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HSR&D Publication Briefs
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  • Underuse of Statins among Veterans with Hypercholesterolemia
    This study sought to examine the prevalence and treatment of Veterans with uncontrolled severe hypercholesterolemia who received VA healthcare. Findings showed a marked underuse of statins in Veterans with uncontrolled severe hypercholesterolemia. Within six months of this abnormal lab value, only 52% were being treated with statins, and less than 10% were on high-intensity statin therapy as recommended by the 2013 ACC/AHA guidelines. Older (over age 75) and younger (under age 35) Veterans were less likely to be treated. Women also were less likely to be treated with statins, whereas minority groups and those with a diagnosis of hypertension were more likely to be treated. Black Veterans were significantly more likely to be on high-intensity statin therapy as compared with Whites (12 vs. 9%), as were those with hypertension (11 vs. 8%) and renal disease (12 vs. 9%). Significant improvement is needed in order to meet guideline-recommended care for Veterans with uncontrolled severe hypercholesterolemia.
    Date: September 1, 2018
  • Impact of Intensive BP Therapy on Patient-Reported Outcomes
    This randomized controlled trial compared two strategies for managing systolic blood pressure (SBP) in older adults with hypertension – an intensive strategy with an SBP target of <120 mmHg versus a standard care strategy targeting <140 mmHg – and whether such intensive therapy affects patient-reported outcomes. Findings showed that intensive therapy resulted in a 14.8 mmHg lower blood pressure compared to standard therapy; however, this had little impact on changes in patient-reported outcomes and adherence. The majority of participants in both groups reported that they were satisfied or very satisfied with their blood pressure care: 89% vs 88% in intensive and standard groups respectively. Overall, 44% of participants reported high adherence with blood pressure medications at 12 months, and no differences were noted between the intensive and standard treatment groups. Results provide reassurance that intensive hypertension therapy not only reduces cardiovascular morbidity and mortality, but will be well-tolerated, even in older patients with multiple comorbidities.
    Date: August 24, 2017
  • 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
  • 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
  • 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
  • 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
  • Study Shows No Evidence that Dual Use of VA and Medicare Advantage Results in Worse Patient Outcomes
    This study assessed characteristics of Veterans who were dually enrolled in both VA and Medicare Advantage (MA) – managed care plans administered by private health insurance companies that contract with the Centers for Medicare and Medicaid Services. This study also compared quality of care using intermediate quality outcomes among Veterans exclusively receiving outpatient care in VA with Veterans receiving outpatient care in both systems. No evidence was found that Veterans with dual use of VA and Medicare Advantage experienced either improved or worsened intermediate outcomes compared with Veterans who exclusively used VA healthcare. Outcomes were marginally better for VA-only users on the measures related to hypertension control and CHD control. Conversely, dual VA-MA users experienced slightly better outcomes on measures relating to diabetes control. Dually-enrolled Veterans with fewer VA outpatient visits had comparable outcomes to Veterans with many VA outpatient visits, suggesting the absence of a threshold number of VA visits for achieving better intermediate outcomes in diabetes, hypertension, and heart disease.
    Date: April 6, 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • “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
  • 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
  • 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
  • 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
  • Adoption of PACT Features is Significantly Associated with Lower Risk of Avoidable Hospitalization
    The primary outcome measured in this study was potentially avoidable hospitalizations for ambulatory care sensitive conditions (ACSC) that included: asthma, angina without procedure, pneumonia, dehydration, COPD, congestive heart failure, complications related to diabetes, hypertension, perforated appendix, and urinary tract infection. In addition, the total number and costs of ACSC hospitalizations were measured for each Veteran during a 12-month follow-up period. Findings showed that greater adoption of medical home features by VA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations. Veterans in clinics with the highest medical home adoption had significantly lower ACSC rates (20 per 1,000) compared to Veterans in clinics with the lowest (25 per 1,000) and medium (26 per 1,000) adoption of medical home features. If clinics were transformed from the mean level of medical home adoption to the maximum level, the reduction in hospitalization costs in an average-sized clinic with 3,500 Veterans could be as much as $83,000 annually. Two PACT features were independently related to lower risk of ACSC hospitalization: access and scheduling, and care coordination/transitions in care. For example, Veterans in clinics with the highest scores on access and scheduling had 17% lower odds of having an ACSC admission compared to the lowest scoring clinics.
    Date: March 26, 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
  • 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 clinicians 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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