- Underuse of Statins among Veterans with Hypercholesterolemia
This study sought to examine the prevalence and treatment of Veterans with uncontrolled severe hypercholesterolemia who received VA healthcare. Findings showed a marked underuse of statins in Veterans with uncontrolled severe hypercholesterolemia. Within six months of this abnormal lab value, only 52% were being treated with statins, and less than 10% were on high-intensity statin therapy as recommended by the 2013 ACC/AHA guidelines. Older (over age 75) and younger (under age 35) Veterans were less likely to be treated. Women also were less likely to be treated with statins, whereas minority groups and those with a diagnosis of hypertension were more likely to be treated. Black Veterans were significantly more likely to be on high-intensity statin therapy as compared with Whites (12 vs. 9%), as were those with hypertension (11 vs. 8%) and renal disease (12 vs. 9%). Significant improvement is needed in order to meet guideline-recommended care for Veterans with uncontrolled severe hypercholesterolemia.
Date: September 1, 2018
- Women Veterans with Pain More Likely to Use Complementary and Integrative Therapies
This study sought to examine complementary and integrative health (CIH) therapy use by gender among Veterans with chronic musculoskeletal pain, and variations in gender differences by race/ethnicity and age. Findings showed that of Veterans with chronic musculoskeletal pain, more women than men used CIH therapies (36% vs. 26%). Black women, regardless of age, were least likely to use CIH therapies compared to other women. Among men, White and Black Veterans were less likely to use CIH therapies, irrespective of age, than men of Hispanic or other race/ethnicities. Among both women and men, CIH therapies were least likely to be used by younger Black or White Veterans. Given the disparities in CIH therapy use, tailoring CIH therapy engagement to gender, race/ethnicity, and age may increase CIH therapy use among Veterans.
Date: September 1, 2018
- Medical Records Flag for Suicide Risk Increases VA Healthcare Visits among Veterans with Substance Use Disorder
VA has identified suicide prevention as a top priority and established policies to include high-risk suicide patient record flags (PRFs) in the electronic medical record to alert providers of patient risk and increase healthcare contacts. This study sought to identify predictors of new PRFs and to describe healthcare use before and after PRF initiation among VA patients who had received a substance use disorder (SUD) diagnosis. Findings showed that consistent with VA policy, 62% of Veterans with new suicide risk flags attended the recommended number of visits in months 1 to 3, with an additional 14% meeting recommended targets in month 1 only. Further, outpatient contacts in mental health and substance use disorder clinics increased 2 and 4 times, respectively, over the three-month follow-up period, with mean contacts in these services exceeding the minimum required one contact per week in month one. ED visits decreased by 45% in the three months following initiation of a PRF. Demographic predictors of PRF initiation included being younger than 35, White, and homeless. Clinical predictors were cocaine, opioid and sedative use disorders, PTSD, psychotic, bipolar, and depressive disorders, and suicide-attempt diagnoses. Suicide risk PRFs in an electronic medical record and subsequent follow-up increased service use for those Veterans with flags initiated.
Date: June 8, 2018
- While the Numbers of Homeless Veterans Continue to Decrease, their Needs Remain Unchanged
For more than two decades, VA’s Project Community Homelessness Assessment, Local Education and Networking Groups (CHALENG) has conducted an annual national survey to assess the needs of homeless Veterans. This study compiled five years of CHALENG survey data (available since the 2011 report) and examined changes in the characteristics of geographically diverse homeless Veteran respondents and their ratings on unmet needs. Findings showed that while the sociodemographic characteristics of homeless Veterans have changed over time (i.e., increasing number of aging, female, and white Veterans), their needs have largely remained unchanged. Across years 2012-2016, there were slight increases in unmet needs related to case management, food, emergency shelter, and medical services, but the highest-rated unmet needs that affected the most homeless Veterans were related to credit, utilities, furniture, dental care, and disability income. The need for legal assistance regarding evictions and foreclosures also was reported as one of the top unmet needs for all five years. Over four of the five years, legal assistance for child support – and in three of the five years, child care also were reported as common unmet needs. Homeless Veterans have begun to identify other needs beyond obtaining housing that pertain to sustaining housing and improving social functioning. Findings highlight numerous areas that may need further attention and intervention as VA continues to prioritize ending homelessness among Veterans.
Date: May 3, 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
- PACT Initiative Did Not Reduce Most Disparities in Improved Hypertension or Diabetes Control among VA Patients
This study sought to determine whether PACTs helped mitigate national racial/ethnic disparities in VA clinical outcomes, after adjusting for variable implementation and social determinants of health. Findings showed that improvements in clinical outcomes for hypertension and diabetes control had not been achieved for whites or most racial/ethnic groups four years into VA’s system-wide roll-out of the PACT initiative. Greater PACT implementation was associated with higher percentages of Veterans who achieved hypertension or diabetes control, but most racial/ethnic disparities in achieving control persisted. Authors suggest that to promote health equity, healthcare innovations such as patient-centered medical homes should incorporate tailored strategies that account for determinants of racial/ethnic variations.
Date: June 1, 2017
- Evaluating Patient-Mediated Health Information Exchange
In 2013, VA’s Office of Rural Health and the Department of Health and Human Services (Office of the National Coordinator) partnered to promote the use of My HealtheVet’s Blue Button capability to facilitate the transfer of Veterans’ health information to non-VA providers to improve care coordination for Veterans living in rural settings who use both VA and non-VA care (dual users). This partnership resulted in the Veteran-Initiated Electronic Care Coordination pilot study, which sought to: 1) train rural-dwelling dual-use Veterans to use Blue Button capabilities to share their health information with non-VA providers, and 2) evaluate whether or not the availability of VA information during community clinical encounters impacted the care they received. Findings from this study showed that with brief training, Veterans were able to generate their Continuity of Care Document (CCD) in My HealtheVet, share it with non-VA providers, and benefit from improved communication about medications and reduced laboratory duplication. After training, 78% of Veterans reported that the CCD would help them be more involved in their healthcare, and 86% planned to share it regularly with non-VA providers. The majority of non-VA providers (97%) were confident in the accuracy of the information, and 96% wanted to continue to receive the CCD. Moreover, 50% of non-VA providers reported that they did not order a laboratory test or other procedure because of CCD information.
Date: October 11, 2016
- Racial Disparities in HIV Quality of Care that May Extend to Common Comorbid Conditions
To more fully understand patterns of racial disparities in the quality of care for persons with HIV infection, this study examined a national cohort of Veterans in care for HIV in the VA healthcare system during 2013. Findings showed that racial disparities were identified in quality of care specific to HIV infection – and in the care of common comorbid conditions. Blacks were less likely than whites to receive combination antiretroviral therapy (90% vs. 93%) or to experience viral control (85% vs. 91%), hypertension control (62% vs. 68%), diabetes control (86% vs. 90%), or lipid monitoring (82% vs. 85%). Although performance on quality measures was generally high, racial disparities in HIV care for Veterans remain problematic and extend to comorbid conditions. Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.
Date: September 22, 2016
- Application of Triggers on VA “Big Data” may Help Identify Patients Experiencing Delays in Diagnostic Evaluation of Chest Imaging
Triggers offer one method to use big electronic health record (EHR) data to prevent and mitigate the impact of delays in care related to missed test results. Triggers consist of computerized algorithms that can scan thousands of patient records to flag those with clues suggestive of patient safety events. This study tested the application of a trigger within VA’s EHR to help identify delays in patient follow-up related to abnormal chest imaging results. Findings showed that the trigger identified delays in patient follow-up with a reasonable accuracy for use in the clinical setting, suggesting that triggers are able to identify almost all delays related to abnormal lung imaging follow-up, and cost-effectively minimize the amount of effort providers spend reviewing false-positive results.
Date: September 1, 2016
- VA National Transplant System Shows No Racial/Ethnic Disparities in Evaluating Veterans for Kidney Transplant
This study examined VA patients of diverse racial/ethnic backgrounds with end-stage kidney disease (ESKD) who underwent the evaluation process for kidney transplantation (KT). Findings showed that in comparing African American Veterans with white Veterans and other minority Veterans, the VA National Transplant System did not exhibit the racial/ethnic disparities in evaluation for kidney transplant that have been found in non-VA transplant centers. Moreover, VA kidney transplant centers are successfully bringing ESKD patients through the evaluation process without race disparities at a time when non-VA transplant centers are unable to do so, while achieving a median time to complete evaluation similar to other published rates in non-VA settings.
Date: August 1, 2016
- Racial and Ethnic Differences in Primary Care Experiences for Veterans with Mental Health and Substance Use Disorders
This study examined racial and ethnic differences in positive and negative experiences in VA Patient-Centered Medical Home (PCMH) settings among Veterans with mental health or substance use disorders (MHSUDs) who completed VA’s 2013 PCMH Survey of Healthcare Experiences of Patients. Findings showed that positive experiences were reported least often for access. Negative experiences were reported most often for self-management support and comprehensiveness, defined as provider attention to MHSUD concerns. One or more racial/ethnic minority groups reported more negative and/or fewer positive experiences than Whites in the following 4 domains: access, communication, office staff helpfulness/courtesy, and comprehensiveness. Solutions are needed to improve access to care for all Veterans with MHSUDs, with additional attention on improving access for Black, Hispanic, and AI/AN Veterans.
Date: June 20, 2016
- Wide Variation Documented Among VA Providers in Potential Overuse of Antibiotics for Acute Respiratory Infections
This study examined trends in antibiotic prescribing for acute respiratory infections (ARIs) within the VA healthcare system over an 8-year period – and identified patient, provider, and setting sources of variation. Findings showed that there was a persistently high prevalence of outpatient antibiotic prescriptions for ARIs among Veterans. Of more than one million ARI visits, the proportion resulting in antibiotic prescription increased from 67.5% in 2005 to 69.2% in 2012. Also, the proportion of antibiotic prescriptions that were macrolides increased from 37% to 47%. There was substantial variation in prescribing at the provider level. The 10% of VA providers who prescribed the most antibiotics did so during at least 95% of their ARI visits, while the 10% who prescribed the least did so during <40% of their ARI visits. Mid-level providers prescribed antibiotics slightly more frequently than physicians (70% vs. 68%). Subgroups associated with higher prevalence of antibiotic prescribing included: diagnosis of sinusitis (86%) or bronchitis (85%), presence of a high fever (78%), occurrence in an urgent care setting (75%), and Southern and Central regions of the U.S. (both 71%). Variation in ARI management seems to be strongly influenced by the prescribing patterns of individual providers. This is a ripe target for further research, quality improvement, and antibiotic stewardship interventions.
Date: July 21, 2015
- 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
- Consequences of Notifying VA Patients about Potential Exposure to Large-Scale Adverse Events
This study sought to determine the intended and unintended consequences of patient notification following a large-scale adverse event (LSAE) within the VA healthcare system, which systematically looks for LSAEs, tracks potentially exposed patients, and communicates with them after LSAE notification. Findings showed that more than two-thirds of potentially exposed patients returned for HCV, HBV, and HIV testing following the receipt of an LSAE notification letter, which was associated with a 72 to 76 percentage point increase in testing.
Among Veterans who sought testing, 57% were tested in the 30 days following notification, and 74% were tested within 60 days. The vast majority (>98%) completed testing in a VA facility; less than 2% were tested at a non-VA facility paid by purchased care or Medicare (when eligible). Among older Veterans, notification was associated with higher odds of increased VA outpatient use in the following 3 months, but decreased odds of using VA healthcare in the subsequent 9 months. Compared to white Veterans, African American Veterans were significantly less likely to return to VA for follow-up testing.
Date: May 1, 2015
- Electronic Health Record-Based Interventions for Reducing Inappropriate Imaging in the Clinical Setting
Given that adoption of electronic health records (EHRs) is expanding, investigators conducted a systematic review and meta-analysis of EHR-based interventions to improve the appropriateness of diagnostic imaging. Findings showed that Computerized clinical decision support that is integrated into the physician order entry system of an electronic health record can help improve the appropriate ordering of diagnostic imaging studies. Of the 23 studies in this review, 21 studies provided moderate-quality evidence that EHR-based interventions can change appropriate test ordering by a moderate amount – and can reduce overall use by a small amount. Interventions that include a “hard stop” to prevent clinicians from ordering imaging tests classified as inappropriate, and implementation in an integrated care delivery setting may improve effectiveness. Potential harms of computerized clinical decision-support interventions have been rarely studied.
Date: April 21, 2015
- Sleep Difficulties Associated with Risk Factors for Cardiovascular Disease among Younger Veterans and Active Duty Personnel
This study examined the relationship between sleep difficulties and several cardiovascular (CVD) risk factors (i.e., smoking status, body mass index, self-reported hypertension, hypertension medication use, clinic-based blood pressure readings, symptoms of depression and PTSD, and diagnosis of depression and PTSD) among relatively younger (mean age, 37 years) Veterans and active duty personnel of the Iraq and Afghanistan wars. Findings showed that 8% of the Veterans in this study endorsed only sleep onset difficulties, 9% endorsed only sleep maintenance difficulties, and 41% endorsed both sleep onset and sleep maintenance difficulties. Study participants with both sleep onset and maintenance difficulties had greater odds of being a current smoker, having a diagnosis of PTSD, having clinically significant PTSD symptoms, having a diagnosis of depression, and having clinically significant depression symptoms. The odds for these risk factors did not differ by race or age. Having the combination of sleep onset and maintenance difficulties also was associated with elevated systolic blood pressure readings and increased likelihood of reporting a hypertension diagnosis among younger white Veterans. Overall, study participants with sleep maintenance difficulties were older, while those having both sleep onset and maintenance difficulties were younger and reported more tours of duty. Veterans reporting sleep difficulties of any kind reported more symptoms of depression and PTSD. Authors note that since sleep difficulties are associated with several CVD risk factors, improving sleep in this younger population may reduce the progression of disease and avert the increased incidence of CVD found in older Veterans.
Date: March 27, 2015
- Having Dependent Children Associated with Increased Risk of PTSD among OEF/OIF Veterans
This is the first study to examine whether being the parent of a dependent child was, in itself, associated with the likelihood of post-deployment PTSD diagnosis among Veterans. Findings showed that after controlling for demographics, mental healthcare use, and other serious mental illness, OEF/OIF Veterans with dependent children were about 40% more likely to carry a diagnosis of PTSD. This association was stronger among men than women. Other variables associated with increased odds of PTSD diagnosis included male gender, white race, Hispanic ethnicity, younger age, Priority 1 status, more than one dependent child, depression or SUD diagnosis, greater use of mental health services, and more medical comorbidities. Veterans with dependent children had greater VA mental healthcare utilization, including inpatient psychiatric admissions and mental health counseling visits. Thus, it may be of value for clinicians to consider parental status when treating Veterans with PTSD.
Date: January 19, 2015
- Improved Performance on Quality Measures is Accompanied by Increased Racial/Ethnic Equity in Care
This study examined the quality and equity of hospital care during the six years following initiation of the Centers for Medicare & Medicaid Services (CMS) Inpatient Quality Reporting (IQR) Program (2005 to 2010), focusing on 17 process-of-care quality indicators publicly reported by the program for white, black, and Hispanic patients hospitalized for AMI, HF, and pneumonia in non-VA hospitals. Findings showed that improved performance on quality measures for white, black, and Hispanic adults hospitalized with AMI, HF, and pneumonia was accompanied by increased racial/ethnic equity in performance rates both within and between U.S. hospitals. Over this time period, adjusted performance rates for the 17 quality measures improved by 3.4 to 57.6 percentage points for these patients. In 2010, unadjusted performance rates exceeded 90% for all subgroups for 14 of 17 measures. Declining racial/ethnic differences occurred through more equitable care for white and minority patients treated in the same hospital, as well as greater performance improvements among hospitals that disproportionately serve minority patients.
Date: December 11, 2014
- Use of Electronic Health Information Exchange may Reduce Emergency Department Utilization
Investigators in this study conducted a systematic review of the health information exchange (HIE) literature, specifically examining the evidence of effect on health outcomes, healthcare use and efficiency, evidence of clinicians’ use of HIE, and the financial sustainability of HIE organizations. Investigators also evaluated evidence about patient and provider attitudes toward HIE, as well as barriers and facilitators to its use. Findings showed that using HIE may reduce emergency department (ED) usage and costs. The effects of HIE on other healthcare outcomes are uncertain. The use of HIE is low relative to the estimated potential need, with most studies reporting use in 2% to 10% of healthcare encounters. However, some sites reported much greater HIE use, and specifics of the context and implementation may be responsible for these differences. All stakeholders claim to value HIE, but many barriers to acceptance and sustainability exist, including workflow and interface issues, privacy and security of patient health information, and the lack of a compelling business case for sustainability.
Date: December 2, 2014
- Compared to Thiazolidinediones, Sulfonylureas May Be More Likely to Cause Death and Hospitalization for Veterans with Diabetes
This study compared long-term outcomes of the two most commonly used second-line oral hypoglycemic medications in the VA healthcare system – sulfonylureas (SUs) and thiazolidinediones (TZDs). Findings showed that Veterans with diabetes who started on SUs compared to TZDs as a second-line agent after metformin were significantly more likely to die or have an ambulatory care sensitive condition hospitalization. Patients in this study were elderly (mean age 69), primarily white (88%), and had high rates of cardiovascular comorbidities (e.g., chronic pulmonary disease, hypertension), and obesity (41%).
Date: December 1, 2014
- Characteristics Associated with Suicide among Male Veterans Treated in VA Primary Care
This study sought to identify characteristics of Veterans who received VA primary care in the six months prior to suicide (in 2009) – and compare these to control patients who also received primary care at the same 41 VA facilities in 11 geographically diverse states. Findings showed that compared to controls, Veterans who died by suicide were significantly more likely to be unmarried, white, and to have major depression, bipolar disorder, anxiety disorder other than PTSD, and/or an alcohol or other substance use disorder diagnosis. Veterans who died by suicide also were more likely to have documented functional decline, sleep disturbance, expressions of anger, and suicidal ideation. The odds of dying by suicide were greatest among Veterans with anxiety disorder diagnoses and functional decline. A diagnosis of PTSD was not significantly associated with suicide, nor was a pain diagnosis or general medical comorbidity. Also, non-white race and a VA service-connected disability rating were associated with decreased odds of suicide. The assessment of anxiety disorders and functional decline, in particular, may be important for determining suicide risk among Veterans. The authors suggest continued development of interventions that support identifying and addressing these conditions in primary care.
Date: December 1, 2014
- Racial/Ethnic Disparities in Treatment Retention for Veterans with PTSD
This study of Veterans recently diagnosed with PTSD sought to determine whether the odds of premature mental health treatment termination varied by patient race/ethnicity and, if so, whether such variation is due to differential access to services or beliefs about mental health treatment, or whether there is a disparity in the provision of treatment. Findings showed that compared to White Veterans, African-American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy and, overall, African-Americans were less likely to receive a minimal trial of any treatment in the six months after being diagnosed with PTSD. Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino Veterans but not African-American Veterans. As expected, positive beliefs about psychotherapy or pharmacotherapy facilitated treatment retention. Access barriers did not contribute to treatment retention disparities. They significantly impacted psychotherapy participation, but equally across the entire sample. To improve treatment equity, clinicians may need to directly address patients’ treatment beliefs and preferences.
Date: November 24, 2014
- Electronic Health Record-based Alerting Systems Can be Source of Turnover for Clinical Practices
The use of certain components of electronic health records (EHRs), such as EHR-based alerting systems (EAS), might reduce provider satisfaction – a strong precursor to turnover. This study examined how providers’ perceptions of the use of EAS (known within the VA CPRS as View Alert notifications) may impact their satisfaction, intention to quit, and turnover. Findings showed that providers’ perceptions of the value of EAS predicted both provider satisfaction and facility-level turnover. For example, perceptions of the degree of monitoring and feedback received regarding EAS were significantly associated with intention to quit, with high levels of monitoring and feedback associated with increased intention to quit. Monitoring/feedback on EAS practices, training on the use of EAS, and the extent to which colleagues used/valued EAS had little impact on provider satisfaction.
Date: November 1, 2014
- Women Veterans, Particularly Black Veterans, Have Worse Risk Factor Control for Cardiovascular Disease than Male Veterans
This study compared gender and racial differences in three risk factors that predispose individuals to cardiovascular disease: diabetes, hypertension, and hyperlipidemia. Findings showed that overall, female Veterans had significantly higher LDL cholesterol levels than male Veterans, despite being almost ten years younger, on average. These differences are similar to gender disparities previously reported both within and outside VHA and represent a clinically significant difference. African-American women Veterans had worse blood pressure control than White women Veterans, and among Veterans with diabetes, male African-Americans had worse control of higher blood pressure, LDL, and HbA1c levels than White males.
Date: September 1, 2014
- Veterans’ Use of Blue Button Feature in MyHealtheVet
The Blue Button feature in VA’s online combined personal health record and patient portal, My HealtheVet (MHV), allows patients to access electronic health record (EHR) components, such as past and future appointments, lab results, and medications. This study aimed to characterize users of the MHV Blue Button, its perceived impact on Veterans’ health, and its role in sharing healthcare information. Findings showed that among users of the Blue Button, the benefit most highly endorsed by Veterans (73%) was the value of having their health history in one place. In addition, 21% of users with a non-VA provider shared their VA health information, and of those, 87% reported the non-VA provider found the information somewhat or very helpful. Veterans’ self-rated computer ability was the strongest factor contributing to both Blue Button use and to sharing information with non-VA providers. The majority of non-users of the Blue Button stated they were not aware of it. However, non-users who were aware of the Blue Button stated they did not use it because they did not know how (34%), they only use MHV for prescription renewal (26%), they preferred other methods to keep track of health information (11%), or they did not know where the Blue Button was located (10%). Age was not associated with Blue Button use.
Date: July 1, 2014
- “Virtual” Hope Box Smartphone App Delivers Patient-Tailored Coping Tools to Help Veterans at Risk for Suicide
Tools that assist patients in accessing and affirming their reasons for living can enable them to mitigate suicidal thoughts. One such tool has been labeled a “hope box”: a physical representation of the patient’s reasons for living, reminders of individual accomplishments and future aspirations, or things the individual finds soothing, e.g., a worry stone, family photographs, or letters. However, a conventional hope box can by physically unwieldy and inconvenient; thus, the investigators in this study developed a “Virtual” Hope Box (VHB) for service members and Veterans that expands the reach of the hope box modality to a smartphone app. This study compared the VHB with a Conventional Hope Box (CHB) integrated into VA behavioral health treatment. Compared with a CHB, more Veterans used the Virtual Hope Box regularly and found it to be beneficial, helpful, and easy to set up. Veterans stated that they would recommend the VHB to their peers, and twice as many preferred the VHB over the CHB for future use. Written comments from Veterans cited the helpfulness of the VHB with managing distress, negativity, hopelessness, anger, and various other symptoms. Moreover, mental health clinicians were unanimous in their praise for the VHB as an eminently usable therapeutic tool.
Date: May 15, 2014
- Penetrating Traumatic Brain Injury Strongly Associated with Risk of Epilepsy among OEF/OIF Veterans
This study examined the association between epilepsy and TBI, including penetrating TBI (pTBI), in OEF/OIF Veterans. Findings showed that epilepsy was associated with previous TBI diagnosis. The estimated risk of epilepsy among Veterans with pTBI was nearly 18 times greater than among those without TBI, even after controlling for other factors. When examined separately, risk for epilepsy was also elevated among Veterans with severe, moderate, and mild TBI. Even among this relatively young group of Veterans, stroke was one of the strongest risk factors for epilepsy. Veterans with epilepsy also were more likely to be younger than 50 years and white, and were more likely to have previously diagnosed substance use disorder, depression, anxiety, bipolar disorder, schizophrenia, and PTSD than those without epilepsy. Headache, cardiac conditions, cerebrovascular disease, and cognitive impairment/dementia were also epilepsy risk factors. An increasing burden of epilepsy in this Veteran population is likely. These Veterans should be followed closely, and systems of care, such as VA Epilepsy Centers of Excellence, should be prepared to provide epilepsy specialty care.
Date: April 1, 2014
- Anxiety Disorders and Depression Associated with Risk of Future Heart Failure among Veterans
This study sought to determine if the risk of heart failure (HF) was greater in Veterans with: 1) a diagnosis of one or more anxiety disorders but who were free of major depressive disorder (MDD); 2) MDD but free of anxiety disorders; or 3) comorbid anxiety and depressive disorders. Findings showed that in the model that corrected for age only, Veterans with anxiety disorders, MDD, or both were each about 20% more likely to develop HF compared to Veterans without these conditions. This effect remained significant after adjusting for other HF risk factors (e.g., sociodemographics, nicotine use, substance use disorders), and was even greater after adjusting for psychotropic medications. Compared to Veterans without HF, patients with HF were significantly older and more frequently male, non-white, unmarried, holders of supplemental insurance, and were significantly more likely to have diagnoses of hypertension, diabetes, and obesity. Veterans with both anxiety and MDD were more likely to have a diagnosis of substance abuse or dependence and history of nicotine use – and to receive a prescription for psychotropic medication.
Date: February 1, 2014
- Health Information Technology
This review sought to examine recent evidence that relates health IT functionalities prescribed in meaningful use regulations to key aspects of healthcare, such as quality, safety, and efficiency. Findings showed that most published IT evaluation studies report positive effects on quality, safety, and efficiency. Strong evidence supports the use of clinical decision support (CDS) and computerized provider order entry (CPOE). Fifty-seven percent of the studies in this review evaluated CDS and CPOE, and most reported positive results. Insufficient reporting of implementation and context of use makes it impossible to determine why some health IT implementations are successful and others are not. Therefore, the most important improvement that can be made in health IT evaluations is increased reporting of the effects of implementation and context. Authors note that with the increasing adoption of electronic health records and other forms of health IT, it is no longer sufficient to ask whether health IT creates value, but rather the most useful studies will help us understand how to realize value from health IT.
Date: January 7, 2014
- Increased Prescribing Rates for Concurrent Sedative Medications among Veterans with PTSD
This is the first national study that sought to characterize polysedative prescribing in Veterans with PTSD. Findings showed that, over time, there was an increase in the use of polysedatives among Veterans with PTSD: from 34% to 37% for two or more sedative classes, and from 10% to 12% for three or more classes. This represents a concerning clinical trend and a relative increase of nearly 25%. The most common combination of sedatives was an opioid plus a benzodiazapine, which were taken concurrently by 16% of Veterans with PTSD. Two other combinations that were used more frequently than expected were opioids plus skeletal muscle relaxants – and benzodiazepines plus atypical antipsychotics. Polysedative use varied across demographic subgroups, with higher rates among women, Veterans residing in rural settings, younger adults, Native Americans, and Whites. Also, benzodiazepine prescribing was markedly elevated among women (44%) compared to men (34%), and was somewhat lower among older adults (31%) compared to younger adults (36%).
Date: December 16, 2013
- Electronic Patient Portals and their Effect on Health Outcomes
Investigators conducted a systematic review of the relevant literature evaluating peer-reviewed articles on patient portals tied to existing electronic medical record systems, specifically looking at whether or not these systems improve health outcomes, patient satisfaction, healthcare utilization and efficiency, and adherence. Findings showed that the evidence is insufficient as to the effects of patient portals on health outcomes. A limited number of studies and variations in study design, portal functionalities, and implementation processes make it difficult to draw strong conclusions or generalizations about this relatively new technology. Examples were identified in which portal use was associated with improved outcomes for patients with chronic diseases (i.e., diabetes, hypertension, depression), but these were generally studies that used the portal in conjunction with case management. Evidence was mixed about the effect of portals on healthcare utilization and efficiency. Some findings included more acceptance of portals by patients who were younger and had more computer literacy or trust in the Internet, and more enthusiasm for portals among patients than physicians. Administrative and human factors in the interface were cited as barriers to use. Thus, the jury is still out on whether patient portals such as MyHealtheVet improve health outcomes or increase healthcare efficiency, although patients seem to value the ability to access their own medical records. While patients’ attitudes on portals are generally positive, more widespread use may require efforts to overcome racial, ethnic, and literacy barriers.
Date: November 19, 2013
- Ethnic Differences in Receipt of Depression Care
This study sought to characterize differences in treatment for multiple racial/ethnic groups of Veterans with ongoing depression. Findings showed that there were significant differences in the receipt of depression care between multiple racial/ethnic groups of chronically depressed Veterans. Compared to white Veterans, nearly all minority groups had lower odds of adequate antidepressant use; adequate psychotherapy was more common among minority Veterans in initial analyses but differences between Hispanic, AI/AN, and white Veterans were no longer significant in adjusted analyses. Primarily due to lower use of antidepressants, nearly all minority groups had lower rates of guideline-concordant care than white Veterans with depression. Overall, 51% of Veterans received adequate antidepressant care for the 6-month period following their most recent VA healthcare visit for depression; 10% of Veterans attended at least 6 psychotherapy visits within the same time period; and 55% received guideline-concordant care. Further research is needed to determine whether the observed differences in treatment arise from patient-centered preferences for care (for example, lower willingness to take anti-depressant medication among minority patients) or from providers’ failure to adhere to best-care practices.
Date: November 1, 2013
- Veterans with PTSD or Major Depression Less Likely to Undergo Four Major Invasive Procedures
This study examined whether PTSD, after controlling for major depression, was associated with the likelihood of having four common types of major invasive procedures. Findings showed that Veterans with PTSD only and with depression only were less likely to undergo all types of procedures examined in this study. Having both PTSD and depression was associated with lower odds of hip/knee, CABG/PCI, and vascular procedures, but not digestive procedures. Vascular procedures had the strongest effect. The odds of undergoing CABG/PCI or vascular procedures for patients with depression only were 35% to 40% lower than for patients with neither PTSD nor depression, while patients with PTSD only were about 25% less likely to receive the procedures. African American and women at-risk patients (those with a pre-existing condition likely to be alleviated by a procedure) were less likely to undergo hip/knee, vascular, and CABG/PCI procedures. Given that African-Americans are more likely than non-Hispanic whites to die of heart disease, their reduced odds of receiving CABG/PCI or vascular procedures could be problematic.
Date: October 1, 2013
- VA Primary Care Physicians Using Electronic Health Records May Miss Important Information Due to Information Overload
This study examined potential predictors of missed test results in the setting of electronic health record (EHR)-based alerts. Findings showed that the median number of alerts VA PCPs reported receiving each day was 63; 87% of PCPs perceived the quantity of alerts to be excessive, and 70% reported receiving more alerts than they could effectively manage (marker of information overload). More than half (56%) of the PCPs reported that the EHR notification system, as currently implemented, made it possible for them to miss test results. Almost a third (30%) reported having personally missed results that led to delays in care for their patients. Further analyses showed that the perceived ease of EHR use by PCPs was related to a lower likelihood of both study outcomes: 1) the perception of potentially missing results, and 2) reporting missed results that led to delays in patient care. Greater concern over electronic hand-offs (i.e., routing alerts to the EHR of a surrogate covering-practitioner) was also related to the potential for and personal history of missed test results. PCPs who reported receiving more alerts than is manageable (information overload) were more likely to report having missed results that led to delayed patient care. Notably, the number of alerts that respondents reported they received per day was unrelated to either outcome.
Date: April 22, 2013
- Journal Issue Highlights the State of Health Information Technology in VA Healthcare
This Medical Care Supplement focuses on the use and impact of health information technology (HIT) in quality improvement research conducted within VHA. Articles in this Supplement highlight a range of specific HIT approaches, including innovative and interactive uses of VHA’s electronic health record, databases, and information systems, as well as applications of automated systems for intervention, evaluation, and tracking patient care.
Date: March 1, 2013
- Primary Care Practitioners’ Views on VA’s Electronic Health Record System and Test Result Notification
This study examined the broad range of social and technical factors that affect test result management in the VA healthcare system, based on a web-based survey of primary care practitioners (PCPs) at 142 VA facilities nationwide. Findings showed that despite an advanced electronic health record (EHR) system, VA PCPs reported both social and technical challenges in ensuring notification of test results to practitioners and Veterans. The vast majority of PCPs in this study had considerable experience with VA’s EHR, but less than half (46%) reported receiving sufficient training on the “View Alert” system. Nevertheless, the majority believed they had knowledge (74%) and proficiency (82%) to use the View Alert system. Just over one-third of the PCPs reported having the help needed for notifying patients of test results. Almost half of the PCPs reported that they did not immediately notify patients of normal test results and relied on patients’ next visit to notify them, whereas about one-fifth relied on the next visit to report abnormal results. A majority of PCPs (86%) stayed after hours or came in on weekends to address patient notifications, and less than one-third (30%) reported receiving protected time for alert management. Nearly half of the PCPs (47%) had prior experience using a non-VA EHR. Of these, 55% indicated that VA’s CPRS was superior to other commercially-available EHRs they had used, 19% thought that the non-VA EHR they used was superior, and 26% perceived them to be the same. PCPs endorsed several new features to improve test result management, including better tracking and visualization of result notifications.
Date: December 25, 2012
- Many OEF/OIF Veterans Delay Initiating Mental Health Care and Completing Effective Mental Health Treatment
This study sought to describe time to initiation (and predictors of time to initiation) of first primary care visit, mental health outpatient visit, and minimally adequate mental healthcare among Veterans with mental health diagnoses seeking VA healthcare post-deployment. Findings indicate delays in initiating and completing minimally adequate mental healthcare among OEF/OIF/OND Veterans using VA services. Among these Veterans, the median time to engagement in mental healthcare was more than two years from the end of the last deployment. Further, after more than three years post-deployment, 75% of Veterans with mental health diagnoses – who were in the VA healthcare system for at least one year – had still not engaged in minimally adequate mental healthcare. There was a median lag time of 7.5 years between coming in for an initial mental health treatment session and beginning a course of minimally adequate mental healthcare. All of the mental health diagnoses, as well as number of comorbid mental health diagnoses, were associated with an increased chance of initiating minimally adequate mental health outpatient care sooner. PTSD had the strongest association with early initiation. Male Veterans waited nearly two years longer to initiate minimally adequate mental healthcare compared to female Veterans. Younger Veterans (<25 years of age) took longer to initiate and seek minimally adequate care; racial/ethnic minorities also took longer than their White counterparts.
Date: December 1, 2012
- Design and Implementation of a VA Hospital-Based Usability Laboratory for Health Information Technology
This article describes the HSR&D Human-Computer Interaction & Simulation Laboratory, housed within one VAMC, which was intended to provide research-level findings about health information technology (HIT) design and was developed to investigate the usability of HIT toward transforming VA’s health information system. Investigators provide insight about the Laboratory’s design and implementation, and the use of a usability laboratory in the healthcare setting.
Date: December 1, 2012
- Equitable Rates of Pain Assessment among African American and White Veterans
This study sought to determine whether African American Veterans were less likely to be screened for pain than their White counterparts – and to determine the factors associated with differences in screening rates. Findings showed that VA’s mandate for pain screening has resulted in high and relatively equitable rates of pain assessment among both African American and White Veterans. Although rates of pain screening were lower among African Americans compared to Whites (78% vs.82%), this disparity was reduced by half after controlling for prior healthcare use, in which African American Veterans had a greater number of outpatient visits, which was associated with lower rates of pain screening at the index visit. Overall, Veterans were less likely to be screened for pain if they were African American, female, and married; if they had a diagnosis of deficiency anemia; if they had a greater number of outpatient visits; and if they were an established (vs. new) patient. Veterans were more likely to be screened if they had prior diagnoses of chronic joint, neck, or back pain; opioid abuse, anemia, and pulmonary circulation disorders; and if they had a non-opioid analgesic prescription and/or greater number of inpatient admissions in the previous two years.
Date: November 21, 2012
- Racial Differences in Outcomes of VA Telephone-Delivered Hypertension Disease Management Program
A combination of home BP monitoring, remote medication management, and telephone-tailored behavioral self-management appears to be particularly effective for improving BP among African American Veterans. However, the effect was not seen among non-Hispanic white Veterans.
Among African Americans, improvement in mean systolic BP was greatest for those receiving the combined intervention: compared to usual care, systolic BP was 6.6 mmHg lower at 12 months and 9.7 mmHg lower at 18 months. These decreases in BP were not seen in non-Hispanic white Veterans.
Date: August 3, 2012
- Review Supports One-to-One Peer Mentorship among Veterans
Across a broad range of populations, peer mentors appeared to be acceptable, credible sources of information. This may be particularly true among current and former members of the Armed Forces, who are accustomed to a culture of mutual support. The literature suggests that peers are capable of conducting assessment and triage, coaching and teaching, and providing direct social support. A White Paper identified three areas where peer mentorship (PM) might play a unique role for military/Veteran populations: coping with combat and operational stress, suicide prevention, and recovery-related issues downstream from combat/injury. In addition, the review suggests PM might play a role in reducing stigma, improving treatment adherence, increasing knowledge of treatment resources, and augmenting or teaching self-management skills.
Date: July 1, 2012
- Anti-Hypertensive Medication May Reduce Risk of Dementia among Veterans with Diabetes
Comorbid hypertension was associated with increased risk of dementia; however, anti-hypertensive medications, particularly ACE inhibitors and ARBs, were associated with reduced risk of dementia, even among Veterans without hypertension. The most protective effect was associated with ARB use (approximately 24% lower risk of dementia), followed by diuretics (14%), ACE inhibitors (11%), CCBs (7%), and beta blockers (4%). Factors associated with higher incidence of dementia included: increasing age (Veterans >85 had more than three times greater risk compared to Veterans age 65), as well as duration of diabetes and higher comorbidity. Also, African Americans and other non-white races were more likely to have dementia. These findings suggest that ARBs and ACE inhibitors be considered when prescribing medication for the control of hypertension among patients with diabetes.
Date: April 20, 2012
- Perceived Discrimination Associated with Risk of Severe Coronary Obstruction among African American Veterans
Compared to white Veterans, African American Veterans with abnormal cardiac nuclear imaging studies had greater perceptions of racial discrimination that were related to increased risk for severe coronary obstruction – and to angiographic coronary obstruction, after controlling for clinical and psychosocial factors related to cardiovascular health. Based on their nuclear imaging studies, 44% of Veterans (both whites and African Americans) were at high risk for severe coronary obstruction. Among both African American and white Veterans, prior myocardial infarction (MI) and smoking were associated with high (vs. low/moderate) risk for severe coronary obstruction, while optimism was related to a decreased risk of severe obstruction. No significant associations between social support, negative affect, or religiosity and results from nuclear imaging or coronary angiography were found.
Date: April 1, 2012
- Relationship between Perceived Racial Discrimination and Wait Times for Kidney Transplant
Compared to whites, African Americans took significantly longer to get accepted for transplant.
There were also significant racial differences on several cultural factors in patients as they began the evaluation process for kidney transplantation. Compared to white patients, African Americans reported experiencing more discrimination in healthcare, more perceptions of racism in healthcare, higher medical mistrust, and more religious objections to living donor kidney transplantation. Comorbidity, dialysis status, and availability of potential living donors were not associated with length of time to be accepted for kidney transplant. Thus, medical factors alone did not explain racial disparities. In analyses to identify which factors predicted racial disparities, the authors found that perceived discrimination in healthcare, less transplant knowledge, more religious objection to transplantation, and lower income explained the racial disparities observed in the time it took to be accepted for transplant. Moreover, after adjusting for demographics, psychosocial, and cultural factors, the association of race with longer time for listing for transplant was no longer significant. Authors suggest these findings indicate that perceived discrimination in healthcare can be as much of a risk factor as race, income, or low transplant knowledge.
Date: February 27, 2012
- Majority of Veterans Interested in Sharing Personal Health Record Information with Caregivers and non-VA Healthcare Providers
This study explored patient preferences regarding shared access to electronic health information by surveying individuals who used VA’s personal health record, My HealtheVet. Findings showed that a majority (79%) of My HealtheVet users were interested in sharing access to their personal health record with someone outside the VA healthcare system: 62% with a spouse/partner, 23% with a child, 15% with another family member, and 25% with a non-VA healthcare provider. Preferences regarding degree of access varied based on the type of information being shared, the type of activity being performed, and the respondent’s relationship with the person. Interest in sharing access to My HealtheVet was modestly, but significantly, greater among older Veterans and men, but did not vary by health status.
Date: December 20, 2011
- Telemedicine-Based Collaborative Care Intervention for Depression has Greater Effect on Minority vs. White Veterans
The Telemedicine Enhanced Antidepressant Management (TEAM) study was a randomized trial of telemedicine-based collaborative care tailored for small, rural primary care practices. Investigators in the current study evaluated racial differences in clinical outcomes among 360 Veterans with depression who were randomized to usual care or the TEAM intervention. Findings showed that in the usual care group, minority Veterans had a lower treatment response rate (8%) than Caucasians (18%), but this was not significant. In contrast, minority Veterans in the TEAM intervention group had a significantly higher treatment response rate (42%) than Caucasians (19%) in the intervention group. Veterans in the minority group were significantly less likely to report that antidepressants were an acceptable form of treatment, and were significantly less likely to have had prior or current depression treatment. However, none of these variables were significantly related to treatment outcomes. Thus, the study was not able to determine why minorities responded better to the intervention than Caucasians.
Date: November 1, 2011
- JGIM Special Supplement Highlights Access to VA Healthcare
The JGIM Supplement includes both the white papers commissioned as background for the September 2010 state-of-the-art (SOTA) conference on “Improving Access to VA Care” and manuscripts submitted in response to a post-SOTA solicitation for original research and reviews pertaining to improving access to VA care. Articles focus on a myriad of topics related to improving access to care for Veterans, including: eHealth technologies (e.g., Care Coordination Home Telehealth program, and My HealtheVet personal electronic health record); measuring the impact of access on healthcare utilization, quality, and outcomes; and redefining access for 21st century healthcare.
Date: November 1, 2011
- Depression and Race may Independently Affect Receipt of Some Surgeries
This study examined race and ethnicity as factors potentially associated with surgeries experienced by Veterans with and without major depressive disorder (MDD). Findings show that Veterans with pre-existing MDD were less likely to undergo digestive, hip/knee, vascular, or CABG surgeries than Veterans without MDD. Minority Veterans were slightly less likely to receive vascular operations compared to white Veterans, but were more likely to undergo digestive system procedures. The effect of depression was independent of race and ethnicity; thus, depression and race would have an additive but not synergistic effect on the odds of receiving surgery. In addition, a gender effect was noted: women Veterans were more likely to have digestive procedures but were less likely to undergo CABG or vascular operations. Authors note that the lack of information regarding severity of illness makes it difficult to determine whether or not diagnostic differences explain differences in surgery.
Date: October 1, 2011
- Natural Language Processing with Electronic Medical Record Improves Identification of VA Post-Operative Complications
This study evaluated a natural language processing (NLP) search approach to detect post-operative surgical complications within VA’s electronic medical record (EMR). Findings showed that, among Veterans undergoing inpatient VA surgery, NLP using the EMR greatly improved the identification of post-operative complications compared to an administrative-code based algorithm. NLP correctly identified 82% of acute renal failure cases compared with 38% for patient safety indicators; 59% vs. 46% for venous thromboembolism; 64% vs. 5% for pneumonia; 89% vs. 34% for sepsis; and 91% vs. 89% for post-operative MI. An accompanying Editorial states that NLP has the potential to greatly enhance the EMR with new applications, such as automated quality assessment to assist in the performance of comparative effectiveness research.
Date: August 24, 2011
- Veterans in Favor of Internet-Provided HIV Screening Information
This study examined patient and provider perceptions of Internet-based outreach to increase HIV screening among Veterans who use the VA healthcare system. Findings showed that both Veterans and providers thought that HIV screening outreach provided electronically via the personal health record (PHR – MyHealtheVet) would improve patient access to health information, with important educational value. Providers believed that it would reinforce messages they give to their patients. Veterans could envision instances in which information provided electronically might be better than verbal information from their doctor because it would be in lay language and readily available. Veterans also believed that electronic outreach would motivate them to be proactive about their health. Most felt that electronic messages would remind them to be screened, or at least contemplate getting screened. Regarding stigma attached to an electronic message about HIV, providers expressed substantially more concerns than Veterans. Providers also expected increased workload from the electronic outreach, and suggested adding primary care resources and devising methods to smooth the flow of patients getting screened.
Date: August 15, 2011
- Racial and Ethnic Differences in Blood Pressure Control among Veterans with Type 2 Diabetes
This study examined racial/ethnic differences in blood pressure control among Veterans with type 2 diabetes and uncontrolled BP at baseline. Findings showed that the adjusted proportion of Veterans with uncontrolled BP (>=140/90 mmHg) decreased in all groups over the study period. However, ethnic minority Veterans had significantly increased odds of poor BP control over a mean follow-up of 5 years compared to non-Hispanic White Veterans, independent of socio-demographic factors and comorbidity patterns. Compared to non-Hispanic Whites (45%), 54% of non-Hispanic Black Veterans, 48% of Hispanic Veterans, and 49% of Veterans with unknown race had poor blood pressure control. In using a more stringent BP cutoff (>=130/80 mmHg) to define poor BP control, 74% of non-Hispanic White Veterans had poor blood pressure control over the 5 years compared to 82% of non-Hispanic Black Veterans, 75% of Hispanic Veterans, and 79% of Veterans with unknown race/ethnicity. The presence of a hypertension diagnosis at the time of study entry appears to be associated with higher odds of achieving BP control over time. Among other comorbidities, cancer, coronary heart disease, congestive heart failure, and substance use disorders were all associated with increased odds of good BP control over time.
Date: June 14, 2011
- Despite Improved Quality of VA Healthcare, Racial Disparity Persists for Important Clinical Outcome
This article reports on trends in the quality of care and racial disparities in relation to 10 VA clinical performance measures that assessed cancer screening, cardiovascular care, and diabetes care from 2000 to 2009. Findings show that in the decade following VA’s organizational transformation, quality of care improved and racial disparities were minimal for most process measures, such as glucose and LDL screening. However, these were not accompanied by meaningful reductions in racial disparity for important clinical outcomes, such as blood pressure, glucose, and cholesterol control. A gap in clinical outcomes of as much as nine percentage points was observed between African-American and white Veterans. Almost all of the disparity in outcomes was explained by within-facility disparity, which suggests that VA medical centers will need to measure and address racial gaps in care for their patient populations. Of the five performance measures with an absolute racial disparity of 5 percentage points or more in the initial year of the study, there were statistically significant reductions in racial disparity for three: glucose control, BP control, and CRC screening. However, the reductions in disparity were modest, and none were reduced by more than 2 percentage points.
Date: April 1, 2011
- No Racial Disparities in Adherence to CRC Screening among Veterans Receiving VA Care
This study examined the contribution of demographic/health-related factors, cognitive factors, and environmental factors to racial disparities in colorectal cancer (CRC) screening in a nationally representative survey of Veterans ages 50 to 75. The effect of race on adherence to CRC screening guidelines was non-significant after adjusting for demographic/health-related factors and environmental factors. Adherence in both African American and White groups was substantially higher than the national average. The high rates of CRC screening are likely, in part, a result of various VA efforts initiated over the past decade to increase screening adherence. There were no racial differences in 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
- 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
- Collaborative Care Intervention Improves Depression in Veterans with HIV
The goal of this study was to adapt an evidence-based primary care model of depression collaborative care for HIV clinic settings (HIV Translating Initiatives for Depression into Effective Solutions [HITIDES])) – and to evaluate its effectiveness. Findings show that the HITIDES intervention was successfully implemented in HIV settings and improved both depression and HIV symptom outcomes. Veterans who participated in the intervention were more likely to report treatment response and remission compared to Veterans in usual care at 6-month follow-up but not at 12-month follow-up. Improved depression response and remission outcomes at 6 but not 12 months suggest that depression symptoms improved more rapidly in the intervention group compared to usual care. Intervention participants also reported more depression-free days over 12 months. Compared to usual care, significant intervention effects also were observed for lowered HIV symptom severity at 6 and 12 months. The authors suggest that the HITIDES intervention may serve as a model for collaborative care interventions in other specialty physical healthcare settings.
Date: January 10, 2011
- VA Patient-Provider Communication Does Not Contribute to Racial Disparities in Use of Total Joint Replacement
This study examined whether there were racial differences in patient-provider communication about treatment of chronic knee/hip osteoarthritis in African American and white Veterans referred to two VA orthopedic clinics over a 3-year period. Findings show that communication between VA orthopedic surgeons and patients regarding the management of chronic knee/hip osteoarthritis did not, for the most part, vary by patient race. No racial differences were observed with regard to length of visit, overall amount of dialogue, discussion of psychosocial issues, Veteran activation/engagement statements, physician verbal dominance, display of positive affect by Veterans or providers, or discussion related to informed decision-making. However, visits with African American Veterans contained less discussion of biomedical topics and more rapport-building statements than visits with white Veterans. These findings diminish the potential role of communication in VA orthopedic settings as an explanation for racial disparities in the use of total joint replacement.
Date: January 10, 2011
- Electronic Health Information’s Effect on Clinical Workflow
This study sought to assess aspects of health information technology (HIT) that impact clinical workflow – and to identify a set of HIT characteristics that support patient care processes. Investigators identified many examples of how HIT affects workflow, but characteristics were strongest within four primary domains: 1) Trustworthy and reliable (e.g., inconsistent incomplete, incorrect information in the electronic health record (EHR); 2) Ubiquitous (e.g., poor accessibility due to lack of computer workstations or lengthy secure login processes, but good information availability ); 3) Effectively displayed (e.g., problems locating scanned documents in the EHR, lack of searchability , information not well-organized or prioritized); and 4) Adaptable to work demands (e.g., EHR is not portable or customizable, difficult to modify information). The findings from this study underscore the value of obtaining input from healthcare employees and may be used to enhance HIT design, clinical practice, and patient safety.
Date: December 1, 2010
- Validated Alcohol Screening Questionnaire Not Enough to Ensure Quality of Screening
This study evaluated the quality of clinical alcohol screening among VA outpatients by comparing Alcohol Use Disorders Identification Test - Consumption Questions (AUDIT-C) results documented during routine clinical care to AUDIT-C results from a confidential mailed survey completed within 90 days of the clinical screen. Of the national sample, 61% of VA outpatients who screened positive for alcohol misuse with the AUDIT-C on mailed surveys screened negative during the same time period with the AUDIT-C in VA outpatient clinical settings. Overall, 11% of Veterans screened positive on the survey screen vs. only 6% on the clinical screen. Patients who screened positive on the AUDIT-C survey were much more likely to have discordant clinical screening results, e.g., among patients whose clinical screens indicated no alcohol use in the past year, 22% reported drinking on the survey screens. Discordance was significantly increased among African American Veterans compared with white Veterans. There were also differences across VA networks: the proportion of Veterans with positive survey screens who had negative clinical screens varied from 43% to 100% across different networks.
Date: September 22, 2010
- Inappropriate Non-Steroidal Anti-Inflammatory Drug Use is Prevalent among Veterans
This study examined the prevalence of inappropriate non-steroidal anti-inflammatory drug (NSAID) use among Veterans– and identified patient and clinical characteristics associated with inappropriate use. The inappropriate use of NSAIDs was prevalent and was associated with more GI symptoms and higher levels of pain. Of the 1,250 Veterans who reported NSAID use, approximately 32% used NSAIDs inappropriately, including taking two or more NSAIDs, exceeding the highest daily recommended dosage, or both. Veterans classified as using NSAIDs inappropriately were more likely to be non-white and were more likely to have an income of less than $20,000.
Date: June 1, 2010
- Disparities in Healthcare Coverage and Access among American Indian/Alaska Native Veterans
American Indian/Alaska Native (AIAN) Veterans have considerable disparities in healthcare coverage and access to care compared to non-Hispanic white Veterans. For example, AIAN Veterans are nearly twice as likely to be uninsured, even after adjusting for sociodemographic and economic characteristics. AIAN Veterans are significantly less likely to report private coverage and significantly more likely to report public coverage, military coverage, and be uninsured. Regarding barriers to healthcare, AIAN Veterans were significantly more likely to delay healthcare due to not getting timely appointments, not getting through on the telephone, and having transportation problems.
Date: June 1, 2010
- Patient Treatment Preferences Play Important Role in Racial Disparities in Knee/Hip Total Joint Replacement
Overall, 10.3% of Veterans treated for knee/hip osteoarthritis at two VA orthopedic clinics underwent total joint replacement (TJR) within six months of study enrollment. TJR was less likely for African-American Veterans compared to white Veterans of similar age and disease severity, but this difference was not significant after adjusting for whether patients had received a recommendation for the procedure from their orthopedic surgeon. African-American Veterans were less likely to receive a recommendation for TJR than white Veterans of similar age and disease severity. However, this difference was not significant after controlling for Veterans’ willingness to undergo TJR, as assessed prior to the visit with their surgeon. This suggests that the observed race differences in recommendations about joint replacement may result from orthopedic surgeons being responsive to patient preferences regarding the procedure.
Date: May 28, 2010
- Lower Mortality Rates for African American Compared with White Patients Hospitalized for Heart Failure
This study examined research reporting mortality by race after hospitalization for heart failure (HF), and combined the results using meta-analyses. Adjusted mortality rates were 32% lower in short-term follow-up (0-30 days) and 16% lower in long-term follow-up (after 30 days) for African American compared with white patients. Authors suggest that differences in mortality imply unmeasured differences by race in clinical severity of illness at hospital admission and may lead to biased hospital mortality profiles.
Date: March 1, 2010
- 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
- Veteran Minorities Equally Likely to Receive PTSD Treatment
This study sought to determine the rates of mental health use in the six months after Veterans received a PTSD diagnosis – and to examine whether service use varied by race or ethnicity. Findings show that minority Veterans were similar to Whites in the likelihood of receiving VA mental health treatment in the six months following a diagnosis of PTSD. Of the 20,284 Veterans with PTSD in this study, 50% received psychotropics, 39% received counseling, and 64% received at least one of these forms of treatment. However, only 24% who received any counseling had at least eight sessions, and most had only one session. These findings indicate that possible treatment preferences exist. The authors suggest that incorporating preferences into treatment planning may facilitate treatment retention and help to maximize treatment outcomes for all Veterans with PTSD.
Date: December 1, 2009
- Veterans’ Age and Disability Status Associated with Choice of Medicare Plans
Medicare-eligible Veterans may choose between care in VA or Medicare (or both), and they also have to choose between obtaining Medicare services in the fee-for-service (FFS) sector or in a Medicare Advantage (MA) plan. This study sought to assess factors associated with enrollment in an MA vs. FFS plan in 2000-2004 among this population. Findings show that age and disability status were both significantly associated with choice of MA vs. FFS plan. For example, age-eligible Veterans were more likely to be enrolled in an MA plan if aged 75 or older, female, able to receive free VA care, or not enrolled in Medicaid, while disability-eligible Veterans were more likely to be enrolled if they were married or elderly. Minority Veterans and Veterans with lower disease risk scores (better average health) were more likely to be enrolled in an MA plan than white Veterans or Veterans with higher risk scores. Overall, Veterans living in zip codes with greater population density and higher per capita income were also more likely to enroll in an MA plan. The authors suggest that future studies examine the Medicare health plan choice of disabled Veterans, particularly OEF/OIF Veterans who begin to qualify for Medicare, to better understand the possible impact of MA enrollment on continuity, duplication, cost, and quality of care.
Date: November 1, 2009
- Ethnic Disparities in Treatment for Chronic Pain
This study sought to identify racial and ethnic differences in patient-reported rates of treatment for chronic pain and ratings of pain-treatment effectiveness among 255,522 Veterans who were treated at more than 800 VA healthcare facilities in FY05. Findings show that 35% of male Veterans and 44% of female Veterans reported receiving treatment for chronic pain. Male and female Veterans who were Hispanic or non-Hispanic black were more likely to report receiving treatment for chronic pain compared to non-Hispanic white Veterans. Among the Veterans who received treatment for chronic pain, non-Hispanic black men were one-fifth less likely to rate pain treatment effectiveness as very good or excellent compared to non-Hispanic white male Veterans.
Date: October 1, 2009
- Use of Medicare and VA Healthcare among Veterans with Dementia
This study sought to characterize healthcare use among Veterans with dementia over a four-year period (1998-2001), and to determine predictors of whether a Veteran will be a VA-only, dual, or Medicare-only user. Findings show that during the four-year study period, Medicare-only use increased while VA-only use decreased. Results also show that an increased likelihood of some Medicare use was associated with being older, white, married, and having higher education, private insurance or Medicaid, and low VA priority level. Further, the number of functional limitations was associated with an increased likelihood of Medicare-only use and a decreased likelihood of VA-only use, while higher comorbidities were associated with a higher likelihood of dual use as opposed to any single system use. The authors suggest that these results imply that different aspects of Veterans’ needs have differential effects on where Veterans seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure patients receive high quality care, particularly among those with multiple comorbidities.
Date: October 1, 2009
- Effect of Medicare Pharmacy Benefit Coverage on VA Healthcare Users
This study examined the influence of Medicare pharmacy benefit coverage on VA pharmacy use among Veterans using the VA healthcare system during 2002, who had diabetes mellitus, ischemic heart disease, or chronic heart failure. Overall, results showed that Veterans dually enrolled in VA and Medicare fee-for-service (FFS) were less likely to receive condition-related medications from VA compared with Veterans enrolled in HMOs with lower levels of prescription drug coverage. One implication of the overall study findings is that VA will become less the healthcare system of choice for Veteran beneficiaries if Medicare pharmacy services become more affordable. Moreover, Veterans with chronic conditions that require many medications and who hit a coverage gap in Medicare Part D or have difficulty making the Medicare co-payments may turn to VA as a safety net at intermittent times rather than using VA pharmacy services more steadily.
Date: October 1, 2009
- Federal Investment in Electronic Medical Records
The American Recovery and Reinvestment Act (ARRA) includes $19 billion in incentives for the adoption of electronic medical records (EMRs) and $50 billion to promote health information technology. Medicare physicians adopting and making “meaningful use” of EMRs in 2011 and 2012 will be eligible for an initial payment of up to $18,000, with reduced payments in 2013 and 2014. However, current EMR systems’ inability to learn from aggregated health data has led to implementations and hospital information technology departments that can actually obstruct quality improvement. For example, much of the information contained in EMRs is formatted as unstructured free text – useful for essential individual communication but unsuitable for detecting quantifiable trends. This commentary suggests that the Department of Health and Human Services capitalize on the opportunity to mandate EMRs that have the potential to learn from data in the EMR system.
Date: September 9, 2009
- “Rights” of Safe Electronic Health Record Use
This JAMA Commentary proposes eight “Rights” of safe electronic health record (EHR) use, which are grounded in an engineering model that addresses work-system design for patient safety. The authors recommend the use of the eight “Rights,” in order to address the complex interaction of organizational, technical, and cognitive factors that affect the safety and effectiveness of EHRs.
Date: September 9, 2009
- African Americans and Whites Equally Appropriate Candidates for Total Joint Arthroplasty
This study sought to determine if racial differences in clinical appropriateness for surgery existed among a sample of primary care patients (425 whites and 260 African Americans) with moderate to severe symptomatic knee or hip osteoarthritis (OA) treated at one VA hospital and one county hospital between 3/03 and 9/06. Findings show that African Americans and whites were equally appropriate candidates for total joint arthroplasty (TJA). There were no significant ethnic differences found between the proportion of those deemed appropriate for TJA and those deemed inappropriate.
Date: September 1, 2009
- Focus Groups Recommend Strategies to Decrease Missed Test Results
This paper reports on the efforts of two focus groups that formed as part of the Diagnostic Error in Medicine – A National Conference, which was held by the American Medical Informatics Association in 2008. Clinicians who were part of the focus groups were asked to develop interventions that might decrease the risk of diagnostic delay due to missed test results in the future. The focus groups concluded that while the electronic medical record helps to improve access to test results, eliminating all missed test results would be difficult to achieve. However, they did recommend several strategies that might decrease the rates of missed test results, including: improving standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow-up of test results, and systems re-engineering to improve the management and presentation of data. They also suggest that healthcare organizations focus initial quality improvement efforts on specific tests that have been identified as high-risk for adverse impact on patient outcomes, such as tests associated with a possible malignancy or acute coronary syndrome.
Date: September 1, 2009
- 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
- Factors Associated with Antibiotic Prescribing for Likely Non-Bacterial Respiratory Infections
This study sought to identify patient and provider factors associated with prescribing antibiotics for emergency department (ED) outpatients with acute respiratory infections of likely non-bacterial etiology. Findings show that antibiotic use varied substantially between the two VAMCs studied and was particularly high for acute bronchitis (97% and 65%). Overall, 26% of the Veterans with upper respiratory infections (URIs) and/or acute bronchitis received antibiotics: 78% for acute bronchitis only, 57% for both infections, and 16% for URIs only. The following factors were associated with prescribing antibiotics for infections of likely non-bacterial etiology: presence of one or more comorbidities, fever, purulent sputum, shortness of breath, altered breath sounds, diagnosis of acute bronchitis, as well as non-internal medicine provider specialty and provider age older than 30.
Date: June 1, 2009
- Alcohol Misuse and Counseling among Minority Veterans
This study sought to describe alcohol consumption across race and ethnicity groups among Veterans treated in VA during FY05, and examine associations between race and ethnicity and receipt of alcohol-related advice by clinicians. Findings show that overall, less than one-third of patients who drank at all and one-third of patients with positive alcohol misuse screens reported receiving alcohol-related advice. After adjusting for demographics, health status, and alcohol consumption, Veterans who self-identified as black, Hispanic, or American Indian/Alaska Native were more likely to report receiving alcohol-related advice from their VA healthcare providers compared to non-Hispanic whites. In addition, women and older Veterans were less likely to receive alcohol-related advice than their male and younger counterparts, respectively.
Date: May 1, 2009
- Costs and Benefits of Health Information Technology
The use of health information technology (HIT) has been promoted as having tremendous promise in improving the efficiency, cost-effectiveness, quality, and safety of medical care delivery. Findings from this literature review show a proliferation of patient-focused HIT applications, many of which are designed for use by patients without significant oversight by healthcare providers. Investigators believe that accelerating the adoption of HIT will require greater public-private partnerships, new policies to address the misalignment of financial incentives, and a more robust evidence base regarding HIT implementation.
Date: March 1, 2009
- 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
- Need for Better Self-Management Education to Address Cultural Differences among Veterans with Diabetes
Although non-white Veterans have documented disparities in the quality of some diabetes care processes and intermediate outcome measures, racial disparities in foot care examinations have not been widely explored. Findings from this study show that there are significant differences in self-reported foot care and education across racial and ethnic groups among Veterans with diabetes. Authors suggest the need for better self-management education to address culture, knowledge, preferences, and unique barriers to care.
Date: January 1, 2009
- African-American Veterans More Likely than White Veterans to Receive Mechanical Ventilation for COPD
African-American Veterans with COPD exacerbation in VA hospitals are more likely than white Veterans to receive mechanical ventilation, and this difference is not explained by available clinical or demographic variables. By contrast, African-American and white Veterans are equally likely to receive non-invasive ventilation (NIV) when being treated for COPD exacerbation. Authors suggest that there is no underuse of mechanical ventilation and NIV in the treatment of racial minorities in this patient population; however, unmeasured factors, such as patient preferences or disease severity may be affecting the use of mechanical ventilation, and thus warrant further investigation.
Date: January 1, 2009
- Racial Differences in Coping with Chronic Osteoarthritis Pain
Compared to white veterans, African American veterans were much more likely to perceive prayer as helpful (85% vs. 66%) and were more likely to have tried it for hip or knee pain (73% vs. 55%). Race was not associated with arthritis pain self-efficacy, arthritis function self-efficacy, or any other coping strategies.
Date: December 1, 2008
- Students Attending Racially and Ethnically Diverse Medical Schools Report Being Better Prepared to Care for Patients in Diverse Society
White students who attend racially diverse medical schools report feeling better prepared than students at less diverse schools to care for racial and ethnic minority patients. They also are more likely to endorse access to adequate health care as a right. However, investigators found no association between the diversity of a medical school and whether white students intended to provide care in underserved areas.
Date: September 10, 2008
- Perceived Racial Discrimination in U.S Healthcare More Prevalent among African Americans and Associated with Worse Health Outcomes
The prevalence of perceived discrimination in U.S. healthcare is considerably higher for African Americans compared to Whites and Hispanics. [These results were not based on VA data.] Perceived discrimination was associated with worse health for both African Americans and Whites. Health care coverage was not significantly related to perceived discrimination for any of the racial/ethnic groups. However, not obtaining medical care due to cost was associated with a greater likelihood of perceiving discrimination for all groups.
Date: September 1, 2008