- Lack of Awareness among VA Providers about Risk Associated with Prescribing Inhaled Corticosteroids to Veterans with
More than 50% of patients with mild-to-moderate
COPD in the U.S. are prescribed inhaled corticosteroids despite recommendations to restrict use to patients with frequent breathing exacerbations. This study explored VA primary care providers’ experiences prescribing inhaled corticosteroids among Veterans with mild-to-moderate
COPD. Of the Veterans with
COPD in this study cohort, 15% were prescribed an inhaled corticosteroid. However, 61% of these prescriptions were not clinically indicated. Providers reported being unaware of current evidence and recommendations for prescribing inhaled corticosteroids; e.g., 46% of providers reported they were unaware of the risk of pneumonia. Providers also reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. Some providers expressed reluctance to change or stop prescribing if their patient was doing well. However, 52% of providers reported they would make an effort to reduce the use of inhaled corticosteroids, and 50% reported that they would make an effort to make greater use of alternative guideline-recommended medications. Study results corroborate prior findings that lack of awareness of current evidence-based guidelines is likely an important part of medical overuse. Efforts to expand access to care by increasing the number of prescribing providers a patient sees could make it more difficult to de-implement harmful prescriptions.
Date: August 8, 2019
- Brief Cognitive Behavioral Therapy Reduces Suicidal Ideation among Veterans with Chronic Illness
Brief cognitive behavioral therapy (bCBT) intervention delivered by VA mental health providers in primary care settings is effective for depression, anxiety, and improves physical health quality of life. Investigators in the current study determined the effect of bCBT on suicidal ideation among Veterans with cardiopulmonary chronic illness receiving mental health treatment in a VA primary care setting. Findings showed that bCBT in primary care reduced suicidal ideation in Veterans with chronic medical illness. Veterans in the bCBT group were less likely to have high suicidal ideation than Veterans in the EUC group post-treatment and at 8-month follow-up after accounting for baseline suicidal ideation. Results suggest that exposure to a brief evidence-based psychotherapy intervention in primary care may significantly reduce distress and suicidal ideation over a prolonged period of time, potentially reducing future suicide-related distress and/or attempts among a high-risk Veteran population.
Date: February 8, 2019
- 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
- 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
- Decreases in VA Hospital Length-of-Stay and Readmission Rates over 14 Years
This study sought to determine trends in hospital length of stay (LOS) and 30-day readmission rates in the VA healthcare system. Findings showed that VA hospitals demonstrated simultaneous improvements in hospital LOS and readmission rates from 1997 to 2010. This demonstrates that LOS reductions have not, thus far, adversely affected the likelihood of hospital readmission. For all medical diagnoses combined, the risk-adjusted mean hospital LOS decreased by 2% annually. Reductions in LOS also were observed for five specific common diagnoses, with the greatest reductions for acute myocardial infarction (2.9 days) and pneumonia (2.2 days). Risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 17% to 14%. Reductions also were observed for the five common diagnoses, with greatest reductions for AMI (23% to 20%) and
COPD (18% to 15%). All-cause mortality 90 days after admission was reduced by 3% annually.
Date: December 18, 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
- 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
- VA Residency Training Program Rankings May Predict Cost of Care but not Hospital Readmission or Mortality Rates
Investigators in this natural experiment analyzed data from nearly 30,000 Veterans from one large, urban VA hospital who had been randomly assigned by standard hospital procedure to teams comprised of physicians affiliated with one of two medical/surgical residency training programs. One program was affiliated with one of the higher-ranked medical schools in the U.S., while the other program ranked lower. Findings show that Veterans treated by a team of VA physicians affiliated with a higher-ranked medical/surgical residency training program had 10% lower healthcare costs compared to Veterans at the same hospital who were treated by a team of VA physicians affiliated with a lower-ranked training program – and up to 25% lower costs for more complicated conditions (e.g., heart failure,
COPD). Differences in cost largely were the result of diagnostic-testing rates: the physician team affiliated with the lower-ranked program took longer to order tests, and ordered more of them. Hospital readmission rates and mortality were unrelated to the physicians’ training program.
Date: October 1, 2010
- Simple Disease Management Program Significantly Reduces Hospitalizations and ED Visits for Veterans with
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
- 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
- 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
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
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