Research into Preventive Care
While Benjamin Franklin may have been referring to fire safety when he wrote, "An ounce of prevention is worth a pound of cure"1, the axiom is most frequently applied to health and healthcare–and with good reason. In the strictest sense, "prevention" is an action or behavior that stops something else (often something worse) from occurring. Within the context of healthcare, prevention may include steps taken to ensure an individual stays healthy (like having a flu shot), and steps taken to ensure the safety of healthcare systems and services (such as instituting sterilization protocols to stop the spread of viruses and bacteria).
As the nation's largest integrated healthcare2 provider, it is critical that the Veterans Health Administration (VHA) focus on a wide variety of prevention efforts in order to ensure optimal health of the more than 8.9 million Veterans seeking care within VHA each year. These preventive measures range from reducing the rate of post-surgical hospital readmissions–to supporting Veterans with diabetes in making healthier lifestyle decisions–to identifying Veterans at risk for suicide.
VA is committed to implementing prevention programs whose efficacy is supported by evidence-based research. Studies funded by VA's Health Services Research & Development Service (HSR&D) address many aspects of prevention from both the patient and healthcare system level. The following studies and publications describe just some of the ongoing and recently concluded investigations being conducted in the area of prevention.
Hospital-onset (HO) blood-borne bacterial infection (bacteremia) is one of the most serious healthcare-associated infections (HAIs), and is a major cause of morbidity and mortality. Gram-negative rods (GNRs), such as E. coli, are responsible for about 25% to 30% of HO-bacteremia, and have become more problematic due to emerging drug resistance combined with lack of investment in antimicrobial drug discovery.
Since 2007, VA has had a comprehensive Methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative, and that program has since expanded in scope to include other pathogens. In this study, investigators sought to determine if that expansion could result in lower rates of infection with other pathogens, specifically, E. coli, Klebsiella, and Pseudomonas. Using data from the Veterans Affairs Informatics and Computing Infrastructure, which includes patient information extracted from VA's electronic medical record system, investigators identified 11,196 Veterans with hospital-onset GNR bacteremia during the study period. Bacteremia episodes were classified as community-acquired (CA), healthcare-associated (HA), and hospital-onset (HO) according to previously published and standardized definitions.
Results showed that over the 11-year study period, the nationwide infection control program expansion that was part of the MRSA Initiative was strongly associated with a sustained and statistically significant 43% decline in HO GNR bacteremia rates. During this time, the proportions of CA and HA GNR episodes increased, while HO episodes decreased, particularly in the second half of the study period.
Implications: With an increase in bacterial resistance to existing antibiotics, preventing HAIs and HO-bacteremia through infection control practices is of vital importance in ensuring the ongoing health of Veterans seeking care in VA. Findings from this study suggest that the non MRSA-specific components of the MRSA Prevention Initiative (e.g., increased infection-control staffing, emphasis on hand hygiene compliance) had collateral benefits in reducing rates of HO GNR bacteremia among Veterans.
Goto M, O'Shea A, Livorsi D, et al and Perencevich E. The Effect of a Nationwide Infection Control Program Expansion on Hospital-Onset Gram-Negative Rod Bacteremia in 130 Veterans Health Administration Medical Centers: An Interrupted Time Series Analysis. Clinical Infectious Diseases 2016 Sep 1;63(5):642-50.
Principal Investigator: Eli Perencevich, MD, MS, is the Director of the VA HSR&D Comprehensive Access & Delivery Research & Evaluation Center, in Iowa City, IA
Ending and preventing homelessness among Veterans are high priority areas for VA. Thus, Veterans "at-risk" for homelessness–especially for the first time–are a major focus of VA prevention efforts. Early warning indicators to identify these Veterans are currently only inferred from known risk factors for homelessness that can be gleaned from administrative data. However, references to indicators of risk in the free text of clinical narratives written by VA providers may precede the formal identification of Veterans as being homeless and potentially represent an untapped resource for early identification.
In this ongoing study investigators developed electronic algorithms to identify Veterans who are currently homeless or are at risk of homelessness using predictive modeling â€“ and the extent to which Veterans are receiving appropriate services. Investigators completed an examination of health records (dating from 2002 to 2012) of Veterans recently separated from the military who were identified as homeless. To determine housing status, conventional identification criteria (ICD-9 and VA specific codes for homeless services) were used and compared to a set of closely allied ICD-9 codes indicating housing instability. VA conventional criteria identified 21,021 homeless Veterans from Operations Enduring Freedom, Iraqi Freedom, and New Dawn (rate 2.5%). Adding the allied codes increased that to 31,260 (rate 3.3%).
While certain demographic differences were noted, Veterans identified as homeless using conventional and allied codes were similar with regards to utilization of homeless, mental health, and substance abuse services, as well as comorbidities. Investigators also looked at the association between misconduct-related separations and homelessness among recently returned active duty military service members. Findings showed that Veterans who separate from the military for misconduct have nearly seven times the likelihood of becoming homeless as compared to those with a normal separation.
Implications: When implemented, the electronic algorithms developed and validated in the study should have a direct impact on planning and allocation of resources to prevent and end homelessness among Veterans seen in VA health care settings. Further, findings from this study indicate that to prevent homelessness, there is a need for identification and provision of case management and rehabilitative services to those with misconduct-related as well as all non-normal military separations.
Gundlapalli AV, Fargo JD, Metraux S, Carter ME, Samore MH, Kane V, Culhane DP. Military Misconduct and Homelessness among US Veterans Separated From Active Duty, 2001-2012. JAMA: The Journal of the American Medical Association. 2015 Aug 25; 314(8):832-4.
Peterson R, Gundlapalli AV, Metraux S, Carter ME, Palmer M, Redd A, Samore MH, Fargo JD. Identifying Homelessness among Veterans Using VA Administrative Data: Opportunities to Expand Detection Criteria. PLoS ONE. 2015 Jul 14; 10(7):e0132664.
Principal Investigator: Adi V. Gundlapalli MD, PhD, is a Core Investigator with the HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0)
Multiple studies have shown that in people with impaired glucose tolerance ("pre-diabetes"), the Diabetes Prevention Program (DPP) can reduce the incidence of type 2 diabetes by between 40 and 60 percent. DPP is an intensive lifestyle intervention aimed at helping individuals with pre-diabetes improve their diet, exercise more, and work toward a healthy weight. Among Veterans, both the prevalence of type 2 diabetes and risk factors for developing diabetes are high. Despite the strong evidence that supports lifestyle modifications in preventing type 2 diabetes, VA does not currently have a lifestyle intervention program that specifically targets Veterans with pre-diabetes, however, it does offer them a weight-management program (VA MOVE!). VA MOVE! provides Veterans who are overweight or obese with a less intensive level of lifestyle change support.
In this study, investigators sought to provide VA's National Center for Health Promotion and Disease Prevention (NCP) with evidence to guide future implementation of the DPP as an option to help prevent type 2 diabetes. They compared a group-based version of DPP in three VA medical centers (VA-DPP). Patients referred to MOVE! were assigned to participate in either MOVE! or VA-DPP. Study objectives were to:
- assess differences in weight management outcomes between the VA MOVE! and VA-DPP programs,
- evaluate implementation of VA-DPP, and
- conduct cost-effectiveness and budget impact analyses.
On average, participants had a blood glucose level of 6.0%, and two-thirds had co-morbid hypertension.
Preliminary results indicate that participation rates were higher in the VA-DPP program over the 12 months compared to MOVE!. Participants in the VA-DPP and MOVE! programs had statistically significant weight loss at six months.
Implications: Because preliminary VA-DPP data provided important and relevant information to NCP, MOVE! group-visit guidance was updated to align more closely with the DPP's curriculum for all Veterans, not just those with pre-diabetes. Implementation of the VA-DPP program has the potential to improve health outcomes for Veterans by delaying or preventing the onset of type 2 diabetes.
Damschroder LJ, Moin T, Datta SK, Reardon CM, Steinle N, Weinreb J, Billington CJ, Maciejewski ML, Yancy WS, Hughes M, Makki F, Richardson CR. Implementation and evaluation of the VA DPP clinical demonstration: protocol for a multi-site non-randomized hybrid effectiveness-implementation type III trial. Implementation Science. 2015 May 12;10(1):68.
Note: The following article was accepted for publication and is currently on press.
Moin T, Damschroder LI, Youles B, Makki F, Billington C, Yancy W, Maciejewski ML, Kinsinger L, Weinreb JE, Steinle N, Richardson C. Implementation of a Prediabetes Identification Algorithm for Overweight/Obese Veterans. Journal of Rehabilitation Research and Development.
Principal Investigator: Laura Damschroder, MPH, is an investigator with the VA HSR&D Center for Clinical Management Research and the Personalizing Options through Veteran Engagement (PROVE) QUERI Program in Ann Arbor, MI
1 Independence Hall Association website
2 Department of Veterans Affairs website