- Increased Hospice Care for Veterans Associated with Less Aggressive Medical Treatment and Lower Medical Costs
This study sought to determine if increased availability of hospice for Veterans is associated with reduced aggressive treatments and medical care costs at the end of life. Findings showed that Veterans with newly diagnosed end-stage lung cancer treated at VAMCs with the most expansion in hospice use had a significantly greater likelihood of receiving chemotherapy or radiation therapy after hospice enrollment – but a lower likelihood of having aggressive treatment or intensive care unit use, compared with similar Veterans treated in VAMCs with low hospice growth. Thus, increasing hospice availability – without restricting treatment access for Veterans with advanced lung cancer – was associated with less aggressive medical treatment and significantly lower medical costs, while still enabling Veterans to receive cancer treatment. Veterans treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care. Radiation therapy was more common than chemotherapy. The six-month costs were lower by an estimated $266 per day for the high-quintile group vs. the low-quintile group. There was no survival difference through 180 days post-diagnosis. The substantial reduction in healthcare costs suggests that the investment in hospice care that VA made has paid off, and will likely continue to pay off without restricting Veterans’ access to radiation and chemotherapy.
Date: March 28, 2019
- Men Using VA More Likely to Receive Appropriate Prostate Cancer Imaging Tests Compared to Those Using Medicare
This study sought to assess the association between the quality of healthcare within VA vs. Medicare, by comparing rates of guideline-concordant and guideline-discordant staging imaging among patients with newly diagnosed prostate cancer utilizing VA services only, Medicare only, or a combination of the two. Findings showed that among men with low-risk prostate cancer, the VA-only and VA-Medicare groups were most likely to receive guideline-concordant care (61% and 56%, respectively) compared with the Medicare-only group (53%). Among men with low-risk prostate cancer, more in the Medicare-only group received at least one inappropriate, guideline-discordant imaging test for staging (53%) compared with the VA-Medicare group (51%) and the VA-only group (46%). For men diagnosed with high-risk prostate cancer, guideline-concordance was similar across the 3 groups, with 71% of the VA-Medicare group, 69% of the VA-only group, and 67% of the Medicare-only group receiving guideline-concordant imaging. Findings suggest that Veterans using the Choice Act to seek care outside VA may experience more utilization of care with no guarantee of improved quality of care.
Date: August 17, 2018
- Increase in Conservative Management of Veterans with Low-Risk Prostate Cancer Suggests Reduction in Over-Treatment
Investigators assessed utilization of conservative management among Veterans by examining treatment patterns for Veterans diagnosed with low-risk prostate cancer. Untreated Veterans were classified as receiving conservative management through either active surveillance (> 2 PSAs and 1 biopsy within 2 years after diagnosis) or watchful waiting. Findings showed that utilization of conservative management increased among both men younger than 65 years and those 65 or older. The increase was primarily due to greater use of active surveillance. Among Veterans diagnosed with low-risk prostate cancer, 52% were treated and 48% received conservative management. Of those who received conservative management, 30% received watchful waiting and 18% received active surveillance. Utilization of conservative management has increased significantly among Veterans with low-risk prostate cancer, suggesting a substantial reduction in over-treatment during the past decade.
Date: June 5, 2018
- VA’s Lower Intensity Treatment of Kidney Failure – Compared to Medicare – Does Not Result in Associated Increased Mortality
This study compared the initiation of dialysis and mortality among Veterans ages 67 and older with incident kidney failure who received pre-end-stage renal disease (ESRD) care in fee-for-service Medicare vs. VA between January 2008 and December 2011. Findings showed that Veterans who received pre-ESRD nephrology care in Medicare received dialysis more often than Veterans who received VA care (82% vs. 53%), yet Medicare patients were more likely to die within two years compared with VA patients (54% vs 43%). Differences in the frequency of dialysis treatment between Medicare and VA were larger among Veterans aged 80 years or older and among Veterans with dementia or metastatic cancer – subgroups that are less likely to realize a survival benefit from dialysis. Results suggest that the VA healthcare system favors lower intensity treatment of kidney failure without an associated increase in mortality.
Date: April 9, 2018
- Evidence Review Identifies Modest Mortality Disparities among Racial and Ethnic Minority Groups in VA Healthcare
To support VA’s efforts to better understand the scale and determinants of disparities in racial and ethnic mortality – and to develop interventions to reduce disparities, investigators from the VA Evidence-based Synthesis Program (ESP) Coordinating Center in Portland, OR conducted an evidence review of mortality disparities specific to VA. Findings showed that although VA’s equal access healthcare system has reduced many racial/ethnic mortality disparities still present in the private sector, modest mortality disparities persist mainly for black Veterans with conditions that include: stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, and stroke. There also were modest disparities in mortality for American Indian and Alaska Native Veterans undergoing major non-cardiac surgery, and for Hispanic Veterans with HIV or traumatic brain injury.
Date: March 1, 2018
- Veterans with Cancer Received Higher Quality, Lower Intensity End-of Life Care in VA Compared to Medicare
This study evaluated the quality of end-of-life cancer care provided by Fee-for-Service (FFS) Medicare and VA, using well-accepted quality-of-care metrics. Findings showed that Veterans treated under FFS Medicare were more likely to get unduly intensive healthcare at end-of-life compared to those treated by VA. For example, Medicare-reliant Veterans were significantly more likely to receive chemotherapy, as well as experience a hospital stay, more hospital days, ICU admission, and death in hospital. Compared to Veterans in highly urban settings, Veterans living in rural areas were less likely to have a hospital admission or ICU stay, spend a greater number of their last 30 days of life in hospital, and were less likely to die in hospital. Compared with white Veterans, black Veterans were more likely to have two or more ED visits, a hospital admission, an ICU stay, or to die in hospital.
Date: January 1, 2018
- HCV-Related Complications Increasing among Women Veterans
This study examined gender-related differences in the incidence and prevalence of cirrhosis, decompensated cirrhosis, and hepatocellular cancer (HCC) between 2000 and 2013. Findings showed that the incidence and prevalence of hepatitis C virus (HCV) complications was higher in men than in women. However, the rate of increase in the incidence rates of cirrhosis and decompensated cirrhosis among HCV-infected women is similar to the rate of increase in men. In 2000, 3% of women vs. 5% of men had been diagnosed with cirrhosis. By 2013, the prevalence for cirrhosis had risen to 14% and 21% in women vs. men, respectively. In 2000, the prevalence of decompensated cirrhosis was 1.6% in women and 2.4% in men, but increased by 2013 to 7% in women and 12% in men.
Date: November 1, 2017
- Hospice Enrollment for Veterans with Advanced Stage Lung Cancer Increases
This study examined the use of hospice care by Veterans with advanced stage lung cancer enrolled in VA healthcare. Findings showed that overall, hospice enrollment among VA patients with advanced stage lung cancer increased from 65% in 2007 to 71% in 2013. Early hospice enrollment also increased, with time from cancer diagnosis to hospice enrollment decreasing by 65 days (32% relative decrease). There was statistically significant regional variability in overall hospice enrollment across the VA healthcare system, ranging from 64% in the Northeast to 77% in the Southeast. Regional variability in the timing of hospice enrollment also was significant; for example, enrollment in the last 3 days of life ranged from 18% in the Northeast to 12% in the Southeast. Significant regional variability in hospice enrollment and patient characteristics associated with the use and timing of enrollment suggest a framework for focused efforts to enhance utilization.
Date: October 10, 2017
- Direct-Acting Antiviral Agents Reduce Risk of Hepatocellular Cancer among Veterans with Hepatitis C
This study examined the risk of hepatocellular cancer (HCC) following sustained virological response (SVR) among 22,500 Veterans with hepatitis C virus (HCV) who received directing-acting antivirals (DAA) treatment at any of 129 VA hospitals between January and December 2015. Findings showed that in Veterans treated with DAAs, SVR was associated with a 76% reduction in the risk of developing hepatocellular cancer compared to those who did not achieve SVR. This benefit persisted even after accounting for demographic and clinical variables. Patients with cirrhosis had the highest annual incidence of HCC after SVR, ranging from 1% to 2% per year based on other demographic and clinical characteristics. In contrast, the risk of HCC was low in almost all Veterans without cirrhosis, with the exception of patients with findings suggesting the presence of advanced fibrosis. There was no evidence to suggest that DAAs promote HCC either during or after treatment completion, as some previous studies have suggested.
Date: October 1, 2017
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- Efficacy of Routine Screening Pelvic Examination in Asymptomatic Average-Risk Women
This systematic review evaluated the benefits and harms of the routine screening pelvic examination in asymptomatic, non-pregnant, adult women for indications other than sexually transmitted infection screening, provision of hormonal contraception, and cervical cancer screening. No data supported the use of the routine pelvic examination (excluding cervical cytology) for reduction in morbidity or mortality from any condition. The percentage of women endorsing pain or discomfort during the pelvic exam ranged from 11% to 60% and the percentage of women endorsing fear, embarrassment, or anxiety ranged from 10% to 80%. No studies evaluated mortality or morbidity outcomes of the screening pelvic examination for the diagnosis of other malignancies or other benign gynecologic conditions (i.e., pelvic inflammatory disease).
Date: July 1, 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 clinical 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
- 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
- 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
- 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
- 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
- Non-Cancer Pain Associated with Suicide
This study evaluated associations between non-cancer, pain-related clinical diagnoses (arthritis, back pain, migraine, tension headache or headache symptom, psychogenic pain, neuropathy, fibromyalgia) and suicide. Findings showed that, after controlling for demographics, most clincial diagnoses of non-cancer pain conditions were associated with risk of suicide in this large national cohort of Veterans. After further controlling for co-occuring psychiatric conditions, the associations between pain conditions and suicide death were reduced; however, significant associations remained for back pain, migraine, and psychogenic pain. In Veterans with a pain condition who died by suicide, the two most common methods of suicide were firearms (68%) and poisoning (17%). There was no relationship between the number of pain conditions and suicide risk. The authors suggest that there is a need for increased awareness of suicide risk among Veterans with back pain, migraine, and psychogenic pain, which may not be fully explained by comorbid psychiatric diagnoses.
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
- 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
- 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
- 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
- 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
- Changes in Health Conditions and VA Healthcare Costs among Women Veterans between 2000 and 2008
The number of women Veterans treated in the VA healthcare system increased from 156,305 in 2000 to 266,978 in 2008; 88% of these women were under 65 years of age. The mean costs of care increased from $4,962 per woman Veteran in FY00 to $6,570 in FY08. Gender-specific, cancer, musculoskeletal, and mental health and substance abuse conditions accounted for a greater share of overall costs during the study period. Psychiatric conditions represented the largest share of costs for female VA patients during the study years. There was a modest rise in costs for psychiatric conditions among all female Veteran patients driven by the growing number of women treated for depression and PTSD. From 2000 to 2008, the proportion of women treated for PTSD increased by 133%, while the proportion of women treated for depression increased by 41%.
Date: May 1, 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
- Complementary and Alternative Medicine Options for Veterans with Chronic Pain
As part of the “Study of the Effectiveness of a Collaborative Approach to Pain,” investigators surveyed Veterans with chronic (non-cancer) pain about their prior use of, and their willingness to try four complementary/alternative medicine (CAM) treatments: massage, chiropractic care, herbal medicines, and acupuncture. Investigators also examined whether demographic characteristics, VA treatment satisfaction, common pain-related characteristics (i.e., pain intensity, disability, depression), or overall disease burden distinguished CAM users from non-users. Findings showed that 82% of Veterans reported previously trying CAM therapy, and nearly all were willing to try one or more of the four CAM treatment options in the study survey. Chiropractic care was the least preferred CAM therapy, whereas massage was the most preferred option. Compared to Veterans who did not use CAM therapy, CAM users were less likely to have service-connected disabilities, and reported having spent a larger percentage of their lives in pain. Investigators detected few differences between Veterans who had tried CAM therapy and those who had not, suggesting CAM may have broad appeal among Veterans with chronic pain. Moreover, study results did not show differences in treatment satisfaction or pain treatment effectiveness ratings between the two groups. This suggests that Veteran patients with chronic pain may use CAM as an additional tool in pain management, rather than as a reaction to perceived inadequacies of conventional care.
Date: December 1, 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- VA Healthcare Outperforms Private-Sector, Medicare-Managed Care among Older Patients
This study compared clinical performance between VA and Medicare-managed care plans, known as Medicare Advantage (MA). Findings show that VA outperformed MA health plans on 10 out of 11 widely used clinical performance indicators assessing diabetes, cardiovascular, and cancer screening care among patients ages 65 and older in the initial study year – and on all 12 measures by the final year. Moreover, for 10 of the 12 measures studied, even the best-performing MA plans lagged behind the lowest-performing VAMCs. The performance advantage for VA was substantial. For example, in 2006 and 2007, adjusted differences between VA and MA ranged from 4.3 percentage points for cholesterol testing in coronary heart disease to 30.8 percentage points for colorectal cancer screening. VA delivered care that was less variable by site, geographic region, and socioeconomic status. For 9 of the 12 measures, socioeconomic disparities were lower in VA than in MA.
Date: March 18, 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 physician 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
- Spaced Education May Improve Learning for Medical Students
‘Spaced education’ refers to online educational programs that are structured to present information in small increments and reinforce learning by repetition. Medical students in this study who received spaced education e-mails demonstrated significant, topic-specific increases in pre-test scores for both prostate cancer/PSA knowledge and BPH/erectile dysfunction knowledge. However, students demonstrated a substantial decline in their urology knowledge in between the post-test and delayed test in both topic areas. Thus, while prospective spaced education can improve learning and retention, it does not appear to be enough to shift urology learning into long-term memory.
Date: January 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
- 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
- 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
- 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