There are approximately 20,000,000 1 men and women Veterans of the United States armed forces. These individuals come from all walks of life and span an age range from 18 to over 90; yet almost 90% of our nation’s Veterans are men over the age of 65. According to the CDC’s National Center for Health Statistics, men are more likely than women to die as a result of cancer, stroke, and chronic obstructive pulmonary disease. Since VA healthcare benefits are utilized by almost 75% of Veterans 2, a significant proportion of VA care addresses the health concerns of aging male Veterans.
Within VA, a number of focused programs address both research into, and clinical supports for, this group of Veterans. The VA’s Geriatrics Research Education and Clinical Center (GRECC) focuses on building new knowledge through research; improving health care through the development of new clinical programs; and ensuring that VA staff are educated about aging-related issues. The GRECCs are located at 20 medical centers across the country, and each is connected with a major research university.
In addition to the GRECCs, VA’s Health Services Research & Development Service’s, (VA HSR&D) Centers of Innovation look at other aspects of care for aging male Veterans, including quality of, access to, and delivery of care. The VA HSR&D Center for Long-term Services and Supports for Vulnerable Veterans focuses on research that enhances the implementation of programs that support the GRECC’s mission and maximize Veterans’ social participation and quality of life in the least restrictive setting possible. In addition, the VA’s Quality Enhancement Research Initiative GeriPACT National Program is assessing how the VA’s Geriatric Patient Aligned Care Team model is impacting the health outcomes of older Veterans.
In this month’s spotlight, VA HSR&D-funded research into the concerns of aging male Veterans is highlighted.
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Within the VA healthcare system, policy, research, and clinical operations have worked together to create highly successful protocols to improve blood pressure (BP) control. VA’s efforts have exceeded performance on existing BP measures by 79% versus only 62% in Medicare. Within the aging Veteran population, a substantial proportion of those using VA care stand to benefit from good BP control; however, older individuals are also at risk from falls due to a range of conditions from medication interaction to multiple chronic health issues. One of the challenges with tight control of BP targets is that it can result in inadvertently low blood pressure—something that can contribute to falling or fainting. In this ongoing HSR&D study, investigators are using VA databases to determine the presence of aggressive hypertension control (AHC) and its relationship to fall injury in primary care patients over age 65.
Using data from VA administrative records, investigators are working to determine the presence of AHC in primary care patients > 65 that were diagnosed with hypertension between July 2011 and June 2013. Investigators will then merge that information with Medicare records to explore whether AHC is linked with increased risk of severe falls and injury, and, if so, whether the risks exceed the cardiovascular benefits (i.e., lower risk of acute strokes and myocardial infarction). Variation in AHC across VA facilities will be examined. Finally, investigators will develop a performance measure to support appropriate hypertension care and assess barriers to implementation in VA.
Data are still being compiled. Investigators also expanded their initial assessment to include a larger, more complex subsample of patients—those with two or more consecutive encounters with AHC from a random sample of 70K patients. In addition, AHC is being calculated at the facility level to determine the proportion of variation arising from the facility. With regard to barriers to implementation, early qualitative information from the second of two leadership panels indicate that physicians find the new American College of Cardiology/American Heart Association guidelines to be less helpful than they hoped due to the number of decision points—and how difficult it is to get an accurate blood pressure reading. All endorse changes in infrastructure and process that would better mirror the measurement method used in the Systolic Blood Pressure Intervention Trial (SPRINT) guidelines. Panel members also want to assess several facility-level variables, including the mean age of primary care providers; the proportion of primary care patients needing hypertension care; the proportion of patients getting care outside VA; what a facility's performance is on non-hypertension measures; and how rural the facility setting is.
Implications. This research integrates fall prevention and hypertension via the use of individual patient data to inform decisions about net benefit (or harm) of various treatment strategies. Findings from this project will inform future performance measures and decision support tools to help minimize both cardiovascular risk and fall injury, and appropriately individualize care for older adults with hypertension.
Principal Investigator: Lillian Chiang Min MD MSHS, is an investigator with the HSR&D Center for Clinical Management Research in Ann Arbor, MI
Publications: This study has no associated publications.
Obstructive sleep apnea (OSA) is a condition in which the upper airway becomes blocked repeatedly during sleep, reducing or completely stopping airflow. OSA is a key cause of daytime sleepiness for millions of Americans, and is also associated with an increased risk for hypertension, cardiovascular disease, stroke, and diminished quality of life due to poor quality sleep. A number of studies have shown that OSA is more common in men 1, 2 than in women. Further, incidence of OSA has been shown to increase with age, including among women.
Among male Veterans, it’s estimated that sleep apnea is on the rise, increasing from 4% in 2005 to 8% in 2014. 3 Typically, treatment of OSA requires the use of a device called a positive airway pressure (PAP)4 machine, which helps the airway stay open during sleep; however, some people find PAP devices to be disruptive, uncomfortable, or cumbersome. For Veterans who have OSA and insomnia, PAP devices may pose an additional challenge to achieving quality sleep. In this recently completed study, VA HSR&D investigators looked at a new way to improve PAP device use for Veterans with both OSA and insomnia.
Recent evidence suggests that insomnia often coexists with OSA and predicts worse outcomes of OSA. Insufficient evidence-based data exist to support the best approaches to manage Veterans with both OSA and insomnia. Current treatment guidelines address each condition separately: positive airway pressure (PAP) therapy for the treatment of OSA, and cognitive behavioral therapy for insomnia (CBT-I) for the treatment of chronic insomnia. One of the best predictors of long-term benefit for PAP therapy is early adherence to treatment; however, Veterans’ adherence rates are very low, and coexisting insomnia predicts even lower adherence to PAP therapy. Further, for many patients, insomnia symptoms are not addressed at all—or are only considered once it’s determined that patients are not using PAP therapy long-term. Given this evidence, investigators developed a novel, integrated, behavioral treatment approach that addresses both OSA and insomnia early in the course of PAP therapy among Veterans.
Investigators conducted a randomized controlled trial among Veterans (age >50 years) referred to the VA Greater Los Angeles Healthcare System sleep clinics for assessment of possible OSA. Participants were assigned to either the intervention (an active treatment group that combined manual-based CBT-I plus a behavioral PAP adherence program delivered by a trained sleep coach) – or to the control group, in which Veterans received manual-based general sleep education from a coach not trained in the intervention.
Follow-up assessments were conducted at post-treatment, and at 3-months and 6-months after randomization. Study results showed that integrating behavioral therapy for insomnia with a PAP adherence program improved both insomnia symptoms and adherence to PAP therapy for Veterans with coexisting moderate to severe OSA and insomnia. Findings indicated that Veterans in the intervention group had greater improvement than Veterans in the control group, between baseline and 3-months, and between baseline and 6-months in areas ranging from time of sleep onset, sleep efficiency, and wakefulness after sleep onset. For PAP adherence, intervention participants used the device more than those in the control group. [Assuming the PI didn’t include stats?]
Three focus groups were also conducted with a total of 17 active treatment participants. Overall, these Veterans reported that they had benefited from the education and support they received with the program. Suggestions for dissemination included conducting the program in groups, and incorporating interactions with experienced PAP users as a means to provide further encouragement and education.
Implications. As improved sleep diminishes an array of risk factors for both chronic and acute conditions, and improves quality of life, this treatment could have considerable positive impact on older Veterans in VA who may be impacted by OSA as they age. Investigators suggest that this therapy be considered for patients who present with coexisting OSA and insomnia and urge wider implementation.
Principal Investigator: Cathy Alessi, MD, is a core investigator with the Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) at the VA Greater Los Angeles.
Alessi C, Martin JL, Fung CH, et al. Randomized controlled trial of behavioral treatment for coexisting insomnia and obstructive sleep apnea: Results in middle-aged versus older veterans. J Amer Geriatr Soc. 2018. 66:S128
Alessi C, Martin JL, Fung CH, et al. Randomized controlled trial of an integrated behavioral treatment in veterans with obstructive sleep apnea and coexisting insomnia. SLEEP. 2018. 41:A155
1 Coleman RM, Miles LE, Guilleminault CC et al. Sleep-wake disorders in the elderly: polysomnographic analysis. J Am Geriatr Soc. July 1981 29(7):289-96.
2 Lin CM, Davidson TM, Ancoli-Israel S. Gender Differences in Obstructive Sleep Apnea and Treatment Implications. Sleep medicine reviews. November 2008;12(6):481-496.
3 Jackson M, Becerra BJ, Marmolejo C, Avina RM, Henley N, Becerra MB. Prevalence and Correlates of Sleep Apnea Among US Male Veterans, 2005–2014. Preventing Chronic Disease. June 2017;14:E47.
4 National Heart, Lung, and Blood Institute Sleep Apnea Fact Sheet. https://www.nhlbi.nih.gov/health-topics/sleep-apnea
The VA healthcare system provides care for nearly 150,000 prostate cancer survivors. Research has shown that a substantial proportion of prostate cancer survivors in the general public have significant, long-term post-treatment symptoms, including incontinence, erectile dysfunction, and metabolic syndrome. Initial research conducted within VA suggests that Veteran prostate cancer survivors experience side effects that are similar to, or worse than, those occurring in the general population. Many of these symptoms can be effectively self-managed, yet there is currently no VA program for assessing ongoing symptom burden in survivors and directing them to receive appropriate primary or specialty care.
In this recently concluded four-year, randomized controlled trial (RCT), investigators sought to address the need for improved, patient-centered, prostate cancer survivorship care management for Veterans.
Investigators enrolled 556 long-term prostate cancer survivors with post-treatment symptoms (urinary, bowel, or sexual health challenges) from four VA sites and followed them from April 2015 to February 2017. Participants were between 1 and 10 years post-treatment, and were randomly assigned to either the intervention (four automated telephone assessments and monthly self-management education) or to usual care (one general newsletter about prostate cancer symptom management).
Of the total number of participants, 426 completed a 5-month follow-up assessment, and 278 completed a 12-month follow-up assessment. At the 5-month follow-up, 30% of intervention participants reported they were moderately satisfied with the program; 44% reported they were very satisfied, and 18% reported they were extremely satisfied with the program.
Investigators also assessed the impact of the intervention on confidence in symptom self-management, and found no significant difference between the intervention and usual care. Data are still being compiled about utilization of services from 9 to 12 months post-enrollment. Initial qualitative data from a small process evaluation has yielded positive responses.
Implications. VA provides care to a significant number of prostate cancer survivors. This study offers much-needed information about how to optimize the quality of care and quality of life for those Veterans. In combination with the promising initial RCT results, investigators believe that additional process evaluation data will help provide recommendations for the broader deployment of an automated prostate cancer survivor symptom self-management program.
Principal Investigator: Sarah T. Hawley PhD, MPH, is an investigator with HSR&D’s Center of Innovation for Clinical Management Research (CCMR)at the VA Ann Arbor Healthcare System. Ted Skolarus, MD, MPH, also with CCMR, was a significant contributing investigator on this project.
This study has resulted in the following publications:
Skolarus TA, Wittmann D, et al. Enhancing prostate cancer survivorship care through self-management. Urologic Oncology. June 2017; 35(9): 564-568
Skolarus TA, Metreger T, et al. Optimizing veteran-centered prostate cancer survivorship care: study protocol for a randomized controlled trial. Trials. April 2017;18(1):181