Health Services Research & Development

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Cardiovascular Disease Research

February 2017

February is American Heart Month. While rates of cardiovascular disease (CVD) have declined over the past 40 years 1, it remains the leading cause of death among Veterans enrolled in VA care. Approximately 80% of Veterans have more than two risk factors for CVD, and certain groups (including women Veterans and racial minorities) are at increased risk for CVD. The American Heart Association defines CVD as conditions that arise from problems of blood flow to the heart muscle, many of which are related to a process called atherosclerosis. Atherosclerosis is a condition that develops when a substance called plaque builds up in the walls of the arteries. This buildup narrows the arteries, making it harder for blood to flow through. If a blood clot forms, it can stop the blood flow, leading to heart attack or stroke.

Studies funded by VA's Health Services Research & Development Service (HSR&D) address many aspects of care for Veterans with CVD, including: gender difference and cardiovascular disease risk; remote support via telemedicine for rural Veterans managing CVD risk factors; and the impact of cardiovascular disease on VA operating costs. The following studies represent just a few of the completed and ongoing HSR&D-funded investigations into CVD.

EMPOWER QUERI: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans

VA's Quality Enhancement Research Initiative (QUERI) focuses on improving the health and care of Veterans by supporting the application of critical evidence into practice. As a part of QUERI's National Program Network, the Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) Program is designed to improve women Veterans' engagement and retention in evidence-based care for three high-priority health conditions: diabetes, cardiovascular health, and depression and anxiety.

The implementation phase of the EMPOWER project, "Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans," will begin in April 2017 in two of VA's Women's Health Practice-Based Research Network sites. Study aims include:

  • Increasing identification of cardiovascular (CV) risk among women Veterans;
  • Enhancing patient/provider communication and shared decision-making about CV risk; and
  • Providing a supportive, coordinated health coaching intervention to facilitate women Veterans' engagement and retention in appropriate health services.

Overall, the CV toolkit components encourage Veterans to become more active participants in their health care by improving communication and interactions between healthcare providers and Veterans - and by giving women choices as to how to achieve their health goals. Nationally, CV risks are pervasive with persistent differences by gender; eliminating these disparities and reducing overall risks is a priority for VA.

EMPOWER QUERI Principal Investigators: Alison Hamilton, PhD, Bevanne Bean-Mayberry, MD, and Tannaz Moin, MD, also are core investigators with the HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy at the Greater Los Angeles VA Healthcare System in Los Angeles, CA.

Cardiovascular Intervention Improvement Telemedicine Study

More than 80% of Veterans have more than two risk factors for cardiovascular disease (CVD), and certain groups (including women Veterans and racial minorities) are at greatest risk for poor CVD control. In this study, investigators looked at several behaviors related to CVD and medication management to determine if a telephone-based, pharmacist-led intervention would improve CVD outcomes.

Working within the Raleigh, NC, Community-Based Outpatient Clinic and the Durham, NC, VA Medical Center's primary care clinic, investigators enrolled 428 participants and randomized 213 to usual care and 215 to pharmacist intervention. Goals for the intervention included reducing CVD risk among vulnerable, high-risk Veterans (e.g., African Americans, low literacy) by addressing three modifiable risk factors: systolic blood pressure (SBP), smoking, and low-density lipoprotein cholesterol (LDL-C). The intervention was tailored to the needs of patients and delivered by a pharmacist familiar with the clinics, thereby enhancing the potential for benefit and generalizability to other settings. The pharmacist intervention calls were delivered to all intervention patients on a monthly basis. Patients randomized to the control group received educational material about CVD reduction at baseline and at 6-month follow-up.

Of the 352 participants who completed the 12-month follow-up, those in the intervention group showed a marginal, but not statistically significant improvement in CVD risk at 6 and 12 months, compared to those in the usual care group. In addition, patients in the pharmacist intervention did not show improvement in SBP at 12 months relative to usual care. Among patients in the intervention group, only 34% received at least 5 of the 12 planned intervention calls and were considered "compliers."

Implications: Given the national prevalence of CVD among Veterans, the ongoing need to improve Veterans' access to care, and the overall low rates of CVD risk factor control, implementing intensive, but easily disseminated telemedicine interventions may help improve CVD care within VA. Investigators emphasize that matching the intervention to individuals with particular CVD risks is essential in order to ensure adequate use of limited resources and improve outcomes.

Principal Investigator: Hayden Bosworth PhD, is Associate Director of the HSR&D Center for Health Services Research in Primary Care, located at the Durham VA Medical Center, in Durham, NC.

Zullig L, Stechuchak K, Goldstein K, et al. Patient-reported medication adherence barriers among patients with cardiovascular risk factors. Journal of Managed Care & Specialty Pharmacy. June 1, 2015; 21(6):479-85. [Fix all citations to be consistent with the format we use.]

Zullig LL, Melnyk SD, Stechuchak KM, McCant F, Danus S, Oddone E, Bastian L, Olsen M, Edelman D, Rakley S, Morey M, Bosworth HB. The Cardiovascular Intervention Improvement Telemedicine Study (CITIES). Telemedicine Journal and e-health. 2014 Feb 1; 20(2):135-43.

Costs and Outcomes of Chronic Heart Disease Care in VHA

Cardiovascular disease is the leading cause of death among Veterans enrolled in VA healthcare, and care for patients with chronic cardiovascular diseases represents a substantial component of VHA's total operating costs. Over the past 25 years, technology to prevent, diagnose, and treat cardiovascular disease (i.e., drugs, devices, imaging, and procedures) has contributed to marked declines in cardiovascular mortality. However, while lowering morbidity and mortality, these new technologies have also contributed to increased healthcare costs.

In this ongoing, three-year study, investigators are using a mixed-methods approach to compare the outcomes and costs of care for two widely prevalent and high-cost cardiovascular conditions—ischemic heart disease (IHD) and chronic heart failure (CHF)—across 140 VA medical centers (VAMCs). Investigators hope to identify, from an operational and programmatic perspective, the root causes that produced the highest value cardiovascular care in the VA healthcare system.

Investigators will identify the VAMCs that consistently produced excellent risk-adjusted health outcomes for Veterans with IHD and CHF from FY2010 to FY2014, and will quantify the costs of care associated with producing these outcomes. Investigators will also identify and quantify the structural aspects of CHF/IHD care at these VAMCs that are most conducive to optimal outcomes and economic efficiency. A particular focus will be on the influence of the local frequency of several high-cost components of care, including: cardiovascular imaging, implantable device utilization, off-station major cardiovascular care, and non-elective hospitalizations.

The study consists of two phases: 1) A retrospective cohort analysis of existing VA national healthcare data to assess healthcare costs and outcomes among Veterans with IHD and CHF; and 2) a prospective series of targeted interviews with administrators and clinicians at VAMCs identified in the first phase as the highest and lowest performing hospitals in terms of cardiovascular healthcare value.

Implications: By identifying the key factors that characterize the nation's top-performing VAMCs in the area of high-value IHD and CHF care, results should provide a critical blueprint to VA clinical and operations leaders seeking to improve cardiovascular care throughout the VA healthcare system. A long-term goal is the inclusion of both clinical outcomes and costs as routine measurements in quality-of-care comparisons across VAMCs, enabling VA policymakers and clinical leaders to make measureable progress toward higher value healthcare.

Principal Investigator: Peter Groeneveld, MD, MS is part of the HSR&D Center for Health Equity Research and Promotion, located at the Pittsburgh, PA and Philadelphia, PA VA medical centers.

Kini V, McCarthy FH, Dayoub E, Bradley SM, Masoudi FA, Ho PM, Groeneveld PW. Cardiac Stress Test Trends Among US Patients Younger Than 65 Years, 2005-2012. JAMA Cardiology. 2016 Dec 1; 1(9):1038-1042.

Blewer AL, Putt ME, Becker LB, Riegel BJ, Li J, Leary M, Shea JA, Kirkpatrick JN, Berg RA, Nadkarni VM, Groeneveld PW, Abella BS, CHIP Study Group. Video-Only Cardiopulmonary Resuscitation Education for High-Risk Families Before Hospital Discharge: A Multicenter Pragmatic Trial. Circulation: Cardiovascular Quality and Outcomes. 2016 Oct 4.

REcovery after in hoSpital Cardiac arrest: late outcomes and Utilization_ResCU

In-hospital cardiac arrest (IHCA) is common and associated with considerable mortality, morbidity, and resource costs. Inpatient survival after IHCA has improved nationally over the last decade, although similar statistics within the VA healthcare system are not available. However, few contemporary data exist—either nationally or in VA—on the long-term survival, care requirements, and health status of patients with IHCA. This study, which concludes in July 2017, seeks to understand patterns of long-term outcomes and care requirements after IHCA, and to translate those insights into quality improvement both within VA and elsewhere.

Study investigators are looking at approximately 18,000 IHCA hospital admissions from 2005-2015, and are using comprehensive data sources from both within and outside VA to more fully characterize the experience of more than 4,500 IHCA survivors. Investigators are also examining a subset of approximately 369 patients to prospectively assess long-term health status after discharge.

Based on preliminary data analyses of a cohort of 50 Veterans who were hospitalized at one VA medical center between September 1, 2013 and October 31, 2013, investigators found that IHCA survivors' self-reported assessment of their health was poor, with 8% and 44% describing their health as "poor" or fair," respectively, but only 6% saying "very good" and none reporting "excellent." Similarly, 27% reported having four or more health-related difficulties in their basic and instrumental activities of daily living, 27% reported 1-3, and 46% none. Scores from the PHQ-9 (a standardized questionnaire designed to screen for depression) were consistent with major depression and were reported by 22% of the IHCA survivors. Of those tested for cognitive impairment, 31% were at risk for at least some cognitive impairment and 10% were found to be impaired.

Implications: Poor self-reported health, as well as disability, cognitive impairment, and depression are common among survivors of IHCA. Investigators expect that when complete, data from this study may be used to develop interventions designed to improve Veterans' long-term health outcomes following IHCA.

Principal Investigators: Jack Iwashyna MD and Brahmajee Nallamothu MD, are investigators with the HSR&D Center for Clinical Management Research at the VA Ann Arbor Healthcare System in Ann Arbor, MI.

Goldberger ZD, Nallamothu BK, Nichol G, Chan PS, Curtis JR, Cooke CR, American Heart Association's Get With the Guidelines-Resuscitation Investigators. Policies allowing family presence during resuscitation and patterns of care during in-hospital cardiac arrest. Circulation: Cardiovascular Quality and Outcomes. 2015 May 1; 8(3):226-34.


1. Casper M, Kramer M, Quick H, et al. Changes in the geographic patterns of heart disease mortality in the United States. Circulation. 2016;133:1171-1180