BACKGROUND/RATIONALE:
This project was conducted to advance understanding about how information obtained directly from patients, in conjunction with information from administrative and clinical databases, could be used to better understand and potentially improve the provision of ambulatory care. We used data collected as part of the Ambulatory Care Quality Improvement Project (ACQUIP) including self-reported diagnoses, longitudinal patient assessments of health status and satisfaction, utilization and clinical data for a series of related analyses.

OBJECTIVE(S):
Main objectives were to: 1) construct models for case-mix and severity-of-illness adjustment that incorporate self-reported diagnoses and health status; 2) develop methods for using condition-specific health status in conjunction with data extracted from VistA to determine whether patients are treated in accordance with nationally accepted clinical practice guidelines; and 3) examine characteristics of patients satisfied with their primary care as well as the satisfaction of providers.

METHODS:
Using a Cox proportional hazards model, a case-mix index, the Seattle Index of Comorbidity (SIC), was constructed/validated using information about age, smoking status and 7 of 25 self-reported medical conditions associated with increased mortality. A separate comparison model was constructed using only age and the Physical (PCS) and Mental (MCS) Component Summary Scores of the SF-36 to predict mortality. The performance of several diagnosis-based case-mix measures was compared in predicting hospital admission (from VA and Medicare data), death and cost. Computerized criteria maps were developed to examine characteristics/outcomes of patients treated in accordance with clinical guidelines for CHD and COPD as compared to patients who were not. Health status, comorbidity, symptom burden and continuity of care were correlated to responses to patient satisfaction questionnaires, and predictive models were developed. Self-reported assessments of provider satisfaction were also obtained.

FINDINGS/RESULTS:
The SIC was predictive of mortality/hospitalizations in a validation set of 5478 patients. The PCS/MCS and the SIC had comparable discriminatory ability (Area Under the Curve [AUC] for discrimination of death within 2 years = 0.71 for both models). Combined, the SIC and SF-36 together had improved discrimination for mortality (AUC=0.74, p-value for difference in AUC < 0.005). Many patients with frequent angina appeared to be receiving an inadequate anti-anginal regimen in terms of both number of agents and dosages. Among 7038 veterans with self-reported CHD disease, 70% had angina or took sublingual nitroglycerin preparations two or fewer times per week. Of the 30% with more frequent symptoms, 22% were receiving no anti-anginal medications, and 33% were receiving only one class of anti-anginal medication. Of those with frequent angina who were prescribed medications, 17% had zero and 51% had only one medication class at a recommended therapeutic dose. Of patients with both COPD diagnosis and bronchodilator use, only 55% had a visit to the Pulmonary Function Test (PFT) lab before, during, or 2 years after the study. Factors associated with PFT referral were shorter length of care in the clinic (p<0.004), no non-VA care (p<0.000), and absence of ischemic heart disease (p<0.008). Severely symptomatic patients, as measured by self-reported symptoms, were also more likely to have been referred (OR 1.44, 95% CI 1.10, 1.45). Scores on general and condition-specific patient satisfaction scales were strongly related to perceived continuity of care, ranging from 86.7 to 61.4 (where 100 is best) among veterans who reported “always” seeing the same provider. Satisfaction scores among veterans who reported “rarely or never” seeing the same provider ranged from 69.5 to 41.9 (p<.001). Symptom severity and burden were modestly correlated with satisfaction in patients with heart disease (r=.28 for angina frequency) but not in patients with the other three conditions (r= 04 to .21). Findings persisted after adjustment for age, education, race, income, VA facility, SF-36 scores and length of time receiving VA care. Personal alignment with organizational philosophy of care accounted for most of the variation in provider satisfaction.

IMPACT:
Completed analyses have yielded important findings and products. The SIC is already being used in a variety of studies. Findings regarding compliance with guidelines have formed the basis for ongoing interventional trials. Measures of self-reported health status provide a valuable adjunct to other clinical and administrative data and our experience has informed efforts in the VA Office of Quality and Performance to establish a national system for collecting these data.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Bryson CL, Au DH, Young B, McDonell MB, Fihn SD. A refill adherence algorithm for multiple short intervals to estimate refill compliance (ReComp). Medical care. 2007 Jun 1; 45(6):497-504. [view]
2. Diehr P, Patrick DL, McDonell MB, Fihn SD. Accounting for deaths in longitudinal studies using the SF-36: the performance of the Physical Component Scale of the Short Form 36-item health survey and the PCTD. Medical care. 2003 Sep 1; 41(9):1065-73. [view]
3. Bridevaux IP, Bradley KA, Bryson CL, McDonell MB, Fihn SD. Alcohol screening results in elderly male veterans: association with health status and mortality. Journal of the American Geriatrics Society. 2004 Sep 1; 52(9):1510-7. [view]
4. Au DH, Kivlahan DR, Bryson CL, Blough D, Bradley KA. Alcohol screening scores and risk of hospitalizations for GI conditions in men. Alcoholism, clinical and experimental research. 2007 Mar 1; 31(3):443-51. [view]
5. Lembke A, Bradley KA, Henderson P, Moos R, Harris AH. Alcohol screening scores and the risk of new-onset gastrointestinal illness or related hospitalization. Journal of general internal medicine. 2011 Jul 1; 26(7):777-82. [view]
6. Burman ML, Kivlahan D, Buchbinder M, Broglio K, Zhou XH, Merrill JO, McDonell MB, Fihn SD, Bradley KA. Alcohol-related advice for Veterans Affairs primary care patients: Who gets it? Who gives it? Journal of Studies On Alcohol. 2004 Sep 1; 65(5):621-30. [view]
7. Au D, Curtis J, Bryson C, Fan V, Udris E, McDonell M, Fihn S. Antihypertensive medications and risk of mortality among patients with COPD and hypertension. American journal of respiratory and critical care medicine. 2003 Apr 1; 167:317. [view]
8. Au D, Curtis J, McDonell M, Anderson S, Fihn S. Assessing internet use by VA patients. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2003 Jul 1; 20:35-51. [view]
9. Williams EC, Bryson CL, Sun H, Chew RB, Chew LD, Blough DK, Au DH, Bradley KA. Association between alcohol screening results and hospitalizations for trauma in Veterans Affairs outpatients. The American journal of drug and alcohol abuse. 2012 Jan 1; 38(1):73-80. [view]
10. Thomas RM, Francis Gerstel PA, Williams EC, Sun H, Bryson CL, Au DH, Bradley KA. Association between alcohol screening scores and diabetic self-care behaviors. Family medicine. 2012 Sep 1; 44(8):555-63. [view]
11. Au DH, Udris EM, Curtis JR, McDonell MB, Fihn SD. Association between chronic heart failure and inhaled beta-2-adrenoceptor agonists. American heart journal. 2004 Nov 1; 148(5):915-20. [view]
12. Au DH, Curtis JR, Every NR, McDonell MB, Fihn SD. Association between inhaled beta-agonists and the risk of unstable angina and myocardial infarction. Chest. 2002 Mar 1; 121(3):846-51. [view]
13. Arterburn DE, McDonell MB, Hedrick SC, Diehr P, Fihn SD. Association of body weight with condition-specific quality of life in male veterans. The American journal of medicine. 2004 Nov 15; 117(10):738-46. [view]
14. Au DH, Bryson CL, Fan VS, Udris EM, Curtis JR, McDonell MB, Fihn SD. Beta-blockers as single-agent therapy for hypertension and the risk of mortality among patients with chronic obstructive pulmonary disease. The American journal of medicine. 2004 Dec 15; 117(12):925-31. [view]
15. Fan VS, Burman M, McDonell MB, Fihn SD. Continuity of care and other determinants of patient satisfaction with primary care. Journal of general internal medicine. 2005 Mar 1; 20(3):226-33. [view]
16. Liu CF, Campbell DG, Chaney EF, Li YF, McDonell M, Fihn SD. Depression diagnosis and antidepressant treatment among depressed VA primary care patients. Administration and policy in mental health. 2006 May 1; 33(3):331-41. [view]
17. Ohldin A, Young B, Derleth A, McDonell M, Diehr P, Kiefe C, Fihn S. Ethnic differences in satisfaction and quality of life in veterans with ischemic heart disease. Journal of the National Medical Association. 2004 Jun 1; 96(6):799-808. [view]
18. Fan VS, Reiber GE, Diehr P, Burman M, McDonell MB, Fihn SD. Functional status and patient satisfaction: a comparison of ischemic heart disease, obstructive lung disease, and diabetes mellitus. Journal of general internal medicine. 2005 May 1; 20(5):452-9. [view]
19. Spertus JA, Jones P, McDonell M, Fan V, Fihn SD. Health status predicts long-term outcome in outpatients with coronary disease. Circulation. 2002 Jul 2; 106(1):43-9. [view]
20. Parimon T, Chien JW, Bryson CL, McDonell MB, Udris EM, Au DH. Inhaled corticosteroids and risk of lung cancer among patients with chronic obstructive pulmonary disease. American journal of respiratory and critical care medicine. 2007 Apr 1; 175(7):712-9. [view]
21. Fan VS, Bryson CL, Curtis JR, Fihn SD, Bridevaux PO, McDonell MB, Au DH. Inhaled corticosteroids in chronic obstructive pulmonary disease and risk of death and hospitalization: time-dependent analysis. American journal of respiratory and critical care medicine. 2003 Dec 15; 168(12):1488-94. [view]
22. Fan VS, Au DH, McDonell MB, Fihn SD. Intraindividual change in SF-36 in ambulatory clinic primary care patients predicted mortality and hospitalizations. Journal of clinical epidemiology. 2004 Mar 1; 57(3):277-83. [view]
23. DeSalvo KB, Fan VS, McDonell MB, Fihn SD. Predicting mortality and healthcare utilization with a single question. Health services research. 2005 Aug 1; 40(4):1234-46. [view]
24. Keeffe B, Subramanian U, Tierney WM, Udris E, Willems J, McDonell M, Fihn SD. Provider response to computer-based care suggestions for chronic heart failure. Medical care. 2005 May 1; 43(5):461-5. [view]
25. Bridevaux P, Au D, Fan V, McDonell M, Fihn S. Regional variations in health status among COPD patients. American journal of respiratory and critical care medicine. 2003 Feb 1; 167:238. [view]
26. Au DH, McDonell MB, Martin DC, Fihn SD. Regional variations in health status. Medical care. 2001 Aug 1; 39(8):879-88. [view]
27. Au DH, Udris EM, Fan VS, Curtis JR, McDonell MB, Fihn SD. Risk of mortality and heart failure exacerbations associated with inhaled beta-adrenoceptor agonists among patients with known left ventricular systolic dysfunction. Chest. 2003 Jun 1; 123(6):1964-9. [view]
28. Wiest FC, Bryson CL, Burman M, McDonell MB, Henikoff JG, Fihn SD. Suboptimal pharmacotherapeutic management of chronic stable angina in the primary care setting. The American journal of medicine. 2004 Aug 15; 117(4):234-41. [view]
29. Slatore CG, Bryson CL, Au DH. The association of inhaled corticosteroid use with serum glucose concentration in a large cohort. The American journal of medicine. 2009 May 1; 122(5):472-8. [view]
30. Yano EM, Bastian LA, Frayne SM, Howell AL, Lipson LR, McGlynn G, Schnurr PP, Seaver MR, Spungen AM, Fihn SD. Toward a VA Women's Health Research Agenda: setting evidence-based priorities to improve the health and health care of women veterans. Journal of general internal medicine. 2006 Mar 1; 21 Suppl 3:S93-101. [view]
31. Davis GE, Bryson CL, Yueh B, McDonell MB, Micek MA, Fihn SD. Treatment delay associated with alternative medicine use among veterans with head and neck cancer. Head & neck. 2006 Oct 1; 28(10):926-31. [view]
32. Bradley KA, Kivlahan DR, Zhou XH, Sporleder JL, Epler AJ, McCormick KA, Merrill JO, McDonell MB, Fihn SD. Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients. Alcoholism, clinical and experimental research. 2004 Mar 1; 28(3):448-55. [view]
33. Fan VS, Curtis JR, Tu SP, McDonell MB, Fihn SD. Using quality of life to predict hospitalization and mortality in patients with obstructive lung diseases. Chest. 2002 Aug 1; 122(2):429-36. [view]
34. Fan VS, Au D, Heagerty P, Deyo RA, McDonell MB, Fihn SD. Validation of case-mix measures derived from self-reports of diagnoses and health. Journal of clinical epidemiology. 2002 Apr 1; 55(4):371-80. [view]
35. Bradley KA, Kivlahan DR, Bush KR, McDonell And, Fihn SD. Variations on the CAGE alcohol screening questionnaire: strengths and limitations in VA general medical patients. Alcoholism, clinical and experimental research. 2001 Oct 1; 25(10):1472-8. [view]

Conference Presentations

1. Bryson CL, Au DH, Young B, McDonell MB, Fihn SD. A refill adherence algorithm for multiple short intervals to estimate refill compliance (ReComp). Poster session presented at: VA HSR&D National Meeting; 2006 Feb 14; Arlington, VA. [view]
2. Bridevaux P, Au D, Fan V, McDonell M, Fihn S. Adherence to guidelines regarding pulmonary function testing in patients with chronic obstructive pulmonary disease. Paper presented at: American College of Surgeons Spring Meeting; 2002 Oct 23; San Diego, CA. [view]
3. Mozaffarian D, Bryson C, Spertus J, McDonell M, Fihn S. Angina predicts mortality in outpatients with CAD irrespective of demographics or comorbidities. Paper presented at: American Heart Association Annual Scientific Sessions; 2003 Mar 31; Miami, FL. [view]
4. Mozaffarian D, Bryson C, Spertus J, McDonell M, Fihn S. Angina predicts mortality in outpatients with CAD irrespective of demographics or comorbidities. Paper presented at: VA HSR&D National Meeting; 2003 Feb 14; Washington, DC. [view]
5. Taneda K, Bryson C, McDonell M, Fihn S. Association between hypertension control and adherence measure using self-report and pharmacy data. Paper presented at: Society of General Internal Medicine Annual Meeting; 2003 May 1; Vancouver, Canada. [view]
6. Taneda K, Bryson C, McDonell M, Fihn S. Association between hypertension control and adherence measure using self-report and pharmacy data. Paper presented at: VA HSR&D National Meeting; 2003 Feb 1; Washington, DC. [view]
7. Arterburn DE, McDonell MB, Diehr PH, Fihn SD. Association of Body Weight with Perceived Health and Severity of Symptoms from Chronic Conditions. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2004 May 15; Chicago, IL. [view]
8. Fihn S. Can reports health status to physicians improve health. Paper presented at: Regenstrief Institute Biennial Conference; 2002 Oct 18; Turkey Run State Park, IN. [view]
9. Bryson C, Davis G, Yueh B, McDonell M, Micek M, Fihn S. Complementary or Alternative: Does alternative medicine use delay traditional therapy for cancer. Paper presented at: Society of General Internal Medicine Annual Meeting; 2003 May 1; Vancouver, Canada. [view]
10. Fihn SD, Bryson CL, McDonell MB, Fan VS. Effect of Reporting Worrisome Results to Primary Care Providers on Processes and Outcomes of Care. Paper presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA. [view]
11. Derleth A, Diehr P, Patrick D, Reiber G, McDonell M, Fihn S. Estimating Preference Weighted Health Status fromSF-36 Responses for the ACQUIP (VA) Patients. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 15; Arlington, VA. [view]
12. Fan V, Bryson C, Au D, Bridevaux P, McDonell M, Fihn S. Inhaled Corticosteroids use over time and risk of death in COPD patients. Paper presented at: American Thoracic Society Annual International Conference; 2003 Jun 1; Seattle, WA. [view]
13. Au D, Curtis J, McDonell M, Anderson S, Fihn S. Limited Internet Use by Patients Cared for in Veterans Affairs Medical Centers. Paper presented at: VA HSR&D National Meeting; 2001 Feb 15; Washington, DC. [view]
14. Fihn S. Management of Chronic Stable Angina. Paper presented at: VA HSR&D National Meeting; 2002 Feb 13; Washington, DC. [view]
15. Fihn SD. Managing Anticoagulation. Paper presented at: American College of Physicians Internal Medicine Annual Meeting; 2004 Apr 22; New Orleans, LA. [view]
16. Fihn S. Outpatient Management of Chronic Stable Angina. Paper presented at: VA HSR&D National Meeting; 2002 Feb 14; Washington, DC. [view]
17. Maciejewski M, Liu C, Derleth A, McDonell M, Anderson S, Fihn S. Prospect of risk adjustment from administrative and self-report data. Paper presented at: AcademyHealth Annual Research Meeting; 2003 Jun 1; Nashville, TN. [view]
18. Maciejewski M, Liu C, Derleth A, McDonell M, Anderson S, Fihn S. Prospect of risk adjustment from administrative and self-report data. Paper presented at: International Health Economics Association Biennial World Congress on Health Economics; 2003 Jun 5; San Francisco, CA. [view]
19. Young B, Boyko E, McDonell M, Fihn S. Risk of Cardiovascular Events with Renal Insufficiency: Results from the Ambulatory Care Quality Improvement Project. Paper presented at: VA HSR&D National Meeting; 2003 Feb 14; Washington, DC. [view]
20. Fihn S. Routine Reporting of Health Status Data Does Not Improve General Heath of Satisfaction. Paper presented at: VA HSR&D National Meeting; 2002 Feb 12; Washington, DC. [view]
21. Greene CC, Williams EC, Bradley KA, Au DH. The Association between Alcohol Misuse and Health Status among Veterans with COPD. Poster session presented at: American Thoracic Society Annual International Conference; 2011 May 15; Denver, CO. [view]
22. Au D, Udris E, Curtis J, McDonell M, Anderson S, Fihn S. The Association Between Hospitalization for Congestive Heart Failure and Use of Inhaled Beta-agonists. Paper presented at: VA HSR&D National Meeting; 2001 Feb 15; Washington, DC. [view]
23. Petryemann Bridevaux, Bradley K, McDonell M, Bridevaux P, Fihn S. The association of alcohol screening questionnaires to mortality among elderly male veterans who drink. Paper presented at: Society of General Internal Medicine Annual Meeting; 2003 May 1; Vancouver, Canada. [view]
24. Fan V, Au D, Heagerty P, Deyo R, McDonell M, Fihn S. Validation of Case-Mix Measures Derived From Self-Reports of Diagnoses and Health. Paper presented at: Society of General Internal Medicine Annual Meeting; 2001 May 1; San Diego, CA. [view]
25. Nguyen J, McDonell M, Young B, Fihn S. Validation of patient self-report of diabetes mellitus. Paper presented at: Society of General Internal Medicine Annual Meeting; 2003 May 1; Vancouver, Canada. [view]

DRA: Health Systems
DRE: Treatment - Observational
Keywords: Primary care, Quality assessment, Research measure
MeSH Terms: none