. This HSR&D clinical trial compared Veterans aged 65 and older (n=179) who had primary care providers (PCPs) and who were enrolled in GRACE following discharge to home, with Veterans who were not GRACE-enrolled post-hospitalization (n=77). During the study period, the GRACE team performed 227 in-home post-hospitalization transition visits, 210 in-home comprehensive geriatric assessment visits, and 347 face-to-face follow-up visits. The hospitalization period for both groups occurred between April 1, 2010 and July 31, 2011.

Using VA data, investigators examined patient demographics, multi-morbidity, and acute care utilization in the one year prior to and following the index hospitalization. In addition to these outcomes, study investigators noted lessons learned during program implementation. Findings were:

  • Enrollment in GRACE was associated with a 7% reduction in emergency department visits, 15% fewer 30-day readmissions, a 38% reduction in hospital admissions, and 29% decreased total bed days of care.
  • The 179 Veterans enrolled in GRACE avoided 15 hospital admissions and 53 readmissions in the year after program enrollment. In the first year, this saved VA more than $200,000 over and above GRACE program costs.
  • Factors that contributed to the success of GRACE included: 1) early engagement of invested, supportive leadership who were provided with regular updates on the program’s progress and positive impact; 2) recruitment of energetic GRACE team staff with experience in geriatrics and interdisciplinary team care; and 3) the natural alignment of the concepts behind GRACE and VA’s Patient-Aligned Care Team (PACT).

Implications: GRACE, an evidence-based model of geriatric care management, is associated with reduced acute care utilization in high-risk older Veterans and has the potential to contribute to overall cost savings in the care of this population.

Schubert CC, Myers LJ, Allen K, Counsell SR. Implementing Geriatric Resources for Assessment and Care of Elders Team Care in a Veterans Affairs Medical Center: Lessons Learned and Effects Observed. Journal of the American Geriatrics Society. 2016 Jul 1; 64(7):1503-9.

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Initiative Decreases Inappropriate Prescribing to Older Veterans in the Emergency  Department

Older adults are particularly susceptible to suboptimal pharmacotherapy,7. Recent guidelines for emergency geriatric care cite improving prescribing quality as a goal to provide high-quality emergency department (ED) care for this population. Within the VA healthcare system, Veterans aged 65 and older represent approximately 40% of all ED visits. This study evaluated the effectiveness and sustainability of the Enhancing Quality of Provider Practices for Older Adults in the ED (EQUiPPED) program, a quality improvement initiative that combines provider education, clinical decision support, and provider feedback to reduce the prescription of potentially inappropriate medications (PIMs).

Investigators implemented this initiative in four urban, academically-affiliated VAMCs with a 24-hour emergency department. The primary outcome was the monthly proportion of PIMs prescribed to Veterans 65 years and older and discharged from the ED. PIMs were defined by the 2012 American Geriatrics Society Updated Beers Criteria medications to avoid in all older adults. The proportion of PIMs was tracked at all four sites for at least six months prior to implementation throughout the intervention, and for at least 12 months after all EQUiPPED components were completed. Results were:

  • EQUiPPED was associated with a sustained reduction in inappropriate medication prescribing at all four VAMCs. Post-intervention, the proportion of PIMs decreased from 12% to 5%, 8% to 5%, 9% to 6%, and 7% to 6% at sites 1-4, respectively.
  • The implementation timeline for the initiative ranged from 6 to 14 months depending on the site. While the implementation timelines varied across sites, all VAMCs achieved a monthly PIM proportion between 5% and 6%.

Implications: The EQUiPPED intervention led to safer prescribing and was sustainable across multiple VA sites. Implementation is currently underway at six additional VA emergency department sites, as well as three non-VA ED sites to evaluate broader dissemination.

Stevens M, Hastings SN, Markland AD, et. al. Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED). Journal of the American Geriatrics Society. 2017 Jul 1; 65(7):1609-1614.

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Frailty Screening Initiative Associated with Improved Post-Operative Survival among Veterans

For the many patients older than 65 who undergo surgery, frailty may be a more powerful predictor of increased perioperative mortality, morbidity, and cost, than age or comorbidity alone. The Nebraska-Western Iowa (NWI) VAMC Surgical Service Line performs approximately 2,800 operations annually on patients in this age range: an average of 42% of all surgeries. In 2011 NWI’s Chief of Surgery designed and implemented a Frailty Screening Initiative (FSI) aimed at improving post-operative survival. The FSI consists of two parts: 1) screening for frailty with the goal of rapid assessment without the need for access to a patient’s chart, and 2) review of surgical decision-making. This study assessed the impact of the FSI on mortality and complications by comparing surgical outcomes before and after implementation of the FSI. Study participants included all Veterans presenting for major, elective, non-cardiac surgery at the NWI VAMC between October 1, 2007 and July 1, 2014 (n=9,153). The main outcome measure was post-operative mortality at 30, 180, and 365 days. Results show:

  • Implementing frailty screening was associated with reduced mortality, suggesting both the feasibility of widespread screening of patients pre-operatively to identify frailty – and the efficacy of system-level initiatives aimed at improving their surgical outcomes. After controlling for age, frailty, and predicted mortality, findings showed that the FSI resulted in a three-fold survival benefit in this study cohort.
  • Overall 30-day mortality decreased from 1.6% to 0.7%, but was greatest among frail patients at 12.2% pre-intervention vs 3.8% once the screening began. Moreover, the magnitude of improvement among frail patients increased at 180 (24% to 8%) and 365 days (35% to 12%).

Based on these findings, similar FSIs have been implemented using the Risk Analysis Index (RAI) at the Pittsburgh and Atlanta VAMCs, and at a large, private, academic multi-hospital healthcare system. The RAI has been recently recalibrated within a large sample of Veteran surgical patients with improved model performance externally validated in Veteran and non-Veteran populations.  In addition, two VA pilot studies are underway to assess the feasibility of intensive “prehabilitation” regimens aimed at improving physiological reserve of frail Veterans before surgery.

Implications: Frailty screening of preoperative patients is feasible, and may be an effective and scalable tool for improving surgical outcomes for aging and increasingly frail U.S. and Veteran populations.

Hall, DE, Arya, S., Schmid, KK, et al. (2017). Association of a frailty screening initiative with postoperative survival at 30, 180, and 365 days. JAMA Surgery. 2017 March 1; 152(3):233-240.

Hall, DE, Arya, S., Schmid, KK, et al. (2016). Development and initial validation of the risk analysis index for measuring frailty in surgical populations. JAMA Surgery. 2016 July 21; 152(2):175–182.

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VA End-of-Life Initiative Increases Veterans’ Use of Hospice

In 2009 VA implemented the Comprehensive End of Life Care (CELC) initiative, augmenting a system-wide palliative care and hospice program aimed at improving end-of-life care for Veterans. CELC increases palliative care training, quality monitoring, and community outreach while simultaneously increasing palliative care staff and VAMC inpatient hospice care units. This study sought to determine if the increased investment in palliative care led to greater use of hospice services for older male Veterans. Through VA and Medicare data, researchers identified male Veterans enrolled in Medicare and a control group of non-Veteran Medicare beneficiaries who died either in the years prior to (FY2007 to FY2008) or following (FY2010 to FY2014) implementation of the CELC initiative. After adjusting for variables such as age, race, ethnicity, and rural vs urban residence, findings were:

  • Older male Veterans who were exposed to CELC showed increased use of hospice over non-Veteran Medicare recipients, especially those who had last-year-of-life stays in VA hospitals, where significant CELC investment had occurred.
  • Veterans with a last-year-of-life stay in CELC-equipped VA hospitals, but who were not enrolled in Medicare had a 50% increase in hospice use compared to a 16% increase in non-Veterans enrolled in Medicare with a hospital stay in the last year of life.
  • Although rates of hospice use increased for all groups in the years after CELC implementation, enrolled Veteran decedents showed an unadjusted increase of hospice use more than double that of non-Veteran Medicare enrolled decedents.

Implications: While these findings show an increase in hospice usage among Veterans who choose VA care, the most impactful challenge is the need to maintain momentum and funding for hospice related implementation, given competing priorities such as Veterans Choice.

Miller SC, Intrator O, Scott W, et al (2017). Increasing Veterans’ Hospice Use: The Veterans Health Administration’s Focus on Improving End-of-Life Care. Health Affairs. 2017 July1; 36(7):1274-1282.

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Improved Outcomes for Veterans with Knee or Hip Osteoarthritis through Positive Psychological Intervention

Many older Veterans live with knee and hip osteoarthritis (OA) – the most prevalent and significantly disabling form of arthritis, for which there is no cure. Many current treatments for OA do not improve functioning and can include addictive opioids or other drugs with substantially negative side effects. Evidence suggests that targeting psychosocial wellness reduces pain and produces better physical functioning. Focusing on underexplored psychosocial treatments, VA HSR&D researchers developed an intervention to build positive psychological skills that were expected to lead to improved symptom severity.

In the first test of this intervention, VA patients (n=42) with knee or hip OA (50 years and older) were randomized into one of two groups that received six weeks of either positive skill-building or neutral control activities, with six-month follow-up. Examples of positive skill-building included Veterans writing down three good things that had happened to them each day, doing five acts of kindness in a single day, and writing a letter of gratitude to someone who has made a positive impact on their lives. Instructions were provided with consideration for reading levels, and follow-up telephone calls were conducted once a week for the six-week duration of the study. Study findings show:

  • Patients in the positive (vs. neutral) program reported significantly more improvement over time in osteoarthritis symptom severity, negative affect, and life satisfaction.
  • The activities were rated as highly beneficial, highly enjoyable, and easy to perform.

Implications: These considerable and lasting benefits for pain and psychological distress indicate that non-pharmacological therapy can have a major impact on moderate to severe pain symptoms and accompanying psychosocial outcomes in Veterans with knee and hip OA. In addition, VA is supporting a larger study of this intervention at multiple VA medical centers. Results are expected to be released early in 2018.

Hausmann LR, Youk AO, Kwoh CK, et al. Testing a Positive Psychological Intervention for Osteoarthritis. Pain Medicine. 2017 Jun 27; e-pub ahead of print.

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Computerized Cognitive Training for Elderly Diabetic Veterans

Older adults who have diabetes mellitus are at increased risk for cognitive decline and dementia compared to those without diabetes.  Cognitive impairment is associated with difficulty in diabetes self-management, including glycemic and blood pressure control, which can worsen cognition, creating a cycle of increasing severity in both diabetes and cognitive impairment. This ongoing HSR&D study is providing the first evaluation of the effects of a computerized cognitive training (CCT) on diabetes self-management behaviors, clinical outcomes, and cognition. 

Veterans aged 55 years and older (target n=200) with diabetes – without cognitive or major visual or auditory impairment – are recruited and randomized to receive either CCT intervention or play computer games only. Subjects are assessed at baseline, the completion of the eight weeks of training, six months and one year after the intervention. Outcomes assessed include diabetes self-management behaviors, cognition, blood pressure, and hemoglobin A1c. Investigators also will explore the impact of patient demographics and health characteristics on outcomes. Data analysis will begin in 2018.

Implications: Study results are expected to provide a basis for the use of CCT to reduce cognitive impairment among older adults with diabetes and improve disease self-management. Given that more than 25% of US adults aged 65 years and older have diabetes, and that type 2 diabetes is associated with approximately a 1.5- to 2.5-fold increase in the risk of dementia – in addition to the high incidence of both diabetes and dementia in the growing population of elderly Veterans – the results of this study will likely have large impact.

Computerized Cognitive Training to Improve Cognition in Diabetic Elderly Veterans
Jeremy Silverman, PhD. /research/abstracts.cfm?Project_ID=2141702011

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References

  1. United States Census Bureau. Annual Estimates of the Resident Population for Selected Age Groups by Sex for the United States, States, Counties, and Puerto Rico Commonwealth and Municipios: April 1, 2010 to July 1, 2015. June 2016. Available at: https://www.census.gov/newsroom/facts-for-features/2017/cb17-ff08.html. Accessed August 9, 2017.
  2. Centers for Disease Control. The State of Aging & Health in America 2013. Available at: https://www.cdc.gov/aging/pdf/State-Aging-Health-in-America-2013.pdf. Accessed August 9, 2017.
  3. S. Department of Veterans Affairs, Veterans Benefits Administration. Elderly Veterans. n.d. Available at: http://www.benefits.va.gov/persona/veteran-elderly.asp. Accessed August 9, 2017.
  4. S. Department of Veterans Affairs. Veteran Population Projections 2017-2037. August 4, 2017. Available at: https://www.va.gov/vetdata/docs/Demographics/New_Vetpop_Model/Vetpop_Infographic_Final26.pdf. Accessed August 9, 2017.
  5. National Council on Aging. Healthy Aging Facts. January 2017. Available at: https://www.ncoa.org/news/resources-for-reporters/get-the-facts/healthy-aging-facts/. Accessed August 9, 2017.
  6. Nasmith L, Kupka S, Ballem P, Creede C. Achieving care goals for people with chronic health conditionsCanadian Family Physician. 2013;59(1):11-13.
  7. Hastings SN, Schmader KE, Sloane RJ et al. Quality of pharmacotherapy and outcomes for older Veterans discharged from the emergency department. J Am Geriatr Soc2008;56:875–880.