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  • VA Hepatitis C Care and Experiences with the Choice Program
    This study examined perspectives and experiences with the VA Choice Program among Veterans with HCV and their providers at three VAMCs in the New England region. Findings showed that the Choice Program has the potential to increase Veterans’ access to hepatitis C virus (HCV) treatment, but Veterans and VA providers described substantial problems in the initial years of the program. Four main themes emerged: (1) Difficulties in enrollment, ongoing support, and billing with third-party administrators (i.e., many Veterans described confusion about eligibility and enrollment for the Program); (2) Veterans experienced a lack of choice in location of treatment (i.e., most Veterans at the study sites did not have the option to receive VA HCV treatment, but many wanted to); (3) Fragmented care led to coordination challenges between VA and community providers (i.e., various challenges arose around sharing medical records, prescription delays, and working with designated VA staff trained on the Choice Program); and (4) VA providers expressed reservations about sending Veterans to community providers (i.e., VA providers were cautious about sending patients to the Choice Program because some community providers lacked specific experience in treating advanced cases of HCV).
    Date: March 3, 2017
  • VA Pharmacy Use in the First Year of Choice Act
    This study sought to describe pharmaceutical use during the first year of the Veterans Choice Program (VCP) and to understand barriers and facilitators for VA pharmacists to dispensing medications under the VCP. Findings showed that a majority of VCP pharmacy spending in the first year was for hepatitis C virus (HCV) medications, which accounted for only 5% of prescriptions but 90% of costs. However, in 2015, VA experienced greater than expected demand for HCV medications, which exceeded available funding, thus some patients obtained medications through the VCP. The impact of HCV medications on the VCP should be short-lived given broadened availability in VA in 2016. Topical eye drops and opioids represented the most commonly dispensed prescriptions: 16% and 9% of all prescriptions, respectively. Most prescriptions dispensed (93%) were for formulary agents, but substantial efforts were required from VA pharmacists to work with non-VA providers to use formulary drugs. Challenges related to obtaining medications from VA pharmacies through VCP included requiring controlled substance prescriptions to be hand-delivered, a lack of access to lab data required to safely dispense medications, and substantial time required by pharmacists to communicate with non-VA providers. Safe use of opioids, efficient management of non-formulary medications, and unintended new barriers to access created by the VCP must be addressed, in addition to robust ongoing evaluations to identify new cost, quality, and safety concerns.
    Date: February 17, 2017
  • Quality Improvement Tool Shows Organizational Factors Related to Access and Quality Measures in VA Mental Healthcare
    This study analyzed performance on measures included in the Mental Health Management System (MHMS) – a performance data and quality improvement tool used by VA to increase the value of mental healthcare for Veterans. The MHMS quality improvement tool showed that organizational factors were associated with performance on key access and quality measures related to VA mental healthcare. Better access was associated with higher staff-to-patient ratios for psychiatrists and other outpatient mental health providers, and with lower mental health provider staffing vacancies. Higher mental health staff-to-patient ratios were associated with higher performance on nearly all patient and provider satisfaction measures. Higher continuity of care was associated with lower no-show rates to appointments, better wait times, higher staff-to-patient ratios, lower mental health provider vacancies, and more space available for clinical work. Over the past decade, VA’s mental health population has grown rapidly compared to its overall patient population (71% vs. 21%, respectively), so these findings are important in showing that MHMS is a robust informatics and quality improvement tool that can serve as a model for health systems planning to adopt a value perspective.
    Date: February 1, 2017
  • Lessons Learned from VA’s History of Transformation and Potential Future Scenarios
    An article by O’Hanlon, et al presents an updated view of the evidence on VA’s quality of care and a strong scientific case to support the conclusion that after its dramatic transformation in the 1990s, VA had quality and safety measures that were as good, or better, than the private sector – and even top-rated healthcare organizations. However, does the controversy over wait times demonstrate that VA has reverted to its old ways? If so, how can the VA healthcare system find its way back? A return to VA’s earlier lessons of the value of decentralized decision-making, tight accountability for quality and efficiency, and respect for two-way communication between the field and central management might result in a systematic review of VA 5 to 10 years from now that reaches the same conclusions as O’Hanlon, et al, but includes success in both quality and access.
    Date: January 1, 2017
  • More than Half of Privately Insured Veterans Younger than 65 Years of Age Access both VA and Non-VA Healthcare
    This study sought to quantify use of VA and non-VA care among working-age Veterans with private insurance by linking VA data to private health insurance plan (PHIP) data. Findings showed that more than half (54%) of Veterans younger than 65 who were enrolled in both VA and private health insurance plans accessed both healthcare systems; 39% used non-VA healthcare only, while 5% used VA healthcare only. Dual system users had the lowest percentage of Veterans under age 40 (15%) and the highest percentage of Veterans over age 50 (71%), while VA-only users had the highest percentage of Veterans under age 40 (22%) and the lowest percentage of Veterans over age 50 (61%). Dual system users also had the highest proportion of Veterans residing in rural settings (61%). VA reliance was 33% for outpatient care, 14% for inpatient care, and 40% for pharmacy. Findings suggest that care coordination efforts for Veterans across age groups should include privately insured Veterans under age 65 in order to ensure safe and coordinated care.
    Date: September 1, 2016
  • Data from Electronic Health Records Can Predict and Possibly Prevent Missed Patient Appointments
    This study sought to develop a model that identifies patients at high risk for missing scheduled appointments (no-shows and cancellations), and to project the impact of predictive over-booking in a gastrointestinal (GI) endoscopy clinic – a resource-intensive environment with a high no-show rate. Findings showed that information from electronic health records can accurately predict whether patients will no-show. The model used in this study was able to correctly classify 711 out of 888 attended appointments, and 317 out of 538 missed appointments. The strongest predictor of no-show was a patient’s cancellation history – the proportion of all outpatient appointments missed. Veterans with histories of mood or substance use disorder, and those with a greater overall disease burden also were less likely to keep appointments. Predictors of being more likely to keep appointments included: being married, having a history of diverticular disease, attending a colonoscopy education class, and having care partly funded by VA. Urgency of appointment, race, ethnicity, and day of the week of appointment were not significant predictors of appointment no-shows. Compared to a strategy that employs a fixed level of overbooking, predictive over-booking was much less likely to lead to days where the clinic was substantially over- or under-booked.
    Date: December 1, 2015
  • Potential Problems and Suggested Solutions for VA as Veterans Take Advantage of Dual Use Care via the “Choice Act”
    This Commentary describes the problems of dual use and care fragmentation, the complexity of the Choice Program, and offers suggestions for ensuring its safe and effective implementation.
    Date: August 20, 2015
  • Effect of ACA’s Medicaid Expansion on Demand for VA Care
    This study examined the historical relationships between policy-driven Medicaid expansion and VA enrollment and utilization of inpatient and outpatient care. Findings showed that if the Affordable Care Act’s Medicaid expansion had been implemented in all states – and holding all else constant – VA enrollment, inpatient days, and outpatient clinic visits would have been 9%, 6%, and 12% lower, respectively. For states in which Medicaid did not expand in 2014, VA enrollment, inpatient days, and outpatient clinic visits were 10, 6, and 13 percentage points higher, respectively, than they would have been otherwise; this higher demand may have contributed to longer wait times. These results suggest that Medicaid expansion could reduce the burden of demand placed on VA medical centers. As policymakers continue to address VA capacity issues, the authors suggest they be mindful of the potential role of Medicaid – and that it may change over time if more states adopt the expansion.
    Date: March 12, 2015
  • VA Maintains Access to Care as Need for Substance Use Treatment Grows
    VA has enhanced funding of mental health programs and substance use disorder (SUD)-specific treatment and also has directed approximately $152 million toward hiring additional SUD staff. This study examined the relationship between dedicated SUD funding and SUD performance measures from 2005 and 2010 for VA medical centers. Findings showed that, overall, access and quality of care kept pace with the demand for SUD services in the VA healthcare system. There was a statistically significant and generally positive correlation between additional, dedicated SUD resources and access and treatment intensity. The number of VA patients with an SUD diagnosis grew from about 310,000 in 2005 to 439,000 in 2010 – an increase of 42%. Average dedicated SUD funding per facility grew from $65,870 in 2005 to $324,416 in 2007, falling to $147,151 in 2009 and 2010. However, not all VAMCs received funding in each year.
    Date: March 12, 2015
  • Increasing VA Rates of Psychotherapy among Rural- and Urban-Dwelling Veterans with Mental Illness
    This retrospective study evaluated changes in rural-dwelling Veterans’ use of psychotherapy during a period of widespread organizational efforts to engage this patient population in mental health service use – and compared their use of psychotherapy with urban-dwelling Veterans. Findings showed that VA psychotherapy use is increasing among both urban- and rural-dwelling Veterans with a new diagnosis of depression, anxiety, or PTSD. Over the four-year study period, the proportion of Veterans receiving any psychotherapy increased from 17% to 22% for rural Veterans and 24% to 28% for urban Veterans. With respect to psychotherapy dose, the proportion of both rural- and urban-dwelling Veterans receiving 4+ and 8+ psychotherapy sessions increased from 2007 to 2010. And although rural-dwelling Veterans received, on average, fewer psychotherapy sessions than urban-dwelling Veterans, this gap decreased over time. By 2010, the mean number of sessions attended by rural Veterans (5 sessions) was only 1 session less than their urban counterparts (6 sessions). Rates of PTSD diagnosis were higher among urban-dwelling Veterans, whereas rates of depression and anxiety were higher among rural-dwelling Veterans.
    Date: December 3, 2014
  • Complementary and Integrative Medicine Use among Veterans and the Military
    A special supplement to the journal Medical Care: “Building the Evidence Base for Complementary and Integrative Medicine Use among Veterans and Military Personnel,” includes 13 original articles as well as two commentaries that describe efforts within VA and the Department of Defense (DoD) to understand and foster the use of CAM among Veterans and active duty military personnel.
    Date: December 1, 2014
  • Poor Communication between VA and Non-VA Primary Care Providers co-Managing Rural Veterans
    This study examined the perspectives of community-based, non-VA primary care providers (PCPs) regarding their experiences co-managing Veterans with VA providers. Findings showed that communication with VA was viewed as poor by 66% of non-VA primary care providers, and many non-VA PCPs (42%) believed this led to poor patient outcomes. They also felt that they interacted with VA as a system rather than with individual VA providers. While the majority of non-VA providers were dissatisfied with their communication with VA providers, this did not translate into a negative opinion of VA healthcare; most felt the overall quality of VA care was high. Veterans were identified as the main medium for information transfer between VA and non-VA providers, which was viewed as undesirable. When non-VA PCPs were asked about their ideal method of communication, they most commonly identified electronic health records and fax that would occur automatically. They also identified the need for a VA point of contact to triage direct calls from non-VA providers.
    Date: November 1, 2014
  • Affordable Care Act May Impact Continuity of Care for Homeless VA Healthcare Users
    This study compared Veterans who are likely eligible for the Medicaid expansion (LEME) and those who are not LEME, stratified by homeless status. Findings showed that among all VA healthcare users under the age of 65, homeless Veterans were two times more likely to be LEME than non-homeless Veterans (64% vs. 30%). Regardless of housing status, Veterans who were LEME were physically healthier than those not LEME. However, Veterans who were LEME were more likely to have substance use disorders and PTSD. Among homeless VA healthcare users, those who were LEME were less than half as likely to be married, to be an OEF/OIF/OND Veteran, and had less than one-third the income of Veterans who were not LEME. Among non-homeless VA healthcare users, those who were LEME were younger and more likley to be OEF/OIF/OND Veterans. Cross-sytem use of VA and Medicaid-funded services may be advantageous for Veterans with extensive medical and psychiatric needs, but also risks fragmented care. Information and education for VA clinicians and patients about possible implications of the Affordable Care Act may be important.
    Date: September 1, 2014
  • Potential Impact of Affordable Care Act on Massachusetts Veterans’ Enrollment in VA Healthcare
    This study examined the potential impact of the Affordable Care Act (ACA) on Veterans’ enrollment in VA, private insurance, and Medicaid, using the Massachusetts Health Care Reform Act (MHCRA), implemented in June 2006, as a proxy for ACA. Findings showed that overall, healthcare reform in Massachusetts was associated with significantly greater Medicaid enrollment, but was not significantly associated with VA and private insurance enrollment. Compared to other Veterans living in New England, Veterans living in Massachusetts decreased their enrollment in VA and private insurance by 0.2 and 0.9 percentage points, respectively, following healthcare reform. By contrast, Medicaid enrollment increased by 2.5 percentage points. Veterans increasingly took advantage of the expanded Medicaid options that were part of MHCRA; Veterans who might otherwise have enrolled in VA or private insurance opted for Medicaid.
    Date: August 1, 2014
  • VA’s “Big Data”: Benefits and Challenges
    This paper provides an overview of VA’s evolving approach to “big data” and illustrates how advanced analytics support clinical activities, with particular emphasis on the Patient-Aligned Care Team (PACT) model of patient-centered primary care. It also shares some of the challenges, concerns, responses, and future plans that have emerged from these initiatives.
    Date: July 9, 2014
  • Veterans Living Greater Distance from VA or Any Transplant Centers May have Less Chance of Receiving Liver Transplant
    This study evaluated the association between distance from a VA transplant center (VATC) and access to wait-listing and liver transplantation, as well as mortality. Findings showed that among VA patients meeting eligibility criteria for liver transplantation, greater distance from a VATC or any transplant center was associated with lower likelihood of wait-listing or transplantation, and greater likelihood of death. Of the 50,637 Veterans classified as potentially transplant-eligible during the study period, 6% were waitlisted (49% at a VATC and 51% at a non-VATC). Overall, 7% of Veterans at a VA medical center =100 miles from a VATC were waitlisted at a VATC, and 11% at any transplant center, compared with 3% and 5%, respectively, living >100 miles from a VATC. Three-year survival from first hepatic decompensation event for waitlisted Veterans differed by distance: 72% (=100 miles from VATC) vs. 66% (>100 miles). Increasing distance to a VATC was associated with significantly increased risk of mortality, with a 3% increased risk of mortality for every doubling of distance from local VAMC to VATC.
    Date: March 26, 2014
  • Affordable Care Act May Have Significant Implications for Veterans and the VA Healthcare System
    This study sought to: 1) Describe the proportion and characteristics of Veterans currently uninsured, as they will likely be required to obtain coverage under the ACA; 2) Determine who among the uninsured are likely eligible for the Medicaid expansion (LEME); and 3) Compare the sociodemographic and health characteristics of those uninsured and LEME – and not LEME, and those who currently have health insurance coverage. Findings showed that of 22 million Veterans, about 7% – or more than 1.5 million Veterans – were uninsured in 2010 and would need to obtain healthcare coverage by enrolling in VA healthcare, the Medicaid expansion, participating in the health insurance exchanges, or finding some other form of health coverage. Of the uninsured Veterans, more than 800,000 are likely eligible for the Medicaid expansion. However, states that do not implement the Medicaid expansion may have many poor, uninsured Veterans who are not able to afford coverage through the health insurance exchanges because of ineligibility for federal subsidies. Compared to Veterans with health coverage, the uninsured were younger and more likely to be single, African American, low-income, and to have been deployed to Iraq and Afghanistan. Among Veterans who were uninsured, those who were LEME reported poorer general health and were more likley to use emergency department services than Veterans who were not LEME.
    Date: March 1, 2014
  • Changes in Care Processes and Patient Outcomes Related to VA’s Implementation of PACT Model
    This study examined whether changes in VA healthcare delivery under the PACT transformation led to changes in organizational processes of care and patient outcomes. Findings showed that medical home implementation in the VA healthcare system resulted in large changes in the structure of care, but few changes in patient-level organizational processes or outcomes. There were significant improvements in two-day post-hospital discharge contact, but not primary care visits occurring by telephone or within three days of the requested date. There was no association between medical home implementation and rates of emergency department use by Veterans. Over the study period, the percentage of PCPs who were part of the PACT model more than tripled, and the percentage of PCPs that implemented elements of the PACT model increased significantly.
    Date: January 30, 2014
  • Veterans with Prostate Cancer Living in Rural Settings have Less Access to Comprehensive Oncology Resources than Urban Veterans, but Receive Similar or Better Quality of Care
    This study sought to determine the degree to which access barriers impact the quality of prostate cancer care for rural patients in the VA healthcare system. Findings showed that Veterans with prostate cancer living in rural settings traveled nearly 5-fold further for care and were less likely to be treated at facilities with comprehensive cancer resources, compared with Veterans living in urban settings. Despite differences in access to resources, rural patients received similar or better quality of care for 4 of 5 measures (e.g., appropriate number of biopsies, no bone scan for low-risk disease, appropriate chemotherapy for progressive disease, and appropriate hormonal therapy for high-risk patients treated with radiation therapy). Time to prostate cancer treatment was similar for Veterans living in rural compared with urban settings (97 days vs. 106 days).
    Date: July 30, 2013
  • Issues for Sexual and Gender Minority Veterans Receiving VA Healthcare
    This article summarizes emergent research findings regarding sexual and gender minority (SGM) Veterans, and the first initiatives that have been implemented by VA to promote quality care. Being a member of both the Veteran and SGM communities may contribute to a higher level of risk for poor health than membership in just one of these populations. A recent VA study indicated that only 33% of SGM Veterans reported open communication about their sexual orientation with VA healthcare providers, while 25% reported avoiding certain VA services because of concerns about stigma. In another study of 202 VA providers and 58 SGM Veterans, less than one-third of all participants viewed VA as welcoming to SGM Veterans. To address these issues, VA has created new programs, such as the Office of Health Equity LGBT Workgroup, which works to address inequities in the healthcare environment for SGM Veterans. VA also created two new part-time LGBT Program Coordinator positions, through the Office of Patient Care Services, who advise leadership on policy and practice issues related to SGM Veterans. In June 2011, VA released the first national policy to describe the services that are available to transgender Veterans. Other recent VA policy changes include “sexual orientation” and “gender identity and expression” now being included in VA non-discrimination and caregiver policies. Educational resources and trainings have been developed for VA staff about culturally appropriate care for SGM Veterans. Further research is needed to better understand the SGM population, their healthcare needs, and how these needs vary in relation to gender, race/ethnicity, and other factors, as well as in evaluation of provider training and policies.
    Date: July 1, 2013
  • Factors Affecting Readiness for Implementation of VA’s Patient-Aligned Care Team Model
    This study sought to describe the impact of readiness for implementation on the efforts of 32 pilot PACT teams to make changes to improve access to healthcare for Veterans – and to identify successful strategies to overcome barriers to change. Findings showed that key factors related to readiness for implementation (or lack thereof) had an impact on which interventions pilot teams could put into place, as well as viability and sustainability of access gains. Leadership Engagement. Lack of leadership engagement/support posed a barrier to open access, however, strategies to engage/educate administrators led to successful interventions to improve access. Staffing Resources. Lack of personnel to staff PACT teams was a barrier to improving access; at sites where funds were made available to hire new staff or where teams were able to re-configure existing staff, access interventions were more often implemented. Access to Information and Knowledge. Having experienced staff who could generate reports from the electronic medical record was a major facilitator of access interventions. Pilot teams used a number of effective strategies for improving access, i.e., extending time between appointments for some Veterans; reorganizing clinic schedules in order to provide a mix of face-to-face, telephone, and same-day appointments; and contacting Veterans after an ED visit to determine appropriate follow-up care. The authors note that wide variations in interventions to improve access occurred across sites, which has important implications for efforts to measure the impact of enhanced access on patient outcomes, costs, and other systems level indicators of the PACT model’s success.
    Date: November 29, 2012
  • Systematic Review Evaluates Patient-Centered Medical Home Model for Primary Care Transformation
    This systematic review sought to describe how studies conducted to date have implemented patient-centered medical homes (PCMH) – and to evaluate the current evidence of the effect of PCMH interventions on patient, staff, and economic outcomes. Findings showed that there is moderately strong evidence that the patient-centered medical home has a small positive impact on patient experiences and small to moderate positive effects on delivery of preventive care services. Staff experiences are also improved by a small to moderate degree (low strength of evidence [SOE]), but no study reported effects on staff retention. Current evidence is insufficient to determine effects on clinical and most economic outcomes, with the exception of emergency department utilization, which was reduced among older adults (low SOE). Given the relatively small number of studies directly evaluating the PCMH, and the evolving approaches to designing and implementing the medical home model, the authors caution that these findings should be considered preliminary. The PCMH evidence base is expected to double in the next two to three years.
    Date: November 27, 2012
  • Government Paying Twice for Some Veterans’ Healthcare
    The federal government spends a substantial and increasing amount of potentially duplicative funds on two separate managed care programs for care of the same patients. The number of Veterans concurrently enrolled in VA and Medicare Advantage (MA) increased from 485,651 in 2004 to 924,792 in 2009. The estimated VA healthcare costs for MA enrollees totaled $13 billion over six years, increasing from $1.3 billion in 2004 to $3.2 billion in 2009. Among MA plans, the proportion of Veterans eligible for VA healthcare ranged from 0.5% to 21%, and the proportion of VA users within these plans ranged from 0.2% to 16%. For this dually-enrolled patient population, VA financed 44% of outpatient visits, 15% of acute medical and surgical inpatient admissions, and 18% of acute medical and surgical hospital days.
    Date: June 26, 2012
  • Barriers to Healthcare Access for Women Veterans
    This study examined the association of general and Veteran-specific barriers on access to healthcare among women Veterans. Findings showed that overall, almost 1 in 5 women Veterans (19%) delayed healthcare or went without needed care in the prior 12 months, including 14% of insured and 55% of uninsured women Veterans. VA healthcare users comprised 21% of those with and 13% of those without delayed healthcare or unmet needs. Younger age groups were associated with a higher prevalence of delayed care or unmet need. Among women Veterans delaying or going without care, barriers that varied by age group were: unaffordable healthcare; inability to take time off work; and transportation difficulties. A higher percentage of women with delayed care or unmet need, compared to those without, were racial/ethnic minorities, lacked a regular source or provider of healthcare, were uninsured, had low income, fair or poor health status, were disabled, and had mental health diagnoses. With respect to Veteran-related factors, women Veterans with delayed care or unmet need were more likely than those without to be OEF/OIF Veterans, in a high-priority group for VA enrollment, and to have experienced military sexual assault.
    Date: November 1, 2011
  • Distance Most Important Barrier for Rural-Residing Veterans Seeking Healthcare
    This study of rural Veterans, providers, and staff examined the impact of travel distance on the use of VA healthcare services, satisfaction, and impact on care delivery. Findings showed that distance was identified by Veterans, providers, and staff as the most important barrier for rural Veterans seeking healthcare. The average one-way distance that Veterans traveled to a VA primary care clinic was 44.5 miles. The most common types of distance barriers discussed pertained to patient health, functioning, and financial or time resources. Other barriers frequently cited included challenges associated with travel, such as limited transportation and cost/expense. Veterans perceived the same travel distance as more burdensome when seeking care for regular services available locally (e.g. laboratory, podiatry), when compared with specialty care (e.g., cardiology, neurology). Many older Veterans who were able to drive viewed distance more as a ‘way of life’ than a ‘barrier.’ However, given that 44% of Veterans are >65 years old, travel distance is likely to become increasingly salient as a barrier in this aging population.
    Date: November 1, 2011
  • JGIM Special Supplement Highlights Access to VA Healthcare
    The JGIM Supplement includes both the white papers commissioned as background for the September 2010 state-of-the-art (SOTA) conference on “Improving Access to VA Care” and manuscripts submitted in response to a post-SOTA solicitation for original research and reviews pertaining to improving access to VA care. Articles focus on a myriad of topics related to improving access to care for Veterans, including: eHealth technologies (e.g., Care Coordination Home Telehealth program, and My HealtheVet personal electronic health record); measuring the impact of access on healthcare utilization, quality, and outcomes; and redefining access for 21st century healthcare.
    Date: November 1, 2011
  • Access to Healthcare and Framework for Reducing Hospital Readmissions
    This Commentary discusses how a patient’s level of access to healthcare can influence readmission risk, and proposes a broader framework that can be used to identify alternative strategies to reduce readmissions – a framework in which readmission rates are determined by access, social determinants of health, and regulatory policies.
    Date: October 26, 2011
  • VA Travel Reimbursement Increases Outpatient Visits
    This study examined the effects of a February 2008 policy change to increase Veterans’ mileage reimbursement rate (from 11 cents per mile to 28.5 cents per mile) on utilization of outpatient, inpatient, and pharmacy services in the 10.5 months before the reimbursement rate increase and the 10.5 months after the rate increase. Findings showed that after the reimbursement rate increase, eligible Veterans at all distances were 7% more likely to have at least one VA outpatient visit and had 3% more outpatient visits compared to Veterans who were not eligible for the travel reimbursement. The increased reimbursement was associated with slightly larger increases in outpatient costs to provide care to Veterans who lived farther away from VA facilities compared to those who lived closer. The odds of having a prescription filled at a VA pharmacy increased by at least 4% for Veterans across all distance definitions, with patients living farther than 50 miles away experiencing the largest increase at 9%. The reimbursement rate also was associated with a significant increase in pharmacy costs to provide medications to Veterans living farther than 50 and 75 miles from a VA facility. Inpatient visits remained generally unaffected, and there was no significant increase in cost.
    Date: August 24, 2011
  • Medicare-Eligible Veterans’ Reliance on VA Primary and Specialty Care Decreased Significantly from 2001 through 2004
    This study assessed longitudinal changes in patterns of cross-system healthcare use in VA and Medicare among Medicare-eligible Veterans who had used VA primary care in FY00. Findings showed that during the study period (FY01-FY04), 39% of all primary and specialty care visits occurred within VA, with almost three times more specialty care visits than primary care visits each year. However, a majority of specialty care and nearly half of all primary care for Medicare-eligible Veterans was provided outside VA over this time period. Reliance on both VA primary and specialty care decreased substantially over the study period but the decrease was greatest in specialty care. By FY04, only 20% of Medicare-eligible Veterans were completely reliant on Medicare for primary care (i.e., had 90% or more of their primary care visits with a Medicare provider) but 47% were completely reliant on Medicare for specialty care. Among Medicare-eligible Veterans, use of Medicare primary care increased among patients who were older, had a greater burden of illness, were served by a VA community-based outpatient clinic, or lived farther from a VA facility. Patient reductions in reliance on VA primary and specialty care suggest increasingly fragmented care and more difficult care coordination. Increasing use of non-VA services may complicate implementation of the PACT model, but also may emphasize new opportunities for care coordination initiatives within PACT.
    Date: June 16, 2011
  • Integrated Primary Care Clinic Improves Access to Mental Health and Social Services for OEF/OIF Veterans
    In April 2007, an OEF/OIF Integrated Care (IC) Clinic was established at the San Francisco VAMC, as part of VA primary care system-wide priorities for improving mental health screening and treatment for OEF/OIF Veterans. This study evaluated whether an initial IC clinic visit improved mental health and social services use among OEF/OIF Veterans entering primary care at the San Francisco VAMC, compared to Veterans who received usual care. Findings showed that OEF/OIF Veterans seen in the IC clinic were significantly more likely to have had initial mental health and social work evaluations within 30 days. Moreover, IC clinic patients were significantly more likely than usual care patients to have had at least one follow-up specialty mental health visit within 90 days of initiating primary care. Women Veterans, younger Veterans, and those with positive mental health and TBI screens were significantly more likely to have had mental health and social service evaluations if seen in the IC versus the usual care clinic. While the Integrated Clinic increased initial mental health evaluations, there was no significant increase in longer-term retention in specialty mental health services among Veterans who screened positive for mental health problems.
    Date: June 7, 2011
  • Less than One-Quarter of Veterans who Complete Suicide Access VA Healthcare in Year Prior to Death
    This study sought to determine the number of Veterans who completed suicide and who had accessed VA healthcare in the Pacific Northwest Region in the year prior to death. Findings show that of the 968 Veterans in this study who completed suicide, less than one-quarter (22%) accessed VA healthcare in the year prior to death, and a minority of those Veterans visited mental health providers. These numbers are consistent with current estimates of the number of Veterans accessing care at VA hospitals and clinics, and suggest that Veterans who go on to complete suicide may access VA healthcare at similar rates as Veterans who do not commit suicide. Of those Veterans who completed suicide, 57% did not have a mental health diagnosis, and 58% had not seen a mental health professional, suggesting that it is perhaps equally important to understand patients with general medical conditions who also may be likely to complete suicide. Of those who completed suicide, 55 were hospitalized during the year prior to death. Of these, 39% with a psychiatric hospitalization and 22% with a medical/surgical hospitalization completed suicide within 30 days. A large number of Veterans (73% of men; 36% of women) completed suicide by use of a firearm, supporting concerns from earlier studies over firearm access as a key risk factor in Veteran suicide.
    Date: April 4, 2011
  • Increasing Access to VA Primary Care via Community Clinics May Alter Veterans’ Use of Healthcare
    This study examined trends in primary care, specialty care, and mental health services use in VA and Medicare among Medicare-eligible Veterans who obtained community-based primary care or hospital-based primary care. Findings show that VA primary care patients who were eligible for Medicare used significant primary care and specialty care outside of VA, but not mental health care. Community-based VA patients used less VA care and more Medicare services, suggesting possible unintended fragmentation of care. Hospital-based VA patients were more likely than community-based patients to obtain primary care and specialty care only at VA. Dual use of VA and Medicare specialty care was the most common care pattern and the most fragmented among both community and hospital-based patients. Mental healthcare services were not fragmented, as most patients used VA only for these services. Use of Medicare only for outpatient primary and specialty care increased over the 4-year study, while use of VA only for these services decreased.
    Date: October 1, 2010
  • VA Increases Prescriptions for Smoking Cessation Medications among Veterans
    Since 2002, VA has implemented a range of policies and programs to increase evidence-based treatment for smoking. This study examined the change in rates of dispensing cessation-related medications to Veterans in the VA healthcare system to assess the impact of these policy changes. Findings show that VA policy initiatives instituted since 2002 have greatly increased prescriptions for smoking cessation medications among Veterans, while decreasing costs. The number of Veterans filling a prescription for nicotine replacement therapy (NRT) increased 63% from FY04 through FY08. Thirty-day-equivalent NRT prescriptions rose nearly 50% over the same period. Bupropion prescribing also rose sharply; the four-year growth rate among Veterans also prescribed a NRT was 61% greater than the 35% growth rate among all Veterans receiving bupropion prescriptions. While prescriptions for NRT and bupropion rose, spending per treated patient fell by 39% for bupropion and by 24% across all NRT formats (e.g., patch, gum).
    Date: September 24, 2010
  • VHA Policymakers May Need to Consider Additional Classification Schemes when Planning Care for “Rural” Veterans
    To better understand the issues confronting Veterans living in rural settings, VHA developed a three-category classification system that designates locations throughout the U.S. as Urban, Rural, or Highly Rural. To understand the policy implications of the VA classification system, this study compared VA’s categories to three Office of Management and Budget (OMB) and four Rural-Urban Commuting Area (RUCA, developed by the University of Washington and the USDA) geographical categories. Findings show that although the three classification schemes differ considerably in the number of VHA healthcare enrollees designated as Rural residents, they all show that the proportions of rural Veterans among enrollees are substantial. VHA’s Rural category (36% of its enrollees) is broadly defined and includes up to 3 to 5 times the enrollees included in the middle RUCA or OMB categories. VHA’s Highly Rural and Urban categories are defined more narrowly than in the other schemes, suggesting that VHA’s categories may more accurately reflect specifically urban or remotely rural populations. Of Veterans enrolled in VA healthcare, roughly 1 in 60 is a Highly Rural resident. If policymakers rely solely on either the RUCA or OMB category scheme, they might conclude that access standards have been met for the majority of VHA enrollees. However, the VHA scheme indicates that access standards have not been met for Veterans living in highly rural settings. Thus, authors suggest that policymakers supplement analyses of Rural Veterans’ healthcare needs with more detailed breakdowns from other classification systems.
    Date: September 1, 2010
  • Disparities in Healthcare Coverage and Access among American Indian/Alaska Native Veterans
    American Indian/Alaska Native (AIAN) Veterans have considerable disparities in healthcare coverage and acess to care compared to non-Hispanic white Veterans. For example, AIAN Veterans are nearly twice as likely to be uninsured, even after adjusting for sociodemographic and economic characteristics. AIAN Veterans are significantly less likely to report private coverage and significantly more likely to report public coverage, military coverage, and be uninsured. Regarding barriers to healthcare, AIAN Veterans were significantly more likely to delay healthcare due to not getting timely appointments, not getting through on the telephone, and having transportation problems.
    Date: June 1, 2010
  • Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings
    Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and quality.
    Date: May 11, 2010
  • VA Provides Broader Variety of Assistive Technologies for Veterans with Stroke at Lower Cost
    Findings from this study suggest that VA provides a broader variety of assistive technology devices (ATDs) at a lower cost than Medicare. In specific ATD comparisons, VA costs were substantially lower than Medicare for purchased items, and slightly lower than Medicare for capped rental payments. More than half of the ATDs provided by VA were ADL-related, compared to only 11% provided by Medicare. Findings also showed that 39% of the cohort had not received an ATD of any kind, while 56% received ATDs from VA only, 3% received ATDs from both systems, and 1% received an ATD from Medicare only. Analyses suggest that VA policy in providing ATDs is driven by Veterans’ needs, whereas Medicare policy may be driven, in part, by cost-containment needs associated with increases in fraudulent claims.
    Date: February 1, 2010
  • Therapy via Video-Teleconference as Effective as In-Person Treatment in Reducing Anger Problems in Veterans with PTSD
    Cognitive behavioral therapy (CBT) anger management conducted via video-teleconference was as effective as in-person delivery of the same treatment in reducing anger problems among Veterans with PTSD who live in rural settings. Moreover, mean improvements in the video-teleconferencing group were actually slightly larger than in the in-person treatment group. Veterans in both treatment groups benefited from anger management therapy (AMT), making this one of the few large randomized controlled trials to show meaningful benefits for reducing anger problems in Veterans with PTSD. Veterans in both treatment groups reported high rates of treatment credibility, satisfaction with care, homework adherence, and high alliance with the therapist.
    Date: January 26, 2010
  • Veterans’ Age and Disability Status Associated with Choice of Medicare Plans
    Medicare-eligible Veterans may choose between care in VA or Medicare (or both), and they also have to choose between obtaining Medicare services in the fee-for-service (FFS) sector or in a Medicare Advantage (MA) plan. This study sought to assess factors associated with enrollment in an MA vs. FFS plan in 2000-2004 among this population. Findings show that age and disability status were both significantly associated with choice of MA vs. FFS plan. For example, age-eligible Veterans were more likely to be enrolled in an MA plan if aged 75 or older, female, able to receive free VA care, or not enrolled in Medicaid, while disability-eligible Veterans were more likely to be enrolled if they were married or elderly. Minority Veterans and Veterans with lower disease risk scores (better average health) were more likely to be enrolled in an MA plan than white Veterans or Veterans with higher risk scores. Overall, Veterans living in zip codes with greater population density and higher per capita income were also more likely to enroll in an MA plan. The authors suggest that future studies examine the Medicare health plan choice of disabled Veterans, particularly OEF/OIF Veterans who begin to qualify for Medicare, to better understand the possible impact of MA enrollment on continuity, duplication, cost, and quality of care.
    Date: November 1, 2009
  • Effect of Medicare Pharmacy Benefit Coverage on VA Healthcare Users
    This study examined the influence of Medicare pharmacy benefit coverage on VA pharmacy use among Veterans using the VA healthcare system during 2002, who had diabetes mellitus, ischemic heart disease, or chronic heart failure. Overall, results showed that Veterans dually enrolled in VA and Medicare fee-for-service (FFS) were less likely to receive condition-related medications from VA compared with Veterans enrolled in HMOs with lower levels of prescription drug coverage. One implication of the overall study findings is that VA will become less the healthcare system of choice for Veteran beneficiaries if Medicare pharmacy services become more affordable. Moreover, Veterans with chronic conditions that require many medications and who hit a coverage gap in Medicare Part D or have difficulty making the Medicare co-payments may turn to VA as a safety net at intermittent times rather than using VA pharmacy services more steadily.
    Date: October 1, 2009
  • Geographic Access to Rehabilitation for OEF/OIF Veterans
    This study sought to ascertain specific geographic areas where the need for VHA rehabilitation services appears greatest and potential access gaps may exist. Findings show that VA provides access to rehabilitation care for the majority of traumatically injured OEF/OIF Veterans; however, more than 10% of Veterans may have potential access barriers due to excessive travel time. For the combined cohort, the median distance to Level I, Level II, and Level III facilities was 411 miles, 121 miles, and 64 miles respectively, and the median distance to the closest VA facility was 22 miles. Clark County, Nevada, and El Paso County, Texas had the highest number of patients with potential access gaps due to excessive travel times.
    Date: October 1, 2009
  • Use of Medicare and VA Healthcare among Veterans with Dementia
    This study sought to characterize healthcare use among Veterans with dementia over a four-year period (1998-2001), and to determine predictors of whether a Veteran will be a VA-only, dual, or Medicare-only user. Findings show that during the four-year study period, Medicare-only use increased while VA-only use decreased. Results also show that an increased likelihood of some Medicare use was associated with being older, white, married, and having higher education, private insurance or Medicaid, and low VA priority level. Further, the number of functional limitations was associated with an increased likelihood of Medicare-only use and a decreased likelihood of VA-only use, while higher comorbidities were associated with a higher likelihood of dual use as opposed to any single system use. The authors suggest that these results imply that different aspects of Veterans’ needs have differential effects on where Veterans seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure patients receive high quality care, particularly among those with multiple comorbidities.
    Date: October 1, 2009
  • Demands on VHA for Post-Deployment Healthcare Needs of OEF/OIF Veterans will be Overshadowed by the Needs of Older Veterans
    This article discusses the implications for the Veterans healthcare system of the demand for healthcare services from OEF/OIF Veterans. Findings show that although the pressing needs of newly discharged Veterans require immediate attention, especially in the areas of TBI, PTSD, and physical disability services, the demand for immediate post-deployment VA healthcare services by OEF/OIF Veterans will be overshadowed by the demands of aging Korean and Vietnam War Veterans (and, eventually, aging OEF/OIF Veterans), in terms of the number of patients and the average cost of their care. Thus, the major demand on VA healthcare services will be from aging Veterans whose usage and needs for services will be relatively stable and predictable; however, it is the extra cost for OEF/OIF Veterans that is difficult to quantify because of the unknowns (e.g., nature, severity, and number of PTSD and TBI cases).
    Date: September 1, 2009
  • Healthcare Utilization among American Indian and Alaska Native Veterans
    Findings show that like other VA healthcare users, American Indian and Alaska Native (AIAN) patients had the same three most frequent diagnoses associated with healthcare encounters: post-traumatic stress disorder, hypertension, and diabetes. VHA-Indian Health Service (IHS) dual-users were more likely to receive primary care from IHS and to receive diagnostic and behavioral healthcare from VA. Many dual-users who had been diagnosed with diabetes, hypertension, and/or cardiovascular disease received overlapping healthcare services in VA and IHS. Therefore, authors suggest that strategies to improve outcomes among the AIAN Veteran population should target those receiving care in both systems and include information sharing or coordination of clinical care to reduce the potential for duplication and for treatment conflicts.
    Date: June 1, 2009
  • Veterans with HIV Treated at Clinics with Integrated Specialty Services More Likely to Achieve Better Outcomes
    The most common way HIV clinics address patients with comorbidities is by integrating non-infectious disease providers (e.g., psychiatrists and social workers) into HIV primary care. This retrospective cohort study evaluated the association between Integrated HIV Care and patient outcomes among 1018 Veterans with HIV who received care at five VA facilities from 2000-2006. Findings show that Veterans who visited HIV clinics with more integrated specialty services were more likely to achieve viral suppression. In particular, Veterans visiting clinics that offered hepatitis, psychiatric, psychological, and social services in addition to primary care and HIV specialty services were three times more likely to achieve viral suppression than Veterans visiting clinics that offered only primary care and HIV specialty services. Results also showed that 93% of Veterans in this study had one or more comorbid conditions, with a mean of 3.2 comorbidities. Authors suggest that resources should be allocated to integrate sub-specialty services into HIV primary care clinics, and that providers should direct patients toward these clinics and retain them in care.
    Date: May 1, 2009
  • Access to Healthcare among Veterans with Bipolar Disorder
    Findings from this study show that despite the fact that all Veterans were currently receiving VA treatment for bipolar disorder, 15%-20% experienced trouble obtaining different aspects of healthcare when needed. Compared with accessing psychiatric care, Veterans with bipolar disorder reported greater difficulty accessing general medical services. Veterans experiencing current bipolar symptoms more frequently avoided psychiatric care due to cost, and perceived greater problems accessing medical specialists. As with mental healthcare services, the dominant influences predicting limitations in obtaining needed general medical care included living alone, an inpatient stay, homelessness, and current bipolar symptoms. The authors suggest that current VA efforts to expand mental healthcare access should be coupled with efforts to ensure adequate access to medical services for Veterans with chronic mental illness.
    Date: April 1, 2009
  • Diffusion of New Drug Therapy for PTSD Lessens with Distance
    This study sought to evaluate the pace and reach of the passive dissemination of a novel, but as yet un-established treatment with the drug prazosin for post-traumatic stress disorder (PTSD) within the VA health care system. Investigators used geographic surveillance data to track the diffusion of prazosin to treat Veterans diagnosed with PTSD in the VA Puget Sound Healthcare System (where the treatment was developed), and at VAMCs ranging up to 2500 miles or farther from Puget Sound. Findings show that the passive diffusion of a new treatment can be rapid in the immediate area in which it is developed, but the geographic gradient of use seems to be steep and changed little during a two-year period, even when cost and organizational barriers were minimal. Veterans with PTSD treated in the area nearest to Puget Sound (<499 miles) were about 63% less likely in 2004 and about 49% less likely in 2006 to be prescribed prazosin than their counterparts treated within Puget Sound. These results suggest that if and when new treatments are definitively demonstrated to be effective, more active dissemination is likely to be needed, especially in geographically remote areas.
    Date: April 1, 2009
  • Teledermatology – Promising Technique for Improving Access to Care
    In this study, teledermatology demonstrated good performance in comparison to clinic-based consultation for diagnostic agreement and diagnostic accuracy. Regarding diagnosis, teledermatologists agreed with each other and with clinic-based dermatologists at a rate comparable to group agreement among clinic dermatologists. Regarding accuracy, when compared to the gold standard of histology, rates ranged from 30% to 92% for clinic dermatologists and from 19% to 95% for teledermatologists.
    Date: April 1, 2009
  • Outpatient Healthcare Use for American Indian and Alaska Native Women Veterans
    American Indian and Alaska Native (AIAN) women are among the growing number of female Veterans who now seek VA healthcare. In 2003, VA and the Indian Health Service (IHS) executed a Memorandum of Understanding (MOU) to improve access and health outcomes for AIAN Veterans by encouraging cooperation and resource sharing. In order to inform inter-agency planning and coordination, this study reports on the demographic characteristics and healthcare utilization patterns of AIAN women Veterans at the outset of the MOU agreement. Findings show that regardless of group, the medical needs of female AIAN Veterans were similar to other Veterans, including other female Veterans. On average, Veteran dual-users received two-thirds of their healthcare at VA facilities, while non-Veteran dual-users received most of their healthcare at IHS facilities. The lowest outpatient utilization rate was for IHS-only users. Results also show that three of the most frequent diagnoses were hypertension, diabetes, and depression.
    Date: March 1, 2009
  • Physicians May Need More Education about Long-Term Care Options for Veterans
    The purpose of this study was to obtain information about VA long-term care (LTC) referrals that could be used to develop interventions that increase the likelihood of referrals to home and community-based services (HCBS) instead of institutional care. Findings indicate that physicians are often seen as having limited familiarity with HCBS options and tend to refer Veterans with LTC needs to nursing homes. Training physicians about LTC referral options, with particular focus on how HCBS can be used to meet Veteran and caregiver needs, may help to increase those referrals.
    Date: February 1, 2009
  • Increase in VA Prescription Co-Pay Leads to Decrease in Adherence to Statins for Veterans at Risk of Heart Disease
    VA’s increase in drug co-payments from $2 to $7 adversely affected lipid-lowering medication adherence among Veterans, including those at high risk of coronary heart disease. After the increase in medication co-payments, the percent of Veterans who were adherent to lipid-lowering therapy declined significantly, even for Veterans with no co-pay. The co-payment increase was also accompanied by a significant increase in the likelihood of having continuous gaps in lipid-lowering medication use.
    Date: January 27, 2009
  • Barriers to Bone Density Testing for Patients with Spinal Cord Injury
    Several barriers to routine bone mineral density assessment among the SCI population were identified, e.g., scanner design that limits accessibility, and increased scanning time that requires additional staff. To help lessen these barriers, investigators recommend several changes, such as: installing ceiling-mounted hydraulic lifts and grab bars to facilitate transfers in the screening room, increasing staff during scans, and partnering with administrators and staff to raise awareness of access issues faced by individuals with spinal cord injury.
    Date: January 1, 2009
  • Hospital Readmission More Likely Following VA vs. non-VA Hospitalization for Older Veterans Living in Rural and Urban Settings
    Regardless of where veterans lived (urban or rural setting), readmission after a VA hospitalization was more common than readmission after a non-VA hospitalization (20.7% vs. 16.8% for rural veterans; 21.2% vs. 16.1% for urban veterans). Authors suggest that VA consider using unplanned 30-day readmission rates as a component of quality assessment.
    Date: January 1, 2009
  • Factors Associated with VA Employee Participation in Quality Improvement Program to Reduce Patient Wait Times
    Perceived group norms and attitudes were related to greater individual participation in the Advanced Clinic Access program, but perceived behavioral control was not found to be significant to participation. Overall, survey respondents typically engaged in just under half of the change behaviors. Employees with greater responsibility (e.g., nurse practitioners, RNs, and physicians) participated in more activities compared to other clinic employees. Team size, academic affiliation, and job satisfaction were not significant predictors of participation.
    Date: November 1, 2008
  • Program Improves Access to Mental Health Care for Veterans
    This article discusses the implementation and outcomes for the first four years of the “Primary Mental Health Care Clinic” (PMHC) program, an innovative program developed at one VA medical center that shifted specialized staffing into an existing mental health clinic in primary care and added advanced clinical access in primary care. Waiting time for new appointments was shortened from a mean of 33 days to 19 minutes. Clinician productivity and evaluations of new referrals more than doubled. In addition, the program has reduced the number of veterans referred into the specialized mental health clinic, thus conserving resources.
    Date: November 1, 2008
  • Most Elderly Veterans Obtain High-Risk Surgeries in Non-VA Hospitals
    Regardless of where they live (rural vs. suburban vs. urban), most elderly veterans obtain high-risk procedures such as heart, vascular, and cancer surgeries in non-VA hospitals. Veterans generally traveled about as long to get to higher performance hospitals as to reach lower performance hospitals. Authors suggest that veterans might benefit from an effort to direct them to higher performance hospitals for these high-risk surgeries, and that this effort might best be initiated by focusing on veterans living beyond urban areas.
    Date: October 1, 2008
  • Psychotherapy Administered via Telephone Reduces Depression
    Findings show a significant reduction in depressive symptoms for patients enrolled in telephone-administered psychotherapy as compared to those in control conditions (e.g. treatment as usual). Moreover, attrition rates were considerably lower than rates reported in face-to-face psychotherapy.
    Date: September 1, 2008

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background-image  Cancer

  • Surgery Does Not Significantly Reduce Mortality among Patients with Prostate Cancer versus Observation after 20 Years of Follow-up
    This study reports on all-cause and prostate cancer mortality through nearly 20 years of follow-up and describes disease progression, treatments received, and patient-reported outcomes during follow-up. Findings showed that surgery (radical prostatectomy) did not significantly reduce all-cause mortality or prostate cancer mortality compared with observation in men with localized prostate cancer diagnosed in the early PSA era. “Any progression” of prostate cancer occurred in 41% of men randomized to surgery versus 68% randomized to observation. Most disease progression was local, and about half asymptomatic. Surgery may reduce mortality in men with intermediate-risk prostate cancer, depending on the pathological classification. However, surgery resulted in large long-term increases in urinary, erectile, and sexual dysfunction and smaller shorter-term adverse effects on physical function and activities of daily living. Authors suggest reducing overtreatment in men with localized prostate cancer, especially those with low-risk disease.
    Date: July 13, 2017
  • Patient and Provider Experiences with Comprehensive Lung Cancer Screening Program
    This article describes the organizational- and patient-level experiences with the VA Lung Cancer Screening Demonstration Project (LCSDP), and estimates the number of VA patients who may be screening candidates. Findings showed that participants in the LCSDP found implementing a comprehensive lung cancer screening program to be challenging and complex, requiring new tools (e.g., electronic tools to capture necessary clinical data in real time) and patient care processes for staff, in addition to dedicated patient coordination. There was wide variation in processes and patient experience among the study sites. For example, across the eight sites, 58% of patients who were offered screening agreed to be screened, ranging from 34% to 66% across the sites. Overall, 60% of the Veterans screened for lung cancer had a positive result, including having nodules that needing tracking, needing a workup for possible lung cancer, and being diagnosed with lung cancer. It is estimated that nearly 900,000 VA patients may be candidates for lung cancer screening. Implementation of lung cancer screening in the VA healthcare system will likely lead to large numbers of screen-eligible patients – and will require substantial clinical effort for both patients and staff.
    Date: March 1, 2017
  • Lung Cancer Screening Programs May Have Unintended Consequences on Beliefs about Smoking Cessation
    This study aimed to learn from patients who were offered screening how the availability of screening influenced their motivations regarding smoking cessation. Findings showed that current smokers attached exaggerated personal benefits to lung cancer screening. Misperceptions about susceptibility to harms from tobacco can be reinforced and potentially exacerbated by screening due to existing cognitive biases about smoking and exaggerated beliefs in the value of early detection provided by lung cancer screening. Five themes emerged around types of misperceptions related to cessation associated with screening: 1) screening was valuable because everyone screened would be protected, 2) screening would show how much damage had been caused by an individual’s smoking, 3) identification and monitoring of a lung nodule was evidence that cancer can be caught early (e.g., detection of a nodule meant that “screening was working”), 4) screening reduces the likelihood of needing cancer treatment (e.g., screening could cure cancer if the cancer was found early enough), and 5) screening verified the belief that smoking doesn’t harm everyone and “won’t harm me personally.”
    Date: September 1, 2015
  • Increase in Thyroid Cancer among Veterans Linked to Increases in Diagnostic Testing
    Investigators in this study examined the number of Veterans who were diagnosed with thyroid cancer in the VA healthcare system between 2000 and 2012, as well as the utilization of thyroid ultrasound (US) and fine needle aspiration (FNA), and then determined annual percent changes in incidence, use of thyroid US, and FNA. Findings showed that the incidence of thyroid cancer among Veterans within the VA healthcare system nearly doubled – from 10.3/100,000 persons to 21.5/100,000. Of the nearly 11 million Veterans who received healthcare during the study period, 8,870 were diagnosed with thyroid cancer. The number of Veterans who underwent a thyroid US increased from 4,493 in 2000 to 21,450 in 2012, and the number of Veterans who underwent a thyroid FNA increased from 275 in 2000 to 2,234 in 2012. Thus, the rates of US increased nearly fivefold, while the rates of FNA increased nearly sevenfold. Among Veterans receiving a thyroid cancer diagnosis, 69% underwent a thyroid US, 32% underwent a thyroid FNA, and 30% did not have either test in the VA healthcare system.
    Date: November 6, 2014
  • Screening for Hepatocellular Cancer
    This systematic review sought to review the benefits and harms of hepatocellular cancer (HCC) screening in patients with chronic liver disease. Findings showed that while screening for hepatocellular cancer can identify more patients with earlier stage disease who are candidates for potentially curative treatments, there is very limited evidence upon which to draw firm conclusions about the balance of health outcome benefits and harms of using routine screening to identify HCC. The body of evidence that serves as the basis for current recommendations for screening has substantial shortcomings.
    Date: June 17, 2014
  • Underuse of Colorectal Cancer Screening among Healthy Veterans and Overuse among Unhealthy Veterans
    This study examined whether the upper age cutoff of the colorectal cancer (CRC) screening quality measure is associated with overuse of screening among 70- to 75-year-olds who are in poor health (limited life expectancy, but within the target age range of the measure) – and underuse in those older than age 75 who are in good health (longer life expectancy, but outside the target age range of the measure). Findings showed that screening rates were relatively stable for Veterans between ages 50-75, but dropped precipitously after age 75. On average, 39% of 75 year-old Veterans were screened, while only 21% of 76 year-old Veterans were screened. However, a Veteran who was 75 years of age and unhealthy – in whom life expectancy may be limited and screening is likely to result in net burden or harm – was significantly more likely to undergo screening than a Veteran who was 76 years of age and healthy (35% vs. 21%, respectively). Future patient-centered quality measures should focus on clincial benefit rather than chronological age to ensure that patients who are likely to benefit from screening receive it (regardless of age), and that those who are are likely to incur harm are spared uncessary and costly care.
    Date: February 26, 2014
  • Gaps in Quality of Supportive VA Cancer Care for Veterans
    This study evaluated non-hospice supportive VA cancer care in a nationally representative sample of Veterans with stage IV metastatic lung, colorectal, and prostate cancers who were diagnosed in 2008. Quality of care was measured using the Cancer Quality-Assessing Symptoms and Side Effects of Supportive Treatment (ASSIST) quality indicators. Findings showed that, overall, Veterans received only about half (49%) of recommended care as measured by ASSIST quality indicators. Gaps in quality of cancer care included: inpatient pain screening was common (96%) but lacking for outpatients (58%); few Veterans had timely dyspnea evaluation (16%) or treatment (11%); only 4% of Veterans had a new diagnosis of depression identified; of patients at high risk for diarrhea from chemotherapy, 24% were offered antidiarrheals; only 18% of Veterans had their goals of care addressed in the month after a diagnosis of advanced cancer; and 64% of patients had timely discussion of goals ICU admission. Most Veterans who died (86%) were referred to palliative care or hospice before death and 72% had an advanced directive or surrogate decision maker documented in the medical record.
    Date: December 9, 2013
  • Home-Based Colorectal Cancer Screening Significantly Improves Screening Rates among Overdue Veterans in a Rural State
    This study sought to determine whether a simple 1-step mailing of a fecal immunochemical test (FIT) accompanied by educational materials would improve colorectal cancer (CRC) screening rates in Veterans who were overdue compared to Veterans who received educational materials only and to Veterans who received no mailings. Findings showed that mailing FITs and educational materials to Veterans overdue for CRC screening resulted in significantly higher screening rates than usual care or educational materials alone. At six months, 21% of Veterans in the FIT group had received CRC screening by any method compared to 6% in the educational materials-only group and 6% in the usual care group. Among respondents eligible for FIT, 90% completed and returned a FIT. Among Veterans in the FIT group, 8 (12%) received positive results. Of these Veterans, 6 received a colonoscopy, while the other 2 were advised against the procedure by their physicians due to terminal conditions. The overwhelming reason for not having at-home testing was that it was not recommended by their provider (62%).
    Date: October 25, 2013
  • National Campaign Reduces Prostate Cancer Imaging in Sweden
    This study assessed Sweden’s National Prostate Cancer Register effort to reduce inappropriate prostate cancer imaging by examining imaging trends over time across Sweden, taking into consideration clinical risk category (low, intermediate, high), geographic region, as well as patients’ age and comorbidity. Findings showed that prostate cancer imaging decreased over time, particularly for men in the low-risk (inappropriate imaging) category, among whom the imaging rate decreased from 45% to 3%, but also for men in the high-risk (appropriate imaging) category, among whom the rate decreased from 63% to 47%. Despite substantial regional variation, all regions in Sweden experienced significant decreases in prostate cancer imaging. Many previous guidelines and policy efforts have failed to reduce inappropriate prostate cancer imaging in the U.S. These results may inform current efforts to promote guideline concordant imaging, especially in a coordinated healthcare system such as VA.
    Date: September 4, 2013
  • Veterans with Prostate Cancer Living in Rural Settings have Less Access to Comprehensive Oncology Resources than Urban Veterans, but Receive Similar or Better Quality of Care
    This study sought to determine the degree to which access barriers impact the quality of prostate cancer care for rural patients in the VA healthcare system. Findings showed that Veterans with prostate cancer living in rural settings traveled nearly 5-fold further for care and were less likely to be treated at facilities with comprehensive cancer resources, compared with Veterans living in urban settings. Despite differences in access to resources, rural patients received similar or better quality of care for 4 of 5 measures (e.g., appropriate number of biopsies, no bone scan for low-risk disease, appropriate chemotherapy for progressive disease, and appropriate hormonal therapy for high-risk patients treated with radiation therapy). Time to prostate cancer treatment was similar for Veterans living in rural compared with urban settings (97 days vs. 106 days).
    Date: July 30, 2013
  • Veterans Receiving Primary Care in CBOCs Less Likely to Receive Several Types of Colon Cancer Screening Tests
    This study evaluated differences in the choice of colorectal cancer (CRC) screening test in Veterans receiving primary care at community-based outpatient clinics (CBOCs) and at VAMCs. Findings showed that Veterans receiving care at a CBOC were less likely to receive colonoscopy, sigmoidoscopy and double-contrast barium enema than Veterans receiving care at VAMCs, even after adjusting for rural location, distance from a parent VAMC, and other patient demographic and clinical characteristics. Lower rates of screening procedures were not offset by higher utilization of fecal occult blood tests, and were consistent in Veterans at average and high risk for CRC. The difference in the use of colonoscopy in CBOCs and VAMCs was larger for Veterans 65 years or older than for patients less than 65 years, suggesting that older Veterans who receive primary care through CBOCs may use more CRC screening services outside VA relative to those under 65. These findings provide indirect evidence of the importance of examining data from non-VA providers when making judgments about adherence to VA performance measures.
    Date: July 5, 2013
  • Rates of Breast Conserving Surgery Performed in VA for Women Veterans with Breast Cancer Comparable to Private Sector
    Previous research suggested a lower rate of breast-conserving surgery (BCS) for the treatment of breast cancer in VA than in the private sector. Combining VA administrative data with VA Centralized Cancer Registry (VACCR) data, this study analyzed utilization rates of BCS among a cohort of women Veterans. Findings showed that, based on procedures performed solely in VA, rates of breast-conserving surgery for women Veterans decreased from 51% in 2000 to 42% in 2006. However, after accounting for procedures conducted in the private sector and paid for by VA, the BCS rate was 60%, which is more in line with private sector data. This suggests that previously reported differences in BCS rates between VA and the private sector may have been caused by the referral of BCS cases to the private sector, but the retention of mastectomies within VA. No statistically significant differences in the use of BCS were found based on age, race, income, marital status, or distance to a VAMC. None of the facility characteristics (including volume) was found to be significantly associated with the use of breast conserving surgery.
    Date: July 1, 2013
  • Wait Times for Treatment at VAMCs Have Increased for Veterans with Colorectal Cancer
    This study examined treatment times from diagnosis to first-course therapy for Veterans with colorectal cancers, and assessed factors associated with prolonged wait times. Findings showed that wait times for treatment at VAMCs have significantly increased over time. For colon cancer, the median time to treatment increased by 68% over the study period, while the median time to treatment for rectal cancer increased by 74%. Among Veterans undergoing resection for colon cancer, the overall median time to treatment was 27 days, which increased from 19 (1998-2000) to 32 median days (2007-2008). Among Veterans with rectal cancer undergoing resection, the overall median time to treatment was 39 days, which increased from 27 (1998-2000) to 47 median days (2007-2008). The strongest factors associated with prolonged time to colectomy (>45 days) were patient age >75 years, year of diagnosis (2007-2008), treatment at a high-volume VAMC, and diagnosis and treatment at different facilities vs. the same VAMC. Predictors for prolonged time to first course of therapy for Veterans with rectal cancer were similar. Compared to Veterans with colon cancer, Veterans with rectal cancer had substantially longer wait times across every tumor, treatment, and hospital characteristic. The authors suggest this may be a result of the multi-modality diagnostic and treatment planning requirements for this type of cancer.
    Date: July 1, 2013
  • Cancer Genetics Toolkit Improves Quality and Frequency of Family History Documentation among VA Primary Care Patients
    Investigators in this study developed a cancer genetics toolkit designed to improve familial risk assessment and appropriate referrals for hereditary breast-ovarian cancer (HBOC) and Lynch syndrome. They then evaluated the impact of the toolkit by comparing clinician behaviors relating to documentation of cancer family history and referral for genetic consultation before and after its implementation in women’s primary care clinics. Findings showed that the toolkit increased the frequency and improved the quality of cancer family history documented by primary care clinicians; increased recognition of high-risk Veterans; and increased the numbers of appropriate referrals for genetic consultation. A clinical reminder in the electronic health record was a key component of the toolkit; when used, it was associated with a two-fold increase in cancer family history documentation, and history was more complete. In addition, veterans whose clinicians completed the reminder were twice as likely to be referred for genetic consultation.
    Date: June 13, 2013
  • Quality of VA Care for Veterans with Newly Diagnosed Lung Cancer is Markedly Higher than Previous Studies Suggest
    This study sought to determine the proportion of Veterans who did not receive evidence-based care who had a documented refusal or contraindication to recommended lung cancer therapy. Findings showed that when accounting for refusals and contraindications, the quality of care for newly diagnosed lung cancer was markedly higher than previous studies suggested. Adherence to quality indicators ranged from 81% for adjuvant chemotherapy in resected stage II/III non-small cell lung cancer (NSCLC) to 98% for curative resection of stage I/II NSCLC. However, many Veterans met quality indicator criteria without having received recommended therapy by having a refusal (0%-14%) or contraindication (1%-30%). Authors note that study results underscore the need for performance measurement systems that capture both patient refusals and medical contraindications. Using data that may not accurately capture quality of care may result in allocation of resources to improve quality where it is not indicated.
    Date: June 10, 2013
  • Colorectal Cancer Screening May Be Overused for Many Veterans
    Of 4,236 fecal occult blood tests (FOBTs) received by Veterans in this study, 21% met overuse criteria: 8% were done sooner than recommended after a previous FOBT, and 13% sooner than recommended after other procedures (colonoscopy, barium enema, or combination). FOBT overuse after prior FOBT declined between 2003 and 2009 (8%-5%), while overuse after other procedures increased (11%-19%). More than 11% of overused FOBTs were followed by colonoscopy within 12 months. FOBT overuse varied across facilities (9%-32%) and regions (12%-23%). Although the odds of FOBT overuse did not vary by patient demographics, they did increase by 16% with each additional outpatient visit.
    Date: July 19, 2012
  • Radical Prostatectomy Does Not Significantly Reduce All-Cause or Prostate-Cancer Mortality
    Among men with localized prostate cancer, which was detected during the early era of PSA testing, radical prostatectomy did not significantly reduce all-cause or prostate cancer mortality, as compared with observation, through at least 12 years. During the median follow-up of 10 years, 171 of 364 men (47%) assigned to radical prostatectomy died, compared with 183 of 367 men (50%) that were assigned to observation. Among men assigned to radical prostatectomy, 21 (6%) died from prostate cancer or treatment compared with 31 men (8%) assigned to observation. Sub-group analyses suggest that surgery might reduce mortality among men with higher PSA values and possibly among men with higher-risk tumors (absolute reductions in mortality between 7% and 13%), but not among men with PSA levels of 10 ng per milliliter or less, or among men with low-risk tumors. The effect of treatment on all-cause and prostate cancer mortality did not differ according to the patient’s age, race, co-existing conditions, or self-reported performance status. Peri-operative complications during the first 30 days after surgery occurred in 21% of men who underwent a radical prostatectomy, and included one death.
    Date: July 19, 2012
  • Despite Guidelines to the Contrary, High Rates of PSA Screening Found among Older Veterans with Limited Life Expectancy
    This study sought to identify medical center characteristics associated with prostate-specific antigen (PSA) screening among men with limited life expectancy. Findings showed that high rates of PSA screening were found among older Veterans with life expectancy of less than 10 years, with substantial variation across VAMCs. Among Veterans with limited life expectancy, 45% received PSA screening in 2003. Across 104 VAMCs, the PSA screening rate for this population ranged from 25-79%. VA medical center characteristics associated with higher PSA screening rates included: no academic affiliation, a ratio of mid-level providers to physicians >3:4, and location in the South. Use of incentives and high scores on performance measures did not significantly affect screening practices. The percentages of men screened with limited and favorable life expectancies were highly correlated, indicating that screening is being poorly targeted. As a result of this and other studies, VHA’s National Center for Health Promotion and Disease Prevention has developed a set of goals to reduce over-screening in older adults starting in FY12.
    Date: December 17, 2011
  • Caregivers of Veterans with Chronic Illness
    This study sought to identify predictors of caregiver strain and satisfaction associated with caring for Veterans with chronic illness. Findings showed that although 76% of caregivers reported feeling very self-confident in their caregiving role, more than one-third (37%) reported high strain. Overall, the mean caregiving satisfaction score indicated a moderate level of satisfaction. Caregiver characteristics that predicted strain included having less support, having depressive symptoms, and using paid help. Veteran characteristics that predicted caregiver strain included greater need for caregiving assistance in IADL (instrumental activities of daily living), and greater levels of depression. Predictors of lower caregiver satisfaction included less social support, older age, depression, and poor Veteran health status. Predictors of higher caregiver satisfaction included helping the Veteran with medical equipment and the coping style of “taking medication.” Both caregivers and Veterans reported similar levels of assistance provided, which were relatively low for ADL (activities of daily living) and IADL. However, caregivers reported providing a mean of 43 hours per week in assistance. Investigators suggest this may be due to the higher percentage of spouse caregivers in this sample, who are available for caregiving around the clock. A majority of caregivers expressed a need to know more about the Veteran’s medication.
    Date: November 22, 2011
  • High Rates of CRC Screening among Veterans Receiving VA Care
    This study examined colorectal cancer (CRC) testing rates in a national sample of Veterans to determine the modalities of CRC testing used and factors associated with the lack of fecal occult blood test (FOBT) card return. Findings showed that overall rates of CRC screening in the VA healthcare system were high (80%) among Veterans aged 51-75 years. This rate compares favorably with population estimates for the U.S., where only 60% of eligible Americans are estimated to have undergone a CRC screening test with either lower endoscopy or FOBT. Of Veterans who had received appropriate screening, the majority underwent colonoscopy in the prior 10 years (72%), followed by FOBT in the prior year (24%). A total of 31% of Veterans did not return FOBT cards that were provided. Factors associated with a lack of return included: younger age, non-Caucasian race, and current smoking. Secondary analyses in an augmented sample of women Veterans showed that findings were similar for both genders. As with men, smoking was associated with lack of FOBT return.
    Date: September 16, 2011
  • Long-Term Outcomes Following Positive Colorectal Screening
    Despite persistently low rates of follow-up colonoscopy in older adults with positive fecal occult blood test (FOBT) results, the long-term outcomes of screening and follow-up practices have not been described. This study examined outcomes following a positive screening FOBT result for 212 Veterans ages 70 years or older at four VA facilities in 2001. Both Veterans who did receive a follow-up colonoscopy and Veterans who did not were followed through 2008. Findings showed that, over a 7-year period, a little more than half of the older Veterans in this study received a follow-up colonoscopy after a positive FOBT. Among Veterans who received follow-up colonoscopy, more than 25% had significant adenomas or cancer detected, were treated, and survived for more than five years. Approximately 59% of Veterans who received follow-up colonoscopy had no significant findings, and 10% experienced complications from colonoscopy or cancer treatment. Among Veterans who did not receive follow-up colonoscopy, 57% underwent some form of follow-up other than colonoscopy (e.g., repeat FOBT or sigmoidoscopy) and 59% had more than one non-colonoscopy follow-up test. Nearly half of the non-colonoscopy group died of other causes within five years, and 3% ultimately died of colorectal cancer. Veterans with the best predicted life expectancy were less likely to experience net burden from screening than Veterans with the worst predicted life expectancy. These findings support guidelines that recommend using life expectancy to guide colorectal cancer screening decisions in older adults, and argue against one-size-fits-all interventions that simply aim to increase overall screening and follow-up rates.
    Date: May 9, 2011
  • No Racial Disparities in Adherence to CRC Screening among Veterans Receiving VA Care
    This study examined the contribution of demographic/health-related factors, cognitive factors, and environmental factors to racial disparities in colorectal cancer (CRC) screening in a nationally representative survey of Veterans ages 50 to 75. The effect of race on adherence to CRC screening guidelines was non-significant after adjusting for demographic/health-related factors and environmental factors. Adherence in both African American and White groups was substantially higher than the national average. The high rates of CRC screening are likely, in part, a result of various VA efforts initiated over the past decade to increase screening adherence. There were no racial differences in physican recommendations for CRC screening: 84% for African Americans and 85% for Whites. Among those who were adherent to CRC screening, African American Veterans had significantly lower rates of colonoscopy compared with White Veterans (47% vs. 57%) and significantly higher rates of fecal occult blood testing (60% vs. 53%).
    Date: March 1, 2011
  • Increased Wait Times for Surgical Cancer Treatment, Particularly at VA Medical Centers and NCI Cancer Centers
    This study sought to assess changes in wait times for initial cancer treatment over a decade (1995 - 2005) and to identify patient, tumor, and hospital factors associated with prolonged wait times, using data from National Cancer Institute (NCI)-designated cancer centers, VA medical centers, academic hospitals, and community hospitals. Findings show that wait times for cancer treatment progressively increased at all four hospital center types over the 10-year study period. The median time from diagnosis to treatment was significantly longer at VA medical centers and NCI-designated cancer centers compared to community hospitals for all eight cancers studied. For patients who were diagnosed and treated at the same hospital, the median time from diagnosis to treatment was longest at VA medical centers, and shortest at community hospitals. Patients were significantly more likely to undergo initial treatment more than 30 days following diagnosis if they were: older, African American, had more comorbidities, had Stage I disease, or were treated at NCI cancer centers or VA medical centers.
    Date: February 25, 2011
  • Electronic Record Intervention Improves Follow-Up of Veterans with Positive Colorectal Cancer Screening
    This randomized trial of eight VAMCs evaluated an electronic record intervention for follow-up of Veterans with a positive fecal occult blood test (FOBT). Findings show that a simple electronic intervention involving an automatic GI consult for Veterans with a positive FOBT result improved follow-up and reduced the time between a positive FOBT and GI evaluation, as well as complete diagnostic evaluation (CDE). The 30, 90, and 180 day GI consult rates improved 21% to 33% among intervention sites, but did not change in the usual care sites. Thirty, 90, and 180 day CDE rates improved 9% to 31% in intervention sites, but did not significantly change in usual care sites. Time to GI consult and CDE decreased significantly over time in the intervention sites, but remained unchanged in the usual care sites.
    Date: February 15, 2011
  • Rates of Liver Cancer and Cirrhosis Increase Significantly among Veterans with Hepatitis C Virus
    This study identified all Veterans with hepatitis C virus (HCV) who visited any of 128 VA medical centers over a 10-year period to examine the prevalence of cirrhosis, hepatic decompensation, and hepatocellular cancer, as well as risk factors that may be associated with an accelerated progression to cirrhosis. The number of Veterans diagnosed with HCV increased over the ten years from 17,261 to 106,242. Over the same time period, among HCV patients, the prevalence of cirrhosis increased from 9% to 18.5%, while the prevalence of liver cancer increased approximately 19-fold (from 0.07% to 1.3%). Regarding risk factors among HCV-infected Veterans, the proportion of patients with co-existing diabetes increased from 12% in to 23%, while the number of patients with HIV, hepatitis B virus, or a diagnosis of alcohol use declined slightly.
    Date: December 22, 2010
  • Education Intervention Decreases Inappropriate Prostate Cancer Screening among Veterans
    This study tested an e-mail-based intervention called “spaced education” (SE) that was developed to reduce clinicians’ inappropriate screening for prostate cancer. Findings show that during the intervention period (36 weeks), clinicians who received the spaced education intervention ordered significantly fewer inappropriate PSA screening tests than clinicians in the control group. Over the 72-week follow-up period, SE clinicians continued to order fewer inappropriate tests compared to controls, representing a 40% relative reduction in inappropriate screening. The impact of the intervention was unaffected by clincians’ age, gender, or provider type.
    Date: November 1, 2010
  • Prostate Screening Does Not Reduce Prostate Cancer or All-Cause Mortality
    In a 2006 review of the evidence, authors identified insufficient evidence to either support or refute the use of routine screening for prostate cancer. This article presents findings from their updated study, in which investigators sought to determine whether population-based screening reduces prostate cancer-specific mortality and/or all-cause mortality. They also examined its impact on quality of life, including adverse events (e.g., harms of screening from false-positive or false-negative results). Findings show that prostate cancer screening did not result in a statistically significant reduction in prostate cancer-specific or all-cause mortality. One of the studies in this review showed a marginally significant benefit for prostate cancer screening among a subgroup of men aged 55 to 69. Among this group, it was reported that 1,410 men would need to be screened, with 48 men needing prostate cancer treatment, to prevent one additional death from prostate cancer during a 9-year period. Any benefits from prosate cancer screening may take up to 10 years to accrue; therefore, the authors suggest that men with a life expectancy of less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. None of the studies reviewed provided detailed assessment of the effect of screening on quality of life or costs associated with screening.
    Date: September 1, 2010
  • Study Identifies Preventable Delays in Lung Cancer Diagnosis
    Preventable delays in lung cancer diagnosis among Veterans at two VA medical centers arose mostly from failure to recognize abnormal imaging results documented in the patients’ electronic health records (EHR) – and failure to complete key diagnostic procedures in a timely manner. Missed diagnostic opportunities were identified in 222 of the 587 (37.8%) cases in this study. Patient adherence contributed to 44% of the missed opportunities. Among missed opportunities attributed to failure to recognize a clinical clue documented in the EHR, the most frequently missed clue was an abnormal chest x-ray. Delays in completing follow-up of an abnormal chest x-ray and in performing first needle biopsy were the most common causes of missed opportunities related to failure to complete a requested clinical action. Median time to diagnosis in cases with and without missed opportunities was 132 days and 19 days, respectively. The authors suggest several potential solutions, including using VA’s electronic health record to improve clinician recognition and tracking of abnormal test results.
    Date: June 7, 2010
  • Study Examines the State of Colorectal Cancer and Finds Cause for Optimism, Particularly within the VA Healthcare System
    In contrast to the health disparities that are evident in the community, when colorectal cancer (CRC) outcomes were studied within an equal-access, integrated healthcare system, such as VA, racial disparities were markedly decreased or absent. The type of screening test used in the US has varied over the last decade, but colonoscopy is becoming the dominant modality. However, VA relies primarily on fecal occult blood tests (FOBT). From 1998 to 2003, the proportion of screened Veterans undergoing FOBT within VA increased from 82% to 90% compared to that of Veterans receiving screening colonoscopies, which decreased from 6% to 5%. From the perspective of population-based screening, VA is actually more successful than the general population at screening, and has CRC screening rates well above the national average.
    Date: June 1, 2010
  • Communication Regarding Health-Related Quality of Life between Cancer Patients and Providers
    Health-related quality of life (HRQOL) discussions between oncologists and patients were common, but the emphasis was often on treatment (e.g., side effects) and symptoms (e.g., pain), even in patients with advanced disease. All provider/patient encounters included some talk of HRQOL, ranging from 3% to 75% of the total conversation, with the average HRQOL discussion taking up 25% of the conversation. An analysis of topics showed that 56% concerned treatment, 14% concerned disease, and 3% concerned testing. Talk of emotions, mental health, and psychological HRQOL was introduced into the conversations more frequently by patients than providers and occurred in only 9% of the audio segments studied. Spiritual HRQOL also was introduced into the conversations more frequently by patients than providers, and was discussed in only 1% of all audio segments. The authors suggest that given the often intense emotional experience of patients with advanced cancer, oncologists may need to pay more attention to psychological, social, and spiritual HRQOL concerns.
    Date: May 1, 2010
  • Addressing Psychosocial Needs of Cancer Patients
    This Commentary discusses the nursing challenges of assessing and managing cancer-related distress, in addition to recommending assessment tools and further research. Measurement tools are available that are both well-established and feasible for nurses working within time-constrained environments.
    Date: April 1, 2010
  • Possible Determinants of Colorectal Cancer Diagnostic Delays among Veterans
    Findings suggest that there is variation within the VA healthcare system regarding the time from initial clinical event until the diagnosis of colorectal cancer (CRC). The median times from initial event to diagnosis were 91 days for screen-detected cancers, 74 days for bleeding-detected cancers, and 73 days for “other.” The CRC stage was III or IV for 57% of the study participants. Compared to screen-detected, bleeding detected and other diagnostic categories were associated with an increased risk of late-stage disease at diagnosis. Older age and any comorbidity level (compared to no comorbidities) were associated with a longer time to diagnosis. The South and West-Midwest regions were associated with a shorter time to diagnosis compared to the Atlantic region.
    Date: March 18, 2010
  • Surveillance Colonoscopy is Cost-Effective for Patients at High Risk for Developing Colorectal Cancer
    A modeling study examining different surveillance strategies for patients who have adenomas on their initial screening colonoscopy found that costs and benefits differed widely depending on the characteristics of the adenomas and the surveillance intervals. Performing routine screening colonoscopies every ten years in patients at low risk of developing colorectal cancer and surveillance colonoscopy every three years in patients at high risk was more costly, but also more effective than a “no surveillance” strategy where everyone got routine screening every ten years. Compared to no surveillance, this “3/10” strategy was highly cost-effective. Compared to the 3/10 strategy, a “3/5”strategy which conducted surveillance every 5 years on low-risk patients was considerably more costly, but only marginally more effective. A “3/3” strategy was cost-ineffective and potentially harmful in comparison to less intensive surveillance. Based on these results, the authors suggest that the 3/10 strategy is the optimal strategy under the vast majority of clinical circumstances for patients with adenomas on screening colonoscopy.
    Date: March 10, 2010
  • Characteristics and Needs of Veteran Cancer Survivors
    Findings show that 11% of the Veterans treated within the VA healthcare system in FY07 were cancer survivors. The most common cancer types were prostate, skin (non-melanoma), and colorectal. Compared to the general population, Veteran cancer survivors are older (84% are older than 60) and predominantly male (97%). Cancer site prevalence statistics vary between the VA and general U.S. cancer patient populations due to differences in age, gender, and risk factors. Overall, the four common symptom concerns reported by cancer survivors are sexual dysfunction, fatigue, anxiety, and depression. The authors suggest that Veteran-specific research is needed on topics such as cancer survival among older Veterans, and the role of military exposures (physical, emotional, and psychological) in causing cancer and impacting recovery. The authors also suggest that four models of care may be relevant to improving care for Veterans who have survived cancer: 1) cancer survivorship clinics, 2) cancer care transition plans, 3) rehabilitation, and 4) chronic disease management. These models of care may help integrate the physical and mental health needs of cancer survivors.
    Date: March 1, 2010
  • Fixing an Electronic Communication Problem that Reduced Follow-Up of Positive Cancer Screens at One VAMC
    This study sought to determine if technical and/or workflow-related aspects of automated communication in VA’s electronic health record could lead to the lack of response to a positive fecal occult blood test (FOBT). A problem with software configuration at one VA medical center intended to alert VA primary care physicians about positive FOBT results led to breakdowns in transmission of a subset of test results. About one-third of the 490 positive FOBTs examined for this study were not directly reported to PCPs as CPRS alerts. Upon correction of the technical problem, lack of timely follow-up of test results decreased from 29.9% to 5.4% -- and was sustained for four months following the intervention. The authors recommend that electronic communication of positive FOBT results should be monitored to avoid limiting the benefits of colorectal cancer screening. They are currently investigating whether this problem exists in other VA facilities, or if this was an isolated event.
    Date: December 9, 2009
  • Intensive Surveillance following Colorectal Cancer Increases Survival
    This article reviews the clinical trials and evidence that inform the current approach to surveillance among colorectal cancer (CRC) survivors, as well as clinical guidelines developed by various organizations. Overall, findings suggest that intensive surveillance, particularly in the first 2-3 years of follow-up, appears to be associated with the early detection of recurrences, and thus has a beneficial impact on all-cause survival at five years. Imaging tests of the chest and abdomen have also increasingly been recommended by professional organizations to detect resectable recurrences.
    Date: December 1, 2009
  • Electronic Reminder Increases Follow-Up Rates for Positive Fecal Occult Blood Tests
    Screening with fecal occult blood tests (FOBT) reduces colorectal cancer mortality by 15-33% and decreases the incidence of the disease by 20%; however, as many as 46-66% of patients with an abnormal FOBT do not receive proper diagnostic testing (e.g., follow-up colonoscopy). This study sought to determine the impact of an electronic reminder on the timeliness and proportion of Veterans referred to gastroenterology (GI) for evaluation after a positive FOBT. Findings show that the electronic reminder was associated with a significant improvement in the proportion and timeliness of follow-up for Veterans with a positive FOBT. The intervention was associated with a 20.3% increase in GI consultations within 14 days, and the median time to colonoscopy decreased by 38 days (105 vs. 143 days).
    Date: September 1, 2009
  • Strategies to Improve Follow-Up for Positive Colorectal Cancer Screening
    In 2006, VA launched a national effort to increase the proportion of patients receiving a colonoscopy within 60 days of a positive fecal occult blood test (FOBT). This study sought to determine the proportion of VA patients with a positive FOBT between March and June of 2007 that received a colonoscopy within 60 days. Investigators also examined data from a 2007 web-based survey that was completed by 132 VAMCs on their FOBT follow-up quality improvement strategies. Results show that only 1 in 4 Veterans received follow-up colonoscopies within 60 days of a positive FOBT for colorectal cancer screening. Findings also show that developing QI infrastructure appears to be an effective strategy for improving FOBT follow-up, when this work is followed by process improvements (e.g., strategies to decrease cancellations, revise colonoscopy prep education protocols). On average, facilities indicated that they had fully implemented 6.84 of 16 improvement strategies. The number of strategies fully implemented was positively associated with 60-day follow-up. The most commonly cited barriers to improvement involved capacity constraints, e.g., sites listing insufficient gastroenterology staff as a barrier had a lower percentage of Veterans receiving timely follow-up. However, none of the improvement strategies designed to address gastroenterology capacity constraints were associated with timely follow-up, suggesting that this barrier may be more difficult or take more time to address than process inefficiencies.
    Date: August 1, 2009
  • Many Healthy Older Veterans Not Being Screened for Colorectal Cancer
    Many healthy older Veterans with substantial life expectancies are not being screened, while some with severe comorbidity are being screened. For example, only 47% of Veterans aged >70 without comorbidity were screened despite having a high probability of living >5 years. Number of outpatient visits was a strong predictor of screening, independent of comorbidity. Veterans without comorbidity who did not attend a VA primary care, gastroenterology, or general surgery clinic had a lower incidence of screening than patients with severe comorbidity who visited these clinics.
    Date: April 7, 2009
  • Multi-faceted Quality Improvement Intervention Improves Follow-up Colonoscopy for Veterans with Positive Colorectal Cancer Screening Test
    Inadequate follow-up of abnormal fecal occult blood test (FOBT) screening for colorectal cancer (CRC) may be related to patient, provider, or system-level factors. Thus, in calendar years 2004 and 2005 the Houston VAMC implemented multi-faceted quality improvement (QI) activities to improve follow-up of positive FOBT results. This study examined the effects of these activities on timeliness and appropriateness of positive-FOBT follow-up for 800 Veterans, and also identified factors that affect colonoscopy performance. Findings show that in cases where a colonoscopy was indicated, the proportion of Veterans who received timely referral and performance was significantly higher after the implementation of the QI activities. In addition, there was a significant decrease in median times to colonoscopy referral and performance. However, colonoscopy was not indicated in more than one-third of Veterans with positive FOBTs, raising concerns about current screening practices and the appropriate performance measures related to CRC screening.
    Date: April 1, 2009
  • Ethnic Differences in Self-Reported Cancer Screening
    Several studies suggest that non-whites may be more likely than whites to over-report screening behavior, which may have considerable implications for research on racial and ethnic disparities in cancer screening. Findings from this study show that racial and ethnic minorities may be less likely to provide accurate reports of their cancer screening behavior and that over-reporting may be particularly problematic. Research suggests that this might be rectified by changing how screening questions are worded and developing different methods for data collection. A conceptual framework offered by study investigators has the potential to guide exploration of where and why possible bias may be occurring and suggests ways in which these biases might be reduced.
    Date: February 1, 2009
  • Do Delays in Diagnostic Colonoscopy Affect Colorectal Cancer Outcomes?
    No meaningful association was found between mortality in veterans with colorectal cancer (CRC) and lag times between referral for colonoscopy and CRC diagnosis for periods up to two-three months.
    Date: November 1, 2008
  • Physicians May Lack Empathy in Treating Veterans with Lung Cancer
    Physicians rarely responded empathically to lung cancer patients’ concerns and generally responded more consistently with empathy when patients presented concrete and positive, rather than abstract or negative concerns. The authors note that there may be several reasons why physicians may not display empathy; for example, they may be too busy to recognize opportunities, or they may believe that biomedical information is more reassuring.
    Date: September 22, 2008
  • Cancer Treatment Rates Low among Elderly Veterans
    Cancer treatment was more common among younger elders (age 70-84) and the authors suggest that it is possible that an exaggerated level of trepidation regarding treatment ramifications among the elderly may be an obstacle to appropriate treatment in patients who could benefit from it.
    Date: September 1, 2008
  • Variation in Care for Recurrent Non-Melanoma Skin Cancer in a University-Based vs. VA Practice
    Treatment choices differed significantly between the two sites: after adjusting for patient, tumor, and clinician characteristics that may have affected treatment choice, tumors treated at the university-based site remained significantly more likely to be treated with Mohs surgery. There was no evidence that the quality of care varied at the two sites.
    Date: September 1, 2008

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background-image  COPD

  • Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008
    This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care.
    Date: December 1, 2011
  • Caregivers of Veterans with Chronic Illness
    This study sought to identify predictors of caregiver strain and satisfaction associated with caring for Veterans with chronic illness. Findings showed that although 76% of caregivers reported feeling very self-confident in their caregiving role, more than one-third (37%) reported high strain. Overall, the mean caregiving satisfaction score indicated a moderate level of satisfaction. Caregiver characteristics that predicted strain included having less support, having depressive symptoms, and using paid help. Veteran characteristics that predicted caregiver strain included greater need for caregiving assistance in IADL (instrumental activities of daily living), and greater levels of depression. Predictors of lower caregiver satisfaction included less social support, older age, depression, and poor Veteran health status. Predictors of higher caregiver satisfaction included helping the Veteran with medical equipment and the coping style of “taking medication.” Both caregivers and Veterans reported similar levels of assistance provided, which were relatively low for ADL (activities of daily living) and IADL. However, caregivers reported providing a mean of 43 hours per week in assistance. Investigators suggest this may be due to the higher percentage of spouse caregivers in this sample, who are available for caregiving around the clock. A majority of caregivers expressed a need to know more about the Veteran’s medication.
    Date: November 22, 2011
  • Veterans with COPD Living in Isolated Rural Areas have Elevated Risk of Mortality
    This study sought to determine if COPD mortality is higher for Veterans living in isolated rural areas, and, if so, to assess whether or not hospital characteristics mediate such associations. Findings showed that Veterans living in the most isolated rural areas of the United States appear to have an elevated risk of COPD-related 30-day mortality. Overall unadjusted mortality was higher for Veterans from isolated rural areas (5.0%) and rural areas (4.0%) compared to Veterans from urban areas (3.8%). Hospital characteristics were not found to account for this effect. Veterans from isolated rural but not rural areas remained at higher risk for death after adjusting for clinical characteristics, the proportion of COPD admissions in hospitals that came from rural areas, and hospital volume.
    Date: July 19, 2011
  • Simple Disease Management Program Significantly Reduces Hospitalizations and ED Visits for Veterans with COPD
    This study sought to determine if a simple disease management program, with a focus on early recognition and self-treatment of COPD exacerbations, would improve outcomes in Veterans with severe COPD. Findings show that the program reduced the total frequency of COPD hospitalizations and emergency visits by 41%. After one year of follow-up, the average number of COPD-related hospitalizations per patient was 30% lower in the disease management group compared to the usual care group, and the average number of COPD-related ED visits was 50% lower. The percentage of patients who experienced at least one COPD-related hospitalization was 23% in the usual care group and 17% in the disease management group; for COPD-related ED visits, the percentages were 23% and 14%, respectively. On average, patients in the disease management group spent 36% less time in the hospital for all causes, and also spent less time in the intensive care unit.
    Date: October 1, 2010
  • Lower Mortality for African American Veterans with COPD Exacerbation not Explained by More Aggressive Care
    This study sought to determine the potential impact of racial differences in ICU admission and the use of ventilator support on mortality among African American and white Veterans admitted to VA hospitals with COPD (chronic obstructive pulmonary disease) exacerbation. Findings show that mortality was lower in African American Veterans compared to white Veterans, even after adjusting for differences in ICU admission rates and ventilator support. However, mortality was similar for African Americans and whites receiving mechanical ventilation (28.8% vs. 31.4%), thus the lower risk-adjusted mortality among African Americans was not explained by more aggressive care.
    Date: July 1, 2009
  • Inhaled Corticosteroids Associated with Higher Glucose Levels in Veterans with Diabetes, but Effect was Dose-Dependent
    This study examined the association between inhaled corticosteroids and glucose concentration among Veterans who received care at seven VA primary care clinics between 12/96 and 5/01. Of the 1,698 Veterans in this study, 19% also had self-reported diabetes. Findings show that after controlling for systemic corticosteroid use and other potential confounders, no association was found between inhaled corticosteroids and serum glucose for Veterans without diabetes. However, among Veterans with diabetes, every additional 100 mcg of inhaled corticosteroid dose was associated with increased glucose concentration. Given this association, authors suggest that clinicians anticipate an increase in serum glucose for patients with diabetes who are using inhaled corticosteroids and adjust serum glucose monitoring accordingly.
    Date: May 1, 2009
  • African-American Veterans More Likely than White Veterans to Receive Mechanical Ventilation for COPD
    African-American Veterans with COPD exacerbation in VA hospitals are more likely than white Veterans to receive mechanical ventilation, and this difference is not explained by available clinical or demographic variables. By contrast, African-American and white Veterans are equally likely to receive non-invasive ventilation (NIV) when being treated for COPD exacerbation. Authors suggest that there is no underuse of mechanical ventilation and NIV in the treatment of racial minorities in this patient population; however, unmeasured factors, such as patient preferences or disease severity may be affecting the use of mechanical ventilation, and thus warrant further investigation.
    Date: January 1, 2009
  • Mortality Risk Associated with Respiratory Medications in Veterans with Newly Diagnosed COPD
    Inhaled corticosteroids and long-acting beta-agonists were associated with a reduction in the odds of all-cause death. Ipratropium was associated with an 11% increase in the risk of death.
    Date: September 16, 2008

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background-image  Data Use

  • Application of Triggers on VA “Big Data” may Help Identify Patients Experiencing Delays in Diagnostic Evaluation of Chest Imaging
    Triggers offer one method to use big electronic health record (EHR) data to prevent and mitigate the impact of delays in care related to missed test results. Triggers consist of computerized algorithms that can scan thousands of patient records to flag those with clues suggestive of patient safety events. This study tested the application of a trigger within VA’s EHR to help identify delays in patient follow-up related to abnormal chest imaging results. Findings showed that the trigger identified delays in patient follow-up with a reasonable accuracy for use in the clinical setting, suggesting that triggers are able to identify almost all delays related to abnormal lung imaging follow-up, and cost-effectively minimize the amount of effort providers spend reviewing false-positive results.
    Date: September 1, 2016
  • Data from Electronic Health Records Can Predict and Possibly Prevent Missed Patient Appointments
    This study sought to develop a model that identifies patients at high risk for missing scheduled appointments (no-shows and cancellations), and to project the impact of predictive over-booking in a gastrointestinal (GI) endoscopy clinic – a resource-intensive environment with a high no-show rate. Findings showed that information from electronic health records can accurately predict whether patients will no-show. The model used in this study was able to correctly classify 711 out of 888 attended appointments, and 317 out of 538 missed appointments. The strongest predictor of no-show was a patient’s cancellation history – the proportion of all outpatient appointments missed. Veterans with histories of mood or substance use disorder, and those with a greater overall disease burden also were less likely to keep appointments. Predictors of being more likely to keep appointments included: being married, having a history of diverticular disease, attending a colonoscopy education class, and having care partly funded by VA. Urgency of appointment, race, ethnicity, and day of the week of appointment were not significant predictors of appointment no-shows. Compared to a strategy that employs a fixed level of overbooking, predictive over-booking was much less likely to lead to days where the clinic was substantially over- or under-booked.
    Date: December 1, 2015
  • Majority of Male VA Enrollees Similar to Medicare Beneficiaries, Suggesting Greater Generalizability of Research Findings
    This is the first study to assess the extent to which Veterans enrolled in VA healthcare have similar demographics and health characteristics as individuals with Medicaid, Medicare, and/or private insurance coverage. Findings showed that a majority of male Veterans enrolled in VA healthcare were similar in both demographics and health characteristics compared to Medicare beneficiaries, but this overlap decreased when comparing Veterans to individuals enrolled in Medicaid or those with private insurance. The proportion of overlap was 21%, 34%, and 41% for the Medicaid, privately insured, and Medicare comparison populations, respectively. When restricting the analysis to males, the proportion of overlap increased to 28% for Medicaid enrollees, to 39% for privately insured adults, and to 55% for Medicare beneficiaries. When restricting the analysis to elderly males (age 65+), the proportion of overlap increased from 55% to 65% for Medicare beneficiaries, suggesting that 2 of every 3 elderly male VA enrollees had a male beneficiary enrolled in Medicare sharing a similar set of characteristics. Findings of intervention studies conducted among VA healthcare enrollees may be generalized to some non-VA populations, particularly male Medicare enrollees. Further, effective interventions developed in elderly and/or male non-Veteran populations may be applicable to comparable VA users.
    Date: November 20, 2015
  • Study Compares Data Sources for Provider Financial Incentives
    This study examined how well data from automated processing of EHRs (AP-EHR) reflect data collected via manual chart review, and assessed the potential impact of data collection methods on incentive earnings for physicians and provider groups participating in a trial evaluating pay-for-performance for hypertension care. Findings showed that the total amount of incentives disbursed to providers would have been lower (by 10%) using the AP-EHR data to reward performance because this method under-reported the number of Veterans receiving appropriate medications – compared to manual review. Regarding how well the AP-EHR reflect data from manual review, results show almost perfect agreement for the BP control measure: manual review indicated 70% of Veterans had controlled BP compared to 67% by AP-EHR review. Moderate agreement was found between the data sources for the use of guideline-recommended anti-hypertensive medication: manual review showed 72% of Veterans were considered to have received guideline-recommended anti-hypertensive medications compared to 65% by AP-EHR. And low agreement was found for the appropriate response to uncontrolled BP: manual review showed that 52% of Veterans received an appropriate response for uncontrolled BP compared to 40% by AP-EHR review. Given the large amount of resources needed for chart review endeavors, investigators feel that a 10% difference in the total amount of incentive earnings disbursed based on AP-EHR data compared to manual review is acceptable.
    Date: October 1, 2015
  • NEJM Perspective Discusses Withholding of CMS Data Related to Substance Use Disorder and Its Impact on Research
    In November 2013, the Centers for Medicare and Medicaid Services (CMS) began to withhold from research data sets any Medicare or Medicaid claim with a substance use disorder (SUD) diagnosis or related procedure code. This move — the result of privacy-protection regulations overseen by the Substance Abuse and Mental Health Services Administration — affects about 4.5% of inpatient Medicare claims [recent research suggests this figure is closer to 7%] and about 8% of inpatient Medicaid claims from key research files, impeding a wide range of research evaluating policies and practices intended to improve care for patients with substance use disorders. As a consequence, VA researchers cannot see the full utilization of Veterans who also use Medicare- or Medicaid-financed healthcare. This Perspective summarizes the problem, quantifies it, describes how it arose, and argues that research access to such data should be restored.
    Date: April 15, 2015
  • Factors Affecting Patient Test Results Follow-Up within VA’s Electronic Health Record System
    This study sought to identify facility-level contextual factors that increase or decrease the risk of missed test results in 40 VA healthcare facilities from across the U.S. Findings showed that primary care providers (PCPs) at VA facilities that used additional strategies or systems to prevent missed test results preceived less risk of missing test results. However, few VA facilities used monitoring strategies to prevent missed test results. For example, facilities monitored follow-up of certain test results only when they considered them “critical” (e.g., x-ray suggestive of malignancy), but the processes for doing so were highly variable. Qualitative analysis identified three high-risk scenarios for missed test results: 1) alerts on tests ordered by trainees (important because 78% of VA facilities were training sites for one or more medical residency programs); 2) alerts “handed off” to another covering clinician; and 3) alerts on patients not assigned in the electronic health record to a PCP. Interventions to reduce missed test results might need to target organizational factors and not just individual providers; for example, monitoring systems to track missed test results.
    Date: November 11, 2014
  • VA’s “Big Data”: Benefits and Challenges
    This paper provides an overview of VA’s evolving approach to “big data” and illustrates how advanced analytics support clinical activities, with particular emphasis on the Patient-Aligned Care Team (PACT) model of patient-centered primary care. It also shares some of the challenges, concerns, responses, and future plans that have emerged from these initiatives.
    Date: July 9, 2014
  • Prediction Model Using VA Data May Help Identify Primary Care Patients at Increased Risk for Hospitalization or Death
    In an attempt to identify high-risk patients, investigators in this study developed statistical models using health information from VA’s clinical and administrative databases to predict the risk of hospitalization or death among all Veterans who were assigned to a primary care provider as of 10/1/10. Findings showed that prediction models using electronic clinical data accurately identified Veterans receiving VA primary care who were at increased risk of hospitalization or death. Of the top 5% of Veterans in terms of predicted risk, 51% were hospitalized or died within the following year. Predictors of death were quite different from predictors of hospitalization. In general, clinical and demographic characteristics (i.e., increasing age, metastatic cancer) were most predictive of death, while recent use of health services was most predictive of hospitalization. The authors suggest that in clinical settings, these values can be used to identify high-risk patients who might benefit from care coordination and special management programs, such as intensive case management, telehealth, home care, specialized clinics, and palliative care.
    Date: April 1, 2013
  • Natural Language Processing with Electronic Medical Record Improves Identification of VA Post-Operative Complications
    This study evaluated a natural language processing (NLP) search approach to detect post-operative surgical complications within VA’s electronic medical record (EMR). Findings showed that, among Veterans undergoing inpatient VA surgery, NLP using the EMR greatly improved the identification of post-operative complications compared to an administrative-code based algorithm. NLP correctly identified 82% of acute renal failure cases compared with 38% for patient safety indicators; 59% vs. 46% for venous thromboembolism; 64% vs. 5% for pneumonia; 89% vs. 34% for sepsis; and 91% vs. 89% for post-operative MI. An accompanying Editorial states that NLP has the potential to greatly enhance the EMR with new applications, such as automated quality assessment to assist in the performance of comparative effectiveness research.
    Date: August 24, 2011
  • Using Administrative Data to Measure Treatment for Veterans with PTSD May Overestimate Delivery of Psychotherapy
    This study sought to determine whether using administrative data to determine the number of psychotherapy sessions Veterans receive is equivalent to manual record review. Manually-classified notes were used to develop an automated coding protocol using the Automated Retrieval Console (ARC), a VA-developed natural language processing program. ARC was then used to independently code the notes, and the performance of the automated coding program was compared to manual coding. Findings showed that, of the notes that were administratively coded as individual psychotherapy for PTSD, 57% were coded as individual psychotherapy after manual review of records. Thus, nearly half of the encounters that would have been counted as the provision of psychotherapy in large administrative studies appeared to be records of services other than psychotherapy (e.g., intakes, psychological testing). Findings suggest that using counts of administrative codes over-estimates the amount of psychotherapy delivered to Veterans with PTSD. This suggests a potential limitation in current studies of the quality of care for PTSD in VA. The ARC program replicated the performance of the manual coders in classifying psychotherapy notes very well. This suggests that ARC may help bridge the gap between the accuracy of manual coding and the scope of administrative coding.
    Date: February 14, 2011
  • Validity of Mental Health Diagnosis Using VA Administrative Data
    This study estimated the validity of eight ICD9-based algorithms for the identification of mental health disorders in administrative data among 124,716 Veterans with diabetes who used the VA healthcare system in 1998, and also participated in the 1999 Large Health Survey of Veteran Enrollees, which included questions about history of mental health diagnoses. Findings show that many Veterans with a diagnosed mental health disorder can be identified through VA administrative data; however, the choice of algorithm influenced conclusions. Since the limitations of administrative data cannot be fully eliminated with any algorithm, the authors suggest that investigators and quality improvement programs also consider conducting sensitivity analyses in which they vary the algorithm, in order to indicate how different assumptions affect conclusions.
    Date: January 1, 2010
  • “Rights” of Safe Electronic Health Record Use
    This JAMA Commentary proposes eight “Rights” of safe electronic health record (EHR) use, which are grounded in an engineering model that addresses work-system design for patient safety. The authors recommend the use of the eight “Rights,” in order to address the complex interaction of organizational, technical, and cognitive factors that affect the safety and effectiveness of EHRs.
    Date: September 9, 2009
  • Federal Investment in Electronic Medical Records
    The American Recovery and Reinvestment Act (ARRA) includes $19 billion in incentives for the adoption of electronic medical records (EMRs) and $50 billion to promote health information technology. Medicare physicians adopting and making “meaningful use” of EMRs in 2011 and 2012 will be eligible for an initial payment of up to $18,000, with reduced payments in 2013 and 2014. However, current EMR systems’ inability to learn from aggregated health data has led to implementations and hospital information technology departments that can actually obstruct quality improvement. For example, much of the information contained in EMRs is formatted as unstructured free text – useful for essential individual communication but unsuitable for detecting quantifiable trends. This commentary suggests that the Department of Health and Human Services capitalize on the opportunity to mandate EMRs that have the potential to learn from data in the EMR system.
    Date: September 9, 2009
  • Focus Groups Recommend Strategies to Decrease Missed Test Results
    This paper reports on the efforts of two focus groups that formed as part of the Diagnostic Error in Medicine – A National Conference, which was held by the American Medical Informatics Association in 2008. Clinicians who were part of the focus groups were asked to develop interventions that might decrease the risk of diagnostic delay due to missed test results in the future. The focus groups concluded that while the electronic medical record helps to improve access to test results, eliminating all missed test results would be difficult to achieve. However, they did recommend several strategies that might decrease the rates of missed test results, including: improving standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow-up of test results, and systems re-engineering to improve the management and presentation of data. They also suggest that healthcare organizations focus initial quality improvement efforts on specific tests that have been identified as high-risk for adverse impact on patient outcomes, such as tests associated with a possible malignancy or acute coronary syndrome.
    Date: September 1, 2009
  • Assessing Accuracy and Completeness of Research Data
    VA benefits from one of the most highly developed health information systems in the world, which includes the Immunology Case Registry (ICR) that was designed to monitor costs and quality of HIV care, and the Decision Support System (DSS) that was developed to monitor utilization and costs of Veterans in care. This study compared ICR and DSS datasets, which share overlapping laboratory data from the same VA electronic record system. Findings show that six of the laboratory tests for HIV patients that were studied demonstrated remarkably similar amounts of overlap (68% to 72%) between the two datasets, showing that ICR and DSS are both good sources of data for these tests. However, several other tests demonstrated much lower proportions of overlap (between 20% and 31%). These findings indicate that validation of laboratory data should be conducted prior to its use in quality and efficiency projects.
    Date: January 1, 2009
  • Using VA Medical Data Alone May Underestimate Post-Stroke Depression and Geographic Variation in this Condition
    When VA medical data alone were used, investigators found no significant geographic variation in the detection of post-stroke depression (PSD). But when VA medical data were used along with Medicare and VA pharmacy data, significant geographic variation (nearly double – 39.1% vs. 20.0%) was observed. This suggests that to gain a comprehensive view of PSD detection in VA patients, investigators must evaluate non-VA data sources because 70% of VA stroke patients were multiple health program users.
    Date: December 1, 2008
  • Association between Nurse Staffing Levels and Patient Mortality in VA Hospitals
    RN staffing was not significantly associated with in-hospital mortality for veterans with an ICU stay; however, increased RN staffing was significantly associated with decreased mortality among non-ICU patients. Continuing to estimate the effect of RN staffing and skill mix on patient outcomes using hospital-level data will provide poor estimates of outcome associations, such as in-hospital mortality.
    Date: September 1, 2008

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background-image  Diabetes

  • VA Diabetes and Cardiovascular Care Quality Comparable between Physicians and Advanced Practice Providers
    This study assessed the effectiveness of diabetes and cardiovascular disease (CVD) care provided to Veterans in VA primary care by advanced practice providers (APPs) compared to physicians. Findings showed that the quality of diabetes and CVD care delivered in VA primary care settings was mostly comparable between physicians and APPs. However, a majority of Veterans with diabetes and CVD – irrespective of their provider type – did not meet performance measures geared toward control of multiple risk factors. Only 27% and 28% of Veterans with diabetes and 54% and 55% of Veterans with CVD receiving care from physicians and APPs, respectively, met all eligible measures. Thus, regardless of provider type, there is a need to improve performance on all eligible measures among these Veterans.
    Date: November 1, 2016
  • Investigators Establish Typology for Veterans with Diabetes who Utilize Both VA Healthcare and Medicare
    This study sought to establish a typology of VA and Medicare utilization among dually-enrolled Veterans with type 2 diabetes, to better understand specific patterns of dual use. Findings showed that Veterans with diabetes can be grouped into four distinct classes of dual health system use. This classification has applications for identifying patients facing differential risk from care fragmentation. By recognizing common characteristics associated with dual users in classes at greatest risk of care fragmentation, (e.g., dual medication users), study findings may be integrated into decision-support tools to help coordinate the care of certain Veterans, and actively address drivers of dual use.
    Date: February 22, 2016
  • Among Older Veterans with Diabetes, Few with Low Glucose or Blood Pressure Levels Undergo Treatment De-intensification
    This study sought to describe the frequency and predictors of treatment de-intensification among potentially over-treated older Veterans with diabetes. Findings showed that among older Veterans with diabetes who were treated for BP or blood glucose control, Veterans’ BP or A1c levels had only a weak relationship to the likelihood of de-intensification. There was a modest association between a Veteran’s estimated life expectancy and de-intensification rates, but there was no consistent interaction between life expectancy, de-intensification rates, and BP or A1c levels. Authors suggest that practice guidelines and performance measures should focus more on reducing over-treatment through de-intensification.
    Date: December 1, 2015
  • Appropriate Prescribing for Veterans with Diabetes at High Risk for Hypoglycemia
    Evidence is accumulating that older individuals with diabetes have little to gain from the treatment burdens of stringent blood glucose control. Moreover, some older patients with diabetes might be at risk for hypoglycemia-related harms from medications prescribed to meet standard hemoglobin A1c (HbA1c) targets. This study examined the beliefs of primary care healthcare professionals (PCPs) who might receive such recommendations. Findings showed that almost half of the PCPs in this study reported that they would not worry about harms of tight control for an older patient with an HbA1c level of 6.5% who is at high risk of hypoglycemia. Of the PCPs in this study, 29% agreed it would be somewhat or very difficult to follow the Choosing Wisely HbA1Crecommendation for older adults. PCPs who agreed that maintaining the HbA1c level below 7% would benefit the patient and who reported worrying about malpractice claims were more likely to report difficulty following the recommendations. Conversely, PCPs who reported worrying that the patient would be harmed with tight blood glucose control were less likely to report difficulty following HbA1c recommendations.
    Date: December 1, 2015
  • Telemedicine-Based Intervention Improves Outcomes for Veterans with Poorly Controlled Diabetes
    Investigators in this pilot trial developed the Advanced Comprehensive Diabetes Care (ACDC) intervention, which bundles four evidence-based telemedicine approaches – telemonitoring, self-management support, medication management, and depression management – and is designed for practical delivery by existing VA Home Telehealth program nurses using standard VA equipment. Findings showed that the ACDC intervention significantly reduced HbA1c by 1.0% versus usual care. Veterans receiving ACDC had significantly better diabetes self-care at six months versus usual care, but depressive symptoms did not differ between groups. Although ACDC did not address hypertension, Veterans in the intervention group had significantly lower systolic and diastolic blood pressure versus usual care. By utilizing Home Telehealth infrastructure that is ubiquitous at VA centers nationwide, ACDC represents a potentially scalable approach to reducing the burden of diabetes within VA.
    Date: November 5, 2015
  • Long-Term Follow-Up of VADT Study Suggests Cardiovascular Benefits of Tight-Glucose Control in Diabetes
    Veterans Affairs Diabetes Trial (VADT) participants were randomly assigned to receive either intensive or standard glucose control. The study ended on May 29, 2008, with a median follow-up of 5.6 years. This study analyzed an additional five years of observational follow-up data on VADT participants (through December 2013), thus achieving a total follow-up of 11.8 years for most study measures. Findings showed that Veterans with type 2 diabetes randomized to intensive glucose control for a median of 5.6 years had a significant 17% relative reduction in major cardiovascular events after almost 10 years of total follow-up (8.6 events prevented per 1,000 person-years) compared to Veterans who received standard glucose therapy. However, intensive glucose control was not associated with a significant decrease in all-cause mortality after almost 12 years of follow-up. Results provide further evidence that improved glycemic control can reduce major cardiovascular events. This potential benefit may be considered in conversations with patients, but balanced with the burdens and safety data for the specific glucose-lowering treatment being considered.
    Date: June 4, 2015
  • Post-Menopausal Symptoms among Women Veterans with and without Type 2 Diabetes
    This study sought to describe the postmenopausal symptom experience in women with type 2 diabetes – and to examine the association between glucose control and symptom severity. Findings showed that, despite higher BMI and increased comorbidities in women Veterans with diabetes compared to those without diabetes, the pattern of menopause symptoms did not differ by group. Symptom severity scores were highest for muscle and joint aches, followed by hot flashes and trouble sleeping, while headaches received the lowest severity scores. Measures of mental health (i.e., anxiety, depressed mood) were similar across groups. Among women Veterans with diabetes, worse glucose control, smoking, and a diagnosis of altered mood demonstrated a positive association with perceived menopause symptom severity, even after adjusting for other covariates. Women without diabetes were younger, of lower BMI, had fewer self-reported comorbid conditions, and reported better physical health.
    Date: June 1, 2015
  • Compared to Thiazolidinediones, Sulfonylureas May Be More Likely to Cause Death and Hospitalization for Veterans with Diabetes
    This study compared long-term outcomes of the two most commonly used second-line oral hypoglycemic medications in the VA healthcare system – sulfonylureas (SUs) and thiazolidinediones (TZDs). Findings showed that Veterans with diabetes who started on SUs compared to TZDs as a second-line agent after metformin were significantly more likely to die or have an ambulatory care sensitive condition hospitalization. Patients in this study were elderly (mean age 69), primarily white (88%), and had high rates of cardiovascular comorbidities (e.g., chronic pulmonary disease, hypertension), and obesity (41%).
    Date: December 1, 2014
  • Most Patients with Type 2 Diabetes Obtain Little or No Benefit from Current Treatment for Tighter Glycemic Control
    This study examined how considering treatment burden would affect the benefits of intensive versus moderate glycemic control in patients with type 2 diabetes. Findings showed that for most patients over the age of 50 with an A1c below 9% who were on metformin, further glycemic treatment usually offered, at most, modest benefits. Across all ages, patients who viewed treatment as modestly burdensome experienced a net loss in quality of life years from treatments to lower A1c. The current approach of broadly advocating intensive glycemic control for millions of patients with diabetes should be reconsidered; instead, treating A1cs of less than 9% should be individualized based on estimates of benefit weighted against the patient’s view of treatment burden.
    Date: June 30, 2014
  • Veterans with Multiple Chronic Conditions Account for Disproportionate Share of VA Healthcare Costs
    This study examined the association between number of chronic conditions and costs of care for non-elderly (<65 years) and elderly Veterans (=65 years) within the VA healthcare system – and estimated VA expenditures for the most prevalent and costly combinations of three conditions (triads). Findings showed that Veterans with multiple chronic conditions account for a disproportionate share of VA healthcare costs. Almost one-third of non-elderly and slightly more than one-third of elderly VA patients had >3 conditions, but they accounted for 65% and 67% of total VA healthcare costs, respectively. The most common triad of chronic conditions for both non-elderly and elderly Veterans was diabetes, hyperlipidemia, and hypertension (24% and 29%, respectively). Conditions present in the most costly triads included: spinal cord injury, heart failure, renal failure, ischemic heart disease, peripheral vascular disease, stroke, and depression. While patients with the most costly triads had average costs that were three times higher than average costs of patients in other triads, the prevalence of these costly triads was extremely low (0.1 to 0.4%). These findings highlight the need for interventions that target the sickest patients who have high resource use to provide more cost-effective care.
    Date: March 1, 2014
  • Potential Over-Treatment of Hypoglycemia among Veterans with Diabetes Using VA Healthcare
    This study evaluated rates of intensive glycemic control as an indication of potential over-treatment among Veterans. Findings showed that intensive control, which may represent possible over-treatment, is common among older and/or sicker Veterans receiving VA healthcare. Of those Veterans who were either older than 75 years, and/or had renal insufficiency, and/or cognitive impairment (31% of the sample), about 1 in 10 patients had an A1c value below 6.0%, 29% below 6.5%, and half had values below 7.0%. Rates of possible over-treatment were only slightly lower using a more expansive definition of Veterans at high hypoglycemic risk, which included those with advanced diabetes-related complications, serious comorbid conditions, including cancer or serious neurological conditions, and cardiovascular or ischemic disease. Variation in over-treatment rates by VISN ranged from 9%-14% (for A1c <6%) to 46%-53% (for A1c <7%). The magnitude of variation by facility was larger, with rates ranging from 6%-23% (for A1c <6%) to 40%-65% (for A1c <7%). Study results suggest the need for greater efforts to promote individualized treatment targets, especially for elderly Veterans with chronic conditions.
    Date: December 9, 2013
  • Receiving VA Care is Stronger Predictor of Appropriate Care for Veterans with Diabetes than Continuity of Care
    This study examined whether quality of diabetes care was associated with care continuity or Veterans’ usual source of primary care. Findings showed that reliance on VA primary care vs. Medicare fee-for-service (FFS) primary care was a stronger predictor of guideline-concordant diabetes care than continuity of care. When both over-provision (getting more tests than needed) and under-provision (getting fewer tests than needed) were examined for three diabetes quality measures, reliance on VA care was a stronger predictor of appropriate care than continuity of care. For example, Veterans who relied only on Medicare FFS for primary care were more likely to be under-provided HbA1c testing than Veterans who relied only on VA primary care. However, dual users of VA and Medicare FFS primary care were significantly more likely to be over-provided HbA1c and microalbumin testing than Veterans who used only VA primary care. In both VA and Medicare FFS, under-provision of diabetes care was more common than over-provision during this period (from 2001 to 2004).
    Date: October 1, 2013
  • Medicare Drug Beneficiaries with Diabetes Use 2 to 3 Times More Brand-Name Drugs than VA Patients, at Substantial Cost
    This study compared the use of brand-name medications among patients using Medicare or VA drug benefits, and estimated how spending would change if the use of brand-name drugs in one system mirrored the other. Findings showed that Medicare beneficiaries with diabetes are more than twice as likely to use brand-name drugs than a comparable group within VA. If brand use in Medicare matched that in VA, investigators estimated more than $1 billion in avoidable spending by Medicare on brand-name drugs in 2008 alone. Conversely, spending in VA would have increased by 57% if Veterans used brand-name drugs at the same rate as in Medicare. Substantial regional variation exists in brand-name use in both Medicare and VA. For each drug group, however, the highest-using VA regions still had lower rates of brand use than the lowest using Medicare regions.
    Date: June 11, 2013
  • Literature Review Compares Bariatric Surgery to Non-Surgical Interventions among Non-Morbidly Obese Patients with Diabetes
    Given the lack of consistency, as well as uncertainties regarding the comparative effectiveness of different procedures for bariatric surgery, investigators conducted a systematic review of the relative risks and benefits associated with surgical and non-surgical therapies for treating diabetes or impaired glucose tolerance in patients with a BMI of less than 35. Findings showed that, for patients with diabetes and a BMI of 30 to 35, current evidence suggests that bariatric surgery is associated with greater short-term weight loss and improvements in HbA1c, fasting blood glucose levels, blood pressure, and hyperlipidemia than non-surgical interventions such as medication, diet, and behavioral changes. However, the evidence was insufficient to reach definitive conclusions about long-term outcomes.
    Date: June 5, 2013
  • Performance Measure for Lipid Management in Veterans with Diabetes Encourages Treatment with Moderate Dose Statins
    Clinical action performance measures are increasingly being recommended to help make performance measurement more clinically meaningful. Investigators developed a clinical action performance measure for lipid management in Veterans with diabetes that is designed to encourage appropriate treatment with moderate dose statins, while minimizing overtreatment. They then assessed what proportion of Veterans received appropriate lipid management according to this new clinical action measure vs. the treat-to-target measure of LDL <100mg/dl that was in place at the time of the study. Findings showed that, of Veterans aged 50-75 years in this study, 85% passed the new clinical action measure, compared to 67% using the existing metric of LDL <100. Veterans who did not meet the clinical action measure had fewer primary care visits, on average, during the measurement period than Veterans who did meet the measure. Of the entire cohort aged >=18 years, 14% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100) had higher rates of potential overtreament. Findings suggest that continued use of threshold measures for lipid management may promote overtreatment. A modified version of the clinical action performance measure is being implemented in the VA healthcare system.
    Date: December 11, 2012
  • Comparing Cardiovascular Outcomes for Two Common Anti-Diabetes Drugs among Veterans
    This study compared cardiovascular disease (CVD) outcomes and all-cause mortality in a cohort of Veterans who received regular VA healthcare and were prescribed metformin or sulfonylureas – the two most commonly used anti-diabetic drugs. Findings showed a modest but clinically important 21% increased risk of hospitalization for heart attack or stroke, or death from any cause associated with the initiation of sulfonylurea compared with metformin therapy. The sulfonylurea group had higher rates of hospitalizations and deaths due to cardiovascular disease: 18 per 1,000 person years for those taking a sulfonylurea and 10 per 1,000 person years for those taking metformin. These findings suggest that for 1,000 patients who are initiating treatment for diabetes using metformin rather than sulfonylureas, there are 2 fewer heart attacks, strokes, or deaths per year of treatment. The findings do not clarify whether the difference in CVD risk is due to harm from sulfonylureas, benefit from metformin, or both.
    Date: November 6, 2012
  • Construction of a Clinical Indicator for the Risk of Over-Treatment among Elderly Patients with Diabetes
    The publication of three major trials, including the VA Diabetes Trial (VADT), has prompted greater attention to the potential harms of overly tight glycemic control among patients with diabetes, especially in the elderly and those with cardiovascular disease. The high frequency of risk factors for hypoglycemia and its adverse impact, the marginal benefits of tight control in individuals with short life expectancy, and potential for inaccurate measures suggest a need for a quality measure to reduce over-treatment, particularly among elderly patients. This Commentary discusses these issues and explores the construction of a clinical indicator for the risk of over-treatment.
    Date: September 10, 2012
  • Veterans with Greater Clinical Complexity Receive Higher Quality of Care for Diabetes
    This study examined the impact of clinical complexity on three quality indicators for diabetes care: glycemic, blood pressure (BP), and lipid control. Findings showed that of the Veterans in this study,18% were controlled for all three quality indicators at index, and 19% were controlled at 90-day follow-up. Veterans with the greatest levels of clinical complexity received higher quality of care for diabetes based on BP, glycemic, and lipid quality indicators compared to less complex patients, regardless of the definition of complexity.
    Date: September 1, 2012
  • Treatment Intensification for Hypertension Not Significantly More Likely to Occur in Veterans with Diabetes and at Higher CV Risk
    Treatment intensification for hypertension was not significantly more likely to occur in Veterans with diabetes and at higher CV risk, compared with patients at low to medium risk. However, physicians were more likely to advance therapy in patients with higher and more consistently elevated blood pressures. Several individual risk factors were associated with higher rates of treatment intensification: systolic BP, mean BP in the prior year, and higher hemoglobin A1c, while self-reported home BP <140/90 was associated with lower rates of TI. The authors suggest that incorporating CV risk into TI decision algorithms could prevent an estimated 38% of cardiac events without increasing the number of patients being treated.
    Date: August 1, 2012
  • Dramatic Improvement in Blood Pressure Management among Veterans with Diabetes, with Potential Over-Treatment
    Clinical action measures that reward clinical actions that are strongly tied to evidence might better capture the complexity of clinical decision making about blood pressure management among patients with diabetes. In this study, 713,790 Veterans were eligible for a newly developed clinical action measure. Of these, 94% (n=668,210) met the clinical action measure for BP measurement (82% had a BP <140/90; an additional 12% had BP >=140/90 but appropriate management). This represents a dramatic improvement in BP management over the past decade. Among all Veterans in this study, 197,291 (20%) had a BP <130/65; of these, 80,903 (41% - or slightly more than 8% of the cohort) had potential over-treatment. Facility rates of potential over-treatment varied from 3% to 20%. Facilities with higher rates of meeting the current threshold measure (<140/90) had higher rates of potential over-treatment. Veterans with potential over-treatment were older, had lower mean index BP, and were more likely to be men and have ischemic heart disease.
    Date: June 25, 2012
  • The Importance of Testing Interventions in Real-World Settings
    Using the best evidence from efficacy trials to improve BP control among patients with diabetes and persistent hypertension, investigators in this study designed a pharmacist-led care management program – the Adherence and Intensification of Medications (AIM) intervention. In examining three-month intervals, the AIM program lowered systolic BP among patients more rapidly than usual care did for patients in the control group. However, usual care patients achieved equally low systolic BP (SBP) levels by six months after the intervention. Thus, by six months and throughout the remainder of follow-up, control team patients’ mean SBP were indistinguishable from those of the intervention group participants. There were no differences in health services utilization between eligible intervention and control patients during the 14-month intervention period. Patients in the AIM intervention group were more likely than patients in the control group to undergo medication changes during the 6-month period following their start date, although both groups had high rates of medication changes. Authors note that these findings emphasize the importance of evaluating programs that are found to be effective in efficacy trials in real-life clinical settings before urging widespread adoption.
    Date: May 8, 2012
  • Anti-Hypertensive Medication May Reduce Risk of Dementia among Veterans with Diabetes
    Comorbid hypertension was associated with increased risk of dementia; however, anti-hypertensive medications, particularly ACE inhibitors and ARBs, were associated with reduced risk of dementia, even among Veterans without hypertension. The most protective effect was associated with ARB use (approximately 24% lower risk of dementia), followed by diuretics (14%), ACE inhibitors (11%), CCBs (7%), and beta blockers (4%). Factors associated with higher incidence of dementia included: increasing age (Veterans >85 had more than three times greater risk compared to Veterans age 65), as well as duration of diabetes and higher comorbidity. Also, African Americans and other non-white races were more likely to have dementia. These findings suggest that ARBs and ACE inhibitors be considered when prescribing medication for the control of hypertension among patients with diabetes.
    Date: April 20, 2012
  • Missed Opportunities to Improve Management of Poorly Controlled Diabetes at VA Hospital Discharge
    Despite evidence of poor diabetes control prior to admission, less than one-quarter (22%) of the Veterans in this study received a change in outpatient diabetes therapy upon hospital discharge, suggesting widespread clinical inertia. Nearly one-third of Veterans (32%) had no change in therapy, no documentation of HgbA1c within 60 days of discharge, and no follow-up appointment within 30 days of discharge. Patients admitted to surgical, psychiatric, or rehabilitation services were less likely to have a change in outpatient therapy compared to patients admitted to medical services. In an adjusted analysis, factors associated with higher odds of a change in diabetes therapy included: inpatient endocrinology consultation, higher pre-admission HgbA1c, higher mean blood glucose during admission, occurrence of inpatient hypoglycemia, and inpatient basal insulin therapy.
    Date: March 30, 2012
  • Peer Mentorship Improves Glucose Control among African American Veterans with Diabetes
    Peer mentorship improved glucose control significantly among African American Veterans, and the improvement was greater than usual care or financial incentives. Over six months, HbA1c decreased from 9.8% to 8.7% among Veterans in the peer mentorship group, from 9.5% to 9.1% in the financial incentive group, and from 9.9% to 9.8% in the usual care group. After adjusting for covariates (e.g., patient characteristics, baseline HbA1c), the mean change relative to control was -1.07 points among Veterans in the peer mentorship group and -0.45 points in the financial incentive group. In the exit survey, participants in the mentorship program reported on aspects of the program they most liked, i.e., support provided (14/28), education (9/28), and the ability to commiserate with mentors (6/28). Mentors reported appreciating helping others (12/24), communicating with their mentee (7/24), and the teaching process (7/24).
    Date: March 20, 2012
  • Study Compares Effectiveness of Oral Anti-diabetic Drugs on Kidney Function for Veterans with Type 2 Diabetes
    Among Veterans with type 2 diabetes, initiation of sulfonylureas compared to metformin was associated with an increased risk of clinically significant decline in kidney function, diagnosis of ESRD, or death. Compared to metformin, the use of rosiglitazone was not significantly associated with any outcomes. Compared to sulfonylureas, the use of rosiglitazone was associated with a decreased risk for all three outcomes. Authors suggest that these findings support the current recommendations of metformin as first-line therapy for patients with type 2 diabetes who are in earlier stages of kidney disease.
    Date: February 1, 2012
  • Diabetes Managed More Intensively in Older Veterans with Dementia and Cognitive Impairment
    This study sought to examine and compare anti-glycemic medication use, glycemic control, and risk of hypoglycemia in older Veterans with and without dementia or cognitive impairment. Findings showed that diabetes was managed more intensively in older Veterans with dementia or cognitive impairment than in those with no impairment, with more patients on insulin (30% vs. 24%) among those with cognitive problems. These conditions were independently associated with a greater risk of hypoglycemia. Of all Veterans taking insulin, the incidence of hypoglycemia was higher among those with dementia (27%) or cognitive impairment (20%) than among those with neither condition (14%). Veterans with dementia or cognitive impairment also had a greater decline in HbA1c over the 2-year study period. These findings suggest that providers were less likely to pursue individualized glycemic goals, as recommended by VA-DoD clinical practice guidelines (updated in 2010), when patients had cognitive problems.
    Date: December 8, 2011
  • Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008
    This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care.
    Date: December 1, 2011
  • Caregivers of Veterans with Chronic Illness
    This study sought to identify predictors of caregiver strain and satisfaction associated with caring for Veterans with chronic illness. Findings showed that although 76% of caregivers reported feeling very self-confident in their caregiving role, more than one-third (37%) reported high strain. Overall, the mean caregiving satisfaction score indicated a moderate level of satisfaction. Caregiver characteristics that predicted strain included having less support, having depressive symptoms, and using paid help. Veteran characteristics that predicted caregiver strain included greater need for caregiving assistance in IADL (instrumental activities of daily living), and greater levels of depression. Predictors of lower caregiver satisfaction included less social support, older age, depression, and poor Veteran health status. Predictors of higher caregiver satisfaction included helping the Veteran with medical equipment and the coping style of “taking medication.” Both caregivers and Veterans reported similar levels of assistance provided, which were relatively low for ADL (activities of daily living) and IADL. However, caregivers reported providing a mean of 43 hours per week in assistance. Investigators suggest this may be due to the higher percentage of spouse caregivers in this sample, who are available for caregiving around the clock. A majority of caregivers expressed a need to know more about the Veteran’s medication.
    Date: November 22, 2011
  • Veterans with Diabetes and Major Depressive Disorder at Significantly Increased Risk of Myocardial Infarction
    This study sought to determine if major depressive disorder (MDD) complicates the course of type 2 diabetes and is associated with increased risk of myocardial infarction (MI) and mortality. Findings showed that Veterans with comorbid MDD and type 2 diabetes were 82% more likely to experience a MI compared to Veterans without MDD and type 2 diabetes. Veterans with MDD alone were 29% more likely to have a MI, and Veterans with type 2 diabetes alone were at 33% increased risk of MI. The incidence of MI increased in a step-wise fashion, from unaffected Veterans (2.6% incidence of MI) to those with depression only (3.5%) to those with diabetes only (5.9%) to Veterans with both conditions (7.4%). Veterans with PTSD, anxiety, and panic disorder were more likely to have a MI, as were Veterans with hypertension, hyperlipidemia, obesity, and nicotine dependence.
    Date: August 1, 2011
  • Racial and Ethnic Differences in Blood Pressure Control among Veterans with Type 2 Diabetes
    This study examined racial/ethnic differences in blood pressure control among Veterans with type 2 diabetes and uncontrolled BP at baseline. Findings showed that the adjusted proportion of Veterans with uncontrolled BP (>=140/90 mmHg) decreased in all groups over the study period. However, ethnic minority Veterans had significantly increased odds of poor BP control over a mean follow-up of 5 years compared to non-Hispanic White Veterans, independent of socio-demographic factors and comorbidity patterns. Compared to non-Hispanic Whites (45%), 54% of non-Hispanic Black Veterans, 48% of Hispanic Veterans, and 49% of Veterans with unknown race had poor blood pressure control. In using a more stringent BP cutoff (>=130/80 mmHg) to define poor BP control, 74% of non-Hispanic White Veterans had poor blood pressure control over the 5 years compared to 82% of non-Hispanic Black Veterans, 75% of Hispanic Veterans, and 79% of Veterans with unknown race/ethnicity. The presence of a hypertension diagnosis at the time of study entry appears to be associated with higher odds of achieving BP control over time. Among other comorbidities, cancer, coronary heart disease, congestive heart failure, and substance use disorders were all associated with increased odds of good BP control over time.
    Date: June 14, 2011
  • Nurse Case Management Decreases Cardiovascular Risk Factors among Veterans with Diabetes Compared to Usual Care
    This study sought to determine if nurse case management could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia among Veterans with diabetes compared to usual care. Findings showed that involving a nurse case manager in the care of patients with diabetes can significantly improve the number of individuals achieving target values for glycemia, lipids, and blood pressure compared to usual care. In this study, a greater number of Veterans in the intervention group had all three outcome measures under control compared to Veterans in the usual care group. In addition, a greater number of Veterans in the nurse case management group achieved individual treatment goals for blood pressure, lipids, and blood sugar compared to Veterans receiving usual care. Observed differences between groups were likely mediated both by enhanced lifestyle changes and a greater intensity of pharmacological treatment among Veterans in the intervention group.
    Date: June 2, 2011
  • Improvements Using Patient-Aligned Group Clinics for Diabetes Care
    This study evaluated the comparative effectiveness of two group self-management interventions for glycemic control among Veterans with treated but uncontrolled diabetes. Findings show that Veterans who participated in the primary care-based “Empowering Patients in Care” (EPIC) intervention had significantly greater improvements in HbA1c levels immediately following the active intervention; these differences remained at one-year follow-up. Thus, primary care-based diabetes group clinics that include patient-aligned approaches to goal-setting (e.g., action plan) for medication management, and diet and exercise changes can significantly improve HbA1c levels. Diabetes self-efficacy measures improved immediately after the intervention in both the EPIC and comparison intervention groups, but were significantly higher in the EPIC group. Self-efficacy was associated with individual changes in HbA1c levels. At 1 year, differences in HbA1c levels between groups remained the same (i.e., there was no return to baseline, but also no further improvements). Self-efficacy levels dropped in both groups at 1 year; but the drop in the EPIC intervention participants was less than the diabetes education participants, resulting in modest (non-significant) differences between the groups at one year.
    Date: March 14, 2011
  • Article Challenges Process for Disseminating Diabetes Performance Measures
    Pressure to develop more stringent measures for “optimal” control of risk factors in patients with diabetes has accelerated, despite the absence of new evidence from 1998 to 2008, and results from recent trials have cast new doubt on the benefits of achieving these “optimal” measures in many patients. This editorial suggests that an examination of Toyota, often portrayed as a leader in quality, may provide some answers as to how diabetes performance measures got ahead of the evidence.
    Date: February 16, 2011
  • Peer Support Improves Diabetes Outcomes
    This study compared the effectiveness of a peer-support program with nurse care management alone in improving glycemic control in a real-world clinical setting. Findings show that among Veterans with diabetes, periodic nurse-facilitated, patient-driven group sessions supplemented with one-on-one peer-support telephone calls (RPS group) improved glycemic control and other key outcomes more than nurse care management services alone (NCM group). More Veterans assigned to peer-support started insulin than those assigned to nurse care management (8 vs. 1), and peer-support participants reported greater increases in diabetes-specific social support at six months.
    Date: October 19, 2010
  • Threshold for Glycemic Control among Veterans with Diabetes
    In 2009, the National Committee for Quality Assurance (NCQA) – Healthcare Employer Information Data Set (HEDIS) measure for good (<7% A1c) glycemic control for individuals with diabetes was revised to apply only to persons younger than 65 years without cardiovascular disease, end-stage diabetes complications, or dementia. However, multiple guidelines recommend that glycemic control targets be individualized, especially in the presence of comorbid medical and mental health conditions. This retrospective study used the NCQA <7% measure to compare overall VA facility rankings with a subset of Veterans receiving complex glycemic treatment regimens (CGR). Findings show that the assessment of the quality of good glycemic control among VA facilities differs using the NCQA-HEDIS measure for the overall study population compared to a subset of patients receiving CGR. For example, the overall top 10% performing facilities achieved a rate of 57% at the <7% A1c threshold compared to 34% for Veterans on CGR using the same measure. Therefore, the authors suggest that reliance upon a <7% A1c threshold measure as the “quality standard” for public reporting or pay-for-performance could have the unintended consequence of adversely impacting patient safety. Moreover, they propose that rather than assessing “good glycemic control” by an all-or-none threshold, developers of measures should provide credit for an A1c result within an acceptable range (e.g. incremental credit for improvement between 7.9% and <7%) in order to balance the trade-offs of benefits, harms, and patient preferences.
    Date: October 1, 2010
  • Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness
    This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains.
    Date: August 1, 2010
  • Risk Related to Serious Hypoglycemia among Diabetics is Under-stated by Current Guidelines and Performance Measurements
    Rapidly evolving evidence from clinical trials and observational studies indicates that serious hypoglycemia is frequent among individuals with type 2 diabetes. Notwithstanding the absence of proven causality between hypoglycemia and mortality, the risks and consequences of hypoglycemia are significant. Despite the significant health burden associated with hypoglycemia, its risks appear to be understated by guideline and performance measurement groups. To increase public and professional awareness about this risk – and to decrease its occurrence, several recommendations are suggested.
    Date: May 26, 2010
  • Interactive Communication between Primary Care and Specialty Care Improves Patient Outcomes
    This meta-analysis showed that interactive communications between collaborating PCPs and specialists were associated with improved patient outcomes. Interactive communication methods included: initial joint patient consultations, regular specialist attendance at primary care team meetings, telepsychiatry with primary care physicians, scheduled phone discussions, and shared electronic progress notes. The studies in this review all involved collaborations with psychiatrists for management of depression and other mental health disorders and with endocrinologists for management of diabetes; however, the consistency of the effects across different primary care-specialty collaborations, healthcare conditions, and study designs suggests the potential for improvement across other specialties and conditions. Effectiveness was enhanced by interventions to improve the quality of information exchange (e.g., needs assessment, joint care planning).
    Date: February 16, 2010
  • Costs and Outcomes Associated with Newer Medications for Glycemic Control in Type 2 Diabetes
    Investigators in this study conducted a cost-effectiveness analysis to better understand the value of adding either of two newer medications (exenatide and sitagliptin) as second-line therapy to glycemic control strategies, compared to an older medication (glyburide), for new-onset type 2 diabetes in persons 25 to 64 years of age. Findings show that newer medications offer more options for glycemic control; however, they come at considerable costs. Exenatide and sitagliptin conferred 0.09 and 0.12 additional quality-adjusted life years respectively, relative to glyburide as second-line therapy. Using sitagliptin as a second-line treatment is associated with additional costs of $20,213 per person over their lifetime compared to a baseline strategy using glyburide as second-line therapy. Using exenatide as a second-line treatment is associated with an additional cost of $23,849 per person over their lifetime compared to glyburide as second-line therapy.
    Date: January 7, 2010
  • Assessing New HEDIS Blood Pressure Quality Measure for Diabetes
    To encourage aggressive treatment of hypertension, the National Committee on Quality Assurance recently adopted a new HEDIS blood pressure performance measure of <130/80 mm Hg for patients with diabetes. Although there is nearly universal agreement on the benefits of aggressive BP treatment (3-4 BP medications) for those with diabetes, the new HEDIS performance measure has generated considerable controversy. This study examined BP levels and medication treatment intensity in patients with diabetes, in order to assess the reasons for failing to meet the new HEDIS measure. Findings suggest that the new diabetes BP measure may not accurately identify poor quality care and could promote overtreatment through its performance incentives. The new measure commonly mislabeled patients as being inadequately treated, especially elderly patients. Thus, the authors recommend that new BP measures be developed to encourage aggressive treatment of hypertension without unduly promoting overtreatment, especially among elderly patients.
    Date: January 1, 2010
  • Long-Term Impact of Home Telehealth on Preventable Hospitalizations for Veterans with Diabetes
    This study assessed the longitudinal effect of a VA Care Coordination Home Telehealth (CCHT) program on preventable hospitalizations for Veterans with diabetes. Findings showed a statistically significant reduction in preventable hospitalizations for Veterans enrolled in the CCHT program during the initial 18 months of follow-up compared to Veterans in the control group, even after adjusting for potential socio-demographic and clinical risk factors. However, the program did not demonstrate a significant impact after the initial 18 months, which may largely be due to the fact that the control group had more deaths than the CCHT group during those 18 months, likely resulting in the control group’s decreased use of preventable hospitalizations during the remainder of the study period. Over the entire four-year study period, the CCHT group had a lower death rate and longer survival time than the control group, while the control group had much higher frequency in all diabetes-related ambulatory care sensitive conditions such as lower-extremity amputations, uncontrolled diabetes, and bacterial pneumonia.
    Date: October 1, 2009
  • Regular Primary Care Associated with Better Survival Rates for Veterans with Schizophrenia and Diabetes
    Medical comorbidity among aging people with schizophrenia is common and many patients with schizophrenia have difficulty managing their medical healthcare needs, which may result in delayed treatment and poor outcomes. This retrospective cohort study assessed whether patterns of VA primary care use among Veterans with diabetes, schizophrenia , or both were a significant predictor of mortality over the study period (FY02-FY05). Findings show that regular primary care and high levels of primary care were associated with better survival for patients with chronic illness, whether psychiatric or medical. For example, increasing use of primary care was least common among Veterans with schizophrenia only (4%) compared with Veterans with diabetes only (7%), or those with both conditions (8%), – and was associated with improved survival. This suggests that innovations in treatment retention targeting at-risk groups can offer significant promise of improving outcomes.
    Date: July 26, 2009
  • Self-Management Intervention for Hypertension has Modest “Spill-Over” Effect on Diabetes Control
    This study evaluated the effect of a tailored hypertension self-management intervention that had been shown to have a modest effect on blood pressure control on the unintended targets of diabetes and cholesterol control. Findings show a modest difference in glycemic control between Veterans with diabetes who received the intervention compared to usual care: the mean HbA1c decreased by 0.28% among Veterans in the intervention, while increasing 0.18% for those in usual care. LDL-C decreased over the two-year period in both groups, but there was no significant difference between the intervention group and usual care. Similar to results found in the analysis of HbA1c, Veterans with higher LDL-C at baseline had steeper rates of improvement over the study period; however, there was no differential effect between the intervention and usual care groups. Thus, this study shows some evidence that a telephone administered, nurse self-management intervention targeting hypertension may have a modest “spill-over” effect on diabetes control.
    Date: July 1, 2009
  • HSR&D Investigators Propose New Measure to Assess Diabetes Care Quality
    This article discusses a conceptual framework for assessing the efficiency of pharmacologic control of three important risk factors for diabetes (glucose, blood pressure, and cholesterol) because of their central role in diabetes management, and policy implications related to higher medication costs. The authors note that a growing body of evidence indicates a need for more flexible measures of diabetes quality of care. Thus, rather than a single optimal threshold approach, they suggest a new framework for measuring quality of care that incorporates the benefit of incremental improvement among multiple populations that differ by age, diabetes duration, and co-existing illness. The new paradigm would assess pharmaceutical efficiency using quality-adjusted life years (QALYs), calculated separately within multiple age/risk categories, as the output (numerator) and acquisition costs of medications as the input (denominator). The QALYs/cost ratio will provide an assessment of the efficiency of pharmacologic utilization. Therefore, measuring efficiency in the treatment of glucose, blood pressure, and cholesterol in persons with diabetes would incorporate the evaluation of a future healthcare benefit that is “purchased” by direct pharmaceutical costs, linking expected healthcare benefits to actual costs.
    Date: June 1, 2009
  • Physicians More Likely than Mid-Level Providers to Initiate Treatment Change for Veterans with Diabetes and Elevated Blood Pressure
    This study sought to examine whether treatment change for Veterans with diabetes and elevated blood pressure (BP) differed between physicians and mid-level providers (nurse practitioners, physician assistants), and to determine reasons for any observed differences. Findings show that mid-level providers were significantly less likely than physicians to change BP treatment for Veterans with diabetes and multiple chronic conditions, even after controlling for a number of patient, provider, and organizational characteristics. For example, after controlling for visit factors, provider practice style, measurement and organizational factors, mid-level providers were still less likely than physicians to initiate treatment change (37.5% vs. 52.5%) for elevated BP. Investigators also note that a fairly comprehensive set of potential explanatory variables did not account for any of the differences between physicians and mid-level providers.
    Date: June 1, 2009
  • Inhaled Corticosteroids Associated with Higher Glucose Levels in Veterans with Diabetes, but Effect was Dose-Dependent
    This study examined the association between inhaled corticosteroids and glucose concentration among Veterans who received care at seven VA primary care clinics between 12/96 and 5/01. Of the 1,698 Veterans in this study, 19% also had self-reported diabetes. Findings show that after controlling for systemic corticosteroid use and other potential confounders, no association was found between inhaled corticosteroids and serum glucose for Veterans without diabetes. However, among Veterans with diabetes, every additional 100 mcg of inhaled corticosteroid dose was associated with increased glucose concentration. Given this association, authors suggest that clinicians anticipate an increase in serum glucose for patients with diabetes who are using inhaled corticosteroids and adjust serum glucose monitoring accordingly.
    Date: May 1, 2009
  • Cardiovascular Risk Reduction Clinic for Veterans with Diabetes
    The Cardiovascular Risk Reduction Clinic (CRRC) is a pharmacist-coordinated clinic at the Providence VAMC designed to treat the four traditional cardiovascular risk factors (diabetes, dyslipidemia, hypertension, and smoking) to attain goals set forth by national guidelines for patients with diabetes or documented cardiovascular disease. Veterans are discharged from the CRRC when guideline-recommended goals for hemoglobin A1c, low-density lipoprotein cholesterol, blood pressure, and smoking are achieved or mostly achieved. This study evaluated the maintenance of these goals for two to three years after discharge from the CRRC. Findings show that Veterans who completed the program maintained two goals – HbA1c and LDL-C – over three years of observation. The effect on blood pressure was less durable, with half of the Veterans who were at target levels at discharge from the CRRC reaching systolic BP >130 within six months after discharge. Results also show that the most important factor to consider for risk of failure after successful attainment of a cardiovascular goal is how poorly controlled the goal was at baseline.
    Date: March 1, 2009
  • Evaluating Profiling Program and New Quality Indicators for Diabetes Care
    This study evaluated the addition of new quality indicators to an ongoing clinician feedback initiative that profiles diabetes care and suggests that rather than relying on benchmarks with high and consistent attainment, profiling programs may want to target indicators that demonstrate low and variant performance to better differentiate care across sites.
    Date: March 1, 2009
  • Transparency Standards for Diabetes Performance Measures
    The development and adoption of performance measures must be transparent. Transparency has been defined as “a process by which information about existing conditions, decisions and actions is made accessible, visible and understandable.” This JAMA Commentary discusses several examples of transparency that might help guide the development of hemoglobin A1c performance measures in the future. Authors suggest that, considering the potential effect on millions of patients and the high cost of antiglycemic medications alone, the upfront investment in ensuring evidence-based, transparently developed performance measures would be worthwhile to protect the public health and restore public and professional confidence.
    Date: January 14, 2009
  • Need for Better Self-Management Education to Address Cultural Differences among Veterans with Diabetes
    Although non-white Veterans have documented disparities in the quality of some diabetes care processes and intermediate outcome measures, racial disparities in foot care examinations have not been widely explored. Findings from this study show that there are significant differences in self-reported foot care and education across racial and ethnic groups among Veterans with diabetes. Authors suggest the need for better self-management education to address culture, knowledge, preferences, and unique barriers to care.
    Date: January 1, 2009
  • Reducing Cardiovascular Risk for Veterans with Diabetes and Depression
    The Cardiovascular Risk Reduction Clinic (CRRC) is an ongoing clinical, multi-disciplinary, disease management program at the Providence VAMC. Veterans with and without a depression diagnosis had a significant improvement in cardiovascular risk reduction after participation in the CRRC program. Veterans with a diagnosis of depression had significantly higher cardiovascular risk than those with no mental health condition, but they had greater improvement after participating in the program.
    Date: October 1, 2008
  • Mental Illness and Substance Use Costs among Veteran Clinic Users with Diabetes
    Alcohol and drug use among veterans with diabetes increased healthcare costs due to greater use of inpatient services, regardless of the presence or severity of mental illness.
    Date: July 1, 2008

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background-image  Disparities

  • PACT Initiative Did Not Reduce Most Disparities in Improved Hypertension or Diabetes Control among VA Patients
    This study sought to determine whether PACTs helped mitigate national racial/ethnic disparities in VA clinical outcomes, after adjusting for variable implementation and social determinants of health. Findings showed that improvements in clinical outcomes for hypertension and diabetes control had not been achieved for whites or most racial/ethnic groups four years into VA’s system-wide roll-out of the PACT initiative. Greater PACT implementation was associated with higher percentages of Veterans who achieved hypertension or diabetes control, but most racial/ethnic disparities in achieving control persisted. Authors suggest that to promote health equity, healthcare innovations such as patient-centered medical homes should incorporate tailored strategies that account for determinants of racial/ethnic variations.
    Date: June 1, 2017
  • Racial Disparities in HIV Quality of Care that May Extend to Common Comorbid Conditions
    To more fully understand patterns of racial disparities in the quality of care for persons with HIV infection, this study examined a national cohort of Veterans in care for HIV in the VA healthcare system during 2013. Findings showed that racial disparities were identified in quality of care specific to HIV infection – and in the care of common comorbid conditions. Blacks were less likely than whites to receive combination antiretroviral therapy (90% vs. 93%) or to experience viral control (85% vs. 91%), hypertension control (62% vs. 68%), diabetes control (86% vs. 90%), or lipid monitoring (82% vs. 85%). Although performance on quality measures was generally high, racial disparities in HIV care for Veterans remain problematic and extend to comorbid conditions. Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.
    Date: September 22, 2016
  • VA National Transplant System Shows No Racial/Ethnic Disparities in Evaluating Veterans for Kidney Transplant
    This study examined VA patients of diverse racial/ethnic backgrounds with end-stage kidney disease (ESKD) who underwent the evaluation process for kidney transplantation (KT). Findings showed that in comparing African American Veterans with white Veterans and other minority Veterans, the VA National Transplant System did not exhibit the racial/ethnic disparities in evaluation for kidney transplant that have been found in non-VA transplant centers. Moreover, VA kidney transplant centers are successfully bringing ESKD patients through the evaluation process without race disparities at a time when non-VA transplant centers are unable to do so, while achieving a median time to complete evaluation similar to other published rates in non-VA settings.
    Date: August 1, 2016
  • Racial and Ethnic Differences in Primary Care Experiences for Veterans with Mental Health and Substance Use Disorders
    This study examined racial and ethnic differences in positive and negative experiences in VA Patient-Centered Medical Home (PCMH) settings among Veterans with mental health or substance use disorders (MHSUDs) who completed VA’s 2013 PCMH Survey of Healthcare Experiences of Patients. Findings showed that positive experiences were reported least often for access. Negative experiences were reported most often for self-management support and comprehensiveness, defined as provider attention to MHSUD concerns. One or more racial/ethnic minority groups reported more negative and/or fewer positive experiences than Whites in the following 4 domains: access, communication, office staff helpfulness/courtesy, and comprehensiveness. Solutions are needed to improve access to care for all Veterans with MHSUDs, with additional attention on improving access for Black, Hispanic, and AI/AN Veterans.
    Date: June 20, 2016
  • Female Veterans with CVD Less Likely to Receive Statin and High-Intensity Statin Therapy Compared to Male Veterans with CVD
    This study sought to identify the proportion of male and female Veterans with cardiovascular disease (CVD) who received care in any of 130 VA facilities between 10/1/10 and 9/30/11, and who received any statin and high-intensity statin. Findings showed that while evidence-based use of both statin and high-intensity statin therapy remains low in both genders, female Veterans with CVD were less likely to receive evidence-based statins (58% vs. 65%) and high-intensity statins (21% vs. 24%) compared with male Veterans. In fully adjusted analyses, female gender was independently associated with a 32% lower likelihood of receiving any statin therapy and a 24% lower likelihood of receiving high-intensity statin therapy. Mean low-density lipoprotein cholesterol levels were higher in female compared with male Veterans (99 vs. 85 mg/dl) with CVD. The use of statin and high-intensity statin therapy among female Veterans with CVD showed substantial facility-level variation. With the “statin dose-based approach” proposed by the recent cholesterol guidelines, these results highlight areas for quality improvement. It is important to note that despite the observed gender disparity noted in this study, statin and high-intensity statin use remain low in both genders. This is concerning, as the patient population studied in these analyses (i.e., those with established CVD) is the one that derives the most benefit from statin and high-intensity statin therapy.
    Date: January 1, 2015
  • Improved Performance on Quality Measures is Accompanied by Increased Racial/Ethnic Equity in Care
    This study examined the quality and equity of hospital care during the six years following initiation of the Centers for Medicare & Medicaid Services (CMS) Inpatient Quality Reporting (IQR) Program (2005 to 2010), focusing on 17 process-of-care quality indicators publicly reported by the program for white, black, and Hispanic patients hospitalized for AMI, HF, and pneumonia in non-VA hospitals. Findings showed that improved performance on quality measures for white, black, and Hispanic adults hospitalized with AMI, HF, and pneumonia was accompanied by increased racial/ethnic equity in performance rates both within and between U.S. hospitals. Over this time period, adjusted performance rates for the 17 quality measures improved by 3.4 to 57.6 percentage points for these patients. In 2010, unadjusted performance rates exceeded 90% for all subgroups for 14 of 17 measures. Declining racial/ethnic differences occurred through more equitable care for white and minority patients treated in the same hospital, as well as greater performance improvements among hospitals that disproportionately serve minority patients.
    Date: December 11, 2014
  • Racial/Ethnic Disparities in Treatment Retention for Veterans with PTSD
    This study of Veterans recently diagnosed with PTSD sought to determine whether the odds of premature mental health treatment termination varied by patient race/ethnicity and, if so, whether such variation is due to differential access to services or beliefs about mental health treatment, or whether there is a disparity in the provision of treatment. Findings showed that compared to White Veterans, African-American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy and, overall, African-Americans were less likely to receive a minimal trial of any treatment in the six months after being diagnosed with PTSD. Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino Veterans but not African-American Veterans. As expected, positive beliefs about psychotherapy or pharmacotherapy facilitated treatment retention. Access barriers did not contribute to treatment retention disparities. They significantly impacted psychotherapy participation, but equally across the entire sample. To improve treatment equity, clinicians may need to directly address patients’ treatment beliefs and preferences.
    Date: November 24, 2014
  • Cardiovascular Outcomes after Addition of Insulin Versus Sulfonylureas in Veterans with Diabetes Taking Metformin
    This study compared time to a combined outcome of acute myocardial infarction (AMI), stroke, or death among Veterans with diabetes that were initially treated with metformin, and subsequently added either insulin or sulfonylurea. Compared to those who added a sulfonylurea, Veterans who added insulin to metformin therapy had a 30% higher risk of the combined outcome of heart attack, stroke, and all-cause mortality. Although new heart attacks and strokes occurred at similar rates in both groups, mortality was higher in patients who added insulin. Although sulfonylurea use predominated as add-on therapy, there was increasing use of insulin intensification over the study years (increasing by an average of 17% per year). Reasons may include a growing prevalence of obesity and insulin resistance, emphasis on metrics such as glycemic targets, increasing comfort with newer analog insulins, and/or the benefit in microvascular outcome prevention.
    Date: June 11, 2014
  • Ethnic Differences in Receipt of Depression Care
    This study sought to characterize differences in treatment for multiple racial/ethnic groups of Veterans with ongoing depression. Findings showed that there were significant differences in the receipt of depression care between multiple racial/ethnic groups of chronically depressed Veterans. Compared to white Veterans, nearly all minority groups had lower odds of adequate antidepressant use; adequate psychotherapy was more common among minority Veterans in initial analyses but differences between Hispanic, AI/AN, and white Veterans were no longer significant in adjusted analyses. Primarily due to lower use of antidepressants, nearly all minority groups had lower rates of guideline-concordant care than white Veterans with depression. Overall, 51% of Veterans received adequate antidepressant care for the 6-month period following their most recent VA healthcare visit for depression; 10% of Veterans attended at least 6 psychotherapy visits within the same time period; and 55% received guideline-concordant care. Further research is needed to determine whether the observed differences in treatment arise from patient-centered preferences for care (for example, lower willingness to take anti-depressant medication among minority patients) or from providers’ failure to adhere to best-care practices.
    Date: November 1, 2013
  • Equitable Rates of Pain Assessment among African American and White Veterans
    This study sought to determine whether African American Veterans were less likely to be screened for pain than their White counterparts – and to determine the factors associated with differences in screening rates. Findings showed that VA’s mandate for pain screening has resulted in high and relatively equitable rates of pain assessment among both African American and White Veterans. Although rates of pain screening were lower among African Americans compared to Whites (78% vs.82%), this disparity was reduced by half after controlling for prior healthcare use, in which African American Veterans had a greater number of outpatient visits, which was associated with lower rates of pain screening at the index visit. Overall, Veterans were less likely to be screened for pain if they were African American, female, and married; if they had a diagnosis of deficiency anemia; if they had a greater number of outpatient visits; and if they were an established (vs. new) patient. Veterans were more likely to be screened if they had prior diagnoses of chronic joint, neck, or back pain; opioid abuse, anemia, and pulmonary circulation disorders; and if they had a non-opioid analgesic prescription and/or greater number of inpatient admissions in the previous two years.
    Date: November 21, 2012
  • Racial Differences in Outcomes of VA Telephone-Delivered Hypertension Disease Management Program
    A combination of home BP monitoring, remote medication management, and telephone-tailored behavioral self-management appears to be particularly effective for improving BP among African American Veterans. However, the effect was not seen among non-Hispanic white Veterans. Among African Americans, improvement in mean systolic BP was greatest for those receiving the combined intervention: compared to usual care, systolic BP was 6.6 mmHg lower at 12 months and 9.7 mmHg lower at 18 months. These decreases in BP were not seen in non-Hispanic white Veterans.
    Date: August 3, 2012
  • Perceived Discrimination Associated with Risk of Severe Coronary Obstruction among African American Veterans
    Compared to white Veterans, African American Veterans with abnormal cardiac nuclear imaging studies had greater perceptions of racial discrimination that were related to increased risk for severe coronary obstruction – and to angiographic coronary obstruction, after controlling for clincal and psychosocial factors related to cardiovascular health. Based on their nuclear imaging studies, 44% of Veterans (both whites and African Americans) were at high risk for severe coronary obstruction. Among both African American and white Veterans, prior myocardial infarction (MI) and smoking were associated with high (vs. low/moderate) risk for severe coronary obstruction, while optimism was related to a decreased risk of severe obstruction. No significant associations between social support, negative affect, or religiosity and results from nuclear imaging or coronary angiography were found.
    Date: April 1, 2012
  • Relationship between Perceived Racial Discrimination and Wait Times for Kidney Transplant
    Compared to whites, African Americans took significantly longer to get accepted for transplant. There were also significant racial differences on several cultural factors in patients as they began the evaluation process for kidney transplantation. Compared to white patients, African Americans reported experiencing more discrimination in healthcare, more perceptions of racism in healthcare, higher medical mistrust, and more religious objections to living donor kidney transplantation. Comorbidity, dialysis status, and availability of potential living donors were not associated with length of time to be accepted for kidney transplant. Thus, medical factors alone did not explain racial disparities. In analyses to identify which factors predicted racial disparities, the authors found that perceived discrimination in healthcare, less transplant knowledge, more religious objection to transplantation, and lower income explained the racial disparities observed in the time it took to be accepted for transplant. Moreover, after adjusting for demographics, psychosocial, and cultural factors, the association of race with longer time for listing for transplant was no longer significant. Authors suggest these findings indicate that perceived discrimination in healthcare can be as much of a risk factor as race, income, or low transplant knowledge.
    Date: February 27, 2012
  • Telemedicine-Based Collaborative Care Intervention for Depression has Greater Effect on Minority vs. White Veterans
    The Telemedicine Enhanced Antidepressant Management (TEAM) study was a randomized trial of telemedicine-based collaborative care tailored for small, rural primary care practices. Investigators in the current study evaluated racial differences in clinical outcomes among 360 Veterans with depression who were randomized to usual care or the TEAM intervention. Findings showed that in the usual care group, minority Veterans had a lower treatment response rate (8%) than Caucasians (18%), but this was not significant. In contrast, minority Veterans in the TEAM intervention group had a significantly higher treatment response rate (42%) than Caucasians (19%) in the intervention group. Veterans in the minority group were significantly less likely to report that antidepressants were an acceptable form of treatment, and were significantly less likely to have had prior or current depression treatment. However, none of these variables were significantly related to treatment outcomes. Thus, the study was not able to determine why minorities responded better to the intervention than Caucasians.
    Date: November 1, 2011
  • Depression and Race may Independently Affect Receipt of Some Surgeries
    This study examined race and ethnicity as factors potentially associated with surgeries experienced by Veterans with and without major depressive disorder (MDD). Findings show that Veterans with pre-existing MDD were less likely to undergo digestive, hip/knee, vascular, or CABG surgeries than Veterans without MDD. Minority Veterans were slightly less likely to receive vascular operations compared to white Veterans, but were more likely to undergo digestive system procedures. The effect of depression was independent of race and ethnicity; thus, depression and race would have an additive but not synergistic effect on the odds of receiving surgery. In addition, a gender effect was noted: women Veterans were more likely to have digestive procedures but were less likely to undergo CABG or vascular operations. Authors note that the lack of information regarding severity of illness makes it difficult to determine whether or not diagnostic differences explain differences in surgery.
    Date: October 1, 2011
  • Veterans with COPD Living in Isolated Rural Areas have Elevated Risk of Mortality
    This study sought to determine if COPD mortality is higher for Veterans living in isolated rural areas, and, if so, to assess whether or not hospital characteristics mediate such associations. Findings showed that Veterans living in the most isolated rural areas of the United States appear to have an elevated risk of COPD-related 30-day mortality. Overall unadjusted mortality was higher for Veterans from isolated rural areas (5.0%) and rural areas (4.0%) compared to Veterans from urban areas (3.8%). Hospital characteristics were not found to account for this effect. Veterans from isolated rural but not rural areas remained at higher risk for death after adjusting for clinical characteristics, the proportion of COPD admissions in hospitals that came from rural areas, and hospital volume.
    Date: July 19, 2011
  • Racial and Ethnic Differences in Blood Pressure Control among Veterans with Type 2 Diabetes
    This study examined racial/ethnic differences in blood pressure control among Veterans with type 2 diabetes and uncontrolled BP at baseline. Findings showed that the adjusted proportion of Veterans with uncontrolled BP (>=140/90 mmHg) decreased in all groups over the study period. However, ethnic minority Veterans had significantly increased odds of poor BP control over a mean follow-up of 5 years compared to non-Hispanic White Veterans, independent of socio-demographic factors and comorbidity patterns. Compared to non-Hispanic Whites (45%), 54% of non-Hispanic Black Veterans, 48% of Hispanic Veterans, and 49% of Veterans with unknown race had poor blood pressure control. In using a more stringent BP cutoff (>=130/80 mmHg) to define poor BP control, 74% of non-Hispanic White Veterans had poor blood pressure control over the 5 years compared to 82% of non-Hispanic Black Veterans, 75% of Hispanic Veterans, and 79% of Veterans with unknown race/ethnicity. The presence of a hypertension diagnosis at the time of study entry appears to be associated with higher odds of achieving BP control over time. Among other comorbidities, cancer, coronary heart disease, congestive heart failure, and substance use disorders were all associated with increased odds of good BP control over time.
    Date: June 14, 2011
  • Despite Improved Quality of VA Healthcare, Racial Disparity Persists for Important Clinical Outcome
    This article reports on trends in the quality of care and racial disparities in relation to 10 VA clinical performance measures that assessed cancer screening, cardiovascular care, and diabetes care from 2000 to 2009. Findings show that in the decade following VA’s organizational transformation, quality of care improved and racial disparities were minimal for most process measures, such as glucose and LDL screening. However, these were not accompanied by meaningful reductions in racial disparity for important clinical outcomes, such as blood pressure, glucose, and cholesterol control. A gap in clinical outcomes of as much as nine percentage points was observed between African-American and white Veterans. Almost all of the disparity in outcomes was explained by within-facility disparity, which suggests that VA medical centers will need to measure and address racial gaps in care for their patient populations. Of the five performance measures with an absolute racial disparity of 5 percentage points or more in the initial year of the study, there were statistically significant reductions in racial disparity for three: glucose control, BP control, and CRC screening. However, the reductions in disparity were modest, and none were reduced by more than 2 percentage points.
    Date: April 1, 2011
  • No Racial Disparities in Adherence to CRC Screening among Veterans Receiving VA Care
    This study examined the contribution of demographic/health-related factors, cognitive factors, and environmental factors to racial disparities in colorectal cancer (CRC) screening in a nationally representative survey of Veterans ages 50 to 75. The effect of race on adherence to CRC screening guidelines was non-significant after adjusting for demographic/health-related factors and environmental factors. Adherence in both African American and White groups was substantially higher than the national average. The high rates of CRC screening are likely, in part, a result of various VA efforts initiated over the past decade to increase screening adherence. There were no racial differences in physican recommendations for CRC screening: 84% for African Americans and 85% for Whites. Among those who were adherent to CRC screening, African American Veterans had significantly lower rates of colonoscopy compared with White Veterans (47% vs. 57%) and significantly higher rates of fecal occult blood testing (60% vs. 53%).
    Date: March 1, 2011
  • VA Patient-Provider Communication Does Not Contribute to Racial Disparities in Use of Total Joint Replacement
    This study examined whether there were racial differences in patient-provider communication about treatment of chronic knee/hip osteoarthritis in African American and white Veterans referred to two VA orthopedic clinics over a 3-year period. Findings show that communication between VA orthopedic surgeons and patients regarding the management of chronic knee/hip osteoarthritis did not, for the most part, vary by patient race. No racial differences were observed with regard to length of visit, overall amount of dialogue, discussion of psychosocial issues, Veteran activation/engagement statements, physician verbal dominance, display of positive affect by Veterans or providers, or discussion related to informed decision-making. However, visits with African American Veterans contained less discussion of biomedical topics and more rapport-building statements than visits with white Veterans. These findings diminish the potential role of communication in VA orthopedic settings as an explanation for racial disparities in the use of total joint replacement.
    Date: January 10, 2011
  • Disparities in Healthcare Coverage and Access among American Indian/Alaska Native Veterans
    American Indian/Alaska Native (AIAN) Veterans have considerable disparities in healthcare coverage and acess to care compared to non-Hispanic white Veterans. For example, AIAN Veterans are nearly twice as likely to be uninsured, even after adjusting for sociodemographic and economic characteristics. AIAN Veterans are significantly less likely to report private coverage and significantly more likely to report public coverage, military coverage, and be uninsured. Regarding barriers to healthcare, AIAN Veterans were significantly more likely to delay healthcare due to not getting timely appointments, not getting through on the telephone, and having transportation problems.
    Date: June 1, 2010
  • Patient Treatment Preferences Play Important Role in Racial Disparities in Knee/Hip Total Joint Replacement
    Overall, 10.3% of Veterans treated for knee/hip osteoarthritis at two VA orthopedic clinics underwent total joint replacement (TJR) within six months of study enrollment. TJR was less likely for African-American Veterans compared to white Veterans of similar age and disease severity, but this difference was not significant after adjusting for whether patients had received a recommendation for the procedure from their orthopedic surgeon. African-American Veterans were less likely to receive a recommendation for TJR than white Veterans of similar age and disease severity. However, this difference was not significant after controlling for Veterans’ willingness to undergo TJR, as assessed prior to the visit with their surgeon. This suggests that the observed race differences in recommendations about joint replacement may result from orthopedic surgeons being responsive to patient preferences regarding the procedure.
    Date: May 28, 2010
  • Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings
    Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and quality.
    Date: May 11, 2010
  • Lower Mortality Rates for African American Compared with White Patients Hospitalized for Heart Failure
    This study examined research reporting mortality by race after hospitalization for heart failure (HF), and combined the results using meta-analyses. Adjusted mortality rates were 32% lower in short-term follow-up (0-30 days) and 16% lower in long-term follow-up (after 30 days) for African American compared with white patients. Authors suggest that differences in mortality imply unmeasured differences by race in clinical severity of illness at hospital admission and may lead to biased hospital mortality profiles.
    Date: March 1, 2010
  • Rural-Dwelling VA Patients have Worse Physical Health but Better Mental Health than Urban-Dwelling Counterparts
    Rural Veterans reported worse physical health but better mental health when compared to their urban counterparts, and these differences persisted across the four survey years. The differences were substantial and statistically significant and persisted after correcting for age, gender, marital and employment status, educational level, and local income level.
    Date: March 1, 2010
  • Veteran Minorities Equally Likely to Receive PTSD Treatment
    This study sought to determine the rates of mental health use in the six months after Veterans received a PTSD diagnosis – and to examine whether service use varied by race or ethnicity. Findings show that minority Veterans were similar to Whites in the likelihood of receiving VA mental health treatment in the six months following a diagnosis of PTSD. Of the 20,284 Veterans with PTSD in this study, 50% received psychotropics, 39% received counseling, and 64% received at least one of these forms of treatment. However, only 24% who received any counseling had at least eight sessions, and most had only one session. These findings indicate that possible treatment preferences exist. The authors suggest that incorporating preferences into treatment planning may facilitate treatment retention and help to maximize treatment outcomes for all Veterans with PTSD.
    Date: December 1, 2009
  • Ethnic Disparities in Treatment for Chronic Pain
    This study sought to identify racial and ethnic differences in patient-reported rates of treatment for chronic pain and ratings of pain-treatment effectiveness among 255,522 Veterans who were treated at more than 800 VA healthcare facilities in FY05. Findings show that 35% of male Veterans and 44% of female Veterans reported receiving treatment for chronic pain. Male and female Veterans who were Hispanic or non-Hispanic black were more likely to report receiving treatment for chronic pain compared to non-Hispanic white Veterans. Among the Veterans who received treatment for chronic pain, non-Hispanic black men were one-fifth less likely to rate pain treatment effectiveness as very good or excellent compared to non-Hispanic white male Veterans.
    Date: October 1, 2009
  • African Americans and Whites Equally Appropriate Candidates for Total Joint Arthroplasty
    This study sought to determine if racial differences in clinical appropriateness for surgery existed among a sample of primary care patients (425 whites and 260 African Americans) with moderate to severe symptomatic knee or hip osteoarthritis (OA) treated at one VA hospital and one county hospital between 3/03 and 9/06. Findings show that African Americans and whites were equally appropriate candidates for total joint arthroplasty (TJA). There were no significant ethnic differences found between the proportion of those deemed appropriate for TJA and those deemed inappropriate.
    Date: September 1, 2009
  • Ethnic Disparities in the Treatment of Veterans with Dementia
    This study sought to determine if there were ethnic disparities in the evaluation and treatment of dementia among 410 Veterans treated at one VAMC between 4/05 and 6/05. Findings show that while laboratory and imaging workup (i.e., CT, MRI) did not differ between ethnic groups, there were significant differences in the treatment of dementia. For example, African American Veterans with dementia were 40% less likely than all other patients to receive acetylcholinesterase inhibitors. This treatment disparity did not appear to be due to differences in the evaluation of dementia, which was similar across groups, although significantly more Caucasian Veterans (43.8%) underwent neuropsychological testing compared to African American (24.8%) or Hispanic Veterans (32.4%).
    Date: September 1, 2009
  • Lower Mortality for African American Veterans with COPD Exacerbation not Explained by More Aggressive Care
    This study sought to determine the potential impact of racial differences in ICU admission and the use of ventilator support on mortality among African American and white Veterans admitted to VA hospitals with COPD (chronic obstructive pulmonary disease) exacerbation. Findings show that mortality was lower in African American Veterans compared to white Veterans, even after adjusting for differences in ICU admission rates and ventilator support. However, mortality was similar for African Americans and whites receiving mechanical ventilation (28.8% vs. 31.4%), thus the lower risk-adjusted mortality among African Americans was not explained by more aggressive care.
    Date: July 1, 2009
  • Perceived Racial Discrimination in Health Care Found to be Low and Similar among Veterans and Non-Veterans
    This study examined rates of perceived discrimination in healthcare settings for Veterans and non-Veterans, as well as for Veterans who used the VA healthcare system and those who did not. Overall, rates of perceived racial discrimination in healthcare were low and barely differed between Veterans (3.4%) and non-Veterans (3.5%). Rates of perceived racial discrimination were equally prevalent among Veterans who used the VA healthcare system and those who did not.
    Date: May 14, 2009
  • Alcohol Misuse and Counseling among Minority Veterans
    This study sought to describe alcohol consumption across race and ethnicity groups among Veterans treated in VA during FY05, and examine associations between race and ethnicity and receipt of alcohol-related advice by clinicians. Findings show that overall, less than one-third of patients who drank at all and one-third of patients with positive alcohol misuse screens reported receiving alcohol-related advice. After adjusting for demographics, health status, and alcohol consumption, Veterans who self-identified as black, Hispanic, or American Indian/Alaska Native were more likely to report receiving alcohol-related advice from their VA healthcare providers compared to non-Hispanic whites. In addition, women and older Veterans were less likely to receive alcohol-related advice than their male and younger counterparts, respectively.
    Date: May 1, 2009
  • Ethnic Differences in Self-Reported Cancer Screening
    Several studies suggest that non-whites may be more likely than whites to over-report screening behavior, which may have considerable implications for research on racial and ethnic disparities in cancer screening. Findings from this study show that racial and ethnic minorities may be less likely to provide accurate reports of their cancer screening behavior and that over-reporting may be particularly problematic. Research suggests that this might be rectified by changing how screening questions are worded and developing different methods for data collection. A conceptual framework offered by study investigators has the potential to guide exploration of where and why possible bias may be occurring and suggests ways in which these biases might be reduced.
    Date: February 1, 2009
  • African-American Veterans More Likely than White Veterans to Receive Mechanical Ventilation for COPD
    African-American Veterans with COPD exacerbation in VA hospitals are more likely than white Veterans to receive mechanical ventilation, and this difference is not explained by available clinical or demographic variables. By contrast, African-American and white Veterans are equally likely to receive non-invasive ventilation (NIV) when being treated for COPD exacerbation. Authors suggest that there is no underuse of mechanical ventilation and NIV in the treatment of racial minorities in this patient population; however, unmeasured factors, such as patient preferences or disease severity may be affecting the use of mechanical ventilation, and thus warrant further investigation.
    Date: January 1, 2009
  • Need for Better Self-Management Education to Address Cultural Differences among Veterans with Diabetes
    Although non-white Veterans have documented disparities in the quality of some diabetes care processes and intermediate outcome measures, racial disparities in foot care examinations have not been widely explored. Findings from this study show that there are significant differences in self-reported foot care and education across racial and ethnic groups among Veterans with diabetes. Authors suggest the need for better self-management education to address culture, knowledge, preferences, and unique barriers to care.
    Date: January 1, 2009
  • Racial Differences in Coping with Chronic Osteoarthritis Pain
    Compared to white veterans, African American veterans were much more likely to perceive prayer as helpful (85% vs. 66%) and were more likely to have tried it for hip or knee pain (73% vs. 55%). Race was not associated with arthritis pain self-efficacy, arthritis function self-efficacy, or any other coping strategies.
    Date: December 1, 2008
  • Students Attending Racially and Ethnically Diverse Medical Schools Report Being Better Prepared to Care for Patients in Diverse Society
    White students who attend racially diverse medical schools report feeling better prepared than students at less diverse schools to care for racial and ethnic minority patients. They also are more likely to endorse access to adequate health care as a right. However, investigators found no association between the diversity of a medical school and whether white students intended to provide care in underserved areas.
    Date: September 10, 2008
  • Disease-Specific Differences in End-of-Life Treatment of Seriously Ill Veterans of Different Ethnic and Racial Backgrounds
    Differences in the level of end-of-life treatments were disease-specific and not based on race and/or ethnicity. In addition, increased end-of-life care for minorities was most pronounced in veterans with dementia, and non-cancer patients received more invasive care than patients with cancer or dementia, independent of their race or ethnicity.
    Date: September 1, 2008
  • Perceived Racial Discrimination in U.S Healthcare More Prevalent among African Americans and Associated with Worse Health Outcomes
    The prevalence of perceived discrimination in U.S. healthcare is considerably higher for African Americans compared to Whites and Hispanics. [These results were not based on VA data.] Perceived discrimination was associated with worse health for both African Americans and Whites. Health care coverage was not significantly related to perceived discrimination for any of the racial/ethnic groups. However, not obtaining medical care due to cost was associated with a greater likelihood of perceiving discrimination for all groups.
    Date: September 1, 2008
  • Variation in Care for Recurrent Non-Melanoma Skin Cancer in a University-Based vs. VA Practice
    Treatment choices differed significantly between the two sites: after adjusting for patient, tumor, and clinician characteristics that may have affected treatment choice, tumors treated at the university-based site remained significantly more likely to be treated with Mohs surgery. There was no evidence that the quality of care varied at the two sites.
    Date: September 1, 2008

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background-image  Elder Care

  • Initiative Decreases Inappropriate Prescribing to Older Veterans Discharged from VA Emergency Department Care
    This study evaluated the effectiveness and sustainability of the Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED) program to reduce the use of potentially inappropriate medications (PIMs). Findings showed that EQUiPPED was associated with a sustained reduction in inappropriate medication prescribing at all four VAMCs in the study. Post-intervention, the proportion of PIMs at site one decreased from 12% to 5%; at site two it decreased from 8% to 5%, at site three from 9% to 6%, and at site four from 7% to 6%. The implementation timeline for the initiative ranged from 6 to 14 months depending on the site. While the implementation timelines varied across sites, all VAMCs achieved a monthly PIM proportion between 5% and 6%. The EQUiPPED intervention led to safer prescribing and was sustainable across multiple VA sites. Implementation is currently underway at six additional VA emergency department sites, as well as three non-VA ED sites to evaluate broader dissemination.
    Date: April 7, 2017
  • Comparing Food Insecurity between Veterans and non-Veterans
    This study examined the prevalence of food insecurity in an older male population. Findings showed that there was a significantly lower prevalence of food insecurity among male Veterans compared to non-Veterans (6% vs. 12%, respectively). Nevertheless, several factors predisposed male Veterans to a higher risk for being food insecure. Younger Veterans (aged 50-64) were more likely to be food insecure and had nearly three times the prevalence of food insecurity compared to Veterans aged 65+ (12% vs. 4%, respectively). Overall, having a psychiatric diagnosis, self-reporting symptoms consistent with clinical depression, smoking, and experiencing any difficulty with activities of daily living (ADLs) were all significantly associated with increased odds of being food insecure, even after adjustment for demographics, medical comorbidities, and economic status. As Veterans aged 50-64 are not yet eligible for Social Security benefits, this group in particular should be screened for food insecurity.
    Date: March 23, 2017
  • Systematic Review Finds Treating Blood Pressure to Current Guidelines in Older Adults Improves Health Outcomes
    This systematic review sought to compare the effects of more versus less intensive blood pressure control in older adults. Findings showed that treating blood pressure in adults over 60 to at least current guideline standards (<150/90 mmHg) substantially improves health outcomes in older adults, including reducing mortality, stroke, and cardiac events. The most consistent and largest effects were seen in studies of patients with higher baseline blood pressure (SBP >160mmHg) who achieved moderate blood pressure control (<150/90 mmHg). There is less consistent evidence, largely from one trial targeting SBP <120 mmHg, that lower blood pressure targets are beneficial for high cardiovascular risk patients. In patients with prior stroke or transient ischemic attack, treating to SBP < 140 mmHg reduces the risk of recurrent stroke. Lower blood pressure targets did not increase falls or cognitive decline, but were associated with hypotension, syncope, and greater medication burden.
    Date: March 21, 2017
  • Veterans with Dementia Using Both VA and Medicare More than Double their Odds of Exposure to Potentially Unsafe Medications
    This study examined the prevalence and effect of dual use of VA and Medicare Part D prescription medications on prescribing safety among a national cohort of Veteran outpatients (aged >68 years) with a diagnosis of dementia prior to 2010, who were dually-eligible. Findings showed that the prevalence of exposure to potentially unsafe medications was high overall (44%), but was particularly high in dual users compared to VA-only users (59% versus 39%). Thus, compared to VA-only users, dual VA/Medicare users more than doubled the odds of exposure to potentially unsafe medications (PUM) overall –and to any “high-risk medications to avoid in older adults.” Dual-users had an adjusted average of 44 additional PUM-days of exposure compared to VA-only users. The odds of antipsychotic PUM exposure were 1.5 times greater for dual-users. Policymakers should consider implementing electronic health information exchanges and additional medication therapy management services across healthcare systems to keep pace with recent policies designed to expand Veterans’ access to non-VA care – and to protect vulnerable patients from risks associated with dual system use.
    Date: December 6, 2016
  • Home-based Geriatric Care Management Decreases Rate of VA Healthcare Utilization for Older Veterans following Hospitalization
    This practical clinical trial assessed Veterans aged 65 years and older with primary care providers (PCPs) from VAMCs in Indianapolis, IN, who were enrolled in the Geriatric Resources for Assessment and Care of Elders (GRACE) Team Care program following hospital discharge to home compared to Veterans who were not enrolled after hospital discharge. Findings showed that enrollment in GRACE was associated with a 7% reduction in emergency department visits, 15% fewer 30-day readmissions, a 38% reduction in hospital admissions, and 29% decreased total bed days of care. The 179 Veterans enrolled in GRACE avoided 15 hospital admissions and 53 readmissions in the year after program enrollment. This saved VA more than $200,000 in the first year – over and above GRACE program costs.
    Date: July 1, 2016
  • Prescription Opioids Associated with Lower Likelihood of Sustained Improvement in Pain among Older Veterans
    This study sought to identify patient factors associated with improvements in pain intensity in a national cohort of Veterans 65 years or older with chronic pain. Findings showed that on average, Veterans prescribed an opioid were less likely to demonstrate sustained improvement in pain intensity scores compared to Veterans who were not prescribed opioids. Overall, average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds of Veterans met criteria for sustained improvement during follow-up. Findings call for further characterization of heterogeneity in pain outcomes in older adults, as well as further analysis of the relationships between prescription opioids and treatment outcomes.
    Date: July 1, 2016
  • Antiviral Treatment Reduces Risk of Cirrhosis, Hepatocellular Cancer and Mortality among Veterans, Irrespective of Age
    This study examined the association between age subgroups and risk of cirrhosis, hepatocellular cancer (HCC), or death among Veterans who tested positive for the hepatitis C virus (HCV), including those who received treatment in VA facilities. Findings showed that receipt of curative antiviral treatment was associated with a reduction in the risk of cirrhosis, HCC, and overall mortality, irrespective of age. Elderly Veterans were significantly less likely to receive antiviral treatment; however, among those who received treatment, sustained virological response was not different among the age groups, even after adjusting for other demographic and clinical factors, including comorbidities. Given the accelerated progression to advanced liver disease, elderly patients with chronic hepatitis C constitute a high-risk group that may need to be prioritized in the era of new antiviral treatments.
    Date: April 3, 2016
  • The Gerontologist Supplement Highlights VA Research on Health Issues Affecting Older Women Veterans
    This Supplement includes 13 articles that highlight findings on a range of topics related to women Veterans and aging, such as, menopause, diabetes, cardiovascular disease, chronic pain, and substance use.
    Date: February 1, 2016
  • Study Assesses VA/Alzheimer’s Association Care Coordination Program for Informal Caregivers of Veterans with Dementia
    A new initiative targeting caregivers of Veterans with dementia is “Partners in Dementia Care” (PDC) — a care-coordination program delivered via a partnership between VA and Alzheimer’s Association chapters. This study assessed the effectiveness of the PDC program. Findings showed that the PDC program is a promising model that improves linkages between VA healthcare services and community services for informal caregivers of Veterans with dementia. Compared to comparison caregivers, those who participated in the PDC program had significant improvement in outcomes representing unmet needs, all three types of caregiver strains, depression, and support resources. Most improvements were evident after six months, with more limited improvements from months 6 – 12. However, improvements after the first six months were maintained during the entire study. Some outcomes improved for all caregivers, while others improved for caregivers with more initial difficulties – or those who were caring for Veterans with more severe impairments.
    Date: August 1, 2013
  • Association between Several Common Antiepileptic Drugs and Suicide-Related Behavior in Older Veterans
    This retrospective study examined the relationship between antiepileptic drugs (AEDs) and suicide-related behaviors among Veterans aged 65 years and older who received VA healthcare. Findings showed that, within the study sample of 2 million older Veterans, there were 332 cases of suicide-related behavior (SRB). Exposure to antiepileptic drugs was significantly associated with suicide-related behavior, even after controlling for psychiatric comorbidity and prior SRB. Individuals who received AEDs were significantly more likely to have prior diagnoses of suicide-related behavior, depression, anxiety, bipolar disorder, PTSD, schizophrenia, substance abuse/dependence, conditions associated with chronic pain, and dementia. Veterans who received prescriptions for several specific AEDs – valproate, gabapentin, lamotrigine, levetiracetam, phenytoin, and topiramate – were at greater risk of diagnosed suicide-related behavior than Veterans with no AED exposure. Findings indicated that suicide-related behavior may occur as early as one week following AED use.
    Date: October 30, 2012
  • Older Veterans Less Likely to Receive Treatment for Depression
    In this study, 64% of Veterans with a new diagnosis of depression received some form of treatment within 12 months; however, one third (36%) of the Veterans in this study did not receive any treatment for their depression. Of those Veterans who did receive treatment, most received both antidepressants and psychotherapy (27%), followed by 21% who received antidepressants only, and 16% who received psychotherapy only. The odds of receiving any kind of treatment decreased notably with increasing age. Veterans ages 50 to 64 were more likely to receive antidepressants, psychotherapy, or both compared to those in the older age groups. Results also showed that depressed older adults with no medical comorbidities were more likely to receive both antidepressants and psychotherapy compared to no treatment. This study highlights the importance of continued outreach and intervention efforts for depressed older Veterans who are vulnerable to being under-treated.
    Date: March 1, 2012
  • Multi-Component Support Program Helps Lessen Burden for Caregivers of Aging Veterans with Disabilities
    A multi-component support services program that allowed Veterans aging with a disability to remain in the home, while also addressing the unmet needs of caregivers, was implemented and evaluated in one VA facility in 2009. Caregivers experienced meaningful improvements in burden after support services were rendered. Although there were no changes in caregivers’ physical health status, the support services program had a positive impact on mental health that was reflected in significant improvements in caregiver scores on the mental health components of the SF-12 health status scale. Satisfaction with services increased from baseline to follow-up.
    Date: February 1, 2012
  • Adverse Drug Reactions Associated with Polypharmacy are Common Cause of Unplanned Hospitalizations among Older Veterans
    This study sought to describe the prevalence of unplanned hospitalizations caused by adverse drug reactions (ADRs) among older Veterans. Findings showed that adverse drug reactions are a common cause of unplanned hospitalization among older Veterans, are frequently preventable, and are associated with polypharmacy (overall, 45% of Veterans took >9 outpatient medications and 35% took 5 to 8). The most common ADRs that occurred were bradycardia, hypoglycemia, falls, and mental status changes. Of the 678 unplanned hospitalizations that occurred during the study period, 70 ADRs involving 113 drugs occurred in 68 older Veterans, of which 37% were preventable. Extrapolating to a population of more than 2.4 million older Veterans receiving care during this time, 8,000 hospitalizations costing about $110 million (using FY04 dollars) may have been unnecessary. The most common reason for a preventable ADR was suboptimal prescribing (52%), followed by patient non-adherence (28%), and suboptimal monitoring (12%). In addition, 4 medication classes (cardiovascular, central nervous system, anti-thrombotic, and endocrine) accounted for almost 80% of all the drugs implicated in ADRs.
    Date: December 8, 2011
  • Diabetes Managed More Intensively in Older Veterans with Dementia and Cognitive Impairment
    This study sought to examine and compare anti-glycemic medication use, glycemic control, and risk of hypoglycemia in older Veterans with and without dementia or cognitive impairment. Findings showed that diabetes was managed more intensively in older Veterans with dementia or cognitive impairment than in those with no impairment, with more patients on insulin (30% vs. 24%) among those with cognitive problems. These conditions were independently associated with a greater risk of hypoglycemia. Of all Veterans taking insulin, the incidence of hypoglycemia was higher among those with dementia (27%) or cognitive impairment (20%) than among those with neither condition (14%). Veterans with dementia or cognitive impairment also had a greater decline in HbA1c over the 2-year study period. These findings suggest that providers were less likely to pursue individualized glycemic goals, as recommended by VA-DoD clinical practice guidelines (updated in 2010), when patients had cognitive problems.
    Date: December 8, 2011
  • Quality Indicators may Lead to Unintended Harm in Elderly Patients with Complex Health Issues
    This article highlights two ways that current quality indicators may lead to unintended harms for older patients with complex medical problems and proposes ways to improve quality indicators by minimizing or preventing those harms. For example, current quality indicators are unbalanced, with many encouraging more appropriate care but few indicators discouraging inappropriate care, such as mammography screening for patients with pre-existing advanced cancer or advanced dementia, who are unlikely to benefit. The authors suggest that quality indicators be refined and improved to drive real quality improvement for the entire patient population.
    Date: October 5, 2011
  • Potential Problems with the Use of Antidepressants among Older Veterans Residing in VA Nursing Homes
    This study examined the prevalence and patient/site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants among Veterans aged 65 years and older that were admitted to any one of 133 VA Community Living Centers (CLC, previously called Nursing Home Care Units). Findings suggest potential problems with the use of antidepressants in older Veterans that reside in VA CLCs. Overall, only 18% of antidepressant use was optimal. Of the 877 Veterans with depression, 25% did not receive an antidepressant, suggesting potential underuse. Among depressed Veterans who received antidepressants, 43% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. In addition, of the 2,815 Veterans who did not have depression, 42% were prescribed one or more antidepressants; of these, only 4% had an FDA-approved labeled indication, suggesting potential overuse. Also, the co-prescribing of antipsychotics (in patients without schizophrenia) among those without depression was associated with an increased risk of antidepressant overuse.
    Date: August 1, 2011
  • Excessive Caution in Prescribing to Veterans with Geriatric Conditions May Be Unnecessary
    This study evaluated whether common geriatric conditions were associated with risk of adverse drug events (ADEs). Findings show that over the one-year study period, 126 Veterans suffered a total of 167 ADEs, but there was no association between the presence of various geriatric conditions and ADEs. However, in exploratory analyses investigators found that the use of new medications (present at 12-month follow-up) was associated with a higher risk of ADEs. The authors suggest that while it is important to consider the unique circumstances of each patient, excessive caution in prescribing to elders with geriatric conditions may not be warranted.
    Date: April 1, 2011
  • Aggression May Be Linked to Psychosis in Elderly Persons with Dementia
    This literature review examined the evidence on whether delusions or hallucinations contribute to the development of agitation or aggression in persons aged 65 and older with dementia. Most studies showed a statistically significant association between psychosis and aggression. Findings also showed that the use of antipsychotic medications in the setting of agitation/aggression and psychosis among patients with dementia is not uniformly supported. Authors note that given the multifactorial etiology of psychosis and aggression with other comorbid symptoms in dementia, it is important to understand the various contributing factors to facilitate more effective treatment interventions with least possible risk.
    Date: June 1, 2010
  • All Antipsychotics May Not Increase Short-Term Risk for Mortality among Veterans with Dementia
    Commonly prescribed doses of haloperidol, olanzapine, and risperidone, but not quetiapine, were associated with short-term increases in mortality. During the first 30 days, there was a significant increase in mortality in subgroups prescribed a daily low dose of haloperidol, olanzapine, or risperidone, after adjusting for demographics, comorbidities, and medication history. However, increased mortality was not seen when quetiapine was prescribed. No antipsychotic was associated with increased mortality after the first 30 days. Therefore, the authors suggest that all antipsychotics might not pose the same degree of risk in all patient groups as implied by the general warnings that have been issued.
    Date: May 7, 2010
  • Assessment Tool for Elderly Adults’ Capacity to Live Independently
    An interdisciplinary team of clinicians developed the Capacity Assessment and Intervention (CAI) model to evaluate vulnerable patients – and to assess their capacity for safe and independent living. Despite some challenges, the authors suggest that the CAI model provides a systematic approach to initiating, conducting, and following through an assessment of an older adult’s capacity to make and execute decisions regarding safe and independent living in the community.
    Date: May 1, 2010
  • More than One-Quarter of Elderly Individuals Require Surrogate Decision-Making Near the End of Life
    Of the 3,746 elderly adults (non-Veterans) in this study, 26.8% required decision-making at the end of life and lacked decision-making capacity. Thus, surrogate decision-making was often required. Of those requiring surrogate decision-making, 67.6% had advance directives. Individuals who authored advance directives received care that was strongly associated with their preferences. And those who requested all care possible were far more likely to receive aggressive care compared to those who did not request it. Individuals with advance directives preferred limited and comfort care more than all care possible. Cognitive impairment, cerebrovascular disease, and nursing home status were associated with the need for decision-making and lost decision-making capacity before death; but these characteristics were so common (present in 65.3% of the study population) as to not be clinically useful risk factors.
    Date: April 1, 2010
  • Nursing Homes’ Disaster Response Activities Following Hurricanes Katrina and Rita
    Hurricanes Katrina and Rita exposed significant flaws in the U.S. preparedness for catastrophic events – and in the nation’s capacity to respond to them. This article reviews VA’s response to these hurricanes, in regard to nursing home evacuation, and the literature on nursing home evacuation. Authors also propose a conceptual model to help guide decision-making for future evacuations.
    Date: March 24, 2010
  • Older Elderly Patients Experience Poorer Outcomes Following Collaborative Depression Care
    This study examined the differences between young-old (age 60 to 74) and old-old (age 75 and older) patients who received collaborative depression care as part of the IMPACT (Improving Mood: Promoting Access to Collaborative Treatment) study, which include both VA and non-VA patients. Findings show that young-old and old-old patients who receive collaborative depression care have a similar initial clinical response, but old-old patients may have a lower rate of long-term treatment response and complete remission. For example, young-old and old-old patients randomized to the IMPACT intervention responded similarly to initial treatment at 3 months, but the old-old were less likely to respond to treatment at later follow-up intervals. Treatment response and remission rates peaked for both age groups at 6 months, although treatment response rates for the young-old were significantly higher than those for the old-old group (51% vs. 44%). Study findings also show that the process of care did not differ between young-old and old-old patients who received the IMPACT intervention.
    Date: December 1, 2009
  • Implementing a Successful Fall Prevention Program for Elderly Veterans
    This article discusses the implementation of a Telecare fall prevention program at the VA Greater Los Angeles Healthcare System (VAGLAHS) that was designed to be sustainable. Findings show that leadership and workgroup meetings led to the development of a functional program. The Telecare fall prevention program screened its first Veteran in October 2008 and is ongoing. The program uses an existing telephone nurse advice line to: 1) place outgoing calls to Veterans at high risk of falling, 2) assess the Veterans’ risk factors, and 3) triage Veterans to the appropriate services. Because Telecare operates via the telephone, it can accept referrals from anywhere in VAGLAHS, thus reaching Veterans in geographically remote areas. The authors suggest that another potential advantage of the Telecare fall prevention program is the opportunity to unburden primary care providers of additional responsibilities by helping assess patients’ needs and arranging the appropriate services.
    Date: November 16, 2009
  • Barriers to Dementia Diagnosis
    The goals of this study were to ascertain what is known about the prevalence of missed and delayed diagnosis of dementia in primary care, and to identify factors contributing to problems in diagnosis. While the findings did not definitively determine the prevalence of missed or delayed dementia diagnoses, estimates suggest that the number is substantial. Major barriers to diagnosing dementia included patient/provider communication (e.g., poor provider communication skills, language barriers), education deficits (e.g., belief that little or nothing can be done to treat dementia), and system resource constraints (e.g., time constraints for office visits). Attitude problems also were found; for example, among providers, a major barrier often noted was the attitude that diagnosis, particularly in the early stages of dementia, was more harmful than helpful, while patients often feared and/or denied cognitive problems.
    Date: October 1, 2009
  • Improving Acute Care for Elders at Risk for Poor Hospital Outcomes
    For patients older than age 65, traditional hospital care frequently results in adverse outcomes that increase their risk of mortality, functional dependency, and institutionalization. There are several alternative models to traditional hospital care that have been shown to address these problems and improve outcomes for older patients. One such model is VA’s Geriatric Evaluation and Management (GEM) program, which was launched in 1976 to provide interdisciplinary, multi-dimensional evaluations for elderly Veterans in need of geriatric treatment, rehabilitation, health promotion, and social service interventions. However, alternative models are not widely disseminated. This Editorial challenges healthcare providers to think outside the traditional hospital box. They suggest broadening the implementation and availability of programs such as GEM and Hospital at Home (non-VA program providing hospital-level care of elders in their own homes) for those patients who would benefit from acute care outside a hospital setting.
    Date: September 28, 2009
  • Appropriate Prescription of Proton-Pump Inhibitors among Elderly Veterans Using NSAIDs
    Using VA data, this observational study assessed VA provider awareness of NSAID gastro-protection and the therapeutic intent of proton-pump inhibitor (PPI) prescription among 1,491 elderly Veterans at one VAMC. In other words, investigators sought to better understand why VA physicians were prescribing these drugs. Findings show that among elderly Veterans who were prescribed a PPI, a therapeutic intent was documented in 71% of the cases, and of these prescriptions, 88.8% were considered appropriate. However, practitioner recognition of the need for gastro-protection in elderly patients was remarkably low (10%). Results also show that poor rates of appropriate therapeutic intent were noted when the PPI was initiated by the inpatient service, by certain sub-specialties (e.g., cardiology, otolaryngology), and for Veterans using the VA for medication refill only.
    Date: September 15, 2009
  • Ethnic Disparities in the Treatment of Veterans with Dementia
    This study sought to determine if there were ethnic disparities in the evaluation and treatment of dementia among 410 Veterans treated at one VAMC between 4/05 and 6/05. Findings show that while laboratory and imaging workup (i.e., CT, MRI) did not differ between ethnic groups, there were significant differences in the treatment of dementia. For example, African American Veterans with dementia were 40% less likely than all other patients to receive acetylcholinesterase inhibitors. This treatment disparity did not appear to be due to differences in the evaluation of dementia, which was similar across groups, although significantly more Caucasian Veterans (43.8%) underwent neuropsychological testing compared to African American (24.8%) or Hispanic Veterans (32.4%).
    Date: September 1, 2009
  • Drugs-to-Avoid Criteria for the Elderly have Limited Value
    Drugs-to-avoid criteria are lists of drugs considered to be potentially inappropriate for the elderly due to adverse effects, limited effectiveness, or both. For example, the Centers for Medicare and Medicaid Services use a version of the criteria of Beers et al. in nursing homes, and the National Committee for Quality Assurance uses the criteria of Zhan et al. to compare the quality of U.S. health plans. This study compared the Beers and Zhan criteria with individualized expert assessment of patients’ medications in 256 elderly Veterans from the Iowa City VAMC who were taking five or more medications. Findings show that the drugs-to-avoid criteria performed poorly when used as quality measures to assess the current state of a patient’s drug therapy. For example, half or more of the drugs flagged by the Beers and Zhan criteria were not considered problematic upon individualized expert review. In addition, the Beers and Zhan criteria identified only 8-15% of drugs that experts judged to be problematic. Therefore, authors suggest that while these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures for the quality of prescribing.
    Date: July 27, 2009
  • Panel Reaches Consensus on Oral Dosing for Primarily Renally Cleared Medications in Older Adults
    Chronic kidney disease (CKD) is a growing public health problem that disproportionately affects older adults. Medications are the most frequently used therapy for the management of CKD-related problems in older adults, but they are often prescribed in inappropriate doses. This study sought to establish consensus dosing guidelines for primarily renally cleared oral medications commonly taken by older adults with renal insufficiency. An expert panel was able to reach consensus agreement on 18 oral medications that are primarily renally cleared, including anti-infectives and central nervous system medications.
    Date: February 1, 2009
  • Providing Better Care for Vulnerable Elders in the Primary Care Setting
    Investigators identify three key processes of care needed to achieve better outcomes for vulnerable elder patients: communication, developing a personal care plan for each patient, and care coordination. They also describe two delivery models of primary care: co-management (e.g., primary care clinician shares patient responsibility with another clinician or care team with additional expertise in caring for vulnerable elders), and augmented primary care (e.g., enhanced decision support for clinicians, such as computerized clinical reminders).
    Date: December 1, 2008
  • Cancer Treatment Rates Low among Elderly Veterans
    Cancer treatment was more common among younger elders (age 70-84) and the authors suggest that it is possible that an exaggerated level of trepidation regarding treatment ramifications among the elderly may be an obstacle to appropriate treatment in patients who could benefit from it.
    Date: September 1, 2008
  • More Daytime Sleeping Predicts Less Functional Recovery among Elderly Undergoing Inpatient Post-Acute Rehabilitation
    More daytime sleep during the rehabilitation stay was associated with less functional recovery from admission to discharge, even after adjusting for other significant predictors (e.g., mental status, reason for admission, and hours of rehabilitation therapy). Further, more daytime sleep remained a predictor of less functional recovery at 3-month follow-up.
    Date: September 1, 2008
  • Fall Prevention and Management for Older Adults
    This article describes fall prevention and management activities from a chronic care perspective that may help researchers, practitioners, and policymakers better understand existing programs and services. The authors propose a "no wrong door" approach to fall prevention and management, in which older adults at risk of falls are evaluated across three domains -- physical activity, medical risks, and home safety. Trained providers would then connect the patients and their caregivers to programs and services that address the identified risk in the most appropriate manner.
    Date: August 1, 2008

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background-image  End of Life Care

  • Timing and Duration of Hospice and Palliative Care across VA, Medicare, and VA-Purchased Care
    This study examined the real-world timing of palliative care in VA, and how timing and duration of hospice care varied across Medicare, VA, and VA-purchased care. Findings showed that most Veterans received hospice care, while fewer received palliative care. Taken together, 86% of Veterans had some exposure to hospice or palliative care in the approximately 180 days before death. Median first exposure to hospice care was slowest in VA (more days before receipt of care) and fastest in VA-purchased environments (fewer days before receipt of care). Patients with VA hospice care first received it a median of 14 days before death, compared with VA-purchased hospice care (median of 28 days before death) and Medicare hospice care (median of 16 days before death). After adjusting for patient age and cancer type, Veterans who received VA hospice care were significantly less likely to receive it for at least three days compared with Veterans who received it through VA-purchased or Medicare environments. Medicare was the largest payer of hospice care for Veterans (61%) followed by VA (44%) and VA-purchased care (10%). There remains a gap between recommended timing of supportive services and real-world practice of care. This is especially true for palliative care, which is recommended for all patients with advanced cancer regardless of terminal status.
    Date: May 26, 2016
  • Surgical Patients Less Likely to Receive Hospice or Palliative Care Compared to Medical Patients
    This study examined the use of end-of-life care in the VA healthcare system among surgical and medical patients at the end of life. Findings showed that VA surgical patients were less likely to receive either hospice or palliative care in the year prior to death compared with medical patients (38% vs. 41%, respectively). This difference also was present in a separate analysis of palliative care (37% surgical vs. 39% medical) and hospice care (21% surgical vs. 24% medical). Moreover, differences in the use of palliative or hospice care were intensified after adjusting for patient characteristics. However, among Veterans who received hospice or palliative care, surgical patients lived significantly longer than their medical counterparts (median of 26 days versus 23 days). The use of palliative services increased over the study period – from 29% to 47% for medical patients and from 27% to 45% for surgical patients. Likewise, hospice use increased from 21% to 27% and from 19% to 24% for medical and surgical patients, respectively. The median time between palliative or hospice initiation and death increased over the study period – from 22 to 25 days for medical patients and from 22 to 30 days for surgical patients.
    Date: September 24, 2014
  • Systematic Frailty Screening may Lead to Reduced Post-Operative Mortality in Frail Veterans
    Investigators in this study implemented a quality improvement initiative to screen Veterans scheduled for elective surgery for frailty in order to identify those at high risk for post-operative mortality and morbidity. This systematic frailty-screening program effectively identified at-risk surgical patients and was associated with a significant reduction in mortality in Veterans undergoing palliative care consultation. Implementation of the screening program was associated with a 33% reduction in 180-day mortality even after controlling for age, frailty, and whether the patients had surgery. Further, given the high risk of dying in this frail cohort, study models suggest that for every four patients screened, one death was prevented or delayed at 180 days. After implementation of the frailty-screening program, palliative care consultations were more frequently ordered by surgeons, and they were more likely to take place before the index operation. Moreover, pre-operative palliative care consultations ordered by a surgeon were associated with the greatest reduction in mortality.
    Date: September 10, 2014
  • Unintended Consequences of Advance Directive Law
    This study sought to identify the unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences. Findings show that unintended negative consequences of advance directive legal restrictions may prevent all patients, vulnerable patients in particular, from making and communicating their end-of-life wishes and having them honored. Five overarching legal and content-related barriers were identified: poor readability (i.e., laws in all states were written above a 12th-grade reading level); restrictions on who may serve as a healthcare agent; execution requirements (steps needed to make forms legally valid); inadequate reciprocity (acceptance of advance directives between states); and religious, cultural, and social inadequacies. These restrictions have rendered advance directives less clinically useful. Advance directive statues meant to protect patients’ right of self-determination may instead better protect physicians from punitive action. For example, many states have provisions that enable physicians to presume the validity of an advance directive in the absence of actual knowledge that the directive is invalid. Author recommendations include improving readability (e.g., older persons read at a 5th-grade level), allowing oral advance directives, and eliminating witness or notary requirements. They also suggest that patients be allowed and encouraged to document their values, cultural traditions, and other socially or culturally important information.
    Date: January 18, 2011
  • More than One-Quarter of Elderly Individuals Require Surrogate Decision-Making Near the End of Life
    Of the 3,746 elderly adults (non-Veterans) in this study, 26.8% required decision-making at the end of life and lacked decision-making capacity. Thus, surrogate decision-making was often required. Of those requiring surrogate decision-making, 67.6% had advance directives. Individuals who authored advance directives received care that was strongly associated with their preferences. And those who requested all care possible were far more likely to receive aggressive care compared to those who did not request it. Individuals with advance directives preferred limited and comfort care more than all care possible. Cognitive impairment, cerebrovascular disease, and nursing home status were associated with the need for decision-making and lost decision-making capacity before death; but these characteristics were so common (present in 65.3% of the study population) as to not be clinically useful risk factors.
    Date: April 1, 2010
  • Patient/Provider Communication in Veterans with Terminal Illness
    When providers communicated to Veterans the life-limiting nature of their illness, Veterans were more likely to understand that aspect of their illness and to discuss care preferences with family members. Veterans who believed they had a life-limiting illness more frequently reported that their provider had communicated this to them than those who did not share that belief. More than half of the Veterans reported discussing care preferences with their providers, and 66% reported such discussions with their family. Findings underscore the need to promote effective communication and mutual understanding between Veterans, families, and providers regarding the patient’s illness and prognosis as part of improving patient-centered, late-life care.
    Date: March 1, 2010
  • Disease-Specific Differences in End-of-Life Treatment of Seriously Ill Veterans of Different Ethnic and Racial Backgrounds
    Differences in the level of end-of-life treatments were disease-specific and not based on race and/or ethnicity. In addition, increased end-of-life care for minorities was most pronounced in veterans with dementia, and non-cancer patients received more invasive care than patients with cancer or dementia, independent of their race or ethnicity.
    Date: September 1, 2008

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background-image  Heart Disease

  • Maximal Doses of High-Intensity Statins Confer Greatest Survival Advantage for Those with Atherosclerotic Cardiovascular Disease
    This study sought to determine one-year cardiovascular mortality for VA patients with atherosclerotic cardiovascular disease by statin intensity – and to assess whether any differences in mortality related to statin intensity, if present, were observed in selected patient sub-groups (i.e., age, gender). Findings showed that high-intensity statins conferred a small but significant survival advantage over moderate intensity statins, even among older adults. Moreover, the maximal doses of high intensity statins conferred a further survival benefit. For example, when the sample was limited to Veterans on high-intensity statins, those treated with maximal doses had a 10% lower mortality when compared with those on sub-maximal doses. There was significant underuse of high-intensity statins and a graded relationship between statin intensity and mortality among Veterans in this study. Only 20% of Veterans received a high-intensity statin, while 43% were on moderate-intensity statins. Older adults (>75 years), women, and some minority groups were less likely to be on a high-intensity statin at baseline. Findings have significant implications for future lipid management practice guidelines.
    Date: November 9, 2016
  • VA Diabetes and Cardiovascular Care Quality Comparable between Physicians and Advanced Practice Providers
    This study assessed the effectiveness of diabetes and cardiovascular disease (CVD) care provided to Veterans in VA primary care by advanced practice providers (APPs) compared to physicians. Findings showed that the quality of diabetes and CVD care delivered in VA primary care settings was mostly comparable between physicians and APPs. However, a majority of Veterans with diabetes and CVD – irrespective of their provider type – did not meet performance measures geared toward control of multiple risk factors. Only 27% and 28% of Veterans with diabetes and 54% and 55% of Veterans with CVD receiving care from physicians and APPs, respectively, met all eligible measures. Thus, regardless of provider type, there is a need to improve performance on all eligible measures among these Veterans.
    Date: November 1, 2016
  • Incorporating Health Status into Routine Care
    This article describes the early efforts of VA’s Patient Reported Health Status Assessment (PROST) system to capture, report, and initiate clinical action in response to patient-reported health status measures, thereby improving the value of care delivered to Veterans undergoing elective percutaneous coronary intervention. Findings suggest that refocusing performance measures on health outcomes that reflect the patient’s perspective may reduce measurement burden and incentivize care delivery improvements that directly improve patient health. Integrating data from patient-reported health status measures such as PROST could lead to efficient and targeted interventions for specific patient populations.
    Date: August 2, 2016
  • Use of Contraindicated Medications among Veterans Undergoing Percutaneous Coronary Intervention
    This study examined the use of contraindicated antiplatelet medications for 64,294 Veterans who underwent a PCI between 2007 and 2013. Findings showed that 18% had a known contraindication to at least 1 of 5 antiplatelet medications. Among these patients, 7% received a contraindicated medication in either the periprocedural setting or upon hospital discharge. Patients on contraindicated antiplatelet therapy showed a non-significant trend for greater risk of 30-day mortality and periprocedural major bleeding. Thus, use of contraindicated antiplatelet medications persists, though the rate of contraindicated medication use is lower in VA compared with U.S. community practice.
    Date: July 1, 2016
  • Use of Oral Anticoagulant Therapy for Veterans with Atrial Fibrillation Declines over 10-Year Period in VA Healthcare
    Among patients with atrial fibrillation (AF), oral anticoagulants (OACs) are recommended when the risk of stroke is moderate or high, but not when the risk of stroke is low. This study sought to quantify trends and evaluate guideline adherence with OACs in Veterans with newly diagnosed AF over a ten-year period within the VA healthcare system. Findings showed that among Veterans with new AF and additional risk factors for stroke, only about half received an oral anticoagulant, and the proportion is declining, including among patients with higher risks for stroke. Overall, initiation of an OAC fell from 51% in 2002 to 43% in 2011. The decline in oral anticoagulant use shown in these results is concerning because patients with AF who fail to receive recommended OAC therapy have high rates of preventable stroke. This study, as well as others, shows an opportunity to improve rates of guideline adherence.
    Date: June 21, 2016
  • Significant Decrease in Rates of Non-Acute Percutaneous Coronary Intervention since Release of Appropriate Use Criteria
    This study sought to examine the trends in percutaneous coronary intervention (PCI) utilization, patient selection, and procedural appropriateness following the introduction of Appropriate Use Criteria to critically examine and improve patient selection for PCI, as well as address concerns about potential overuse. Findings showed that since the publication of the Appropriate Use Criteria in 2009, there have been signficant reductions in non-acute PCI volume. Among patients undergoing PCI between July 2009 and December 2014, the volumes of non-acute PCIs declined significantly – from 89,704 in 2010 to 59,375 in 2014, while the volume of acute PCIs remained stable – 377,540 in 2010 to 374,543 in 2014. There also were significant reductions in the proportion of non-acute PCIs classified as being inappropriate – from 26% in 2009 to 13% in 2014. However, there was persistent hospital-level variation in the rate of inappropriate PCIs, ranging from 6% to 23% in 2014.
    Date: November 17, 2015
  • Long-Term Follow-Up of VADT Study Suggests Cardiovascular Benefits of Tight-Glucose Control in Diabetes
    Veterans Affairs Diabetes Trial (VADT) participants were randomly assigned to receive either intensive or standard glucose control. The study ended on May 29, 2008, with a median follow-up of 5.6 years. This study analyzed an additional five years of observational follow-up data on VADT participants (through December 2013), thus achieving a total follow-up of 11.8 years for most study measures. Findings showed that Veterans with type 2 diabetes randomized to intensive glucose control for a median of 5.6 years had a significant 17% relative reduction in major cardiovascular events after almost 10 years of total follow-up (8.6 events prevented per 1,000 person-years) compared to Veterans who received standard glucose therapy. However, intensive glucose control was not associated with a significant decrease in all-cause mortality after almost 12 years of follow-up. Results provide further evidence that improved glycemic control can reduce major cardiovascular events. This potential benefit may be considered in conversations with patients, but balanced with the burdens and safety data for the specific glucose-lowering treatment being considered.
    Date: June 4, 2015
  • Pharmacist Support Key in Medication Adherence for Veterans Prescribed Dabigatran for Atrial Fibrillation
    This study assessed site-level variation in dabigatran adherence and identified practices associated with higher dabigatran adherence within the VA healthcare system. Findings showed that among VA patients who were treated with dabigatran, there was significant site-level variation in medication adherence across VAMCs – with the site average ranging from 42% to 93%. Veterans were more likely to be adherent and without missing doses when they were monitored by VA pharmacists. Longer duration of pharmacist-led monitoring and providing more intensive care to non-adherent patients, in collaboration with the clinician, also improved medication adherence. Findings suggest extra patient support (i.e., pharmacist availability) may significantly improve adherence to dabigatran. These data affirm that VA’s rich infrastructure of pharmacist-led, specialized anticoagulation care may continue to have an important role in maximizing safety, effectiveness, and appropriate use of these new agents, even as warfarin use continues to decline.
    Date: April 14, 2015
  • Patient Outcomes for Multi-faceted Intervention for Veterans with Heart Failure Comparable to Usual Care
    Investigators in this study developed the Patient-Centered Disease Management (PCDM) intervention for patients with heart failure (HF) that combines multidisciplinary collaborative care by a nurse coordinator, cardiologist, psychiatrist and primary care provider, home tele-monitoring, and depression management. The primary aim of the study was to determine whether or not Veterans enrolled in the intervention experienced better health status (i.e., symptom burden, functional status, and quality of life) compared with Veterans enrolled in usual care. Findings showed that the PCDM intervention did not improve HF health status for Veterans compared with usual care. While there was significant improvement in overall summary scores in both groups after one year (mean increase of 13.5 points in each group), there was no significant difference between Veterans in the intervention group compared to Veterans in the usual care group. Among secondary outcomes, there were significantly fewer deaths at one year among Veterans in the intervention group (8 of 187, or 4%) than in the usual care group (19 of 197, or 10%). Among Veterans who screened positive for depression, there also was greater improvement in depression scores after one year for Veterans in the intervention group compared to Veterans in the usual care group. There was no significant difference in 1-year hospitalization rates between groups (29% vs. 30%).
    Date: March 30, 2015
  • Sleep Difficulties Associated with Risk Factors for Cardiovascular Disease among Younger Veterans and Active Duty Personnel
    This study examined the relationship between sleep difficulties and several cardiovascular (CVD) risk factors (i.e., smoking status, body mass index, self-reported hypertension, hypertension medication use, clinic-based blood pressure readings, symptoms of depression and PTSD, and diagnosis of depression and PTSD) among relatively younger (mean age, 37 years) Veterans and active duty personnel of the Iraq and Afghanistan wars. Findings showed that 8% of the Veterans in this study endorsed only sleep onset difficulties, 9% endorsed only sleep maintenance difficulties, and 41% endorsed both sleep onset and sleep maintenance difficulties. Study participants with both sleep onset and maintenance difficulties had greater odds of being a current smoker, having a diagnosis of PTSD, having clinically significant PTSD symptoms, having a diagnosis of depression, and having clinically significant depression symptoms. The odds for these risk factors did not differ by race or age. Having the combination of sleep onset and maintenance difficulties also was associated with elevated systolic blood pressure readings and increased likelihood of reporting a hypertension diagnosis among younger white Veterans. Overall, study participants with sleep maintenance difficulties were older, while those having both sleep onset and maintenance difficulties were younger and reported more tours of duty. Veterans reporting sleep difficulties of any kind reported more symptoms of depression and PTSD. Authors note that since sleep difficulties are associated with several CVD risk factors, improving sleep in this younger population may reduce the progression of disease and avert the increased incidence of CVD found in older Veterans.
    Date: March 27, 2015
  • Differences between Men and Women Veterans Undergoing Cardiac Catheterization in VA
    This study sought to determine whether there were gender differences in clinical characteristics and comorbidities, coronary anatomy and treatment, and procedural complications and long-term outcomes after diagnostic catheterization. Findings showed that female Veterans were younger (57 vs 63 years), with fewer traditional cardiovascular risk factors, but had more obesity, depression, and PTSD than male Veterans. Compared to male Veterans, female Veterans had lower rates of obstructive coronary artery disease (CAD) (23% vs 53%), similar or lower rates of procedural complications, and lower rates of all-cause rehospitalization. Women Veterans had lower mortality at one year, even when adjusted for age, presence of obstructive disease, and multiple comorbidities. Findings suggest that a significant portion of women Veterans treated in VA catheterization labs have chest pain not related to obstructive CAD. This may represent a complex interplay of psychological stressors and somatic disease, but further research is needed.
    Date: March 1, 2015
  • Female Veterans with CVD Less Likely to Receive Statin and High-Intensity Statin Therapy Compared to Male Veterans with CVD
    This study sought to identify the proportion of male and female Veterans with cardiovascular disease (CVD) who received care in any of 130 VA facilities between 10/1/10 and 9/30/11, and who received any statin and high-intensity statin. Findings showed that while evidence-based use of both statin and high-intensity statin therapy remains low in both genders, female Veterans with CVD were less likely to receive evidence-based statins (58% vs. 65%) and high-intensity statins (21% vs. 24%) compared with male Veterans. In fully adjusted analyses, female gender was independently associated with a 32% lower likelihood of receiving any statin therapy and a 24% lower likelihood of receiving high-intensity statin therapy. Mean low-density lipoprotein cholesterol levels were higher in female compared with male Veterans (99 vs. 85 mg/dl) with CVD. The use of statin and high-intensity statin therapy among female Veterans with CVD showed substantial facility-level variation. With the “statin dose-based approach” proposed by the recent cholesterol guidelines, these results highlight areas for quality improvement. It is important to note that despite the observed gender disparity noted in this study, statin and high-intensity statin use remain low in both genders. This is concerning, as the patient population studied in these analyses (i.e., those with established CVD) is the one that derives the most benefit from statin and high-intensity statin therapy.
    Date: January 1, 2015
  • Veterans with Non-Obstructive Coronary Artery Disease at Significantly Greater Risk of MI and Mortality
    This study compared incidence of myocardial infarction (MI) and mortality between patients with non-obstructive coronary artery disease (CAD), obstructive CAD, and no apparent CAD in a national cohort of Veterans receiving VA care. Findings showed that compared to Veterans with no apparent CAD, Veterans with non-obstructive CAD were at significantly greater risk of MI and all-cause mortality at one year. The one-year risk of MI progressively increased by extent of CAD, rather than abruptly increasing between non-obstructive and obstructive CAD. For example, among Veterans with no apparent CAD, the one-year MI rate was 0.11%, while the one-year MI rate for 1-vessel non-obstructive CAD was 0.24%, increasing to 0.59% for 3-vessel non-obstructive CAD. One-year mortality rates also were associated with increasing extent of CAD, ranging from 1.4% among Veterans with no apparent CAD to 4% for Veterans with 3-vessel or LM (left main) obstructive CAD. After risk adjustment, there was no significant association between 1- or 2-vessel non-obstructive CAD and mortality, but there were significant associations with mortality for 3-vessel non-obstructive CAD and 1-, 2-, and 3-vessel or LM obstructive CAD. Age and cardiovascular risk factors (e.g., hypertension, hyperlipidemia, and diabetes) all increased with increasing extent of CAD. The frequency of prescriptions for post-angiography cardiovascular medications and rates of coronary revascularization also increased with CAD extent. Findings suggest that non-obstructive CAD is common, confers significant risk for MI and mortality, and warrants immediate consideration of preventative therapies for patients with this condition.
    Date: November 5, 2014
  • Delays in Filling Clopidogrel Prescription Associated with Increased Major Adverse Events Following PCI
    This study assessed the frequency of delays in filling an initial clopidogrel prescription after hospital discharge for Veterans who underwent percutaneous coronary intervention (PCI) with stent implantation between 1/05 and 9/10 at any of 60 VA hospitals. Findings showed that approximately 1 in 14 Veterans delayed filling clopidogrel prescriptions after PCI. Moreover, delays were associated with increased risk of major adverse events; specifically, patients with a delay in filling their clopidogrel prescription more often suffered MI (12% vs. 6%) and death (2.2% vs. 1.5%) compared to those without delay. The percentage of Veterans with delays varied by VA hospital, ranging from 0% to nearly 44%. This large variation suggests a need to identify best practices that allow hospitals to optimize prescription filling at discharge to potentially improve patient outcomes. In the VA healthcare system, delayed filling of clopidogrel prescription occurred less than half as often as in a prior study conducted with a Medicare population, which found that 20% of patients delayed filling their clopidogrel prescription after hospital discharge. Therefore, it is possible that the lower rate of delayed prescription filling within VA (7%) may be attributable to greater coordination of care, since inpatient and outpatient prescriptions are managed by a single VA pharmacy service.
    Date: September 1, 2014
  • Women Veterans, Particularly Black Veterans, Have Worse Risk Factor Control for Cardiovascular Disease than Male Veterans
    This study compared gender and racial differences in three risk factors that predispose individuals to cardiovascular disease: diabetes, hypertension, and hyperlipidemia. Findings showed that overall, female Veterans had significantly higher LDL cholesterol levels than male Veterans, despite being almost ten years younger, on average. These differences are similar to gender disparities previously reported both within and outside VHA and represent a clinically significant difference. African-American women Veterans had worse blood pressure control than White women Veterans, and among Veterans with diabetes, male African-Americans had worse control of higher blood pressure, LDL, and HbA1c levels than White males.
    Date: September 1, 2014
  • Digoxin Significantly Associated with Increased Risk of Death among Veterans with Atrial Fibrillation
    This study investigated the association of digoxin therapy with mortality in a large cohort of Veterans with atrial fibrillation (AF). Findings showed that among Veterans with newly diagnosed AF, treatment with digoxin was significantly and independently associated with increased risk of death, regardless of age, gender, kidney function, heart failure status, concomitant therapies, or drug adherence. Of the Veterans in the study, 23% received digoxin. Compared with non-recipients, digoxin recipients had a higher prevalence of heart failure (HF) and receipt of beta-blockers, angiotensin receptor blockers, antiplatelet therapy, diuretic agents, and warfarin. Digoxin increased the risk of death by 1.21 times compared to comparable patients treated with other therapies for AF. While these findings challenge current cardiovascular society recommendations, the implication is not that every patient should come off this drug and every doctor should stop using it. Rather, physicians should consider alternatives to digoxin in managing patients with AF as it may still have a useful role under specific and carefully monitored conditions.
    Date: August 19, 2014
  • Under-utilization of Cardiac Rehabilitation for Veterans Hospitalized for Ischemic Heart Disease
    This study sought to determine: 1) the proportion of Veterans with ischemic heart disease (IHD) who participate in cardiac rehabilitation (CR); 2) whether the presence of an onsite CR program was associated with greater participation; and 3) patient characteristics associated with participation. Findings showed that only 8% of the Veterans in this study who had been hospitalized for MI, PCI, or CABG participated in one or more sessions of outpatient cardiac rehabilitation. Overall, Veterans were more likely to participate in CR if they had been hospitalized at a VA facility with an onsite CR program versus without one (11% vs. 7%). However, participation was extremely low regardless of the presence or absence of an onsite program. Characteristics associated with greater participation in CR included: younger age, being married, higher BMI, living closer to a VA facility, hyperlipidemia, absence of heart failure, absence of chronic kidney disease, and hospitalization for CABG (vs. PCI or MI). After controlling for these variables, the presence of an onsite CR program was associated with 75% greater odds of attending a CR program.
    Date: August 18, 2014
  • Combat Deployments Associated with New-Onset Coronary Heart Disease among Young U.S. Service Members and Veterans
    This study sought to determine whether specific deployment experiences and PTSD symptoms are associated with newly reported coronary heart disease (CHD) among a young cohort (mean age = 34 years at baseline) of U.S. military personnel (active duty) from all service branches. Findings showed that combat deployments were associated with new-onset CHD among young U.S. service members and Veterans. Service members who reported combat experiences had nearly twice the odds of having a diagnosis code for new-onset CHD than service members without combat exposure. This suggests that experiences of intense stress may increase the risk for CHD over a relatively short period among young adults. Screening positive for PTSD symptoms was associated with self-reported CHD prior to – but not after adjusting for depression and anxiety, and was not associated with a new diagnosis of CHD.
    Date: March 11, 2014
  • Veterans with Multiple Chronic Conditions Account for Disproportionate Share of VA Healthcare Costs
    This study examined the association between number of chronic conditions and costs of care for non-elderly (<65 years) and elderly Veterans (=65 years) within the VA healthcare system – and estimated VA expenditures for the most prevalent and costly combinations of three conditions (triads). Findings showed that Veterans with multiple chronic conditions account for a disproportionate share of VA healthcare costs. Almost one-third of non-elderly and slightly more than one-third of elderly VA patients had >3 conditions, but they accounted for 65% and 67% of total VA healthcare costs, respectively. The most common triad of chronic conditions for both non-elderly and elderly Veterans was diabetes, hyperlipidemia, and hypertension (24% and 29%, respectively). Conditions present in the most costly triads included: spinal cord injury, heart failure, renal failure, ischemic heart disease, peripheral vascular disease, stroke, and depression. While patients with the most costly triads had average costs that were three times higher than average costs of patients in other triads, the prevalence of these costly triads was extremely low (0.1 to 0.4%). These findings highlight the need for interventions that target the sickest patients who have high resource use to provide more cost-effective care.
    Date: March 1, 2014
  • Anxiety Disorders and Depression Associated with Risk of Future Heart Failure among Veterans
    This study sought to determine if the risk of heart failure (HF) was greater in Veterans with: 1) a diagnosis of one or more anxiety disorders but who were free of major depressive disorder (MDD); 2) MDD but free of anxiety disorders; or 3) comorbid anxiety and depressive disorders. Findings showed that in the model that corrected for age only, Veterans with anxiety disorders, MDD, or both were each about 20% more likely to develop HF compared to Veterans without these conditions. This effect remained significant after adjusting for other HF risk factors (e.g., sociodemographics, nicotine use, substance use disorders), and was even greater after adjusting for psychotropic medications. Compared to Veterans without HF, patients with HF were significantly older and more frequently male, non-white, unmarried, holders of supplemental insurance, and were significantly more likely to have diagnoses of hypertension, diabetes, and obesity. Veterans with both anxiety and MDD were more likely to have a diagnosis of substance abuse or dependence and history of nicotine use – and to receive a prescription for psychotropic medication.
    Date: February 1, 2014
  • Multifaceted Intervention Improves Medication Adherence for Veterans following Hospitalization for Acute Coronary Syndrome
    This study tested a multifaceted intervention to improve adherence to cardiac medications in the year after acute coronary syndrome (ACS) hospital discharge. Findings showed that, based on the four classes of cardio-protective medications in the study, a greater proportion of Veterans in the intervention group were adherent to medications in the year following hospitalization for ACS compared to Veterans in the usual care group: 89% vs. 74%, respectively. For the secondary prevention measures, there were no differences in the proportion of patients who achieved BP and LDL goals. There were no significant differences between Veterans in the intervention and usual care groups for rehospitalization for myocardial infarction (7% vs. 4%), revascularization (12% vs. 18%), or death (9% vs. 8%).
    Date: November 18, 2013
  • Normal Coronary Rates for Elective Angiography
    This study sought to determine if VA is selective and consistent in the use of angiography, as reflected by rates of normal coronaries found in patients undergoing angiography. Findings showed that among Veterans undergoing elective coronary angiography in the VA healthcare system, about 1 in 5 patients (21%) had normal coronaries. This is a lower average rate of normal coronaries, compared with previous findings from other U.S. hospitals (39%). Across VA hospitals, the median proportion of normal angiograms among Veterans who had undergone elective coronary angiography ranged from 6% to 49%. Veterans at hospitals with lower normal coronary rates were more likely to undergo stress testing prior to angiography compared with hospitals with higher rates of normal results, and rates of obstructive coronary artery disease and subsequent revascularization were higher at hospitals with lower rates of normal coronaries.
    Date: October 18, 2013
  • Risk Factors for Adverse Cardiac Events after non-Cardiac Surgery in Veterans with Coronary Stents
    This study examined the risk factors for major adverse cardiac events (MACE) in Veterans undergoing non-cardiac surgery following coronary stent implantation, including the relationship between stent type and time from stent to surgery. Findings showed that the three most significant risk factors associated with MACE following non-cardiac surgery in Veterans with recent coronary stent implantation were non-elective surgical admission, history of MI in the six months preceding surgery, and a revised cardiac risk index greater than 2. Stent type and timing of surgery beyond 6 months following stent implantation were not associated with MACE. Also, no association between APT cessation and MACE was observed. Investigators suggest that a more comprehensive approach to perioperative risk assessment and management among Veterans with coronary stents that emphasizes cardiac and surgical risk factors, rather than stent type, may be warranted.
    Date: October 9, 2013
  • Redundant Lipid Testing in Veterans with CHD
    Repeat lipid testing for coronary heart disease (CHD) patients who have already attained guideline-recommended LDL-C treatment targets and receive no treatment intensification may represent overutilization and possibly waste of healthcare resources. This study sought to determine the frequency and correlates of repeat lipid testing in Veterans with CHD who had already attained the LDL-C treatment target, and who received no treatment intensification. Findings showed that one-third of the Veterans with CHD who had attained guideline-recommended LDL-C levels had additional lipid testing performed without treatment intensification in the 11 months following their initial lipid panel. Collectively, these patients had 12,686 additional lipid panels performed, with an annual extra cost of $203,990 for the one VA network included in the study. This does not include the cost of the patients’ time to undergo testing, or the providers’ time to manage results and notify the patient. Veterans with concomitant diabetes, hypertension, and higher illness burden, and those who had more frequent primary care visits were more likely to undergo repeat lipid testing, while Veterans with good medication adherence were less likely to undergo repeat testing.
    Date: July 1, 2013
  • Comparing Cardiovascular Outcomes for Two Common Anti-Diabetes Drugs among Veterans
    This study compared cardiovascular disease (CVD) outcomes and all-cause mortality in a cohort of Veterans who received regular VA healthcare and were prescribed metformin or sulfonylureas – the two most commonly used anti-diabetic drugs. Findings showed a modest but clinically important 21% increased risk of hospitalization for heart attack or stroke, or death from any cause associated with the initiation of sulfonylurea compared with metformin therapy. The sulfonylurea group had higher rates of hospitalizations and deaths due to cardiovascular disease: 18 per 1,000 person years for those taking a sulfonylurea and 10 per 1,000 person years for those taking metformin. These findings suggest that for 1,000 patients who are initiating treatment for diabetes using metformin rather than sulfonylureas, there are 2 fewer heart attacks, strokes, or deaths per year of treatment. The findings do not clarify whether the difference in CVD risk is due to harm from sulfonylureas, benefit from metformin, or both.
    Date: November 6, 2012
  • Treatment Intensification for Hypertension Not Significantly More Likely to Occur in Veterans with Diabetes and at Higher CV Risk
    Treatment intensification for hypertension was not significantly more likely to occur in Veterans with diabetes and at higher CV risk, compared with patients at low to medium risk. However, physicians were more likely to advance therapy in patients with higher and more consistently elevated blood pressures. Several individual risk factors were associated with higher rates of treatment intensification: systolic BP, mean BP in the prior year, and higher hemoglobin A1c, while self-reported home BP <140/90 was associated with lower rates of TI. The authors suggest that incorporating CV risk into TI decision algorithms could prevent an estimated 38% of cardiac events without increasing the number of patients being treated.
    Date: August 1, 2012
  • Perceived Discrimination Associated with Risk of Severe Coronary Obstruction among African American Veterans
    Compared to white Veterans, African American Veterans with abnormal cardiac nuclear imaging studies had greater perceptions of racial discrimination that were related to increased risk for severe coronary obstruction – and to angiographic coronary obstruction, after controlling for clincal and psychosocial factors related to cardiovascular health. Based on their nuclear imaging studies, 44% of Veterans (both whites and African Americans) were at high risk for severe coronary obstruction. Among both African American and white Veterans, prior myocardial infarction (MI) and smoking were associated with high (vs. low/moderate) risk for severe coronary obstruction, while optimism was related to a decreased risk of severe obstruction. No significant associations between social support, negative affect, or religiosity and results from nuclear imaging or coronary angiography were found.
    Date: April 1, 2012
  • Non-Cardiac Surgery Soon after Cardiac Revascularization with Stents Decreasing among Veterans
    In November 2007, American College of Cardiology/American Heart Association (ACC/AHA) guidelines were released that recommended delay of elective non-cardiac surgery for 12 months after cardiac revascularization with drug eluting stents (DES), compared with six weeks for bare metal stents (BMS). In this study, 12% of Veterans in the BMS cohort had early surgery (less than 6 weeks) compared with 47% of Veterans in the DES cohort who had early surgery (less than 12 months). Rates of non-cardiac surgery within the first year after a DES placement have steadily declined (15% to 8%), suggesting that the ACC/AHA guidelines are being adopted into practice across the VA healthcare system. The authors note that nearly half of operations after a DES, including major procedures, were performed within the first 12 months. Thus, many Veterans are still undergoing high-risk non-cardiac procedures during the high-risk time period after cardiac stent placement.
    Date: February 15, 2012
  • Top Performing VA Anticoagulation Clinics Share Characteristics
    The top performing VA anticoagluation clinics shared six characteristics: 1. Adequate pharmacist staffing and effective use of non-pharmacist personnel; 2. Innovation to standardize clinical practice around evidence-based guidelines; 3. Presence of a quality champion for the anticoagulation clinic (ACC); 4. Higher staff qualifications (e.g., all pharmacists had completed pharmacy residencies); 5. Climate of ongoing group learning; and 6. Internal efforts to measure performance. No low-outlier ACC had more than two of these characteristics. Therefore, the authors suggest that efforts to improve performance should focus on the six common domains. At least five domains were not associated with ACC performance, including use of the electronic medical record, and configuration of the clinic (e.g., face-to-face patient contact vs. telephone care).
    Date: February 1, 2012
  • Veterans with Serious Mental Illness Using Co-Located/Integrated Primary Care and Outpatient Mental Health Clinic Care have Reduced Cardiovascular Risk
    Veterans with serious mental illness (SMI) were more likely to attain cardiovascular risk goals after being enrolled in a primary care clinic co-located and integrated into an outpatient mental health clinic. Compared to prior to enrollment, Veterans enrolled in SMIPCC had significantly more primary care visits over six months – and significantly improved BP, LDL, triglycerides, and BMI. There were no significant differences in the attainment of goals for HDL or HbA1c. Prior to enrollment, 49% of primary care visits were on the same day as any scheduled mental health visit; this increased to 86% post-enrollment. Among the 28 Veterans in this study with coronary artery disease and/or diabetes, SMIPCC enrollment was associated with a significant improvement in BP goal attainment, but not with any other measures.
    Date: February 1, 2012
  • Increased Risk of Mortality Following Heart Attack for Veterans Insufficiently Treated for Major Depressive Disorder
    This study sought to determine if mortality following acute MI was associated with treatment-resistant depression (TRD). Findings show that all-cause mortality following an acute MI is greatest in Veterans with depression that is insufficiently treated – and is a risk in Veterans with treatment-resistant depression. Veterans who were insufficiently treated were 3.04 times more likely to die than those who received treatment. Veterans with TRD were 1.71 times more likely to die; however, this risk was partly explained by comorbid disorders.
    Date: January 12, 2012
  • Investigators Provide Rationale for New LDL Guidelines
    Updated guidelines for cholesterol testing and management from the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults are due to be published in 2012. A primary focus of the previous version of the guidelines was treating patients to low-density lipoprotein (LDL) cholesterol level targets, with the primary goals of therapy and the cut-points for initiating treatment stated in terms of LDL. However, the authors of this commentary believe this reasoning diverges from clinical evidence and present three primary reasons that justify a major change in the next generation of guidelines: 1) There is no scientific basis to support treating to LDL targets, 2) The safety of treating to LDL targets has never been proven, and 3) Tailored treatment is a simpler, safer, more effective, and more evidence-based approach. This perspective is synergistic with recent activities in VA, in which a multidisciplinary group of leaders provided input that led to the suspension of VA’s Performance Measure that was strictly focused on achievement of lipid targets. They are now working to substitute a performance measure that emphasizes the prescription of statin medications.
    Date: January 1, 2012
  • Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008
    This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care.
    Date: December 1, 2011
  • Caregivers of Veterans with Chronic Illness
    This study sought to identify predictors of caregiver strain and satisfaction associated with caring for Veterans with chronic illness. Findings showed that although 76% of caregivers reported feeling very self-confident in their caregiving role, more than one-third (37%) reported high strain. Overall, the mean caregiving satisfaction score indicated a moderate level of satisfaction. Caregiver characteristics that predicted strain included having less support, having depressive symptoms, and using paid help. Veteran characteristics that predicted caregiver strain included greater need for caregiving assistance in IADL (instrumental activities of daily living), and greater levels of depression. Predictors of lower caregiver satisfaction included less social support, older age, depression, and poor Veteran health status. Predictors of higher caregiver satisfaction included helping the Veteran with medical equipment and the coping style of “taking medication.” Both caregivers and Veterans reported similar levels of assistance provided, which were relatively low for ADL (activities of daily living) and IADL. However, caregivers reported providing a mean of 43 hours per week in assistance. Investigators suggest this may be due to the higher percentage of spouse caregivers in this sample, who are available for caregiving around the clock. A majority of caregivers expressed a need to know more about the Veteran’s medication.
    Date: November 22, 2011
  • Missed Opportunities for Providers to Discuss Advance Care Planning with Veterans with Heart Failure
    This study sought to identify and characterize potential opportunities for physicians to engage in advance care planning (ACP) discussions – and to examine their responses to opportunities during follow-up with Veterans recently hospitalized for heart failure. Findings showed that in 13 of 71 outpatient consultations, Veterans expressed concerns, questions, and thoughts regarding their future care that gave providers opportunities to engage in an ACP discussion. The majority of these opportunities (84%) were missed by physicians. Instead, physicians changed the subject back to the routine biomedical aspects of the visit; hedged their response about prognosis; denied or contradicted the patient’s expressed emotion or preference; or inadequately acknowledged the question or sentiment underlying the patient’s statement. In order to successfully leverage opportunities to engage in ACP discussions, authors suggest that communication training efforts should focus on helping physicians identify patient openers and providing a toolbox to encourage appropriate physician responses.
    Date: October 25, 2011
  • Health of Gulf War Veterans Worsened in 10-Year Study
    Since the 1991 Gulf War, initial concerns regarding health consequences of participation in the war have turned to requests for longitudinal evaluation of how the health of Gulf War Veterans has changed over time. To help in this evaluation, investigators conducted health surveys of deployed and non-deployed Gulf War-era Veterans in 1995 and again in 2005. Findings showed that the health of deployed Gulf War Veterans worsened during the 10-year period from 1995 to 2005 in comparison with non-deployed Gulf War Veterans. Perceived health of fair or poor was more likely to persist among deployed Veterans, and relatively more deployed Veterans reported that their health status had worsened over the 10-year follow-up. Deployed Veterans were less likely to recover from any prior functional impairment, limitation of activities, or PTSD that they had in 1995 – and were more likely to report new onset of these adverse health outcomes in 2005 compared with non-deployed Veterans. Authors note that the extent to which any of the health problems experienced by Gulf War Veterans were due to the effects of military service in the Gulf War is difficult to detemine.
    Date: October 1, 2011
  • Collaborative Care Intervention for Veterans with Ischemic Heart Disease Treated in VA Primary Care Setting
    The Collaborative Cardiac Care Project sought to determine whether a multi-faceted intervention using a collaborative care model ? directed through primary care providers ? would improve symptoms of angina, self-perceived health, and concordance with practice guidelines for managing chronic stable angina among Veterans with ischemic heart disease (IHD). Findings showed that the collaborative care intervention had no significant effects on symptoms or self-perceived health, but significantly improved receipt of guideline-concordant care in Veterans with stable angina. Although concordance with guidelines improved 4.5% more among Veterans receiving collaborative care than those receiving usual care, this was mainly due to increased use of diagnostic testing rather than recommended medications. The collaborative care model was well received by primary care providers, who implemented 92% of 701 recommendations made by collaborative care teams. Nearly half of the recommendations were related to medications, e.g., adjustments to beta blockers, long-acting nitrates, and statins.
    Date: September 12, 2011
  • Veterans with Diabetes and Major Depressive Disorder at Significantly Increased Risk of Myocardial Infarction
    This study sought to determine if major depressive disorder (MDD) complicates the course of type 2 diabetes and is associated with increased risk of myocardial infarction (MI) and mortality. Findings showed that Veterans with comorbid MDD and type 2 diabetes were 82% more likely to experience a MI compared to Veterans without MDD and type 2 diabetes. Veterans with MDD alone were 29% more likely to have a MI, and Veterans with type 2 diabetes alone were at 33% increased risk of MI. The incidence of MI increased in a step-wise fashion, from unaffected Veterans (2.6% incidence of MI) to those with depression only (3.5%) to those with diabetes only (5.9%) to Veterans with both conditions (7.4%). Veterans with PTSD, anxiety, and panic disorder were more likely to have a MI, as were Veterans with hypertension, hyperlipidemia, obesity, and nicotine dependence.
    Date: August 1, 2011
  • Nurse Case Management Decreases Cardiovascular Risk Factors among Veterans with Diabetes Compared to Usual Care
    This study sought to determine if nurse case management could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia among Veterans with diabetes compared to usual care. Findings showed that involving a nurse case manager in the care of patients with diabetes can significantly improve the number of individuals achieving target values for glycemia, lipids, and blood pressure compared to usual care. In this study, a greater number of Veterans in the intervention group had all three outcome measures under control compared to Veterans in the usual care group. In addition, a greater number of Veterans in the nurse case management group achieved individual treatment goals for blood pressure, lipids, and blood sugar compared to Veterans receiving usual care. Observed differences between groups were likely mediated both by enhanced lifestyle changes and a greater intensity of pharmacological treatment among Veterans in the intervention group.
    Date: June 2, 2011
  • Newly FDA-Approved Dabigatran May Be Cost-Effective Alternative to Warfarin for Patients at Increased Risk of Stroke
    Atrial fibrillation (AF) is the second most common cardiovascular condition in the U.S. – and the second most common condition affecting Veterans. AF also increases the risk of ischemic stroke by five-fold. Research shows that anticoagulation therapy with warfarin and other vitamin K antagonists can reduce the relative risk of stroke in AF by two-thirds. Dabigatran – a newer anticoagulant and the first such drug approved by the FDA in 20 years – produces similar or reduced rates of ischemic stroke and hemorrhage compared with warfarin and requires no blood testing. This study evaluated the quality-adjusted survival, costs, and cost-effectiveness of dabigatran compared with warfarin for the prevention of ischemic stroke in patients >65 years with non-valvular AF. Findings show that dabigatran could be a cost-effective alternative to adjusted dose warfarin. High-dose dabigatran was the most effective and the most cost-effective therapy examined. The quality-adjusted life expectancy was 10.28 quality-adjusted life years (QALYs) with warfarin, 10.70 QALYs with low-dose dabigatran, and 10.84 QALYs with high-dose dabigatran. Thus, high-dose dabigatran yielded an additional half year of quality-adjusted life compared to warfarin. With dabigatran given at 150 mg twice daily – the approved dosage for most patients – the incremental cost compared with using warfarin is under the conventional cost-effectiveness threshold of $50,000 per QALY gained. Total costs were $143,193 for warfarin, $164,576 for low-dose dabigatran, and $168,398 for high-dose dabigatran.
    Date: January 4, 2011
  • Risk-Adjusted Time in Therapeutic Range Can Be Used as Quality Indicator for Outpatient Oral Anticoagulation
    This study examined the suitability of risk-adjusted time in therapeutic range (TTR) as a potential quality indicator for anticoagulation therapy among VA patients. Findings show that TTR can be used to profile the quality of outpatient oral anticoagulation in a large, integrated healthcare system. Thus, this measure can serve as the basis for quality measurement and quality improvement efforts. TTR differed among VA anticoagulation clinics – from 38% to 69%, or from poor to excellent. Risk-adjustment did not alter performance rankings for many sites, but for other sites it made an important difference. For example, the anticoagulation clinic that was ranked 27th out of 100 before risk adjustment was ranked as one of the best (7th) after risk-adjustment. Risk-adjusted site rankings were consistent between the first and second years of the study, suggesting that risk-adjusted TTR measures a construct (quality of care) that is stable over time.
    Date: January 1, 2011
  • Use of Automated External Defibrillators on Hospitalized Patients Not Associated with Improved Survival
    The use of automated external defibrillators (AEDs) has been proposed as a strategy to reduce times to defibrillation and improve survival from cardiac arrests that occur in the hospital setting. This study evaluated the association of AED use and survival for patients with cardiac arrests in general hospital wards. Findings show that the use of AEDs to assess and treat hospitalized patients with cardiac arrest was not associated with improved survival. Overall, the use of an AED in this study population was associated with a lower rate of survival after in-hospital cardiac arrest compared with no AED use (16% vs. 19%). Among cardiac arrests due to non-shockable heart rhythms (e.g., asystole, pulseless electrical activity), AED use was associated with lower survival (10% vs. 15%). In contrast, for cardiac arrests due to shockable heart rhythms (e.g., ventricular fibrillation, pulseless ventricular tachycardia), AED use was not associated with survival (38% vs. 40%).There were no differences by age or gender, but there was a slightly higher rate of AED use among African Americans.
    Date: November 17, 2010
  • Model Used for Cholesterol Guidelines May Lead to Misclassification of Risk for Heart Attack and Coronary Death
    National cholesterol guidelines use the “Framingham model” to calculate a person’s 10-year risk of myocardial infarction or coronary death. Based on this risk, patients are categorized into different risk groups, which are used to guide treatment decisions. Both original and point-based versions of the model are in use and endorsed by national guidelines. Given that approximately 36 million persons in the U.S. are eligible for lipid-lowering therapy, differences in risk classification depending on which model is used could result in millions receiving different lipid-lowering therapy. This study compared differences in predicted risk between the original and point-based Framingham calculations. Findings show that compared with the original Framingham model, the point-based version of the tool misclassifies millions of Americans into different risk groups, with 25-46% of affected individuals experiencing potential impacts on drug treatment recommendations for cholesterol control.
    Date: November 1, 2010
  • Using One Classification System for Estimates of Urban/Rural Impact on AMI Outcomes among Veterans May Not Be Adequate
    This study examined whether: 1) two different rural classification systems identify differential rates of Veterans admitted for AMI; 2) rural-urban disparities exist for risk-adjusted AMI outcomes (measured by mortality and receipt of coronary revascularization); and 3) whether hospital transfer rates differ for patients admitted with AMI. Findings showed no observed differences between rural-dwelling and urban-dwelling Veterans in risk-adjusted 30-day mortality, regardless of the urban-rural classification system used. However, rural-dwelling Veterans were less likely to receive revascularization compared to urban-dwelling Veterans, but risk estimations were dependent upon the urban-rural classification system used. Regardless of classification system, Veterans residing in rural settings were transferred more often and were more likely to be admitted to VA hospitals without revascularization facilities. This study demonstrates that using a single rural classification system for estimating the effects of living in a rural setting on AMI outcomes among Veterans may not be adequate.
    Date: September 1, 2010
  • Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness
    This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains.
    Date: August 1, 2010
  • Heart Failure Mortality Decreases While Rehospitalization Increases among Veterans
    Heart failure is the number one reason for admission among Veterans enrolled in the VA healthcare system. In order to improve care for this chronic disease, VA has incorporated the use of guideline-recommended treatments; however, it is unclear if the increased performance on process of care measures for hospitalized Veterans has led to improvements in outcomes. This study sought to determine if recent mortality and readmission rates have improved within VA. Findings show that mortality and rehospitalization rates for Veterans with a first hospitalization for heart failure in the VA healthcare system or in a non-VA hospital that was paid for by VA trended in opposite directions between 2002 and 2006. Mortality rates at 30 days decreased (7.1% to 5.0%), while rehospitalization rates for heart failure at 30 days increased (5.6% to 6.1%). Over the same time period, use of guideline recommended therapy increased. During the six months prior to hospital admission and during the three months following admission, there were large increases in the use of beta-blockers. The use of angiotensin-receptor blockers also increased. Examination of patient characteristics showed that most comorbid diagnoses increased significantly from 2002 to 2006, suggesting that Veterans hospitalized in 2006 were more ill. The authors suggest that the use of rehospitalization for heart failure as a marker of poor care may be flawed. Further studies to determine the reasons for the decline in mortality and the portion of hospitalizations that are preventable are recommended.
    Date: July 27, 2010
  • Additional Evidence of Clustering of Cardiovascular Events Following Cessation of Clopidogrel in Patients with ACS
    In multivariable analysis, including adjustment for total duration of clopidogrel treatment, the 0-90 day interval after stopping clopidogrel was associated with significantly increased risk of death/MI compared to the 91-360 day interval among a non-VA population. There was a similar trend of increased adverse events after stopping clopidogrel for various subgroups (women vs. men, medical therapy vs. percutaneous coronary intervention, stent type, and = or <6 months of clopidogrel treatment). This clustering of adverse events was not present among patients stopping ACE-inhibitors, suggesting that the events are not a general effect of stopping medications. There was no association between the 91-360 day interval after stopping clopidogrel and adverse outcomes compared to patients remaining on clopidogrel.
    Date: May 1, 2010
  • History of Depression Remains a Risk Factor for Heart Disease after Accounting for Other Contributing Factors among Twin Veterans
    A history of depression remained a risk factor for incident heart disease even after adjusting for numerous covariates including: sociodemographics, co-occurring psychopathology, smoking, obesity, diabetes, hypertension, and social isolation. Moreover, twins with both high genetic and phenotypic expression of depression were at greatest risk of ischemic heart disease (IHD). Results also show that twins with hypertension and twins with diabetes were more likely to have IHD, as were twins who reported no social support. Age, race, education, and marital status were not associated with IHD status.
    Date: May 1, 2010
  • Lower Mortality Rates for African American Compared with White Patients Hospitalized for Heart Failure
    This study examined research reporting mortality by race after hospitalization for heart failure (HF), and combined the results using meta-analyses. Adjusted mortality rates were 32% lower in short-term follow-up (0-30 days) and 16% lower in long-term follow-up (after 30 days) for African American compared with white patients. Authors suggest that differences in mortality imply unmeasured differences by race in clinical severity of illness at hospital admission and may lead to biased hospital mortality profiles.
    Date: March 1, 2010
  • Strategies to Reduce Sodium Intake Likely to Decrease Stroke and Heart Disease, and Save Billions in Costs
    Using a mathematical model, investigators examined the cost-effectiveness of two governmental strategies to reduce sodium intake in the U.S.: 1) government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience; and 2) a tax on sodium. Findings show that strategies to reduce sodium intake on a population level are likely to substantially reduce the incidence of stroke and myocardial infarction, saving billions of dollars in medical expenses.
    Date: March 1, 2010
  • Relationship between Cost of Care and Quality of Care for Two Conditions in Non-VA Hospitals
    The relationship between (non-VA) hospitals’ cost of care and quality of care for a particular condition was small and differed by condition. However, evidence did not support the hypothesis that low-cost hospitals discharge patients with congestive heart failure (CHF) or pneumonia earlier, only to increase readmission rates and incur greater inpatient cost of care over time. Low-cost hospitals had similar or slightly higher 30-day readmission rates compared with high-cost hospitals. Hospitals in the highest-cost quartile for CHF care had higher quality-of-care scores and lower mortality. For pneumonia, the opposite was true: high-cost hospitals had lower quality-of-care scores and higher mortality. Risk-adjusted costs of care for CHF and pneumonia varied widely between hospitals, although hospital cost-of-care patterns seemed stable over time.
    Date: February 22, 2010
  • Comparing Treat-to-Target Strategies to Tailored Approach for Statin Therapy
    This study examined how a simple Tailored Treatment strategy for statin therapy compared with a Treat-to-Target strategy based on National Cholesterol Education Program (NCEP) III treatment recommendations. Findings show that a simple Tailored Treatment strategy was more efficient and prevented substantially more coronary artery disease morbidity and mortality than any of the currently recommended Treat-to-Target approaches. The Tailored Treatment approach was predicted to save 520,000 more quality-adjusted life years among Americans aged 30-75 than the best NCEP III Treat-to-Target approach for every five years of treatment, even though fewer people were treated with high doses of statins. The authors indicate that these results suggest that a Tailored Treatment approach to medicine can substantially improve care, while also reducing unnecessary treatment and costs. Thus, they recommend that given its potential to better tailor treatments to individual patients, the principles underlying a Tailored Treatment approach should be considered during deliberations about guidelines and performance measures.
    Date: January 19, 2010
  • Veterans with Psychosis More Likely to Die from Heart Disease
    This study assessed whether Veterans with mental disorders receiving care in the VA healthcare system were more likely to die from heart disease than Veterans without these disorders, and whether modifiable factors may explain mortality risks. Findings show that compared to Veterans without a mental health diagnosis, Veterans with psychosis (schizophrenia or other psychotic disorder diagnoses) were more likely to die from heart disease. Smoking and physical inactivity were the behavioral factors most strongly associated with mortality related to heart disease. Veterans with schizophrenia were the most likely to be current smokers, and those with bipolar disorder were the least likely to report adequate physical activity. Controlling for behavioral factors (e.g., smoking and physical inactivity) diminished but did not eliminate the impact of psychosis on mortality. The authors suggest that to reduce mortality related to heart disease, early interventions that promote smoking cessation and physical activity among Veterans with psychotic disorders are warranted.
    Date: November 1, 2009
  • Mental Health Diagnoses Associated with Cardiovascular Risk Factors among OEF/OIF Veterans
    Studies of Veterans from prior wars found that those with PTSD are at increased risk of developing and dying from cardiovascular disease, but this risk had not yet been evaluated in OEF/OIF Veterans. This article discusses findings from a study on the association between mental health disorders, including PTSD, and cardiovascular risk factors. Findings show that OEF/OIF Veterans (male and female) with mental health diagnoses had a significantly higher prevalence of cardiovascular risk factors (e.g., hypertension, obesity, diabetes, tobacco use). The association between mental health diagnoses and cardiovascular risk factors remained after adjusting for demographics and military factors. The most common mental health diagnosis was PTSD (24%). The majority of Veterans with PTSD had comorbid mental health diagnoses: depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), as well as other psychiatric diagnoses (33%).
    Date: August 5, 2009
  • Improving Adherence to Cardiovascular Medications
    This article focuses on cardiovascular medication adherence and discusses studies that address: 1) different methods of measuring adherence, 2) prevalence of non-adherence, 3) association between non-adherence and outcomes, 4) reasons for non-adherence, and 5) interventions to improve medication adherence. Findings show that while there are many different methods for assessing medication adherence, non-adherence to cardiovascular medications is common and associated with adverse outcomes. The authors also found that non-adherence is not solely a patient problem but is impacted by both providers and the healthcare system. To date, interventions targeting medication adherence have produced only modest success. Multi-modal interventions have shown the most promise in improving adherence, but require the clinical personnel to manage and coordinate multiple intervention components.
    Date: June 16, 2009
  • Men and Women Veterans Receive Equal Care for AMI in VA Hospitals
    This study sought to describe the clinical characteristics, treatment, and survival in women Veterans compared with men admitted to VA hospitals for AMI between 10/03 and 3/05. Findings show that after adjusting for clinical characteristics, men and women Veterans treated for AMI in VA hospitals had similar levels of care and survival. There were no significant differences in the treatment provided to men and women Veterans, and cardiac catheterization was provided at equal rates (34.9% for men vs. 36.9% for women). Men did have higher mortality rates, but after adjusting for clinical characteristics this difference was no longer significant. In addition, significantly more men were prescribed aspirin and angiotensin-converting enzyme inhibitors, but there were no differences with regard to other platelet inhibitors, beta-blockers, or lipid-lowering medications.
    Date: May 1, 2009
  • Neither Warfarin nor Clopidogrel Superior to Aspirin as Antiplatelet Therapy for Chronic Heart Failure
    The Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) Trial was conducted to determine the optimal anti-thrombotic agent for heart failure patients with reduced ejection fraction who are in sinus rhythm. WATCH Trial findings do not support the primary hypotheses that warfarin or clopidogrel is superior to aspirin. For the primary combined outcome of mortality, non-fatal MI, or non-fatal stroke, major differences between anticoagulation with warfarin and anti-platelet therapy with aspirin or clopidogrel are unlikely. Warfarin was associated with fewer non-fatal strokes than aspirin or clopidogrel, but also was associated with more frequent bleeding episodes compared to clopidogrel, and a non-significant excess of bleeding compared to aspirin.
    Date: March 31, 2009
  • Study Compares PCI Strategies to Medical Therapy in Patients with Non-Acute CAD
    This study compared medical therapy (e.g., lifestyle modifications, medication) to various percutaneous coronary intervention (PCI) strategies in the treatment of patients with non-acute coronary artery disease (CAD). Findings show that while bare metal stents and drug-eluting stents yielded increased improvements in diminishing the need for revascularization, innovations in PCI technologies have not improved outcomes (i.e., incidence of myocardial infarction, mortality) compared to medical therapy.
    Date: March 14, 2009
  • Concomitant Use of Clopidogrel and Proton-Pump Inhibitors after ACS is Associated with Higher Risk of Adverse Outcomes
    Proton-pump inhibitors (PPI) were frequently prescribed with clopidogrel (63.9%) for Veterans following hospitalization for acute coronary syndrome (ACS); the concomitant use of clopidogrel and PPI was associated with a higher risk of adverse outcomes compared to the use of clopidogrel alone. The combined primary outcome of mortality or re-hospitalization occurred in 20.8% of Veterans prescribed clopidogrel only, and in 29.8% of Veterans prescribed clopidogrel and PPI. Among secondary outcomes, Veterans taking clopidogrel and PPI also had a higher risk of recurrent hospitalization for ACS and revascularization procedures. Longer duration of clopidogrel plus PPI treatment was associated with adverse outcomes, suggesting that time on combination treatment is important. Pending further studies to confirm results and prospectively assess cardiovascular outcomes for Veterans taking clopidogrel and PPI versus clopidogrel alone, these results may suggest that PPIs should be used for patients with a clear indication for the medication, rather than prophylactically.
    Date: March 4, 2009
  • Cardiovascular Risk Reduction Clinic for Veterans with Diabetes
    The Cardiovascular Risk Reduction Clinic (CRRC) is a pharmacist-coordinated clinic at the Providence VAMC designed to treat the four traditional cardiovascular risk factors (diabetes, dyslipidemia, hypertension, and smoking) to attain goals set forth by national guidelines for patients with diabetes or documented cardiovascular disease. Veterans are discharged from the CRRC when guideline-recommended goals for hemoglobin A1c, low-density lipoprotein cholesterol, blood pressure, and smoking are achieved or mostly achieved. This study evaluated the maintenance of these goals for two to three years after discharge from the CRRC. Findings show that Veterans who completed the program maintained two goals – HbA1c and LDL-C – over three years of observation. The effect on blood pressure was less durable, with half of the Veterans who were at target levels at discharge from the CRRC reaching systolic BP >130 within six months after discharge. Results also show that the most important factor to consider for risk of failure after successful attainment of a cardiovascular goal is how poorly controlled the goal was at baseline.
    Date: March 1, 2009
  • Increase in VA Prescription Co-Pay Leads to Decrease in Adherence to Statins for Veterans at Risk of Heart Disease
    VA’s increase in drug co-payments from $2 to $7 adversely affected lipid-lowering medication adherence among Veterans, including those at high risk of coronary heart disease. After the increase in medication co-payments, the percent of Veterans who were adherent to lipid-lowering therapy declined significantly, even for Veterans with no co-pay. The co-payment increase was also accompanied by a significant increase in the likelihood of having continuous gaps in lipid-lowering medication use.
    Date: January 27, 2009
  • Improving Treatment Adherence for Veterans with Coronary Artery Disease
    Nearly 40% of the veterans in this study did not keep their appointments for testing or treatment for coronary artery disease, indicating that non-attendance in this particular patient population is a significant problem. Several factors associated with non-attendance were: slightly younger age, lower income, unemployment, and longer wait times for appointments (136 vs. 54 days for non-attenders compared to attenders). Veterans who missed appointments also reported fewer cardiac symptoms and were more likely to attribute them to something other than heart disease. Other reasons given for non-attendance were fear of diagnostic procedures (22.3%), as well as dissatisfaction with VA care and lack of trust in the physicians or hospital (16.5%).
    Date: December 1, 2008
  • Reducing Cardiovascular Risk for Veterans with Diabetes and Depression
    The Cardiovascular Risk Reduction Clinic (CRRC) is an ongoing clinical, multi-disciplinary, disease management program at the Providence VAMC. Veterans with and without a depression diagnosis had a significant improvement in cardiovascular risk reduction after participation in the CRRC program. Veterans with a diagnosis of depression had significantly higher cardiovascular risk than those with no mental health condition, but they had greater improvement after participating in the program.
    Date: October 1, 2008
  • Early Invasive Strategy Associated with Improved Clinical Outcomes for Patients with STEMI after Fibrinolytic Therapy
    An early invasive strategy was associated with significant reductions in mortality and re-infarction for patients with ST-segment elevation myocardial infarction (STEMI) compared with ischemia-guided management. There were no significant differences in the risk of stroke or major bleeding.
    Date: September 1, 2008

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background-image  Hepatitis C

  • VA Hepatitis C Care and Experiences with the Choice Program
    This study examined perspectives and experiences with the VA Choice Program among Veterans with HCV and their providers at three VAMCs in the New England region. Findings showed that the Choice Program has the potential to increase Veterans’ access to hepatitis C virus (HCV) treatment, but Veterans and VA providers described substantial problems in the initial years of the program. Four main themes emerged: (1) Difficulties in enrollment, ongoing support, and billing with third-party administrators (i.e., many Veterans described confusion about eligibility and enrollment for the Program); (2) Veterans experienced a lack of choice in location of treatment (i.e., most Veterans at the study sites did not have the option to receive VA HCV treatment, but many wanted to); (3) Fragmented care led to coordination challenges between VA and community providers (i.e., various challenges arose around sharing medical records, prescription delays, and working with designated VA staff trained on the Choice Program); and (4) VA providers expressed reservations about sending Veterans to community providers (i.e., VA providers were cautious about sending patients to the Choice Program because some community providers lacked specific experience in treating advanced cases of HCV).
    Date: March 3, 2017
  • Engagement in Hepatitis C Virus Care among Homeless and non-Homeless VA Patients
    This study sought to describe engagement in hepatitis C virus (HCV) care among homeless and non-homeless Veterans in the new era of HCV treatment, which includes direct-acting agents (DAAs) with shorter treatment durations, fewer side effects, and higher sustained virologic response (SVR) rates than the older treatment regimens. Findings showed that VA providers do a better job of testing for and diagnosing chronic HCV infection among homeless Veterans than they do among non-homeless Veterans: 90% of homeless Veterans who were estimated to have chronic HCV were diagnosed by laboratory testing compared with 77% of non-homeless Veterans. The percentage of the total homeless population with chronic HCV infection who had ever received HCV antiviral therapy (23%) was lower than the percentage of the total non-homeless population who had ever received HCV antiviral therapy (31%). However, the cumulative SVR rates achieved among homeless Veterans who had ever received HCV antiviral therapy (68%) and non-homeless Veterans who had ever received HCV antiviral therapy (74%) were comparable. Efforts are needed to identify appropriate interventions to ensure that more homeless Veterans are candidates for HCV antiviral therapy. Homelessness should not necessarily preclude receipt of HCV antiviral therapy as the direction of future HCV care and treatment eligibility criteria with all-oral DAA regimens is considered.
    Date: March 1, 2017
  • Cost-Effectiveness of New Hepatitis C Virus Treatments in VA and Non-VA Patient Populations
    This study analyzed the cost-effectiveness of multiple new hepatitis C virus (HCV) treatments for VA and non-VA treatment-naïve patients, accounting for differences in patient characteristics and costs of ongoing care and current drug prices, as well as potential reductions in these prices. Findings showed that in the non-VA HCV population, the latest generation of highly effective but costly HCV treatments delivers good value – comparable to other medical interventions commonly deemed high value. HCV treatment is even more cost-effective in VA’s patient population due to VA’s lower costs of drugs, despite patients being older with more comorbid conditions.
    Date: October 3, 2016
  • Antiviral Treatment Reduces Risk of Cirrhosis, Hepatocellular Cancer and Mortality among Veterans, Irrespective of Age
    This study examined the association between age subgroups and risk of cirrhosis, hepatocellular cancer (HCC), or death among Veterans who tested positive for the hepatitis C virus (HCV), including those who received treatment in VA facilities. Findings showed that receipt of curative antiviral treatment was associated with a reduction in the risk of cirrhosis, HCC, and overall mortality, irrespective of age. Elderly Veterans were significantly less likely to receive antiviral treatment; however, among those who received treatment, sustained virological response was not different among the age groups, even after adjusting for other demographic and clinical factors, including comorbidities. Given the accelerated progression to advanced liver disease, elderly patients with chronic hepatitis C constitute a high-risk group that may need to be prioritized in the era of new antiviral treatments.
    Date: April 3, 2016
  • Hepatitis C Virus Genotype 3 Associated with Increased Risk of Cirrhosis and Hepatocellular Cancer among Veterans
    Investigators in this study identified 110,484 Veterans with chronic Hepatitis C virus (HCV) infection and an average follow-up of more than five years to examine the differences between HCV genotypes in the risk of progression to cirrhosis and hepatocellular cancer (HCC). Findings showed that HCV genotype 3 (present in 8% of all cases) was associated with a significantly increased risk of developing cirrhosis and HCC compared to HCV genotype 1 (80% of cases). Veterans with HCV genotype 3 were 31% and 80% more likely to develop cirrhosis and HCC, respectively, compared to Veterans with the most common HCV genotype 1 infection. Genotype 3 has traditionally been considered easier to treat than genotype 1 infection. Investigators found that a significantly higher proportion of Veterans with genotype 3 received and subsequently responded to antiviral treatment than those with genotype 1. However, this therapeutic advantage did not counterbalance the negative impact of genotype 3 on cirrhosis and HCC. Given the accelerated progression to advanced liver disease, patients with HCV genotype 3 may serve as a high-risk group that will need to be prioritized in the era of new antiviral treatments.
    Date: February 24, 2014
  • VA HIV and Hepatitis C Telemedicine Clinics Improve Patient Outcomes among Rural Veterans
    Among a rural-dwelling study sample, HIV and hepatitis C telemedicine clinics were associated with improved access, high patient satisfaction, and a reduction in health visit-related time. Clinic completion rates (proxy for access) were higher for telemedicine (76%) than for in-person visits (61%). Of the 43 Veterans in the study, 30 (70%) completed a telemedicine-facilitated survey. More than 95% of these Veterans rated telemedicine at the highest level of satisfaction and preferred telemedicine to in-person visits. Veterans estimated that total health visit time was 340 minutes less for telemedicine compared to in-person visits. The majority of perceived time reduction was related to travel.
    Date: April 1, 2012
  • Rates of Liver Cancer and Cirrhosis Increase Significantly among Veterans with Hepatitis C Virus
    This study identified all Veterans with hepatitis C virus (HCV) who visited any of 128 VA medical centers over a 10-year period to examine the prevalence of cirrhosis, hepatic decompensation, and hepatocellular cancer, as well as risk factors that may be associated with an accelerated progression to cirrhosis. The number of Veterans diagnosed with HCV increased over the ten years from 17,261 to 106,242. Over the same time period, among HCV patients, the prevalence of cirrhosis increased from 9% to 18.5%, while the prevalence of liver cancer increased approximately 19-fold (from 0.07% to 1.3%). Regarding risk factors among HCV-infected Veterans, the proportion of patients with co-existing diabetes increased from 12% in to 23%, while the number of patients with HIV, hepatitis B virus, or a diagnosis of alcohol use declined slightly.
    Date: December 22, 2010
  • Patients with Hepatitis C Benefit from Collaborative Care
    This study evaluated the quality of healthcare that patients (non-Veterans) with Hepatitis C (HCV) receive and factors associated with receipt of quality care, using research data from one of the largest commercial health insurance carriers in the U.S. Findings show that collaboration between specialists and primary care physicians translates into better care for patients with HCV. Patients were less likely to receive any recommended care if they were being treated by specialists or generalists only, compared with being seen by both. Only about 19% of patients with HCV received all recommended care, and the proportion of patients who met quality indicators varied substantially. For example, most patients (79%) received a genotype test before treatment, whereas relatively few (25%) received recommended vaccinations.
    Date: August 17, 2010
  • Self-Management Program for Veterans with Hepatitis C Improves Health, Independent of Antiviral Therapy
    This randomized controlled trial sought to examine the effects of a Hepatitis C (HCV) self-management intervention on the quality of life of Veterans with HCV who were not currently on or scheduled to start antiviral treatment. Findings show that the HCV Self-Management Program was well attended and produced significant improvements along a number of dimensions of quality of life and other outcomes six weeks later. When compared to the information-only group, Veterans who attended the self-management workshop improved more on HCV knowledge, self-efficacy, and had more energy and vitality.
    Date: May 31, 2010
  • Chronic Kidney Failure Associated with Increased Mortality among Veterans with HIV and Hepatitis C Virus
    Compared with their mono-infected counterparts, Veterans with HIV who were co-infected with HCV had significantly higher rates of chronic kidney disease (14% vs. 11%) and mortality. HCV co-infection independently increased the likelihood of death by nearly 25%, after adjusting for other important HIV- and HCV-related factors. Co-infected Veterans also were less likely to have received highly active antiretroviral therapy (HAART) at baseline. Authors suggest that efforts should be targeted toward optimizing medical care for mono- and co-infected Veterans, including HAART therapy, HCV antiviral therapy, and treatment of comorbid medical conditions.
    Date: February 1, 2010
  • Areas for Mental Health Intervention for Patients with Hepatitis C
    In addition to the physiological side effects of treatment for the hepatitis C virus (HCV), there also can be significant neuropsychiatric effects such as depression, anxiety, psychosis, and suicidality. Moreover, numerous studies have documented the high prevalence of pre-existing psychiatric disorders among patients with HCV. This article reviews the psychological and psychosocial issues that are relevant to patients with HCV and provides mental health treatment recommendations. Some of these issues include stigma (i.e., more than half diagnosed with HCV have experienced discrimination) and social support. The authors also identify areas in which clinicians can intervene, including adjustment to having a chronic medical illness, management of side effects, and implementing healthy lifestyle recommendations.
    Date: March 1, 2009
  • Low Rates of Hepatitis Vaccination among Veterans with HCV
    Among veterans diagnosed with HCV between 2000 and 2005, approximately 8% overall received hepatitis vaccination and 7% of those with cirrhosis were vaccinated. In veterans with HCV who did not receive hepatitis vaccinations, 66%-96% had hepatitis A or B serology checked and about one-third had negative serology indicating susceptibility to co-infection and missed opportunity for vaccination.
    Date: November 1, 2008

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background-image  HIT

  • Evaluating Patient-Mediated Health Information Exchange
    In 2013, VA’s Office of Rural Health and the Department of Health and Human Services (Office of the National Coordinator) partnered to promote the use of My HealtheVet’s Blue Button capability to facilitate the transfer of Veterans’ health information to non-VA providers to improve care coordination for Veterans living in rural settings who use both VA and non-VA care (dual users). This partnership resulted in the Veteran-Initiated Electronic Care Coordination pilot study, which sought to: 1) train rural-dwelling dual-use Veterans to use Blue Button capabilities to share their health information with non-VA providers, and 2) evaluate whether or not the availability of VA information during community clinical encounters impacted the care they received. Findings from this study showed that with brief training, Veterans were able to generate their Continuity of Care Document (CCD) in My HealtheVet, share it with non-VA providers, and benefit from improved communication about medications and reduced laboratory duplication. After training, 78% of Veterans reported that the CCD would help them be more involved in their healthcare, and 86% planned to share it regularly with non-VA providers. The majority of non-VA providers (97%) were confident in the accuracy of the information, and 96% wanted to continue to receive the CCD. Moreover, 50% of non-VA providers reported that they did not order a laboratory test or other procedure because of CCD information.
    Date: October 11, 2016
  • Application of Triggers on VA “Big Data” may Help Identify Patients Experiencing Delays in Diagnostic Evaluation of Chest Imaging
    Triggers offer one method to use big electronic health record (EHR) data to prevent and mitigate the impact of delays in care related to missed test results. Triggers consist of computerized algorithms that can scan thousands of patient records to flag those with clues suggestive of patient safety events. This study tested the application of a trigger within VA’s EHR to help identify delays in patient follow-up related to abnormal chest imaging results. Findings showed that the trigger identified delays in patient follow-up with a reasonable accuracy for use in the clinical setting, suggesting that triggers are able to identify almost all delays related to abnormal lung imaging follow-up, and cost-effectively minimize the amount of effort providers spend reviewing false-positive results.
    Date: September 1, 2016
  • Electronic Health Record-Based Interventions for Reducing Inappropriate Imaging in the Clinical Setting
    Given that adoption of electronic health records (EHRs) is expanding, investigators conducted a systematic review and meta-analysis of EHR-based interventions to improve the appropriateness of diagnostic imaging. Findings showed that Computerized clinical decision support that is integrated into the physican order entry system of an electronic health record can help improve the appropriate ordering of diagnostic imaging studies. Of the 23 studies in this review, 21 studies provided moderate-quality evidence that EHR-based interventions can change appropriate test ordering by a moderate amount – and can reduce overall use by a small amount. Interventions that include a “hard stop” to prevent clinicians from ordering imaging tests classified as inappropriate, and implementation in an integrated care delivery setting may improve effectiveness. Potential harms of computerized clinical decision-support interventions have been rarely studied.
    Date: April 21, 2015
  • Use of Electronic Health Information Exchange may Reduce Emergency Department Utilization
    Investigators in this study conducted a systematic review of the health information exchange (HIE) literature, specifically examining the evidence of effect on health outcomes, healthcare use and efficiency, evidence of clinicians’ use of HIE, and the financial sustainability of HIE organizations. Investigators also evaluated evidence about patient and provider attitudes toward HIE, as well as barriers and facilitators to its use. Findings showed that using HIE may reduce emergency department (ED) usage and costs. The effects of HIE on other healthcare outcomes are uncertain. The use of HIE is low relative to the estimated potential need, with most studies reporting use in 2% to 10% of healthcare encounters. However, some sites reported much greater HIE use, and specifics of the context and implementation may be responsible for these differences. All stakeholders claim to value HIE, but many barriers to acceptance and sustainability exist, including workflow and interface issues, privacy and security of patient health information, and the lack of a compelling business case for sustainability.
    Date: December 2, 2014
  • Electronic Health Record-based Alerting Systems Can be Source of Turnover for Clinical Practices
    The use of certain components of electronic health records (EHRs), such as EHR-based alerting systems (EAS), might reduce provider satisfaction – a strong precursor to turnover. This study examined how providers’ perceptions of the use of EAS (known within the VA CPRS as View Alert notifications) may impact their satisfaction, intention to quit, and turnover. Findings showed that providers’ perceptions of the value of EAS predicted both provider satisfaction and facility-level turnover. For example, perceptions of the degree of monitoring and feedback received regarding EAS were significantly associated with intention to quit, with high levels of monitoring and feedback associated with increased intention to quit. Monitoring/feedback on EAS practices, training on the use of EAS, and the extent to which colleagues used/valued EAS had little impact on provider satisfaction.
    Date: November 1, 2014
  • Veterans’ Use of Blue Button Feature in MyHealtheVet
    The Blue Button feature in VA’s online combined personal health record and patient portal, My HealtheVet (MHV), allows patients to access electronic health record (EHR) components, such as past and future appointments, lab results, and medications. This study aimed to characterize users of the MHV Blue Button, its perceived impact on Veterans’ health, and its role in sharing healthcare information. Findings showed that among users of the Blue Button, the benefit most highly endorsed by Veterans (73%) was the value of having their health history in one place. In addition, 21% of users with a non-VA provider shared their VA health information, and of those, 87% reported the non-VA provider found the information somewhat or very helpful. Veterans’ self-rated computer ability was the strongest factor contributing to both Blue Button use and to sharing information with non-VA providers. The majority of non-users of the Blue Button stated they were not aware of it. However, non-users who were aware of the Blue Button stated they did not use it because they did not know how (34%), they only use MHV for prescription renewal (26%), they preferred other methods to keep track of health information (11%), or they did not know where the Blue Button was located (10%). Age was not associated with Blue Button use.
    Date: July 1, 2014
  • “Virtual” Hope Box Smartphone App Delivers Patient-Tailored Coping Tools to Help Veterans at Risk for Suicide
    Tools that assist patients in accessing and affirming their reasons for living can enable them to mitigate suicidal thoughts. One such tool has been labeled a “hope box”: a physical representation of the patient’s reasons for living, reminders of individual accomplishments and future aspirations, or things the individual finds soothing, e.g., a worry stone, family photographs, or letters. However, a conventional hope box can by physically unwieldy and inconvenient; thus, the investigators in this study developed a “Virtual” Hope Box (VHB) for service members and Veterans that expands the reach of the hope box modality to a smartphone app. This study compared the VHB with a Conventional Hope Box (CHB) integrated into VA behavioral health treatment. Compared with a CHB, more Veterans used the Virtual Hope Box regularly and found it to be beneficial, helpful, and easy to set up. Veterans stated that they would recommend the VHB to their peers, and twice as many preferred the VHB over the CHB for future use. Written comments from Veterans cited the helpfulness of the VHB with managing distress, negativity, hopelessness, anger, and various other symptoms. Moreover, mental health clinicians were unanimous in their praise for the VHB as an eminently usable therapeutic tool.
    Date: May 15, 2014
  • Health Information Technology
    This review sought to examine recent evidence that relates health IT functionalities prescribed in meaningful use regulations to key aspects of healthcare, such as quality, safety, and efficiency. Findings showed that most published IT evaluation studies report positive effects on quality, safety, and efficiency. Strong evidence supports the use of clinical decision support (CDS) and computerized provider order entry (CPOE). Fifty-seven percent of the studies in this review evaluated CDS and CPOE, and most reported positive results. Insufficient reporting of implementation and context of use makes it impossible to determine why some health IT implementations are successful and others are not. Therefore, the most important improvement that can be made in health IT evaluations is increased reporting of the effects of implementation and context. Authors note that with the increasing adoption of electronic health records and other forms of health IT, it is no longer sufficient to ask whether health IT creates value, but rather the most useful studies will help us understand how to realize value from health IT.
    Date: January 7, 2014
  • Electronic Patient Portals and their Effect on Health Outcomes
    Investigators conducted a systematic review of the relevant literature evaluating peer-reviewed articles on patient portals tied to existing electronic medical record systems, specifically looking at whether or not these systems improve health outcomes, patient satisfaction, healthcare utilization and efficiency, and adherence. Findings showed that the evidence is insufficient as to the effects of patient portals on health outcomes. A limited number of studies and variations in study design, portal functionalities, and implementation processes make it difficult to draw strong conclusions or generalizations about this relatively new technology. Examples were identified in which portal use was associated with improved outcomes for patients with chronic diseases (i.e., diabetes, hypertension, depression), but these were generally studies that used the portal in conjunction with case management. Evidence was mixed about the effect of portals on healthcare utilization and efficiency. Some findings included more acceptance of portals by patients who were younger and had more computer literacy or trust in the Internet, and more enthusiasm for portals among patients than physicians. Administrative and human factors in the interface were cited as barriers to use. Thus, the jury is still out on whether patient portals such as MyHealtheVet improve health outcomes or increase healthcare efficiency, although patients seem to value the ability to access their own medical records. While patients’ attitudes on portals are generally positive, more widespread use may require efforts to overcome racial, ethnic, and literacy barriers.
    Date: November 19, 2013
  • VA Primary Care Physicians Using Electronic Health Records May Miss Important Information Due to Information Overload
    This study examined potential predictors of missed test results in the setting of electronic health record (EHR)-based alerts. Findings showed that the median number of alerts VA PCPs reported receiving each day was 63; 87% of PCPs perceived the quantity of alerts to be excessive, and 70% reported receiving more alerts than they could effectively manage (marker of information overload). More than half (56%) of the PCPs reported that the EHR notification system, as currently implemented, made it possible for them to miss test results. Almost a third (30%) reported having personally missed results that led to delays in care for their patients. Further analyses showed that the perceived ease of EHR use by PCPs was related to a lower likelihood of both study outcomes: 1) the perception of potentially missing results, and 2) reporting missed results that led to delays in patient care. Greater concern over electronic hand-offs (i.e., routing alerts to the EHR of a surrogate covering-practitioner) was also related to the potential for and personal history of missed test results. PCPs who reported receiving more alerts than is manageable (information overload) were more likely to report having missed results that led to delayed patient care. Notably, the number of alerts that respondents reported they received per day was unrelated to either outcome.
    Date: April 22, 2013
  • Journal Issue Highlights the State of Health Information Technology in VA Healthcare
    This Medical Care Supplement focuses on the use and impact of health information technology (HIT) in quality improvement research conducted within VHA. Articles in this Supplement highlight a range of specific HIT approaches, including innovative and interactive uses of VHA’s electronic health record, databases, and information systems, as well as applications of automated systems for intervention, evaluation, and tracking patient care.
    Date: March 1, 2013
  • Primary Care Practitioners’ Views on VA’s Electronic Health Record System and Test Result Notification
    This study examined the broad range of social and technical factors that affect test result management in the VA healthcare system, based on a web-based survey of primary care practitioners (PCPs) at 142 VA facilities nationwide. Findings showed that despite an advanced electronic health record (EHR) system, VA PCPs reported both social and technical challenges in ensuring notification of test results to practitioners and Veterans. The vast majority of PCPs in this study had considerable experience with VA’s EHR, but less than half (46%) reported receiving sufficient training on the “View Alert” system. Nevertheless, the majority believed they had knowledge (74%) and proficiency (82%) to use the View Alert system. Just over one-third of the PCPs reported having the help needed for notifying patients of test results. Almost half of the PCPs reported that they did not immediately notify patients of normal test results and relied on patients’ next visit to notify them, whereas about one-fifth relied on the next visit to report abnormal results. A majority of PCPs (86%) stayed after hours or came in on weekends to address patient notifications, and less than one-third (30%) reported receiving protected time for alert management. Nearly half of the PCPs (47%) had prior experience using a non-VA EHR. Of these, 55% indicated that VA’s CPRS was superior to other commercially-available EHRs they had used, 19% thought that the non-VA EHR they used was superior, and 26% perceived them to be the same. PCPs endorsed several new features to improve test result management, including better tracking and visualization of result notifications.
    Date: December 25, 2012
  • Design and Implementation of a VA Hospital-Based Usability Laboratory for Health Information Technology
    This article describes the HSR&D Human-Computer Interaction & Simulation Laboratory, housed within one VAMC, which was intended to provide research-level findings about health information technology (HIT) design and was developed to investigate the usability of HIT toward transforming VA’s health information system. Investigators provide insight about the Laboratory’s design and implementation, and the use of a usability laboratory in the healthcare setting.
    Date: December 1, 2012
  • Majority of Veterans Interested in Sharing Personal Health Record Information with Caregivers and non-VA Healthcare Providers
    This study explored patient preferences regarding shared access to electronic health information by surveying individuals who used VA’s personal health record, My HealtheVet. Findings showed that a majority (79%) of My HealtheVet users were interested in sharing access to their personal health record with someone outside the VA healthcare system: 62% with a spouse/partner, 23% with a child, 15% with another family member, and 25% with a non-VA healthcare provider. Preferences regarding degree of access varied based on the type of information being shared, the type of activity being performed, and the respondent’s relationship with the person. Interest in sharing access to My HealtheVet was modestly, but significantly, greater among older Veterans and men, but did not vary by health status.
    Date: December 20, 2011
  • Natural Language Processing with Electronic Medical Record Improves Identification of VA Post-Operative Complications
    This study evaluated a natural language processing (NLP) search approach to detect post-operative surgical complications within VA’s electronic medical record (EMR). Findings showed that, among Veterans undergoing inpatient VA surgery, NLP using the EMR greatly improved the identification of post-operative complications compared to an administrative-code based algorithm. NLP correctly identified 82% of acute renal failure cases compared with 38% for patient safety indicators; 59% vs. 46% for venous thromboembolism; 64% vs. 5% for pneumonia; 89% vs. 34% for sepsis; and 91% vs. 89% for post-operative MI. An accompanying Editorial states that NLP has the potential to greatly enhance the EMR with new applications, such as automated quality assessment to assist in the performance of comparative effectiveness research.
    Date: August 24, 2011
  • Veterans in Favor of Internet-Provided HIV Screening Information
    This study examined patient and provider perceptions of Internet-based outreach to increase HIV screening among Veterans who use the VA healthcare system. Findings showed that both Veterans and providers thought that HIV screening outreach provided electronically via the personal health record (PHR – MyHealtheVet) would improve patient access to health information, with important educational value. Providers believed that it would reinforce messages they give to their patients. Veterans could envision instances in which information provided electronically might be better than verbal information from their doctor because it would be in lay language and readily available. Veterans also believed that electronic outreach would motivate them to be proactive about their health. Most felt that electronic messages would remind them to be screened, or at least contemplate getting screened. Regarding stigma attached to an electronic message about HIV, providers expressed substantially more concerns than Veterans. Providers also expected increased workload from the electronic outreach, and suggested adding primary care resources and devising methods to smooth the flow of patients getting screened.
    Date: August 15, 2011
  • Electronic Record Intervention Improves Follow-Up of Veterans with Positive Colorectal Cancer Screening
    This randomized trial of eight VAMCs evaluated an electronic record intervention for follow-up of Veterans with a positive fecal occult blood test (FOBT). Findings show that a simple electronic intervention involving an automatic GI consult for Veterans with a positive FOBT result improved follow-up and reduced the time between a positive FOBT and GI evaluation, as well as complete diagnostic evaluation (CDE). The 30, 90, and 180 day GI consult rates improved 21% to 33% among intervention sites, but did not change in the usual care sites. Thirty, 90, and 180 day CDE rates improved 9% to 31% in intervention sites, but did not significantly change in usual care sites. Time to GI consult and CDE decreased significantly over time in the intervention sites, but remained unchanged in the usual care sites.
    Date: February 15, 2011
  • Electronic Health Information’s Effect on Clinical Workflow
    This study sought to assess aspects of health information technology (HIT) that impact clinical workflow – and to identify a set of HIT characteristics that support patient care processes. Investigators identified many examples of how HIT affects workflow, but characteristics were strongest within four primary domains: 1) Trustworthy and reliable (e.g., inconsistent incomplete, incorrect information in the electronic health record (EHR); 2) Ubiquitous (e.g., poor accessibility due to lack of computer workstations or lengthy secure login processes, but good information availability ); 3) Effectively displayed (e.g., problems locating scanned documents in the EHR, lack of searchability , information not well-organized or prioritized); and 4) Adaptable to work demands (e.g., EHR is not portable or customizable, difficult to modify information). The findings from this study underscore the value of obtaining input from healthcare employees and may be used to enhance HIT design, clinical practice, and patient safety.
    Date: December 1, 2010
  • Fixing an Electronic Communication Problem that Reduced Follow-Up of Positive Cancer Screens at One VAMC
    This study sought to determine if technical and/or workflow-related aspects of automated communication in VA’s electronic health record could lead to the lack of response to a positive fecal occult blood test (FOBT). A problem with software configuration at one VA medical center intended to alert VA primary care physicians about positive FOBT results led to breakdowns in transmission of a subset of test results. About one-third of the 490 positive FOBTs examined for this study were not directly reported to PCPs as CPRS alerts. Upon correction of the technical problem, lack of timely follow-up of test results decreased from 29.9% to 5.4% -- and was sustained for four months following the intervention. The authors recommend that electronic communication of positive FOBT results should be monitored to avoid limiting the benefits of colorectal cancer screening. They are currently investigating whether this problem exists in other VA facilities, or if this was an isolated event.
    Date: December 9, 2009
  • “Rights” of Safe Electronic Health Record Use
    This JAMA Commentary proposes eight “Rights” of safe electronic health record (EHR) use, which are grounded in an engineering model that addresses work-system design for patient safety. The authors recommend the use of the eight “Rights,” in order to address the complex interaction of organizational, technical, and cognitive factors that affect the safety and effectiveness of EHRs.
    Date: September 9, 2009
  • Federal Investment in Electronic Medical Records
    The American Recovery and Reinvestment Act (ARRA) includes $19 billion in incentives for the adoption of electronic medical records (EMRs) and $50 billion to promote health information technology. Medicare physicians adopting and making “meaningful use” of EMRs in 2011 and 2012 will be eligible for an initial payment of up to $18,000, with reduced payments in 2013 and 2014. However, current EMR systems’ inability to learn from aggregated health data has led to implementations and hospital information technology departments that can actually obstruct quality improvement. For example, much of the information contained in EMRs is formatted as unstructured free text – useful for essential individual communication but unsuitable for detecting quantifiable trends. This commentary suggests that the Department of Health and Human Services capitalize on the opportunity to mandate EMRs that have the potential to learn from data in the EMR system.
    Date: September 9, 2009
  • Focus Groups Recommend Strategies to Decrease Missed Test Results
    This paper reports on the efforts of two focus groups that formed as part of the Diagnostic Error in Medicine – A National Conference, which was held by the American Medical Informatics Association in 2008. Clinicians who were part of the focus groups were asked to develop interventions that might decrease the risk of diagnostic delay due to missed test results in the future. The focus groups concluded that while the electronic medical record helps to improve access to test results, eliminating all missed test results would be difficult to achieve. However, they did recommend several strategies that might decrease the rates of missed test results, including: improving standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow-up of test results, and systems re-engineering to improve the management and presentation of data. They also suggest that healthcare organizations focus initial quality improvement efforts on specific tests that have been identified as high-risk for adverse impact on patient outcomes, such as tests associated with a possible malignancy or acute coronary syndrome.
    Date: September 1, 2009
  • Costs and Benefits of Health Information Technology
    The use of health information technology (HIT) has been promoted as having tremendous promise in improving the efficiency, cost-effectiveness, quality, and safety of medical care delivery. Findings from this literature review show a proliferation of patient-focused HIT applications, many of which are designed for use by patients without significant oversight by healthcare providers. Investigators believe that accelerating the adoption of HIT will require greater public-private partnerships, new policies to address the misalignment of financial incentives, and a more robust evidence base regarding HIT implementation.
    Date: March 1, 2009

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background-image  HIV

  • Racial Disparities in HIV Quality of Care that May Extend to Common Comorbid Conditions
    To more fully understand patterns of racial disparities in the quality of care for persons with HIV infection, this study examined a national cohort of Veterans in care for HIV in the VA healthcare system during 2013. Findings showed that racial disparities were identified in quality of care specific to HIV infection – and in the care of common comorbid conditions. Blacks were less likely than whites to receive combination antiretroviral therapy (90% vs. 93%) or to experience viral control (85% vs. 91%), hypertension control (62% vs. 68%), diabetes control (86% vs. 90%), or lipid monitoring (82% vs. 85%). Although performance on quality measures was generally high, racial disparities in HIV care for Veterans remain problematic and extend to comorbid conditions. Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.
    Date: September 22, 2016
  • New Guidelines May Significantly Decrease Cost for Testing Immune Function in Veterans with HIV
    In 2012, the Department of Health and Human Services recommended CD4 testing in patients with HIV every 3 to 6 months – except in patients with consistently suppressed virus and sustained CD4 cell count, who could be tested every 6 to 12 months. In 2014, updated guidelines recommended that in individuals with viral suppression, CD4 testing be considered either optional or annual, depending on the cell count. This study evaluated how these recommendations might affect Veterans with HIV who receive care from the largest provider of HIV care in the United States – the VA healthcare system. Findings showed that VA providers decreased the frequency of CD4 testing by 11% between 2009 and 2012, reducing the direct cost of testing by $196,000 per year. While VA has made substantial progress in reducing the frequency of optional CD4 testing, it could be reduced a further 29% by full implementation of new treatment guidelines, with an expected annual savings of $600,000. Reduced CD4 monitoring also would likely reduce patient anxiety with little or no impact on quality of care.
    Date: July 1, 2016
  • Pilot Study Implements HIV Rapid-Testing in Homeless Shelters
    Investigators in this pilot study developed and implemented an HIV rapid-testing/linkage-to-care initiative between VA and local government in Los Angeles County (LAC) to provide rapid testing in homeless shelters – and to link individuals with HIV to care. The initiative was considered a success, with stakeholders noting that the collaboration had prompted their participation in testing within homeless shelters. For example, stakeholders stated that once VA investigators were able “to solidify and secure those shelters, it was easy for us to come in… all that groundwork was done,” showing that different levels of government (i.e., federal, county, city) can work collaboratively to implement HIV testing. During the 26-month duration of the initiative, counselors made 189 visits and administered 817 tests (4.5% were to Veterans), identifying seven preliminary HIV-positive individuals. Five were confirmed and linked to care, one did not return for results, and the other refused linkage to care. Cost analysis showed that the cost per HIV-positive individual was $5,714, with costs highest during the first six months. The initiation and support provided by VA was a catalyst in allowing other agencies to concentrate resources. Investigators note this model can be adapted as a “plug and play” intervention, for the most part.
    Date: January 1, 2015
  • Multimodal Intervention Increases HIV Testing in VA Primary Care
    Investigators with VA/HSR&D’s HIV/Hepatitis Quality Enhancement Research Initiative (QUERI) previously developed, implemented, and evaluated a multimodal program to promote HIV testing, which more than doubled testing among at-risk Veterans. These results prompted the current study that scaled up this intervention in a large number of diverse VA facilities. Investigators examined the effectiveness of promoting routine as well as risk-based HIV testing, and the effect of providing different levels of organizational support at study sites. Findings showed that the use of clinical reminders, provider feedback, education, and social marketing in this HIV-testing intervention significantly increased the frequency with which HIV testing was offered and performed within the VA healthcare system. Implementation of this intervention increased the rate of risk-based HIV testing two- to three-fold, and increased routine testing three- to four-fold. Risk-based and routine HIV testing increased in all facility-, provider-, and patient-level groups.
    Date: April 19, 2013
  • VA HIV and Hepatitis C Telemedicine Clinics Improve Patient Outcomes among Rural Veterans
    Among a rural-dwelling study sample, HIV and hepatitis C telemedicine clinics were associated with improved access, high patient satisfaction, and a reduction in health visit-related time. Clinic completion rates (proxy for access) were higher for telemedicine (76%) than for in-person visits (61%). Of the 43 Veterans in the study, 30 (70%) completed a telemedicine-facilitated survey. More than 95% of these Veterans rated telemedicine at the highest level of satisfaction and preferred telemedicine to in-person visits. Veterans estimated that total health visit time was 340 minutes less for telemedicine compared to in-person visits. The majority of perceived time reduction was related to travel.
    Date: April 1, 2012
  • Intervention to Increase HIV Testing Can Be Successfully Implemented by Non-Research Staff
    This study reports on the one-year results of implementing a program that doubled HIV testing rates in at-risk Veterans receiving care at two VAMCs in two other VA facilities where the research team played a much smaller part in the intervention implementation. Findings showed that the annual rate of HIV testing among at-risk Veterans increased by 6% and 16% after the end of the first year for the two sites to which the project was newly exported, and where non-research staff were responsible for implementation. In contrast, for the original two implementation sites where research staff played a major role, testing rates increased by 9% and 12%. There was no change in the rate of testing at the one control site that did not participate in the project. Authors note that even with differences between the original and “export” sites (e.g., strength of academic affiliations, emphasis on specialized services), the successful implementation and similar increases in HIV testing rates across patient and sub-facility levels provides further support for the generalizability of the intervention.
    Date: December 1, 2011
  • Veterans in Favor of Internet-Provided HIV Screening Information
    This study examined patient and provider perceptions of Internet-based outreach to increase HIV screening among Veterans who use the VA healthcare system. Findings showed that both Veterans and providers thought that HIV screening outreach provided electronically via the personal health record (PHR – MyHealtheVet) would improve patient access to health information, with important educational value. Providers believed that it would reinforce messages they give to their patients. Veterans could envision instances in which information provided electronically might be better than verbal information from their doctor because it would be in lay language and readily available. Veterans also believed that electronic outreach would motivate them to be proactive about their health. Most felt that electronic messages would remind them to be screened, or at least contemplate getting screened. Regarding stigma attached to an electronic message about HIV, providers expressed substantially more concerns than Veterans. Providers also expected increased workload from the electronic outreach, and suggested adding primary care resources and devising methods to smooth the flow of patients getting screened.
    Date: August 15, 2011
  • Routine, Oral, Rapid HIV Testing in VA Emergency Departments Financially Equivalent to Usual Care
    Using a dynamic decision analysis model, this study examined the budget impact of implementing a routine oral HIV rapid-testing program in a VA emergency department (ED) versus the impact of following ‘usual’ care. Findings show that a routine oral HIV screening program using a rapid testing approach is financially equivalent to following a usual care approach within the VA healthcare system. Assuming a 1% prevalence of the disease and an 80% acceptance of testing, the total cost of HIV rapid-testing was $1,418,088 versus $1,320,338 for ‘usual care.’ While the HIV rapid-testing program had substantial screening costs, they were offset by lower inpatient expenses associated with earlier identification of disease. The higher treatment costs for ‘usual care’ patients were largely due to inpatient stays, reflecting more hospitalizations for these patients due to opportunistic infections. Given that early detection of HIV and linkage to treatment is associated with better health outcomes – and non-targeted testing does not result in a greater budget impact than usual care – the authors suggest that this analysis provides support for the implementation of a routine oral rapid testing program within VA.
    Date: January 27, 2011
  • Collaborative Care Intervention Improves Depression in Veterans with HIV
    The goal of this study was to adapt an evidence-based primary care model of depression collaborative care for HIV clinic settings (HIV Translating Initiatives for Depression into Effective Solutions [HITIDES])) – and to evaluate its effectiveness. Findings show that the HITIDES intervention was successfully implemented in HIV settings and improved both depression and HIV symptom outcomes. Veterans who participated in the intervention were more likely to report treatment response and remission compared to Veterans in usual care at 6-month follow-up but not at 12-month follow-up. Improved depression response and remission outcomes at 6 but not 12 months suggest that depression symptoms improved more rapidly in the intervention group compared to usual care. Intervention participants also reported more depression-free days over 12 months. Compared to usual care, significant intervention effects also were observed for lowered HIV symptom severity at 6 and 12 months. The authors suggest that the HITIDES intervention may serve as a model for collaborative care interventions in other specialty physical healthcare settings.
    Date: January 10, 2011
  • Nurse-Initiated Rapid HIV Testing was Cost-Effective and Increased Screening Rates among Veterans
    Nurse-initiated routine screening (i.e. recommending HIV testing to all Veterans) with rapid HIV testing and streamlined counseling increased rates of testing and receipt of test results among Veterans – and was cost-effective compared with traditional risk-based HIV testing strategies. When benefits to sexual partners from reduced transmission was considered, rapid testing with streamlined counseling was even more favorable. Traditional risk-based HIV counseling and testing resulted in the lowest costs and effectiveness.
    Date: March 4, 2010
  • Chronic Kidney Failure Associated with Increased Mortality among Veterans with HIV and Hepatitis C Virus
    Compared with their mono-infected counterparts, Veterans with HIV who were co-infected with HCV had significantly higher rates of chronic kidney disease (14% vs. 11%) and mortality. HCV co-infection independently increased the likelihood of death by nearly 25%, after adjusting for other important HIV- and HCV-related factors. Co-infected Veterans also were less likely to have received highly active antiretroviral therapy (HAART) at baseline. Authors suggest that efforts should be targeted toward optimizing medical care for mono- and co-infected Veterans, including HAART therapy, HCV antiviral therapy, and treatment of comorbid medical conditions.
    Date: February 1, 2010
  • Predictors Associated with Use of Complementary/Alternative Medicine in Men with HIV
    This study sought to describe the types, frequency, and intensity of complementary/alternative medicine (CAM) use among men living with HIV infection in southern California and northern Florida/southern Georgia, and to identify predictors of CAM use and intensity. Findings show that the majority of men with HIV infection in this study (69%) reported some CAM use. The most frequently cited types of CAM use were drug or dietary supplements (71%) and spiritual therapies (66%). CAM use was almost three times higher in California compared to Florida/Georgia, and was also greater in men who reported depression or more health-promoting behaviors. The odds of CAM use intensity increased with greater symptom frequency and more health-promoting behaviors. In addition, vitamins, dietary supplements, and herbs were used by the majority of men in this study. The authors suggest that high levels of CAM use among men with HIV infection should alert healthcare providers to assess CAM use and to incorporate CAM-related patient education into their clinical practices.
    Date: November 1, 2009
  • Improving Provider-Patient Communication about Routine HIV Testing in VA
    This study sought to understand patient and provider perspectives on the adoption of routine HIV testing within the VA healthcare system. Findings show that Veterans and providers agreed that the implementation of routine HIV testing, treating HIV like other chronic diseases, and removing requirements for written informed consent and pre-test counseling would benefit both Veterans and public health. Veterans wished to have HIV testing routinely offered by providers so that they could decide whether or not to be tested; they also believed that routine testing would help de-stigmatize HIV. Six steps for providers to use in communicating about routine testing also were identified, such as raising the topic of HIV testing, reassuring the Veteran that he/she is not showing clinical signs of the disease, and responding to Veteran questions about HIV.
    Date: October 1, 2009
  • Low Rates of HIV Screening among Veterans with Substance Use Disorders
    This study sought to determine the rate of HIV screening among Veterans with substance use disorders. Findings show that among the 371,749 Veterans with substance use disorders in this study, only 20% had evidence of ever having been screened for HIV. HIV screening was lowest among Veterans with alcohol use disorders alone (11%), and highest among Veterans treated in substance use programs (28%) or receiving inpatient care (28%). Authors suggest that these findings support the need for more widespread interventions to expand routine voluntary HIV screening nationally – within and outside VA.
    Date: October 1, 2009
  • Effective Clinical Decision Support Tool for HIV Symptom Management
    This pilot study produced a clinical decision support tool called TEMS that was developed to: elicit information about symptoms at routine clinic visits; organize information to emphasize what is most useful for clinical care; present information at the point-of-care; and recommend clinical responses based on that information. TEMS was implemented as part of VA’s electronic medical record at one VA medical center, to increase provider awareness of and response to common HIV symptoms. Investigators then studied the tool’s feasibility in routine care within a weekly HIV clinic, comparing a 4-week intervention period with a 4-week control period. Findings show that TEMS was accepted by Veterans and their providers and did not substantially impede workflow. In addition, there was a trend toward including a greater number of symptoms in the progress notes documented during the intervention period compared to the control period.
    Date: July 1, 2009
  • Veterans with HIV Treated at Clinics with Integrated Specialty Services More Likely to Achieve Better Outcomes
    The most common way HIV clinics address patients with comorbidities is by integrating non-infectious disease providers (e.g., psychiatrists and social workers) into HIV primary care. This retrospective cohort study evaluated the association between Integrated HIV Care and patient outcomes among 1018 Veterans with HIV who received care at five VA facilities from 2000-2006. Findings show that Veterans who visited HIV clinics with more integrated specialty services were more likely to achieve viral suppression. In particular, Veterans visiting clinics that offered hepatitis, psychiatric, psychological, and social services in addition to primary care and HIV specialty services were three times more likely to achieve viral suppression than Veterans visiting clinics that offered only primary care and HIV specialty services. Results also showed that 93% of Veterans in this study had one or more comorbid conditions, with a mean of 3.2 comorbidities. Authors suggest that resources should be allocated to integrate sub-specialty services into HIV primary care clinics, and that providers should direct patients toward these clinics and retain them in care.
    Date: May 1, 2009
  • Quality Indicators to Help Treat Veterans with HIV and Depression
    Quality indicators were developed based on a review of the existing clinical guidelines for depression, particularly depression related to HIV, in addition to a review of the literature. Authors suggest that quality indicators identified in this study provide a useful tool for measuring and informing the quality of HIV depression care.
    Date: October 1, 2008

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background-image  Homelessness

  • Special Journal Issue Features Articles by HSR&D Researchers on Homelessness among Veterans
    For more than two decades, VA has dedicated substantial resources to addressing homelessness among Veterans. Moreover, in the past five years VA has spent billions of dollars on a federal initiative to prevent and end homelessness among Veterans. This special issue of Psychological Services focuses on homelessness and includes several articles by HSR&D researchers.
    Date: May 1, 2017
  • Engagement in Hepatitis C Virus Care among Homeless and non-Homeless VA Patients
    This study sought to describe engagement in hepatitis C virus (HCV) care among homeless and non-homeless Veterans in the new era of HCV treatment, which includes direct-acting agents (DAAs) with shorter treatment durations, fewer side effects, and higher sustained virologic response (SVR) rates than the older treatment regimens. Findings showed that VA providers do a better job of testing for and diagnosing chronic HCV infection among homeless Veterans than they do among non-homeless Veterans: 90% of homeless Veterans who were estimated to have chronic HCV were diagnosed by laboratory testing compared with 77% of non-homeless Veterans. The percentage of the total homeless population with chronic HCV infection who had ever received HCV antiviral therapy (23%) was lower than the percentage of the total non-homeless population who had ever received HCV antiviral therapy (31%). However, the cumulative SVR rates achieved among homeless Veterans who had ever received HCV antiviral therapy (68%) and non-homeless Veterans who had ever received HCV antiviral therapy (74%) were comparable. Efforts are needed to identify appropriate interventions to ensure that more homeless Veterans are candidates for HCV antiviral therapy. Homelessness should not necessarily preclude receipt of HCV antiviral therapy as the direction of future HCV care and treatment eligibility criteria with all-oral DAA regimens is considered.
    Date: March 1, 2017
  • Effects of Homeless Veterans’ Use of Peer Mentors
    This trial tested the use of peer mentors among homeless Veterans at VA primary care clinics. Findings showed that while significant impacts of peer mentors on healthcare patterns or costs were not detected, some patients engaged in frequent contact with peer mentors. Most (87%) of the peer mentor group had at least one peer contact – and spent the most time discussing housing and health issues. Patients also spent time discussing basic needs (i.e., food and clothing), VA benefits, work experience, and social issues. Peer mentor patients had more outpatient encounters, although differences were not significant. There were no other differences in utilization or costs between groups. Costs of the peer mentor intervention were estimated to be $737 per patient. Peer mentors may serve a key role in building trust between patients and providers to foster engagement with the healthcare system.
    Date: February 1, 2017
  • Military Sexual Trauma is Independent Risk Factor for Homelessness among Veterans, Particularly Male Veterans
    This study examined the relationship between military sexual trauma (MST) and post-deployment homelessness among a large cohort of OEF/OIF Veterans, including whether the relationship varied by sex, and whether MST was a predictor of homelessness independent of other risk factors (i.e., mental health and/or substance use disorders). Findings showed that a positive MST screen was independently related to post-deployment homelessness. In unadjusted models, Veterans with a positive screen had odds for homelessness that were approximately double those who screened negative. Moreover, findings in the 30-day and 1-year follow-up cohorts suggested a greater risk for homelessness among men with a history of MST than among women. After adjusting for mental health and substance use diagnoses, MST screening status remained a significant predictor of homelessness, with Veterans who had a positive MST screen having approximately 1.5 times greater odds for homelessness than those who screened negative. Findings of greater risk among men also remained. Among Veterans with a positive MST screen, the incidence of homelessness was 2% within 30 days, 4% within one year, and 10% within five years. The stronger risk conferred by MST for homelessness among men suggests that men with a positive MST screen are a particularly vulnerable group.
    Date: June 1, 2016
  • Association between Separation from Military due to Misconduct and Homelessness
    This study analyzed the association between misconduct-related separations and homelessness among recently returned active-duty military service members. Findings showed that the incidence of homelessness at their first encounter with VA healthcare was significantly greater for Veterans who experienced separation due to misconduct compared to Veterans with a normal separation, as well as within one year and at five years. Although only 6% of the Veterans in this study separated for misconduct, they represented 26% of homeless Veterans at their first VA healthcare encounter, 28% within 1 year of separation, and 21% within 5 years. The overall incidence of homeless among Veterans was 0.3% at the time of their first VA healthcare encounter, 1% within one year, and 2% within 5 years. These findings support reports of recently returned Veterans with records of misconduct having difficulties re-entering civilian life.
    Date: August 25, 2015
  • Commentary Challenges Findings in Previous Study on Housing First Approach for Homeless Veterans
    Recently, VA adopted an evidence-based approach to housing and recovery known as “Housing First,” which includes: removing traditional pre-conditions to housing (i.e., completing substance abuse treatment), providing extensive support for recovery, and delivering support services according to the Veteran’s choice. However, a 2013 article offered a skeptical view of both Housing First as a recovery approach and HUD-VASH as a program. This Commentary suggests that the study reported in that article was problematic, both in its conceptualization of the matters it sought to address – and in its science. However, despite these limitations, the 2013 study highlights pressing challenges in the adoption of Housing First, including the necessity for strong resource supports for clinical care in combination with leadership actions necessary to foster institutional change.
    Date: July 1, 2015
  • Substantial Proportion of Homeless and Unstably Housed Veterans with Minor Children has Serious Mental Illness
    This study examined the prevalence of homeless and unstably housed Veterans with minor children and compared sociodemographic characteristics, as well as medical and mental health conditions of homeless and unstably housed Veterans with and without children. Findings showed that unstably housed Veterans were more likely to have children than homeless Veterans, and women more likely than men. Among both homeless and unstably housed male Veterans with minor children, only about one-third to one-half had custody of their minor children, whereas among women, nearly all had custody of their minor children. Both homeless male and female Veterans with children were younger and less likely to have chronic medical conditions and psychiatric disorders than their homeless counterparts. However, 72% of male and 67% of female Veterans with children had a psychiatric diagnosis, and 11% of both men and women were diagnosed with a psychotic disorder. Men also were more likely to have PTSD and other anxiety disorders compared to male Veterans without children. Veterans with minor children were more likely to be referred and admitted to VA’s permanent supported housing program than other Veterans, and women with minor children in their custody were even more likely to be referred and admitted than men. Rates of referrals to mental health services were relatively low (22% and 25% for Veterans with and without children, respectively) given the high prevalence of psychiatric diagnoses in the sample.
    Date: May 15, 2015
  • No Significant Association between Public Support Income, VA Disability Compensation, and Money Spent on Alcohol and Drugs among Homeless Veterans
    This study describes the amount of money homeless Veterans report spending on alcohol and drugs, and examines the association between public support dollars received – and VA disability compensation in particular – and dollars spent on alcohol and drugs. Findings showed that about one-third of homeless Veterans reported spending money on alcohol and about one-fifth reported spending money on drugs in the past month. However, no positive association was found between public support income and money spent on alcohol or drugs, and there was no association found between VA disability compensation and substance use. This suggests that the amount of income homeless Veterans received from disability and other public support sources did not influence their amount of substance use. Employment income was positively associated with days of alcohol use and money spent on alcohol, as well as with money spent on drugs. Other sources of income (e.g., family and friends, panhandling) were also positively associated with alcohol use and money spent on alcohol along with drug use and money spent on drugs. In contrast, public support income was negatively associated with alcohol use and money spent on alcohol.
    Date: March 1, 2015
  • Pilot Study Implements HIV Rapid-Testing in Homeless Shelters
    Investigators in this pilot study developed and implemented an HIV rapid-testing/linkage-to-care initiative between VA and local government in Los Angeles County (LAC) to provide rapid testing in homeless shelters – and to link individuals with HIV to care. The initiative was considered a success, with stakeholders noting that the collaboration had prompted their participation in testing within homeless shelters. For example, stakeholders stated that once VA investigators were able “to solidify and secure those shelters, it was easy for us to come in… all that groundwork was done,” showing that different levels of government (i.e., federal, county, city) can work collaboratively to implement HIV testing. During the 26-month duration of the initiative, counselors made 189 visits and administered 817 tests (4.5% were to Veterans), identifying seven preliminary HIV-positive individuals. Five were confirmed and linked to care, one did not return for results, and the other refused linkage to care. Cost analysis showed that the cost per HIV-positive individual was $5,714, with costs highest during the first six months. The initiation and support provided by VA was a catalyst in allowing other agencies to concentrate resources. Investigators note this model can be adapted as a “plug and play” intervention, for the most part.
    Date: January 1, 2015
  • JGIM Supplement Highlights VA’s Partnered Research
    In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management, suicide prevention, homelessness, medical home models, and communication of adverse events.
    Date: November 1, 2014
  • Affordable Care Act May Impact Continuity of Care for Homeless VA Healthcare Users
    This study compared Veterans who are likely eligible for the Medicaid expansion (LEME) and those who are not LEME, stratified by homeless status. Findings showed that among all VA healthcare users under the age of 65, homeless Veterans were two times more likely to be LEME than non-homeless Veterans (64% vs. 30%). Regardless of housing status, Veterans who were LEME were physically healthier than those not LEME. However, Veterans who were LEME were more likely to have substance use disorders and PTSD. Among homeless VA healthcare users, those who were LEME were less than half as likely to be married, to be an OEF/OIF/OND Veteran, and had less than one-third the income of Veterans who were not LEME. Among non-homeless VA healthcare users, those who were LEME were younger and more likley to be OEF/OIF/OND Veterans. Cross-sytem use of VA and Medicaid-funded services may be advantageous for Veterans with extensive medical and psychiatric needs, but also risks fragmented care. Information and education for VA clinicians and patients about possible implications of the Affordable Care Act may be important.
    Date: September 1, 2014
  • Supportive Housing May Address Homeless Veterans’ Underuse of VA Services
    This study examined rates of VA healthcare use (inpatient and outpatient) among four groups of Veterans: 1) formerly homeless Veterans housed through Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH); 2) currently homeless Veterans; 3) housed, low-income Veterans not in HUD-VASH; and 4) housed, not low-income Veterans. Findings showed that currently homeless Veterans underuse healthcare relative to housed Veterans, and HUD-VASH may address utilization differences by providing housing and linkages to needed services. Veterans who participated in HUD-VASH had more inpatient, outpatient, and emergency department visits than currently homeless Veterans. Higher primary care use among HUD-VASH Veterans may explain many of the differences in service use seen between HUD-VASH Veterans and their currently homeless peers.
    Date: May 1, 2014
  • Characteristics and Outcomes of Homeless Male and Female Veterans
    This study examined a recent national sample of homeless Veterans in the Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program to report differences between homeless male and female Veterans on individual characteristics at referral, as well as housing and clinical outcomes over a one-year period after program admission. Findings showed that among Veterans who stayed in the program, there were no gender differences in housing outcomes over time, except females tended to stay more nights in someone else’s place, while males stayed more nights in transitional housing. Homeless female Veterans were younger, more likely to have recently served in the military, had shorter homeless histories, were less likely to have been incarcerated, and were less likely to have alcohol and drug use disorders. Despite being less likely to report combat exposure, female Veterans were more likely to have PTSD than male Veterans. Homeless female Veterans also were much more likely to have dependent children with them, and to plan to live with family members in supported housing. For all Veterans, it took an average of over 40 days to be admitted to HUD-VASH after referral, an average of over 40 days to obtain a voucher after being admitted, and then an average of more than 50 days to sign a lease after obtaining a voucher.
    Date: April 14, 2014
  • Strong Association between Substance Abuse and Homelessness among Veterans
    This study examined the prevalence of alcohol and drug use disorders among homeless Veterans entering the HUD-VASH program, and its association with both housing and clinical outcomes. Findings showed that there was a strong association between substance abuse and homelessness, particularly in Veterans with comorbid alcohol and drug use disorders. The majority (60%) of homeless Veterans admitted to the HUD-VASH program had a substance use disorder (SUD), and the majority (54%) of those had both an alcohol and drug use disorder. In the first 6 months after entering the HUD-VASH program, significant improvements were observed in both housing and clinical outcomes, with no significant differences between Veterans with and without substance use disorders on housing outcomes. However, Veterans with any substance use disorder showed improvement at a slower rate than those with no SUD. These findings suggest that despite strong associations between SUD and homelessness, the HUD-VASH program is able to successfully house homeless Veterans with SUD, although additional services may be needed to address their substance abuse after they become housed. Before entering supported housing, homeless Veterans with comborbid alcohol and drug use disorders had more extensive histories of being homeless than Veterans with only alcohol or only drug use disorders, while those with no SUD had the least extensive homeless histories. Compared to other homeless Veterans, those with both alcohol and drug use disorders were most likely to have comorbid psychotic or mood disorders. Homeless Veterans with both alcohol and drug use disorders or only a drug use disorder were more likely to also have PTSD.
    Date: February 1, 2014
  • VA’s “Housing First” Approach to Helping Homeless Veterans Presents Several Challenges
    Over the past three years VA has shifted toward a Housing First (HF) approach to its HUD-VASH program, pivoting away from the traditional approach (often termed “Treatment First”), which emphasized housing readiness prior to awarding rental vouchers. This study examined the experiences of eight VA facilities that were at varying stages of HF adoption in 2012. Findings showed that front-line staff faced challenges in rapidly housing homeless Veterans due to difficult rental markets, the need to coordinate with local public housing authorities, and a lack of available funds for move-in costs. Finding interim sheltering options for Veterans waiting for housing (i.e., with no expectations of sobriety or treatment participation) also presented a significant challenge to the implementation of HF. Staff struggled to balance the time spent on housing search activities with intensive case management of highly vulnerable Veterans; this tension is acute immediately after the release of vouchers, when facilities are closely monitored on the speed with which the vouchers are used. Facility leadership supported HF implementation through resource allocation, performance monitoring, and reliance on mid-level managers to meet the challenges of implementation. The authors suggest that HF cannot successfully proceed unless VA is able to secure housing in discrete geographies and markets. Moreover, securing housing while simultaneously advancing the recovery agenda for each Veteran remains an ambitious undertaking.
    Date: January 15, 2014
  • Better Experiences among Homeless Patients with Tailored Primary Care
    This study compared assessments of recently or currently homeless patients across five settings that varied in their degree of homeless-tailored service design – from none (i.e., “mainstream primary care”) to intensive tailoring. Four of the five sites were in VA. Findings showed that patients rated their primary care experience more highly when their healthcare was obtained in settings that explicitly tailored services for the homeless population through variations in service design. Survey scores at the tailored non-VA site were higher (reflecting more positive experiences with care) than at the three mainstream VA sites. The tailored VA site generally had scores that were either similar to the three mainstream VA sites or somewhat higher, depending on the subscale of interest. An unfavorable experience was a 1.5 to 2 times more common in domains of patient-clinician relationship, cooperation, and accessibility/coordination for the mainstream VA sites compared to the tailored non-VA site, with the tailored VA site attaining intermediate results.
    Date: December 1, 2013

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background-image  Hypertension

  • Systematic Review Finds Treating Blood Pressure to Current Guidelines in Older Adults Improves Health Outcomes
    This systematic review sought to compare the effects of more versus less intensive blood pressure control in older adults. Findings showed that treating blood pressure in adults over 60 to at least current guideline standards (<150/90 mmHg) substantially improves health outcomes in older adults, including reducing mortality, stroke, and cardiac events. The most consistent and largest effects were seen in studies of patients with higher baseline blood pressure (SBP >160mmHg) who achieved moderate blood pressure control (<150/90 mmHg). There is less consistent evidence, largely from one trial targeting SBP <120 mmHg, that lower blood pressure targets are beneficial for high cardiovascular risk patients. In patients with prior stroke or transient ischemic attack, treating to SBP < 140 mmHg reduces the risk of recurrent stroke. Lower blood pressure targets did not increase falls or cognitive decline, but were associated with hypotension, syncope, and greater medication burden.
    Date: March 21, 2017
  • Pay-for-Performance Intervention Improves Blood Pressure Control among Black Veterans with Hypertension without Unintended Consequences
    This study sought to evaluate the effect of a pay-for-performance intervention on the quality of hypertension care provided to black Veterans. Findings showed that VA physicians who received performance incentives for meeting guideline-recommended hypertension quality measures demonstrated better performance than control group physicians on a combined measure of BP control or appropriate clinical response to uncontrolled BP in black Veterans. The proportion of black patients who achieved BP control or received appropriate response to uncontrolled BP was 6% greater for physicians who received an incentive. There was no evidence found for risk selection, i.e., there was no difference between intervention and control groups in the proportion of Veterans who switched providers, and there were no differences in visit frequency or panel turnover, creating reassurance that the incentives did not have negative unintended effects on the care of black patients.
    Date: June 22, 2016
  • Sustained Improvement in Hypertension with Intervention Combining Behavioral and Medication Management
    This study examined clinical and economic outcomes 18 months after completion of an 18-month hypertension self-management randomized trial. Findings showed that an intervention combining behavioral and medication management significantly improved BP control among Veterans with hypertension during an 18-month trial compared to usual care, and these improvements were sustained 18 months after trial completion, particularly for Veterans who had inadequate BP control at baseline. Eighteen months after trial completion, a statistically significant higher proportion of Veterans in the behavioral intervention (17%), the medication management intervention (20%), and the combined intervention (20%) had estimated BP improvements compared to usual care. Among Veterans with inadequate baseline BP control, estimated mean systolic BP was significantly lower in the combined intervention as compared to usual care during and after the 18-month trial. Estimated mean outpatient expenditures and estimated total expenditures also were similar for Veterans in the 18 months during the trial and the 18 months after trial completion.
    Date: March 1, 2014
  • Veterans with Multiple Chronic Conditions Account for Disproportionate Share of VA Healthcare Costs
    This study examined the association between number of chronic conditions and costs of care for non-elderly (<65 years) and elderly Veterans (=65 years) within the VA healthcare system – and estimated VA expenditures for the most prevalent and costly combinations of three conditions (triads). Findings showed that Veterans with multiple chronic conditions account for a disproportionate share of VA healthcare costs. Almost one-third of non-elderly and slightly more than one-third of elderly VA patients had >3 conditions, but they accounted for 65% and 67% of total VA healthcare costs, respectively. The most common triad of chronic conditions for both non-elderly and elderly Veterans was diabetes, hyperlipidemia, and hypertension (24% and 29%, respectively). Conditions present in the most costly triads included: spinal cord injury, heart failure, renal failure, ischemic heart disease, peripheral vascular disease, stroke, and depression. While patients with the most costly triads had average costs that were three times higher than average costs of patients in other triads, the prevalence of these costly triads was extremely low (0.1 to 0.4%). These findings highlight the need for interventions that target the sickest patients who have high resource use to provide more cost-effective care.
    Date: March 1, 2014
  • “Tailored” Treatment of Blood Pressure May Prevent Many More Heart Attacks and Strokes than Current Guidelines
    Most current blood pressure (BP) guidelines advocate a treat-to-target (TTT) strategy, which titrates treatment towards intermediate outcomes, notably a BP goal. Benefit-based tailored treatment (BTT) strategies estimate an individual’s net absolute benefit from treatment – taking into account the patient’s estimated risk reduction from treatment, as well as potential harms associated with treatment. This study sought to determine whether a BTT strategy for the treatment of hypertension would prove superior to a traditional TTT strategy. Findings showed that BTT was both more effective and required less antihypertensive medication than current guidelines based on treating to specific blood pressure goals. Over five years, BTT would prevent 900,000 more cardiovascular disease events and save 2.8 million more quality-adjusted life years (QALYs), despite using 6% fewer medications, compared to TTT. While 55% of the 176 million “simulated” patients in this study would be treated identically under the two treatment approaches, in the 45% of the population treated differently by the strategies, BTT would save 159 QALYs per 1,000 treated versus 74 QALYs per 1,000 treated by the TTT approach.
    Date: November 19, 2013
  • Individual Financial Incentives for VA Providers Result in Better Hypertension Treatment than Audit and Feedback Alone
    This trial tested the effect of financial incentives to individual physicians and practice teams for the delivery of guideline-recommended care for hypertension. Findings showed that VA physicians randomized to the individual incentive group were more likely than controls to improve their treatment of hypertension. A physician in the individual incentive group caring for 1,000 patients with hypertension would have about 84 additional patients achieving blood pressure control or appropriate response after 1 year. The effect of the incentive was not sustained after the washout period. Although performance did not decline to pre-intervention levels, the decline was significant. None of the incentives resulted in increased incidence of hypotension compared with controls. While the use of guideline-recommended medications increased significantly over the course of the study in the intervention groups, there was no significant change compared to the control group.
    Date: September 11, 2013
  • Racial Differences in Outcomes of VA Telephone-Delivered Hypertension Disease Management Program
    A combination of home BP monitoring, remote medication management, and telephone-tailored behavioral self-management appears to be particularly effective for improving BP among African American Veterans. However, the effect was not seen among non-Hispanic white Veterans. Among African Americans, improvement in mean systolic BP was greatest for those receiving the combined intervention: compared to usual care, systolic BP was 6.6 mmHg lower at 12 months and 9.7 mmHg lower at 18 months. These decreases in BP were not seen in non-Hispanic white Veterans.
    Date: August 3, 2012
  • Treatment Intensification for Hypertension Not Significantly More Likely to Occur in Veterans with Diabetes and at Higher CV Risk
    Treatment intensification for hypertension was not significantly more likely to occur in Veterans with diabetes and at higher CV risk, compared with patients at low to medium risk. However, physicians were more likely to advance therapy in patients with higher and more consistently elevated blood pressures. Several individual risk factors were associated with higher rates of treatment intensification: systolic BP, mean BP in the prior year, and higher hemoglobin A1c, while self-reported home BP <140/90 was associated with lower rates of TI. The authors suggest that incorporating CV risk into TI decision algorithms could prevent an estimated 38% of cardiac events without increasing the number of patients being treated.
    Date: August 1, 2012
  • Dramatic Improvement in Blood Pressure Management among Veterans with Diabetes, with Potential Over-Treatment
    Clinical action measures that reward clinical actions that are strongly tied to evidence might better capture the complexity of clinical decision making about blood pressure management among patients with diabetes. In this study, 713,790 Veterans were eligible for a newly developed clinical action measure. Of these, 94% (n=668,210) met the clinical action measure for BP measurement (82% had a BP <140/90; an additional 12% had BP >=140/90 but appropriate management). This represents a dramatic improvement in BP management over the past decade. Among all Veterans in this study, 197,291 (20%) had a BP <130/65; of these, 80,903 (41% - or slightly more than 8% of the cohort) had potential over-treatment. Facility rates of potential over-treatment varied from 3% to 20%. Facilities with higher rates of meeting the current threshold measure (<140/90) had higher rates of potential over-treatment. Veterans with potential over-treatment were older, had lower mean index BP, and were more likely to be men and have ischemic heart disease.
    Date: June 25, 2012
  • No Significant Cost Increase for Telephone-based BP Intervention for Veterans with Hypertension
    Average intervention costs were similar in the three study arms, and at 18 months there were no significant differences in direct VA medical costs or total VA costs between treatment arms and usual care. Mean total VA costs per patient in the treatment arms were $14,441 for behavioral management; $14,453 for medication management; $13,009 for combined treatment; and $12,328 for usual care. The combined intervention resulted in observed net savings in outpatient care and overall medical care, as well as the lowest mean cost difference and total cost, but these differences were not statistically significant relative to the other intervention arms. Patients in all three intervention arms incurred $289 to $1,127 less in outpatient care compared to those treated under usual care, but these savings were not statistically significant.
    Date: June 1, 2012
  • IRB Process for Multisite, Minimal-Risk VA Trial
    Complying with IRB requirements for a minimal-risk randomized controlled trial involved 115 submissions, consumed more than 6,700 staff hours, and lasted nearly two years longer than planned. The IRB approval process had a profound financial impact on the project, costing close to $170,000 in staff salaries. Delays in approval affected participant recruitment and retention; for example, seven physician participants had left their primary care settings before all IRB approvals were received. One IRB’s concern about incentivizing a medication recommended by national guidelines prompted a protocol modification (broadening study inclusion criteria beyond uncomplicated hypertension) at all sites in order to preserve the study’s internal validity. Requirements for local site principal investigators and for IRB and R&D committee approvals resulted in the inclusion of more highly-affiliated, urban sites that were treating more complex patients, potentially affecting the external validity (generalizability) of the study findings.
    Date: May 15, 2012
  • The Importance of Testing Interventions in Real-World Settings
    Using the best evidence from efficacy trials to improve BP control among patients with diabetes and persistent hypertension, investigators in this study designed a pharmacist-led care management program – the Adherence and Intensification of Medications (AIM) intervention. In examining three-month intervals, the AIM program lowered systolic BP among patients more rapidly than usual care did for patients in the control group. However, usual care patients achieved equally low systolic BP (SBP) levels by six months after the intervention. Thus, by six months and throughout the remainder of follow-up, control team patients’ mean SBP were indistinguishable from those of the intervention group participants. There were no differences in health services utilization between eligible intervention and control patients during the 14-month intervention period. Patients in the AIM intervention group were more likely than patients in the control group to undergo medication changes during the 6-month period following their start date, although both groups had high rates of medication changes. Authors note that these findings emphasize the importance of evaluating programs that are found to be effective in efficacy trials in real-life clinical settings before urging widespread adoption.
    Date: May 8, 2012
  • Clinically-Guided Approach for Improving Performance Measurement for Hypertension
    This study tested a novel performance measurement system for BP control that was designed to mimic clinical reasoning. Using an algorithm that replicates clinical decision-making, this approach focuses on: 1) exempting Veterans for whom tight BP control may not be appropriate or feasible, and 2) assessing BP over time. Nearly one in three Veterans with hypertension would be exempted from BP performance measurement based on clincially-guided criteria. The most common reasons for exemption were inadequate opportunity for clinicans to manage Veterans’ BP, and the patient’s use of four or more anti-hypertensive medications. After accounting for clinically-guided exemptions and methods of BP assessment, only 15 of 72 Veterans (21%) whose last BP was >140/90 mm Hg were classified as problematic by the clinically-guided approach, i.e., eligible for performance assessment and defined as having uncontrolled BP.
    Date: May 1, 2012
  • Anti-Hypertensive Medication May Reduce Risk of Dementia among Veterans with Diabetes
    Comorbid hypertension was associated with increased risk of dementia; however, anti-hypertensive medications, particularly ACE inhibitors and ARBs, were associated with reduced risk of dementia, even among Veterans without hypertension. The most protective effect was associated with ARB use (approximately 24% lower risk of dementia), followed by diuretics (14%), ACE inhibitors (11%), CCBs (7%), and beta blockers (4%). Factors associated with higher incidence of dementia included: increasing age (Veterans >85 had more than three times greater risk compared to Veterans age 65), as well as duration of diabetes and higher comorbidity. Also, African Americans and other non-white races were more likely to have dementia. These findings suggest that ARBs and ACE inhibitors be considered when prescribing medication for the control of hypertension among patients with diabetes.
    Date: April 20, 2012
  • Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008
    This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care.
    Date: December 1, 2011
  • Health of Gulf War Veterans Worsened in 10-Year Study
    Since the 1991 Gulf War, initial concerns regarding health consequences of participation in the war have turned to requests for longitudinal evaluation of how the health of Gulf War Veterans has changed over time. To help in this evaluation, investigators conducted health surveys of deployed and non-deployed Gulf War-era Veterans in 1995 and again in 2005. Findings showed that the health of deployed Gulf War Veterans worsened during the 10-year period from 1995 to 2005 in comparison with non-deployed Gulf War Veterans. Perceived health of fair or poor was more likely to persist among deployed Veterans, and relatively more deployed Veterans reported that their health status had worsened over the 10-year follow-up. Deployed Veterans were less likely to recover from any prior functional impairment, limitation of activities, or PTSD that they had in 1995 – and were more likely to report new onset of these adverse health outcomes in 2005 compared with non-deployed Veterans. Authors note that the extent to which any of the health problems experienced by Gulf War Veterans were due to the effects of military service in the Gulf War is difficult to detemine.
    Date: October 1, 2011
  • Behavioral and Medication Management Interventions Improve Blood Pressure Control for Veterans
    This randomized clinical trial evaluated three nurse-led, home tele-monitoring interventions that were developed to improve blood pressure (BP) – and also tested which intervention was most effective among Veterans treated in VA primary care. Findings showed that overall, the behavioral and medication management intervention groups had a greater increase in the proportion of Veterans with BP measurements within target, relative to the usual care group, at 12 months. These findings were not sustained at 18 months; however, among Veterans with poor baseline BP control, the combined intervention significantly decreased blood pressure at both 12 and 18 months.
    Date: July 11, 2011
  • Averaging Multiple Blood Pressure Measurements May Provide Optimal Assessment for Veterans with Hypertension
    This study compared home, clinic, and research systolic blood pressure (SBP) measurements in Veterans with hypertension – and estimated the certainty with which an individual’s true BP can be determined. Findings showed that clinicians who want to be certain that they are correctly classifying patients’ blood pressure control should average multiple measurements. Hypertension quality metrics based on a single clinic measurement potentially misclassify a large proportion of patients. The relationship between mean clinic and home SBP varied substantially, e.g., 52% had a mean clinic SBP that was at least 10 mm Hg greater than their mean home SBP. The within-individual variance declined markedly with increasing number of measurements and the relationship was similar across all three modes of measurement, with little added value of additional readings beyond 4-6 observed SBP measurements for all three modes. The proportion of patients with their SBP in control within the first 30 days (<140 mm Hg for clinic or research measurement; <135 mm Hg for home measurement) differed between mode of measurement: 28% were in control based on clinic measurement; 47% based on home measurement; and 68% based on research measurement.
    Date: June 21, 2011
  • Racial and Ethnic Differences in Blood Pressure Control among Veterans with Type 2 Diabetes
    This study examined racial/ethnic differences in blood pressure control among Veterans with type 2 diabetes and uncontrolled BP at baseline. Findings showed that the adjusted proportion of Veterans with uncontrolled BP (>=140/90 mmHg) decreased in all groups over the study period. However, ethnic minority Veterans had significantly increased odds of poor BP control over a mean follow-up of 5 years compared to non-Hispanic White Veterans, independent of socio-demographic factors and comorbidity patterns. Compared to non-Hispanic Whites (45%), 54% of non-Hispanic Black Veterans, 48% of Hispanic Veterans, and 49% of Veterans with unknown race had poor blood pressure control. In using a more stringent BP cutoff (>=130/80 mmHg) to define poor BP control, 74% of non-Hispanic White Veterans had poor blood pressure control over the 5 years compared to 82% of non-Hispanic Black Veterans, 75% of Hispanic Veterans, and 79% of Veterans with unknown race/ethnicity. The presence of a hypertension diagnosis at the time of study entry appears to be associated with higher odds of achieving BP control over time. Among other comorbidities, cancer, coronary heart disease, congestive heart failure, and substance use disorders were all associated with increased odds of good BP control over time.
    Date: June 14, 2011
  • Nurse Case Management Decreases Cardiovascular Risk Factors among Veterans with Diabetes Compared to Usual Care
    This study sought to determine if nurse case management could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia among Veterans with diabetes compared to usual care. Findings showed that involving a nurse case manager in the care of patients with diabetes can significantly improve the number of individuals achieving target values for glycemia, lipids, and blood pressure compared to usual care. In this study, a greater number of Veterans in the intervention group had all three outcome measures under control compared to Veterans in the usual care group. In addition, a greater number of Veterans in the nurse case management group achieved individual treatment goals for blood pressure, lipids, and blood sugar compared to Veterans receiving usual care. Observed differences between groups were likely mediated both by enhanced lifestyle changes and a greater intensity of pharmacological treatment among Veterans in the intervention group.
    Date: June 2, 2011
  • Redefining “Normal” Blood Pressure
    This study examined the independent effects of diastolic (DBP) and systolic (SBP) blood pressure on mortality – and estimated the number of Americans affected by accounting for these effects in the definition of “normal.” Findings show that systolic blood pressure elevations are more important than diastolic blood pressure elevations in individuals older than age 50. The situation was reversed in individuals younger than age 50, in whom DBP was the more important predictor of mortality. For individuals older than age 50, the lowest and highest blood pressures were associated with the greatest rates of death. Without adjusting for SBP, the rate of death began to increase at a DBP of 90 or higher; however, adjusting for SBP made the relationship disappear. The mortality rate began to significantly increase at SBP >140 – independent of DBP. For individuals younger than age 50, a DBP above 100 was associated with significant increases in mortality, with or without adjustment for SBP. The current definition of normal BP (<120/80) leads an estimated 160 million adult Americans to be labeled abnormal. Redefining normal BP as one that does not confer an increased mortality risk (DBP <100 under age 50, SBP <140 over age 50) would reduce that number to less than 60 million.
    Date: March 15, 2011
  • Hypertension Care Management Program Provided by Clinical Pharmacists Reduces Blood Pressure among Veterans
    This study evaluated the effectiveness of a hypertensive care management program provided by clinical pharmacists in collaboration with primary care physicians within four VA primary care teams at one urban Midwest VAMC. Findings show that Veterans referred to the hypertension care management program provided by VA clinical pharmacists had a significant reduction in blood pressure, and most met their BP treatment goals. Overall, the change in mean systolic BP at the final visit was –11.2 mm Hg from the initial visit, whereas the change in mean diastolic BP at the final visit was –4.6 mm Hg from the initial visit. By the final visit, 75% of Veterans had reached their BP treatment goals, which was 99.5% of the Veterans who completed the program. For Veterans with diabetes or chronic kidney disease (CKD), both systolic and diastolic BP measurements were significantly reduced from the initial pharmacist visit to the final pharmacist visit. Approximately 60% of all Veterans in the program with diabetes and 56% of those with CKD reached their BP goals.
    Date: January 1, 2011
  • Possible Hypertension Medication Gaps in Veterans Switching Healthcare Systems
    This study sought to measure the relationship between switching healthcare systems (VA and Medicaid) when filling prescriptions and gaps in medication adherence for Veterans with a diagnosis of hypertension. Findings show a significant and positive relationship between switching healthcare systems where prescriptions are filled and medication gaps when all drug classes are combined. Veterans who switched between healthcare systems were predicted to significantly increase their percent of days without drugs by 7% compared to individuals who received their drugs in one system. The authors suggest that healthcare policymakers and providers pay particular attention to patients who are switching payers for drug coverage because their medication regime may be compromised.
    Date: January 1, 2011
  • Rapid-Induction Group Clinic May Be Effective Method of Increasing Rates of Hypertension Control
    This report describes the process of care and outcomes of a QI initiative that used group clinics to rapidly induce hypertension control among Veterans in a VA primary care setting at one VAMC. Findings show that among Veterans with chronically treated but persistently uncontrolled hypertension, more than half (54%) were able to rapidly lower their blood pressures to controlled levels within six weeks using a group clinic quality improvement initiative. Moreover, Veterans maintained BP control over the follow-up period (10 months after QI protocol completion). Adherence to the QI protocol predicted hypertension control at follow-up, even after controlling for multiple baseline variables (e.g., diabetes, body mass index, medication compliance). Two-thirds of Veterans without diabetes achieved hypertension control, including more than 80% of those who adhered to the group-clinic protocol.
    Date: September 1, 2010
  • Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness
    This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains.
    Date: August 1, 2010
  • Article Suggests Achieving Blood Pressure Control within Three Months Should be New Therapy Goal
    The authors argue that to improve cardiovascular outcomes, evidence now indicates that a new paradigm emphasizing the rapid achievement of blood pressure control is required. Central to this paradigm is an explicit expectation of the timeframe in which blood pressure control should be achieved. Higher rates of control in shorter time periods have been seen in more recent clinical trials, and rapid blood pressure control is safe and associated with few side effects. Thus, the authors believe that the balance of the evidence supports changing the paradigm of hypertension treatment and implementing an expectation that blood pressure control should be achieved within three months of starting medication therapy.
    Date: May 1, 2010
  • Strategies to Reduce Sodium Intake Likely to Decrease Stroke and Heart Disease, and Save Billions in Costs
    Using a mathematical model, investigators examined the cost-effectiveness of two governmental strategies to reduce sodium intake in the U.S.: 1) government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience; and 2) a tax on sodium. Findings show that strategies to reduce sodium intake on a population level are likely to substantially reduce the incidence of stroke and myocardial infarction, saving billions of dollars in medical expenses.
    Date: March 1, 2010
  • Assessing New HEDIS Blood Pressure Quality Measure for Diabetes
    To encourage aggressive treatment of hypertension, the National Committee on Quality Assurance recently adopted a new HEDIS blood pressure performance measure of <130/80 mm Hg for patients with diabetes. Although there is nearly universal agreement on the benefits of aggressive BP treatment (3-4 BP medications) for those with diabetes, the new HEDIS performance measure has generated considerable controversy. This study examined BP levels and medication treatment intensity in patients with diabetes, in order to assess the reasons for failing to meet the new HEDIS measure. Findings suggest that the new diabetes BP measure may not accurately identify poor quality care and could promote overtreatment through its performance incentives. The new measure commonly mislabeled patients as being inadequately treated, especially elderly patients. Thus, the authors recommend that new BP measures be developed to encourage aggressive treatment of hypertension without unduly promoting overtreatment, especially among elderly patients.
    Date: January 1, 2010
  • Team-Based Care Led by Pharmacists or Nurses Improves Blood Pressure Control
    Investigators in this study conducted a systematic review of the literature to evaluate the effectiveness of team-based BP care involving pharmacists and nurses. Findings indicate that team-based interventions involving nurses or pharmacists were associated with significantly improved blood pressure control, with community pharmacists having the greatest impact. In addition, counseling on lifestyle modification and providing free BP medications had a significant impact on lowering systolic BP. Results also show that intervention strategies that provided medication education were the most effective, but this strategy cannot be evaluated on its own merit because it was usually provided with additional strategies.
    Date: October 26, 2009
  • Blood Pressure Telemonitoring Feasible for Most Veterans
    This article reports on the first six months of the Hypertension Intervention Nurse Telemedicine Study – an 18-month randomized clinical intervention to improve blood pressure (BP) control. Findings focus on the feasibility of using home BP telemonitoring devices to manage BP among Veterans. Technical alerts were generated if patients did not transmit their BP readings via the telemonitoring devices. Findings show that 75% of Veterans using the BP intervention were able to set up the telemonitoring devices and adhere to the study protocol. During the first six months of this study, 693 technical alerts were generated by 267 Veterans: 61% of the alerts were attributed to patient non-adherence, and 5% were attributed to a lack of patient knowledge (e.g., difficulty setting up the equipment, putting on the BP cuff). The authors suggest that despite the possibilities of improving health care using home BP telemonitoring equipment, there are groups who may require more support using this technology.
    Date: September 1, 2009
  • Self-Management Intervention for Hypertension has Modest “Spill-Over” Effect on Diabetes Control
    This study evaluated the effect of a tailored hypertension self-management intervention that had been shown to have a modest effect on blood pressure control on the unintended targets of diabetes and cholesterol control. Findings show a modest difference in glycemic control between Veterans with diabetes who received the intervention compared to usual care: the mean HbA1c decreased by 0.28% among Veterans in the intervention, while increasing 0.18% for those in usual care. LDL-C decreased over the two-year period in both groups, but there was no significant difference between the intervention group and usual care. Similar to results found in the analysis of HbA1c, Veterans with higher LDL-C at baseline had steeper rates of improvement over the study period; however, there was no differential effect between the intervention and usual care groups. Thus, this study shows some evidence that a telephone administered, nurse self-management intervention targeting hypertension may have a modest “spill-over” effect on diabetes control.
    Date: July 1, 2009
  • Standard-Based Method is Preferred Measure of Treatment Intensity for BP Control
    One possible measure of the quality of hypertension care is the intensity of clinical management when blood pressure (BP) is uncontrolled, thus there is increasing interest in measuring treatment intensification (TI). This study compared different TI measures in predicting BP control among 819 outpatients with hypertension. The three TI scores/measures evaluated were: 1) any/none score, which divides patients into those who had any therapy increase during the study vs. none; 2) Norm-Based Method (NBM), which scores each patient based on whether they received more or fewer medication increases than predicted at each visit; and 3) Standard-Based Method (SBM), which is similar to NBM but expects a medication increase whenever the BP is uncontrolled. Findings show that the SBM score was an excellent predictor of the final systolic blood pressure, thus the authors suggest that SBM serve as the basis for research and quality improvement efforts for better hypertension care. The any/none measure produced paradoxical results (therapy increases were associated with a higher final BP), while the NBM was not predictive of BP control.
    Date: July 1, 2009
  • Veterans with Hypertension and Comorbidities Receive Better Care than Veterans with Hypertension Alone
    This study sought to determine the impact of different types of co-existing chronic diseases on quality of care for hypertension, as well as patient perceptions of quality. Findings show that Veterans with hypertension and comorbid conditions had greater odds of receiving good quality of care. Moreover, as the number of chronic conditions increased, so did the odds of receiving appropriate overall care for hypertension. No relationship was found between the provision of guideline-recommended care for hypertension and Veterans’ perception of quality of care, nor did Veterans’ assessment of quality of care vary by the presence of co-existing conditions.
    Date: June 16, 2009
  • Physicians More Likely than Mid-Level Providers to Initiate Treatment Change for Veterans with Diabetes and Elevated Blood Pressure
    This study sought to examine whether treatment change for Veterans with diabetes and elevated blood pressure (BP) differed between physicians and mid-level providers (nurse practitioners, physician assistants), and to determine reasons for any observed differences. Findings show that mid-level providers were significantly less likely than physicians to change BP treatment for Veterans with diabetes and multiple chronic conditions, even after controlling for a number of patient, provider, and organizational characteristics. For example, after controlling for visit factors, provider practice style, measurement and organizational factors, mid-level providers were still less likely than physicians to initiate treatment change (37.5% vs. 52.5%) for elevated BP. Investigators also note that a fairly comprehensive set of potential explanatory variables did not account for any of the differences between physicians and mid-level providers.
    Date: June 1, 2009

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background-image  Informed Consent

  • New Concept Regarding Patient Autonomy When Coping with Multiple Chronic Conditions
    The clinical benchmark for evaluating patient autonomy in the acute care setting is patients’ capacity to participate in the informed consent process. However, this one-component concept of patient autonomy may be problematic in the context of multiple chronic conditions that require the patient to participate in their treatment plan beyond providing consent. Authors in this article call for a new two-component concept that includes both autonomous decision-making and the execution of the agreed upon treatment plan.
    Date: February 1, 2009
  • Appreciation of Research Information in Patients with Bipolar Disorder
    Patients with bipolar disorder were able to weigh risk levels associated with various studies, and to appreciate that their participation was voluntary. However, patients demonstrated two misconceptions: their appreciation of research goals was flawed (a substantial proportion had difficulty distinguishing clinical research from clinical care), and they incorrectly applied concepts of 'double-blind' and 'randomization.' In addition, more than half believed that their primary mental health provider could convince them to participate in a study even if they did not want to.
    Date: July 1, 2008
  • Conveying Risk Information Presented During the Informed Consent Process
    Whether numeric or word formats lead to better decisions about participation in research is largely unknown. A few small studies indicate that using numbers rather than words to communicate the likelihood of adverse outcomes can make a difference, and suggest that many people prefer the chances of adverse effects be expressed in numerical terms. The author recommends minimizing probabilistic words (e.g., rarely, possible) and encourages the use of simple frequencies with common denominators (e.g., one out of 100 people).
    Date: July 1, 2008

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background-image  Kidney Disease

  • VA National Transplant System Shows No Racial/Ethnic Disparities in Evaluating Veterans for Kidney Transplant
    This study examined VA patients of diverse racial/ethnic backgrounds with end-stage kidney disease (ESKD) who underwent the evaluation process for kidney transplantation (KT). Findings showed that in comparing African American Veterans with white Veterans and other minority Veterans, the VA National Transplant System did not exhibit the racial/ethnic disparities in evaluation for kidney transplant that have been found in non-VA transplant centers. Moreover, VA kidney transplant centers are successfully bringing ESKD patients through the evaluation process without race disparities at a time when non-VA transplant centers are unable to do so, while achieving a median time to complete evaluation similar to other published rates in non-VA settings.
    Date: August 1, 2016
  • Inpatient Conditions Associated with Increased Risk for Recurrent Acute Kidney Injury among Veterans
    This study sought to identify clinical risk factors for recurrent acute kidney injury (AKI) that were present during the index hospitalization for AKI. Findings showed that, in addition to known demographic and comorbid risk factors for AKI (i.e., older age, diabetes, dementia), Veterans at highest risk for hospitalization with recurrent AKI were those whose index AKI hospitalization included congestive heart failure as a primary diagnosis, decompensated advanced liver disease, cancer with or without chemotherapy, acute coronary syndrome, and intravascular volume depletion. Of the Veterans in this cohort, 49% were hospitalized at least once during the follow-up period, and 25% were hospitalized with recurrent AKI within 12 months of discharge. Median time to recurrent AKI was 64 days. The one-year mortality from time of discharge was 23%, and approximately 40% of Veterans who died were re-hospitalized with recurrent AKI before death.
    Date: August 11, 2015
  • Relationship between Perceived Racial Discrimination and Wait Times for Kidney Transplant
    Compared to whites, African Americans took significantly longer to get accepted for transplant. There were also significant racial differences on several cultural factors in patients as they began the evaluation process for kidney transplantation. Compared to white patients, African Americans reported experiencing more discrimination in healthcare, more perceptions of racism in healthcare, higher medical mistrust, and more religious objections to living donor kidney transplantation. Comorbidity, dialysis status, and availability of potential living donors were not associated with length of time to be accepted for kidney transplant. Thus, medical factors alone did not explain racial disparities. In analyses to identify which factors predicted racial disparities, the authors found that perceived discrimination in healthcare, less transplant knowledge, more religious objection to transplantation, and lower income explained the racial disparities observed in the time it took to be accepted for transplant. Moreover, after adjusting for demographics, psychosocial, and cultural factors, the association of race with longer time for listing for transplant was no longer significant. Authors suggest these findings indicate that perceived discrimination in healthcare can be as much of a risk factor as race, income, or low transplant knowledge.
    Date: February 27, 2012
  • Study Compares Effectiveness of Oral Anti-diabetic Drugs on Kidney Function for Veterans with Type 2 Diabetes
    Among Veterans with type 2 diabetes, initiation of sulfonylureas compared to metformin was associated with an increased risk of clinically significant decline in kidney function, diagnosis of ESRD, or death. Compared to metformin, the use of rosiglitazone was not significantly associated with any outcomes. Compared to sulfonylureas, the use of rosiglitazone was associated with a decreased risk for all three outcomes. Authors suggest that these findings support the current recommendations of metformin as first-line therapy for patients with type 2 diabetes who are in earlier stages of kidney disease.
    Date: February 1, 2012
  • Low Rate of Referral for Outpatient Nephrology Consultation for Veterans Hospitalized with Acute Kidney Injury
    This study examined the likelihood of nephrology referral among survivors of acute kidney injury (AKI) at risk for subsequent decline in kidney function. Findings showed that the majority of Veterans (56%) had persistent CKD (Stage III or IV) one year following their acute event. Consistent with non-VA cohorts, there was a low rate of outpatient referral for kidney specialist care among Veterans hospitalized with acute kidney injury. The cumulative incidence of nephrology referral before death, dialysis, or improvement in kidney function was 8.5%.
    Date: December 8, 2011
  • Chronic Kidney Failure Associated with Increased Mortality among Veterans with HIV and Hepatitis C Virus
    Compared with their mono-infected counterparts, Veterans with HIV who were co-infected with HCV had significantly higher rates of chronic kidney disease (14% vs. 11%) and mortality. HCV co-infection independently increased the likelihood of death by nearly 25%, after adjusting for other important HIV- and HCV-related factors. Co-infected Veterans also were less likely to have received highly active antiretroviral therapy (HAART) at baseline. Authors suggest that efforts should be targeted toward optimizing medical care for mono- and co-infected Veterans, including HAART therapy, HCV antiviral therapy, and treatment of comorbid medical conditions.
    Date: February 1, 2010
  • Panel Reaches Consensus on Oral Dosing for Primarily Renally Cleared Medications in Older Adults
    Chronic kidney disease (CKD) is a growing public health problem that disproportionately affects older adults. Medications are the most frequently used therapy for the management of CKD-related problems in older adults, but they are often prescribed in inappropriate doses. This study sought to establish consensus dosing guidelines for primarily renally cleared oral medications commonly taken by older adults with renal insufficiency. An expert panel was able to reach consensus agreement on 18 oral medications that are primarily renally cleared, including anti-infectives and central nervous system medications.
    Date: February 1, 2009
  • Contrast-Induced Acute Kidney Injury (CIAKI) Following Computed Tomography
    Clinically significant CIAKI following non-emergent computed tomography is very uncommon among outpatients with mild kidney disease. CIAKI was not associated with need for post-procedure dialysis, hospital admission, or 30-day mortality.
    Date: September 1, 2008

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background-image  Long-Term Care

  • Impact of Comprehensive Caregiver Support Program on VA Healthcare Utilization and Cost
    The Program of Comprehensive Assistance for Family Caregivers (PCAFC) supports caregivers of Veterans from the post-9/11 era who need assistance with activities of daily living (ADLs) or supervision or protection because of the residual effect of injuries sustained during their service. A monthly stipend is provided to caregivers based on Veterans’ care needs. In this study, investigators examined the early impact of PCAFC on VA healthcare utilization and costs. Findings showed that Veterans in PCAFC had similar acute care utilization when compared with those in the control group, but significantly greater primary, specialty, and mental health outpatient care use at least 30 – and up to 36 months post-application. Compared with Veterans in the control group, over time, Veterans in the PCAFC group had about a 10 percentage point higher probability of receiving any VA primary care. In the first six months, Veterans in the PCAFC group had an increased probability of using any VA specialty care (75% vs. 64%). Veterans in the treatment group also had an increased probability of using mental healthcare in the first 6 months (84% vs. 77%) and this increase was sustained through 31-36 months. Estimated total healthcare costs for Veterans in the PCAFC group were $1,500 to $3,400 higher per Veteran per 6-month interval than for Veterans in the control group. Findings suggest that comprehensive supports for family caregivers can increase patient engagement in outpatient care in the short term, which may enhance long-term health outcomes.
    Date: April 1, 2017
  • Some VA Polytrauma Team Members Caring for Veterans with Traumatic Brain Injury at Risk for Job Burnout
    This study sought to examine the extent of job burnout among VA polytrauma team members engaged in the diagnosis and treatment of traumatic brain injury – and to identify their coping strategies for dealing with job-related stress. Findings showed that VA polytrauma team members experienced moderate levels of emotional exhaustion, low levels of depersonalization, and high levels of personal accomplishment. However, 24% of participants in this study reported high levels of emotional exhaustion, which may be a precursor to job burnout. Polytrauma team members who reported caring for Veterans with TBI >50% of their time experienced higher levels of emotional exhaustion than those who spent <50% of their time caring for Veterans with TBI. Coping strategies included: connecting with others (e.g., relating to family, friends, and coworkers); promoting a healthy lifestyle (e.g., healthy diet, exercise); pursuing outside interests (e.g., hobbies); managing the work environment (e.g., staying organized); and maintaining positive thinking. No significant differences in participant characteristics for any of the subscales that were measured (emotional exhaustion, depersonalization, and personal accomplishment) were found for age category, race, years in practice, years at VA, primary role, or percent of time providing direct care.
    Date: March 1, 2013
  • Significant Financial Burden for Caregivers of Veterans with Polytrauma and Traumatic Brain Injury
    This study (conducted prior to the implementation of stipends from the Caregivers and Veterans Omnibus Health Services Act) evaluated the prevalence of financial strain as measured by asset depletion and/or debt accumulation, and labor force exit among caregivers of Veterans with polytrauma and traumatic brain injury (TBI). Findings showed that financial strain is common for caregivers: 62% reported depleted assets and/or accumulated debt, and 41% reported leaving the labor force. The latter finding stands in sharp contrast to studies in other populations internationally, where between 2% to 27% of caregivers left the labor force. If a severely injured Veteran needed intensive help with activities of daily living, the primary caregiver faced 4.6 higher odds of leaving the labor force, and used $27,576 more assets and/or debt to help care for the Veteran compared to caregivers of Veterans needing little or no help. Male caregivers, those providing care since the time of injury, and those providing care to Veterans with high-intensity needs and with the lowest overall functioning at time of discharge experienced significantly higher amounts of asset depletion and/or debt accumulation compared to female caregivers, caregivers relatively new to their role, and those providing care to higher functioning Veterans with low-intensity care needs. Spouses did not face higher financial strain compared to parents; financial strain was no higher for caregivers of those injured in Iraq, Afghanistan or the Middle East compared to those injured in the U.S., and the timing of injury was not associated with greater financial strain.
    Date: February 1, 2013
  • Unintended Consequences of Advance Directive Law
    This study sought to identify the unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences. Findings show that unintended negative consequences of advance directive legal restrictions may prevent all patients, vulnerable patients in particular, from making and communicating their end-of-life wishes and having them honored. Five overarching legal and content-related barriers were identified: poor readability (i.e., laws in all states were written above a 12th-grade reading level); restrictions on who may serve as a healthcare agent; execution requirements (steps needed to make forms legally valid); inadequate reciprocity (acceptance of advance directives between states); and religious, cultural, and social inadequacies. These restrictions have rendered advance directives less clinically useful. Advance directive statues meant to protect patients’ right of self-determination may instead better protect physicians from punitive action. For example, many states have provisions that enable physicians to presume the validity of an advance directive in the absence of actual knowledge that the directive is invalid. Author recommendations include improving readability (e.g., older persons read at a 5th-grade level), allowing oral advance directives, and eliminating witness or notary requirements. They also suggest that patients be allowed and encouraged to document their values, cultural traditions, and other socially or culturally important information.
    Date: January 18, 2011
  • Physicians May Need More Education about Long-Term Care Options for Veterans
    The purpose of this study was to obtain information about VA long-term care (LTC) referrals that could be used to develop interventions that increase the likelihood of referrals to home and community-based services (HCBS) instead of institutional care. Findings indicate that physicians are often seen as having limited familiarity with HCBS options and tend to refer Veterans with LTC needs to nursing homes. Training physicians about LTC referral options, with particular focus on how HCBS can be used to meet Veteran and caregiver needs, may help to increase those referrals.
    Date: February 1, 2009
  • Prescribing Discrepancies during Patient Transfer May Result in Adverse Drug Events
    The objective of this study was to examine medication discrepancies related to adverse drug events (ADEs) in nursing home patients transferred to and from the hospital. Findings show that less than 5% of discrepancies caused ADEs, which is consistent with reviews that suggest only a small fraction of errors result in harm. Authors note that information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients, and inform the development of decision-support tools at the time of patient transfer.
    Date: February 1, 2009
  • Veterans Using Home Healthcare have Higher Rates of Outpatient, Inpatient, and Nursing Home Care
    Veterans receiving VA home health care in 2002 increased their absolute chance of using VA outpatient care by 3%, inpatient care by nearly 12%, and nursing home care by 5% in 2003. Moreover, although utilization rates were low, VA HHC users were about 10 times more likely to have used hospice, adult day health care, or respite care in the VA system than non-users.
    Date: October 1, 2008

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background-image  Medication

  • Systematic Review: Patient Outcomes in Dose Reduction or Discontinuation of Long-term Opioid Therapy Suggest Utility of Multimodal Care
    Investigators examined the evidence on the effectiveness of strategies to reduce or discontinue long-term opioid therapy (LTOT) prescribed for chronic pain – and the effect of dose reduction or discontinuation on important patient outcomes, including pain severity and pain-related function. Findings showed that there are multiple strategies to reduce or discontinue long-term opioid treatment for chronic pain, however the quality of the evidence for effectiveness was very low. In 3 good-quality trials of behavioral interventions and 11 fair-quality studies of interdisciplinary pain programs, patients received multimodal care that emphasized non-pharmacologic and self-management strategies. Sixteen fair-quality studies reported improvement in pain severity (8/8 studies), function (5/5 studies), and quality of life (3/3 studies) following opioid dose reduction. However, few studies examined the potential risks of opioid dose reduction such as adverse events (i.e., opioid overdose), illicit substance abuse, or suicide.
    Date: July 18, 2017
  • Greater Risk of Opioid Prescription Overlap in Veterans Using Medicare Part D–Reimbursed Pharmacies
    This study sought to identify trends in dispensed prescriptions for opioids and the frequency of overlapping days’ supply of prescriptions for opioid medications in Veterans dually eligible for VA and Medicare Part D benefits. Findings showed that over the study period, there was an increasing reliance on the use of Part D–reimbursed pharmacies for opioid prescriptions among Veterans. Although opioid overlap appears to be declining within the VA healthcare system, overlap is increasing among opioid prescriptions dispensed from Medicare Part D–reimbursed pharmacies. Predictors for overlap included female gender, Part D enrollment, no VA medication copay, sleep disorders, psychiatric diagnoses, and substance or alcohol abuse. Veterans who were Hispanic, older, and had higher incomes had lower odds of overlap.
    Date: May 1, 2017
  • Initiative Decreases Inappropriate Prescribing to Older Veterans Discharged from VA Emergency Department Care
    This study evaluated the effectiveness and sustainability of the Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED) program to reduce the use of potentially inappropriate medications (PIMs). Findings showed that EQUiPPED was associated with a sustained reduction in inappropriate medication prescribing at all four VAMCs in the study. Post-intervention, the proportion of PIMs at site one decreased from 12% to 5%; at site two it decreased from 8% to 5%, at site three from 9% to 6%, and at site four from 7% to 6%. The implementation timeline for the initiative ranged from 6 to 14 months depending on the site. While the implementation timelines varied across sites, all VAMCs achieved a monthly PIM proportion between 5% and 6%. The EQUiPPED intervention led to safer prescribing and was sustainable across multiple VA sites. Implementation is currently underway at six additional VA emergency department sites, as well as three non-VA ED sites to evaluate broader dissemination.
    Date: April 7, 2017
  • Comparing Effectiveness of Two Medications for Veterans with Clostridium Difficile Infection
    This multi-year comparative effectiveness study evaluated the risk of recurrence and all-cause 30-day mortality among Veterans receiving metronidazole or vancomycin for the treatment of mild to moderate and severe Clostridium difficile infection (CDI) in the VA healthcare system. Findings showed that recurrence rates were similar among Veterans treated with vancomycin and metronidazole; however, Veterans with severe CDI treated with vancomycin were about 20% less likely to die from any cause within 30 days than Veterans treated with metronidazole. Overall, Veterans who received vancomycin had a lower risk of mortality compared to Veterans treated with metronidazole. Of the Veterans in this study, 4%-6% initially received vancomycin, despite 42% of the episodes having been classified as severe. While the use of vancomycin increased over the study period, by 2012 half of the patients with severe CDI still did not receive vancomycin. Although excess treatment costs of vancomycin relative to metronidazole and the concern for vancomycin-resistant enterococci will likely remain barriers, improved clinical cure and mortality rates may warrant reconsideration of current guidelines, particularly in cases of severe CDI.
    Date: April 1, 2017
  • Opioid Use among Afghanistan and Iraq War Veterans
    This study sought to understand current opioid use in OEF/OIF/OND Veterans who are regular users of VA care and did not have a cancer diagnosis at the time of this study. Findings showed that opioid use among OEF/OIF/OND Veterans is characterized by moderate doses that are used over relatively long periods of time by a minority of Veterans. Approximately 23% of all OEF/OIF/OND Veterans received opioids, with 7-8% receiving them chronically. The prevalence of high-dose opioids, concurrent use of multiple opioids, and use of long-acting opioids was fairly low. Diagnoses of PTSD, major depressive disorder, and tobacco use disorder were strongly associated with chronic opioid use. Back pain also was strongly associated with chronic use. Findings suggest that the use of opioids is less common among OEF/OIF/OND Veterans compared with Veterans as a whole, and provide a strong baseline for evaluating the impact of recently implemented opioid-related policies.
    Date: March 25, 2017
  • Addressing the Opioid Epidemic: Lessons Learned from VA
    This article describes VA’s efforts to address the opioid epidemic, and lessons learned that can inform other healthcare systems planning comprehensive action to reduce the risks associated with opioid therapy.
    Date: March 13, 2017
  • Discontinuation of Long-Term Opioid Therapy among Veterans is Overwhelmingly Initiated by VA Clinicians
    The aim of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between Veterans with and without substance use disorder (SUD) receiving care within the VA healthcare system in the years following release of 2009 and 2010 clinical practice guidelines. Findings showed that the majority of Veterans (85%) discontinued opioid use because their clinician stopped prescribing, rather than the patients deciding to stop. For patients whose clinicians initiated discontinuation, 75% were discontinued due to opioid-related aberrant behaviors (i.e., suspected substance abuse, aberrant urine drug test). Veterans with SUD diagnoses were more likely to discontinue LTOT due to aberrant behaviors, particularly abuse of alcohol or other substances, compared to Veterans without SUD. High proportions of patients received diagnoses for mental health disorders in the year prior to discontinuation of LTOT, including PTSD, anxiety disorders other than PTSD, and depressive disorders (25%). Increasing rates of opioid discontinuation are likely to occur due to policies and programs that encourage close monitoring of Veterans on LTOT for opioid misuse behaviors. Integrating non-opioid pain therapies and SUD treatment into multiple settings such as primary care and specialty SUD care is one possible approach to enhance their care.
    Date: March 1, 2017
  • VA Pharmacy Use in the First Year of Choice Act
    This study sought to describe pharmaceutical use during the first year of the Veterans Choice Program (VCP) and to understand barriers and facilitators for VA pharmacists to dispensing medications under the VCP. Findings showed that a majority of VCP pharmacy spending in the first year was for hepatitis C virus (HCV) medications, which accounted for only 5% of prescriptions but 90% of costs. However, in 2015, VA experienced greater than expected demand for HCV medications, which exceeded available funding, thus some patients obtained medications through the VCP. The impact of HCV medications on the VCP should be short-lived given broadened availability in VA in 2016. Topical eye drops and opioids represented the most commonly dispensed prescriptions: 16% and 9% of all prescriptions, respectively. Most prescriptions dispensed (93%) were for formulary agents, but substantial efforts were required from VA pharmacists to work with non-VA providers to use formulary drugs. Challenges related to obtaining medications from VA pharmacies through VCP included requiring controlled substance prescriptions to be hand-delivered, a lack of access to lab data required to safely dispense medications, and substantial time required by pharmacists to communicate with non-VA providers. Safe use of opioids, efficient management of non-formulary medications, and unintended new barriers to access created by the VCP must be addressed, in addition to robust ongoing evaluations to identify new cost, quality, and safety concerns.
    Date: February 17, 2017
  • Substantial Portion of Elderly Veterans Receive Medications from Medicare Part D-Reimbursed Pharmacies – Either Alone or in Conjunction with VA Pharmacies
    This study examined patterns of medication acquisition from VA and Medicare Part D-reimbursed pharmacies following the implementation of Part D. Findings showed that nearly one-third of VA healthcare users received medications from Part D-reimbursed pharmacies, either alone or in combination with VA pharmacies. Veterans who lived in rural areas, were not black, had VA medication copayments, or were dual or Medicare-only outpatient users were more likely to be dual (i.e., both VA and Part D) pharmacy users or Part D-reimbursed only pharmacy users compared to other Veterans. Among dual pharmacy users, more than half of the Veterans received medications from the same drug class from both VA and Part D-reimbursed pharmacies that overlapped by more than seven days. Results highlight the clinical importance of assessing medications from VA and non-VA sources. At particular risk for suboptimal medication reconciliation are those Veterans who receive care within VA only or from both VA and Medicare outpatient clinics, but who solely obtain their medications from non-VA pharmacies.
    Date: February 1, 2017
  • VA Opioid Safety Initiative Decreases Potentially Risky Opioid Prescriptions among Veterans
    This study examined changes associated with Opioid Safety Initiative (OSI) implementation among all adult VA patients who filled outpatient opioid prescriptions from October 2012 through September 2014 in any of 141 VA facilities. Findings showed that during the two-year study period there was a decrease in the number of VA patients receiving risky opioid regimens, with an overall reduction of 16% among Veterans receiving >100 morphine-equivalent milligrams (mEq) daily dosages and 24% among Veterans receiving >200 mEq. There was a 21% reduction in Veterans receiving benzodiazepines concurrently with opioids. Implementation of the OSI dashboard tool was associated with a significant decrease in all three outcomes (>100 mEq, >200 mEq and concurrent opioid/benzodiazepine prescribing). The implementation of the OSI dashboard tool was associated with a significant decrease in risky opioid prescribing across the VA healthcare system, which highlights the possibility of system-wide approaches to address high-risk opioid prescribing. However, a large number of VA patients remained on these regimens at the end of the study period, which emphasizes the challenges of making significant changes in healthcare systems that treat a large population of complex patients.
    Date: January 4, 2017
  • Safety Risk for Veterans Receiving Overlapping Buprenorphine, Opioid, and Benzodiazepine Prescriptions from VA and Medicare Part D
    Ensuring safe buprenorphine prescribing is especially challenging for VA, which treats a substantial number of Veterans with chronic pain and opioid use disorder, as well as an increasing number of patients who receive concurrent care in the private sector (i.e., Medicare Part D). This study identified Veterans dually enrolled in VA and Medicare Part D who filled a buprenorphine prescription in 2012 from either healthcare system and identified the proportion of Veterans with overlapping prescriptions from either system. Findings showed that more than one in four Veterans who received a VA prescription for buprenorphine – and one in five Veterans who received a Medicare prescription for buprenorphine – also received overlapping prescriptions for opioids from a different healthcare system. Among Veterans receiving buprenorphine from VA, 1% received an overlapping benzodiazepine prescription from Medicare, while among those receiving buprenorphine from Medicare, 16% received an overlapping benzodiazepine prescription from VA. Among VA and Part D buprenorphine recipients who had cross-system opioid overlap, 25% and 35%, respectively, had >90 days of overlap. Findings indicate a previously undocumented safety risk for Veterans dually enrolled in VA and Medicare who are receiving prescriptions for buprenorphine and overlapping prescriptions for opioids and/or benzodiazepines.
    Date: December 7, 2016
  • Veterans with Dementia Using Both VA and Medicare More than Double their Odds of Exposure to Potentially Unsafe Medications
    This study examined the prevalence and effect of dual use of VA and Medicare Part D prescription medications on prescribing safety among a national cohort of Veteran outpatients (aged >68 years) with a diagnosis of dementia prior to 2010, who were dually-eligible. Findings showed that the prevalence of exposure to potentially unsafe medications was high overall (44%), but was particularly high in dual users compared to VA-only users (59% versus 39%). Thus, compared to VA-only users, dual VA/Medicare users more than doubled the odds of exposure to potentially unsafe medications (PUM) overall –and to any “high-risk medications to avoid in older adults.” Dual-users had an adjusted average of 44 additional PUM-days of exposure compared to VA-only users. The odds of antipsychotic PUM exposure were 1.5 times greater for dual-users. Policymakers should consider implementing electronic health information exchanges and additional medication therapy management services across healthcare systems to keep pace with recent policies designed to expand Veterans’ access to non-VA care – and to protect vulnerable patients from risks associated with dual system use.
    Date: December 6, 2016
  • Maximal Doses of High-Intensity Statins Confer Greatest Survival Advantage for Those with Atherosclerotic Cardiovascular Disease
    This study sought to determine one-year cardiovascular mortality for VA patients with atherosclerotic cardiovascular disease by statin intensity – and to assess whether any differences in mortality related to statin intensity, if present, were observed in selected patient sub-groups (i.e., age, gender). Findings showed that high-intensity statins conferred a small but significant survival advantage over moderate intensity statins, even among older adults. Moreover, the maximal doses of high intensity statins conferred a further survival benefit. For example, when the sample was limited to Veterans on high-intensity statins, those treated with maximal doses had a 10% lower mortality when compared with those on sub-maximal doses. There was significant underuse of high-intensity statins and a graded relationship between statin intensity and mortality among Veterans in this study. Only 20% of Veterans received a high-intensity statin, while 43% were on moderate-intensity statins. Older adults (>75 years), women, and some minority groups were less likely to be on a high-intensity statin at baseline. Findings have significant implications for future lipid management practice guidelines.
    Date: November 9, 2016
  • Cost-Effectiveness of New Hepatitis C Virus Treatments in VA and Non-VA Patient Populations
    This study analyzed the cost-effectiveness of multiple new hepatitis C virus (HCV) treatments for VA and non-VA treatment-naïve patients, accounting for differences in patient characteristics and costs of ongoing care and current drug prices, as well as potential reductions in these prices. Findings showed that in the non-VA HCV population, the latest generation of highly effective but costly HCV treatments delivers good value – comparable to other medical interventions commonly deemed high value. HCV treatment is even more cost-effective in VA’s patient population due to VA’s lower costs of drugs, despite patients being older with more comorbid conditions.
    Date: October 3, 2016
  • OEF/OIF/OND Veterans that Currently Smoke More Likely to Receive Opioid Prescription than Non-Smokers
    This study sought to determine if smoking status is associated with the receipt of opioids among OEF/OIF/OND Veterans – and to examine important covariates of smoking (i.e., current pain intensity, gender, and mental health diagnoses) and receipt of opioids. Findings showed that compared to non-smokers, OEF/OIF/OND Veterans who were current smokers were more likely to receive an opioid prescription, even after controlling for covariates including: pain intensity, age, gender, service-connection, substance use disorder, mood disorders, and anxiety disorders. Veterans who reported a higher current pain intensity and those with pain diagnoses also were more likely to receive an opioid prescription. Among this young cohort of Veterans (mean age=30 years), more than one-third (34%) reported moderate to severe current pain intensity within +/-30 days of smoking status, with approximately 8% receiving at least one opioid prescription.
    Date: September 21, 2016
  • Lithium or Valproate Associated with Better Outcomes Compared to Second-Generation Antipsychotics for Bipolar Disorder
    This study assessed a nationwide population of Veteran outpatients with bipolar disorder treated at VAMCs, who were newly initiated on an antimanic agent between 2003 and 2010. The primary outcome was likelihood of all-cause hospitalization during the year after initiation. Findings showed that after extensive control for covariates, initiation of lithium or valproate alone – compared to initiation of an second-generation antipsychotic (SGA) alone – was associated with a significantly lower likelihood of all-cause hospitalization, a longer time to hospitalization, and fewer hospitalizations in the subsequent year. Veterans receiving combination treatment (i.e., SGA + lithium, SGA + valproate) had a significantly higher likelihood of hospitalization, although they also had a longer time to addition of another antimanic agent or antidepressant. Among monotherapies, the only significant differences were found in psychosis, with it being more likely in those initiated on SGAs rather than those initiated on lithium, valproate, or carbamazepine/oxcarbazepine.
    Date: September 1, 2016
  • Erectile Dysfunction Medication Use among Veterans Eligible for Medicare Part D
    This retrospective cohort study determined oral phosphodiesterase-5 inhibitor (PDE-5) medication use, which is considered first-line therapy for erectile dysfunction (ED), among Veterans who were dually eligible for VA and Medicare Part D benefits. Findings showed that during the period when PDE-5 inhibitors were allowed on the Medicare Part D formulary, prescriptions from VA pharmacies decreased, while PDE-5 inhibitor fills from Medicare-reimbursed pharmacies increased. However, this trend reversed after PDE-5 inhibitors were removed from the Part D formulary. VA formulary restrictions can increase the likelihood that Veterans who have access to non-VA healthcare obtain medications from the private sector. Since use of non-VA pharmacies may be unknown to VA providers, these Veterans may be at higher risk of adverse events or drug interactions. This is especially a concern for lifestyle drugs, such as those used for ED.
    Date: July 1, 2016
  • Prescription Opioids Associated with Lower Likelihood of Sustained Improvement in Pain among Older Veterans
    This study sought to identify patient factors associated with improvements in pain intensity in a national cohort of Veterans 65 years or older with chronic pain. Findings showed that on average, Veterans prescribed an opioid were less likely to demonstrate sustained improvement in pain intensity scores compared to Veterans who were not prescribed opioids. Overall, average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds of Veterans met criteria for sustained improvement during follow-up. Findings call for further characterization of heterogeneity in pain outcomes in older adults, as well as further analysis of the relationships between prescription opioids and treatment outcomes.
    Date: July 1, 2016
  • Use of Contraindicated Medications among Veterans Undergoing Percutaneous Coronary Intervention
    This study examined the use of contraindicated antiplatelet medications for 64,294 Veterans who underwent a PCI between 2007 and 2013. Findings showed that 18% had a known contraindication to at least 1 of 5 antiplatelet medications. Among these patients, 7% received a contraindicated medication in either the periprocedural setting or upon hospital discharge. Patients on contraindicated antiplatelet therapy showed a non-significant trend for greater risk of 30-day mortality and periprocedural major bleeding. Thus, use of contraindicated antiplatelet medications persists, though the rate of contraindicated medication use is lower in VA compared with U.S. community practice.
    Date: July 1, 2016
  • Use of Oral Anticoagulant Therapy for Veterans with Atrial Fibrillation Declines over 10-Year Period in VA Healthcare
    Among patients with atrial fibrillation (AF), oral anticoagulants (OACs) are recommended when the risk of stroke is moderate or high, but not when the risk of stroke is low. This study sought to quantify trends and evaluate guideline adherence with OACs in Veterans with newly diagnosed AF over a ten-year period within the VA healthcare system. Findings showed that among Veterans with new AF and additional risk factors for stroke, only about half received an oral anticoagulant, and the proportion is declining, including among patients with higher risks for stroke. Overall, initiation of an OAC fell from 51% in 2002 to 43% in 2011. The decline in oral anticoagulant use shown in these results is concerning because patients with AF who fail to receive recommended OAC therapy have high rates of preventable stroke. This study, as well as others, shows an opportunity to improve rates of guideline adherence.
    Date: June 21, 2016
  • Barriers and Facilitators to Use of Clozapine for Treatment-Resistant Veterans with Schizophrenia
    This study sought to identify facilitators and barriers to clozapine use – and to inform the development of interventions to maximize appropriate use. Findings showed that factors associated with high utilization of clozapine for Veterans with schizophrenia included: providing access to transportation for Veterans; having sufficient capacity to enroll patients; use of multi-disciplinary teams, including non-physician providers; better coordination of care through mental health intensive case management (MHICM) or clozapine clinics; and creation of systems to reduce reliance on too few individuals. Factors associated with low utilization of clozapine included lack of champions to support clozapine processes and limited-capacity care systems. Barriers identified at both high- and low-utilization facilities included time-consuming paperwork, reliance on few individuals to facilitate processes, and issues related to transportation for Veterans living far from VA care facilities.
    Date: June 15, 2016
  • Use of Clozapine for Veterans with Treatment-Resistant Schizophrenia Could Result in Significant Cost Savings
    This cost-benefit analysis sought to simulate potential cost savings for VA that would result from increasing the use of clozapine among Veterans with treatment-resistant schizophrenia. Findings showed that modest increases in clozapine use could result in significant cost savings for VA. Among Veterans with treatment-resistant schizophrenia, VA would save $22,444 per Veteran over the first year of treatment, primarily from 18.6 fewer inpatient hospitalization days per patient. Given this finding, if current clozapine use was doubled from 20% of patients with treatment-resistant schizophrenia to 40%, VA would accrue an estimated cost savings of $80 million over the first year. Moreover, full utilization of clozapine would save VA $320 million over the first year. Findings suggest VA should strongly consider initiatives to substantially increase clozapine use among Veterans with treatment-resistant schizophrenia. Deaths from clozapine-related adverse events are more than balanced out by decreased incidence of suicide attempts, with a net result of slightly fewer deaths with increased use of clozapine.
    Date: June 15, 2016
  • Systematic Review Compares Pharmacist-Led Care to Usual Care for Chronic Disease Management
    This systematic review sought to determine the effectiveness and harms of pharmacist-led chronic disease management for community-dwelling adults. Findings showed that compared with usual care, pharmacist-led care was associated with similar numbers of office visits, urgent care or emergency department visits, and hospitalizations, as well as medication adherence. Compared with usual care, pharmacist-led care increased the number or dose of medications received and improved glycemic, BP, and lipid goal attainment. Mortality and clinical events were similar between patients in usual care versus pharmacist-led care. Pharmacist-led chronic disease management was associated with effects similar to those of usual care for resource utilization and may improve physiologic goal attainment.
    Date: April 26, 2016
  • Prescription Opioid Use among Patients with Recent History of Depression Increases Risk of Recurrence
    This study examined whether patients in depression remission who were prescribed opioids for non-cancer pain had an increased risk of depression recurrence. Investigators analyzed two patient populations: Veterans treated in the VA healthcare system, and patients treated by a non-profit integrated healthcare system located in Texas. Findings showed that prescription opioid use among patients with a recent history of depression increased the chance of depression recurrence, and this effect was independent of pain diagnoses and pain intensity scores. Patients with remitted depression who were exposed to opioid analgesics at any point during the follow-up period were 77% to 117% more likely to experience a recurrence of depression than those who remained opioid free, after controlling for other factors. Among VA patients with depression remission, those who received opioids during follow-up were younger, had more psychiatric comorbidities, and had more painful conditions and higher pain scores than those who didn’t receive opioids.
    Date: April 1, 2016
  • Prescription Use of Codeine Associated with Greater Risk of New Onset Depression among Veterans
    This study sought to determine whether the hazard of new depression diagnosis differs among VA patients prescribed only codeine, only hydrocodone, or only oxycodone. Findings showed that Veterans prescribed only codeine for 30 days or longer had a 29% increased risk of a new diagnosis of depression compared to Veterans prescribed only hydrocodone for 30 days or longer. Those prescribed only oxycodone for 30 days or longer were not significantly more likely to develop a new depression diagnosis compared to patients prescribed hydrocodone only. Opioid use of 30-90 days was most common among oxycodone users, and opioid use of more than 90 days was most common among hydrocodone users. The distribution of individual comorbid conditions did not significantly differ across the three types of opioids.
    Date: March 22, 2016
  • Central Nervous System Polypharmacy May Increase Risk of Overdose and Suicide-Related Behavior among OEF/OIF Veterans
    This study examined the prevalence of central nervous system (CNS) polypharmacy and its association with drug/alcohol overdose and suicide-related behaviors in a national cohort of OEF/OIF Veterans. Findings showed that of the Veterans in this study, 8% had received five or more CNS-acting medications in 2011. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI – and was independently associated with overdose and suicide-related behaviors after controlling for known risk factors. Women and Veterans between ages 31 and 50 years were more likely to have CNS polypharmacy. Findings suggest that CNS polypharmacy may be used as a “trigger tool” to identify individuals who may benefit from referral to a tailored inter-disciplinary treatment team comprised of experts from relevant fields. Ideally, these teams would work together to optimize medication profiles and treatment plans, and to examine non-pharmacological treatment options.
    Date: March 1, 2016
  • Increased Dose of Prescription Opioids Raises Risk of Suicide among Veterans with Chronic Non-Cancer Pain
    This study examined the association between prescribed opioid dose and suicide in a national sample of VA patients with a chronic non-cancer pain condition who received opioid therapy. Findings showed that increased dose of opioids was found to be a marker of increased suicide risk, even when relevant demographic and clinical factors were statistically controlled. Type of opioid dosing schedule (i.e., regularly scheduled, as needed, or both) did not significantly affect suicide risk after accounting for other factors. Similar to the U.S. population and other large studies of VA patients, the vast majority of suicides involved firearms (64%), with overdose accounting for 20% of all suicides.
    Date: January 5, 2016
  • Among Older Veterans with Diabetes, Few with Low Glucose or Blood Pressure Levels Undergo Treatment De-intensification
    This study sought to describe the frequency and predictors of treatment de-intensification among potentially over-treated older Veterans with diabetes. Findings showed that among older Veterans with diabetes who were treated for BP or blood glucose control, Veterans’ BP or A1c levels had only a weak relationship to the likelihood of de-intensification. There was a modest association between a Veteran’s estimated life expectancy and de-intensification rates, but there was no consistent interaction between life expectancy, de-intensification rates, and BP or A1c levels. Authors suggest that practice guidelines and performance measures should focus more on reducing over-treatment through de-intensification.
    Date: December 1, 2015
  • Appropriate Prescribing for Veterans with Diabetes at High Risk for Hypoglycemia
    Evidence is accumulating that older individuals with diabetes have little to gain from the treatment burdens of stringent blood glucose control. Moreover, some older patients with diabetes might be at risk for hypoglycemia-related harms from medications prescribed to meet standard hemoglobin A1c (HbA1c) targets. This study examined the beliefs of primary care healthcare professionals (PCPs) who might receive such recommendations. Findings showed that almost half of the PCPs in this study reported that they would not worry about harms of tight control for an older patient with an HbA1c level of 6.5% who is at high risk of hypoglycemia. Of the PCPs in this study, 29% agreed it would be somewhat or very difficult to follow the Choosing Wisely HbA1Crecommendation for older adults. PCPs who agreed that maintaining the HbA1c level below 7% would benefit the patient and who reported worrying about malpractice claims were more likely to report difficulty following the recommendations. Conversely, PCPs who reported worrying that the patient would be harmed with tight blood glucose control were less likely to report difficulty following HbA1c recommendations.
    Date: December 1, 2015
  • Study Suggests Veterans Do Not Receive Appropriate Testing for Testosterone Therapy within VA Healthcare System
    This study evaluated whether the dispensing of testosterone therapy in the VA healthcare system was preceded by an appropriate diagnostic evaluation of testosterone deficiency. Findings showed that only a small proportion of male Veterans receiving testosterone in the VA healthcare system underwent appropriate testing: 3% of men who received testosterone met the criteria for an “ideal” evaluation, with two or more low testosterone levels in the morning, measurement of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels, and no contraindications; while 17% did not have their testosterone level checked at all. Moreover, 52% of Medicare-enrolled Veterans who did not have any testosterone testing within VA also had no testing outside VA. Some Veterans received therapy despite important contraindications: 8% had obstructive sleep apnea, 4% had elevated hematocrit at baseline, and 1% had prostate cancer. New testosterone dispensing in VA increased from 20,437 in FY2009 to 36,394 in FY2012 – a 78% increase, while the number of male VA patients increased by 5% during the same period. While there are currently no official VA guidelines on testosterone prescribing, promotion of a more uniform application of clinical guidelines on testosterone therapy may help limit the therapy to those who are most likely to benefit and least likely to be harmed.
    Date: September 1, 2015
  • Wide Variation Documented Among VA Providers in Potential Overuse of Antibiotics for Acute Respiratory Infections
    This study examined trends in antibiotic prescribing for acute respiratory infections (ARIs) within the VA healthcare system over an 8-year period – and identified patient, provider, and setting sources of variation. Findings showed that there was a persistently high prevalence of outpatient antibiotic prescriptions for ARIs among Veterans. Of more than one million ARI visits, the proportion resulting in antibiotic prescription increased from 67.5% in 2005 to 69.2% in 2012. Also, the proportion of antibiotic prescriptions that were macrolides increased from 37% to 47%. There was substantial variation in prescribing at the provider level. The 10% of VA providers who prescribed the most antibiotics did so during at least 95% of their ARI visits, while the 10% who prescribed the least did so during <40% of their ARI visits. Mid-level providers prescribed antibiotics slightly more frequently than physicians (70% vs. 68%). Subgroups associated with higher prevalence of antibiotic prescribing included: diagnosis of sinusitis (86%) or bronchitis (85%), presence of a high fever (78%), occurrence in an urgent care setting (75%), and Southern and Central regions of the U.S. (both 71%). Variation in ARI management seems to be strongly influenced by the prescribing patterns of individual providers. This is a ripe target for further research, quality improvement, and antibiotic stewardship interventions.
    Date: July 21, 2015
  • Individual and Facility-Level Factors Associated with Higher Risk of Suicide Attempt among Veterans Receiving Opioid Therapy
    This study examined the associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide-related events, assessing associations between individual-level and facility-level delivery of recommended care, and individual-level suicide-related events. Findings showed that within 180 days following opioid prescription, 1.6% of the study population on chronic short-acting opioids and 2.1% of the study population on long-acting opioids experienced suicide-related events. At the individual level, Veterans who received opioid therapy and had medical frailty, drug, alcohol, or mood disorder, and/or traumatic brain injury had a higher risk of suicide-related events. Patients on opioid therapy within VA facilities that ordered more drug screens were associated with a decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities that provided more follow-up after new prescriptions also were associated with decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities having higher sedative co-prescription rates had an increased risk of suicide -related events. Among the sub-population of patients with a substance use disorder and a short-acting opioid prescription, the facility rate use of specialty substance use disorder treatment was associated with lower risk of suicide-related events. Encouraging facilities to make more consistent use of drug screening, providing follow-up within four weeks for patients initiating new opioid prescriptions, avoiding sedative co-prescription in combination with long-acting opioids, and engaging patients with substance use disorders in specialty substance use treatment, may help prevent suicide-related events.
    Date: July 1, 2015
  • Stewardship Intervention Reduces Overuse of Antibiotics in the Treatment of Asymptomatic Bacteriuria among Veterans
    The Kicking CAUTI: The No Knee-Jerk Antibiotics Campaign intervention to reduce asymptomatic bacteriuria (ASB) overtreatment features case-based audit and feedback and an actionable algorithm to distinguish ASB from catheter-associated urinary tract infection (CAUTI). This study evaluated the effectiveness of the Kicking CAUTI intervention in two VAMCs between July 2010 and June 2013. Findings showed that, at the intervention site, the Kicking CAUTI intervention successfully decreased inappropriate screening for ASB and decreased ASB overtreatment with antimicrobials, without increasing the undertreatment of CAUTI. In stratified analysis, the effect of the intervention was more significant in long-term care wards and was modest on acute medicine wards. The overall rate of ordering urine cultures decreased during the intervention period – from 41.2 to 23.3 per 1000 bed-days, and even further during the maintenance period – to 12.0 per 1000 bed-days. At the comparison site, cultures ordered did not change significantly across periods. Overtreatment of ASB at the intervention site fell significantly during the intervention period from 1.6 to 0.6 per 1000 bed-days, and these reductions persisted during the maintenance period – to 0.4 per 1000 bed-days. Overtreatment of ASB at the comparison site was similar across all periods.
    Date: July 1, 2015
  • Receipt of Opioid Analgesics and Benzodiazepines Associated with Increased Risk of Death Due to Drug Overdose
    This study sought to describe the relationship between the receipt of concurrent benzodiazepines and opioid analgesics and death due to drug overdose in patients receiving prescription opioids for acute, chronic, and non-terminal cancer pain. Findings showed that during the study period, 27% of Veterans who received opioid analgesics also received benzodiazepines. Among those receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death due to drug overdose. About half of the overdose deaths occurred when Veterans were concurrently prescribed benzodiazepines and opioids. Patients who were prescribed concurrent opioids and benzodiazepines –and then stopped receiving benzodiazepines had higher rates of overdose than those patients who had only received opioids. Veterans who received benzodiazepines were more likely to be female, middle-aged, white, and to reside in wealthier areas. Veterans who received benzodiazepines were also more likely to have had a recent mental health or substance use disorder-related hospitalization, a diagnosis of a substance use disorder, or a number of psychiatric disorders (i.e., PTSD, depression, anxiety). These findings provide empirical support for the goal of the VA Opioid Safety Initiative (OSI) to reduce unnecessary co-prescribing of opioids and benzodiazepines, for which there had been limited evidence prior to this study.
    Date: June 10, 2015
  • Early Discontinuation and Sub-Optimal Dosing for Drug to Treat Sleep Disorders Associated with PTSD
    This study sought to identify a cohort of Veterans with PTSD initiating prazosin, and then characterize the typical duration of use and dosing patterns over the first year following initiation. Findings showed that approximately 20% of Veterans never refilled the initial prescription, while only 38% of Veterans continued the medication for at least one year. Veterans taking serotonin- reuptake inhibitor (SSRIs) or serotonin-norepinephrine reuptake inhibitor (SNRIs) antidepressants were more likely to maintain prazosin treatment for one year (41%) compared to non-users (33%). One-year prazosin persistence also increased with the patient’s age and number of concurrent medications. Prazosin persistence was not associated with gender, or rural residence. The mean maximum dose of prazosin reached in the first year of treatment was 3.6 mg/day, with only 15% of Veterans reaching the minimum guideline recommended dose of 6 mg/day. Research is needed to identify what factors inhibit patients from reaching the minimum recommended target dose and what characteristics are associated with prazosin response.
    Date: May 1, 2015
  • Pharmacist Support Key in Medication Adherence for Veterans Prescribed Dabigatran for Atrial Fibrillation
    This study assessed site-level variation in dabigatran adherence and identified practices associated with higher dabigatran adherence within the VA healthcare system. Findings showed that among VA patients who were treated with dabigatran, there was significant site-level variation in medication adherence across VAMCs – with the site average ranging from 42% to 93%. Veterans were more likely to be adherent and without missing doses when they were monitored by VA pharmacists. Longer duration of pharmacist-led monitoring and providing more intensive care to non-adherent patients, in collaboration with the clinician, also improved medication adherence. Findings suggest extra patient support (i.e., pharmacist availability) may significantly improve adherence to dabigatran. These data affirm that VA’s rich infrastructure of pharmacist-led, specialized anticoagulation care may continue to have an important role in maximizing safety, effectiveness, and appropriate use of these new agents, even as warfarin use continues to decline.
    Date: April 14, 2015
  • Antipsychotics Prescribed to Substantial Minority of Veterans with PTSD without Bipolar Disorder or Schizophrenia
    Given limited knowledge about the use of antipsychotics in Veterans with PTSD returning from Iraq and Afghanistan, this study examined the rates of antipsychotic use in this patient population. Findings showed that antipsychotics were prescribed to a substantial minority of OEF/OIF/OND Veterans with PTSD who did not also have a diagnosis of bipolar disorder or schizophrenia. Of the Veterans in this study, 20% received no psychiatric medications, 61% received psychiatric mediations other than antipsychotics, and 19% received antipsychotics. Male Veterans and those in the Army, of lower rank, and with active duty status (vs. National Guard/Reserve) were more likely to be prescribed antipsychotics. Comorbid psychiatric conditions, particularly substance use and personality disorders, as well as suicidal ideation also were associated with greater use of antipsychotics compared to other types of psychiatric medications. Antipsychotics were prescribed much later after the date of PTSD diagnosis than other psychiatric medications, suggesting they were not first-line medications. Given limited evidence of the benefit of antipsychotics for PTSD and their potential adverse metabolic side effects, authors suggest that clinicians carefully weigh the risks and benefits of antipsychotic use in Veterans with PTSD.
    Date: March 3, 2015
  • VA Primary Care Intervention Decreases High-Dose Opioid Prescription for Veterans with Non-Cancer Pain
    In October 2013, VA initiated a nationwide Opioid Safety Initiative (OSI) that includes goals of decreasing high-risk opioid prescribing practices, including prescribing of high-dose opioids. Prior to this national initiative, the Minneapolis VA Health Care System implemented a primary care population-based OSI aimed primarily at reducing high-dose opioid prescribing. This study evaluated the Minneapolis initiative. Findings showed that the number of Veterans prescribed daily high-dose opioids decreased from 342 to 65. Overall, the number of unique pharmacy patients who received at least one opioid prescription within 90 days decreased 14%. The number of Veterans receiving oxycodone SA decreased from 292 to 3 over the study time period. The number of Veterans receiving other long-acting opioids, as well as hydrocodone-acetaminophen, hydromorphone, and oxycodone/acetaminophen also decreased. The proportion of primary care providers who agreed that it was reasonable for the medical center to set a dosage limit was 76% at baseline and 87% at follow-up. The two most commonly endorsed barriers to lowering doses were patients becoming upset (62% baseline and 64% follow-up) and pressure from patient service representatives or the administration (59% baseline and 22% follow-up).
    Date: February 3, 2015
  • Female Veterans with CVD Less Likely to Receive Statin and High-Intensity Statin Therapy Compared to Male Veterans with CVD
    This study sought to identify the proportion of male and female Veterans with cardiovascular disease (CVD) who received care in any of 130 VA facilities between 10/1/10 and 9/30/11, and who received any statin and high-intensity statin. Findings showed that while evidence-based use of both statin and high-intensity statin therapy remains low in both genders, female Veterans with CVD were less likely to receive evidence-based statins (58% vs. 65%) and high-intensity statins (21% vs. 24%) compared with male Veterans. In fully adjusted analyses, female gender was independently associated with a 32% lower likelihood of receiving any statin therapy and a 24% lower likelihood of receiving high-intensity statin therapy. Mean low-density lipoprotein cholesterol levels were higher in female compared with male Veterans (99 vs. 85 mg/dl) with CVD. The use of statin and high-intensity statin therapy among female Veterans with CVD showed substantial facility-level variation. With the “statin dose-based approach” proposed by the recent cholesterol guidelines, these results highlight areas for quality improvement. It is important to note that despite the observed gender disparity noted in this study, statin and high-intensity statin use remain low in both genders. This is concerning, as the patient population studied in these analyses (i.e., those with established CVD) is the one that derives the most benefit from statin and high-intensity statin therapy.
    Date: January 1, 2015
  • Compared to Thiazolidinediones, Sulfonylureas May Be More Likely to Cause Death and Hospitalization for Veterans with Diabetes
    This study compared long-term outcomes of the two most commonly used second-line oral hypoglycemic medications in the VA healthcare system – sulfonylureas (SUs) and thiazolidinediones (TZDs). Findings showed that Veterans with diabetes who started on SUs compared to TZDs as a second-line agent after metformin were significantly more likely to die or have an ambulatory care sensitive condition hospitalization. Patients in this study were elderly (mean age 69), primarily white (88%), and had high rates of cardiovascular comorbidities (e.g., chronic pulmonary disease, hypertension), and obesity (41%).
    Date: December 1, 2014
  • JGIM Supplement Highlights VA’s Partnered Research
    In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management, suicide prevention, homelessness, medical home models, and communication of adverse events.
    Date: November 1, 2014
  • Delays in Filling Clopidogrel Prescription Associated with Increased Major Adverse Events Following PCI
    This study assessed the frequency of delays in filling an initial clopidogrel prescription after hospital discharge for Veterans who underwent percutaneous coronary intervention (PCI) with stent implantation between 1/05 and 9/10 at any of 60 VA hospitals. Findings showed that approximately 1 in 14 Veterans delayed filling clopidogrel prescriptions after PCI. Moreover, delays were associated with increased risk of major adverse events; specifically, patients with a delay in filling their clopidogrel prescription more often suffered MI (12% vs. 6%) and death (2.2% vs. 1.5%) compared to those without delay. The percentage of Veterans with delays varied by VA hospital, ranging from 0% to nearly 44%. This large variation suggests a need to identify best practices that allow hospitals to optimize prescription filling at discharge to potentially improve patient outcomes. In the VA healthcare system, delayed filling of clopidogrel prescription occurred less than half as often as in a prior study conducted with a Medicare population, which found that 20% of patients delayed filling their clopidogrel prescription after hospital discharge. Therefore, it is possible that the lower rate of delayed prescription filling within VA (7%) may be attributable to greater coordination of care, since inpatient and outpatient prescriptions are managed by a single VA pharmacy service.
    Date: September 1, 2014
  • Digoxin Significantly Associated with Increased Risk of Death among Veterans with Atrial Fibrillation
    This study investigated the association of digoxin therapy with mortality in a large cohort of Veterans with atrial fibrillation (AF). Findings showed that among Veterans with newly diagnosed AF, treatment with digoxin was significantly and independently associated with increased risk of death, regardless of age, gender, kidney function, heart failure status, concomitant therapies, or drug adherence. Of the Veterans in the study, 23% received digoxin. Compared with non-recipients, digoxin recipients had a higher prevalence of heart failure (HF) and receipt of beta-blockers, angiotensin receptor blockers, antiplatelet therapy, diuretic agents, and warfarin. Digoxin increased the risk of death by 1.21 times compared to comparable patients treated with other therapies for AF. While these findings challenge current cardiovascular society recommendations, the implication is not that every patient should come off this drug and every doctor should stop using it. Rather, physicians should consider alternatives to digoxin in managing patients with AF as it may still have a useful role under specific and carefully monitored conditions.
    Date: August 19, 2014
  • Most Patients with Type 2 Diabetes Obtain Little or No Benefit from Current Treatment for Tighter Glycemic Control
    This study examined how considering treatment burden would affect the benefits of intensive versus moderate glycemic control in patients with type 2 diabetes. Findings showed that for most patients over the age of 50 with an A1c below 9% who were on metformin, further glycemic treatment usually offered, at most, modest benefits. Across all ages, patients who viewed treatment as modestly burdensome experienced a net loss in quality of life years from treatments to lower A1c. The current approach of broadly advocating intensive glycemic control for millions of patients with diabetes should be reconsidered; instead, treating A1cs of less than 9% should be individualized based on estimates of benefit weighted against the patient’s view of treatment burden.
    Date: June 30, 2014
  • Cardiovascular Outcomes after Addition of Insulin Versus Sulfonylureas in Veterans with Diabetes Taking Metformin
    This study compared time to a combined outcome of acute myocardial infarction (AMI), stroke, or death among Veterans with diabetes that were initially treated with metformin, and subsequently added either insulin or sulfonylurea. Compared to those who added a sulfonylurea, Veterans who added insulin to metformin therapy had a 30% higher risk of the combined outcome of heart attack, stroke, and all-cause mortality. Although new heart attacks and strokes occurred at similar rates in both groups, mortality was higher in patients who added insulin. Although sulfonylurea use predominated as add-on therapy, there was increasing use of insulin intensification over the study years (increasing by an average of 17% per year). Reasons may include a growing prevalence of obesity and insulin resistance, emphasis on metrics such as glycemic targets, increasing comfort with newer analog insulins, and/or the benefit in microvascular outcome prevention.
    Date: June 11, 2014
  • Increased Prescribing Rates for Concurrent Sedative Medications among Veterans with PTSD
    This is the first national study that sought to characterize polysedative prescribing in Veterans with PTSD. Findings showed that, over time, there was an increase in the use of polysedatives among Veterans with PTSD: from 34% to 37% for two or more sedative classes, and from 10% to 12% for three or more classes. This represents a concerning clinical trend and a relative increase of nearly 25%. The most common combination of sedatives was an opioid plus a benzodiazapine, which were taken concurrently by 16% of Veterans with PTSD. Two other combinations that were used more frequently than expected were opioids plus skeletal muscle relaxants – and benzodiazepines plus atypical antipsychotics. Polysedative use varied across demographic subgroups, with higher rates among women, Veterans residing in rural settings, younger adults, Native Americans, and Whites. Also, benzodiazepine prescribing was markedly elevated among women (44%) compared to men (34%), and was somewhat lower among older adults (31%) compared to younger adults (36%).
    Date: December 16, 2013
  • Chronic Opioid Therapy Common among Hospitalized Veterans, Associated with Increased Risk of Death and Re-Admission
    This study sought to determine the prevalence of prior chronic opioid therapy (COT) among hospitalized medical patients, in addition to examining characteristics associated with inpatients that had previous opioid therapy compared to those with no opioid therapy prior to hospital admission. Findings showed that COT is common among hospitalized Veterans; moreover, occasional and chronic opioid use was associated with increased risk of hospital readmission and COT was associated with increased risk of death. Nearly 1 in 4 hospitalized Veterans had current or recent COT at the time of hospital admission for non-surgical conditions, and nearly half had been prescribed any opioids. Among the Veterans in this study, 26% had received COT in the prior 6 months, and 20% had occasional opioid therapy. Diagnoses more common in Veterans with COT included COPD, complicated diabetes, PTSD, and other mental health disorders.
    Date: December 6, 2013
  • Risk of Suicide-Related Behavior among Older Veterans Receiving Antiepileptic Drugs
    This study examined the temporal relationship between new antiepileptic drug (AED) monotherapy exposure and suicide-related behavior (SRB) in older Veterans. Findings showed that Veterans receiving their first AED during the study period were more likely to have suicide-related behavior during the 30 days prior to AED exposure than at any other time period in the year before and after exposure, even after controlling for psychiatric comorbidity. There were 106 SRB events among 92 Veterans in the year after exposure, with approximately 22% (n=16) of those Veterans also having an SRB event before their first AED exposure. Moreover, the rate of SRB after starting on an AED was gradually reduced over time. Results suggest that the peak in suicide-related behavior is prior to AED exposure. However, as the risk for recurrent SRB was 22% in individuals with SRB prior to exposure to AED therapy, these Veterans should be followed closely to prevent recurrent SRB.
    Date: November 26, 2013
  • “Tailored” Treatment of Blood Pressure May Prevent Many More Heart Attacks and Strokes than Current Guidelines
    Most current blood pressure (BP) guidelines advocate a treat-to-target (TTT) strategy, which titrates treatment towards intermediate outcomes, notably a BP goal. Benefit-based tailored treatment (BTT) strategies estimate an individual’s net absolute benefit from treatment – taking into account the patient’s estimated risk reduction from treatment, as well as potential harms associated with treatment. This study sought to determine whether a BTT strategy for the treatment of hypertension would prove superior to a traditional TTT strategy. Findings showed that BTT was both more effective and required less antihypertensive medication than current guidelines based on treating to specific blood pressure goals. Over five years, BTT would prevent 900,000 more cardiovascular disease events and save 2.8 million more quality-adjusted life years (QALYs), despite using 6% fewer medications, compared to TTT. While 55% of the 176 million “simulated” patients in this study would be treated identically under the two treatment approaches, in the 45% of the population treated differently by the strategies, BTT would save 159 QALYs per 1,000 treated versus 74 QALYs per 1,000 treated by the TTT approach.
    Date: November 19, 2013
  • Multifaceted Intervention Improves Medication Adherence for Veterans following Hospitalization for Acute Coronary Syndrome
    This study tested a multifaceted intervention to improve adherence to cardiac medications in the year after acute coronary syndrome (ACS) hospital discharge. Findings showed that, based on the four classes of cardio-protective medications in the study, a greater proportion of Veterans in the intervention group were adherent to medications in the year following hospitalization for ACS compared to Veterans in the usual care group: 89% vs. 74%, respectively. For the secondary prevention measures, there were no differences in the proportion of patients who achieved BP and LDL goals. There were no significant differences between Veterans in the intervention and usual care groups for rehospitalization for myocardial infarction (7% vs. 4%), revascularization (12% vs. 18%), or death (9% vs. 8%).
    Date: November 18, 2013
  • Testosterone Therapy Associated with Adverse Cardiovascular Outcomes among Veterans
    This study evaluated the association between the use of testosterone therapy and all-cause mortality, myocardial infarction (MI), and/or stroke among male Veterans who underwent coronary angiography in VA and had low testosterone levels between 2005 and 2011. Findings showed that the use of testosterone therapy was associated with increased risk of mortality, MI, and/or ischemic stroke. This association was consistent among patients with and without coronary artery disease. The absolute rate of events was 26% in the testosterone therapy group and 20% in the no-testosterone therapy group at 3 years after angiography, corresponding to one additional event for every 17 Veterans begun on testosterone. The increased risk of adverse outcomes associated with testosterone therapy use was not related to differences in risk factor control or rates of secondary prevention medication use since patients in both groups had similar blood pressure, LDL levels, and use of secondary prevention medications. Authors suggest that while physicians should continue to discuss the symptomatic benefits of testosterone therapy with patients, it is also important to inform them that long-term risks are unknown and that there is a possibility that testosterone therapy might be harmful.
    Date: November 6, 2013
  • Musculoskeletal Conditions, Injuries, and Pain More Prevalent among Patients Using Statins
    This study sought to determine whether statin use was associated with musculoskeletal conditions, including arthropathy (joint disease) and injury. Findings showed that musculoskeletal conditions, injuries, and pain were more common among statin users than similar non-users. In addition, arthropathy was found to be more common among statin users than non-users. Authors note that these findings are concerning, since starting statins at a young age for primary prevention of cardiovascular diseases has been widely advocated.
    Date: July 22, 2013
  • Medicare Drug Beneficiaries with Diabetes Use 2 to 3 Times More Brand-Name Drugs than VA Patients, at Substantial Cost
    This study compared the use of brand-name medications among patients using Medicare or VA drug benefits, and estimated how spending would change if the use of brand-name drugs in one system mirrored the other. Findings showed that Medicare beneficiaries with diabetes are more than twice as likely to use brand-name drugs than a comparable group within VA. If brand use in Medicare matched that in VA, investigators estimated more than $1 billion in avoidable spending by Medicare on brand-name drugs in 2008 alone. Conversely, spending in VA would have increased by 57% if Veterans used brand-name drugs at the same rate as in Medicare. Substantial regional variation exists in brand-name use in both Medicare and VA. For each drug group, however, the highest-using VA regions still had lower rates of brand use than the lowest using Medicare regions.
    Date: June 11, 2013
  • Many Older Veterans Do Not Discuss Non-VA Medications with VA Providers, Complicating Medication Reconciliation
    Investigators in this study conducted a survey of Veterans who received care at one Midwestern VAMC and were eligible for the Medicare Part D drug benefit in order to ascertain their sources of coverage for medications, their medication acquisition from VA and non-VA pharmacies, and their communication with VA physicians about non-VA pharmacy use. Findings showed that Medicare-eligible Veterans often take multiple medications and use non-VA services and pharmacies. More than half of Veterans who used non-VA pharmacies reported having infrequent or no discussions with their VA physicians about their non-VA medications (54%), non-VA medication coverage (62%), and non-VA providers (56%). Of the Veterans in this study with a chronic condition, 93% reported taking more than one prescription regularly, and 30% of these individuals reported using medications for that condition that were prescribed by both VA and non-VA providers.
    Date: May 1, 2013
  • Possible Overuse of Proton Pump Inhibitors to Treat Veterans with Gastroesophageal Reflux Disease
    This study sought to determine how proton pump inhibitors (PPIs) are initially prescribed for Veterans diagnosed with gastroesophageal reflux disease (GERD) – and to characterize subsequent PPI use over two years after the initial prescription. Findings showed that many Veterans received high total daily dose PPI prescriptions as initial therapy for GERD, but few patients had evidence of cessation or reduction of therapy. Of the Veterans in this study, 23% had high daily dose initial PPI prescriptions, and 77% had standard daily dose initial prescriptions. The majority of Veterans (66%) received a 90-day or greater initial prescription. Over two years, 13% of patients with initial standard daily dose prescriptions had evidence of step-up therapy. Only 7% of patients with initial high daily dose prescriptions had evidence of step-down therapy. The authors suggest that efforts should be made to ensure that VA providers prescribe the minimum effective PPI dose and prevent unnecessary PPI prescriptions. This could include decision support in the electronic health record via automatic alerts, as well as the need for justification when physicians attempt to prescribe high daily doses of PPIs.
    Date: February 12, 2013
  • Opioid Prescribing for Veterans with Chronic Non-Cancer Pain
    This study sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among Veterans with persistent non-cancer pain. Findings showed that the initiation of opioid drug therapy is common among Veterans with persistent pain, but most Veterans are not prescribed opioids long-term. During the study year, 35% of Veterans in the sample received an opioid prescription: 30% were prescribed opioids on a short-term basis (<90 days), and 5% received chronic opioid therapy (>90 days). Clinical factors associated with initiating COT include increased pain intensity, nicotine dependence, substance use disorders, and major depression diagnoses. Nearly one-quarter of Veterans prescribed COT also received prescriptions for benzodiazepine medications, which is a concern given that overdose deaths have been linked to the use of multiple sedating medications. Two-thirds of opioid prescriptions resulting in COT were initiated by primary care clinicians. The authors suggest that this supports the development of guidelines geared toward primary care practice. It also supports the provision of interventions and structures in primary care that facilitate proactive planning around opioid use and its monitoring.
    Date: February 1, 2013
  • Patient and Facility Characteristics Associated with Prescribing Benzodiazepines for Veterans with PTSD
    This study examined patient and facility-level correlates of benzodiazepine prescribing among Veterans with PTSD in the VA healthcare system. Findings showed that 30% of the Veterans in this study received a benzodiazepine. The majority (94%) of Veterans with any benzodiazepine use received = 30 days’ supply, and approximately two-thirds received more than 90 days of continuous benzodiazepine treatment. Among patient characteristics predicting benzodiazepine use, the largest odds ratios were observed for anxiety disorder comorbidity. Other characteristics associated with increased risk for benzodiazepine exposure included female gender, age = 30 years, rural residence, service connection = 50%, Vietnam era service, and duration of PTSD diagnosis. However, case-mix adjustment for these variables accounted for <1% of the variation in benzodiazepine prescribing across VA facilities. Main study findings were corroborated in replication analyses using data from two additional years (FY2003 and FY2006).The wide variation in facility-level benzodiazepine prescribing across VA cannot be explained by differences in patient characteristics across facilities.
    Date: February 1, 2013
  • Benzodiazepine Prescribing for Veterans with PTSD Remains Common and Varied across the VA Healthcare System
    This study examined variation in benzodiazepine prescribing frequency across the VA healthcare system (by VAMC, VISN, and region), and evaluated differences in prescribing frequency among rural vs. urban residents, and between community-based outpatient clinics (CBOCs) relative to medical centers. Findings showed that benzodiazepine prescribing among Veterans with PTSD remains common despite guideline recommendations against their use, and the level of practice variation was extensive. While prescribing variation at the regional, network, and facility levels declined over the study period, facility-level benzodiazepine prescribing variation remains high at 15% to 57%. Rural veterans with PTSD received equivalent, if not higher, quality of care (as reflected by benzodiazepine prescribing frequency) from community-based outpatient clinics compared to medical centers. The authors suggest that the wide variation in prescribing practices reflects uncertainty among providers regarding best practices, and is ultimately due to the limited number of effective PTSD treatments supported by a strong evidence base.
    Date: January 1, 2013
  • Performance Measure for Lipid Management in Veterans with Diabetes Encourages Treatment with Moderate Dose Statins
    Clinical action performance measures are increasingly being recommended to help make performance measurement more clinically meaningful. Investigators developed a clinical action performance measure for lipid management in Veterans with diabetes that is designed to encourage appropriate treatment with moderate dose statins, while minimizing overtreatment. They then assessed what proportion of Veterans received appropriate lipid management according to this new clinical action measure vs. the treat-to-target measure of LDL <100mg/dl that was in place at the time of the study. Findings showed that, of Veterans aged 50-75 years in this study, 85% passed the new clinical action measure, compared to 67% using the existing metric of LDL <100. Veterans who did not meet the clinical action measure had fewer primary care visits, on average, during the measurement period than Veterans who did meet the measure. Of the entire cohort aged >=18 years, 14% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100) had higher rates of potential overtreament. Findings suggest that continued use of threshold measures for lipid management may promote overtreatment. A modified version of the clinical action performance measure is being implemented in the VA healthcare system.
    Date: December 11, 2012
  • Comparing Cardiovascular Outcomes for Two Common Anti-Diabetes Drugs among Veterans
    This study compared cardiovascular disease (CVD) outcomes and all-cause mortality in a cohort of Veterans who received regular VA healthcare and were prescribed metformin or sulfonylureas – the two most commonly used anti-diabetic drugs. Findings showed a modest but clinically important 21% increased risk of hospitalization for heart attack or stroke, or death from any cause associated with the initiation of sulfonylurea compared with metformin therapy. The sulfonylurea group had higher rates of hospitalizations and deaths due to cardiovascular disease: 18 per 1,000 person years for those taking a sulfonylurea and 10 per 1,000 person years for those taking metformin. These findings suggest that for 1,000 patients who are initiating treatment for diabetes using metformin rather than sulfonylureas, there are 2 fewer heart attacks, strokes, or deaths per year of treatment. The findings do not clarify whether the difference in CVD risk is due to harm from sulfonylureas, benefit from metformin, or both.
    Date: November 6, 2012
  • Association between Several Common Antiepileptic Drugs and Suicide-Related Behavior in Older Veterans
    This retrospective study examined the relationship between antiepileptic drugs (AEDs) and suicide-related behaviors among Veterans aged 65 years and older who received VA healthcare. Findings showed that, within the study sample of 2 million older Veterans, there were 332 cases of suicide-related behavior (SRB). Exposure to antiepileptic drugs was significantly associated with suicide-related behavior, even after controlling for psychiatric comorbidity and prior SRB. Individuals who received AEDs were significantly more likely to have prior diagnoses of suicide-related behavior, depression, anxiety, bipolar disorder, PTSD, schizophrenia, substance abuse/dependence, conditions associated with chronic pain, and dementia. Veterans who received prescriptions for several specific AEDs – valproate, gabapentin, lamotrigine, levetiracetam, phenytoin, and topiramate – were at greater risk of diagnosed suicide-related behavior than Veterans with no AED exposure. Findings indicated that suicide-related behavior may occur as early as one week following AED use.
    Date: October 30, 2012
  • New Anticoagulants are Viable Option for Patients Receiving Long-Term Anticoagulation
    New oral anticoagulants are a viable option for patients receiving long-term anticoagulation. Direct thrombin inhibitors (DTIs) and factor Xa (FXa) inhibitors have the advantage of a more predictable anticoagulant effect, and fewer drug-drug interactions as well as equivalent or better mortality and vascular outcomes compared with warfarin. However, treatment benefits compared with warfarin are small and vary depending on the control achieved by warfarin treatment. Six good quality randomized controlled trials comparing new oral anticoagulants (NOACs) with warfarin showed that in patients with atrial fibrillation (AF), NOACs decreased all-cause mortality. In patients with venous thromboembolism, NOACs did not differ for mortality or outcomes. Across indications, the risk of major and fatal bleeding was decreased with NOACs compared with warfarin. However, the bleeding risk with NOACs may be increased in individuals over the age of 75, and in those with renal impairment. Sub-group analyses suggest a higher risk for myocardial infarction or acute coronary events with dabigatran (DTI) compared with FXa inhibitors. Recent thromboprophylaxis guidelines conclude that patients with AF who are on good warfarin treatment control have little to gain by switching to dabigatran.
    Date: August 28, 2012
  • Anti-Hypertensive Medication May Reduce Risk of Dementia among Veterans with Diabetes
    Comorbid hypertension was associated with increased risk of dementia; however, anti-hypertensive medications, particularly ACE inhibitors and ARBs, were associated with reduced risk of dementia, even among Veterans without hypertension. The most protective effect was associated with ARB use (approximately 24% lower risk of dementia), followed by diuretics (14%), ACE inhibitors (11%), CCBs (7%), and beta blockers (4%). Factors associated with higher incidence of dementia included: increasing age (Veterans >85 had more than three times greater risk compared to Veterans age 65), as well as duration of diabetes and higher comorbidity. Also, African Americans and other non-white races were more likely to have dementia. These findings suggest that ARBs and ACE inhibitors be considered when prescribing medication for the control of hypertension among patients with diabetes.
    Date: April 20, 2012
  • Increase in Proportion of Veterans with PTSD Prescribed Guideline-Concordant Medications
    The number of Veterans being treated for PTSD in the VA healthcare system increased nearly 3-fold – from 170,685 in FY1999 to 498,081 in FY2009. The majority of these Veterans (80%) received one of the medications recommended in the clinical practice guideline (CPG) for the treatment of this disorder. The proportion of Veterans receiving either of the two CPG-recommended first-line pharmacotherapy treatments for PTSD – selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) – increased from 50% in 1999 to 59% in 2009. This increase represents more than 46,000 Veterans receiving first-line, guideline recommended medications. The overall frequency of antipsychotic use declined by 6% – from 20% in 1999 to 14% in 2009, and there also was a reduction in benzodiazepine prescriptions (the CPG cautions against prescribing benzodiazepines to manage core PTSD symptoms). However, non-benzodiazepine hypnotic drug prescribing tripled when zolpidem (Ambien) was added to the VA national formulary. Prazosin use increased more than 6-fold, from 1% in 1999 to 9% in 2009, suggesting that it is now more widely prescribed to Veterans with PTSD.
    Date: March 1, 2012
  • Study Compares Effectiveness of Oral Anti-diabetic Drugs on Kidney Function for Veterans with Type 2 Diabetes
    Among Veterans with type 2 diabetes, initiation of sulfonylureas compared to metformin was associated with an increased risk of clinically significant decline in kidney function, diagnosis of ESRD, or death. Compared to metformin, the use of rosiglitazone was not significantly associated with any outcomes. Compared to sulfonylureas, the use of rosiglitazone was associated with a decreased risk for all three outcomes. Authors suggest that these findings support the current recommendations of metformin as first-line therapy for patients with type 2 diabetes who are in earlier stages of kidney disease.
    Date: February 1, 2012
  • Few Veterans Receive Appropriate Thrombolysis Following Stroke
    This study examined the use and misuse of thrombolytic therapy with tissue plasminogen activator (tPA) in a national sample of Veterans with acute ischemic stroke who were admitted to one of 129 VA medical centers in FY07. Findings show that VA treatment of Veterans with acute ischemic stroke who are eligible for thrombolytic therapy is similar to that in non-stroke center hospitals in the private sector. Among the 532 Veterans with ischemic stroke presenting to VA within three hours of symptom onset, 33% were eligible for tPA, and 11% received it. Considering only the 135 Veterans who arrived within two hours of symptom onset (allowing adequate time for testing and evaluation), 14% received tPA. Among the 30 Veterans who received tPA (whether eligible to receive it or not), 17% received the wrong dose. Eligible Veterans receiving tPA were similar to eligible Veterans who did not receive tPA in terms of clinical conditions and time to brain imaging.
    Date: January 1, 2012
  • Adverse Drug Reactions Associated with Polypharmacy are Common Cause of Unplanned Hospitalizations among Older Veterans
    This study sought to describe the prevalence of unplanned hospitalizations caused by adverse drug reactions (ADRs) among older Veterans. Findings showed that adverse drug reactions are a common cause of unplanned hospitalization among older Veterans, are frequently preventable, and are associated with polypharmacy (overall, 45% of Veterans took >9 outpatient medications and 35% took 5 to 8). The most common ADRs that occurred were bradycardia, hypoglycemia, falls, and mental status changes. Of the 678 unplanned hospitalizations that occurred during the study period, 70 ADRs involving 113 drugs occurred in 68 older Veterans, of which 37% were preventable. Extrapolating to a population of more than 2.4 million older Veterans receiving care during this time, 8,000 hospitalizations costing about $110 million (using FY04 dollars) may have been unnecessary. The most common reason for a preventable ADR was suboptimal prescribing (52%), followed by patient non-adherence (28%), and suboptimal monitoring (12%). In addition, 4 medication classes (cardiovascular, central nervous system, anti-thrombotic, and endocrine) accounted for almost 80% of all the drugs implicated in ADRs.
    Date: December 8, 2011
  • Diabetes Managed More Intensively in Older Veterans with Dementia and Cognitive Impairment
    This study sought to examine and compare anti-glycemic medication use, glycemic control, and risk of hypoglycemia in older Veterans with and without dementia or cognitive impairment. Findings showed that diabetes was managed more intensively in older Veterans with dementia or cognitive impairment than in those with no impairment, with more patients on insulin (30% vs. 24%) among those with cognitive problems. These conditions were independently associated with a greater risk of hypoglycemia. Of all Veterans taking insulin, the incidence of hypoglycemia was higher among those with dementia (27%) or cognitive impairment (20%) than among those with neither condition (14%). Veterans with dementia or cognitive impairment also had a greater decline in HbA1c over the 2-year study period. These findings suggest that providers were less likely to pursue individualized glycemic goals, as recommended by VA-DoD clinical practice guidelines (updated in 2010), when patients had cognitive problems.
    Date: December 8, 2011
  • Decreased Use of Benzodiazepines among Veterans with PTSD
    This study examined trends in benzodiazepine prescribing among Veterans with PTSD. Findings show that the overall proportion of Veterans receiving a benzodiazepine decreased from 37% in 1999 to 31% in 2009. In addition, the proportion of long-term users (>90 days) decreased from 69% to 64%, and the mean daily dose declined by nearly 15%. The likelihood of receiving benzodiazepines was influenced by time since first VA PTSD diagnosis. For example, in 2009, patients newly diagnosed with PTSD were the least likely to receive a benzodiazepine (21%) compared to patients with a history of three or more years of treatment (36%). Clonazepam was the most commonly prescribed benzodiazepine across all study years.Despite decreasing frequency of use, the absolute number of Veterans with PTSD who received benzodiazepines increased nearly 250% due to the increasing numbers of Veterans receiving care for PTSD in the VA healthcare system. Therefore, the authors suggest that minimizing benzodiazepine exposure will remain a vital policy issue.
    Date: November 29, 2011
  • Majority of OEF/OIF Veterans with Chronic Non-Cancer Pain are Prescribed Opioids by VA Outpatient Providers
    This study sought to describe the prevalence of prescription opioid use, types and doses of opioids received, as well as factors associated with the prescription of opioids among OEF/OIF Veterans. Findings showed that about two-thirds of OEF/OIF Veterans with chronic non-cancer pain were prescribed opioids over a one-year timeframe. Of Veterans prescribed any opioids, 59% were prescribed opioids ‘short-term’ compared to 41% prescribed opioids ‘long-term’ (more than 90 days). The mean duration of opioid prescription was 61 days for Veterans in the short-term group and 285 days for Veterans in the long-term group. Several findings suggest a need for improvement in adherence to pain and opioid treatment guidelines. For example, among long-term opioid users, 51% were prescribed short-acting opioids only (guidelines recommend transitioning to long-acting opioids); only 31% were administered one or more urine drug screens (guidelines suggest more frequent drug screening); and 33% were also prescribed sedative-hypnotic medications (monitoring by prescribing physicians is recommended to prevent possible overdose or death). Diagnoses associated with an increased likelihood of receiving an opioid prescription included: low back pain, migraine headache, PTSD, and nicotine use disorder.
    Date: September 7, 2011
  • Potential Problems with the Use of Antidepressants among Older Veterans Residing in VA Nursing Homes
    This study examined the prevalence and patient/site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants among Veterans aged 65 years and older that were admitted to any one of 133 VA Community Living Centers (CLC, previously called Nursing Home Care Units). Findings suggest potential problems with the use of antidepressants in older Veterans that reside in VA CLCs. Overall, only 18% of antidepressant use was optimal. Of the 877 Veterans with depression, 25% did not receive an antidepressant, suggesting potential underuse. Among depressed Veterans who received antidepressants, 43% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. In addition, of the 2,815 Veterans who did not have depression, 42% were prescribed one or more antidepressants; of these, only 4% had an FDA-approved labeled indication, suggesting potential overuse. Also, the co-prescribing of antipsychotics (in patients without schizophrenia) among those without depression was associated with an increased risk of antidepressant overuse.
    Date: August 1, 2011
  • Quality Improvement Program for Oral Anticoagulation has Potential to Save Lives and Millions in VA Healthcare Costs
    Quality of anticoagulation can be measured by percent time in the therapeutic range (TTR). Because VA is considering a quality improvement program to increase TTR, this study sought to determine whether a "business case" could be made for such a program, including whether or not it has the potential to save money in the short term. Findings showed that even after considering the cost of implementing the program, a quality improvement program for oral anticoagulation therapy in Veterans with atrial fibrillation has the potential to save lives and millions in VA healthcare costs. In this study population, a modest improvement in TTR (5%) would be expected to avert 1,114 adverse events over two years, many of them fatal. Such an improvement would result in a savings of $15.9 million (minus the cost of the quality improvement program). Improving TTR by 10% prevented 2,087 events and saved $29.7 million (again, minus the cost of the quality improvement program).
    Date: July 1, 2011
  • Medication Reconciliation Reduces Adverse Drug Events Related to Some Hospital Admission Prescribing Changes
    This study estimated the effectiveness of inpatient medication reconciliation at the time of hospital admission on adverse drug events (ADEs) caused by admission prescribing changes. Findings showed that medication reconciliation at the time of hospital admission reduced ADEs caused by admission prescribing changes that were classified as errors by 43%, but it did not reduce ADEs caused by all admission prescribing changes. Non-error-related ADEs would not be averted by one-time medication reconciliation on admission, but they might be averted by improved provider awareness and monitoring of admission prescribing changes during the hospital stay. The potential impact of such an intervention is large, as 50% of the ADEs in this study were caused by admission medication changes that were not errors.
    Date: May 9, 2011
  • Veterans Receiving Higher-Dose Opioid Prescriptions for Pain at Increased Risk of Death from Overdose
    This study examined the association of maximum prescribed daily opioid dose and dosing schedule (“as needed,” regularly scheduled, or both) with risk of opioid overdose death among Veterans with cancer, chronic pain, acute pain, and substance use disorders. Findings showed that among Veterans receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of death from opioid overdose. The frequency of fatal overdose among Veterans treated with opioids was rare – estimated to be 0.04% - and was directly related to the maximum prescribed daily dose of opioid medication. There was no significant increased risk of opioid overdose among Veterans who were treated with both “as-needed” and regularly scheduled opioids – a strategy for treating pain exacerbations – after adjusting for maximum daily dose and patient characteristics. Veterans who died from opioid overdose were significantly more likely to have chronic or acute pain, substance use disorders, and other psychiatric disorders, but they were less likely to have cancer. This study highlights the importance of implementing strategies for reducing opioid overdose among patients being treated for pain, for example, ascertaining history of substance abuse, using treatment contracts, and scheduling frequent follow-up visits and toxicological screens for patients at special risk.
    Date: April 6, 2011
  • Patient Self-Testing/Management May Decrease Mortality and Thromboembolic Events among Patients on Long-Term Anticoagulation
    This evidence review sought to determine whether patient self-testing (PST), either alone or in combination with self-dose adjustment (patient self-management, PSM), is associated with fewer thromboembolic complications and all-cause mortality – without an increase in major bleeding – compared to usual care. Findings showed that PST with or without PSM is associated with significantly fewer deaths and thromboembolic events – without an increased risk of serious bleeding – for a highly select group of motivated adult patients requiring long-term anticoagulation with Vitamin K antagonists. Patients randomized to PST/PSM had a 26% lower risk of death and a 42% reduction in major thromboembolism without any increased risk of major bleeding events. Whether or not this care model is cost-effective and can be implemented successfully in typical U.S. healthcare settings is unknown.
    Date: April 5, 2011
  • Excessive Caution in Prescribing to Veterans with Geriatric Conditions May Be Unnecessary
    This study evaluated whether common geriatric conditions were associated with risk of adverse drug events (ADEs). Findings show that over the one-year study period, 126 Veterans suffered a total of 167 ADEs, but there was no association between the presence of various geriatric conditions and ADEs. However, in exploratory analyses investigators found that the use of new medications (present at 12-month follow-up) was associated with a higher risk of ADEs. The authors suggest that while it is important to consider the unique circumstances of each patient, excessive caution in prescribing to elders with geriatric conditions may not be warranted.
    Date: April 1, 2011
  • Rates of Accidental Poisoning among VA Patients Higher than General Population
    This study describes the rate of accidental poisoning mortality among Veterans who used VA healthcare services, compares this rate to the general U.S. population, and describes the drugs/medications involved. Findings show that for FY05, VA patients had nearly twice the rate of fatal accidental poisoning compared to adults in the general population. Among VA patients who died from accidental poisoning, opioid medications (including methadone) made up 32% of the reported deaths; cocaine also was common at 23%. In both the VA and U.S. general populations, the rate of accidental poisoning mortality was higher for men than women, and higher for individuals ages 30 to 64 as compared to those ages 18 to 29, or ages 65 and older. Although VA patients have a greater risk of suicide than death by accidental poisoning, their risk for accidental poisoning death relative to the general population is larger than that of suicide.
    Date: April 1, 2011
  • Newly FDA-Approved Dabigatran May Be Cost-Effective Alternative to Warfarin for Patients at Increased Risk of Stroke
    Atrial fibrillation (AF) is the second most common cardiovascular condition in the U.S. – and the second most common condition affecting Veterans. AF also increases the risk of ischemic stroke by five-fold. Research shows that anticoagulation therapy with warfarin and other vitamin K antagonists can reduce the relative risk of stroke in AF by two-thirds. Dabigatran – a newer anticoagulant and the first such drug approved by the FDA in 20 years – produces similar or reduced rates of ischemic stroke and hemorrhage compared with warfarin and requires no blood testing. This study evaluated the quality-adjusted survival, costs, and cost-effectiveness of dabigatran compared with warfarin for the prevention of ischemic stroke in patients >65 years with non-valvular AF. Findings show that dabigatran could be a cost-effective alternative to adjusted dose warfarin. High-dose dabigatran was the most effective and the most cost-effective therapy examined. The quality-adjusted life expectancy was 10.28 quality-adjusted life years (QALYs) with warfarin, 10.70 QALYs with low-dose dabigatran, and 10.84 QALYs with high-dose dabigatran. Thus, high-dose dabigatran yielded an additional half year of quality-adjusted life compared to warfarin. With dabigatran given at 150 mg twice daily – the approved dosage for most patients – the incremental cost compared with using warfarin is under the conventional cost-effectiveness threshold of $50,000 per QALY gained. Total costs were $143,193 for warfarin, $164,576 for low-dose dabigatran, and $168,398 for high-dose dabigatran.
    Date: January 4, 2011
  • Possible Hypertension Medication Gaps in Veterans Switching Healthcare Systems
    This study sought to measure the relationship between switching healthcare systems (VA and Medicaid) when filling prescriptions and gaps in medication adherence for Veterans with a diagnosis of hypertension. Findings show a significant and positive relationship between switching healthcare systems where prescriptions are filled and medication gaps when all drug classes are combined. Veterans who switched between healthcare systems were predicted to significantly increase their percent of days without drugs by 7% compared to individuals who received their drugs in one system. The authors suggest that healthcare policymakers and providers pay particular attention to patients who are switching payers for drug coverage because their medication regime may be compromised.
    Date: January 1, 2011
  • Risk-Adjusted Time in Therapeutic Range Can Be Used as Quality Indicator for Outpatient Oral Anticoagulation
    This study examined the suitability of risk-adjusted time in therapeutic range (TTR) as a potential quality indicator for anticoagulation therapy among VA patients. Findings show that TTR can be used to profile the quality of outpatient oral anticoagulation in a large, integrated healthcare system. Thus, this measure can serve as the basis for quality measurement and quality improvement efforts. TTR differed among VA anticoagulation clinics – from 38% to 69%, or from poor to excellent. Risk-adjustment did not alter performance rankings for many sites, but for other sites it made an important difference. For example, the anticoagulation clinic that was ranked 27th out of 100 before risk adjustment was ranked as one of the best (7th) after risk-adjustment. Risk-adjusted site rankings were consistent between the first and second years of the study, suggesting that risk-adjusted TTR measures a construct (quality of care) that is stable over time.
    Date: January 1, 2011
  • Model Used for Cholesterol Guidelines May Lead to Misclassification of Risk for Heart Attack and Coronary Death
    National cholesterol guidelines use the “Framingham model” to calculate a person’s 10-year risk of myocardial infarction or coronary death. Based on this risk, patients are categorized into different risk groups, which are used to guide treatment decisions. Both original and point-based versions of the model are in use and endorsed by national guidelines. Given that approximately 36 million persons in the U.S. are eligible for lipid-lowering therapy, differences in risk classification depending on which model is used could result in millions receiving different lipid-lowering therapy. This study compared differences in predicted risk between the original and point-based Framingham calculations. Findings show that compared with the original Framingham model, the point-based version of the tool misclassifies millions of Americans into different risk groups, with 25-46% of affected individuals experiencing potential impacts on drug treatment recommendations for cholesterol control.
    Date: November 1, 2010
  • VA Increases Prescriptions for Smoking Cessation Medications among Veterans
    Since 2002, VA has implemented a range of policies and programs to increase evidence-based treatment for smoking. This study examined the change in rates of dispensing cessation-related medications to Veterans in the VA healthcare system to assess the impact of these policy changes. Findings show that VA policy initiatives instituted since 2002 have greatly increased prescriptions for smoking cessation medications among Veterans, while decreasing costs. The number of Veterans filling a prescription for nicotine replacement therapy (NRT) increased 63% from FY04 through FY08. Thirty-day-equivalent NRT prescriptions rose nearly 50% over the same period. Bupropion prescribing also rose sharply; the four-year growth rate among Veterans also prescribed a NRT was 61% greater than the 35% growth rate among all Veterans receiving bupropion prescriptions. While prescriptions for NRT and bupropion rose, spending per treated patient fell by 39% for bupropion and by 24% across all NRT formats (e.g., patch, gum).
    Date: September 24, 2010
  • Medication Management for Veterans with Schizophrenia
    This study examined medication management for a random sample of Veterans who received drug therapy for schizophrenia at any one of three VA mental health clinics in Southern California between 2002 and 2003. Overall, 67% of Veterans had inappropriate management at baseline: 32% had inappropriate management of psychotic symptoms, 45% had inappropriate management of weight, and 8% had inappropriate management of tardive dyskinesia (TD). Further, 11% had depression that was moderately severe or worse. At one year, the appropriateness of management for psychotic and depressive symptoms had not changed. The appropriateness of management of TD also did not change over time, but the management of elevated weight improved modestly. There were no significant differences between the three clinics in the prevalence of symptoms or side effects, or in the appropriateness of medication management. However, psychiatrists with more than 12 patients were significantly more likely to improve their patients’ care over time.
    Date: July 1, 2010
  • Inappropriate Non-Steroidal Anti-Inflammatory Drug Use is Prevalent among Veterans
    This study examined the prevalence of inappropriate non-steroidal anti-inflammatory drug (NSAID) use among Veterans– and identified patient and clinical characteristics associated with inappropriate use. The inappropriate use of NSAIDs was prevalent and was associated with more GI symptoms and higher levels of pain. Of the 1,250 Veterans who reported NSAID use, approximately 32% used NSAIDs inappropriately, including taking two or more NSAIDs, exceeding the highest daily recommended dosage, or both. Veterans classified as using NSAIDs inappropriately were more likely to be non-white and were more likely to have an income of less than $20,000.
    Date: June 1, 2010
  • All Antipsychotics May Not Increase Short-Term Risk for Mortality among Veterans with Dementia
    Commonly prescribed doses of haloperidol, olanzapine, and risperidone, but not quetiapine, were associated with short-term increases in mortality. During the first 30 days, there was a significant increase in mortality in subgroups prescribed a daily low dose of haloperidol, olanzapine, or risperidone, after adjusting for demographics, comorbidities, and medication history. However, increased mortality was not seen when quetiapine was prescribed. No antipsychotic was associated with increased mortality after the first 30 days. Therefore, the authors suggest that all antipsychotics might not pose the same degree of risk in all patient groups as implied by the general warnings that have been issued.
    Date: May 7, 2010
  • Additional Evidence of Clustering of Cardiovascular Events Following Cessation of Clopidogrel in Patients with ACS
    In multivariable analysis, including adjustment for total duration of clopidogrel treatment, the 0-90 day interval after stopping clopidogrel was associated with significantly increased risk of death/MI compared to the 91-360 day interval among a non-VA population. There was a similar trend of increased adverse events after stopping clopidogrel for various subgroups (women vs. men, medical therapy vs. percutaneous coronary intervention, stent type, and = or <6 months of clopidogrel treatment). This clustering of adverse events was not present among patients stopping ACE-inhibitors, suggesting that the events are not a general effect of stopping medications. There was no association between the 91-360 day interval after stopping clopidogrel and adverse outcomes compared to patients remaining on clopidogrel.
    Date: May 1, 2010
  • Article Suggests Achieving Blood Pressure Control within Three Months Should be New Therapy Goal
    The authors argue that to improve cardiovascular outcomes, evidence now indicates that a new paradigm emphasizing the rapid achievement of blood pressure control is required. Central to this paradigm is an explicit expectation of the timeframe in which blood pressure control should be achieved. Higher rates of control in shorter time periods have been seen in more recent clinical trials, and rapid blood pressure control is safe and associated with few side effects. Thus, the authors believe that the balance of the evidence supports changing the paradigm of hypertension treatment and implementing an expectation that blood pressure control should be achieved within three months of starting medication therapy.
    Date: May 1, 2010
  • Pharmacotherapy May Be Underused for Veterans with Alcohol Addiction
    In FY06 and FY07, only about 3% of more than a quarter of a million VA patients with alcohol use disorders received treatment with one of four drugs specifically approved for treating alcohol dependence. [This apparent underutilization is not unique to VA, as utilization rates are within the range of rates reported in other settings.] Receipt of pharmacotherapy was more likely among Veterans receiving specialty addiction care, Veterans with alcohol dependence (vs. abuse), Veterans younger than 55 years old, and women. SSRI antidepressants were used about five times as often as alcohol use disorder medications in Veterans with an alcohol use disorder but without a psychiatric indication for SSRIs.
    Date: April 1, 2010
  • Comparing Treat-to-Target Strategies to Tailored Approach for Statin Therapy
    This study examined how a simple Tailored Treatment strategy for statin therapy compared with a Treat-to-Target strategy based on National Cholesterol Education Program (NCEP) III treatment recommendations. Findings show that a simple Tailored Treatment strategy was more efficient and prevented substantially more coronary artery disease morbidity and mortality than any of the currently recommended Treat-to-Target approaches. The Tailored Treatment approach was predicted to save 520,000 more quality-adjusted life years among Americans aged 30-75 than the best NCEP III Treat-to-Target approach for every five years of treatment, even though fewer people were treated with high doses of statins. The authors indicate that these results suggest that a Tailored Treatment approach to medicine can substantially improve care, while also reducing unnecessary treatment and costs. Thus, they recommend that given its potential to better tailor treatments to individual patients, the principles underlying a Tailored Treatment approach should be considered during deliberations about guidelines and performance measures.
    Date: January 19, 2010
  • Affective Disorders Strongest Predictor of Suicidal Behavior in Elderly Veterans Receiving Anti-Epileptic Medication
    In January 2008, the FDA issued an alert indicating that anti-epileptic drug (AED) treatment is associated with increased risk for suicidal ideation, attempt, and completion. This study sought to assess variation in suicide-related behaviors in a population not well-represented by the data used for the FDA analysis – individuals 66 years and older with new exposure to AEDs. Findings show that in older Veterans who were started on AED monotherapy, the strongest reliable predictor of suicide-related behaviors was the diagnosis of an affective disorder prior to AED treatment. Increased suicide-related behaviors were not associated with individual AEDs. However, while most Veterans in this study received AED prescriptions for gabapentin (76.8%), a trend for increased suicide-related behaviors was found among those prescribed levetiracetam or lamotrigine, but interpretation was difficult since few Veterans received either drug (0.6%). The associations between suicide-related behaviors and chronic pain or chronic disease burden were not statistically significant, but dementia was significantly associated with suicide-related behaviors (42.2% with dementia vs. 25.8% without).
    Date: January 11, 2010
  • Costs and Outcomes Associated with Newer Medications for Glycemic Control in Type 2 Diabetes
    Investigators in this study conducted a cost-effectiveness analysis to better understand the value of adding either of two newer medications (exenatide and sitagliptin) as second-line therapy to glycemic control strategies, compared to an older medication (glyburide), for new-onset type 2 diabetes in persons 25 to 64 years of age. Findings show that newer medications offer more options for glycemic control; however, they come at considerable costs. Exenatide and sitagliptin conferred 0.09 and 0.12 additional quality-adjusted life years respectively, relative to glyburide as second-line therapy. Using sitagliptin as a second-line treatment is associated with additional costs of $20,213 per person over their lifetime compared to a baseline strategy using glyburide as second-line therapy. Using exenatide as a second-line treatment is associated with an additional cost of $23,849 per person over their lifetime compared to glyburide as second-line therapy.
    Date: January 7, 2010
  • Increase in VA Drug Co-Payment Resulted in Decrease in Veterans’ Adherence to Some Medications
    This study examined the impact of the VA medication co-payment increase on adherence to diabetes, hypertension, and hyperlipidemic medications by Veterans with diabetes or hypertension at 4 VAMCs during a 35-month period (2/01--12/03). Findings showed that a medication co-payment increase from $2 to $7 adversely impacted adherence to statins and anti-hypertensives by Veterans subject to the co-payment, but the impact was greatest among Veterans taking oral hypoglycemic medication. Adherence to all medications increased in the short term for all Veterans (12 months after co-payment increase), but then declined in the longer term (subsequent 11-month period). The impact of the co-payment increase was particularly adverse for Veterans with diabetes who were responsible for co-payments. Their adherence to oral hypoglycemic medication in the period 13-23 months after the co-payment increase was 10.3% lower than their pre-period adherence – and 9% lower than comparable Veterans who were exempt from co-payments.
    Date: January 1, 2010
  • Importance of Communicating Drug Information to Clinicians
    The most direct way that the Food and Drug Administration (FDA) communicates prescribing information to clinicians is through the drug label. However, critical information that the FDA has at the time of drug approval may not appear on the drug label or in relevant journal articles. This commentary reviews several instances of information not included on drug labels and suggests the importance of better communicating this information to clinicians.
    Date: October 29, 2009
  • Delays in Initiating Antibiotic Therapy for Veterans Hospitalized with Pneumonia
    Time to first antibiotic dose (TFAD) is an important quality indicator for pneumonia care. Findings from this study, which included 20 VA hospitals, show that of the 82 survey participants, 72% perceived that ordering and performing chest X-ray was the most frequent step resulting in TFAD delays. Additional steps reported to cause TFAD delays were medical provider assessment, chest X-ray interpretation, ordering/obtaining blood cultures, and ordering/administering initial antibiotic therapy. The most commonly perceived barriers were patient and X-ray equipment transportation delays and communication delays between providers. The most frequently used strategies to reduce TFAD were stocking antibiotics in the emergency department and physician education. Focus groups emphasized the importance of multi-faceted quality improvement approaches and a top-down hospital leadership style to improve performance on this pneumonia quality measure.
    Date: October 1, 2009
  • Effect of Medicare Pharmacy Benefit Coverage on VA Healthcare Users
    This study examined the influence of Medicare pharmacy benefit coverage on VA pharmacy use among Veterans using the VA healthcare system during 2002, who had diabetes mellitus, ischemic heart disease, or chronic heart failure. Overall, results showed that Veterans dually enrolled in VA and Medicare fee-for-service (FFS) were less likely to receive condition-related medications from VA compared with Veterans enrolled in HMOs with lower levels of prescription drug coverage. One implication of the overall study findings is that VA will become less the healthcare system of choice for Veteran beneficiaries if Medicare pharmacy services become more affordable. Moreover, Veterans with chronic conditions that require many medications and who hit a coverage gap in Medicare Part D or have difficulty making the Medicare co-payments may turn to VA as a safety net at intermittent times rather than using VA pharmacy services more steadily.
    Date: October 1, 2009
  • Veterans Using VA Pharmacy Services are More Ill than their Counterparts
    This study compared users and non-users of VA pharmacy services separately by age group – Veterans ages 18-64 (non-elderly) vs. age 65 and older (elderly). Findings suggest that Veterans who use VA pharmacy services appear to be more ill than their counterparts who do not use the VA pharmacy benefit. Among younger Veterans, users of the VA pharmacy were more than twice as likely to report fair or poor general health status and more than three times as likely to report fair or poor mental health status. Moreover, both non-elderly and elderly users of VA pharmacy services reported more medical conditions and were more disabled. Overall results show a higher proportion of Veterans who use VA pharmacy services are African American and have no alternative insurance. Compared to non-users, VA pharmacy users also were more likely to be unemployed or out of the labor force, and living in a poor or low income family.
    Date: October 1, 2009
  • Appropriate Prescription of Proton-Pump Inhibitors among Elderly Veterans Using NSAIDs
    Using VA data, this observational study assessed VA provider awareness of NSAID gastro-protection and the therapeutic intent of proton-pump inhibitor (PPI) prescription among 1,491 elderly Veterans at one VAMC. In other words, investigators sought to better understand why VA physicians were prescribing these drugs. Findings show that among elderly Veterans who were prescribed a PPI, a therapeutic intent was documented in 71% of the cases, and of these prescriptions, 88.8% were considered appropriate. However, practitioner recognition of the need for gastro-protection in elderly patients was remarkably low (10%). Results also show that poor rates of appropriate therapeutic intent were noted when the PPI was initiated by the inpatient service, by certain sub-specialties (e.g., cardiology, otolaryngology), and for Veterans using the VA for medication refill only.
    Date: September 15, 2009
  • Toyota Production System Methodology Leads to Improved Peri-Operative Care in One VAMC
    In the Toyota Production System (TPS) industrial engineering approach, front-line work groups identify problems, experiment with possible solutions, measure the results, and implement strategies to improve quality, resulting in a “ground-up” rather than “top-down” approach to solving system problems. Beginning in 2001, one VAMC instituted TPS methods to reduce Methicillin Resistant Staphylococcus Aureus (MRSA) infections on a general surgical floor. The intervention then evolved to address other areas for QI on the surgical unit, such as increasing appropriate prophylactic peri-operative antibiotic therapy. The aims of this study were to determine: 1) whether the QI intervention for peri-operative antibiotic therapy was associated with improvements in selection and duration of prophylactic therapy; and 2) if the overall MRSA prevention initiative was associated with decreased hospital stay (LOS). Findings show that use of the TPS methodology resulted in a QI intervention that was associated with an increase in appropriate peri-operative antibiotic therapy among surgical patients. The proportion of all surgical admissions in this study (n=2,550) receiving appropriate peri-operative antibiotics was significantly higher in 2004 after initiation of the TPS intervention (44.0%) compared to the previous four years (range 23.4% to 29.8%). Results also showed no statistically significant decrease in LOS over time.
    Date: September 1, 2009
  • Drugs-to-Avoid Criteria for the Elderly have Limited Value
    Drugs-to-avoid criteria are lists of drugs considered to be potentially inappropriate for the elderly due to adverse effects, limited effectiveness, or both. For example, the Centers for Medicare and Medicaid Services use a version of the criteria of Beers et al. in nursing homes, and the National Committee for Quality Assurance uses the criteria of Zhan et al. to compare the quality of U.S. health plans. This study compared the Beers and Zhan criteria with individualized expert assessment of patients’ medications in 256 elderly Veterans from the Iowa City VAMC who were taking five or more medications. Findings show that the drugs-to-avoid criteria performed poorly when used as quality measures to assess the current state of a patient’s drug therapy. For example, half or more of the drugs flagged by the Beers and Zhan criteria were not considered problematic upon individualized expert review. In addition, the Beers and Zhan criteria identified only 8-15% of drugs that experts judged to be problematic. Therefore, authors suggest that while these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures for the quality of prescribing.
    Date: July 27, 2009
  • Improving Adherence to Cardiovascular Medications
    This article focuses on cardiovascular medication adherence and discusses studies that address: 1) different methods of measuring adherence, 2) prevalence of non-adherence, 3) association between non-adherence and outcomes, 4) reasons for non-adherence, and 5) interventions to improve medication adherence. Findings show that while there are many different methods for assessing medication adherence, non-adherence to cardiovascular medications is common and associated with adverse outcomes. The authors also found that non-adherence is not solely a patient problem but is impacted by both providers and the healthcare system. To date, interventions targeting medication adherence have produced only modest success. Multi-modal interventions have shown the most promise in improving adherence, but require the clinical personnel to manage and coordinate multiple intervention components.
    Date: June 16, 2009
  • Factors Associated with Antibiotic Prescribing for Likely Non-Bacterial Respiratory Infections
    This study sought to identify patient and provider factors associated with prescribing antibiotics for emergency department (ED) outpatients with acute respiratory infections of likely non-bacterial etiology. Findings show that antibiotic use varied substantially between the two VAMCs studied and was particularly high for acute bronchitis (97% and 65%). Overall, 26% of the Veterans with upper respiratory infections (URIs) and/or acute bronchitis received antibiotics: 78% for acute bronchitis only, 57% for both infections, and 16% for URIs only. The following factors were associated with prescribing antibiotics for infections of likely non-bacterial etiology: presence of one or more comorbidities, fever, purulent sputum, shortness of breath, altered breath sounds, diagnosis of acute bronchitis, as well as non-internal medicine provider specialty and provider age older than 30.
    Date: June 1, 2009
  • Physicians More Likely than Mid-Level Providers to Initiate Treatment Change for Veterans with Diabetes and Elevated Blood Pressure
    This study sought to examine whether treatment change for Veterans with diabetes and elevated blood pressure (BP) differed between physicians and mid-level providers (nurse practitioners, physician assistants), and to determine reasons for any observed differences. Findings show that mid-level providers were significantly less likely than physicians to change BP treatment for Veterans with diabetes and multiple chronic conditions, even after controlling for a number of patient, provider, and organizational characteristics. For example, after controlling for visit factors, provider practice style, measurement and organizational factors, mid-level providers were still less likely than physicians to initiate treatment change (37.5% vs. 52.5%) for elevated BP. Investigators also note that a fairly comprehensive set of potential explanatory variables did not account for any of the differences between physicians and mid-level providers.
    Date: June 1, 2009
  • Inhaled Corticosteroids Associated with Higher Glucose Levels in Veterans with Diabetes, but Effect was Dose-Dependent
    This study examined the association between inhaled corticosteroids and glucose concentration among Veterans who received care at seven VA primary care clinics between 12/96 and 5/01. Of the 1,698 Veterans in this study, 19% also had self-reported diabetes. Findings show that after controlling for systemic corticosteroid use and other potential confounders, no association was found between inhaled corticosteroids and serum glucose for Veterans without diabetes. However, among Veterans with diabetes, every additional 100 mcg of inhaled corticosteroid dose was associated with increased glucose concentration. Given this association, authors suggest that clinicians anticipate an increase in serum glucose for patients with diabetes who are using inhaled corticosteroids and adjust serum glucose monitoring accordingly.
    Date: May 1, 2009
  • Adapting Pharmaceutical Company Strategies to Improve Physician NSAID Prescribing Behaviors
    This study sought to describe the social and communicative strategies that pharmaceutical companies use to influence non-steroidal anti-inflammatory drug (NSAID) prescribing behaviors – and to elicit physicians’ perceptions and counterbalances to these strategies. Physicians described several strategies used by pharmaceutical companies to influence their NSAID prescribing behaviors, including detailing and direct contact with pharmaceutical representatives, requests from patients inspired by direct-to-consumer advertisements, and marketing during formative medical school and residency training. Practice guidelines and peer-reviewed evidence, as well as local physician experts were viewed as important counterbalances to the influence of pharmaceutical companies.
    Date: April 1, 2009
  • Diffusion of New Drug Therapy for PTSD Lessens with Distance
    This study sought to evaluate the pace and reach of the passive dissemination of a novel, but as yet un-established treatment with the drug prazosin for post-traumatic stress disorder (PTSD) within the VA health care system. Investigators used geographic surveillance data to track the diffusion of prazosin to treat Veterans diagnosed with PTSD in the VA Puget Sound Healthcare System (where the treatment was developed), and at VAMCs ranging up to 2500 miles or farther from Puget Sound. Findings show that the passive diffusion of a new treatment can be rapid in the immediate area in which it is developed, but the geographic gradient of use seems to be steep and changed little during a two-year period, even when cost and organizational barriers were minimal. Veterans with PTSD treated in the area nearest to Puget Sound (<499 miles) were about 63% less likely in 2004 and about 49% less likely in 2006 to be prescribed prazosin than their counterparts treated within Puget Sound. These results suggest that if and when new treatments are definitively demonstrated to be effective, more active dissemination is likely to be needed, especially in geographically remote areas.
    Date: April 1, 2009
  • Neither Warfarin nor Clopidogrel Superior to Aspirin as Antiplatelet Therapy for Chronic Heart Failure
    The Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) Trial was conducted to determine the optimal anti-thrombotic agent for heart failure patients with reduced ejection fraction who are in sinus rhythm. WATCH Trial findings do not support the primary hypotheses that warfarin or clopidogrel is superior to aspirin. For the primary combined outcome of mortality, non-fatal MI, or non-fatal stroke, major differences between anticoagulation with warfarin and anti-platelet therapy with aspirin or clopidogrel are unlikely. Warfarin was associated with fewer non-fatal strokes than aspirin or clopidogrel, but also was associated with more frequent bleeding episodes compared to clopidogrel, and a non-significant excess of bleeding compared to aspirin.
    Date: March 31, 2009
  • Primary Care-Based Collaborative Care for Chronic Pain May Be More Effective than Usual Care
    A primary care-based collaborative care intervention for chronic pain was significantly more effective than usual care across a variety of outcome measures, including pain disability and intensity. However, these improvements were generally modest. Depression severity and pain disability and intensity improved among Veterans in the intervention group who reported both chronic pain and depression. Greater use of adjunctive pain medications and long-term opioids among the intervention group suggested that the intervention contributed to the delivery of guideline-concordant care.
    Date: March 25, 2009
  • Concomitant Use of Clopidogrel and Proton-Pump Inhibitors after ACS is Associated with Higher Risk of Adverse Outcomes
    Proton-pump inhibitors (PPI) were frequently prescribed with clopidogrel (63.9%) for Veterans following hospitalization for acute coronary syndrome (ACS); the concomitant use of clopidogrel and PPI was associated with a higher risk of adverse outcomes compared to the use of clopidogrel alone. The combined primary outcome of mortality or re-hospitalization occurred in 20.8% of Veterans prescribed clopidogrel only, and in 29.8% of Veterans prescribed clopidogrel and PPI. Among secondary outcomes, Veterans taking clopidogrel and PPI also had a higher risk of recurrent hospitalization for ACS and revascularization procedures. Longer duration of clopidogrel plus PPI treatment was associated with adverse outcomes, suggesting that time on combination treatment is important. Pending further studies to confirm results and prospectively assess cardiovascular outcomes for Veterans taking clopidogrel and PPI versus clopidogrel alone, these results may suggest that PPIs should be used for patients with a clear indication for the medication, rather than prophylactically.
    Date: March 4, 2009
  • Research Agenda for Oral Anticoagulation Quality Measurement
    Efforts to measure the quality of oral anticoagulation care have focused disproportionately on the identification of ideal candidates for warfarin therapy, with little effort in measuring the quality of oral anticoagulation once therapy has begun. To address this knowledge gap, investigators propose a research agenda to advance our understanding of how to measure the quality of care in oral anticoagulation. Authors propose that valid quality indicators will provide a framework for quality improvement that will maximize the effectiveness of therapy and minimize patient harm.
    Date: March 1, 2009
  • Panel Reaches Consensus on Oral Dosing for Primarily Renally Cleared Medications in Older Adults
    Chronic kidney disease (CKD) is a growing public health problem that disproportionately affects older adults. Medications are the most frequently used therapy for the management of CKD-related problems in older adults, but they are often prescribed in inappropriate doses. This study sought to establish consensus dosing guidelines for primarily renally cleared oral medications commonly taken by older adults with renal insufficiency. An expert panel was able to reach consensus agreement on 18 oral medications that are primarily renally cleared, including anti-infectives and central nervous system medications.
    Date: February 1, 2009
  • Prescribing Discrepancies during Patient Transfer May Result in Adverse Drug Events
    The objective of this study was to examine medication discrepancies related to adverse drug events (ADEs) in nursing home patients transferred to and from the hospital. Findings show that less than 5% of discrepancies caused ADEs, which is consistent with reviews that suggest only a small fraction of errors result in harm. Authors note that information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients, and inform the development of decision-support tools at the time of patient transfer.
    Date: February 1, 2009
  • Increase in VA Prescription Co-Pay Leads to Decrease in Adherence to Statins for Veterans at Risk of Heart Disease
    VA’s increase in drug co-payments from $2 to $7 adversely affected lipid-lowering medication adherence among Veterans, including those at high risk of coronary heart disease. After the increase in medication co-payments, the percent of Veterans who were adherent to lipid-lowering therapy declined significantly, even for Veterans with no co-pay. The co-payment increase was also accompanied by a significant increase in the likelihood of having continuous gaps in lipid-lowering medication use.
    Date: January 27, 2009
  • Lessons Learned from Deceptive Marketing of Neurontin™
    Recent lawsuits alleging injury from the illegal marketing of gabapentin (Neurontin™) have yielded remarkable discoveries about the structure and function of pharmaceutical marketing. This article summarizes the marketing tactics used and offers actions to prevent similar occurrences.
    Date: January 8, 2009
  • Study Suggests Changes Needed in Warfarin Dosing
    The lack of evidence regarding optimal management strategies for warfarin probably contributes to limited success in maintaining patients within the target International Normalized Ratio (INR) range (system used to report testing for coagulation). Findings from this study show that providers vary widely in their dose change thresholds in similar clinical situations and that the INR value was by far the most important predictor of dose change. Authors suggest that in addition to offering warfarin to as many optimal candidates as possible, we also need to optimize warfarin dose management to fully realize the benefits of anticoagulation.
    Date: January 1, 2009
  • ACE Inhibitors May Benefit Patients with Pneumonia
    Prior outpatient use of lipophilic, but not hydrophilic ACE inhibitors was associated with decreased 30-day mortality for patients hospitalized with community-acquired pneumonia. Study results also provide further support demonstrating that ACE inhibitor use, in general, is associated with decreased mortality for patients with pneumonia.
    Date: December 1, 2008
  • Controlling Medicare Costs: Study Suggests VA-Administered Drug-Only Benefit for Veterans Enrolled in Medicare
    This article discusses the role of interest groups in drug-plan policy differences between Medicare and VA. Authors suggest a partnership between Medicare and VA that could provide access to the VA drug benefit to a large number of Medicare-enrolled veterans who do not currently have it.
    Date: December 1, 2008
  • Treatments for Co-Occurring Schizophrenia and Substance Use Disorders
    While studies to date suggest better outcomes with second-generation antipsychotics (SGAs), for example, olanzapine and risperidone, the available evidence does not clearly demonstrate an advantage for any particular SGA; thus investigators recommend that clinicians select the medication that balances efficacy and side effects for each individual patient.
    Date: October 1, 2008
  • Veteran Perceptions of In-Home Medication Dispensing Devices
    No significant differences were found across types of devices in the perceived likelihood that using the device would improve medication adherence. Moreover, even if VA paid for the devices, patient participants reported that they would be unlikely to use them.
    Date: July 1, 2008

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background-image  Mental Health

  • A Positive Psychological Intervention Improves Outcomes for Veterans with Knee or Hip Osteoarthritis
    This study sought to determine whether patients randomized to a program designed to boost positive affect and develop positive psychological skills (e.g., gratitude and kindness) would report greater improvements over time in osteoarthritis (OA) symptom severity and measures of psychosocial well-being compared with patients randomized to a neutral control program. Findings showed that the 6-week positive psychological intervention produced large reductions in OA symptom severity, decreased negative affect, and increased life satisfaction compared to a robust control program among Veterans with knee or hip osteoarthritis. Retention through both 6-week programs was high, with 79% of participants completing at least 5 of 6 weekly calls and 64% reporting that they completed 80% or more of their weekly activities. Participants rated the activities as highly beneficial, highly enjoyable, and low in difficulty. Results indicate the potential of a non-pharmacological therapy to improve symptom management in this population with moderate to severe pain and suggest that using positive activities as part of an overall treatment program for patients with OA could have a large impact.
    Date: June 27, 2017
  • Delivery of Brief Cognitive Behavioral Therapy in Primary Care Improves Mental Health Symptoms in Chronically Ill Veterans
    This trial sought to determine whether an integrated brief cognitive behavioral therapy (bCBT) intervention would improve depression, anxiety, and quality of life for medically ill Veterans. Findings showed that integrated bCBT resulted in significant immediate and 12-month improvements related to depression and anxiety. Brief CBT also resulted in significant short-term improvements related to physical health quality of life for Veterans with chronic lung conditions. Delivery of bCBT in VA primary care clinics resulted in Veterans receiving an average of 3.9 sessions with high levels of Veteran engagement (84% receiving care) and treatment completion (63% with 4 or more sessions). Veterans and VA providers reported very high satisfaction with bCBT.
    Date: June 20, 2017
  • Systematic Review of Suicide Risk Assessment and Prevention
    This systematic review evaluated studies assessing the accuracy of methods to identify individuals at increased risk for suicide, and the effectiveness and adverse effects of healthcare interventions relevant to Veteran and military populations in reducing suicide and suicide attempts. Findings showed that suicide rates were reduced in 6 of 8 observational studies of various types of multiple-component population-level interventions, including two studies in Veteran and military populations. Only 2 of 10 trials of individual-level psychotherapy reported statistically significant differences between treatment and usual care, however, most trials were inadequately designed to detect differences. No studies described the adverse effects of risk assessment methods or interventions for suicide prevention. Risk assessment methods are sensitive predictors of subsequent suicide and suicide attempts in studies, but the frequency of false positives limits their clinical utility. Future research should continue to refine these methods and examine their clinical applications.
    Date: June 15, 2017
  • Factors Associated with Suicide within One Week of Discharge from VA Psychiatric Facilities
    To better understand system and organizational factors associated with post-discharge suicide, this study reviewed root-cause analysis (RCA) reports of death by suicide within seven days of discharge from all VA inpatient mental health units between FY2002 and FY2015. Findings showed that risk for suicide in the week following hospital discharge may be highest during the first few days after discharge. There were 141 reports of suicide within seven days of discharge: 40% occurred during the first day of discharge; 67% within 72 hours of discharge, and nearly 80% within four days of discharge. Further, 43% of suicides followed an unplanned discharge. Root causes for suicide fell into three major categories: 1) challenges for clinicians and patients following the established process of care, 2) awareness and communication of suicide risk, and 3) flaws in the established process of care. No association was found between length of hospital stay and days to suicide. Authors suggest that current VA policies mandating mental health follow-up within 7 days of discharge may be insufficient and that other methods of intervention to better reach this vulnerable patient population may need to be considered (e.g., tele-monitoring). The authors also suggest that inpatient teams be aware of the potentially heightened risk for suicide in patients whose discharge is unplanned.
    Date: June 1, 2017
  • Meta-Analysis of Interventions to Prevent Suicide
    This study conducted a meta-analysis of randomized controlled trials (RCTs) that compared the efficacy of various interventions versus control to prevent death by suicide among adults. Of the studies included in this review, 29 RCTs reported on complex psychosocial interventions, with 3 reporting on the WHO Brief Intervention and Contact (BIC) intervention, which includes an educational session on suicide prevention followed by regular contact with a trained provider (phone or in-person) for up to 18 months. The WHO BIC intervention was associated with significantly lower odds of death by suicide. No other suicide prevention intervention showed a statistically significant effect in reducing death by suicide.
    Date: June 1, 2017
  • Study Identifies which VA Mental Health Program Characteristics are Associated with Patient Satisfaction
    This study examined the relationships between a set of patient satisfaction measures and a large collection of mental health program characteristics for Veterans with a recent mental health encounter in the VA healthcare system. Findings showed that broad measures of mental healthcare program reach (i.e., proportion of patients served) and intensity (i.e., number of visits) – and nearly all measures of treatment continuity were consistently and positively associated with patient satisfaction. More narrow performance measures – those that focus on specific diagnostic populations (e.g., those with PTSD and serious mental illness) – were less likely to be positively associated with satisfaction. Satisfaction with access to VA healthcare among Veterans with mental health conditions was higher than satisfaction with care encounters.
    Date: May 19, 2017
  • Current Diagnosis of PTSD is Risk Factor for Pregnant Women
    This analysis evaluated the associations between PTSD and antepartum complications to explore how PTSD’s pathophysiology impacts pregnancy in a large cohort of women Veterans. Findings showed that a current diagnosis of PTSD increases the risk of hypertensive/ischemic placental complications of pregnancy, specifically preeclampsia, and is a risk factor for gestational diabetes. PTSD also was associated with an increased risk of prolonged (>4 day) delivery hospitalization and repeat hospitalization. Authors suggest that pregnancies in women with currently active PTSD should be identified as potentially high-risk, high-need pregnancies.
    Date: May 1, 2017
  • Quality Improvement Tool Shows Organizational Factors Related to Access and Quality Measures in VA Mental Healthcare
    This study analyzed performance on measures included in the Mental Health Management System (MHMS) – a performance data and quality improvement tool used by VA to increase the value of mental healthcare for Veterans. The MHMS quality improvement tool showed that organizational factors were associated with performance on key access and quality measures related to VA mental healthcare. Better access was associated with higher staff-to-patient ratios for psychiatrists and other outpatient mental health providers, and with lower mental health provider staffing vacancies. Higher mental health staff-to-patient ratios were associated with higher performance on nearly all patient and provider satisfaction measures. Higher continuity of care was associated with lower no-show rates to appointments, better wait times, higher staff-to-patient ratios, lower mental health provider vacancies, and more space available for clinical work. Over the past decade, VA’s mental health population has grown rapidly compared to its overall patient population (71% vs. 21%, respectively), so these findings are important in showing that MHMS is a robust informatics and quality improvement tool that can serve as a model for health systems planning to adopt a value perspective.
    Date: February 1, 2017
  • “Virtual Hope Box” Smartphone App Helps Veterans Regulate Emotion and Cope with Distress that Can Lead to Suicide
    Investigators in this study developed a smartphone app, Virtual Hope Box (VHB), to provide a portable and easily accessed suite of tools to enhance coping self-efficacy. They then assessed the impact of VHB on stress coping skills, suicidal ideation, and perceived reasons for living in patients at elevated risk of suicide and self-harm. Findings showed that VHB users reported significantly greater ability to cope with unpleasant emotions and thoughts (i.e., coping, self-efficacy) at 3 and 12 weeks compared with Veterans in the control group. There was no significant advantage of treatment augmented by the VHB for other outcome measures. The most frequently cited reasons for using VHB by Veterans were for distress, when emotions were overwhelming, when they felt like hurting themselves, and for relaxation, distraction, and/or inspiration. Data suggested that clinicians appreciated the VHB's capacity to serve as an additional therapeutic tool – and valued the fact that the VHB served to reinforce patients' existing coping skills and gave them an outlet to practice these skills. Because the Virtual Hope Box smartphone app is easily disseminated across a large population of users, investigators believe it has broad, positive utility in behavioral healthcare.
    Date: November 15, 2016
  • Lithium or Valproate Associated with Better Outcomes Compared to Second-Generation Antipsychotics for Bipolar Disorder
    This study assessed a nationwide population of Veteran outpatients with bipolar disorder treated at VAMCs, who were newly initiated on an antimanic agent between 2003 and 2010. The primary outcome was likelihood of all-cause hospitalization during the year after initiation. Findings showed that after extensive control for covariates, initiation of lithium or valproate alone – compared to initiation of an second-generation antipsychotic (SGA) alone – was associated with a significantly lower likelihood of all-cause hospitalization, a longer time to hospitalization, and fewer hospitalizations in the subsequent year. Veterans receiving combination treatment (i.e., SGA + lithium, SGA + valproate) had a significantly higher likelihood of hospitalization, although they also had a longer time to addition of another antimanic agent or antidepressant. Among monotherapies, the only significant differences were found in psychosis, with it being more likely in those initiated on SGAs rather than those initiated on lithium, valproate, or carbamazepine/oxcarbazepine.
    Date: September 1, 2016
  • Higher Risk of Suicidal Ideation among Veterans Seeking Mental Health Treatment from both VA and non-VA Facilities
    VA researchers developed the Veterans Health Module (VHM) to be implemented within the Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS). This report presents data from the 2011-2012 VHM telephone survey. Findings showed that after adjusting for sociodemographic and VHM variables, Veterans who sought mental health treatment from both VA and non-VA facilities had more than four-fold increased odds of suicidal ideation than Veterans who sought mental health treatment from VA facilities only. Overall, 5% of the study cohort reported recent suicidal ideation, and 1% reported attempting suicide. There were no sex differences in prevalence of suicidal ideation or attempt. In the overall sample, lifetime diagnosis of depression, anxiety, or PTSD was the strongest correlate of both suicidal ideation and attempt.
    Date: June 24, 2016
  • Racial and Ethnic Differences in Primary Care Experiences for Veterans with Mental Health and Substance Use Disorders
    This study examined racial and ethnic differences in positive and negative experiences in VA Patient-Centered Medical Home (PCMH) settings among Veterans with mental health or substance use disorders (MHSUDs) who completed VA’s 2013 PCMH Survey of Healthcare Experiences of Patients. Findings showed that positive experiences were reported least often for access. Negative experiences were reported most often for self-management support and comprehensiveness, defined as provider attention to MHSUD concerns. One or more racial/ethnic minority groups reported more negative and/or fewer positive experiences than Whites in the following 4 domains: access, communication, office staff helpfulness/courtesy, and comprehensiveness. Solutions are needed to improve access to care for all Veterans with MHSUDs, with additional attention on improving access for Black, Hispanic, and AI/AN Veterans.
    Date: June 20, 2016
  • Barriers and Facilitators to Use of Clozapine for Treatment-Resistant Veterans with Schizophrenia
    This study sought to identify facilitators and barriers to clozapine use – and to inform the development of interventions to maximize appropriate use. Findings showed that factors associated with high utilization of clozapine for Veterans with schizophrenia included: providing access to transportation for Veterans; having sufficient capacity to enroll patients; use of multi-disciplinary teams, including non-physician providers; better coordination of care through mental health intensive case management (MHICM) or clozapine clinics; and creation of systems to reduce reliance on too few individuals. Factors associated with low utilization of clozapine included lack of champions to support clozapine processes and limited-capacity care systems. Barriers identified at both high- and low-utilization facilities included time-consuming paperwork, reliance on few individuals to facilitate processes, and issues related to transportation for Veterans living far from VA care facilities.
    Date: June 15, 2016
  • Use of Clozapine for Veterans with Treatment-Resistant Schizophrenia Could Result in Significant Cost Savings
    This cost-benefit analysis sought to simulate potential cost savings for VA that would result from increasing the use of clozapine among Veterans with treatment-resistant schizophrenia. Findings showed that modest increases in clozapine use could result in significant cost savings for VA. Among Veterans with treatment-resistant schizophrenia, VA would save $22,444 per Veteran over the first year of treatment, primarily from 18.6 fewer inpatient hospitalization days per patient. Given this finding, if current clozapine use was doubled from 20% of patients with treatment-resistant schizophrenia to 40%, VA would accrue an estimated cost savings of $80 million over the first year. Moreover, full utilization of clozapine would save VA $320 million over the first year. Findings suggest VA should strongly consider initiatives to substantially increase clozapine use among Veterans with treatment-resistant schizophrenia. Deaths from clozapine-related adverse events are more than balanced out by decreased incidence of suicide attempts, with a net result of slightly fewer deaths with increased use of clozapine.
    Date: June 15, 2016
  • Prescription Opioid Use among Patients with Recent History of Depression Increases Risk of Recurrence
    This study examined whether patients in depression remission who were prescribed opioids for non-cancer pain had an increased risk of depression recurrence. Investigators analyzed two patient populations: Veterans treated in the VA healthcare system, and patients treated by a non-profit integrated healthcare system located in Texas. Findings showed that prescription opioid use among patients with a recent history of depression increased the chance of depression recurrence, and this effect was independent of pain diagnoses and pain intensity scores. Patients with remitted depression who were exposed to opioid analgesics at any point during the follow-up period were 77% to 117% more likely to experience a recurrence of depression than those who remained opioid free, after controlling for other factors. Among VA patients with depression remission, those who received opioids during follow-up were younger, had more psychiatric comorbidities, and had more painful conditions and higher pain scores than those who didn’t receive opioids.
    Date: April 1, 2016
  • Prescription Use of Codeine Associated with Greater Risk of New Onset Depression among Veterans
    This study sought to determine whether the hazard of new depression diagnosis differs among VA patients prescribed only codeine, only hydrocodone, or only oxycodone. Findings showed that Veterans prescribed only codeine for 30 days or longer had a 29% increased risk of a new diagnosis of depression compared to Veterans prescribed only hydrocodone for 30 days or longer. Those prescribed only oxycodone for 30 days or longer were not significantly more likely to develop a new depression diagnosis compared to patients prescribed hydrocodone only. Opioid use of 30-90 days was most common among oxycodone users, and opioid use of more than 90 days was most common among hydrocodone users. The distribution of individual comorbid conditions did not significantly differ across the three types of opioids.
    Date: March 22, 2016
  • Central Nervous System Polypharmacy May Increase Risk of Overdose and Suicide-Related Behavior among OEF/OIF Veterans
    This study examined the prevalence of central nervous system (CNS) polypharmacy and its association with drug/alcohol overdose and suicide-related behaviors in a national cohort of OEF/OIF Veterans. Findings showed that of the Veterans in this study, 8% had received five or more CNS-acting medications in 2011. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI – and was independently associated with overdose and suicide-related behaviors after controlling for known risk factors. Women and Veterans between ages 31 and 50 years were more likely to have CNS polypharmacy. Findings suggest that CNS polypharmacy may be used as a “trigger tool” to identify individuals who may benefit from referral to a tailored inter-disciplinary treatment team comprised of experts from relevant fields. Ideally, these teams would work together to optimize medication profiles and treatment plans, and to examine non-pharmacological treatment options.
    Date: March 1, 2016
  • Factors Associated with VA and Non-VA Mental Health Service Use among National Guard Soldiers
    This study sought to determine the associations between mental health need, enabling, and predisposing factors and mental health service use among National Guard soldiers in the first year following a combat deployment to Iraq or Afghanistan. Findings showed that overall mental health service use was strongly associated with need, including higher number of mental health conditions and worse physical health. Among those using services, predisposing factors (middle age and female gender) and enabling factors (employment, income greater than $50,000, and private insurance) were associated with greater non-VA service use. Among the survey respondents reporting mental health treatment in the prior 12 months, 81% received any VA treatment and 19% received only non-VA treatment. Approximately 30% of those receiving VA treatment also had received treatment from a non-VA source.
    Date: February 3, 2016
  • Mental Health Conditions Common among Patients Seeking and Undergoing Bariatric Surgery
    This systematic review had three aims: 1) to estimate the prevalence of mental health conditions among bariatric surgery candidates and recipients; 2) to evaluate the association between preoperative mental health conditions and weight loss after surgery; and 3) to evaluate the association between surgery and the clinical course of mental health conditions. Findings showed that mental health conditions are common among patients seeking and undergoing bariatric surgery, particularly depression and binge-eating disorder (BED). Prevalence estimates for mood disorders (22%), depression (19%), and BED (17%) were higher than published rates for the general U.S. population, (10%, 8%, and 1-5%, respectively) suggesting that special attention should be paid to these conditions among bariatric patients. There was moderate-quality evidence to support an association between bariatric surgery and lower rates of depression post-operatively. Depression improved following surgery in 11 of the 12 studies, including two randomized controlled trials evaluating preoperative behavioral health interventions.
    Date: January 12, 2016
  • Increased Dose of Prescription Opioids Raises Risk of Suicide among Veterans with Chronic Non-Cancer Pain
    This study examined the association between prescribed opioid dose and suicide in a national sample of VA patients with a chronic non-cancer pain condition who received opioid therapy. Findings showed that increased dose of opioids was found to be a marker of increased suicide risk, even when relevant demographic and clinical factors were statistically controlled. Type of opioid dosing schedule (i.e., regularly scheduled, as needed, or both) did not significantly affect suicide risk after accounting for other factors. Similar to the U.S. population and other large studies of VA patients, the vast majority of suicides involved firearms (64%), with overdose accounting for 20% of all suicides.
    Date: January 5, 2016
  • Veterans Exiting Prison Have Extensive Treatment Needs, Particularly for Mental Health and Substance Use Issues
    This study determined incarcerated Veterans’ contact with VA healthcare in the year after a Health Care for Reentry Veterans (HCRV) visit (prior to release from prison), the prevalence of mental health and substance use disorder (SUD) diagnoses, and rates of mental health or SUD treatment entry and engagement in the first month after diagnosis. Findings showed that of the Veterans with an HCRV outreach visit, 56% had contact with VA healthcare within one year, including primary care, mental health or SUD treatment, or other VA services. Among Veterans with an HCRV outreach visit who had contact with VA healthcare, 69% were diagnosed with at least one mental health or substance use disorder, and 35% were diagnosed with co-occurring mental health and substance use disorders. The three most common disorders were depressive disorders, alcohol use disorder, and PTSD. Of Veterans diagnosed with a mental health disorder, 77% entered mental health treatment in the first month after diagnosis and 28% engaged in treatment. At one year after diagnosis, 93% of Veterans had entered and 52% had engaged in mental health treatment. Of those Veterans diagnosed with a SUD, 37% entered and 24% engaged in SUD treatment in the first month, while 57% had entered and 39% engaged in treatment at one year following diagnosis.
    Date: December 21, 2015
  • Sexual Trauma during Military Service Increases Risk of Subsequent Suicide among Veterans
    This was the first large-scale, population-based study of sexual trauma and suicide mortality that examined risks associated with military sexual trauma (MST) among both male and female Veterans receiving VA care. Findings showed that women and men who reported MST had an increased risk of suicide, and MST remained an independent risk factor even after adjusting for other known risk factors for suicide among Veterans, including mental health conditions, medical morbidity, and demographic characteristics. Among Veterans who reported MST, those who died by suicide were significantly more likely to be treated for mental health conditions determined by their provider to be related to MST experiences: men 50% vs. 36%, and women 67% vs. 48%. Overall, 2% of the Veterans in this study reported MST when screened (1% of men, and 21% of women), with 97% reporting no MST, and 0.3% declining to complete the screen.
    Date: December 14, 2015
  • Telemedicine-Delivered Psychotherapy for Older Veterans with Depression as Effective as In-Person Psychotherapy
    This study assessed the efficacy of psychotherapy delivered to older Veterans via telemedicine in their homes. Findings showed that telemedicine-delivered psychotherapy for older Veterans with major depression produced outcomes that were no worse than in-person treatment delivery. Treatment response did not differ significantly between the telemedicine and same-room therapy groups on any of the instruments used. A high proportion of Veterans were rural residents (71%) and average session attendance was high (81% of Veterans in the telemedicine group completed all 8 sessions as did 79% of Veterans in the same-room group).
    Date: August 1, 2015
  • Substantial Proportion of Homeless and Unstably Housed Veterans with Minor Children has Serious Mental Illness
    This study examined the prevalence of homeless and unstably housed Veterans with minor children and compared sociodemographic characteristics, as well as medical and mental health conditions of homeless and unstably housed Veterans with and without children. Findings showed that unstably housed Veterans were more likely to have children than homeless Veterans, and women more likely than men. Among both homeless and unstably housed male Veterans with minor children, only about one-third to one-half had custody of their minor children, whereas among women, nearly all had custody of their minor children. Both homeless male and female Veterans with children were younger and less likely to have chronic medical conditions and psychiatric disorders than their homeless counterparts. However, 72% of male and 67% of female Veterans with children had a psychiatric diagnosis, and 11% of both men and women were diagnosed with a psychotic disorder. Men also were more likely to have PTSD and other anxiety disorders compared to male Veterans without children. Veterans with minor children were more likely to be referred and admitted to VA’s permanent supported housing program than other Veterans, and women with minor children in their custody were even more likely to be referred and admitted than men. Rates of referrals to mental health services were relatively low (22% and 25% for Veterans with and without children, respectively) given the high prevalence of psychiatric diagnoses in the sample.
    Date: May 15, 2015
  • Increasing VA Rates of Psychotherapy among Rural- and Urban-Dwelling Veterans with Mental Illness
    This retrospective study evaluated changes in rural-dwelling Veterans’ use of psychotherapy during a period of widespread organizational efforts to engage this patient population in mental health service use – and compared their use of psychotherapy with urban-dwelling Veterans. Findings showed that VA psychotherapy use is increasing among both urban- and rural-dwelling Veterans with a new diagnosis of depression, anxiety, or PTSD. Over the four-year study period, the proportion of Veterans receiving any psychotherapy increased from 17% to 22% for rural Veterans and 24% to 28% for urban Veterans. With respect to psychotherapy dose, the proportion of both rural- and urban-dwelling Veterans receiving 4+ and 8+ psychotherapy sessions increased from 2007 to 2010. And although rural-dwelling Veterans received, on average, fewer psychotherapy sessions than urban-dwelling Veterans, this gap decreased over time. By 2010, the mean number of sessions attended by rural Veterans (5 sessions) was only 1 session less than their urban counterparts (6 sessions). Rates of PTSD diagnosis were higher among urban-dwelling Veterans, whereas rates of depression and anxiety were higher among rural-dwelling Veterans.
    Date: December 3, 2014
  • Characteristics Associated with Suicide among Male Veterans Treated in VA Primary Care
    This study sought to identify characteristics of Veterans who received VA primary care in the six months prior to suicide (in 2009) – and compare these to control patients who also received primary care at the same 41 VA facilities in 11 geographically diverse states. Findings showed that compared to controls, Veterans who died by suicide were significantly more likely to be unmarried, white, and to have major depression, bipolar disorder, anxiety disorder other than PTSD, and/or an alcohol or other substance use disorder diagnosis. Veterans who died by suicide also were more likely to have documented functional decline, sleep disturbance, expressions of anger, and suicidal ideation. The odds of dying by suicide were greatest among Veterans with anxiety disorder diagnoses and functional decline. A diagnosis of PTSD was not significantly associated with suicide, nor was a pain diagnosis or general medical comorbidity. Also, non-white race and a VA service-connected disability rating were associated with decreased odds of suicide. The assessment of anxiety disorders and functional decline, in particular, may be important for determining suicide risk among Veterans. The authors suggest continued development of interventions that support identifying and addressing these conditions in primary care.
    Date: December 1, 2014
  • Rates of Suicide Higher among Transgender Veterans
    This study sought to document all-cause and suicide mortality among VA healthcare users with an ICD-9-CM diagnosis consistent with transgender status. Findings showed that the crude suicide rate among Veterans with transgender-related diagnoses across the 10-year study period was approximately 82/100,000 person-years, which approximated the crude suicide death rates for Veterans with serious mental illness (e.g., depression, schizophrenia). However, this rate was higher than in both the general VA and U.S. populations. Comparisons of age at time of death suggest Veterans with transgender-related diagnoses may be dying by suicide at younger ages than Veterans without such diagnoses. The average age of transgender Veterans at the time of death by suicide was 49 years compared with studies that show the average age of death among non-transgender Veterans who die from suicide was between 55 and 60 years. Diseases of the circulatory system and neoplasms were the first and second leading causes of death among transgender Veterans, however, the other ranked causes of death differed somewhat from patterns among the general U.S. population for the same time period. For example, certain infectious and parasitic diseases were the 6th leading cause of death among transgender Veterans, whereas they ranked 9th among the general U.S. population. Authors suggest future research is needed to examine how transgender Veterans seek or receive mental health services and that programs aimed at suicide prevention may benefit from clinical education and training about transgender populations.
    Date: December 1, 2014
  • Study Highlights Mental Health Services Important to Women Veterans
    Investigators in this study identified a subset of women Veteran primary care users who were potential stakeholders for mental health services, and then quantified their priorities for these services. Treatment for depression, pain management, coping with chronic conditions, sleep problems, weight management, and PTSD emerged as the top six mental healthcare priorities for women. The majority of women Veterans in this study (98%) selected at least one of these services as important, and 80% selected at least three of these six services as important. The majority of women who prioritized each of these six services reported that they had either used this type of service in the past year or were quite a bit or extremely likely to use the service within the next six months, ranging from 62% for weight management to 96% for chronic conditions. Findings suggest that women’s primary care clinics, which are available at many VA healthcare facilities, are a strategic setting to enhance the implementation of women’s health services through primary care-mental health integration.
    Date: November 17, 2014
  • Gender Differences in Attitudes and Their Relationship to VA Mental Healthcare Use
    This study explored gender differences in attitudinal barriers to and facilitators of care for OEF/OIF Veterans, and determined the relationship of those factors to VA mental health service use among female and male Veterans with probable mental health conditions. Findings showed that Veterans were similar in their perceptions of VA healthcare and their perceived fit within the VA healthcare setting. Men held slightly more negative attitudes about mental illness and treatment than women. For both women and men, perceived entitlement to VA care was associated with increased likelihood of service use, and negative beliefs about treatment seeking (e.g., a problem would have to be really bad to seek mental health treatment) were associated with a reduced likelihood of seeking mental healthcare in the past six months. For female Veterans only, positive perceptions of VA healthcare were associated with increased likelihood of seeking VA mental health treatment. For male Veterans only, researchers found a positive relationship between VA service use and negative attitudes toward mental health treatment (e.g., mental health treatment does not work). Perceived similarity to other VA healthcare users was also associated with increased likelihood of service use, while negative beliefs about mental illness (e.g., people with mental health problems are violent or dangerous) were associated with lower likelihood of service use.
    Date: November 3, 2014
  • JGIM Supplement Highlights VA’s Partnered Research
    In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management, suicide prevention, homelessness, medical home models, and communication of adverse events.
    Date: November 1, 2014
  • Predictors of Worsening Mental Health among OEF/OIF Veterans
    This study sought to identify predictors of worsening mental health, including PTSD and alcohol use, as well as variables that are protective (resilience factors) against worsening mental health in a national sample of OEF/OIF Veterans. Findings showed that 14–25% of these returning OEF/OIF military personnel showed clinically worse mental health, PTSD, or alcohol use at 6-month follow-up. Eleven variables were significantly associated with a decline in overall mental health status from Time 1 to Time 2: Black race, being in the National Guard, more bothersome physical health problems, worse mental health at Time 1, less PTSD symptom severity, lack of psychiatric care between Time 1 and Time 2, more difficult deployment environment, less perceived threat, less sexual harassment, higher levels of hardiness, and lower levels of self-efficacy. Nine variables predicted a worsening of PTSD symptom severity: being younger than 26 years old, unemployed, divorced or separated, higher PTSD symptom severity at Time 1, lack of any psychiatric treatment between Time 1 and Time 2, difficult childhood family environment, greater sexual harassment in one’s unit, lower levels of deployment preparedness, and higher levels of post-deployment social support. Fourteen variables predicted worsening alcohol use, including being male, under 26 years old, less educated, Hispanic, separated or divorced, and being in the National Guard or Marines. National Guard and other Reserve soldiers worsened on both the general mental health and alcohol use measures from Time 1 to Time 2 compared to active duty soldiers, suggesting that these groups may require help with reintegration. Higher education, self-efficacy, unit support, and deployment preparedness had a protective effect on both worsening PTSD and alcohol use.
    Date: October 1, 2014
  • Adverse Childhood Experiences More Common among Men with Military Service
    Those with a history of military service may be a specific subpopulation of interest regarding adverse childhood experiences (ACE), as some may enlist to escape personal problems, potentially elevating the prevalence of ACE among military populations. This study sought to compare the prevalence of ACE among individuals with and without histories of military service based on service during the draft era (enlisted prior to 1973) or during the all-volunteer era (enlisted on/after 1973). Findings showed that men with military service during the all-volunteer era had a higher prevalance of all 11 ACE items than men without military service in this era. Notably, men with military service during this era had more than twice the odds of men without military service history of reporting household drug or alcohol abuse while growing up, suffering physical abuse or witnessing domestic violence, or some form of sexual abuse (being touched or being forced to touch, or to have sex before age 18). During this era, men with military service had more than twice the prevalence of experiencing 4 or more ACE categories (27% vs. 13%) compared to those without military service. Markedly fewer differences in ACE were found among women with and without military service histories across either era. Women with military service histories from both eras had similar patterns of elevated odds for physical abuse, household alcohol abuse, exposure to domestic violence, and emotional abuse compared with women without military service. Identifying the presence of ACE among military service members and Veterans may aid in better understanding the etiology of trauma-related mental and behavioral health conditions as well as the cumulative impact of trauma.
    Date: September 1, 2014
  • Providers’ Endorsement of Stigma Regarding Mental Illness Is Related to Patient Treatment Options
    This study examined provider response to two treatment options that might be offered to a male patient with schizophrenia who was seeking help for low back pain due to arthritis: 1) referral for specialist consult, or 2) refilling the patient’s prescription for Naproxen. Findings showed that healthcare providers who endorsed more stigmatizing attitudes about mental illness were likely to be more pessimistic about the patient’s adherence to treatment. Stigmatizing attitudes were greater among those providers who were relatively less comfortable with using mental health services themselves. Greater perceived treatment adherence was positively associated with both health decisions: referrals and prescription refill. Thus, poor perceived adherence was partly a proxy for stigmatizing attitudes providers held about people with mental illness, which in turn led to different treatment decisions in patients with serious mental illness. Providers from mental health backgrounds showed no difference in expectations about treatment response than primary care professionals, suggesting that both primary care and mental health providers should be targets of interventions aimed at decreasing disparities in clinical care.
    Date: August 15, 2014
  • Detection of Suicidal Ideation Not Associated with Increased Mental Health Utilization in Year Following SI Assessment
    This study evaluated the impact of brief suicidal ideation (SI) assessments on mental healthcare use among new-to-care OEF/OIF Veterans. Findings showed that 32% of the Veterans in this study had positive SI assessment results. The detection and presence of suicidal ideation was not associated with subsequent mental healthcare utilization over the following year, when accounting for the severity of depression symptoms. In other words, SI itself was not found to be associated with increased Veteran engagement in specialty mental healthcare over and above depression symptom severity. When a Veteran’s inaugural visit to VA healthcare included a mental health clinician, the Veteran was more likely to attend more subsequent specialty mental health visits – and to receive an antidepressant medication – than Veterans who were seen by a primary care clinician only.
    Date: July 30, 2014
  • Risk Factors for Suicide-Related Behavior among OEF/OIF Veterans with “Polytrauma Clinical Triad”
    The co-occurrence of PTSD, TBI, and chronic pain is known as the “Polytrauma Clinical Triad” (PCT). This study examined the association of these conditions, independently and in interaction with other conditions, with the risk of suicide-related behavior (SRB) among OEF/OIF Veterans. Findings showed that the PCT was a moderate predictor of suicide-related behavior, but did not appear to increase risk for SRB above that associated with PTSD, depression, or substance abuse alone. Moreover, PTSD comorbid with either depression or substance abuse significantly increased risk for suicidal ideation. Veterans with a diagnosis of bipolar disorder, anxiety, substance abuse, schizophrenia, depression, or PTSD were significantly more likely to be diagnosed with all three categories of SRB. Female Veterans were less likely than male Veterans to exhibit suicidal ideation, which contradicts prior research and may suggest that females are less comfortable reporting ideation within VA. Risk for SRB was highest in the 18-25 year old age group.
    Date: July 17, 2014
  • Only Small Percentage of Veterans with Mental Illness Access VA Employment Services
    This study sought to assess the reach of Therapeutic and Supported Employment Services (TSES) over one year by examining the percentage of VA healthcare users with psychiatric diagnoses that accessed any TSES services, as well as specific types of services (i.e., supported employment, transitional work, incentive therapy, and vocational assistance). Findings showed that only a small percentage of Veterans with psychiatric diagnoses (4%) accessed even one VA employment service in FY10. Among Veterans who accessed at least one visit for employment services, 35% received transitional work, 30% vocational assistance, 28% supported employment (considered the gold standard, evidence-based practice), and 8% incentive therapy. Veterans with schizophrenia and bipolar disorder were more likely to receive any employment services and to receive supported employment than Veterans with depression, PTSD, or other anxiety disorders. Veterans with depression and PTSD were more likely to receive transitional work and vocational assistance than those with schizophrenia. African Americans, and those with a substance use disorder or an indication of homelessness were more likely to receive employment services, but were less likely to receive supported employment, specifically.
    Date: July 1, 2014
  • Negative Mental Health Beliefs are a Significant Barrier to Care for OEF/OIF Veterans with Mental Health Problems
    The primary aim of this study was to document concerns about stigma and personal beliefs about mental illness and treatment among OEF/OIF Veterans. Findings showed that OEF/OIF Veterans endorsed a variety of mental health beliefs that may serve as barriers to care. Concerns about stigma in the workplace were most commonly reported, followed by negative beliefs about treatment-seeking, concerns about stigma from loved ones, and negative beliefs about mental illness. Although more than one-third of the Veterans in the study generally disagreed with survey items reflecting negative beliefs about mental health treatment, 50% of the survey respondents were classified in the “neither agree nor disagree” category, suggesting that they may be neutral or undecided in their beliefs about treatment. Veterans with probable mental health problems were more likely to report negative mental health beliefs than Veterans without mental health problems. Specifically, Veterans with probable diagnoses of depression and PTSD were more concerned about stigma from loved ones and in the workplace than Veterans without these conditions. Negative beliefs about treatment-seeking were related to lower likelihood of seeking mental healthcare for Veterans with probable PTSD, depression, and alcohol abuse. Although concern about stigma in the workplace was most commonly reported, it was unrelated to healthcare use.
    Date: June 1, 2014
  • Factors Related to Use of Psychotherapy among Veterans
    This study sought to examine predisposing, enabling, and need factors related to low, moderate, high, and very high levels of psychotherapy use among Veterans newly diagnosed with PTSD, depression, and anxiety. Findings showed that need factors appeared to be most strongly linked to psychotherapy utilization. Very high psychotherapy users had higher rates of PTSD and substance use disorders (SUD), more comorbid psychiatric diagnoses, and more inpatient psychiatric stays. In the year after initiating psychotherapy, half of the sample received only 1-3 psychotherapy sessions (low-users); 42% received 4-18 sessions (moderate-users); 5% received 19-51 sessions (high-users), and 2% received more than 52 sessions (very high-users). Low-users predominantly received individual psychotherapy; very high-users received relatively more group psychotherapy. Younger (<35) and older (65+) Veterans were proportionately more likely to be low-users. Low-users also had lower psychiatric comorbidity, fewer inpatient days, and were less likely to be diagnosed with PTSD and SUD. Results suggest many Veterans may not receive a clinically optimal dose of psychotherapy, highlighting the need to enhance retention in therapy for low utilizers and examine whether very high utilizers are benefitting from extensive courses of treatment.
    Date: May 19, 2014
  • “Virtual” Hope Box Smartphone App Delivers Patient-Tailored Coping Tools to Help Veterans at Risk for Suicide
    Tools that assist patients in accessing and affirming their reasons for living can enable them to mitigate suicidal thoughts. One such tool has been labeled a “hope box”: a physical representation of the patient’s reasons for living, reminders of individual accomplishments and future aspirations, or things the individual finds soothing, e.g., a worry stone, family photographs, or letters. However, a conventional hope box can by physically unwieldy and inconvenient; thus, the investigators in this study developed a “Virtual” Hope Box (VHB) for service members and Veterans that expands the reach of the hope box modality to a smartphone app. This study compared the VHB with a Conventional Hope Box (CHB) integrated into VA behavioral health treatment. Compared with a CHB, more Veterans used the Virtual Hope Box regularly and found it to be beneficial, helpful, and easy to set up. Veterans stated that they would recommend the VHB to their peers, and twice as many preferred the VHB over the CHB for future use. Written comments from Veterans cited the helpfulness of the VHB with managing distress, negativity, hopelessness, anger, and various other symptoms. Moreover, mental health clinicians were unanimous in their praise for the VHB as an eminently usable therapeutic tool.
    Date: May 15, 2014
  • Benefits for Veterans with Dementia who Participate in VA Program Integrating Healthcare and Community Services
    This study tested the effectiveness of a telephone-based care-coordination program – Partners in Dementia Care (PDC) – that integrated healthcare and community services through structured coaching and support. PDC targeted both Veterans and their primary informal caregivers. Findings showed that compared to usual care, PDC was associated with significantly lower levels of self-reported adverse outcomes among Veterans. Improvements in all but one outcome (embarrassment about memory problems) were restricted to Veterans who were more cognitively impaired or had more difficulties with personal care. Beneficial effects after 6 months were evident in reduced relationship strain, depression, and unmet needs for more impaired Veterans – and reduced embarrassment about memory problems for all Veterans. In addition, between months 6 and 12, there were further reductions in unmet needs for more impaired Veterans.
    Date: February 28, 2014
  • Social Network Encouragement Helps Veterans with PTSD Seek VA Mental Healthcare
    This study sought to determine whether beliefs about mental health treatment and/or social encouragement to seek treatment influence initiation of mental healthcare among Veterans with PTSD. Findings showed that whether Veterans initiate mental healthcare after a PTSD diagnosis depends not only on symptom severity and access to treatment, but also on encouragement by those in their social network, whether the Veteran perceives the need for treatment, how they view treatment for PTSD (e.g., positive beliefs about the efficacy of antidepressants), as well as their ability to follow treatment recommendations. Encouragement to get mental healthcare by individuals in their social network increased the odds of getting treatment, even after controlling for beliefs, particularly if encouragement was given by both family and friends/other Veterans. While not the focus of this study, investigators noted that for all outcomes, older VA healthcare users, Veterans with service connection, and those who were diagnosed in non-mental health clinics were less likely to receive treatment. In addition, Veterans who were seen in PTSD specialty clinics, though less likely to receive medication than those in general mental health clinics, were more likely to receive psychotherapy.
    Date: February 3, 2014
  • Anxiety Disorders and Depression Associated with Risk of Future Heart Failure among Veterans
    This study sought to determine if the risk of heart failure (HF) was greater in Veterans with: 1) a diagnosis of one or more anxiety disorders but who were free of major depressive disorder (MDD); 2) MDD but free of anxiety disorders; or 3) comorbid anxiety and depressive disorders. Findings showed that in the model that corrected for age only, Veterans with anxiety disorders, MDD, or both were each about 20% more likely to develop HF compared to Veterans without these conditions. This effect remained significant after adjusting for other HF risk factors (e.g., sociodemographics, nicotine use, substance use disorders), and was even greater after adjusting for psychotropic medications. Compared to Veterans without HF, patients with HF were significantly older and more frequently male, non-white, unmarried, holders of supplemental insurance, and were significantly more likely to have diagnoses of hypertension, diabetes, and obesity. Veterans with both anxiety and MDD were more likely to have a diagnosis of substance abuse or dependence and history of nicotine use – and to receive a prescription for psychotropic medication.
    Date: February 1, 2014
  • Ethnic Differences in Receipt of Depression Care
    This study sought to characterize differences in treatment for multiple racial/ethnic groups of Veterans with ongoing depression. Findings showed that there were significant differences in the receipt of depression care between multiple racial/ethnic groups of chronically depressed Veterans. Compared to white Veterans, nearly all minority groups had lower odds of adequate antidepressant use; adequate psychotherapy was more common among minority Veterans in initial analyses but differences between Hispanic, AI/AN, and white Veterans were no longer significant in adjusted analyses. Primarily due to lower use of antidepressants, nearly all minority groups had lower rates of guideline-concordant care than white Veterans with depression. Overall, 51% of Veterans received adequate antidepressant care for the 6-month period following their most recent VA healthcare visit for depression; 10% of Veterans attended at least 6 psychotherapy visits within the same time period; and 55% received guideline-concordant care. Further research is needed to determine whether the observed differences in treatment arise from patient-centered preferences for care (for example, lower willingness to take anti-depressant medication among minority patients) or from providers’ failure to adhere to best-care practices.
    Date: November 1, 2013
  • Veterans with Non-Specific Anxiety Diagnosis Less Likely to Access Mental Healthcare than Veterans with Specific Anxiety Disorders
    This study sought to determine the rates of specific and non-specific anxiety diagnoses in a national sample of Veterans receiving outpatient care at VAMCs – and to examine patterns of mental healthcare use in the year following diagnosis. Findings showed that “Anxiety Disorder Not Otherwise Specified” (anxiety NOS) was diagnosed in 38% of this Veteran cohort. Most Veterans with a specific anxiety diagnosis received mental health services, with treatment rates for patients with the most frequently diagnosed specific anxiety disorders (PTSD, generalized anxiety disorder, and panic disorder) ranging between 60% and 67%. In contrast, only 32% of patients with anxiety NOS received mental health services during the 12 months following diagnosis. Most Veterans with an anxiety NOS diagnosis did not go on to receive a specific diagnosis in the next 12 months. However, most anxiety NOS patients who later received a diagnosis of a specific anxiety disorder (87%) received mental health services in the year following their index date, compared to 29% of Veterans who did not receive a subsequent specific anxiety disorder diagnosis. Patient factors that increased the likelihood of an anxiety NOS diagnosis included: female gender, older age, the absence of specific comorbid diagnoses (i.e., substance-use disorders, bipolar disorder), and absence of service-connected disability. Veterans diagnosed in specialty mental health or integrated primary care-mental health settings were less likely to receive an anxiety NOS diagnosis than patients in primary care.
    Date: October 22, 2013
  • Home Safety Intervention Improves Caregiver Competence for Individuals with Alzheimer’s Disease
    This trial sought to give informal caregivers the knowledge and resources to prevent risky behaviors and accidents in the homes of persons with dementia of the Alzheimer’s type (DAT) or a related dementia. Investigators designed a Home Safety Toolkit that includes a booklet on high-frequency/high-severity risks for accidents and injuries in the home, and sample items (i.e., smoke alarm, night lights, slide bolt lock, medicine case) that allow caregivers to make easy home safety modifications. Findings showed that all outcome variables improved more for caregivers in the Home Safety Toolkit intervention group than for caregivers in the control group. For example, caregivers in the intervention group had significantly improved home environmental safety compared to those in the control group, and patients in the intervention group had fewer risky behaviors and accidents compared to patients in the control group. The intervention group had 80% overall confidence in their ability to make a home safer compared to 75% for caregivers in the control group. Caregivers in the intervention group also had lower perceived strain in caregiving compared to caregivers in the control group.
    Date: October 1, 2013
  • Increase in Psychotherapy Since 2004 Corresponds with VA’s Efforts to Improve Access to Mental Health
    This study examined longitudinal changes in VA psychotherapy use corresponding with widespread programmatic change targeting increased availability and quality of mental healthcare. Findings showed that the number of Veterans newly diagnosed with depression, anxiety, or PTSD increased by nearly 40% between 2004 and 2010. Rates of PTSD grew most substantially, increasing by more than 2-fold. During this time, the proportion of Veterans with depression, anxiety, or PTSD receiving psychotherapy grew from 21% to 27%. In addition, psychotherapy dose increased – a growing proportion of Veterans received eight or more psychotherapy sessions. More Veterans engaged in individual than group psychotherapy across all study years. However, Veterans who engaged in group psychotherapy received more sessions of psychotherapy than those in individual psychotherapy. Treatment delays decreased across study time points. The median time between index diagnosis and psychotherapy dropped from 56 days in 2004 to 47 days in 2010. Although Veterans with PTSD consistently had shorter delays than Veterans with depression or anxiety, diagnostic disparities in time until treatment grew smaller across the study time points. Consistent with VA expansion efforts, more substantial increases in psychotherapy access, dose, and timeliness occurred between 2007 and 2010 relative to 2004 and 2007.
    Date: October 1, 2013
  • Veterans with PTSD or Major Depression Less Likely to Undergo Four Major Invasive Procedures
    This study examined whether PTSD, after controlling for major depression, was associated with the likelihood of having four common types of major invasive procedures. Findings showed that Veterans with PTSD only and with depression only were less likely to undergo all types of procedures examined in this study. Having both PTSD and depression was associated with lower odds of hip/knee, CABG/PCI, and vascular procedures, but not digestive procedures. Vascular procedures had the strongest effect. The odds of undergoing CABG/PCI or vascular procedures for patients with depression only were 35% to 40% lower than for patients with neither PTSD nor depression, while patients with PTSD only were about 25% less likely to receive the procedures. African American and women at-risk patients (those with a pre-existing condition likely to be alleviated by a procedure) were less likely to undergo hip/knee, vascular, and CABG/PCI procedures. Given that African-Americans are more likely than non-Hispanic whites to die of heart disease, their reduced odds of receiving CABG/PCI or vascular procedures could be problematic.
    Date: October 1, 2013
  • Low Rates of VA Vocational Service Use among OEF/OIF Veterans with Mental Health Conditions
    This study assessed nationwide patterns of supported employment and vocational service use among OEF/OIF Veterans with the top four mental health conditions: PTSD, depression, substance use disorder, or traumatic brain injury (TBI). Findings showed that of the Veterans with mental health diagnoses included in this study, only 8% had a vocational services encounter during the study period, with 2% of these receiving evidence-based supported employment. Moreover, retention was low, with most Veterans attending just one to two appointments. Veterans with TBI – and those with more mental health conditions overall – were more likely to access vocational services. Among Veterans whose employment was tracked, 51% with at least one supported employment encounter worked competitively, compared to 21% of those who did not receive supported employment. Thus, supported employment was effective when it was provided. Results indicate that recovery-oriented, evidence-based, supported employment is the best way to assist unemployed Veterans with mental health conditions to achieve competitive employment. However, resources are limited for Veterans without psychosis and those who are not homeless. Given that OEF/OIF Veterans with TBI are more likely to need vocational services, the authors suggest supported employment could be effectively integrated into VA polytrauma clinics.
    Date: August 1, 2013
  • Study Assesses VA/Alzheimer’s Association Care Coordination Program for Informal Caregivers of Veterans with Dementia
    A new initiative targeting caregivers of Veterans with dementia is “Partners in Dementia Care” (PDC) — a care-coordination program delivered via a partnership between VA and Alzheimer’s Association chapters. This study assessed the effectiveness of the PDC program. Findings showed that the PDC program is a promising model that improves linkages between VA healthcare services and community services for informal caregivers of Veterans with dementia. Compared to comparison caregivers, those who participated in the PDC program had significant improvement in outcomes representing unmet needs, all three types of caregiver strains, depression, and support resources. Most improvements were evident after six months, with more limited improvements from months 6 – 12. However, improvements after the first six months were maintained during the entire study. Some outcomes improved for all caregivers, while others improved for caregivers with more initial difficulties – or those who were caring for Veterans with more severe impairments.
    Date: August 1, 2013
  • Suicidal Ideation is Common among OEF/OIF Veterans who Receive VA Healthcare
    This study sought to determine the prevalence and correlates of suicidal ideation among OEF/OIF Veterans who screened positive for depression following implementation of required brief assessments. Findings showed that suicidal ideation is common among OEF/OIF Veterans who receive VA healthcare: one in three Veterans who screened positive for depression acknowledged possible suicidal ideation. High PHQ-2 scores (> 5) nearly doubled the odds of suicidal ideation, even when controlling for diagnoses of depression. Depression and bipolar or schizophrenia diagnoses significantly increased the odds of suicidal ideation. In addition, having a single diagnosed psychiatric disorder did not significantly increase the odds of suicidal ideation, but two disorders were associated with a 60% increase, and three or more disorders more than doubled the odds. In contrast to previous reports, this study found no increase in suicidal ideation for Veterans with PTSD, substance use disorders, anxiety disorders, or traumatic brain injury. However, the authors note that a recently published evidence-based synthesis concluded that despite mixed results, PTSD should be considered a risk factor for suicide attempts and completion among Veterans.
    Date: July 1, 2013
  • Importance of Parenting Interventions for Veterans’ and their Children’s Health
    This study reviewed the literature to examine the links between deployment, child mental health, and Veteran mental health. Using an example treatment, Parent-Child Interaction Therapy (PCIT), investigators also outline the components needed to make a parenting intervention most useful to Veterans – and propose research directions which would lay the necessary groundwork for large-scale provision of this type of treatment for Veterans.
    Date: May 1, 2013
  • Significant Disparities among Women Veterans with and without Mental Illness in Delaying or Going without Medical Care
    This study examined associations of PTSD and depressive symptoms with unmet medical needs and barriers to care among women Veterans. Findings showed that there was a significant degree of disparities reported by women Veterans with and without mental health symptoms in delaying or going without needed medical care. The majority of those who screened positive for both PTSD and depressive symptoms had unmet medical care needs in the prior 12 months (59%) – compared to 30% of women with PTSD symptoms only, 18% of those with depressive symptoms only, and 16% of women with neither set of symptoms. This pattern remained the same after adjustment (e.g., for demographics, insurance, combat exposure). Overall, among women Veterans in this study who reported unmet medical needs (19% of the women surveyed), those with both PTSD and depressive symptoms were more likely than women in the other groups to identify affordability as a reason for going without or delaying care (69%). Being unable to take time off work (31%) was the second most common reason reported among this group. Women with PTSD symptoms (w/ or w/o depression) were less likely than all other groups to have health insurance to cover non-VA care.
    Date: May 1, 2013
  • Psychiatrists’ Workplace Satisfaction Improved Despite Significant Changes in VA Mental Healthcare Services
    This study examined whether VA psychiatrists’ self-reported outcomes for work satisfaction and work environment perceptions changed during a period of transformation in which VA mental health resources were augmented, while direction and accountability for their use increased. Findings showed that extensive reorganization of VA mental health services was associated with improvements in psychiatrists’ workplace satisfaction, and these increases were sustained over time. Most of the increases in survey measures occurred between 2004 and 2006, with gains maintained thereafter. Pay satisfaction showed the strongest trend increase, and was significantly higher in all years subsequent to 2004. Ratings of management practices were also higher over time. Both skill development and workplace civility were higher in all years except 2007. Intention to leave, job autonomy, and turnover rates did not significantly change over the study period. However, the patterns for satisfaction with work amount and overall job satisfaction differed; values increased from 2004 to 2006 but declined significantly between 2006 and 2010, ending up close to their baseline levels.
    Date: March 15, 2013
  • Most OEF/OIF Veterans who Screen Positive for Depression Receive Timely Assessments for Suicidal Ideation
    This study describes brief structured assessment (BSA) processes for suicidal ideation, including frequency of administration, among OEF/OIF Veterans who screened positive for depression – and identifies individual and system factors that are associated with BSA completion. Findings showed that overall, 81% of Veterans received a BSA for suicidal ideation within one month of screening positive for depression, and 94% of BSAs were conducted within one day of positive screens. Assessment for suicidal ideation was 50% to 80% more likely to occur when Veterans received a diagnosis of PTSD or depression, respectively, on the day of assessment. Neither race/ethnicity nor age was associated with BSA receipt.
    Date: January 23, 2013
  • Prolonged Exposure or Cognitive Processing Therapy May Reduce Use of Mental Health Services in Veterans with PTSD
    This study evaluated the impact of a course of Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT) on VA mental health and medical service utilization and healthcare costs. Findings showed that Veterans who had successfully completed PE or CPT for PTSD experienced a reduction of both PTSD and depression symptomatology; they also reduced their mental health service utilization by 32% in the year following treatment when compared to the year prior to the initiation of PE or CPT. There was a slight, non-significant decline in primary care usage among Veterans who had completed therapy, while emergency department usage remained virtually the same. Per Veteran, there was a 39% reduction in total costs – from an average of $5,173 in the year prior to treatment to $3,133 in the year following treatment. These preliminary findings suggest that the successful completion of PE and CPT for the treatment of PTSD significantly reduces mental health service use and outweighs the cost of treatment.
    Date: January 1, 2013
  • Same-Day Receipt of Integrated VA Primary Care-Mental Health Services Increases Odds of Subsequent Mental Health Visit
    This study evaluated whether same-day receipt of Primary Care-Mental Health Integration (PC-MHI) services was associated with the likelihood of receiving a mental health encounter in the following 90 days. Findings showed that of the Veterans in this study, 7% received same-day PC-MHI services. Those who received same-day PC-MHI services had more than twice the odds of receiving a subsequent mental health encounter within 90 days compared with Veterans who did not receive same-day PC-MHI services, after adjustment for other covariates. Overall, 48% of the Veterans in this study had a subsequent visit for a mental health condition within 90 days of their initial visit. Among those with same-day PC-MHI, 74% had a follow-up, as compared to 45% who did not receive same-day services. OEF/OIF Veterans had greater odds of a 90-day return visit compared with non-OEF/OIF Veterans. Also, Veterans in the two younger age groups (18-44 yrs and 45-64 yrs) had greater odds of a return visit than Veterans in the oldest age group (65+yrs). Each of the mental health disorders, with the exception of alcohol use disorder, was positively associated with a 90-day return visit, while Veterans with a physical comorbidity were less likely to return in the following 90 days.
    Date: January 1, 2013
  • Majority of Veterans with Serious Mental Illness Prefer Family Involvement in their Care
    This article reports on baseline data from the Recovery Oriented Decisions for Relative’s Support (REORDER) intervention, an innovative, manualized protocol that uses a shared decision-making process to facilitate a patient’s consideration of family involvement in care. Findings showed that the majority (78%) of Veterans in this study wanted their family involved in their care. Veterans were concerned about the impact family involvement would have on themselves and their family. Veterans also expressed concerns about the negative effects of involvement, including a loss of personal privacy and decreased time for the involved family member to attend to other responsibilities. The degree to which a Veteran expected benefits from family involvement in care predicted the degree of desired family involvement, whereas anticipating barriers did not.
    Date: December 15, 2012
  • Many OEF/OIF Veterans Delay Initiating Mental Health Care and Completing Effective Mental Health Treatment
    This study sought to describe time to initiation (and predictors of time to initiation) of first primary care visit, mental health outpatient visit, and minimally adequate mental healthcare among Veterans with mental health diagnoses seeking VA healthcare post-deployment. Findings indicate delays in initiating and completing minimally adequate mental healthcare among OEF/OIF/OND Veterans using VA services. Among these Veterans, the median time to engagement in mental healthcare was more than two years from the end of the last deployment. Further, after more than three years post-deployment, 75% of Veterans with mental health diagnoses – who were in the VA healthcare system for at least one year – had still not engaged in minimally adequate mental healthcare. There was a median lag time of 7.5 years between coming in for an initial mental health treatment session and beginning a course of minimally adequate mental healthcare. All of the mental health diagnoses, as well as number of comorbid mental health diagnoses, were associated with an increased chance of initiating minimally adequate mental health outpatient care sooner. PTSD had the strongest association with early initiation. Male Veterans waited nearly two years longer to initiate minimally adequate mental healthcare compared to female Veterans. Younger Veterans (<25 years of age) took longer to initiate and seek minimally adequate care; racial/ethnic minorities also took longer than their White counterparts.
    Date: December 1, 2012
  • OEF/OIF Veterans Most in Need of Psychiatric Care are Accessing Mental Health Services, Primarily at VA
    In this study, investigators conducted the first survey to employ a random sample of U.S. military post-9/11 that examined treatment use and perceived problems with treatment, including both VA and non-VA service users. Findings showed that 43% of the Veterans in this study screened positive for PTSD, major depression, or alcohol misuse. Overall, 40% of Veterans had ever received VA inpatient mental health care, 46% had ever received VA outpatient care, and 16% had ever received inpatient or outpatient care in both VA and non-VA settings. Nearly 70% of Veterans with probable PTSD or major depression and 45% of Veterans with probable alcohol misuse reported accessing mental health care in the past year. Authors suggest that Veterans who are ambivalent about accessing mental healthcare may be more willing to do so if they are made aware that a substantial number of Veterans are getting the help they need. Veterans with mental health needs who did not access treatment were more likely to believe that they had to solve problems themselves and that medications would not help. Those who had accessed treatment were more likely to express stigma beliefs and concern about being seen as weak. This suggests barriers to accessing care may be distinct from barriers to engaging in care. Veterans with higher PTSD and depression symptoms were more likely to access care. This finding suggests that, above a certain threshold of symptoms, Veterans were significantly more likely to seek mental health services, even if they viewed those services in a negative light.
    Date: November 15, 2012
  • Same-Day Primary Care-Mental Health Integration Services May Facilitate Timely Receipt of Treatment for Depression
    This study assessed whether VA patients with same-day Primary Care-Mental Health Integration (PC-MHI) services were more likely to receive depression treatment within 12 weeks, as compared to similar patients who did not receive same-day PC-MHI. Findings showed that a greater percentage of Veterans seen in either PC-MHI or specialty mental health (SMH) settings were diagnosed with depression on the same day of screening (68% and 60%, respectively), compared with Veterans seen in PC-only settings (30%). Also, Veterans who received same-day PC-MHI services were more likely to initiate depression-related treatment than were those receiving only PC services. By six months, the probability of diagnosis had increased in all groups, but PC-only patients had the lowest percentage of depression diagnoses (44%). Being seen in PC-MHI or SMH on the day of the depression screen increased the probability of receiving both psychotherapy and antidepressant treatment.
    Date: November 13, 2012
  • Telemental Health Expands in VA between 2006-2010
    This is the first large scale study to describe the types of telemental health services provided by the VA healthcare system. Findings show that each type of telemental health encounter increased substantially across the five years; for example, the number of encounters for medication management increased from 13,466 in FY06 to 32,284 in FY10, representing a 140% increase over the five-year period. Psychotherapy with medication management was the fastest growing type of telemental health service, increasing from 14,188 encounters in FY06 to 45,107 encounters in FY10, a 218% increase. The use of videoconferencing technology has expanded beyond medication management alone to include telepsychotherapy services (individual and group psychotherapy) and diagnostic assessments. The increase in telemental health services is encouraging, given the large number of returning Veterans who live in rural areas and may have difficulty accessing mental healthcare.
    Date: November 1, 2012
  • Factors Associated with Increased Aggression in Veterans with Dementia
    This study sought to examine the factors predicting the development of aggression among Veterans with dementia. Findings show that potentially mutable factors were associated with the development of aggression in Veterans with newly diagnosed dementia. Mutable factors that predicted increased risk of aggression included: higher levels of baseline caregiver burden, worst patient pain, declining patient-caregiver relationship, and increasing non-aggressive physical agitation. Baseline dementia severity and depression were indirectly related to the onset of aggression.
    Date: October 26, 2012
  • Risk of Suicide and Mental Disorder Comorbidity among Male Veterans Using VA Healthcare
    This study examined mental disorder comorbidity and suicide in a large national cohort of Veterans who use VA healthcare, particularly the association between differing two-way combinations of mental disorders and suicide risk. Findings showed that among Veterans who died by suicide between FY00 and FY06 (0.25% of the study cohort), 47% had been diagnosed with a mental disorder(s) including 19% with one mental disorder and 27% with two or more. Each mental disorder was associated with increased risk for suicide. However, nearly all two-way combinations of mental disorders showed a smaller increase in risk for suicide than would be expected by considering the risk associated with each disorder separately, which is interpreted to indicate sub-additive risk. Depression was the most common diagnosis among Veterans who died by suicide (31%), followed by substance use disorder (21%), anxiety disorder (15%), PTSD (12%), schizophrenia (9%), and bipolar disorder (9%).
    Date: October 22, 2012
  • Pre-Military Trauma Associated with Post-Recruit Training Suicide Attempts among Marines
    This study examined pre- and post-Marine recruit training risk factors for suicide attempts among current and former Marines in the 10 years following training. Findings showed that stressful and traumatic life events (e.g., childhood physical, sexual and emotional abuse, sexual harassment during recruit training) and suicide attempts made before recruit training had strong associations with suicide attempts after recruit training. Those who experienced at least one life stressor prior to joining the Marines had 4 times the odds of suicide attempt compared to those who did not report any life stressors prior to joining. Half of the Marines in this study who died by suicide (per death certificate) in the 10 years following recruit training (n=3) reported at least one significant life stressor prior to joining the Marines. Marines who experienced military sexual harassment during recruit training had 3 times the odds of suicide attempt in the 10 years following training compared with those who did not report this experience. Marines with PTSD symptoms consistent with a diagnosis had about double the odds of suicide attempts compared with those without PTSD symptoms.
    Date: October 20, 2012
  • Determinants of Implementing Depression Care Improvement Models in VA Primary Care Practices
    This study examined three VA-endorsed depression care models and tested the relationships between measures of organizational readiness and implementation of the models in VA primary care clinics. The three models include: 1) collocation of mental health specialists in primary care settings, 2) the Translating Initiatives in Depression (TIDES) model, and 3) the Behavioral Health Laboratory (BHL) model. Findings show that pre-existing demographic and readiness characteristics of primary care practices are associated with whether the practice chooses to implement a depression care improvement model – and with what type of model the practice chooses. Of the three approaches, primary care practices appear most ready to implement collocation, which had been present the longest (average 6 years) in practices adopting it. Moreover, the majority of practices that had not adopted it planned to do so. By 2007, 48% of clinics had implemented collocation, 17% had implemented TIDES, and 8% had implemented BHL. Having established quality improvement processes or a depression clinician champion was associated with collocation. Being located in a VA regional network that endorsed TIDES was associated with TIDES implementation. The presence of psychologists or psychiatrists on primary care staff, greater financial sufficiency, or greater space sufficiency was associated with BHL implementation.
    Date: October 5, 2012
  • Prescription Drug and Alcohol Misuse Associated with Higher Suicide Deaths among Veterans with Depression
    This study sought to assess the association between factors noted in the electronic medical record and suicide mortality for a cohort of Veterans who had received treatment for depression. Findings showed that suicidal behaviors and substance-related variables were the strongest independent predictors of suicide. Compared with Veterans without a suicide attempt or ideation, those with a suicide attempt in the prior year were 7 times more likely to die of suicide, and Veterans with suicidal ideation without an attempt were 3 times more likely to die of suicide. Veterans with prescription drug misuse and those with alcohol abuse were 7 times and 3 times, respectively, more likely to die of suicide than those without. Based on these findings, the authors suggest that prescription drug and alcohol misuse assessments should be prioritized in suicide assessments among Veterans diagnosed with a depressive disorder. Veterans for whom providers considered a hospitalization for psychological issues had 3 times higher risk of suicide death than those for whom hospitalization was not considered.
    Date: October 1, 2012
  • Perceptions of Coercive Treatment and Satisfaction with Care among Veterans Hospitalized for Severe Mental Illness
    This study examined associations between perceptions of coercive treatment and satisfaction with care among psychiatric inpatients at one VAMC. Findings show that both involuntary commitment status and perceptions of coercion were independently and negatively associated with patient satisfaction with psychiatric inpatient hospitalization. Among the Veterans who were psychiatric inpatients in this study, 15% were involuntarily admitted, 40% reported prior involuntary admissions, and nearly half endorsed the perception of some coercion during their index admission. In addition, self-reported history of being denied a requested medication during psychiatric hospitalization (a potentially coercive treatment) may influence appraisal of care during the current hospitalization. Self-reported lifetime rates of other coercive treatment experiences ranged from 22% reporting being forced to take medications to 46% reporting ever being transported to the ER or hospital by law enforcement.
    Date: September 28, 2012
  • Promoting Gun Safety and Delayed Gun Access to High-Risk Patients is Acceptable to Veterans and Providers
    This study explored VA stakeholders’ perceptions about gun safety and interventions to delay gun access among Veterans with a mental health diagnosis during high-risk periods. Findings showed that several measures to promote gun safety and to delay access to guns for high-risk patient groups are acceptable to VA patients and providers, if judiciously applied. For example, most patients and clinicians in this study indicated that routine screening for gun access was acceptable, particularly for patients receiving mental healthcare. Clinicians and patients reported having very little discussion regarding gun ownership during the course of routine treatment. Both groups indicated that gun access was typically discussed only during suicide or homicide risk assessments, and then only if the patient expressed suicidal/homicidal ideation that involved guns. However, nearly all patients felt that clinicians should routinely speak to their patients about guns. One of the most widely suggested and accepted interventions – across all stakeholders – was further education on suicide, including risks related to guns, for VA patients, family members, and clinicians.
    Date: September 5, 2012
  • Higher Rates of Reproductive and Physical Health Problems in OEF/OIF Women Veterans with Mental Illness
    OEF/OIF women Veterans with any mental health diagnoses had significantly higher prevalence of nearly all categories of reproductive and physical disease diagnoses compared to women Veterans without mental health diagnoses. Women with mental health diagnoses had approximately two to four times the odds of receiving diagnoses of sexually transmitted infections, cervical dysplasia, dysmenorrhea, and gynecologic pain syndromes, as well as other reproductive and gynecologic health conditions, with prevalence being highest in women with comorbid PTSD and depression. The most striking difference was in sexual dysfunction (a relatively rare outcome), in which women Veterans diagnosed with mental health disorders had 6 to 10 times the odds of receiving this diagnosis than women without mental disorders. Findings were similar after adjusting for demographics, military service characteristics, and distance to/type of nearest VAMC. The magnitude of the associations of mental and physical health diagnoses were reduced after adjusting for primary care utilization, but most remained significant.
    Date: September 1, 2012
  • Collaborative Care Models Improve Physical and Mental Health Outcomes for Individuals with Mental Disorders
    Collaborative chronic care models (CCM)s can improve mental and physical outcomes for individuals with mental disorders across a wide variety of care settings and provide a robust clinical and policy framework for care integration. Meta-analysis of unadjusted outcomes demonstrated significant small-to-medium effects of CCMs across multiple disorders in clinical symptoms, mental and physical quality of life, and social role function, with no net increase in total healthcare costs. Systematic review of a broader range of studies largely confirmed meta-analytic findings. The authors suggest that CCMs provide a framework of broad applicability for management for a variety of mental health conditions across a wide range of treatment settings, as they do for chronic medical illnesses.
    Date: August 1, 2012
  • Warning Signs Associated with Suicide among Veterans Receiving VA Healthcare
    Of the 381 Veterans in this study who used VA healthcare in their last year of life, 67 (18%) died by suicide within one week of contact. Among these Veterans, documented suicidal ideation was the strongest predictor of suicide. Psychotic symptoms noted during the last VA healthcare visit also were associated with suicide. Of the 381 Veterans who used VA healthcare in their last year of life, 174 (46%) died within one month of contact. Among these Veterans, the warning signs noted above (suicidal ideation and psychotic symptoms) were also risk factors that predicted suicide within a month of contact. Authors note that assessment of suicidal ideation is critical to identifying Veterans at immediate risk, but that both suicidal ideation and psychotic symptoms may also suggest ongoing risk.
    Date: July 13, 2012
  • Effects and Costs of Mobile, Team-Based Outpatient Care Model for Veterans with Serious Mental Illness
    Assertive Community Treatment (ACT) – called Mental Health Intensive Case Management (MHICM) in VA – is a mobile, team-based outpatient service model for providing comprehensive psychiatric care and case management support to individuals with serious mental illness who intensively use inpatient psychiatric care. In this study, the proportion of ACT enrollees admitted to inpatient mental health care did not differ significantly from non-enrollees admitted (62% vs. 63%). However, compared to non-enrollees, ACT enrollees had 16 fewer mental health inpatient bed days during the first 12 months of enrollment. For ACT program participants, savings depended on new clients’ “intensity” of psychiatiric inpatient utilization prior to entering the ACT program. VA ACT services are cost-saving for Veterans with serious mental illness and more than 95 mental health inpatient bed days in the 12 months prior to entering ACT, but cost-increasing for Veterans with fewer than 95 bed days. Between FY01 and FY04, new VA ACT clients had just over 68 bed days in the 12 months prior to entering ACT on average, and their entry into ACT was estimated to result in an increase of $4,529 in VA mental health costs. Trends in psychiatric inpatient use among ACT program entrants remained stable after FY04, through FY10. However, eligibility for ACT declined by 37% because fewer Veterans met eligibility based on high prior inpatient use. Thus, authors suggest that the “high hospital use” criterion may impose a trade-off between program cost-effectiveness and program access. Fewer Veterans are attaining the high hospital use threshold as inpatient use falls. This winnowing of the target population may indicate a need to reconsider the administrative criteria for entry into VA ACT services.
    Date: May 17, 2012
  • Integration of Primary Care and Mental Health Improves both Mental and Medical Care Utilization for OEF/OIF Veterans
    There was a significant association between VA’s Primary Care-Mental Health Integration (PC-MHI) program and OEF/OIF Veterans’ receipt of short- or long-term mental or medical care. Of the 181 Veterans who participated in the PC-MHI program, 60% sought mental health care within one month after their initial encounter in PC-MHI, and 82% after one year, while 18% sought medical care within one month, and 74% within one year. The average length of time to a subsequent specialty mental health care visit after the Veterans’ first PC-MHI encounter was about 5 months. The average length of time to a subsequent medical care visit after the first PC-MHI encounter was about 10 months. While PTSD was the primary condition associated with OEF/OIF Veterans remaining in VA care for mental health care, retention in long-term medical care was not associated with mental health disorders measured in this study (PTSD, substance use disorder, major depressive disorder, and anxiety/phobia).
    Date: April 30, 2012
  • Killing Experiences Independently Associated with Suicidal Ideation among Vietnam Veterans
    Vietnam Veterans in this study with war-related killing experiences were twice as likely to report suicidal ideation as those who did not kill, even after accounting for PTSD, depression, substance use disorder diagnoses, and combat exposure. This is the first study demonstrating that killing experiences are independently associated with suicidal ideation, after taking mental health diagnoses into account. In regression analyses that included demographic variables, PTSD, depression, substance use disorders, combat experiences, and killing experiences, PTSD was the only variable significantly associated with suicide attempts. Nearly 14% of Veterans in this study met diagnostic criteria for current PTSD.
    Date: April 13, 2012
  • Caregiver Satisfaction with VA Dementia Care
    On average, caregivers reported about 17 unmet care needs, indicating that they needed more information about or help with approximately one-third of the care needs used in the study analyses. Total unmet need was the only significant predictor of satisfaction with physician care, indicating that as the number of unmet needs increase, satisfaction with physician care suffers. Similarly, total unmet need was the strongest predictor of satisfaction with VA care, indicating that as the number of unmet needs increase, satisfaction with VA healthcare also suffers. Behavior problems and VA site were additionally predictive of satisfaction with VA care.
    Date: April 1, 2012
  • Journal Issue Targets Veterans’ Sexual Health and Functioning
    The International Journal of Sexual Health is the first scientific journal to devote an issue to the sexual health and functioning of military Veterans. Articles in this issue, many authored or co-authored by HSR&D investigators, describe the effects of combat experiences on American Veterans’ sexual functioning, sexual risk behavior, mental health, health status, and relationships. In addition, articles describe the effects of sexual assault on women’s sexual health, and healthcare use among transgender Veterans.
    Date: April 1, 2012
  • Mental Health Diagnoses Associated with Opioid Prescription, High-Risk Use, and Adverse Outcomes among OEF/OIF Veterans
    Among OEF/OIF Veterans with pain, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids, high-risk opioid use, and adverse clinical outcomes. Compared to those without mental health diagnoses, Veterans with PTSD who were prescribed opioids were more likely to receive higher-dose opioids (16% vs. 23%), receive two or more opioids concurrently (11% vs. 20%), receive sedative hypnotics concurrently (8% vs. 41%), and to obtain early opioid refills (20% vs. 34%). Receiving prescription opioids (vs. not) increased risk for serious adverse clinical outcomes for Veterans (10% vs. 4%) across all mental health categories and was most pronounced in Veterans with PTSD. Of the 141,029 Veterans with pain diagnoses, 15,676 (11%) received prescription opioids for = 20 consecutive days; 77% of which were prescribed by VA primary care providers. Veterans with PTSD and mental health diagnoses excluding PTSD were significantly more likely to receive opioids for pain (18% and 12%) compared to Veterans without mental health diagnoses (7%).
    Date: March 7, 2012
  • Use of Mental Health and Non-Mental Health Outpatient Care by OEF/OIF Veterans with Military Sexual Trauma
    The most notable factor that influenced the receipt and intensity of MST-related care was gender. Male Veterans used less care than female Veterans and had a lower intensity of MST-related care compared to women, even after controlling for total number of healthcare visits. Other sociodemographic and military variables associated with less use and/or less intensity of MST-related care were younger age, unknown race/ethnicity, being in the Marines or Air Force, and being in the National Guard or Reserve. Among all Veterans who screened positive for MST, the majority (76%) received at least one MST-related care visit within a year of the positive screen. In examining diagnostic characteristics of MST-related care, the most common primary diagnoses related to a Veterans’ MST-related care were mental health diagnoses. Overall, more than half of all Veterans received MST-related care with an associated mental health primary diagnosis (57% of women and 50% of men); the most common diagnoses were PTSD, depression, and other anxiety disorders. The authors note that the high proportion of Veterans accessing MST-related care confirms the effectiveness of VA’s universal screening program to promote the use of mental health services for Veterans with positive MST screens.
    Date: March 7, 2012
  • Older Veterans Less Likely to Receive Treatment for Depression
    In this study, 64% of Veterans with a new diagnosis of depression received some form of treatment within 12 months; however, one third (36%) of the Veterans in this study did not receive any treatment for their depression. Of those Veterans who did receive treatment, most received both antidepressants and psychotherapy (27%), followed by 21% who received antidepressants only, and 16% who received psychotherapy only. The odds of receiving any kind of treatment decreased notably with increasing age. Veterans ages 50 to 64 were more likely to receive antidepressants, psychotherapy, or both compared to those in the older age groups. Results also showed that depressed older adults with no medical comorbidities were more likely to receive both antidepressants and psychotherapy compared to no treatment. This study highlights the importance of continued outreach and intervention efforts for depressed older Veterans who are vulnerable to being under-treated.
    Date: March 1, 2012
  • Veterans with Serious Mental Illness Using Co-Located/Integrated Primary Care and Outpatient Mental Health Clinic Care have Reduced Cardiovascular Risk
    Veterans with serious mental illness (SMI) were more likely to attain cardiovascular risk goals after being enrolled in a primary care clinic co-located and integrated into an outpatient mental health clinic. Compared to prior to enrollment, Veterans enrolled in SMIPCC had significantly more primary care visits over six months – and significantly improved BP, LDL, triglycerides, and BMI. There were no significant differences in the attainment of goals for HDL or HbA1c. Prior to enrollment, 49% of primary care visits were on the same day as any scheduled mental health visit; this increased to 86% post-enrollment. Among the 28 Veterans in this study with coronary artery disease and/or diabetes, SMIPCC enrollment was associated with a significant improvement in BP goal attainment, but not with any other measures.
    Date: February 1, 2012
  • Increased Risk of Mortality Following Heart Attack for Veterans Insufficiently Treated for Major Depressive Disorder
    This study sought to determine if mortality following acute MI was associated with treatment-resistant depression (TRD). Findings show that all-cause mortality following an acute MI is greatest in Veterans with depression that is insufficiently treated – and is a risk in Veterans with treatment-resistant depression. Veterans who were insufficiently treated were 3.04 times more likely to die than those who received treatment. Veterans with TRD were 1.71 times more likely to die; however, this risk was partly explained by comorbid disorders.
    Date: January 12, 2012
  • Majority of OEF/OIF Veterans with Traumatic Brain Injury also Diagnosed with Mental Illness and Head, Neck or Back Pain
    This study examined the prevalence and VA healthcare costs of TBI with and without comorbid psychiatric illness and pain among OEF/OIF Veterans who used VA healthcare services (inpatient or outpatient) during FY09. Findings showed that 7% of the Veterans who used VA healthcare received a diagnosis of TBI. Among this patient subgroup, the vast majority (89%) also had a psychiatric diagnosis (most frequently PTSD: 73%), and 70% had a diagnosis of head, neck or back pain. More than half had both PTSD and pain (54%). Overall, depression was the second most common (45%) mental health diagnosis. Annual costs for OEF/OIF Veterans with TBI were four times greater than for those without TBI ($5,831 vs. $1,547), and costs increased as clinical complexity increased. For example, Veterans with TBI, PTSD, and pain demonstrated the highest median cost per patient ($7,974).
    Date: January 4, 2012
  • AJPH Features Articles on Veterans and Suicide
    This special supplement of AJPH focuses on Veterans and mental health, and includes four articles on suicide among Veterans.
    Date: January 1, 2012
  • Mental and Physical Health – and Substance Use in Veterans One Year after Deployment to Iraq or Afghanistan
    Within one year of returning from deployment, OEF/OIF Veterans in this study reported significantly worse mental health functioning than the general population. In addition, 39% screened positive for “probable alcohol abuse,” which is considerably higher than numbers reported based on mandated screening of VA outpatients. OIF (Iraq) Veterans reported more depression/functioning problems, as well as alcohol and drug use than OEF (Afghanistan) Veterans. Marine and Army Veterans reported worse mental and physical health than Air Force or Navy Veterans. Men reported more alcohol and drug use than women, but there were no gender differences in PTSD or other mental health domains. The authors suggest that continued identification of Veterans at risk for mental health and substance use problems is important for the development and implementation of evidence-based interventions intended to increase resilience and enhance treatment.
    Date: January 1, 2012
  • Gender Differences in Combat Exposure, Military Sexual Trauma, and Mental Health among Active Duty Soldiers
    This study examined gender differences in combat exposure, military sexual trauma (MST), and their associations with mental health outcomes among OEF/OIF active-duty personnel. Findings showed that although men reported greater exposure to high-intensity combat experiences than women, results indicate that women are experiencing combat at higher rates than observed in prior cohorts. For example, 7% of women reported injury in the war zone, and 4% reported killing in war, compared to 2% and 1%, respectively, for a Gulf War cohort. MST was a significant predictor of both PTSD and depression symptoms: 12% of women and less than 1% of men reported MST in the war zone. There were no gender differences in PTSD symptoms; however, there was a stronger assocation between injury in combat and PTSD symptoms for women than for men. Men were more likely to report hazardous alcohol use, while female gender was more likely to be associated with depression symptoms.
    Date: December 13, 2011
  • Diabetes Managed More Intensively in Older Veterans with Dementia and Cognitive Impairment
    This study sought to examine and compare anti-glycemic medication use, glycemic control, and risk of hypoglycemia in older Veterans with and without dementia or cognitive impairment. Findings showed that diabetes was managed more intensively in older Veterans with dementia or cognitive impairment than in those with no impairment, with more patients on insulin (30% vs. 24%) among those with cognitive problems. These conditions were independently associated with a greater risk of hypoglycemia. Of all Veterans taking insulin, the incidence of hypoglycemia was higher among those with dementia (27%) or cognitive impairment (20%) than among those with neither condition (14%). Veterans with dementia or cognitive impairment also had a greater decline in HbA1c over the 2-year study period. These findings suggest that providers were less likely to pursue individualized glycemic goals, as recommended by VA-DoD clinical practice guidelines (updated in 2010), when patients had cognitive problems.
    Date: December 8, 2011
  • History of Military Sexual Trauma Increases Risk of Sexual Health Diagnoses among OEF/OIF Veterans
    This study examined the prevalence rates of sexually transmitted infections (STIs) and sexual dysfunction disorders (SDDs) among OEF/OIF Veterans with and without reported military sexual trauma (MST). Investigators also explored whether the presence of a co-existing mental health diagnosis (e.g., PTSD, depression, substance use disorder) was associated with higher rates of STIs and SDDs among Veterans who screened positive for MST. Findings show that a number of STI and SDD diagnoses were more common among OEF/OIF Veterans who reported a history of MST compared to Veterans without a history of MST. There were no instances in which any of the sexual health diagnoses were significantly higher among Veterans who did not report a history of MST, even after controlling for age and length of time in VA healthcare. Moreover, among Veterans with a history of MST, the risk of having an STI or SDD increased in the presence of certain mental health diagnoses. Among women with a history of MST, those with a diagnosis of PTSD, depression, or a substance use disorder were significantly more likely to have an STI than women without these diagnoses. Among men with MST, only substance use disorder increased their risk for an STI. Among women with a history of MST, those with a diagnosis of depression were significantly more likely to have an SDD than women without a depressive disorder. Among men with MST, those with a diagnosis of PTSD or depression were more likely to have an SDD diagnosis than men without either disorder. This study emphasizes the importance of sexual health screening, particularly among Veterans with a history of MST.
    Date: December 5, 2011
  • Telemedicine-Based Collaborative Care Intervention for Depression has Greater Effect on Minority vs. White Veterans
    The Telemedicine Enhanced Antidepressant Management (TEAM) study was a randomized trial of telemedicine-based collaborative care tailored for small, rural primary care practices. Investigators in the current study evaluated racial differences in clinical outcomes among 360 Veterans with depression who were randomized to usual care or the TEAM intervention. Findings showed that in the usual care group, minority Veterans had a lower treatment response rate (8%) than Caucasians (18%), but this was not significant. In contrast, minority Veterans in the TEAM intervention group had a significantly higher treatment response rate (42%) than Caucasians (19%) in the intervention group. Veterans in the minority group were significantly less likely to report that antidepressants were an acceptable form of treatment, and were significantly less likely to have had prior or current depression treatment. However, none of these variables were significantly related to treatment outcomes. Thus, the study was not able to determine why minorities responded better to the intervention than Caucasians.
    Date: November 1, 2011
  • Survey-based vs. Chart-based Screening Yields Significantly Higher Rates of Depression among Veterans in Primary Care
    This study sought to characterize the yield of practice-based screening in 10 diverse VA primary care clinics (rural and urban), as well as the care needs of Veterans assessed as having depression. Findings showed that practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. Practice-wide depression screening yielded 20% positive depression screens and 12% probable major depression. This is substantially higher than most previously reported VA rates. In addition, comorbid medical and mental illness were highly prevalent.
    Date: October 6, 2011
  • VA Mental Health Care Staff More Satisfied and Suffer Less Burnout Compared to Non-VA Community Mental Health Staff
    This study compared burnout and job satisfaction between VA staff and non-VA community mental health staff working in the same large Midwestern city in 2009. Findings show VA staff reported significantly greater job satisfaction and accomplishment, less emotional exhaustion, and lower likelihood of leaving their job. VA and non-VA community mental health clinic (CMHC) staff also differed significantly in two categories. CMHC staff were significantly more likely to report job-related aspects as being challenging, such as lack of flexibility in the schedule and little pay. VA staff were more likely than CMHC staff to report administrative issues as being challenging, e.g., bureaucracy, red tape, and policies. Authors suggest that while CMHC leadership may need to find ways to address concerns related to job responsibilities (e.g., pay, schedule), VA may need greater focus helping workers navigate administrative concerns.
    Date: October 5, 2011
  • Depression and Race may Independently Affect Receipt of Some Surgeries
    This study examined race and ethnicity as factors potentially associated with surgeries experienced by Veterans with and without major depressive disorder (MDD). Findings show that Veterans with pre-existing MDD were less likely to undergo digestive, hip/knee, vascular, or CABG surgeries than Veterans without MDD. Minority Veterans were slightly less likely to receive vascular operations compared to white Veterans, but were more likely to undergo digestive system procedures. The effect of depression was independent of race and ethnicity; thus, depression and race would have an additive but not synergistic effect on the odds of receiving surgery. In addition, a gender effect was noted: women Veterans were more likely to have digestive procedures but were less likely to undergo CABG or vascular operations. Authors note that the lack of information regarding severity of illness makes it difficult to determine whether or not diagnostic differences explain differences in surgery.
    Date: October 1, 2011
  • Military Sexual Trauma Associated with Increased Rate of Mental Health Disorders among Male and Female Veterans with Comorbid PTSD
    This study examined correlates of PTSD in OEF/OIF Veterans, as well as mental health comorbidities by gender among Veterans with PTSD – with and without military sexual trauma (MST). Findings showed that overall, MST was associated with a nearly three-fold increase in odds of PTSD in men, and more than a four-fold increase in women Veterans. Among women Veterans with PTSD, 31% screened positive for MST, and 1% of men with PTSD screened positive for MST. Among Veterans with PTSD, those with military sexual trauma also had more comorbid mental health diagnoses than those without MST. Three-quarters of women Veterans with PTSD and MST had comorbid depression, more than one-third had another anxiety disorder, and 4% were diagnosed with eating disorders. Male Veterans with PTSD and MST were more likely to have comorbid depression and substance use than male Veterans with PTSD, but without MST.
    Date: September 8, 2011
  • Quality of VA Mental Health Care Following Psychiatric Hospitalization for Veterans with Depression
    This study sought to assess the quality of depression care (e.g., antidepressant treatment, psychotherapy) during the high-risk period following a psychiatric hospitalization. Findings show that less than half of Veterans hospitalized for major depression had outpatient mental health follow-up within 7 days of discharge (39%), which is similar to rates found in the general U.S. population among Medicare (38%) and Medicaid (43%) beneficiaries in 2008. Mental health follow-up within 30 days for Veterans in this study was substantially more common (76%). Many Veterans also received adequate psychopharmacologic treatment following a hospitalization for depression (59%), but relatively few received adequate psychotherapy post-discharge (13%).
    Date: September 1, 2011
  • Study Suggests PTSD Associated with Cognitive Impairment
    This systematic review analyzed data from 21 articles published between 1968 and 2009 that examined memory and cognitive function in subjects with chronic PTSD compared to subjects who had been exposed to trauma but did not have PTSD. Eight of the studies that were analyzed included Veterans. Findings showed that chronic post-traumatic stress disorder is associated with cognitive impairment, particularly in Veterans, when compared to individuals with a history of trauma but no PTSD. The severity of PTSD is positively correlated with cognitive impairment. Strong evidence, especially in studies of Veterans, refugees, and war victims, suggests that individuals with PTSD have a poorer ability to sustain attention compared with individuals who have a history of exposure to trauma.
    Date: September 1, 2011
  • Co-Location of Primary Care in VA Mental Health Clinics Associated with Better Processes of Care for Veterans with Serious Mental Illness
    This study sought to determine the association between the co-location of primary care services and quality of medical care for patients with serious mental illness (SMI) receiving care in VA mental health clinics. Findings showed that the co-location of primary care services within VA mental health clinics was associated with better quality of care for Veterans with serious mental illness, particularly for key processes of care. After adjusting for organizational and patient-level factors, Veterans from co-located clinics were more likely to receive diabetes foot exams and screening for colorectal cancer and alcohol misuse (process measures), and to have satisfactory blood pressure control (outcome measure). Co-location was not associated with better outcomes for hemoglobin A1C levels among Veterans with diabetes. Observed quality of care in this sample exceeded national averages. Overall, integrated medical care may potentially provide an effective medical home model that can improve processes of medical care for Veterans with SMI.
    Date: August 1, 2011
  • Potential Problems with the Use of Antidepressants among Older Veterans Residing in VA Nursing Homes
    This study examined the prevalence and patient/site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants among Veterans aged 65 years and older that were admitted to any one of 133 VA Community Living Centers (CLC, previously called Nursing Home Care Units). Findings suggest potential problems with the use of antidepressants in older Veterans that reside in VA CLCs. Overall, only 18% of antidepressant use was optimal. Of the 877 Veterans with depression, 25% did not receive an antidepressant, suggesting potential underuse. Among depressed Veterans who received antidepressants, 43% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. In addition, of the 2,815 Veterans who did not have depression, 42% were prescribed one or more antidepressants; of these, only 4% had an FDA-approved labeled indication, suggesting potential overuse. Also, the co-prescribing of antipsychotics (in patients without schizophrenia) among those without depression was associated with an increased risk of antidepressant overuse.
    Date: August 1, 2011
  • Veterans with Diabetes and Major Depressive Disorder at Significantly Increased Risk of Myocardial Infarction
    This study sought to determine if major depressive disorder (MDD) complicates the course of type 2 diabetes and is associated with increased risk of myocardial infarction (MI) and mortality. Findings showed that Veterans with comorbid MDD and type 2 diabetes were 82% more likely to experience a MI compared to Veterans without MDD and type 2 diabetes. Veterans with MDD alone were 29% more likely to have a MI, and Veterans with type 2 diabetes alone were at 33% increased risk of MI. The incidence of MI increased in a step-wise fashion, from unaffected Veterans (2.6% incidence of MI) to those with depression only (3.5%) to those with diabetes only (5.9%) to Veterans with both conditions (7.4%). Veterans with PTSD, anxiety, and panic disorder were more likely to have a MI, as were Veterans with hypertension, hyperlipidemia, obesity, and nicotine dependence.
    Date: August 1, 2011
  • Differences in Communication between Providers in VA Mental Health Clinics and General Medical Providers in Treating Veterans with Serious Mental Illness
    Integrated care for co-occurring substance use and general medical disorders is considered essential for improving quality of care for individuals with serious mental illness (SMI), and is one of VA’s priority goals. This study sought to describe the barriers and facilitators of integrated care (from the perspective of mental health providers) for nearly 20,000 Veterans with SMI. Findings show that mental health providers from VA mental health clinics with high versus low quality of care scores differed in their ability to communicate with general medical providers regarding care for Veterans with SMI. Among mental health providers from low-performing sites, lack of communication with primary care providers was a key barrier. Barriers to communication included lack of opportunities to interact on a face-to-face basis and lack of opportunities to have team meetings. In addition, they were concerned that primary care providers did not want to see patients with SMI because of the perception that they were difficult to treat. Stigma was not mentioned as a problem for providers among the high-performing sites, with general medical providers viewed as sensitive to the needs of Veterans with SMI. The authors suggest that these findings indicate that efforts to improve communication between mental health and primary care providers, as well as delineating roles and responsibilities across both types of providers may potentially facilitate integrated medical care for Veterans with serious mental illness.
    Date: July 7, 2011
  • Integrated Primary Care Clinic Improves Access to Mental Health and Social Services for OEF/OIF Veterans
    In April 2007, an OEF/OIF Integrated Care (IC) Clinic was established at the San Francisco VAMC, as part of VA primary care system-wide priorities for improving mental health screening and treatment for OEF/OIF Veterans. This study evaluated whether an initial IC clinic visit improved mental health and social services use among OEF/OIF Veterans entering primary care at the San Francisco VAMC, compared to Veterans who received usual care. Findings showed that OEF/OIF Veterans seen in the IC clinic were significantly more likely to have had initial mental health and social work evaluations within 30 days. Moreover, IC clinic patients were significantly more likely than usual care patients to have had at least one follow-up specialty mental health visit within 90 days of initiating primary care. Women Veterans, younger Veterans, and those with positive mental health and TBI screens were significantly more likely to have had mental health and social service evaluations if seen in the IC versus the usual care clinic. While the Integrated Clinic increased initial mental health evaluations, there was no significant increase in longer-term retention in specialty mental health services among Veterans who screened positive for mental health problems.
    Date: June 7, 2011
  • Women as Resilient to Combat-Related Stress as Men in the First Year Following Return from OEF/OIF Deployment
    This study examined gender differences in various dimensions of combat-related stress and associated consequences for post-deployment mental health in a nationally representative sample of male and female OEF/OIF Veterans. Study results suggest that women OEF/OIF service members may be as resilient to combat-related stress as men in the first year following deployment. There were no significant interactions between combat-related stressors and gender in the prediction of post-traumatic stress symptomatology, mental health functioning, or depression. Women reported slightly less exposure than men to most combat-related stressors, but higher exposure to other stressors (i.e., prior life stress, deployment sexual harassment). There were no differences between men and women in reports of perceived threat in the war zone.
    Date: May 30, 2011
  • Telemedicine-Based Collaborative Care Does Not Increase Total Workload for Primary Care or Mental Health Providers
    This study examined patterns of healthcare utilization and cost associated with telemedicine-based collaborative care for depression among Veterans who received care in seven VA community-based outpatient clinics (CBOCs). Findings suggest that telemedicine-based collaborative care does not increase total workload for primary care or mental health providers; therefore, there is no disincentive for mental health providers to offer telemedicine-based care ? or for primary care providers to refer Veterans to telemedicine care. There was no significant difference in the total number or cost of primary care encounters between Veterans in the intervention group and those in the usual care group. Between the two groups, there also were no statistically significant differences in total mental health encounters or cost; however, Veterans in the intervention group did have significantly more cost and encounters in specialty physical health clinics. In addition, Veterans in the intervention group had a significantly greater total outpatient cost compared to Veterans in usual care. These differences were likely due to the high levels of physical and mental health comorbidities in this study population.
    Date: May 26, 2011
  • Book Examines Social and Cultural Factors Contributing to Combat-Related PTSD among OEF/OIF Veterans
    This book follows a group of OEF/OIF Veterans and tells their personal stories of war, trauma, and recovery as they re-enter civilian life while dealing with combat-related PTSD. Written from an anthropologist’s perspective, the author examines the cultural, political, and historical influences that shape individual experiences of PTSD – and how Veterans with PTSD are perceived by the military, medical personnel, and society at large. Despite widespread media coverage and public controversy over the military’s response to wounded and traumatized service members, debate continues about how best to provide treatment and compensation for service-related disabilities. At the same time, new and highly effective treatments are revolutionizing how VA provides trauma care, and redefining the way PTSD is understood. Fields of Combat discusses real-life issues related to living with PTSD, and suggests recommendations to improve PTSD care.
    Date: May 19, 2011
  • Effect of Housing Vouchers on Homeless Veterans with Mental Illness
    This study examined how homeless Veterans with mental illness obtain housing without a voucher, and whether greater employment earnings or better clinical outcomes were associated with such housing success. Findings showed that Veterans who obtained independent housing without a voucher worked more days and had higher employment income than those with a voucher, but they were less satisfied with their housing. Veterans who used vouchers lived in housing with the highest rent, but paid less of their own income toward rent because of their vouchers. They also reported the highest quality of life with respect to their living situation, higher satisfaction with their housing, and higher safety scores. About one-third of Veterans who obtained independent housing without a voucher lived with others, most often with a family member, and reported lower total rent costs, but paid the greatest share of the rent themselves. Approximately 80% of participants were diagnosed with alcohol or drug dependency. There were no differences in psychiatric, substance abuse, or legal outcomes between groups at three months; however, data over all three years shows that Veterans who were not housed had higher psychiatric, substance abuse, and work problems over time than all other groups.
    Date: May 1, 2011
  • Veterans Reporting a History of Military Sexual Trauma are Treated in a Variety of VA Outpatient Mental Health Settings
    This study sought to determine the VA mental health outpatient settings in which patients with military sexual trauma (MST) are most likely to be treated, which might help set priorities for targeted MST-related education and training. Findings showed that more than one-third of female Veterans (36%) and 2% of male Veterans seen in VA outpatient mental healthcare settings during FY08 reported a history of military sexual trauma. Both women and men with MST were more likely to use more than one type of mental health clinic setting, compared to those without MST. A significantly larger proportion of women seen in MST specialty clinics reported MST as compared to all other settings (81% vs. 34%). However, there was a wide range of clinic visit settings for female Veterans with MST, including: MST specialty clinics, PTSD specialty clinics, psychosocial rehabilitation, and substance use disorder clinics. Male Veterans represented a small proportion of patients seen in all clinics, and a larger proportion of men seen in MST specialty clinics reported MST as compared to other settings (56% vs. 2%). These findings indicate that mental health providers who treat women Veterans, even if they work in settings that do not traditionally incorporate interventions focused on traumatic stress, may encounter issues related to MST. Therefore the authors suggest that training in how to respond to sexual trauma disclosure be an important component in all VA mental healthcare settings.
    Date: May 1, 2011
  • Less than One-Quarter of Veterans who Complete Suicide Access VA Healthcare in Year Prior to Death
    This study sought to determine the number of Veterans who completed suicide and who had accessed VA healthcare in the Pacific Northwest Region in the year prior to death. Findings show that of the 968 Veterans in this study who completed suicide, less than one-quarter (22%) accessed VA healthcare in the year prior to death, and a minority of those Veterans visited mental health providers. These numbers are consistent with current estimates of the number of Veterans accessing care at VA hospitals and clinics, and suggest that Veterans who go on to complete suicide may access VA healthcare at similar rates as Veterans who do not commit suicide. Of those Veterans who completed suicide, 57% did not have a mental health diagnosis, and 58% had not seen a mental health professional, suggesting that it is perhaps equally important to understand patients with general medical conditions who also may be likely to complete suicide. Of those who completed suicide, 55 were hospitalized during the year prior to death. Of these, 39% with a psychiatric hospitalization and 22% with a medical/surgical hospitalization completed suicide within 30 days. A large number of Veterans (73% of men; 36% of women) completed suicide by use of a firearm, supporting concerns from earlier studies over firearm access as a key risk factor in Veteran suicide.
    Date: April 4, 2011
  • Initial Implementation of VA Primary Care Mental Health Not Associated with Differences in Specialty Mental Health Clinic Use by Veterans
    This study sought to determine whether the implementation of primary care mental health services is associated with differences in specialty mental health clinic use within the VA healthcare system. Findings show that the initial implementation of primary care mental health within VA is not associated with substantial differences in mental health clinic use – or diagnoses received in specialty mental health clinics by primary care patients. Facilities with primary care mental health – compared to those without – had similar rates of primary care patients initiating specialty mental health treatment (5.6% vs. 5.8%), and their primary care patients averaged similar total specialty mental health clinic visits (7.0 vs. 6.3). After adjusting for facility characteristics and multiple comparisons, there were no statistically significant differences with regard to diagnoses for Veterans who initiated specialty mental health clinic treatment at primary care mental health facilities. The authors note that primary care mental health may impact mental health clinic use over longer periods of time as these programs mature.
    Date: April 1, 2011
  • Successful Translation of Behavioral Intervention for Caregivers of Veterans with Dementia
    This study assessed the translation of the NIA/NINR Resources for Enhancing Alzheimer’s Caregivers Health (REACH II) intervention into REACH VA – a behavioral intervention for caregivers of Veterans with dementia that ran from 9/07 through 8/09. Findings show that the REACH VA intervention provided clinically significant benefits for caregivers of Veterans with progressive dementia. Caregivers reported significantly decreased burden, depression, impact of depression on daily life, frustrations associated with caregiving, and number of troubling dementia-related behaviors. Also, a decrease of two hours per day “on duty” trended toward significance. Of the caregivers who participated in the REACH VA intervention, 96% believed that the program should be provided by VA to caregivers.
    Date: February 28, 2011
  • Using Administrative Data to Measure Treatment for Veterans with PTSD May Overestimate Delivery of Psychotherapy
    This study sought to determine whether using administrative data to determine the number of psychotherapy sessions Veterans receive is equivalent to manual record review. Manually-classified notes were used to develop an automated coding protocol using the Automated Retrieval Console (ARC), a VA-developed natural language processing program. ARC was then used to independently code the notes, and the performance of the automated coding program was compared to manual coding. Findings showed that, of the notes that were administratively coded as individual psychotherapy for PTSD, 57% were coded as individual psychotherapy after manual review of records. Thus, nearly half of the encounters that would have been counted as the provision of psychotherapy in large administrative studies appeared to be records of services other than psychotherapy (e.g., intakes, psychological testing). Findings suggest that using counts of administrative codes over-estimates the amount of psychotherapy delivered to Veterans with PTSD. This suggests a potential limitation in current studies of the quality of care for PTSD in VA. The ARC program replicated the performance of the manual coders in classifying psychotherapy notes very well. This suggests that ARC may help bridge the gap between the accuracy of manual coding and the scope of administrative coding.
    Date: February 14, 2011
  • Study Evaluates Workshop to Assist OEF/OIF Veterans with Reintegration and Resiliency
    Few programs to promote healthy reintegration exist that are evidence-based and designed for individuals who are not receiving formal mental health care. In response to this need, a two-hour workshop, Life Guard, was developed for the Arkansas National Guard. This pilot study evaluated the effectiveness of the Life Guard workshop for OEF/OIF National Guard Veterans. Findings show that Veterans who participated in the workshop reported significant declines in symptoms of depression, anxiety, and PTSD, in addition to increased satisfaction with relationships. Results also show high levels of exposure to traumatic events, physical injury, and symptoms of psychosocial distress. The authors suggest that these findings support the continued evaluation of Life Guard as a valuable tool to help service members with reintegration and resiliency.
    Date: February 1, 2011
  • Rates of PTSD and Depression Highly Prevalent among OEF/OIF Veterans with Alcohol and/or Drug Use Disorders
    This study sought to determine the prevalence and independent correlates of alcohol use disorders (AUD) and drug use disorders (DUD) among OEF/OIF Veterans who were first-time users of VA healthcare. Findings show that, overall, 11% of the OEF/OIF Veterans in this study received diagnoses of AUD, DUD, or both; 10% received AUD diagnoses and 5% received DUD diagnoses. Post-deployment AUD and DUD diagnoses were more prevalent in particular sub-groups of OEF/OIF Veterans and were highly comorbid with PTSD and depression. Among Veterans diagnosed with AUD, DUD, or both, 55% to 75% also received a diagnosis of PTSD or depression. AUD, DUD, or both diagnoses were 3 to 4.5 times more likely among Veterans with PTSD and depression. AUD and DUD diagnoses were more prevalent among Veterans younger than age 25, men, and Veterans who were more likely to have had greater exposure to combat, e.g., Veterans who were enlisted versus officers, and those who served in the Army and Marines.
    Date: January 28, 2011
  • Suicide Risk Factors for OIF Veterans
    This study examined combat and mental health as risk factors for suicidal ideation among OIF Veterans. Findings show that, overall, 2.8% of the OIF Veterans in the study reported suicidal thinking, the desire for self-harm, or both. Post-deployment depression symptoms were associated with suicidal thoughts, while post-deployment PTSD symptoms were associated with current desire for self-harm. Post-deployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while post-deployment PTSD symptoms mediated the association between killing in combat and the desire for self-harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning Veterans.
    Date: January 22, 2011
  • Telephone-based Care Coordination Intervention Complements Care for Veterans with Dementia and Supports their Caregivers
    This article provides a detailed description of a telephone-based care coordination intervention – Partners in Dementia Care (PDC) – developed for Veterans with dementia and their family caregivers across all stages of the disease. Findings show that, overall, the PDC intervention addresses the diverse needs of Veterans with dementia and their caregivers, including non-medical care issues such as understanding VA benefits, accessing community resources, and addressing caregiver strain. The authors also note that the PDC intervention incorporates several unique features that distinguish it from most other services and programs for dementia caregiving, such as the delivery of the intervention through formal partnerships between VAMCs and local Alzheimer’s Association Chapters, the inclusion of family caregivers, and the breadth of issues addressed for both Veterans and their caregivers. The consumer-directed philosophy of the program enabled Care Coordinators to serve a large number of families in a cost-efficient way, since Veterans and families were taking action on their own with support and guidance from both VA and Alzheimer’s Association care coordinators.
    Date: January 17, 2011
  • Collaborative Care Intervention Improves Depression in Veterans with HIV
    The goal of this study was to adapt an evidence-based primary care model of depression collaborative care for HIV clinic settings (HIV Translating Initiatives for Depression into Effective Solutions [HITIDES])) – and to evaluate its effectiveness. Findings show that the HITIDES intervention was successfully implemented in HIV settings and improved both depression and HIV symptom outcomes. Veterans who participated in the intervention were more likely to report treatment response and remission compared to Veterans in usual care at 6-month follow-up but not at 12-month follow-up. Improved depression response and remission outcomes at 6 but not 12 months suggest that depression symptoms improved more rapidly in the intervention group compared to usual care. Intervention participants also reported more depression-free days over 12 months. Compared to usual care, significant intervention effects also were observed for lowered HIV symptom severity at 6 and 12 months. The authors suggest that the HITIDES intervention may serve as a model for collaborative care interventions in other specialty physical healthcare settings.
    Date: January 10, 2011
  • Peer-Support Interventions May Reduce Symptoms of Depression Better than Usual Care
    Investigators in this study conducted a meta-analysis of published randomized clinical trials (RCTs) to determine whether peer-support interventions resulted in a greater reduction of depression symptoms compared to either usual care or psychotherapy (group cognitive behavioral therapy only). Seven RCTs comparing peer support vs. usual care for depression showed a significantly greater reduction in mean depression scores with peer support. Seven RCTs comparing a peer-support intervention to group cognitive behavioral therapy (CBT) showed no statistically significant difference between group CBT and peer interventions. These findings suggest that peer-support interventions have the potential to be effective components of depression care.
    Date: January 1, 2011
  • Pregnancy and Mental Health Conditions among Female OEF/OIF Veterans Using VA Healthcare
    This study sought to determine the prevalence of mental health problems among 43,078 OEF/OIF women Veterans who received a pregnancy diagnosis in the VA healthcare system over a five-year study period (2003-2008). Although a relatively small proportion of OEF/OIF women Veterans received VA healthcare related to pregnancy (7%), a substantial proportion of these women (32%) received one or more mental health diagnoses compared with 21% of women without a pregnancy-related condition. Compared with all women Veterans enrolled in VA healthcare, Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, PTSD, bipolar disorder, or schizophrenia than those without a pregnancy. The most common mental health diagnoses among Veterans with a pregnancy were anxiety (43%), depression (36%), and PTSD (21%), followed by bipolar disorder (3%), and alcohol abuse/dependence (3%). [Sum is greater than 100% due to comorbidity.] Veterans with a pregnancy were significantly more likely to have a service-connected disability than those without a pregnancy. 71% of Veterans with a pregnancy were either never married or no longer married. On average, women Veterans experienced their index pregnancy nearly two years after returning from their last deployment.
    Date: December 1, 2010
  • Veterans who Commit Suicide May Not Show Apparent Emotional Distress During Last Healthcare Contact
    This retrospective study examined VA healthcare contacts (by phone or in person) by Veterans in the year prior to their deaths by suicide. The majority of Veterans in this study were seen for routine VA medical care in the year prior to committing suicide, and did not show apparent signs of emotional distress at their last healthcare visit. In the year prior to death, nearly 50% of the Veterans had one or more mental health contacts, and 63% had one or more primary care contacts. Just over half of the Veterans received care in the 30 days prior to death, with 20% receiving mental health care and 15% receiving primary care. Forty percent of these Veterans were assessed for suicidal ideation during the year prior to death, and 16% were assessed during their last contact. Nearly three-quarters of those who were specifically asked about thoughts of suicide in the year prior to death denied having such thoughts. The median number of days between final VA healthcare contact and date of death was 42. Of the 26 Veterans whose final contacts were with mental health, 87% were assessed for depression, substance use disorder, or PTSD, and 54% were assessed for suicidal ideation. Of the 22 Veterans whose final contacts were with primary care, 55% were assessed for depression, substance use disorder, or PTSD, and 9% were assessed for suicidal ideation.
    Date: December 1, 2010
  • Differences in Mental Health Diagnoses among OEF/OIF Soldiers Transitioning from DoD to VA Care
    This study assessed the transition of healthcare from DoD to VA for service members traumatically injured in OEF/OIF, and their subsequent psychiatric care. Findings show that although none of the 994 DoD inpatients received a diagnosis of PTSD, 21% (209) had other mental health diagnoses, primarily drug abuse (12%). Of the 216 service members who transitioned to VA care, 71% (153) subsequently had at least one psychiatric diagnosis, with PTSD (52%) and depression (40%) the most common. OEF/OIF service members who were discharged from DoD care in FY06 were more likely to transition into VA care (31%) than were patients discharged in earlier years. Of service members who sought VA care, 38% did so within six months of DoD discharge, and 75% within one year of discharge. Nearly 88% of those service members who transitioned to VA healthcare were still using VA care in the final year of the study, FY09. Treatment retention was significantly greater for those receiving psychiatric care: 98% vs. 62% for those not receiving psychiatric care.
    Date: November 2, 2010
  • Link between Psychiatric Diagnosis and Higher Risk of Suicide among Veterans
    As part of VA’s ongoing evaluation of suicide risk among Veterans being treated in VA facilities, this study examined the impact of different psychiatric diagnoses on the risk of suicide. Findings show that a clinical diagnosis of a psychiatric disorder increased the risk of subsequent suicide by 160%. Psychiatric diagnoses were an especially strong risk factor for suicide among women, increasing their risk of suicide more than 5-fold. Bipolar disorder was the least common diagnosis (only 3% of all Veterans studied), but was diagnosed in approximately 9% of all Veterans who died by suicide. A diagnosis of bipolar disorder increased the risk of suicide nearly 3-fold in men and 6-fold in women. Authors suggest this makes bipolar disorder particularly appropriate for targeted interventions (e.g., improving medication adherence). Overall, suicides were more than three times as common in men than in women and were 37% to 77% more common in Veterans ages 30 and older than among those ages 18 to 29.
    Date: November 1, 2010
  • Providing Free Care for Veterans with Military Sexual Trauma Does Not Result in Major Income Loss to VA
    Since 2002 there have been no co-payments for VA healthcare related to military sexual trauma (MST), defined by VA as sexual assault or harassment that took place during military service. However, eliminating co-payments reduces income for the VA healthcare system. This retrospective study estimated the loss in outpatient co-payment revenue for VA due to the mandate for free care related to MST. Findings show that about 95% of Veterans who received outpatient care for military sexual trauma would have had no co-payment, even in the absence of a free-care mandate. The estimated co-payment revenue foregone by the free-care mandate for MST was modest, totaling about $418,000 in FY06, $517,000 in FY07, and $455,000 in FY08. These totals represented only .04-.05% of first-party co-payment revenues for outpatient care. These results suggest that VA can continue to provide free care for patients who have experienced military sexual trauma without major income loss.
    Date: November 1, 2010
  • Substantial Gaps in Processes of Care for Veterans with Bipolar Disorder
    This study applied a comprehensive set of process of care measures that reflect the integration of psychosocial, patient preference, and continuum of care approaches to mental health – and evaluated whether Veterans with bipolar disorder received care concordant with these practices. Findings show substantial gaps in care for Veterans with bipolar disorder, especially for patient-centered processes such as symptom assessment and treatment experience. Only half of the patients received care in accordance with clinical practice guidelines. Moreover, only 17% had documented assessment of psychiatric symptoms, 28% had documented patient treatment preferences, 56% had documented assessment of substance abuse and psychiatric comorbidity, and 62% had documented assessment of cardiometabolics. Monitoring of weight gain was noted in 54% of the patient charts, and no-show visits were followed up only 20% of the time. However, 72% of the patients received appropriate anti-manic medication, and all patients were assessed for suicidal ideation. Overall, results suggest that in order to present a more patient-centered view of quality, processes of care for bipolar disorder cannot be distilled into a single measure; but rather, a series of patient-centered composite indicators.
    Date: November 1, 2010
  • Gender Differences in Mental Health Diagnoses among OEF/OIF Veterans
    This study examined differences in socio-demographic, military service, and mental health characteristics between female and male OEF/OIF Veterans. Findings show that female OEF/OIF Veterans who were new users of VA healthcare were younger, more often African-American, and more frequently diagnosed with depression. In addition, older age was associated with a higher prevalence of PTSD and depression diagnoses among female Veterans. Male OEF/OIF Veterans who were new users of VA healthcare were more frequently diagnosed with PTSD and alcohol use disorder. Among male Veterans, younger age indicated greater risk for PTSD. Both female and male OEF/OIF Veterans with higher combat exposure were more likely to receive a diagnosis of PTSD.
    Date: October 21, 2010
  • PTSD Associated with Poorer Couple Adjustment and Increased Parenting Challenges among Male OIF National Guard Troops
    This study examined associations among combat-related PTSD symptoms, parenting behaviors, and couple adjustment among male National Guard troops who had served in Iraq (OIF). Findings show that increases in PTSD symptoms were associated with poorer couple adjustment and greater perceived parenting challenges one year post-deployment. Further, PTSD symptoms predicted parenting challenges independently of their impact on couple adjustment. PTSD was associated with higher levels of alcohol use, but alcohol use was not significantly associated with couple adjustment or parenting. Deployment injury also was independently associated with increased PTSD symptoms. Findings suggest that symptoms of PTSD may exert their influence at multiple levels within the family, making transitions from combat to home life even more complicated. This highlights the importance of investigating and intervening to support parenting and couple-adjustment among combat-affected National Guard families, who often lack the support available to active duty families via the military base community.
    Date: October 1, 2010
  • Dementia More Prevalent among Older Veterans with PTSD
    This study sought to determine the association between PTSD and dementia in older Veterans. Findings show that older Veterans with PTSD had twice the incidence and prevalence of dementia diagnoses, even after accounting for confounding illnesses, combat-related trauma (measured by receipt of a Purple Heart), and number of primary care visits. Rates of TBI were highest in the group with PTSD and a Purple Heart, while rates of stroke were slightly higher among all groups with PTSD (regardless of Purple Heart receipt). The prevalence of drug dependence and abuse and the rates of alcohol dependence and abuse were highest in the group with PTSD, but without a Purple Heart. The mechanism for the observed increased incidence and prevalence of dementia among Veterans with PTSD is unknown. Possibilities include a common risk factor underlying PTSD and dementia, or PTSD being a risk factor for dementia. Regardless, the authors suggest that veterans over 65 years of age with PTSD be considered for dementia screening.
    Date: September 1, 2010
  • Measuring the Quality of Mental Healthcare: Barriers and Strategies
    This article discusses the barriers to mental health quality measurement – and identifies strategies to enhance the development and use of quality measures in order to improve outcomes for people with mental health disorders. The authors suggest that key reasons for the lag in mental health performance measurement include: lack of sufficient evidence regarding appropriate mental health care, poorly defined quality measures, limited descriptions of mental health services from existing clinical data, and lack of linked electronic health information. The refinement of quality measures and, ultimately, enhanced outcomes in mental health will require investment in information technology, additional studies to support the evidence base, and the development of a culture of measurement-based care. Sustaining efforts to improve mental health performance measurement will require rethinking how quality measurement is used to promote the uptake of evidence-based mental healthcare across systems of care. In addition, measurement systems should cut across mental health disorders, physical disorders, and substance use disorders, which often co-occur.
    Date: September 1, 2010
  • Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness
    This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains.
    Date: August 1, 2010
  • Medication Management for Veterans with Schizophrenia
    This study examined medication management for a random sample of Veterans who received drug therapy for schizophrenia at any one of three VA mental health clinics in Southern California between 2002 and 2003. Overall, 67% of Veterans had inappropriate management at baseline: 32% had inappropriate management of psychotic symptoms, 45% had inappropriate management of weight, and 8% had inappropriate management of tardive dyskinesia (TD). Further, 11% had depression that was moderately severe or worse. At one year, the appropriateness of management for psychotic and depressive symptoms had not changed. The appropriateness of management of TD also did not change over time, but the management of elevated weight improved modestly. There were no significant differences between the three clinics in the prevalence of symptoms or side effects, or in the appropriateness of medication management. However, psychiatrists with more than 12 patients were significantly more likely to improve their patients’ care over time.
    Date: July 1, 2010
  • Most VA Patients with Substance Use Disorders Who Die from Suicide Use Violent Means
    Most VA patients with substance use disorders (SUDs) who died from suicide used violent means (70%, n=600), and the majority were carried out with firearms. No specific SUD was associated with increased risks of violent suicide, but several SUD diagnoses (e.g., cocaine use and opiate use) were associated with a higher risk of non-violent suicide. Alcohol use was associated with a lower likelihood of non-violent suicide. While many psychiatric disorders (e.g., major depression, PTSD, schizophrenia) were associated with increased risk of both violent and non-violent suicide, the strength of the association between the disorder and type of suicide was greater for non-violent than violent suicide. The authors suggest that by linking data on risk factors to information about the specific methods used, future interventions designed to decrease access to lethal means could be tailored to focus on those at greatest risk of dying by specific means.
    Date: July 1, 2010
  • Military Sexual Trauma: Important Mental Health Issue for OEF/OIF Veterans
    Of the 125,729 OEF/OIF Veterans who received VA primary care or mental health services between 10/01 and 9/07, 15% of women and 0.7% of men reported military sexual trauma (MST) based on results of universal screening that asks about sexual assault or harassment. Women and men who reported a history of MST were significantly more likely than those who did not to be diagnosed with mental health conditions, including PTSD, other anxiety disorders, depression, and substance use disorders. This finding remained consistent after adjusting for demographics, healthcare use, and military service characteristics. The relationship of MST to PTSD was stronger among women compared to men, suggesting that MST may be a particularly relevant issue for women Veterans seeking care for PTSD. There were high rates of post-deployment mental health conditions among all OEF/OIF patients.
    Date: June 17, 2010
  • Majority of National Guard Soldiers Recently Returned from Combat in Iraq Did Not Meet Criteria for Mental Health Disorder
    This study provides the first known report of rates of mental health disorders and comorbidities diagnosed by structured clinical interviews, as opposed to self-report, in a sample of 348 National Guard troops who returned from Iraq. Findings show that a majority (62%) did not meet criteria for a mental health disorder. However, the soldiers had slightly higher rates than community and non-deployed military samples across all mental health diagnoses, with the exception of drug use disorders. Depressive disorders were the most common, followed by non-PTSD anxiety disorders. Mental health diagnoses were associated with poorer functioning and quality of life, with PTSD having the strongest negative relationship with social functioning and quality of life. Results also show that more than 85% of soldiers with a diagnosis of PTSD had at least one additional mental health diagnosis, with depressive disorders being the most common. In addition, female soldiers were significantly more likely to have a mental health diagnosis than male soldiers. Specifically, women were diagnosed with PTSD, depressive disorders, and non-PTSD anxiety disorders at twice the rate of men.
    Date: June 9, 2010
  • Aggression May Be Linked to Psychosis in Elderly Persons with Dementia
    This literature review examined the evidence on whether delusions or hallucinations contribute to the development of agitation or aggression in persons aged 65 and older with dementia. Most studies showed a statistically significant association between psychosis and aggression. Findings also showed that the use of antipsychotic medications in the setting of agitation/aggression and psychosis among patients with dementia is not uniformly supported. Authors note that given the multifactorial etiology of psychosis and aggression with other comorbid symptoms in dementia, it is important to understand the various contributing factors to facilitate more effective treatment interventions with least possible risk.
    Date: June 1, 2010
  • Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings
    Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and quality.
    Date: May 11, 2010
  • All Antipsychotics May Not Increase Short-Term Risk for Mortality among Veterans with Dementia
    Commonly prescribed doses of haloperidol, olanzapine, and risperidone, but not quetiapine, were associated with short-term increases in mortality. During the first 30 days, there was a significant increase in mortality in subgroups prescribed a daily low dose of haloperidol, olanzapine, or risperidone, after adjusting for demographics, comorbidities, and medication history. However, increased mortality was not seen when quetiapine was prescribed. No antipsychotic was associated with increased mortality after the first 30 days. Therefore, the authors suggest that all antipsychotics might not pose the same degree of risk in all patient groups as implied by the general warnings that have been issued.
    Date: May 7, 2010
  • History of Depression Remains a Risk Factor for Heart Disease after Accounting for Other Contributing Factors among Twin Veterans
    A history of depression remained a risk factor for incident heart disease even after adjusting for numerous covariates including: sociodemographics, co-occurring psychopathology, smoking, obesity, diabetes, hypertension, and social isolation. Moreover, twins with both high genetic and phenotypic expression of depression were at greatest risk of ischemic heart disease (IHD). Results also show that twins with hypertension and twins with diabetes were more likely to have IHD, as were twins who reported no social support. Age, race, education, and marital status were not associated with IHD status.
    Date: May 1, 2010
  • Predictors of Veterans’ Use of Mental Health Services
    Findings show that being older, female, having greater clinical need, lack of enabling resources (e.g., employment, stable housing, social support), and fewer problems with access to treatment significantly predicted increased mental health services use over the three-month follow-up period. Results also show that fewer outpatient mental health visits did not adversely affect clinical outcomes. Findings support VA’s ongoing commitment to provide special programs and initiatives focused on easing access to mental health services, vocational rehabilitation, and housing assistance.
    Date: April 1, 2010
  • Rates of Depression Rise among VA Nursing Home Residents
    Prevalence rates for dementia and schizophrenia fluctuated moderately from 1990 to 2006, but rates for depression were substantially higher in 2006 than in 1998. Results also show that PTSD was more prevalent, while the prevalence of alcohol use disorders declined. The prevalence of serious mental illness (e.g., schizophrenia, bipolar and manic disorders) was relatively stable over this time period, except for increases among the oldest residents. Understanding recent changes in the prevalence of mental health disorders among VA nursing home residents can contribute to optimal planning to meet their treatment needs.
    Date: April 1, 2010
  • Aggression is Common among Veterans with Dementia
    Findings showed that 41% of Veterans with newly diagnosed dementia became aggressive within 24 months, corroborating the findings of previous studies that aggression is common in persons with dementia. The use of antipsychotic medications increased significantly in Veterans after they became aggressive, and this group also had a ten-fold greater occurrence of injuries. In addition, almost twice as many aggressive Veterans were admitted to nursing homes. There were no differences in rates of restraint use or in- and outpatient visits between Veterans who became aggressive and those who did not.
    Date: March 1, 2010
  • Interactive Communication between Primary Care and Specialty Care Improves Patient Outcomes
    This meta-analysis showed that interactive communications between collaborating PCPs and specialists were associated with improved patient outcomes. Interactive communication methods included: initial joint patient consultations, regular specialist attendance at primary care team meetings, telepsychiatry with primary care physicians, scheduled phone discussions, and shared electronic progress notes. The studies in this review all involved collaborations with psychiatrists for management of depression and other mental health disorders and with endocrinologists for management of diabetes; however, the consistency of the effects across different primary care-specialty collaborations, healthcare conditions, and study designs suggests the potential for improvement across other specialties and conditions. Effectiveness was enhanced by interventions to improve the quality of information exchange (e.g., needs assessment, joint care planning).
    Date: February 16, 2010
  • Male OEF/OIF Veterans with PTSD More Likely to Perpetrate and Experience Aggressive Behavior toward/from Female Partners
    This study examined the nature and frequency of self-reported partner aggression among three male cohorts recruited from one large VAMC outpatient PTSD clinic: OEF/OIF Veterans with PTSD, OEF/OIF Veterans without PTSD, and Vietnam Veterans with PTSD. Findings show that OEF/OIF Veterans with PTSD were significantly more likely to report psychologically abusing their partners than OEF/OIF Veterans without PTSD. Although other comparisons did not reach significance, results suggested that OEF/OIF Veterans with PTSD were about two to three times more likely than the other two groups to report perpetrating or sustaining violence. OEF/OIF Veterans with PTSD also were six times more likely to report sustaining injury from their female partners than OEF/OIF Veterans without PTSD. Significant correlations among reports of violence perpetrated and sustained suggest many men may have been in mutually violent relationships. In terms of family functioning, 63% of OEF/OIF Veterans with PTSD reported having children in the home. These results emphasize the importance of assessing partner aggression in VA clinical settings in order to provide a more complete psychological picture of Veterans and their families’ potential treatment considerations.
    Date: February 2, 2010
  • Mental Health Treatment Seeking among OIF National Guard Soldiers
    This study sought to determine the rate of reported mental health treatment-seeking in 424 returning OIF National Guard soldiers – and to examine potential barriers to and facilitators of treatment-seeking. Findings show that approximately one-third of the soldiers in this study reported post-deployment mental health treatment through military, VA, or other sources; however, 51% of soldiers who screened positive for PTSD and 40% who screened positive for depression did not report involvement in mental health treatment. Of the 34.7% who reported receiving mental health services, 22.9% had received psychotherapy only, 4.5% received psychiatric medications only, and 7.3% had received both. Reported treatment-seeking was more common among soldiers who screened positive for either PTSD or depression. Injury in-theater, illness-based need (e.g. presence and severity of mental illness), and mental health treatment in-theater were significantly associated with both self-reported psychotherapy and medication treatment-seeking. More positive attitudes regarding mental health treatment were associated with greater reported utilization of both psychotherapy and medication. Findings also indicate that while concerns about stigma were present, they were not associated with reported treatment-seeking behavior.
    Date: February 1, 2010
  • Minority of OEF/OIF Veterans Receive Recommended Treatment for PTSD
    This study examined OEF/OIF Veterans use of VA mental health services within the first year of receiving new mental health diagnoses. Only a minority of OEF/OIF Veterans with newly diagnosed PTSD received a recommended number and intensity of VA mental health treatment sessions within the first year of diagnosis. Of the 49,425 OEF/OIF Veterans with newly diagnosed PTSD, only 9.5% attended >9 VA mental health treatment sessions in 15 weeks or less in the first year of diagnosis. Overall, two-thirds of OEF/OIF Veterans who received new mental health diagnoses from any VA outpatient clinic had at least one follow-up VA mental health visit in the first year of diagnosis, including 80% of OEF/OIF Veterans with a new PTSD diagnosis and nearly 50% with mental health diagnoses other than PTSD. Among the 35,547 OEF/OIF Veterans with new mental health diagnoses other than PTSD, 42.3% were diagnosed with a depressive disorder and 34.1% with an adjustment disorder. Overall, 60.3% received two or more new mental health diagnoses.
    Date: February 1, 2010
  • Prior Violence Associated with Greater Risk of Suicidal Thoughts and Attempts in Patients Seeking SUD Treatment
    Even after accounting for other known risk factors, such as symptoms of depression or childhood victimization, a history of violent behavior was consistently associated with a higher likelihood of lifetime suicidal thoughts and behaviors. Suicidal thoughts and attempts are common in those with substance use disorders (SUD): more than 43% of the participants in this study reported either prior suicide attempts or suicidal ideation at some point in their lives. A history of either suicidal ideation or suicide attempt(s) was more common among substance users who were female and those with a history of depression or childhood abuse.
    Date: February 1, 2010
  • Taking a Life in War Associated with Higher Rates of PTSD and Behavioral/Adjustment Problems in OIF Soldiers
    This study examined the relationship between killing and mental health among 2,797 soldiers returning from Operation Iraqi Freedom (OIF). Overall, 40% of the soldiers in this study reported direct killing or being responsible for killing during their deployment. Taking another life in war was an independent predictor of multiple mental health symptoms. Even after controlling for combat exposure, killing was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems. In addition, 22% of soldiers met threshold screening criteria for PTSD, 32% for depression, and 25% for alcohol abuse. The authors suggest a comprehensive evaluation of Veterans returning from combat should include an assessment of direct and indirect killing and reactions to killing. This information could be part of a treatment plan, including specific interventions targeted at the impact of taking a life.
    Date: February 1, 2010
  • Veterans Diagnosed with Traumatic Brain Injury Significantly More Likely to Experience Mental Illness
    In April 2007, VA implemented national screening for symptomatic TBI resulting from combat exposure. Using VA data for 13,201 OEF/OIF Veterans who were screened for TBI in VISN 23, investigators examined rates of psychiatric disorders in relation to both TBI screening results and post-screening confirmation of TBI status. Findings show that among 836 Veterans with confirmed TBI, 85% had at least one psychiatric diagnosis, and 64% had two or more distinct diagnoses. Compared to Veterans with negative TBI screens, those with positive screens but without confirmed TBI were three times more likely to have PTSD – and were two times more likely to have depression and substance-related diagnoses. Veterans with clinically confirmed TBI were more likely than those with positive screens but no confirmed TBI to have diagnoses of PTSD, anxiety, and adjustment disorders. Nearly half of all OEF/OIF Veterans screened for TBI in VISN 23 had at least one psychiatric disorder, with PTSD (25.9%) and depression (25.6%) being the most common.
    Date: February 1, 2010
  • Therapy via Video-Teleconference as Effective as In-Person Treatment in Reducing Anger Problems in Veterans with PTSD
    Cognitive behavioral therapy (CBT) anger management conducted via video-teleconference was as effective as in-person delivery of the same treatment in reducing anger problems among Veterans with PTSD who live in rural settings. Moreover, mean improvements in the video-teleconferencing group were actually slightly larger than in the in-person treatment group. Veterans in both treatment groups benefited from anger management therapy (AMT), making this one of the few large randomized controlled trials to show meaningful benefits for reducing anger problems in Veterans with PTSD. Veterans in both treatment groups reported high rates of treatment credibility, satisfaction with care, homework adherence, and high alliance with the therapist.
    Date: January 26, 2010
  • Affective Disorders Strongest Predictor of Suicidal Behavior in Elderly Veterans Receiving Anti-Epileptic Medication
    In January 2008, the FDA issued an alert indicating that anti-epileptic drug (AED) treatment is associated with increased risk for suicidal ideation, attempt, and completion. This study sought to assess variation in suicide-related behaviors in a population not well-represented by the data used for the FDA analysis – individuals 66 years and older with new exposure to AEDs. Findings show that in older Veterans who were started on AED monotherapy, the strongest reliable predictor of suicide-related behaviors was the diagnosis of an affective disorder prior to AED treatment. Increased suicide-related behaviors were not associated with individual AEDs. However, while most Veterans in this study received AED prescriptions for gabapentin (76.8%), a trend for increased suicide-related behaviors was found among those prescribed levetiracetam or lamotrigine, but interpretation was difficult since few Veterans received either drug (0.6%). The associations between suicide-related behaviors and chronic pain or chronic disease burden were not statistically significant, but dementia was significantly associated with suicide-related behaviors (42.2% with dementia vs. 25.8% without).
    Date: January 11, 2010
  • Cost/Benefit of Collaborative Care Intervention for Veterans with Chronic Pain and Depression
    This study reports on the incremental benefit (pain disability-free days – PDFDs) and incremental health services costs of the Study of the Effectiveness of a Collaborative Approach to Pain (SEACAP) intervention from a VA healthcare perspective. Findings show that the collaborative care intervention resulted in more pain-free days for Veterans with chronic pain and depression, but was more expensive than usual care. Veterans in the intervention group experienced an average of 16 additional PDFDs over the 12 month follow-up period compared to Veterans in the treatment as usual group, with a cost per PDFD of $364 (overall, about $2300 per patient during the study year). Study results also show that important predictors of costs were baseline medical comorbidities, depression severity, and prior year treatment costs.
    Date: January 1, 2010
  • Lower Quality of Care for Cardiometabolic Disease among Veterans with Mental Disorders, Regardless of Rural or Urban Dwelling
    Mental disorders (MD) were associated with a decreased likelihood of obtaining quality cardiometabolic care. When compared to those without MD, Veterans with MD were less likely to receive diabetes sensory foot exams, retinal exams, and renal tests. Rural residence was not associated with differences in quality measures. Primary care visit volume was associated with a greater likelihood of obtaining diabetic retinal exam and renal testing, but did not explain disparities among patients with MD.
    Date: January 1, 2010
  • Validity of Mental Health Diagnosis Using VA Administrative Data
    This study estimated the validity of eight ICD9-based algorithms for the identification of mental health disorders in administrative data among 124,716 Veterans with diabetes who used the VA healthcare system in 1998, and also participated in the 1999 Large Health Survey of Veteran Enrollees, which included questions about history of mental health diagnoses. Findings show that many Veterans with a diagnosed mental health disorder can be identified through VA administrative data; however, the choice of algorithm influenced conclusions. Since the limitations of administrative data cannot be fully eliminated with any algorithm, the authors suggest that investigators and quality improvement programs also consider conducting sensitivity analyses in which they vary the algorithm, in order to indicate how different assumptions affect conclusions.
    Date: January 1, 2010
  • Effectiveness of Residential Substance Use Disorder Programs in Treating Veterans with SUDs and Mental Illness
    This study compared processes and outcomes for alcohol-dependent Veterans with and without comorbid psychiatric illness at one and five years following treatment in 15 residential substance use disorder (SUD) treatment programs affiliated with VA. Findings show that dually-diagnosed (DD) Veterans did not perceive SUD programs as positively as Veterans with SUD alone, and DD Veterans had worse proximal outcomes at discharge from treatment. For example, DD patients saw fewer benefits to quitting and had less self-efficacy in regard to staying abstinent. Results also showed that dually-diagnosed Veterans did as well as SUD patients on 1-year and 5-year substance use outcomes but had worse psychiatric outcomes. Veterans from both groups who perceived treatment more positively and had better outcomes at discharge had better longer-term outcomes; however, DD patients perceived the programs to be less supportive and clear, and were less satisfied with treatment. The authors suggest that SUD programs either need to add resources directed toward treating psychiatric problems, or that DD Veterans need to be treated in sequential or integrated programs. They note, however, that standard SUD programs may offer more components of integrated treatment than standard psychiatric programs do.
    Date: December 1, 2009
  • Older Elderly Patients Experience Poorer Outcomes Following Collaborative Depression Care
    This study examined the differences between young-old (age 60 to 74) and old-old (age 75 and older) patients who received collaborative depression care as part of the IMPACT (Improving Mood: Promoting Access to Collaborative Treatment) study, which include both VA and non-VA patients. Findings show that young-old and old-old patients who receive collaborative depression care have a similar initial clinical response, but old-old patients may have a lower rate of long-term treatment response and complete remission. For example, young-old and old-old patients randomized to the IMPACT intervention responded similarly to initial treatment at 3 months, but the old-old were less likely to respond to treatment at later follow-up intervals. Treatment response and remission rates peaked for both age groups at 6 months, although treatment response rates for the young-old were significantly higher than those for the old-old group (51% vs. 44%). Study findings also show that the process of care did not differ between young-old and old-old patients who received the IMPACT intervention.
    Date: December 1, 2009
  • Veteran Minorities Equally Likely to Receive PTSD Treatment
    This study sought to determine the rates of mental health use in the six months after Veterans received a PTSD diagnosis – and to examine whether service use varied by race or ethnicity. Findings show that minority Veterans were similar to Whites in the likelihood of receiving VA mental health treatment in the six months following a diagnosis of PTSD. Of the 20,284 Veterans with PTSD in this study, 50% received psychotropics, 39% received counseling, and 64% received at least one of these forms of treatment. However, only 24% who received any counseling had at least eight sessions, and most had only one session. These findings indicate that possible treatment preferences exist. The authors suggest that incorporating preferences into treatment planning may facilitate treatment retention and help to maximize treatment outcomes for all Veterans with PTSD.
    Date: December 1, 2009
  • Mental Illness and Substance Use Disorders Highly Prevalent Among Veterans with Spinal Cord Injury
    Using VA and Medicare data, this study sought to estimate the prevalence of mental illness and substance use disorders (SUDs) among 8,338 Veterans with spinal cord injury (SCI) who used outpatient or hospital care in VA or Medicare facilities between FY00 and FY01. Findings show that mental illness and SUDs are highly prevalent among Veterans with SCI. Overall, 47% of the Veterans in this study had either a mental illness or SUD. The most common mental illness was depression (27%), followed by anxiety (10%) and PTSD (6%). Tobacco use also was prevalent (19%), followed by alcohol (9%) and illicit drugs (8%). Moreover, mood and anxiety disorders were highly prevalent among those with chronic physical conditions such as diabetes, hypertension, and COPD. Results also showed that women Veterans had higher rates of mental illness and lower rates of SUD, and were significantly more likely to have mental illness only. In addition, as the duration of SCI increased, the likelihood of mental illness or SUD alone or in combination decreased.
    Date: November 1, 2009
  • Substance Abuse is Strongest Predictor of Suicide among Veterans with Depression
    This study was an analysis designed to derive an empirically-based set of interactions related to rates of suicide in a national sample of VA patients diagnosed with depression. Findings show that among Veterans with depression those at highest risk for suicide have the combined risk factors of a substance use disorder (SUD), non-African American race, and a psychiatric inpatient stay in the past 12 months. Substance use disorder was also identified as the strongest single risk factor for suicide. Among Veterans without a substance use disorder, gender was the strongest predictor of suicide risk – rates were significantly higher for men than for women. Ethnicity also was related to suicide risk in this group. African American Veterans without an SUD were less likely to die by suicide compared to non-African American Veterans. The authors suggest that providers treating patients with these characteristics should be aware of these risks and consider target strategies to screen for current suicidal ideation.
    Date: November 1, 2009
  • Veterans with Psychosis More Likely to Die from Heart Disease
    This study assessed whether Veterans with mental disorders receiving care in the VA healthcare system were more likely to die from heart disease than Veterans without these disorders, and whether modifiable factors may explain mortality risks. Findings show that compared to Veterans without a mental health diagnosis, Veterans with psychosis (schizophrenia or other psychotic disorder diagnoses) were more likely to die from heart disease. Smoking and physical inactivity were the behavioral factors most strongly associated with mortality related to heart disease. Veterans with schizophrenia were the most likely to be current smokers, and those with bipolar disorder were the least likely to report adequate physical activity. Controlling for behavioral factors (e.g., smoking and physical inactivity) diminished but did not eliminate the impact of psychosis on mortality. The authors suggest that to reduce mortality related to heart disease, early interventions that promote smoking cessation and physical activity among Veterans with psychotic disorders are warranted.
    Date: November 1, 2009
  • Aggressive Behavior Prevalent in Veterans with Dementia
    This study examined aggressive behavior in 400 community-dwelling Veterans, 60 years or older and newly diagnosed with dementia at one VAMC, who were non-aggressive at the beginning of the study. Findings show that 40.9% of initially non-aggressive Veterans with dementia became aggressive within the 24-month study period, and most aggression was verbal. Verbal aggression was associated with the highest levels of disruptiveness, with 69.3% of verbally aggressive behaviors considered moderately or extremely disruptive, while 39.8% of physically aggressive behaviors and 12.5% of sexually aggressive behaviors were considered moderately or extremely disruptive. Results also show that most caregivers were women (94%), and there were no significant differences found in aggressive vs. non-aggressive Veterans with dementia in terms of demographics.
    Date: October 1, 2009
  • Barriers to Dementia Diagnosis
    The goals of this study were to ascertain what is known about the prevalence of missed and delayed diagnosis of dementia in primary care, and to identify factors contributing to problems in diagnosis. While the findings did not definitively determine the prevalence of missed or delayed dementia diagnoses, estimates suggest that the number is substantial. Major barriers to diagnosing dementia included patient/provider communication (e.g., poor provider communication skills, language barriers), education deficits (e.g., belief that little or nothing can be done to treat dementia), and system resource constraints (e.g., time constraints for office visits). Attitude problems also were found; for example, among providers, a major barrier often noted was the attitude that diagnosis, particularly in the early stages of dementia, was more harmful than helpful, while patients often feared and/or denied cognitive problems.
    Date: October 1, 2009
  • Determinants of Veteran Treatment-Seeking for PTSD
    This study explored determinants of PTSD treatment initiation among 21 treatment-seeking and 23 non-treatment-seeking Veterans who had served in Vietnam, or the current conflicts in Afghanistan and Iraq (14 of the 44 participants were women Veterans). Findings show that both Veterans who were and were not in treatment for PTSD described similar factors that hindered their help-seeking, including their own values and priorities (e.g., pride in self reliance), treatment-discouraging beliefs (e.g., providers would not believe them, or would treat them as if they were “crazy”), and trauma-related avoidance (e.g., avoiding discussion of the traumatic event). They also cited an invalidating post-trauma environment as a detriment to seeking treatment; for example, some women cited a military culture that silenced the reporting of sexual assault. But for some participants, facilitators located within the healthcare system and Veterans’ social networks led to help-seeking despite individual-level barriers. In some cases, it was a trusting relationship with the primary care provider that led the Veteran to follow the provider’s recommendation to seek mental health care. This suggests that factors outside the individual can promote mental health service use for PTSD, even when the Veteran is reluctant.
    Date: October 1, 2009
  • Use of Medicare and VA Healthcare among Veterans with Dementia
    This study sought to characterize healthcare use among Veterans with dementia over a four-year period (1998-2001), and to determine predictors of whether a Veteran will be a VA-only, dual, or Medicare-only user. Findings show that during the four-year study period, Medicare-only use increased while VA-only use decreased. Results also show that an increased likelihood of some Medicare use was associated with being older, white, married, and having higher education, private insurance or Medicaid, and low VA priority level. Further, the number of functional limitations was associated with an increased likelihood of Medicare-only use and a decreased likelihood of VA-only use, while higher comorbidities were associated with a higher likelihood of dual use as opposed to any single system use. The authors suggest that these results imply that different aspects of Veterans’ needs have differential effects on where Veterans seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure patients receive high quality care, particularly among those with multiple comorbidities.
    Date: October 1, 2009
  • OEF/OIF Veterans with Mental Health Diagnoses, Particularly PTSD, Use More Non-Mental Health VA Services
    Using national data from all returning OEF/OIF Veterans (N=249,440) who used VA healthcare between 10/01 and 3/07, this study sought to examine the association of PTSD and other mental disorders with non-mental health outpatient, inpatient, and emergency services utilization. Findings show that OEF/OIF Veterans diagnosed with mental health disorders had significantly greater utilization of all types of non-mental health care services than OEF/OIF Veterans with no mental health diagnoses. In adjusted analyses, compared with OEF/OIF Veterans without mental disorders, those with mental disorders other than PTSD had 55% greater utilization of all non-mental health outpatient services; Veterans with PTSD had 91% higher utilization. Results also showed that female gender and lower rank were independently associated with greater utilization. The authors suggest that as more Veterans return home, many with mental and physical injuries, evaluating the capacity of VA and other healthcare systems to meet their needs will be increasingly important.
    Date: September 29, 2009
  • Ethnic Disparities in the Treatment of Veterans with Dementia
    This study sought to determine if there were ethnic disparities in the evaluation and treatment of dementia among 410 Veterans treated at one VAMC between 4/05 and 6/05. Findings show that while laboratory and imaging workup (i.e., CT, MRI) did not differ between ethnic groups, there were significant differences in the treatment of dementia. For example, African American Veterans with dementia were 40% less likely than all other patients to receive acetylcholinesterase inhibitors. This treatment disparity did not appear to be due to differences in the evaluation of dementia, which was similar across groups, although significantly more Caucasian Veterans (43.8%) underwent neuropsychological testing compared to African American (24.8%) or Hispanic Veterans (32.4%).
    Date: September 1, 2009
  • Mental Health Diagnoses Associated with Cardiovascular Risk Factors among OEF/OIF Veterans
    Studies of Veterans from prior wars found that those with PTSD are at increased risk of developing and dying from cardiovascular disease, but this risk had not yet been evaluated in OEF/OIF Veterans. This article discusses findings from a study on the association between mental health disorders, including PTSD, and cardiovascular risk factors. Findings show that OEF/OIF Veterans (male and female) with mental health diagnoses had a significantly higher prevalence of cardiovascular risk factors (e.g., hypertension, obesity, diabetes, tobacco use). The association between mental health diagnoses and cardiovascular risk factors remained after adjusting for demographics and military factors. The most common mental health diagnosis was PTSD (24%). The majority of Veterans with PTSD had comorbid mental health diagnoses: depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), as well as other psychiatric diagnoses (33%).
    Date: August 5, 2009
  • Regular Primary Care Associated with Better Survival Rates for Veterans with Schizophrenia and Diabetes
    Medical comorbidity among aging people with schizophrenia is common and many patients with schizophrenia have difficulty managing their medical healthcare needs, which may result in delayed treatment and poor outcomes. This retrospective cohort study assessed whether patterns of VA primary care use among Veterans with diabetes, schizophrenia , or both were a significant predictor of mortality over the study period (FY02-FY05). Findings show that regular primary care and high levels of primary care were associated with better survival for patients with chronic illness, whether psychiatric or medical. For example, increasing use of primary care was least common among Veterans with schizophrenia only (4%) compared with Veterans with diabetes only (7%), or those with both conditions (8%), – and was associated with improved survival. This suggests that innovations in treatment retention targeting at-risk groups can offer significant promise of improving outcomes.
    Date: July 26, 2009
  • Mental Health Diagnoses among OEF/OIF Veterans Increased Rapidly Following Invasion of Iraq
    This study sought to investigate longitudinal trends and risk factors for mental health diagnoses among OEF/OIF Veterans. Findings show that the prevalence of new mental health diagnoses among OEF/OIF Veterans using VA healthcare increased rapidly following the Iraq invasion. Among the 289,328 Veterans in this study, new mental health diagnoses increased 6-fold from 6.4% in April 2002 to 36.9% by March 2008. 21.8% of Veterans were diagnosed with post-traumatic stress disorder (PTSD), and 17.4% with depression. Two-year prevalence rates of PTSD increased 4-7 times after the invasion of Iraq. The youngest active duty OEF/OIF Veterans (< 25 years) were at nearly twice the risk for PTSD, more than twice the risk for alcohol use disorders, and at a nearly 5-fold risk for drug use disorders than older active duty Veterans (> 40 years). Among National Guard/Reserve Veterans, those older than age 40 were at greater risk for PTSD and depression. Women Veterans from both service components (active duty and Guard/Reserve) were at higher risk for depression, while male Veterans were at greater risk for drug use disorders. Authors suggest that early targeted interventions may prevent chronic mental illness.
    Date: July 16, 2009
  • Smoking Cessation Services for Veterans in VA Psychiatric Facility
    This study had two goals: 1) determine staff characteristics that are associated with attitudes about providing smoking cessation services to Veterans who are psychiatric patients, and 2) seek suggestions from staff about what would be important to include in a tobacco cessation program. Findings show that nearly 75% of staff in this study thought that VA should do more to assist Veterans to quit smoking, yet only about 25% said that they personally provide cessation services. However, more than 50% felt moderately, very, or extremely confident in providing cessation services. Interestingly, nurses were less likely than other staff to feel that it was important to provide cessation services, which could be because of competing job demands. The most common reasons given by all respondents for not providing services were not enough time and lack of training. When asked how VA could best assist smokers to quit, most responses focused on educating Veterans about tobacco use and how they can quit, as well as providing tobacco cessation medications.
    Date: June 1, 2009
  • High Rate of Suicidal Ideation among Veterans with Bipolar Disorder
    Some suicidal ideation within the past two weeks was reported in 49% of Veterans with bipolar disorder in this study. Approximately 32% of the Veterans reported suicidal ideation for several days, 9% reported suicidal ideation more than half of the days, and 8% reported experiencing it nearly every day. Elevated rates of suicidal ideation were found in Veterans who reported drug use, poorer mental health status, and poorer general functioning. After accounting for current mood state and other risk factors, even minimal increases in the extent to which Veterans perceived their therapeutic relationship as collaborative were associated with a reduction in the risk of suicidal ideation.
    Date: May 1, 2009
  • Strong Association between Homelessness and Incarceration among Veterans with Bipolar Disorder
    This study assessed the association between homelessness and incarceration in 435 Veterans with bipolar disorder who received inpatient or outpatient care at one large, urban VAMC from 7/04 to 7/06. Findings show that homelessness and incarceration are common among Veterans with bipolar disorder, and share many risk factors. Among Veterans with bipolar disorder, 12% reported having been homeless in the previous four weeks, and 55% reported ever having been homeless or incarcerated. Results also show that lifetime experience of homelessness was associated with 4-fold increased odds of lifetime experience of incarceration. Moreover, recent homelessness was strongly related to recent incarceration. Programs that better coordinate psychiatric and drug treatment with housing programs may reduce the cycle of incarceration, homelessness, and treatment disruption among this vulnerable patient population.
    Date: May 1, 2009
  • Suicide Risk Significantly Higher for VHA Patients Compared to the General Population
    Suicide rates among the Veterans enrolled in the VA healthcare system during FY00 and FY01 were found to be significantly higher than those in the general population. However, the differentials between suicide rates for VA patients and the general population were less than what might be expected given previous comparisons. Overall, for men and women combined, suicide risks among Veterans were 66% higher than those observed in the general population. Among male Veterans, suicide rates were highest for those aged 30-49 years and lowest among Veterans aged 18-29 and 60-69. Among women Veterans, suicide rates were highest among those aged 50-59 years. It is important to emphasize that this study compares a general population to users of a health care system where the prevalence of all conditions would be expected to be higher. Also, the study population precedes current conflicts in Iraq and Afghanistan.
    Date: April 15, 2009
  • Access to Healthcare among Veterans with Bipolar Disorder
    Findings from this study show that despite the fact that all Veterans were currently receiving VA treatment for bipolar disorder, 15%-20% experienced trouble obtaining different aspects of healthcare when needed. Compared with accessing psychiatric care, Veterans with bipolar disorder reported greater difficulty accessing general medical services. Veterans experiencing current bipolar symptoms more frequently avoided psychiatric care due to cost, and perceived greater problems accessing medical specialists. As with mental healthcare services, the dominant influences predicting limitations in obtaining needed general medical care included living alone, an inpatient stay, homelessness, and current bipolar symptoms. The authors suggest that current VA efforts to expand mental healthcare access should be coupled with efforts to ensure adequate access to medical services for Veterans with chronic mental illness.
    Date: April 1, 2009
  • Primary Care-Based Collaborative Care for Chronic Pain May Be More Effective than Usual Care
    A primary care-based collaborative care intervention for chronic pain was significantly more effective than usual care across a variety of outcome measures, including pain disability and intensity. However, these improvements were generally modest. Depression severity and pain disability and intensity improved among Veterans in the intervention group who reported both chronic pain and depression. Greater use of adjunctive pain medications and long-term opioids among the intervention group suggested that the intervention contributed to the delivery of guideline-concordant care.
    Date: March 25, 2009
  • Areas for Mental Health Intervention for Patients with Hepatitis C
    In addition to the physiological side effects of treatment for the hepatitis C virus (HCV), there also can be significant neuropsychiatric effects such as depression, anxiety, psychosis, and suicidality. Moreover, numerous studies have documented the high prevalence of pre-existing psychiatric disorders among patients with HCV. This article reviews the psychological and psychosocial issues that are relevant to patients with HCV and provides mental health treatment recommendations. Some of these issues include stigma (i.e., more than half diagnosed with HCV have experienced discrimination) and social support. The authors also identify areas in which clinicians can intervene, including adjustment to having a chronic medical illness, management of side effects, and implementing healthy lifestyle recommendations.
    Date: March 1, 2009
  • Assessing Healthcare Utilization among Veterans with Depression
    Nearly half of VA primary care patients with significant depressive symptoms also used non-VA care. Among dual users, 94.9% used both VA and non-VA care for physical health problems, but only 20.3% used both for emotional health problems. Lower levels of alcohol use and the presence of PTSD were associated with the use of non-VA outpatient care for emotional health services. Authors suggest that care management strategies for Veterans with depression should include communication and coordination with non-VA providers.
    Date: March 1, 2009
  • Costs Associated with Providing Depression Care in the Primary Care Setting
    This study reports on organizational costs associated with depression care quality improvement, specifically introducing an evidence-based depression model – Translating Initiatives in Depression into Effective Solutions (TIDES) Project – into VA primary care settings. Findings show that organizational costs for the TIDES project (in the locations studied) were significant, and should be accounted for in planning the implementation of evidence-based depression care.
    Date: February 1, 2009
  • Hybrid Quality Improvement Approach May Be Best
    There is a growing consensus that a hybrid of two common approaches to quality improvement (QI) – local participatory QI and central expert QI – might be the best method for achieving quality care across a variety of conditions. This study examined preferen