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IIR 01-191 – HSR&D Study

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IIR 01-191
Establishing a VA Model for Best Practices in Management of Acute UGIH
Paul G Shekelle MD PhD MPH
VA Greater Los Angeles Healthcare System, West Los Angeles, CA
West Los Angeles, CA
Funding Period: October 2002 - August 2006

BACKGROUND/RATIONALE:
Acute UGIH is a prevalent, clinically significant, and expensive healthcare problem. The annual incidence of acute UGIH in the United States has been estimated to be 100 - 150 cases per 100,000 adults, translating into more than 350,000 hospital admissions per year. VA specific data are not available, but given the know risk factors for UGIH in the VA population such as alcohol use, chronic liver disease, aspirin / not-steroidal anti-inflammatory drug (NSAID) use, and H. pylori incidence, it is likely that at least this level of burden of disease is found within VA. Moreover, for acute UGIH, direct medical costs for in-hospital care are estimated to be several thousand dollars per admission or more than 2.5 billion dollars annually. Since the incidence of UGIH increases with age, this medical problem is expected to increase as the U.S. and VA populations age over the next several decades. Furthermore, extensive variation in resource utilization in managing acute UGIH has been demonstrated without demonstrative differences in outcome.

OBJECTIVE(S):
The purpose of this research is to test a best practices model aimed at improving utilization of healthcare resources for "low-risk" VA patients with acute, nonvariceal upper gastrointestinal bleeding (UGIB) while maintaining or improving quality of care. Specifically, as compared to current clinical practice, does a best practices model significantly decrease this low-risk cohort's hospital length of stay, proportion of "low-risk" patients admitted / residing in an ICU or monitored bed setting, utilization of in-hospital ancillary services, and patient complication rates?

METHODS:
This is a cross-sectional study of 600 veterans, half African-American and half White, with chronic hip or knee pain, cared for in VA primary care clinics. We are using two primary methodologies: 1) A structured survey with items measuring constructs in each of the above objectives. This includes the severity of the patients’ arthritis, the impact of the arthritis on functional status and quality of life, cultural beliefs about arthritis, and the acceptability of different treatments of osteoarthritis. 2) A semi-structured, interview, analyzed with qualitative techniques. This interview focuses on the patients’ interaction with the VA health care system, and the reasons for the patient’s success or lack of success in obtaining satisfactory treatment for their osteoarthritis symptoms.

FINDINGS/RESULTS:
Subject inclusion criteria were amended in 7/04 to include veterans presenting with acute UGIH and, who after undergoing upper endoscopy, have a "complete"Rockall score of 0-4. Previously, we were including as "low-risk" only those veterans who have a "complete" Rockall score of 0-2. However, there are emerging data that persons with a "complete" Rockall score of 0-4 may be low-risk and be considered for early hospital discharge. This protocol modification was approved by the VA Greater Los Angeles Healthcare System IRB. See enclosed approval notofication.

With this protocol modification, we will be able to significantly increase our enrollment of "low-risk" veterans with acute upper gastrointestinal hemorrhage. Considering our local data that we have accumulated since 7/03, as well as emerging published data from outside investigators, we believe increasing the "low-risk" veteran population will allow for the more efficient management of this patient population and will do this in a safe manner. Subjects will be able to leave the hospital sooner and thus be less exposed to possible nosocomial infections and medical errors

IMPACT:
Our study will provide important insight into the clinical, system, and cultural factors that may account for variations in procedure use in veterans with osteoarthritis. Our study will also provide insight into the differences in disease perceptions and values between African-American and White veterans. This insight will help VA providers deliver care that is more culturally sensitive.

PUBLICATIONS:

Journal Articles

  1. Karsan HA, Morton SC, Shekelle PG, Spiegel BM, Suttorp MJ, Edelstein MA, Gralnek IM. Combination endoscopic band ligation and sclerotherapy compared with endoscopic band ligation alone for the secondary prophylaxis of esophageal variceal hemorrhage: a meta-analysis. Digestive diseases and sciences. 2005 Feb 1; 50(2):399-406.


DRA: Health Systems
DRE: Treatment - Observational
Keywords: Clinical practice guidelines, Patient outcomes, Utilization patterns
MeSH Terms: none

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