- Among Veterans Who Experience Homelessness, Non-fatal Overdose is a Relatively Common Problem
Overdose is one of the most common causes of death for younger homeless individuals, but the prevalence of non-fatal overdose among the homeless is unknown. Investigators in this study administered a survey to Veterans who had experienced homelessness (current or past) and received primary care at one of 26 VA medical centers across the nation asking if they had experienced an overdose within the past three years that required an ED visit or immediate medical care (and the substances involved in the overdose) – and/or if they had witnessed someone else experience an overdose during the same time period. Findings showed that 7% reported an overdose in the previous three years. Those who reported an overdose were nearly three times as likely to have witnessed an overdose. Compared to Veterans without overdose, those reporting an overdose were younger, more likely to be white, more likely to be homeless at the time of the survey, more likely to be taking medication for mental health issues, had greater psychological distress, and were more likely to report an alcohol or drug problem. Alcohol was the most common substance reported with overdose, nearly as common as all drugs combined and more than twice as common as opioids. Improving access to addiction treatment for homeless and recently-housed Veterans, especially for those who have experienced or witnessed overdose, could protect this population. Also, given the prevalence of high emotional distress in persons who experienced overdose, enhanced mental health services could mitigate some risk for individuals residing on the streets, in shelters, or newly in housing.
Date: March 17, 2020
- Computer-Based Cognitive Behavioral Therapy with Peer Support Provides Greater Improvement of Depression Symptoms
This trial sought to determine whether computer-based cognitive behavioral therapy (cCBT) combined with peer support improved outcomes relative to enhanced usual care (EUC) for 330 primary care patients with depression who were treated at three Midwestern VA medical centers and two of their associated outpatient clinics. Findings showed that peer-supported cCBT as an add-on to usual primary care treatment for depression was associated with greater improvements in depression symptoms, quality of life, and mental health recovery at three months compared to enhanced usual care alone. Improvements in mental health recovery, although not the other outcomes, were sustained up to six months. Remission rates were 14% for Veterans in the peer-supported cCBT group and 6% for Veterans in the EUC group at three months, and 22% and 11%, respectively, at six months. The more modest benefits found with peer-supported cCBT should be considered in the context that more than 50% of Veterans also received antidepressant medication with high levels of adherence and over 30% received some in-person psychotherapy. Computerized CBT with peer support should be considered for implementation and evaluation in primary care, and adaptations to the computer CBT and peer support components should be considered to further improve effectiveness.
Date: March 1, 2020
- Anti-MRSA Therapy Associated with Greater 30-day Mortality Compared with Standard Therapy for Veterans with Pneumonia
This study sought to determine the association of empirical anti-MRSA therapy with 30-day mortality for Veterans hospitalized with pneumonia. Findings showed that empirical anti-MRSA therapy was significantly associated with greater 30-day mortality compared with standard therapy alone. There was a significant increase in 30-day mortality associated with empirical anti-MRSA therapy plus standard therapy, compared with standard therapy alone, among patients admitted to the intensive care unit (ICU) and those with a high clinical risk for MRSA. Thus, investigators could establish no benefit of empirical anti-MRSA therapy, even when risk factors for MRSA were present or clinical severity warranted admission to the ICU. The use of anti-MRSA therapy also was associated with increased risk of kidney injury and secondary infections.
Date: February 17, 2020
- Few Disparities in Medical Treatment for Opioid Use Disorder after Non-Fatal Overdose
This study assessed the association between race and ethnicity and patterns of opioid prescribing before and after a non-fatal opioid overdose – and also assessed the receipt of medications for opioid use disorder (MOUD: buprenorphine, methadone, and naltrexone) following such events among VA patients. Findings showed that receipt of an opioid prescription decreased by 16-21 percentage points in the 30 days after overdose, but remained high, with no significant differences across racial and ethnic groups. After overdose, the frequency of receiving opioids was reduced by 18.3, 16.4, and 20.6 percentage points in whites, blacks, and Hispanics, respectively. Overall, MOUD prescribing in VA was very low in all racial groups in the 30 days after overdose, though statistically significantly higher in black and Hispanic patients. After overdose, 3% of patients received MOUDs (3% white, 5% black, and 6% Hispanic). Blacks and Hispanics had significantly larger odds of receiving MOUDs than whites. Findings demonstrate an opportunity to improve the quality of care for all patients with opioid use disorder, particularly in the vulnerable period around a non-fatal overdose event.
Date: January 21, 2020
- Weight Management as Effective as Medication Intensification for Glycemic Control among Veterans with Type 2 Diabetes
This randomized clinical trial sought to determine whether adding intensive weight management to group medical visits (WM/GMV) improves glycemia compared with GMV alone, while enhancing weight loss and decreasing medication intensity in patients with uncontrolled type 2 diabetes. Findings showed that for Veterans with diabetes who attended group medical visits, adding intensive weight management using low-carbohydrate nutrition counseling showed comparable glycemic improvement in addition to other clinical advantages (i.e., reduced weight, medication burden, and hypoglycemic events). The largest differences between the GMV vs. the WM/GMV arms occurred at 16 weeks after the intensive initial phase of the WM/GMV 48-week program. The WM/GMV intervention decreased HbA1c levels by 1.7% from baseline, which was 0.7% lower than the GMV arm. The intervention also led to a 5.6 point difference in diabetes distress symptoms (i.e., stress, depression). The estimated intervention cost per patient was $1,513.42 for patients in the WM/GMV arm, and $1,264.49 for patients in the GMV arm. Thus, weight management using a low-carbohydrate diet can be as effective for glycemic improvement as medication intensification, with additional benefits (i.e., weight reduction, fewer hypoglycemic events, less medication use); however, strategies are needed to help patients sustain these improvements.
Date: November 4, 2019
- Excess Medication Supply Potentially High among Veterans Using VA Healthcare
This study sought to determine the prevalence of potential medication excess in the VA healthcare system – and to identify associated medication-, patient-, and system-level factors. Findings showed that medication excess was high among VA healthcare users in this study, with nearly two-thirds of patients (64%) experiencing at least one duplicative medication. Medication excess was more likely for Veterans with multiple prescribing providers or with higher comorbidity scores. Conversely, having a co-pay for medications was associated with lower rates of medication excess [a majority of patients (69%) did not have a co-pay]. Patients that had a combination of filling locations (CMOP or local pharmacy) and/or durations supplied had higher medication excess than those who had prescriptions from a single location or with uniform durations. As systems such as mail-order pharmacies and 90-day supply are increasingly implemented to reduce costs and improve medication adherence, it is important to recognize the potential for systems-level inefficiencies and inappropriate prescribing. Further efforts should be made to develop and implement strategies and systems (i.e., synchronized dispensing – refilling all prescriptions at the same time) that foster the appropriate and safe use of medications.
Date: November 1, 2019
- Unintentional Consequences of FDA Warnings: Varenicline
This study examined the association between FDA drug safety communications and the use of varenicline (Chantix) – a prescription drug used to treat addiction to smoking. Investigators tracked varenicline and nicotine replacement therapy (NRT) prescribing and evaluated the potential consequences of decreased varenicline use on lost opportunities to assist patients with quitting smoking and health outcomes, including mortality. Within 12 months of FDA communications about a labeling change for varenicline, there was a 69% reduction in VA outpatient prescriptions and a 38% decrease in Medicaid prescriptions. Varenicline use reached its low point in VA in early 2014, when the number of unique quarterly users was 5,990, representing an 82% decline from the first quarter of 2008. In addition, from 2008 to 2018, NRT users in VA increased by 73%. One year after the 2016 publication of a study that showed no significant increase in psychiatric/behavioral effects with varenicline compared with NRT or placebo, quarterly varenicline use had increased by 43% in VA patients and by 26% in Medicaid patients. The number of VA patients who did not quit smoking due to decreased varenicline use was estimated to be 20,544, which likely was associated with negative health effects.
Date: September 4, 2019
- Lack of Awareness among VA Providers about Risk Associated with Prescribing Inhaled Corticosteroids to Veterans with COPD
More than 50% of patients with mild-to-moderate COPD in the U.S. are prescribed inhaled corticosteroids despite recommendations to restrict use to patients with frequent breathing exacerbations. This study explored VA primary care providers’ experiences prescribing inhaled corticosteroids among Veterans with mild-to-moderate COPD. Of the Veterans with COPD in this study cohort, 15% were prescribed an inhaled corticosteroid. However, 61% of these prescriptions were not clinically indicated. Providers reported being unaware of current evidence and recommendations for prescribing inhaled corticosteroids; e.g., 46% of providers reported they were unaware of the risk of pneumonia. Providers also reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. Some providers expressed reluctance to change or stop prescribing if their patient was doing well. However, 52% of providers reported they would make an effort to reduce the use of inhaled corticosteroids, and 50% reported that they would make an effort to make greater use of alternative guideline-recommended medications. Study results corroborate prior findings that lack of awareness of current evidence-based guidelines is likely an important part of medical overuse. Efforts to expand access to care by increasing the number of prescribing providers a patient sees could make it more difficult to de-implement harmful prescriptions.
Date: August 8, 2019
- Video Telehealth Tablet Initiative Improves Access to and Continuity of Mental Healthcare for Veterans
In 2016, VA initiated a program to distribute video-enabled tablets to Veterans with geographic, clinical, or social access barriers to in-person care so that they could receive services in their homes or other convenient locations: 75% of tablet recipients had a mental health diagnosis, providing a unique opportunity to assess the effectiveness of this national dissemination of tablets. Findings showed that distributing the tablets to Veterans with mental health conditions appeared to improve access to and continuity of mental health services while also improving clinical efficiency. Compared to the control group, tablet recipients experienced an increase of 1.9 psychotherapy encounters; an increase of 1.1 medication management visits; a 19% increase in their likelihood of receiving recommended mental healthcare continuity; and a 20% decrease in their missed opportunity rate (i.e., missed appointments) six months post-tablet receipt.
Date: August 5, 2019
- VA Opioid Treatment Outcomes Vary Significantly among Homeless and Unstably Housed Veterans
To better address the opioid epidemic in Veterans who are unstably housed or homeless, it is necessary to determine where gaps in opioid-related care exist. This study examined a national sample of 59,954 Veterans who accessed VA homeless programs and represented a range of homeless experiences; 6% of this cohort (3,624 Veterans) entered a homeless program with a history of opioid use disorder (OUD). Findings showed that among the subgroup of homeless Veterans with an OUD history, opioid dose prescribing practices and rates of medication for addiction treatment (MAT) and naloxone receipt varied significantly. Less than one-quarter (23%) of Veterans received a prescription for naloxone, with homeless program-level rates of receipt ranging from 19% to 32%. Thirty-eight percent of Veterans received MAT in the year following entry into a VA homeless program, with program-specific rates ranging from 31% to 50%. Rates of high-dose opioid prescribing and concomitant opioid-benzodiazepine prescribing were highest, and rates of MAT and naloxone prescribing were lowest, among those ages 55+. Current treatment gaps indicate the need for universal policy goals to address OUD among Veterans at risk of being homeless – or who are currently or formerly homeless. Implementation strategies are needed to tailor opioid treatment access and dissemination to homeless and similar vulnerable Veteran groups.
Date: August 1, 2019
- Dual use of VA and Medicare Drug Benefits Associated with Potentially Unsafe Medication Prescribing among Veterans
Previous research shows that dual VA-Medicare Part D prescription drug use is a risk factor for potentially unsafe medication (PUM) exposure in Veterans with dementia and opioid users. Thus, this study evaluated the association of dual prescription use through VA and Part D (vs. VA-only use) with the prevalence of PUM exposure in a national cohort of dually-eligible older Veterans. Findings showed that dual use of VA and Part D prescription drug benefits was associated with an almost 2-fold increase in the odds of exposure to any PUM compared with VA-only use and more than 3 times the odds of exposure to severe drug-drug interactions. PUM exposure was lowest among VA-only users, and PUM exposure peaked in Veterans receiving prescriptions in near-equal proportions (50/50) from VA and Part D. To mitigate the potential risks associated with unsafe medication prescribing, policies intended to expand access to non-VA providers must ensure patient information is shared and integrated into routine practice for all patients seeking care across multiple healthcare systems.
Date: July 22, 2019
- Significant Cost Savings for VA in Allowing for 12-Month Dispensing of Oral Contraceptive Pills
Like most US health plans, VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). This study sought to determine the expected financial and reproductive health implications for the VA healthcare system in implementing a 12-month dispensing option for oral contraceptive pills. Findings showed that adoption of a 12-month dispensing option for oral contraceptive pills is expected to produce substantial cost savings for VA compared to standard 3-month dispensing, while reducing unintended pregnancies among women Veterans. The 12-month dispensing option resulted in anticipated VA cost savings of $87.12/woman/year compared to 3-month dispensing, or an estimated $2,117,800 total saved annually. Cost savings resulted from an absolute reduction of 24 unintended pregnancies/1,000 women/year with 12-month dispensing, or 583 unintended pregnancies averted annually. Financial gains are a secondary benefit to improving contraceptive access and facilitating women Veterans’ individual abilities to manage their reproductive lives as they see fit.
Date: July 8, 2019
- Six Readily Available Processes of Care Can Decrease Mortality for Individuals with TIA or Non-Severe Stroke
This study sought to identify specific processes of care that are associated with reduced risk of recurrent stroke or death among patients with TIA or non-severe stroke. Six processes were found to be effective in acute TIA management studies: brain imaging, carotid artery imaging, hypertension medication intensification, high-moderate potency statin, antithrombotics, and anticoagulation for atrial fibrillation. VA patients who received all of these processes for which they were eligible were classified as passing the “without-fail care” rate. The six without-fail care processes can be provided routinely across diverse medical centers because they do not require specialized structures of care. Without-fail care – including the six readily available processes – was associated with lower odds of death (31% reduction at 1-year) but not recurrent stroke risk. However, among 8,076 TIA or non-severe stroke patients, only 15% received the without-fail care for which they were eligible. In analyses restricted to =65-year-olds, results were virtually identical to the main results.
Date: July 3, 2019
- Substantial Variation in Opioid Prescribing Rates among ED Providers in the Same VA Healthcare Facility
The study team examined the extent to which variation in individual ED physicians’ opioid prescribing was independently associated with long-term opioid use in Veterans. Using VA data, investigators identified Veterans with an index ED visit at any VA facility in 2012 – and who were opioid naïve (without opioid prescriptions in the prior 6 months). Findings showed that there was a three-fold variation in the rates of opioid prescribing by ED physicians within the same VA facility (21% vs. 6%), regardless of patients’ severity of pain or primary diagnosis. The frequency of long-term opioid use was higher among opioid-naïve Veterans treated by high vs. low-quartile ED prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%). Though the increase in long-term opioid use among Veterans treated by the highest-prescribing ED providers was not significant in the overall sample, it was significant among important patient subgroups, including those with back pain, musculoskeletal pain, or depression. High-intensity prescribers were more likely to prescribe opioids across the spectrum of pain intensity, while low-intensity prescribers were less likely to prescribe opioids across the spectrum.
Date: May 29, 2019
- Risk of Adverse Events Increases with Each Additional Day of Prophylactic Antimicrobial Exposure following Surgery
National guidelines recommend surgical antimicrobial prophylaxis be initiated within 1 hour prior to incision and discontinued within 24 hours post-operatively for most procedures – and within 48 hours for cardiac surgery. This study sought to characterize the association of type and duration of prophylaxis with surgical site infection (SSI), acute kidney injury (AKI), and Clostridium difficile infection among all Veterans undergoing major cardiac, orthopedic total joint replacement, colorectal, and vascular procedures between October 2008 and September 2013. Findings showed that every day matters. Surgical prophylaxis durations lasting for greater than 24 hours increase the incidence of adverse events, such as acute kidney injury and C. difficile, but do not reduce surgical site infections. Risk of harm increases with each additional day of antimicrobial exposure. The choice of surgical prophylaxis affects the incidence of SSI and other adverse events. For example, the use of vancomycin was independently associated with increased odds of AKI following both cardiac procedures and non-cardiac procedures.
Date: April 24, 2019
- Receipt of Opioid Prescriptions from Both VA and Medicare Associated with Greater Likelihood of Overdose Death
This study assessed the association between dual receipt of opioid prescriptions from VA and Medicare Part D and prescription opioid overdose death among Veterans enrolled in both VA and Part D. Findings showed that receipt of opioid prescriptions from both VA and Part D was associated with 2-3 times greater odds of overdose death than among Veterans receiving opioids from VA or Part D only. Dual users also had a higher cumulative opioid dose over 180 days and average daily opioid dose. Dual enrollees are a vulnerable group of Veterans, emphasizing the importance of care coordination across providers and healthcare systems to increase the safety of opioid prescribing within and outside VA.
Date: March 12, 2019
- Over-Prescribing of Medication for Insomnia, Particularly among Women Veterans
Zolpidem, a non-benzodiazepine sedative hypnotic, is extensively prescribed in the U.S. for short-term treatment of insomnia. FDA recommends cutting the dose for women in half because women metabolize the same dose of zolpidem more slowly than men; VA’s national Pharmacy Benefits Management service policy is in line with FDA guidelines. This study examined prescribing patterns among all VA patients who received zolpidem from FY2012-FY2016. Findings showed that there was inappropriate prescribing of zolpidem in terms of both guideline-discordant dosage and co-prescribing with benzodiazepines, with female Veterans affected more than male Veterans. In 2016, among Veterans who were prescribed zolpidem, 30% of female Veterans received an inappropriately high guideline-discordant dosage compared to 0.1% of male Veterans. Further, more women than men had overlapping benzodiazepine and zolpidem prescriptions (19% vs. 14%). For both male and female Veterans, having a substance use disorder was associated with an inappropriate high dose. Further, mental health conditions, including anxiety and PTSD, were associated with co-prescribing of zolpidem with benzodiazepines for both male and female Veterans.
Date: March 1, 2019
- Higher Statin Adherence Associated with Lower Mortality in Veterans with Atherosclerotic Cardiovascular Disease
This analysis sought to determine whether statin adherence is associated with mortality in stable patients with atherosclerotic cardiovascular disease (ASCVD). Findings showed that higher statin adherence was associated with lower mortality in a national sample of Veterans with ACSVD. Also, ischemic heart disease or stroke hospitalizations in the VA healthcare system were more frequent in Veterans who were less adherent to statins. Overall, statin adherence in this cohort on a stable statin intensity was high (88%). Veterans on moderate-intensity statin therapy were more adherent than Veterans on high-intensity statin therapy. Veterans with peripheral artery disease and cerebrovascular disease were less adherent than those with coronary artery disease. Women and minority groups were less adherent to statin therapy, with adherence lowest among black patients. Younger and older patients were less adherent, compared with adults aged 65-74.
Date: February 13, 2019
- Links Between Opioid Use and Suicide
This review describes what is known about the links between suicide and overdoses, with a focus on pathways through opioid use, issues of intent, risk factors, prevention strategies, and unresolved issues. Many factors promote the initiation and persistence of opioid use, but several specific pathways toward vulnerability to overdose and suicide are highlighted. Interventions that address shared causes and risk factors, such as programs to improve the quality of pain care, expanding access to psychotherapy, and increasing access to medication-assisted treatment for opioid use disorders, have the potential to be high-value investments by addressing both problems.
Date: January 3, 2019
- Antihypertensive Deintensification Associated with Fewer Falls among Older VA Nursing Home Residents
This study sought to: 1) describe the frequency of antihypertensive de-intensification during scenarios suggesting over-aggressive treatment, 2) identify characteristics of residents associated with antihypertensive de-intensification, and 3) examine the association between antihypertensive de-intensification and subsequent falls. Findings showed that among Veterans with possibly over-aggressive antihypertensive treatment, just 11% underwent antihypertensive de-intensification. Among Veterans with low systolic blood pressure (SBP 80-100), antihypertensive de-intensification was associated with a lower risk of falling, but was not associated with risk of hospitalization or death. Among Veterans with possibly low SBP (101-120), antihypertensive de-intensification was associated with a higher risk of death, but not with risk of falling or hospitalization. In frail older adults, clinicians should repeatedly re-evaluate intensity of blood pressure management, taking into account the individual’s prognosis, goals of care, and an individualized estimate of the benefits and harms associated with the intensity of antihypertensive medication.
Date: December 1, 2018
- Link between Length of Prescription for Initial Exposure to Opioids and Long-Term Use
This study examined the association between initial opioid exposure and subsequent long-term use in two national VA cohorts from 2011 and 2016. Findings showed a strong relationship between initial opioid exposure and the future likelihood for long-term use. Cumulative days’ supply of prescription opioids emerged as the strongest predictor of long-term opioid use, which occurred in only 2% of Veterans dispensed 7 days’ or less supply, and in 28% of patients dispensed greater than 30 days’ supply. Comparing 2011 and 2016 data, the association between day’s supply and long-term use persisted, even as the overall rate of long-term opioid use decreased. Findings suggest that limiting initial opioid exposure may reduce risk for long-term opioid use. Moreover, examination of early opioid exposure may offer an opportunity to recognize when a patient is in the process of starting long-term opioid use.
Date: November 5, 2018
- Pharmacotherapy for Opioid Use Disorder Highly Variable across VA Residential Substance Abuse Treatment Programs
Pharmacotherapy, including methadone, buprenorphine, and naltrexone, is both efficacious and cost-effective for treating opioid use disorder (OUD), however it is infrequently prescribed in VA. Investigators in this study sought to describe barriers to and facilitators of pharmacotherapy provided to a national cohort of VA patients with OUD in VA residential substance use disorder (SUD) treatment programs in FY2012. Findings showed that implementation of pharmacotherapy for OUD is highly variable across VA residential SUD treatment programs. Across all 97 treatment programs, the average rate of receipt of pharmacotherapy for OUD in FY2012 was 21% and ranged from 0% to 67%. There were 11 programs where 0% of patients received pharmacotherapy for OUD. Barriers included program or provider philosophy against pharmacotherapy and a lack of care coordination with non-residential treatment settings. Facilitators included education for staff and patients and having a prescriber on staff. Intensive educational programs, such as academic detailing, and policy changes such as mandating buprenorphine waiver training for VA providers, may help improve receipt of pharmacotherapy for OUD.
Date: November 1, 2018
- Veterans Receiving Prescriptions Through Both VA and Medicare Are More Likely to Be Taking Opioids and Benzodiazepines
This study sought to assess the association between receiving medications from both VA and Medicare Part D (dual use) and the receipt of overlapping opioid and benzodiazepine prescriptions. Findings showed that receiving prescription medications from both VA and Medicare Part D was associated with a 27% increased risk of overlapping opioids and benzodiazepines – and more than twice the risk of overlapping high-dose opioids with benzodiazepines – compared to receiving prescriptions from VA alone. Receipt of prescriptions from both VA and Medicare also was associated with a greater risk of opioid/benzodiazepine overlap compared to Medicare alone, although the difference was smaller. Receipt of medications from more than one healthcare system is a key risk factor for unsafe prescribing practices, highlighting the need to enhance coordination of care across healthcare systems to optimize the quality and safety of prescribing.
Date: October 9, 2018
- 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
- Pain Intensity Following Discontinuation of Long-Term Opioid Therapy Does Not, on Average, Worsen for Patients
This study sought to characterize pain intensity over 12 months following opioid discontinuation. Findings showed that average pain intensity did not significantly worsen in the 12 months after Veterans discontinued opioid therapy; for some patients, pain intensity improved. Mean estimated pain at the time of opioid discontinuation was 4.9 on a scale from 0-10. Changes in pain following discontinuation were characterized by slight but statistically non-significant declines in pain intensity over 12 months post-discontinuation. Veterans in the mild (average pain = 3.9) and moderate (average pain = 6.3) pain categories experienced the greatest pain reductions post-discontinuation. Of this study cohort, 87% of Veterans were diagnosed with chronic musculoskeletal pain, 6% with neuropathic pain, and 11% with headache pain (including migraine). Study findings can aid clinicians during discussions with patients about opioid discontinuation.
Date: June 13, 2018
- Online Toolkit to Improve Primary Care Coordination within VA and with Community Providers
The Coordination Toolkit and Coaching (CTAC) project aims to improve patients’ experience of care coordination, while also developing better methods for bringing research evidence on care coordination into routine care. In this article, investigators describe CTAC’s first phase, which involved selecting tools for an online care coordination toolkit and developing a VA Intranet site to support the tools. The final Care Coordination Toolkit, available on the VA Intranet at https://vaww.visn10.portal.va.gov/sites/Toolkits/toolkit/Pages/Home.aspx, provides access to 18 tools that remained after the selection process noted above, as well as detailed information about tools’ expected benefits, and the resources required for tool implementation. The 18 tools cover 5 topics: 1) managing referrals to specialty care, 2) medication management, 3) patient after-visit summary, 4) patient activation materials, and 5) provider contact information for patients. The CTAC project is expected to improve care coordination in VA primary care clinics and provide readily-applicable methods for spreading improvements throughout VA. In addition, the project will inform VA policymakers regarding what other implementation strategies, including the use of distance coaching, might influence the use of toolkits within healthcare delivery systems.
Date: May 23, 2018
- No Decrease in Drinking among Veterans despite Alcohol-Related Nurse Care Management Intervention in Primary Care
The Choosing Healthier Drinking Options in Primary Care (CHOICE) intervention was designed to improve drinking outcomes by engaging Veterans at high risk for alcohol use disorders (AUDs) in patient-centered, alcohol-related care. Investigators in this study examined whether 12 months of alcohol care management via the CHOICE intervention – compared with usual primary care – improved drinking outcomes (abstinence was not a required goal). Findings showed that the CHOICE intervention did not decrease heavy drinking or alcohol-related problems at 12 months even though more Veterans engaged in alcohol-related care, including a four-fold increase in initiation of medications for alcohol use disorders. Primary outcomes improved at 12 months but did not differ between groups. The mean percentage of heavy drinking days decreased from 61% at baseline to 39% and 35% in the intervention and usual care groups, respectively. The percentage of Veterans with good drinking outcomes was 15% and 20% in the intervention and usual care groups, respectively. Current quality measures for AUDs are based on the assumption that engagement in alcohol-related care emphasizing brief intervention and reduced drinking is sufficient to improve outcomes. This trial’s results, in addition to existing literature, suggest that more intensive measures, such as recommending abstinence (vs. reduction in drinking), engaging most patients in use of naltrexone, and/or offering effective behavioral treatment might be needed for alcohol care programs in primary care to be more effective.
Date: May 1, 2018
- Then and Now: Medications for Opioid Use Disorder in VA
As the largest provider of substance use disorder treatment in the nation, VA has taken proactive steps to increase access to medications indicated for opioid use disorder (OUD), which is an essential component of evidence-based care. This article examines the history of those medications (methadone, buprenorphine, and injectable naltrexone) within VA, as well as early and ongoing efforts to increase access to and build capacity for the treatment of OUD, which included adding buprenorphine to the VA formulary in 2006, educational and quality improvement initiatives, targeted resources, national policy, and “big data” initiatives. This article also summarizes research on barriers and facilitators to prescribing and medication receipt.
Date: March 29, 2018
- State-based Prescription Drug Monitoring Programs Might Help Increase Opioid Prescribing Safety among Veterans Using VA and Non-VA Healthcare
This study evaluated VA physicians’ perspectives and experiences regarding the use of state-based Prescription Drug Monitoring Programs (PDMPs) to monitor Veterans’ receipt of opioids from non-VA prescribers. Findings showed that VA primary care physicians broadly embraced PDMPs as a tool to monitor Veterans’ receipt of opioids from non-VA sources despite identifying multiple barriers to optimal use. They also identified several key best practices currently used within VA and made suggestions for future improvements that may enhance efforts to ensure safe opioid prescribing. Key barriers included incomplete or unavailable prescribing data, while key facilitators included linking PDMPs with VA’s electronic health record, using templated notes to document PDMP use, and delegating routine PDMP queries to ancillary staff (i.e., nurses or clinical pharmacists). Applying improvements identified in this study may enable VA to serve as a national model for those seeking to enhance PDMP use, thereby improving opioid prescribing safety.
Date: March 8, 2018
- VA Successfully Implements Interferon-free Treatment for Hepatitis C Virus in Previously Undertreated Patient Populations
This study examined the adoption of interferon-free treatment for hepatitis C virus (HCV) in VA to learn who received this therapy and whether the limitations of interferon-containing treatments have been overcome, including low rates of use among VA healthcare users who are African American or Hispanic, and among those with HCV-HIV co-infection. Findings showed that with the advent of interferon-free regimens, the percentage of VA patients with HCV infection that was treated increased from 2% in 2010 to 18% in 2015, an absolute increase of 16%. There were large treatment gains realized by groups of patients that had been less likely to be treated in 2010. Large absolute increases in the percentage treated were achieved in Veterans with HIV co-infection (19%), alcohol use disorder (12%), and drug use disorder (13%), and in Veterans who were African-American (14%) or Hispanic (14%). Veterans with mental illnesses exacerbated by interferon, depression, PTSD, and bipolar disorder, had absolute increases in treatment that were larger than the overall increase.
Date: March 7, 2018
- Opioids Do Not Result in Better Pain-Related Function or Pain Intensity Compared to Non-Opioid Drugs in Veterans with Chronic Pain
This randomized trial compared opioid therapy versus non-opioid medication therapy over 12 months for primary care patients with chronic back pain or hip or knee osteoarthritis pain. Findings showed that the use of opioid therapy compared with non-opioid medication therapy did not result in significantly better pain-related function over 12 months. Opioid therapy compared with non-opioid medication therapy resulted in significantly worse pain intensity over 12 months, but the importance of this is unclear because the magnitude was small. Opioids caused significantly more medication-related adverse symptoms than non-opioid medications. Overall, opioids did not demonstrate any advantage over non-opioid medications that could potentially outweigh their greater risk of overdose and other serious harms. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip/knee osteoarthritis pain.
Date: March 6, 2018
- Dual Use of VA and Medicare Associated with Substantial Increase in Risk of Potentially Unsafe Opioid Use among Veterans
This study sought to estimate the prevalence and consequences of receiving prescription opioids from both VA and Medicare Part D for all dually-enrolled Veterans who filled a prescription opioid in either system in calendar year 2012. Findings showed that among Veterans dually enrolled in Medicare Part D and VA and receiving prescription opioids in 2012, more than 1 in 8 received opioids from both systems, in many cases concurrently. Compared to VA-only use of opioids, dual use was associated with a 3-fold higher risk of high-dose opioid exposure and more than twice the risk of long-term high-dose opioid exposure. Dual use also was associated with a 60-90% greater risk of these exposures than Part D only use. VA is evolving into a less integrated delivery system with more community care options. As these options increase, the prevalence of poorly coordinated dual-system care (e.g., overlapping opioids and other drug interactions and duplication) also will likely increase.
Date: February 1, 2018
- Declining Rates in VA Prescriptions for Long-Term Opioids
This study sought to characterize the overall prevalence of opioid prescribing in the VA healthcare system from 2010 through 2016 by duration of use. Findings showed that opioid prescribing trends followed similar trajectories in VA and non-VA settings, peaking around 2012 and subsequently declining. The prevalence of VA opioid prescribing was 20.8% in 2010, 21.2% in 2012, and declined annually to 16.1% in 2016. Changes in long-term opioid prescribing accounted for 83% of the decline seen in VA patients. Comparing data from 2010-2011 to data from 2015-2016, declining rates in new long-term use accounted for more than 90% of the decreasing prevalence of long-term opioid use among Veterans, whereas increases in cessation among existing long-term users was less than 10%.
Investigators observed a decrease in overall opioid prevalence between 2012 and 2015 of 16% in VA healthcare settings, compared to 13% reported in non-VA settings. Recent VA opioid initiatives may be preventing patients from initiating long-term use.
Date: January 29, 2018
- Medical Record Alert Associated with Reduced Opioid and Benzodiazepine Co-prescribing
This implementation project evaluated the effectiveness of an advanced medication alert designed to reduce opioid and benzodiazepine co-prescribing among Veterans with high-risk conditions (substance use disorder, sleep apnea, suicide risk, and age =65) at one VA healthcare system (VA Puget Sound). Findings showed that the proportions of patients with concurrent prescriptions decreased significantly post-alert launch among Veterans with substance use (25%), sleep apnea (39%), and suicide risk (62%), with greater decreases at the alert site relative to the comparison site in sleep apnea and suicide-risk cohorts. Significant decreases in benzodiazepine prescribing were observed at the alert site only.
Date: December 28, 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
- Veterans are Commonly Prescribed Statins for Indications Unsupported by Guidelines for Managing High Cholesterol
This study of new statin prescriptions in the VA healthcare system examined concordance with ATP-III guidelines (in force in 2102) and ACC-AHA guidelines (updated in 2013). Findings showed that Veterans were commonly prescribed statins for indications not supported by either the ATP-III or the ACC-AHA 2013 guidelines. Of Veterans receiving new statins for primary prevention, 48% did not meet ATP III guidelines; 20% did not fulfill the new ACC-AHA guidelines. Of the Veterans included in the study, 68% of new statins were prescribed for primary prevention and 32% were for secondary prevention of atherosclerotic cardiovascular disease. Nineteen percent of Veterans receiving statins did not meet either set of guidelines.
Date: September 19, 2017
- Online Game Improves Glucose Control in Veterans with Diabetes
This randomized trial sought to determine whether a team-based game on diabetes self-management education (DSME) topics delivered to VA patients with type 2 diabetes could generate sustained improvements in their HbA1c levels. Findings showed that the game delivering DSME content generated significant improvements in HbA1c over 12 months among Veterans with type 2 diabetes, with the difference between cohorts (DSME vs. civics game) manifesting primarily in the 6 months following the games. Among DSME game patients with elevated HbA1c at baseline, the overall reduction in HbA1c was comparable to that of starting a new diabetes medication. The online, interactive methodology used in this intervention may be an effective and scalable method by which to improve health outcomes in Veterans with diabetes and other chronic diseases.
Date: September 1, 2017
- Impact of Intensive BP Therapy on Patient-Reported Outcomes
This randomized controlled trial compared two strategies for managing systolic blood pressure (SBP) in older adults with hypertension – an intensive strategy with an SBP target of <120 mmHg versus a standard care strategy targeting <140 mmHg – and whether such intensive therapy affects patient-reported outcomes. Findings showed that intensive therapy resulted in a 14.8 mmHg lower blood pressure compared to standard therapy; however, this had little impact on changes in patient-reported outcomes and adherence. The majority of participants in both groups reported that they were satisfied or very satisfied with their blood pressure care: 89% vs 88% in intensive and standard groups respectively. Overall, 44% of participants reported high adherence with blood pressure medications at 12 months, and no differences were noted between the intensive and standard treatment groups. Results provide reassurance that intensive hypertension therapy not only reduces cardiovascular morbidity and mortality, but will be well-tolerated, even in older patients with multiple comorbidities.
Date: August 24, 2017
- Systematic Review: Patient Outcomes in Dose Reduction or Discontinuation of Long-term Opioid Therapy Suggest Utility of Multimodal Care
Investigators examined the evidence on the effectiveness of strategies to reduce or discontinue long-term opioid therapy (LTOT) prescribed for chronic pain – and the effect of dose reduction or discontinuation on important patient outcomes, including pain severity and pain-related function. Findings showed that there are multiple strategies to reduce or discontinue long-term opioid treatment for chronic pain, however the quality of the evidence for effectiveness was very low. In 3 good-quality trials of behavioral interventions and 11 fair-quality studies of interdisciplinary pain programs, patients received multimodal care that emphasized non-pharmacologic and self-management strategies. Sixteen fair-quality studies reported improvement in pain severity (8/8 studies), function (5/5 studies), and quality of life (3/3 studies) following opioid dose reduction. However, few studies examined the potential risks of opioid dose reduction such as adverse events (i.e., opioid overdose), illicit substance abuse, or suicide.
Date: July 18, 2017
- Higher Risk of Suicidal Ideation and Suicidal Self-Directed Violence following Discontinuation of Long-term Opioid Therapy
The primary objective of this study was to identify predictors of suicidal ideation (SI) and non-fatal suicidal self-directed violence (SSV) following clinician-initiated discontinuation of long-term opioid therapy. Findings showed that a substantial proportion of Veterans with substance use disorder diagnoses and similar matched patients experienced suicidal ideation or suicidal self-directed violence following discontinuation of long-term opioid therapy by their opioid-prescribing clinicians, most of whom represent new onset cases. Approximately 12% of patients in this sample had SSV and/or SI documented in the medical record in the 12 months following discontinuation of opioid therapy: 47 patients had SI only, while 12 had SSV. Half of patients with SSV attempted suicide by overdose, most commonly with benzodiazepines. Mental health diagnoses associated with having SI/SSV included PTSD and psychotic disorders. The majority of patients (75%) were discontinued from opioid therapy due to aberrant behaviors. Healthcare providers should pay special attention to safety when patients are discontinued from long-term opioid therapy, particularly patients with PTSD or psychotic disorders.
Date: July 1, 2017
- Greater Risk of Opioid Prescription Overlap in Veterans Using Medicare Part D–Reimbursed Pharmacies
This study sought to identify trends in dispensed prescriptions for opioids and the frequency of overlapping days’ supply of prescriptions for opioid medications in Veterans dually eligible for VA and Medicare Part D benefits. Findings showed that over the study period, there was an increasing reliance on the use of Part D–reimbursed pharmacies for opioid prescriptions among Veterans. Although opioid overlap appears to be declining within the VA healthcare system, overlap is increasing among opioid prescriptions dispensed from Medicare Part D–reimbursed pharmacies. Predictors for overlap included female gender, Part D enrollment, no VA medication copay, sleep disorders, psychiatric diagnoses, and substance or alcohol abuse. Veterans who were Hispanic, older, and had higher incomes had lower odds of overlap.
Date: May 1, 2017
- Initiative Decreases Inappropriate Prescribing to Older Veterans Discharged from VA Emergency Department Care
This study evaluated the effectiveness and sustainability of the Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED) program to reduce the use of potentially inappropriate medications (PIMs). Findings showed that EQUiPPED was associated with a sustained reduction in inappropriate medication prescribing at all four VAMCs in the study. Post-intervention, the proportion of PIMs at site one decreased from 12% to 5%; at site two it decreased from 8% to 5%, at site three from 9% to 6%, and at site four from 7% to 6%. The implementation timeline for the initiative ranged from 6 to 14 months depending on the site. While the implementation timelines varied across sites, all VAMCs achieved a monthly PIM proportion between 5% and 6%. The EQUiPPED intervention led to safer prescribing and was sustainable across multiple VA sites. Implementation is currently underway at six additional VA emergency department sites, as well as three non-VA ED sites to evaluate broader dissemination.
Date: April 7, 2017
- Comparing Effectiveness of Two Medications for Veterans with Clostridium Difficile Infection
This multi-year comparative effectiveness study evaluated the risk of recurrence and all-cause 30-day mortality among Veterans receiving metronidazole or vancomycin for the treatment of mild to moderate and severe Clostridium difficile infection (CDI) in the VA healthcare system. Findings showed that recurrence rates were similar among Veterans treated with vancomycin and metronidazole; however, Veterans with severe CDI treated with vancomycin were about 20% less likely to die from any cause within 30 days than Veterans treated with metronidazole. Overall, Veterans who received vancomycin had a lower risk of mortality compared to Veterans treated with metronidazole. Of the Veterans in this study, 4%-6% initially received vancomycin, despite 42% of the episodes having been classified as severe. While the use of vancomycin increased over the study period, by 2012 half of the patients with severe CDI still did not receive vancomycin. Although excess treatment costs of vancomycin relative to metronidazole and the concern for vancomycin-resistant enterococci will likely remain barriers, improved clinical cure and mortality rates may warrant reconsideration of current guidelines, particularly in cases of severe CDI.
Date: April 1, 2017
- Opioid Use among Afghanistan and Iraq War Veterans
This study sought to understand current opioid use in OEF/OIF/OND Veterans who are regular users of VA care and did not have a cancer diagnosis at the time of this study. Findings showed that opioid use among OEF/OIF/OND Veterans is characterized by moderate doses that are used over relatively long periods of time by a minority of Veterans. Approximately 23% of all OEF/OIF/OND Veterans received opioids, with 7-8% receiving them chronically. The prevalence of high-dose opioids, concurrent use of multiple opioids, and use of long-acting opioids was fairly low. Diagnoses of PTSD, major depressive disorder, and tobacco use disorder were strongly associated with chronic opioid use. Back pain also was strongly associated with chronic use. Findings suggest that the use of opioids is less common among OEF/OIF/OND Veterans compared with Veterans as a whole, and provide a strong baseline for evaluating the impact of recently implemented opioid-related policies.
Date: March 25, 2017
- Systematic Review Finds Treating Blood Pressure to Current Guidelines in Older Adults Improves Health Outcomes
This systematic review sought to compare the effects of more versus less intensive blood pressure control in older adults. Findings showed that treating blood pressure in adults over 60 to at least current guideline standards (<150/90 mmHg) substantially improves health outcomes in older adults, including reducing mortality, stroke, and cardiac events. The most consistent and largest effects were seen in studies of patients with higher baseline blood pressure (SBP >160mmHg) who achieved moderate blood pressure control (<150/90 mmHg). There is less consistent evidence, largely from one trial targeting SBP <120 mmHg, that lower blood pressure targets are beneficial for high cardiovascular risk patients. In patients with prior stroke or transient ischemic attack, treating to SBP < 140 mmHg reduces the risk of recurrent stroke. Lower blood pressure targets did not increase falls or cognitive decline, but were associated with hypotension, syncope, and greater medication burden.
Date: March 21, 2017
- Addressing the Opioid Epidemic: Lessons Learned from VA
This article describes VA’s efforts to address the opioid epidemic, and lessons learned that can inform other healthcare systems planning comprehensive action to reduce the risks associated with opioid therapy.
Date: March 13, 2017
- Discontinuation of Long-Term Opioid Therapy among Veterans is Overwhelmingly Initiated by VA Clinicians
The aim of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between Veterans with and without substance use disorder (SUD) receiving care within the VA healthcare system in the years following release of 2009 and 2010 clinical practice guidelines. Findings showed that the majority of Veterans (85%) discontinued opioid use because their clinician stopped prescribing, rather than the patients deciding to stop. For patients whose clinicians initiated discontinuation, 75% were discontinued due to opioid-related aberrant behaviors (i.e., suspected substance abuse, aberrant urine drug test). Veterans with SUD diagnoses were more likely to discontinue LTOT due to aberrant behaviors, particularly abuse of alcohol or other substances, compared to Veterans without SUD. High proportions of patients received diagnoses for mental health disorders in the year prior to discontinuation of LTOT, including PTSD, anxiety disorders other than PTSD, and depressive disorders (25%). Increasing rates of opioid discontinuation are likely to occur due to policies and programs that encourage close monitoring of Veterans on LTOT for opioid misuse behaviors. Integrating non-opioid pain therapies and SUD treatment into multiple settings such as primary care and specialty SUD care is one possible approach to enhance their care.
Date: March 1, 2017
- VA Pharmacy Use in the First Year of Choice Act
This study sought to describe pharmaceutical use during the first year of the Veterans Choice Program (VCP) and to understand barriers and facilitators for VA pharmacists to dispensing medications under the VCP. Findings showed that a majority of VCP pharmacy spending in the first year was for hepatitis C virus (HCV) medications, which accounted for only 5% of prescriptions but 90% of costs. However, in 2015, VA experienced greater than expected demand for HCV medications, which exceeded available funding, thus some patients obtained medications through the VCP. The impact of HCV medications on the VCP should be short-lived given broadened availability in VA in 2016. Topical eye drops and opioids represented the most commonly dispensed prescriptions: 16% and 9% of all prescriptions, respectively.
Most prescriptions dispensed (93%) were for formulary agents, but substantial efforts were required from VA pharmacists to work with non-VA providers to use formulary drugs. Challenges related to obtaining medications from VA pharmacies through VCP included requiring controlled substance prescriptions to be hand-delivered, a lack of access to lab data required to safely dispense medications, and substantial time required by pharmacists to communicate with non-VA providers. Safe use of opioids, efficient management of non-formulary medications, and unintended new barriers to access created by the VCP must be addressed, in addition to robust ongoing evaluations to identify new cost, quality, and safety concerns.
Date: February 17, 2017
- Substantial Portion of Elderly Veterans Receive Medications from Medicare Part D-Reimbursed Pharmacies – Either Alone or in Conjunction with VA Pharmacies
This study examined patterns of medication acquisition from VA and Medicare Part D-reimbursed pharmacies following the implementation of Part D. Findings showed that nearly one-third of VA healthcare users received medications from Part D-reimbursed pharmacies, either alone or in combination with VA pharmacies. Veterans who lived in rural areas, were not black, had VA medication copayments, or were dual or Medicare-only outpatient users were more likely to be dual (i.e., both VA and Part D) pharmacy users or Part D-reimbursed only pharmacy users compared to other Veterans. Among dual pharmacy users, more than half of the Veterans received medications from the same drug class from both VA and Part D-reimbursed pharmacies that overlapped by more than seven days. Results highlight the clinical importance of assessing medications from VA and non-VA sources. At particular risk for suboptimal medication reconciliation are those Veterans who receive care within VA only or from both VA and Medicare outpatient clinics, but who solely obtain their medications from non-VA pharmacies.
Date: February 1, 2017
- VA Opioid Safety Initiative Decreases Potentially Risky Opioid Prescriptions among Veterans
This study examined changes associated with Opioid Safety Initiative (OSI) implementation among all adult VA patients who filled outpatient opioid prescriptions from October 2012 through September 2014 in any of 141 VA facilities. Findings showed that during the two-year study period there was a decrease in the number of VA patients receiving risky opioid regimens, with an overall reduction of 16% among Veterans receiving >100 morphine-equivalent milligrams (mEq) daily dosages and 24% among Veterans receiving >200 mEq. There was a 21% reduction in Veterans receiving benzodiazepines concurrently with opioids. Implementation of the OSI dashboard tool was associated with a significant decrease in all three outcomes (>100 mEq, >200 mEq and concurrent opioid/benzodiazepine prescribing). The implementation of the OSI dashboard tool was associated with a significant decrease in risky opioid prescribing across the VA healthcare system, which highlights the possibility of system-wide approaches to address high-risk opioid prescribing. However, a large number of VA patients remained on these regimens at the end of the study period, which emphasizes the challenges of making significant changes in healthcare systems that treat a large population of complex patients.
Date: January 4, 2017
- Safety Risk for Veterans Receiving Overlapping Buprenorphine, Opioid, and Benzodiazepine Prescriptions from VA and Medicare Part D
Ensuring safe buprenorphine prescribing is especially challenging for VA, which treats a substantial number of Veterans with chronic pain and opioid use disorder, as well as an increasing number of patients who receive concurrent care in the private sector (i.e., Medicare Part D). This study identified Veterans dually enrolled in VA and Medicare Part D who filled a buprenorphine prescription in 2012 from either healthcare system and identified the proportion of Veterans with overlapping prescriptions from either system. Findings showed that more than one in four Veterans who received a VA prescription for buprenorphine – and one in five Veterans who received a Medicare prescription for buprenorphine – also received overlapping prescriptions for opioids from a different healthcare system. Among Veterans receiving buprenorphine from VA, 1% received an overlapping benzodiazepine prescription from Medicare, while among those receiving buprenorphine from Medicare, 16% received an overlapping benzodiazepine prescription from VA. Among VA and Part D buprenorphine recipients who had cross-system opioid overlap, 25% and 35%, respectively, had >90 days of overlap. Findings indicate a previously undocumented safety risk for Veterans dually enrolled in VA and Medicare who are receiving prescriptions for buprenorphine and overlapping prescriptions for opioids and/or benzodiazepines.
Date: December 7, 2016
- Veterans with Dementia Using Both VA and Medicare More than Double their Odds of Exposure to Potentially Unsafe Medications
This study examined the prevalence and effect of dual use of VA and Medicare Part D prescription medications on prescribing safety among a national cohort of Veteran outpatients (aged >68 years) with a diagnosis of dementia prior to 2010, who were dually-eligible. Findings showed that the prevalence of exposure to potentially unsafe medications was high overall (44%), but was particularly high in dual users compared to VA-only users (59% versus 39%). Thus, compared to VA-only users, dual VA/Medicare users more than doubled the odds of exposure to potentially unsafe medications (PUM) overall –and to any “high-risk medications to avoid in older adults.” Dual-users had an adjusted average of 44 additional PUM-days of exposure compared to VA-only users. The odds of antipsychotic PUM exposure were 1.5 times greater for dual-users. Policymakers should consider implementing electronic health information exchanges and additional medication therapy management services across healthcare systems to keep pace with recent policies designed to expand Veterans’ access to non-VA care – and to protect vulnerable patients from risks associated with dual system use.
Date: December 6, 2016
- Maximal Doses of High-Intensity Statins Confer Greatest Survival Advantage for Those with Atherosclerotic Cardiovascular Disease
This study sought to determine one-year cardiovascular mortality for VA patients with atherosclerotic cardiovascular disease by statin intensity – and to assess whether any differences in mortality related to statin intensity, if present, were observed in selected patient sub-groups (i.e., age, gender). Findings showed that high-intensity statins conferred a small but significant survival advantage over moderate intensity statins, even among older adults. Moreover, the maximal doses of high intensity statins conferred a further survival benefit. For example, when the sample was limited to Veterans on high-intensity statins, those treated with maximal doses had a 10% lower mortality when compared with those on sub-maximal doses. There was significant underuse of high-intensity statins and a graded relationship between statin intensity and mortality among Veterans in this study. Only 20% of Veterans received a high-intensity statin, while 43% were on moderate-intensity statins. Older adults (>75 years), women, and some minority groups were less likely to be on a high-intensity statin at baseline. Findings have significant implications for future lipid management practice guidelines.
Date: November 9, 2016
- 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
- Cost-Effectiveness of New Hepatitis C Virus Treatments in VA and Non-VA Patient Populations
This study analyzed the cost-effectiveness of multiple new hepatitis C virus (HCV) treatments for VA and non-VA treatment-naïve patients, accounting for differences in patient characteristics and costs of ongoing care and current drug prices, as well as potential reductions in these prices. Findings showed that in the non-VA HCV population, the latest generation of highly effective but costly HCV treatments delivers good value – comparable to other medical interventions commonly deemed high value. HCV treatment is even more cost-effective in VA’s patient population due to VA’s lower costs of drugs, despite patients being older with more comorbid conditions.
Date: October 3, 2016
- OEF/OIF/OND Veterans that Currently Smoke More Likely to Receive Opioid Prescription than Non-Smokers
This study sought to determine if smoking status is associated with the receipt of opioids among OEF/OIF/OND Veterans – and to examine important covariates of smoking (i.e., current pain intensity, gender, and mental health diagnoses) and receipt of opioids. Findings showed that compared to non-smokers, OEF/OIF/OND Veterans who were current smokers were more likely to receive an opioid prescription, even after controlling for covariates including: pain intensity, age, gender, service-connection, substance use disorder, mood disorders, and anxiety disorders. Veterans who reported a higher current pain intensity and those with pain diagnoses also were more likely to receive an opioid prescription. Among this young cohort of Veterans (mean age=30 years), more than one-third (34%) reported moderate to severe current pain intensity within +/-30 days of smoking status, with approximately 8% receiving at least one opioid prescription.
Date: September 21, 2016
- Lithium or Valproate Associated with Better Outcomes Compared to Second-Generation Antipsychotics for Bipolar Disorder
This study assessed a nationwide population of Veteran outpatients with bipolar disorder treated at VAMCs, who were newly initiated on an antimanic agent between 2003 and 2010. The primary outcome was likelihood of all-cause hospitalization during the year after initiation. Findings showed that after extensive control for covariates, initiation of lithium or valproate alone – compared to initiation of an second-generation antipsychotic (SGA) alone – was associated with a significantly lower likelihood of all-cause hospitalization, a longer time to hospitalization, and fewer hospitalizations in the subsequent year. Veterans receiving combination treatment (i.e., SGA + lithium, SGA + valproate) had a significantly higher likelihood of hospitalization, although they also had a longer time to addition of another antimanic agent or antidepressant. Among monotherapies, the only significant differences were found in psychosis, with it being more likely in those initiated on SGAs rather than those initiated on lithium, valproate, or carbamazepine/oxcarbazepine.
Date: September 1, 2016
- Use of Contraindicated Medications among Veterans Undergoing Percutaneous Coronary Intervention
This study examined the use of contraindicated antiplatelet medications for 64,294 Veterans who underwent a PCI between 2007 and 2013. Findings showed that 18% had a known contraindication to at least 1 of 5 antiplatelet medications. Among these patients, 7% received a contraindicated medication in either the periprocedural setting or upon hospital discharge. Patients on contraindicated antiplatelet therapy showed a non-significant trend for greater risk of 30-day mortality and periprocedural major bleeding. Thus, use of contraindicated antiplatelet medications persists, though the rate of contraindicated medication use is lower in VA compared with U.S. community practice.
Date: July 1, 2016
- Prescription Opioids Associated with Lower Likelihood of Sustained Improvement in Pain among Older Veterans
This study sought to identify patient factors associated with improvements in pain intensity in a national cohort of Veterans 65 years or older with chronic pain. Findings showed that on average, Veterans prescribed an opioid were less likely to demonstrate sustained improvement in pain intensity scores compared to Veterans who were not prescribed opioids. Overall, average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds of Veterans met criteria for sustained improvement during follow-up. Findings call for further characterization of heterogeneity in pain outcomes in older adults, as well as further analysis of the relationships between prescription opioids and treatment outcomes.
Date: July 1, 2016
- Erectile Dysfunction Medication Use among Veterans Eligible for Medicare Part D
This retrospective cohort study determined oral phosphodiesterase-5 inhibitor (PDE-5) medication use, which is considered first-line therapy for erectile dysfunction (ED), among Veterans who were dually eligible for VA and Medicare Part D benefits. Findings showed that during the period when PDE-5 inhibitors were allowed on the Medicare Part D formulary, prescriptions from VA pharmacies decreased, while PDE-5 inhibitor fills from Medicare-reimbursed pharmacies increased. However, this trend reversed after PDE-5 inhibitors were removed from the Part D formulary. VA formulary restrictions can increase the likelihood that Veterans who have access to non-VA healthcare obtain medications from the private sector. Since use of non-VA pharmacies may be unknown to VA providers, these Veterans may be at higher risk of adverse events or drug interactions. This is especially a concern for lifestyle drugs, such as those used for ED.
Date: July 1, 2016
- Use of Oral Anticoagulant Therapy for Veterans with Atrial Fibrillation Declines over 10-Year Period in VA Healthcare
Among patients with atrial fibrillation (AF), oral anticoagulants (OACs) are recommended when the risk of stroke is moderate or high, but not when the risk of stroke is low. This study sought to quantify trends and evaluate guideline adherence with OACs in Veterans with newly diagnosed AF over a ten-year period within the VA healthcare system. Findings showed that among Veterans with new AF and additional risk factors for stroke, only about half received an oral anticoagulant, and the proportion is declining, including among patients with higher risks for stroke. Overall, initiation of an OAC fell from 51% in 2002 to 43% in 2011. The decline in oral anticoagulant use shown in these results is concerning because patients with AF who fail to receive recommended OAC therapy have high rates of preventable stroke. This study, as well as others, shows an opportunity to improve rates of guideline adherence.
Date: June 21, 2016
- Use of Clozapine for Veterans with Treatment-Resistant Schizophrenia Could Result in Significant Cost Savings
This cost-benefit analysis sought to simulate potential cost savings for VA that would result from increasing the use of clozapine among Veterans with treatment-resistant schizophrenia. Findings showed that modest increases in clozapine use could result in significant cost savings for VA. Among Veterans with treatment-resistant schizophrenia, VA would save $22,444 per Veteran over the first year of treatment, primarily from 18.6 fewer inpatient hospitalization days per patient. Given this finding, if current clozapine use was doubled from 20% of patients with treatment-resistant schizophrenia to 40%, VA would accrue an estimated cost savings of $80 million over the first year. Moreover, full utilization of clozapine would save VA $320 million over the first year. Findings suggest VA should strongly consider initiatives to substantially increase clozapine use among Veterans with treatment-resistant schizophrenia. Deaths from clozapine-related adverse events are more than balanced out by decreased incidence of suicide attempts, with a net result of slightly fewer deaths with increased use of clozapine.
Date: June 15, 2016
- Barriers and Facilitators to Use of Clozapine for Treatment-Resistant Veterans with Schizophrenia
This study sought to identify facilitators and barriers to clozapine use – and to inform the development of interventions to maximize appropriate use. Findings showed that factors associated with high utilization of clozapine for Veterans with schizophrenia included: providing access to transportation for Veterans; having sufficient capacity to enroll patients; use of multi-disciplinary teams, including non-physician providers; better coordination of care through mental health intensive case management (MHICM) or clozapine clinics; and creation of systems to reduce reliance on too few individuals. Factors associated with low utilization of clozapine included lack of champions to support clozapine processes and limited-capacity care systems. Barriers identified at both high- and low-utilization facilities included time-consuming paperwork, reliance on few individuals to facilitate processes, and issues related to transportation for Veterans living far from VA care facilities.
Date: June 15, 2016
- Systematic Review Compares Pharmacist-Led Care to Usual Care for Chronic Disease Management
This systematic review sought to determine the effectiveness and harms of pharmacist-led chronic disease management for community-dwelling adults. Findings showed that compared with usual care, pharmacist-led care was associated with similar numbers of office visits, urgent care or emergency department visits, and hospitalizations, as well as medication adherence. Compared with usual care, pharmacist-led care increased the number or dose of medications received and improved glycemic, BP, and lipid goal attainment. Mortality and clinical events were similar between patients in usual care versus pharmacist-led care. Pharmacist-led chronic disease management was associated with effects similar to those of usual care for resource utilization and may improve physiologic goal attainment.
Date: April 26, 2016
- Prescription Opioid Use among Patients with Recent History of Depression Increases Risk of Recurrence
This study examined whether patients in depression remission who were prescribed opioids for non-cancer pain had an increased risk of depression recurrence. Investigators analyzed two patient populations: Veterans treated in the VA healthcare system, and patients treated by a non-profit integrated healthcare system located in Texas. Findings showed that prescription opioid use among patients with a recent history of depression increased the chance of depression recurrence, and this effect was independent of pain diagnoses and pain intensity scores. Patients with remitted depression who were exposed to opioid analgesics at any point during the follow-up period were 77% to 117% more likely to experience a recurrence of depression than those who remained opioid free, after controlling for other factors. Among VA patients with depression remission, those who received opioids during follow-up were younger, had more psychiatric comorbidities, and had more painful conditions and higher pain scores than those who didn’t receive opioids.
Date: April 1, 2016
- Prescription Use of Codeine Associated with Greater Risk of New Onset Depression among Veterans
This study sought to determine whether the hazard of new depression diagnosis differs among VA patients prescribed only codeine, only hydrocodone, or only oxycodone. Findings showed that Veterans prescribed only codeine for 30 days or longer had a 29% increased risk of a new diagnosis of depression compared to Veterans prescribed only hydrocodone for 30 days or longer. Those prescribed only oxycodone for 30 days or longer were not significantly more likely to develop a new depression diagnosis compared to patients prescribed hydrocodone only. Opioid use of 30-90 days was most common among oxycodone users, and opioid use of more than 90 days was most common among hydrocodone users. The distribution of individual comorbid conditions did not significantly differ across the three types of opioids.
Date: March 22, 2016
- Central Nervous System Polypharmacy May Increase Risk of Overdose and Suicide-Related Behavior among OEF/OIF Veterans
This study examined the prevalence of central nervous system (CNS) polypharmacy and its association with drug/alcohol overdose and suicide-related behaviors in a national cohort of OEF/OIF Veterans. Findings showed that of the Veterans in this study, 8% had received five or more CNS-acting medications in 2011. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI – and was independently associated with overdose and suicide-related behaviors after controlling for known risk factors. Women and Veterans between ages 31 and 50 years were more likely to have CNS polypharmacy. Findings suggest that CNS polypharmacy may be used as a “trigger tool” to identify individuals who may benefit from referral to a tailored inter-disciplinary treatment team comprised of experts from relevant fields. Ideally, these teams would work together to optimize medication profiles and treatment plans, and to examine non-pharmacological treatment options.
Date: March 1, 2016
- Investigators Establish Typology for Veterans with Diabetes who Utilize Both VA Healthcare and Medicare
This study sought to establish a typology of VA and Medicare utilization among dually-enrolled Veterans with type 2 diabetes, to better understand specific patterns of dual use. Findings showed that Veterans with diabetes can be grouped into four distinct classes of dual health system use. This classification has applications for identifying patients facing differential risk from care fragmentation. By recognizing common characteristics associated with dual users in classes at greatest risk of care fragmentation, (e.g., dual medication users), study findings may be integrated into decision-support tools to help coordinate the care of certain Veterans, and actively address drivers of dual use.
Date: February 22, 2016
- Increased Dose of Prescription Opioids Raises Risk of Suicide among Veterans with Chronic Non-Cancer Pain
This study examined the association between prescribed opioid dose and suicide in a national sample of VA patients with a chronic non-cancer pain condition who received opioid therapy. Findings showed that increased dose of opioids was found to be a marker of increased suicide risk, even when relevant demographic and clinical factors were statistically controlled. Type of opioid dosing schedule (i.e., regularly scheduled, as needed, or both) did not significantly affect suicide risk after accounting for other factors. Similar to the U.S. population and other large studies of VA patients, the vast majority of suicides involved firearms (64%), with overdose accounting for 20% of all suicides.
Date: January 5, 2016
- Among Older Veterans with Diabetes, Few with Low Glucose or Blood Pressure Levels Undergo Treatment De-intensification
This study sought to describe the frequency and predictors of treatment de-intensification among potentially over-treated older Veterans with diabetes. Findings showed that among older Veterans with diabetes who were treated for BP or blood glucose control, Veterans’ BP or A1c levels had only a weak relationship to the likelihood of de-intensification. There was a modest association between a Veteran’s estimated life expectancy and de-intensification rates, but there was no consistent interaction between life expectancy, de-intensification rates, and BP or A1c levels. Authors suggest that practice guidelines and performance measures should focus more on reducing over-treatment through de-intensification.
Date: December 1, 2015
- Appropriate Prescribing for Veterans with Diabetes at High Risk for Hypoglycemia
Evidence is accumulating that older individuals with diabetes have little to gain from the treatment burdens of stringent blood glucose control. Moreover, some older patients with diabetes might be at risk for hypoglycemia-related harms from medications prescribed to meet standard hemoglobin A1c (HbA1c) targets. This study examined the beliefs of primary care healthcare professionals (PCPs) who might receive such recommendations. Findings showed that almost half of the PCPs in this study reported that they would not worry about harms of tight control for an older patient with an HbA1c level of 6.5% who is at high risk of hypoglycemia. Of the PCPs in this study, 29% agreed it would be somewhat or very difficult to follow the Choosing Wisely HbA1Crecommendation for older adults. PCPs who agreed that maintaining the HbA1c level below 7% would benefit the patient and who reported worrying about malpractice claims were more likely to report difficulty following the recommendations. Conversely, PCPs who reported worrying that the patient would be harmed with tight blood glucose control were less likely to report difficulty following HbA1c recommendations.
Date: December 1, 2015
- Telemedicine-Based Intervention Improves Outcomes for Veterans with Poorly Controlled Diabetes
Investigators in this pilot trial developed the Advanced Comprehensive Diabetes Care (ACDC) intervention, which bundles four evidence-based telemedicine approaches – telemonitoring, self-management support, medication management, and depression management – and is designed for practical delivery by existing VA Home Telehealth program nurses using standard VA equipment. Findings showed that the ACDC intervention significantly reduced HbA1c by 1.0% versus usual care. Veterans receiving ACDC had significantly better diabetes self-care at six months versus usual care, but depressive symptoms did not differ between groups. Although ACDC did not address hypertension, Veterans in the intervention group had significantly lower systolic and diastolic blood pressure versus usual care. By utilizing Home Telehealth infrastructure that is ubiquitous at VA centers nationwide, ACDC represents a potentially scalable approach to reducing the burden of diabetes within VA.
Date: November 5, 2015
- Study Compares Data Sources for Provider Financial Incentives
This study examined how well data from automated processing of EHRs (AP-EHR) reflect data collected via manual chart review, and assessed the potential impact of data collection methods on incentive earnings for physicians and provider groups participating in a trial evaluating pay-for-performance for hypertension care. Findings showed that the total amount of incentives disbursed to providers would have been lower (by 10%) using the AP-EHR data to reward performance because this method under-reported the number of Veterans receiving appropriate medications – compared to manual review. Regarding how well the AP-EHR reflect data from manual review, results show almost perfect agreement for the BP control measure: manual review indicated 70% of Veterans had controlled BP compared to 67% by AP-EHR review. Moderate agreement was found between the data sources for the use of guideline-recommended anti-hypertensive medication: manual review showed 72% of Veterans were considered to have received guideline-recommended anti-hypertensive medications compared to 65% by AP-EHR. And low agreement was found for the appropriate response to uncontrolled BP: manual review showed that 52% of Veterans received an appropriate response for uncontrolled BP compared to 40% by AP-EHR review. Given the large amount of resources needed for chart review endeavors, investigators feel that a 10% difference in the total amount of incentive earnings disbursed based on AP-EHR data compared to manual review is acceptable.
Date: October 1, 2015
- Study Suggests Veterans Do Not Receive Appropriate Testing for Testosterone Therapy within VA Healthcare System
This study evaluated whether the dispensing of testosterone therapy in the VA healthcare system was preceded by an appropriate diagnostic evaluation of testosterone deficiency. Findings showed that only a small proportion of male Veterans receiving testosterone in the VA healthcare system underwent appropriate testing: 3% of men who received testosterone met the criteria for an “ideal” evaluation, with two or more low testosterone levels in the morning, measurement of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels, and no contraindications; while 17% did not have their testosterone level checked at all. Moreover, 52% of Medicare-enrolled Veterans who did not have any testosterone testing within VA also had no testing outside VA. Some Veterans received therapy despite important contraindications: 8% had obstructive sleep apnea, 4% had elevated hematocrit at baseline, and 1% had prostate cancer. New testosterone dispensing in VA increased from 20,437 in FY2009 to 36,394 in FY2012 – a 78% increase, while the number of male VA patients increased by 5% during the same period. While there are currently no official VA guidelines on testosterone prescribing, promotion of a more uniform application of clinical guidelines on testosterone therapy may help limit the therapy to those who are most likely to benefit and least likely to be harmed.
Date: September 1, 2015
- Wide Variation Documented Among VA Providers in Potential Overuse of Antibiotics for Acute Respiratory Infections
This study examined trends in antibiotic prescribing for acute respiratory infections (ARIs) within the VA healthcare system over an 8-year period – and identified patient, provider, and setting sources of variation. Findings showed that there was a persistently high prevalence of outpatient antibiotic prescriptions for ARIs among Veterans. Of more than one million ARI visits, the proportion resulting in antibiotic prescription increased from 67.5% in 2005 to 69.2% in 2012. Also, the proportion of antibiotic prescriptions that were macrolides increased from 37% to 47%. There was substantial variation in prescribing at the provider level. The 10% of VA providers who prescribed the most antibiotics did so during at least 95% of their ARI visits, while the 10% who prescribed the least did so during <40% of their ARI visits. Mid-level providers prescribed antibiotics slightly more frequently than physicians (70% vs. 68%). Subgroups associated with higher prevalence of antibiotic prescribing included: diagnosis of sinusitis (86%) or bronchitis (85%), presence of a high fever (78%), occurrence in an urgent care setting (75%), and Southern and Central regions of the U.S. (both 71%). Variation in ARI management seems to be strongly influenced by the prescribing patterns of individual providers. This is a ripe target for further research, quality improvement, and antibiotic stewardship interventions.
Date: July 21, 2015
- Stewardship Intervention Reduces Overuse of Antibiotics in the Treatment of Asymptomatic Bacteriuria among Veterans
The Kicking CAUTI: The No Knee-Jerk Antibiotics Campaign intervention to reduce asymptomatic bacteriuria (ASB) overtreatment features case-based audit and feedback and an actionable algorithm to distinguish ASB from catheter-associated urinary tract infection (CAUTI). This study evaluated the effectiveness of the Kicking CAUTI intervention in two VAMCs between July 2010 and June 2013. Findings showed that, at the intervention site, the Kicking CAUTI intervention successfully decreased inappropriate screening for ASB and decreased ASB overtreatment with antimicrobials, without increasing the undertreatment of CAUTI. In stratified analysis, the effect of the intervention was more significant in long-term care wards and was modest on acute medicine wards. The overall rate of ordering urine cultures decreased during the intervention period – from 41.2 to 23.3 per 1000 bed-days, and even further during the maintenance period – to 12.0 per 1000 bed-days. At the comparison site, cultures ordered did not change significantly across periods. Overtreatment of ASB at the intervention site fell significantly during the intervention period from 1.6 to 0.6 per 1000 bed-days, and these reductions persisted during the maintenance period – to 0.4 per 1000 bed-days. Overtreatment of ASB at the comparison site was similar across all periods.
Date: July 1, 2015
- Individual and Facility-Level Factors Associated with Higher Risk of Suicide Attempt among Veterans Receiving Opioid Therapy
This study examined the associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide-related events, assessing associations between individual-level and facility-level delivery of recommended care, and individual-level suicide-related events. Findings showed that within 180 days following opioid prescription, 1.6% of the study population on chronic short-acting opioids and 2.1% of the study population on long-acting opioids experienced suicide-related events. At the individual level, Veterans who received opioid therapy and had medical frailty, drug, alcohol, or mood disorder, and/or traumatic brain injury had a higher risk of suicide-related events. Patients on opioid therapy within VA facilities that ordered more drug screens were associated with a decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities that provided more follow-up after new prescriptions also were associated with decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities having higher sedative co-prescription rates had an increased risk of suicide -related events. Among the sub-population of patients with a substance use disorder and a short-acting opioid prescription, the facility rate use of specialty substance use disorder treatment was associated with lower risk of suicide-related events. Encouraging facilities to make more consistent use of drug screening, providing follow-up within four weeks for patients initiating new opioid prescriptions, avoiding sedative co-prescription in combination with long-acting opioids, and engaging patients with substance use disorders in specialty substance use treatment, may help prevent suicide-related events.
Date: July 1, 2015
- Receipt of Opioid Analgesics and Benzodiazepines Associated with Increased Risk of Death Due to Drug Overdose
This study sought to describe the relationship between the receipt of concurrent benzodiazepines and opioid analgesics and death due to drug overdose in patients receiving prescription opioids for acute, chronic, and non-terminal cancer pain. Findings showed that during the study period, 27% of Veterans who received opioid analgesics also received benzodiazepines. Among those receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death due to drug overdose. About half of the overdose deaths occurred when Veterans were concurrently prescribed benzodiazepines and opioids. Patients who were prescribed concurrent opioids and benzodiazepines –and then stopped receiving benzodiazepines had higher rates of overdose than those patients who had only received opioids. Veterans who received benzodiazepines were more likely to be female, middle-aged, white, and to reside in wealthier areas. Veterans who received benzodiazepines were also more likely to have had a recent mental health or substance use disorder-related hospitalization, a diagnosis of a substance use disorder, or a number of psychiatric disorders (i.e., PTSD, depression, anxiety). These findings provide empirical support for the goal of the VA Opioid Safety Initiative (OSI) to reduce unnecessary co-prescribing of opioids and benzodiazepines, for which there had been limited evidence prior to this study.
Date: June 10, 2015
- Early Discontinuation and Sub-Optimal Dosing for Drug to Treat Sleep Disorders Associated with PTSD
This study sought to identify a cohort of Veterans with PTSD initiating prazosin, and then characterize the typical duration of use and dosing patterns over the first year following initiation. Findings showed that approximately 20% of Veterans never refilled the initial prescription, while only 38% of Veterans continued the medication for at least one year. Veterans taking serotonin- reuptake inhibitor (SSRIs) or serotonin-norepinephrine reuptake inhibitor (SNRIs) antidepressants were more likely to maintain prazosin treatment for one year (41%) compared to non-users (33%). One-year prazosin persistence also increased with the patient’s age and number of concurrent medications. Prazosin persistence was not associated with gender, or rural residence. The mean maximum dose of prazosin reached in the first year of treatment was 3.6 mg/day, with only 15% of Veterans reaching the minimum guideline recommended dose of 6 mg/day. Research is needed to identify what factors inhibit patients from reaching the minimum recommended target dose and what characteristics are associated with prazosin response.
Date: May 1, 2015
- Pharmacist Support Key in Medication Adherence for Veterans Prescribed Dabigatran for Atrial Fibrillation
This study assessed site-level variation in dabigatran adherence and identified practices associated with higher dabigatran adherence within the VA healthcare system. Findings showed that among VA patients who were treated with dabigatran, there was significant site-level variation in medication adherence across VAMCs – with the site average ranging from 42% to 93%. Veterans were more likely to be adherent and without missing doses when they were monitored by VA pharmacists. Longer duration of pharmacist-led monitoring and providing more intensive care to non-adherent patients, in collaboration with the clinician, also improved medication adherence. Findings suggest extra patient support (i.e., pharmacist availability) may significantly improve adherence to dabigatran. These data affirm that VA’s rich infrastructure of pharmacist-led, specialized anticoagulation care may continue to have an important role in maximizing safety, effectiveness, and appropriate use of these new agents, even as warfarin use continues to decline.
Date: April 14, 2015
- 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
- Antipsychotics Prescribed to Substantial Minority of Veterans with PTSD without Bipolar Disorder or Schizophrenia
Given limited knowledge about the use of antipsychotics in Veterans with PTSD returning from Iraq and Afghanistan, this study examined the rates of antipsychotic use in this patient population. Findings showed that antipsychotics were prescribed to a substantial minority of OEF/OIF/OND Veterans with PTSD who did not also have a diagnosis of bipolar disorder or schizophrenia. Of the Veterans in this study, 20% received no psychiatric medications, 61% received psychiatric mediations other than antipsychotics, and 19% received antipsychotics. Male Veterans and those in the Army, of lower rank, and with active duty status (vs. National Guard/Reserve) were more likely to be prescribed antipsychotics. Comorbid psychiatric conditions, particularly substance use and personality disorders, as well as suicidal ideation also were associated with greater use of antipsychotics compared to other types of psychiatric medications. Antipsychotics were prescribed much later after the date of PTSD diagnosis than other psychiatric medications, suggesting they were not first-line medications. Given limited evidence of the benefit of antipsychotics for PTSD and their potential adverse metabolic side effects, authors suggest that clinicians carefully weigh the risks and benefits of antipsychotic use in Veterans with PTSD.
Date: March 3, 2015
- VA Primary Care Intervention Decreases High-Dose Opioid Prescription for Veterans with Non-Cancer Pain
In October 2013, VA initiated a nationwide Opioid Safety Initiative (OSI) that includes goals of decreasing high-risk opioid prescribing practices, including prescribing of high-dose opioids. Prior to this national initiative, the Minneapolis VA Health Care System implemented a primary care population-based OSI aimed primarily at reducing high-dose opioid prescribing. This study evaluated the Minneapolis initiative. Findings showed that the number of Veterans prescribed daily high-dose opioids decreased from 342 to 65. Overall, the number of unique pharmacy patients who received at least one opioid prescription within 90 days decreased 14%. The number of Veterans receiving oxycodone SA decreased from 292 to 3 over the study time period. The number of Veterans receiving other long-acting opioids, as well as hydrocodone-acetaminophen, hydromorphone, and oxycodone/acetaminophen also decreased. The proportion of primary care providers who agreed that it was reasonable for the medical center to set a dosage limit was 76% at baseline and 87% at follow-up. The two most commonly endorsed barriers to lowering doses were patients becoming upset (62% baseline and 64% follow-up) and pressure from patient service representatives or the administration (59% baseline and 22% follow-up).
Date: February 3, 2015
- Female Veterans with CVD Less Likely to Receive Statin and High-Intensity Statin Therapy Compared to Male Veterans with CVD
This study sought to identify the proportion of male and female Veterans with cardiovascular disease (CVD) who received care in any of 130 VA facilities between 10/1/10 and 9/30/11, and who received any statin and high-intensity statin. Findings showed that while evidence-based use of both statin and high-intensity statin therapy remains low in both genders, female Veterans with CVD were less likely to receive evidence-based statins (58% vs. 65%) and high-intensity statins (21% vs. 24%) compared with male Veterans. In fully adjusted analyses, female gender was independently associated with a 32% lower likelihood of receiving any statin therapy and a 24% lower likelihood of receiving high-intensity statin therapy. Mean low-density lipoprotein cholesterol levels were higher in female compared with male Veterans (99 vs. 85 mg/dl) with CVD. The use of statin and high-intensity statin therapy among female Veterans with CVD showed substantial facility-level variation. With the “statin dose-based approach” proposed by the recent cholesterol guidelines, these results highlight areas for quality improvement. It is important to note that despite the observed gender disparity noted in this study, statin and high-intensity statin use remain low in both genders. This is concerning, as the patient population studied in these analyses (i.e., those with established CVD) is the one that derives the most benefit from statin and high-intensity statin therapy.
Date: January 1, 2015
- Compared to Thiazolidinediones, Sulfonylureas May Be More Likely to Cause Death and Hospitalization for Veterans with Diabetes
This study compared long-term outcomes of the two most commonly used second-line oral hypoglycemic medications in the VA healthcare system – sulfonylureas (SUs) and thiazolidinediones (TZDs). Findings showed that Veterans with diabetes who started on SUs compared to TZDs as a second-line agent after metformin were significantly more likely to die or have an ambulatory care sensitive condition hospitalization. Patients in this study were elderly (mean age 69), primarily white (88%), and had high rates of cardiovascular comorbidities (e.g., chronic pulmonary disease, hypertension), and obesity (41%).
Date: December 1, 2014
- Veterans with Non-Obstructive Coronary Artery Disease at Significantly Greater Risk of MI and Mortality
This study compared incidence of myocardial infarction (MI) and mortality between patients with non-obstructive coronary artery disease (CAD), obstructive CAD, and no apparent CAD in a national cohort of Veterans receiving VA care. Findings showed that compared to Veterans with no apparent CAD, Veterans with non-obstructive CAD were at significantly greater risk of MI and all-cause mortality at one year. The one-year risk of MI progressively increased by extent of CAD, rather than abruptly increasing between non-obstructive and obstructive CAD. For example, among Veterans with no apparent CAD, the one-year MI rate was 0.11%, while the one-year MI rate for 1-vessel non-obstructive CAD was 0.24%, increasing to 0.59% for 3-vessel non-obstructive CAD. One-year mortality rates also were associated with increasing extent of CAD, ranging from 1.4% among Veterans with no apparent CAD to 4% for Veterans with 3-vessel or LM (left main) obstructive CAD. After risk adjustment, there was no significant association between 1- or 2-vessel non-obstructive CAD and mortality, but there were significant associations with mortality for 3-vessel non-obstructive CAD and 1-, 2-, and 3-vessel or LM obstructive CAD. Age and cardiovascular risk factors (e.g., hypertension, hyperlipidemia, and diabetes) all increased with increasing extent of CAD. The frequency of prescriptions for post-angiography cardiovascular medications and rates of coronary revascularization also increased with CAD extent. Findings suggest that non-obstructive CAD is common, confers significant risk for MI and mortality, and warrants immediate consideration of preventative therapies for patients with this condition.
Date: November 5, 2014
- JGIM Supplement Highlights VA’s Partnered Research
In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management, suicide prevention, homelessness, medical home models, and communication of adverse events.
Date: November 1, 2014
- Delays in Filling Clopidogrel Prescription Associated with Increased Major Adverse Events Following PCI
This study assessed the frequency of delays in filling an initial clopidogrel prescription after hospital discharge for Veterans who underwent percutaneous coronary intervention (PCI) with stent implantation between 1/05 and 9/10 at any of 60 VA hospitals. Findings showed that approximately 1 in 14 Veterans delayed filling clopidogrel prescriptions after PCI. Moreover, delays were associated with increased risk of major adverse events; specifically, patients with a delay in filling their clopidogrel prescription more often suffered MI (12% vs. 6%) and death (2.2% vs. 1.5%) compared to those without delay. The percentage of Veterans with delays varied by VA hospital, ranging from 0% to nearly 44%. This large variation suggests a need to identify best practices that allow hospitals to optimize prescription filling at discharge to potentially improve patient outcomes. In the VA healthcare system, delayed filling of clopidogrel prescription occurred less than half as often as in a prior study conducted with a Medicare population, which found that 20% of patients delayed filling their clopidogrel prescription after hospital discharge. Therefore, it is possible that the lower rate of delayed prescription filling within VA (7%) may be attributable to greater coordination of care, since inpatient and outpatient prescriptions are managed by a single VA pharmacy service.
Date: September 1, 2014
- Digoxin Significantly Associated with Increased Risk of Death among Veterans with Atrial Fibrillation
This study investigated the association of digoxin therapy with mortality in a large cohort of Veterans with atrial fibrillation (AF). Findings showed that among Veterans with newly diagnosed AF, treatment with digoxin was significantly and independently associated with increased risk of death, regardless of age, gender, kidney function, heart failure status, concomitant therapies, or drug adherence. Of the Veterans in the study, 23% received digoxin. Compared with non-recipients, digoxin recipients had a higher prevalence of heart failure (HF) and receipt of beta-blockers, angiotensin receptor blockers, antiplatelet therapy, diuretic agents, and warfarin. Digoxin increased the risk of death by 1.21 times compared to comparable patients treated with other therapies for AF. While these findings challenge current cardiovascular society recommendations, the implication is not that every patient should come off this drug and every doctor should stop using it. Rather, physicians should consider alternatives to digoxin in managing patients with AF as it may still have a useful role under specific and carefully monitored conditions.
Date: August 19, 2014
- Detection of Suicidal Ideation Not Associated with Increased Mental Health Utilization in Year Following SI Assessment
This study evaluated the impact of brief suicidal ideation (SI) assessments on mental healthcare use among new-to-care OEF/OIF Veterans. Findings showed that 32% of the Veterans in this study had positive SI assessment results. The detection and presence of suicidal ideation was not associated with subsequent mental healthcare utilization over the following year, when accounting for the severity of depression symptoms. In other words, SI itself was not found to be associated with increased Veteran engagement in specialty mental healthcare over and above depression symptom severity. When a Veteran’s inaugural visit to VA healthcare included a mental health clinician, the Veteran was more likely to attend more subsequent specialty mental health visits – and to receive an antidepressant medication – than Veterans who were seen by a primary care clinician only.
Date: July 30, 2014
- 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
- Most Patients with Type 2 Diabetes Obtain Little or No Benefit from Current Treatment for Tighter Glycemic Control
This study examined how considering treatment burden would affect the benefits of intensive versus moderate glycemic control in patients with type 2 diabetes. Findings showed that for most patients over the age of 50 with an A1c below 9% who were on metformin, further glycemic treatment usually offered, at most, modest benefits. Across all ages, patients who viewed treatment as modestly burdensome experienced a net loss in quality of life years from treatments to lower A1c. The current approach of broadly advocating intensive glycemic control for millions of patients with diabetes should be reconsidered; instead, treating A1cs of less than 9% should be individualized based on estimates of benefit weighted against the patient’s view of treatment burden.
Date: June 30, 2014
- Cardiovascular Outcomes after Addition of Insulin Versus Sulfonylureas in Veterans with Diabetes Taking Metformin
This study compared time to a combined outcome of acute myocardial infarction (AMI), stroke, or death among Veterans with diabetes that were initially treated with metformin, and subsequently added either insulin or sulfonylurea. Compared to those who added a sulfonylurea, Veterans who added insulin to metformin therapy had a 30% higher risk of the combined outcome of heart attack, stroke, and all-cause mortality. Although new heart attacks and strokes occurred at similar rates in both groups, mortality was higher in patients who added insulin. Although sulfonylurea use predominated as add-on therapy, there was increasing use of insulin intensification over the study years (increasing by an average of 17% per year). Reasons may include a growing prevalence of obesity and insulin resistance, emphasis on metrics such as glycemic targets, increasing comfort with newer analog insulins, and/or the benefit in microvascular outcome prevention.
Date: June 11, 2014
- Proactive Tobacco Treatment More Successful than Usual Care among Veterans Attempting to Quit Smoking
This randomized controlled trial – the Veterans Victory over Tobacco Study – compared the effects of a proactive tobacco cessation care model versus a traditional cessation care model on the use of tobacco treatment and subsequent population-level smoking cessation rates. Findings showed that proactive tobacco cessation care that connected smokers to evidence-based telephone or in-person smoking cessation services is effective for increasing long-term, population-level cessation rates. The six-month prolonged smoking abstinence rate at one year was 14% for Veterans in the proactive care group, a significant increase compared to 11% for Veterans in the usual care group, and much higher than the 6% population-level cessation rate of the total US population. The proactive care group reported significantly higher rates of behavioral counseling combined with medication treatment compared to usual care (13% versus 5%). There was also a significant increase in receipt of a smoking cessation medication from VA providers among proactive care compared to usual care (35% versus 30%). About 85% of the usual care group and 83% of the proactive care group were daily smokers.
Date: March 10, 2014
- Sustained Improvement in Hypertension with Intervention Combining Behavioral and Medication Management
This study examined clinical and economic outcomes 18 months after completion of an 18-month hypertension self-management randomized trial. Findings showed that an intervention combining behavioral and medication management significantly improved BP control among Veterans with hypertension during an 18-month trial compared to usual care, and these improvements were sustained 18 months after trial completion, particularly for Veterans who had inadequate BP control at baseline. Eighteen months after trial completion, a statistically significant higher proportion of Veterans in the behavioral intervention (17%), the medication management intervention (20%), and the combined intervention (20%) had estimated BP improvements compared to usual care. Among Veterans with inadequate baseline BP control, estimated mean systolic BP was significantly lower in the combined intervention as compared to usual care during and after the 18-month trial. Estimated mean outpatient expenditures and estimated total expenditures also were similar for Veterans in the 18 months during the trial and the 18 months after trial completion.
Date: March 1, 2014
- Social Network Encouragement Helps Veterans with PTSD Seek VA Mental Healthcare
This study sought to determine whether beliefs about mental health treatment and/or social encouragement to seek treatment influence initiation of mental healthcare among Veterans with PTSD. Findings showed that whether Veterans initiate mental healthcare after a PTSD diagnosis depends not only on symptom severity and access to treatment, but also on encouragement by those in their social network, whether the Veteran perceives the need for treatment, how they view treatment for PTSD (e.g., positive beliefs about the efficacy of antidepressants), as well as their ability to follow treatment recommendations. Encouragement to get mental healthcare by individuals in their social network increased the odds of getting treatment, even after controlling for beliefs, particularly if encouragement was given by both family and friends/other Veterans. While not the focus of this study, investigators noted that for all outcomes, older VA healthcare users, Veterans with service connection, and those who were diagnosed in non-mental health clinics were less likely to receive treatment. In addition, Veterans who were seen in PTSD specialty clinics, though less likely to receive medication than those in general mental health clinics, were more likely to receive psychotherapy.
Date: February 3, 2014
- Anxiety Disorders and Depression Associated with Risk of Future Heart Failure among Veterans
This study sought to determine if the risk of heart failure (HF) was greater in Veterans with: 1) a diagnosis of one or more anxiety disorders but who were free of major depressive disorder (MDD); 2) MDD but free of anxiety disorders; or 3) comorbid anxiety and depressive disorders. Findings showed that in the model that corrected for age only, Veterans with anxiety disorders, MDD, or both were each about 20% more likely to develop HF compared to Veterans without these conditions. This effect remained significant after adjusting for other HF risk factors (e.g., sociodemographics, nicotine use, substance use disorders), and was even greater after adjusting for psychotropic medications. Compared to Veterans without HF, patients with HF were significantly older and more frequently male, non-white, unmarried, holders of supplemental insurance, and were significantly more likely to have diagnoses of hypertension, diabetes, and obesity. Veterans with both anxiety and MDD were more likely to have a diagnosis of substance abuse or dependence and history of nicotine use – and to receive a prescription for psychotropic medication.
Date: February 1, 2014
- Increased Prescribing Rates for Concurrent Sedative Medications among Veterans with PTSD
This is the first national study that sought to characterize polysedative prescribing in Veterans with PTSD. Findings showed that, over time, there was an increase in the use of polysedatives among Veterans with PTSD: from 34% to 37% for two or more sedative classes, and from 10% to 12% for three or more classes. This represents a concerning clinical trend and a relative increase of nearly 25%. The most common combination of sedatives was an opioid plus a benzodiazapine, which were taken concurrently by 16% of Veterans with PTSD. Two other combinations that were used more frequently than expected were opioids plus skeletal muscle relaxants – and benzodiazepines plus atypical antipsychotics. Polysedative use varied across demographic subgroups, with higher rates among women, Veterans residing in rural settings, younger adults, Native Americans, and Whites. Also, benzodiazepine prescribing was markedly elevated among women (44%) compared to men (34%), and was somewhat lower among older adults (31%) compared to younger adults (36%).
Date: December 16, 2013
- Chronic Opioid Therapy Common among Hospitalized Veterans, Associated with Increased Risk of Death and Re-Admission
This study sought to determine the prevalence of prior chronic opioid therapy (COT) among hospitalized medical patients, in addition to examining characteristics associated with inpatients that had previous opioid therapy compared to those with no opioid therapy prior to hospital admission. Findings showed that COT is common among hospitalized Veterans; moreover, occasional and chronic opioid use was associated with increased risk of hospital readmission and COT was associated with increased risk of death. Nearly 1 in 4 hospitalized Veterans had current or recent COT at the time of hospital admission for non-surgical conditions, and nearly half had been prescribed any opioids. Among the Veterans in this study, 26% had received COT in the prior 6 months, and 20% had occasional opioid therapy. Diagnoses more common in Veterans with COT included COPD, complicated diabetes, PTSD, and other mental health disorders.
Date: December 6, 2013
- Risk of Suicide-Related Behavior among Older Veterans Receiving Antiepileptic Drugs
This study examined the temporal relationship between new antiepileptic drug (AED) monotherapy exposure and suicide-related behavior (SRB) in older Veterans. Findings showed that Veterans receiving their first AED during the study period were more likely to have suicide-related behavior during the 30 days prior to AED exposure than at any other time period in the year before and after exposure, even after controlling for psychiatric comorbidity. There were 106 SRB events among 92 Veterans in the year after exposure, with approximately 22% (n=16) of those Veterans also having an SRB event before their first AED exposure. Moreover, the rate of SRB after starting on an AED was gradually reduced over time. Results suggest that the peak in suicide-related behavior is prior to AED exposure. However, as the risk for recurrent SRB was 22% in individuals with SRB prior to exposure to AED therapy, these Veterans should be followed closely to prevent recurrent SRB.
Date: November 26, 2013
- “Tailored” Treatment of Blood Pressure May Prevent Many More Heart Attacks and Strokes than Current Guidelines
Most current blood pressure (BP) guidelines advocate a treat-to-target (TTT) strategy, which titrates treatment towards intermediate outcomes, notably a BP goal. Benefit-based tailored treatment (BTT) strategies estimate an individual’s net absolute benefit from treatment – taking into account the patient’s estimated risk reduction from treatment, as well as potential harms associated with treatment. This study sought to determine whether a BTT strategy for the treatment of hypertension would prove superior to a traditional TTT strategy. Findings showed that BTT was both more effective and required less antihypertensive medication than current guidelines based on treating to specific blood pressure goals. Over five years, BTT would prevent 900,000 more cardiovascular disease events and save 2.8 million more quality-adjusted life years (QALYs), despite using 6% fewer medications, compared to TTT. While 55% of the 176 million “simulated” patients in this study would be treated identically under the two treatment approaches, in the 45% of the population treated differently by the strategies, BTT would save 159 QALYs per 1,000 treated versus 74 QALYs per 1,000 treated by the TTT approach.
Date: November 19, 2013
- Multifaceted Intervention Improves Medication Adherence for Veterans following Hospitalization for Acute Coronary Syndrome
This study tested a multifaceted intervention to improve adherence to cardiac medications in the year after acute coronary syndrome (ACS) hospital discharge. Findings showed that, based on the four classes of cardio-protective medications in the study, a greater proportion of Veterans in the intervention group were adherent to medications in the year following hospitalization for ACS compared to Veterans in the usual care group: 89% vs. 74%, respectively. For the secondary prevention measures, there were no differences in the proportion of patients who achieved BP and LDL goals. There were no significant differences between Veterans in the intervention and usual care groups for rehospitalization for myocardial infarction (7% vs. 4%), revascularization (12% vs. 18%), or death (9% vs. 8%).
Date: November 18, 2013
- Testosterone Therapy Associated with Adverse Cardiovascular Outcomes among Veterans
This study evaluated the association between the use of testosterone therapy and all-cause mortality, myocardial infarction (MI), and/or stroke among male Veterans who underwent coronary angiography in VA and had low testosterone levels between 2005 and 2011. Findings showed that the use of testosterone therapy was associated with increased risk of mortality, MI, and/or ischemic stroke. This association was consistent among patients with and without coronary artery disease. The absolute rate of events was 26% in the testosterone therapy group and 20% in the no-testosterone therapy group at 3 years after angiography, corresponding to one additional event for every 17 Veterans begun on testosterone. The increased risk of adverse outcomes associated with testosterone therapy use was not related to differences in risk factor control or rates of secondary prevention medication use since patients in both groups had similar blood pressure, LDL levels, and use of secondary prevention medications. Authors suggest that while physicians should continue to discuss the symptomatic benefits of testosterone therapy with patients, it is also important to inform them that long-term risks are unknown and that there is a possibility that testosterone therapy might be harmful.
Date: November 6, 2013
- 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
- Individual Financial Incentives for VA Providers Result in Better Hypertension Treatment than Audit and Feedback Alone
This trial tested the effect of financial incentives to individual physicians and practice teams for the delivery of guideline-recommended care for hypertension. Findings showed that VA physicians randomized to the individual incentive group were more likely than controls to improve their treatment of hypertension. A physician in the individual incentive group caring for 1,000 patients with hypertension would have about 84 additional patients achieving blood pressure control or appropriate response after 1 year. The effect of the incentive was not sustained after the washout period. Although performance did not decline to pre-intervention levels, the decline was significant. None of the incentives resulted in increased incidence of hypotension compared with controls. While the use of guideline-recommended medications increased significantly over the course of the study in the intervention groups, there was no significant change compared to the control group.
Date: September 11, 2013
- Musculoskeletal Conditions, Injuries, and Pain More Prevalent among Patients Using Statins
This study sought to determine whether statin use was associated with musculoskeletal conditions, including arthropathy (joint disease) and injury. Findings showed that musculoskeletal conditions, injuries, and pain were more common among statin users than similar non-users. In addition, arthropathy was found to be more common among statin users than non-users. Authors note that these findings are concerning, since starting statins at a young age for primary prevention of cardiovascular diseases has been widely advocated.
Date: July 22, 2013
- Redundant Lipid Testing in Veterans with CHD
Repeat lipid testing for coronary heart disease (CHD) patients who have already attained guideline-recommended LDL-C treatment targets and receive no treatment intensification may represent overutilization and possibly waste of healthcare resources. This study sought to determine the frequency and correlates of repeat lipid testing in Veterans with CHD who had already attained the LDL-C treatment target, and who received no treatment intensification. Findings showed that one-third of the Veterans with CHD who had attained guideline-recommended LDL-C levels had additional lipid testing performed without treatment intensification in the 11 months following their initial lipid panel. Collectively, these patients had 12,686 additional lipid panels performed, with an annual extra cost of $203,990 for the one VA network included in the study. This does not include the cost of the patients’ time to undergo testing, or the providers’ time to manage results and notify the patient. Veterans with concomitant diabetes, hypertension, and higher illness burden, and those who had more frequent primary care visits were more likely to undergo repeat lipid testing, while Veterans with good medication adherence were less likely to undergo repeat testing.
Date: July 1, 2013
- Medicare Drug Beneficiaries with Diabetes Use 2 to 3 Times More Brand-Name Drugs than VA Patients, at Substantial Cost
This study compared the use of brand-name medications among patients using Medicare or VA drug benefits, and estimated how spending would change if the use of brand-name drugs in one system mirrored the other. Findings showed that Medicare beneficiaries with diabetes are more than twice as likely to use brand-name drugs than a comparable group within VA. If brand use in Medicare matched that in VA, investigators estimated more than $1 billion in avoidable spending by Medicare on brand-name drugs in 2008 alone. Conversely, spending in VA would have increased by 57% if Veterans used brand-name drugs at the same rate as in Medicare. Substantial regional variation exists in brand-name use in both Medicare and VA. For each drug group, however, the highest-using VA regions still had lower rates of brand use than the lowest using Medicare regions.
Date: June 11, 2013
- Literature Review Compares Bariatric Surgery to Non-Surgical Interventions among Non-Morbidly Obese Patients with Diabetes
Given the lack of consistency, as well as uncertainties regarding the comparative effectiveness of different procedures for bariatric surgery, investigators conducted a systematic review of the relative risks and benefits associated with surgical and non-surgical therapies for treating diabetes or impaired glucose tolerance in patients with a BMI of less than 35. Findings showed that, for patients with diabetes and a BMI of 30 to 35, current evidence suggests that bariatric surgery is associated with greater short-term weight loss and improvements in HbA1c, fasting blood glucose levels, blood pressure, and hyperlipidemia than non-surgical interventions such as medication, diet, and behavioral changes. However, the evidence was insufficient to reach definitive conclusions about long-term outcomes.
Date: June 5, 2013
- Many Older Veterans Do Not Discuss Non-VA Medications with VA Providers, Complicating Medication Reconciliation
Investigators in this study conducted a survey of Veterans who received care at one Midwestern VAMC and were eligible for the Medicare Part D drug benefit in order to ascertain their sources of coverage for medications, their medication acquisition from VA and non-VA pharmacies, and their communication with VA physicians about non-VA pharmacy use. Findings showed that Medicare-eligible Veterans often take multiple medications and use non-VA services and pharmacies. More than half of Veterans who used non-VA pharmacies reported having infrequent or no discussions with their VA physicians about their non-VA medications (54%), non-VA medication coverage (62%), and non-VA providers (56%). Of the Veterans in this study with a chronic condition, 93% reported taking more than one prescription regularly, and 30% of these individuals reported using medications for that condition that were prescribed by both VA and non-VA providers.
Date: May 1, 2013
- Possible Overuse of Proton Pump Inhibitors to Treat Veterans with Gastroesophageal Reflux Disease
This study sought to determine how proton pump inhibitors (PPIs) are initially prescribed for Veterans diagnosed with gastroesophageal reflux disease (GERD) – and to characterize subsequent PPI use over two years after the initial prescription. Findings showed that many Veterans received high total daily dose PPI prescriptions as initial therapy for GERD, but few patients had evidence of cessation or reduction of therapy. Of the Veterans in this study, 23% had high daily dose initial PPI prescriptions, and 77% had standard daily dose initial prescriptions. The majority of Veterans (66%) received a 90-day or greater initial prescription. Over two years, 13% of patients with initial standard daily dose prescriptions had evidence of step-up therapy. Only 7% of patients with initial high daily dose prescriptions had evidence of step-down therapy. The authors suggest that efforts should be made to ensure that VA providers prescribe the minimum effective PPI dose and prevent unnecessary PPI prescriptions. This could include decision support in the electronic health record via automatic alerts, as well as the need for justification when physicians attempt to prescribe high daily doses of PPIs.
Date: February 12, 2013
- Opioid Prescribing for Veterans with Chronic Non-Cancer Pain
This study sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among Veterans with persistent non-cancer pain. Findings showed that the initiation of opioid drug therapy is common among Veterans with persistent pain, but most Veterans are not prescribed opioids long-term. During the study year, 35% of Veterans in the sample received an opioid prescription: 30% were prescribed opioids on a short-term basis (<90 days), and 5% received chronic opioid therapy (>90 days). Clinical factors associated with initiating COT include increased pain intensity, nicotine dependence, substance use disorders, and major depression diagnoses. Nearly one-quarter of Veterans prescribed COT also received prescriptions for benzodiazepine medications, which is a concern given that overdose deaths have been linked to the use of multiple sedating medications. Two-thirds of opioid prescriptions resulting in COT were initiated by primary care clinicians. The authors suggest that this supports the development of guidelines geared toward primary care practice. It also supports the provision of interventions and structures in primary care that facilitate proactive planning around opioid use and its monitoring.
Date: February 1, 2013
- Patient and Facility Characteristics Associated with Prescribing Benzodiazepines for Veterans with PTSD
This study examined patient and facility-level correlates of benzodiazepine prescribing among Veterans with PTSD in the VA healthcare system. Findings showed that 30% of the Veterans in this study received a benzodiazepine. The majority (94%) of Veterans with any benzodiazepine use received = 30 days’ supply, and approximately two-thirds received more than 90 days of continuous benzodiazepine treatment. Among patient characteristics predicting benzodiazepine use, the largest odds ratios were observed for anxiety disorder comorbidity. Other characteristics associated with increased risk for benzodiazepine exposure included female gender, age = 30 years, rural residence, service connection = 50%, Vietnam era service, and duration of PTSD diagnosis. However, case-mix adjustment for these variables accounted for <1% of the variation in benzodiazepine prescribing across VA facilities. Main study findings were corroborated in replication analyses using data from two additional years (FY2003 and FY2006).The wide variation in facility-level benzodiazepine prescribing across VA cannot be explained by differences in patient characteristics across facilities.
Date: February 1, 2013
- Benzodiazepine Prescribing for Veterans with PTSD Remains Common and Varied across the VA Healthcare System
This study examined variation in benzodiazepine prescribing frequency across the VA healthcare system (by VAMC, VISN, and region), and evaluated differences in prescribing frequency among rural vs. urban residents, and between community-based outpatient clinics (CBOCs) relative to medical centers. Findings showed that benzodiazepine prescribing among Veterans with PTSD remains common despite guideline recommendations against their use, and the level of practice variation was extensive. While prescribing variation at the regional, network, and facility levels declined over the study period, facility-level benzodiazepine prescribing variation remains high at 15% to 57%. Rural veterans with PTSD received equivalent, if not higher, quality of care (as reflected by benzodiazepine prescribing frequency) from community-based outpatient clinics compared to medical centers. The authors suggest that the wide variation in prescribing practices reflects uncertainty among providers regarding best practices, and is ultimately due to the limited number of effective PTSD treatments supported by a strong evidence base.
Date: January 1, 2013
- Performance Measure for Lipid Management in Veterans with Diabetes Encourages Treatment with Moderate Dose Statins
Clinical action performance measures are increasingly being recommended to help make performance measurement more clinically meaningful. Investigators developed a clinical action performance measure for lipid management in Veterans with diabetes that is designed to encourage appropriate treatment with moderate dose statins, while minimizing overtreatment. They then assessed what proportion of Veterans received appropriate lipid management according to this new clinical action measure vs. the treat-to-target measure of LDL <100mg/dl that was in place at the time of the study. Findings showed that, of Veterans aged 50-75 years in this study, 85% passed the new clinical action measure, compared to 67% using the existing metric of LDL <100. Veterans who did not meet the clinical action measure had fewer primary care visits, on average, during the measurement period than Veterans who did meet the measure. Of the entire cohort aged >=18 years, 14% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100) had higher rates of potential overtreament. Findings suggest that continued use of threshold measures for lipid management may promote overtreatment. A modified version of the clinical action performance measure is being implemented in the VA healthcare system.
Date: December 11, 2012
- OEF/OIF Veterans Most in Need of Psychiatric Care are Accessing Mental Health Services, Primarily at VA
In this study, investigators conducted the first survey to employ a random sample of U.S. military post-9/11 that examined treatment use and perceived problems with treatment, including both VA and non-VA service users. Findings showed that 43% of the Veterans in this study screened positive for PTSD, major depression, or alcohol misuse. Overall, 40% of Veterans had ever received VA inpatient mental health care, 46% had ever received VA outpatient care, and 16% had ever received inpatient or outpatient care in both VA and non-VA settings. Nearly 70% of Veterans with probable PTSD or major depression and 45% of Veterans with probable alcohol misuse reported accessing mental health care in the past year. Authors suggest that Veterans who are ambivalent about accessing mental healthcare may be more willing to do so if they are made aware that a substantial number of Veterans are getting the help they need. Veterans with mental health needs who did not access treatment were more likely to believe that they had to solve problems themselves and that medications would not help. Those who had accessed treatment were more likely to express stigma beliefs and concern about being seen as weak. This suggests barriers to accessing care may be distinct from barriers to engaging in care. Veterans with higher PTSD and depression symptoms were more likely to access care. This finding suggests that, above a certain threshold of symptoms, Veterans were significantly more likely to seek mental health services, even if they viewed those services in a negative light.
Date: November 15, 2012
- Comparing Cardiovascular Outcomes for Two Common Anti-Diabetes Drugs among Veterans
This study compared cardiovascular disease (CVD) outcomes and all-cause mortality in a cohort of Veterans who received regular VA healthcare and were prescribed metformin or sulfonylureas – the two most commonly used anti-diabetic drugs. Findings showed a modest but clinically important 21% increased risk of hospitalization for heart attack or stroke, or death from any cause associated with the initiation of sulfonylurea compared with metformin therapy. The sulfonylurea group had higher rates of hospitalizations and deaths due to cardiovascular disease: 18 per 1,000 person years for those taking a sulfonylurea and 10 per 1,000 person years for those taking metformin. These findings suggest that for 1,000 patients who are initiating treatment for diabetes using metformin rather than sulfonylureas, there are 2 fewer heart attacks, strokes, or deaths per year of treatment. The findings do not clarify whether the difference in CVD risk is due to harm from sulfonylureas, benefit from metformin, or both.
Date: November 6, 2012
- Telemental Health Expands in VA between 2006-2010
This is the first large scale study to describe the types of telemental health services provided by the VA healthcare system. Findings show that each type of telemental health encounter increased substantially across the five years; for example, the number of encounters for medication management increased from 13,466 in FY06 to 32,284 in FY10, representing a 140% increase over the five-year period. Psychotherapy with medication management was the fastest growing type of telemental health service, increasing from 14,188 encounters in FY06 to 45,107 encounters in FY10, a 218% increase. The use of videoconferencing technology has expanded beyond medication management alone to include telepsychotherapy services (individual and group psychotherapy) and diagnostic assessments. The increase in telemental health services is encouraging, given the large number of returning Veterans who live in rural areas and may have difficulty accessing mental healthcare.
Date: November 1, 2012
- Association between Several Common Antiepileptic Drugs and Suicide-Related Behavior in Older Veterans
This retrospective study examined the relationship between antiepileptic drugs (AEDs) and suicide-related behaviors among Veterans aged 65 years and older who received VA healthcare. Findings showed that, within the study sample of 2 million older Veterans, there were 332 cases of suicide-related behavior (SRB). Exposure to antiepileptic drugs was significantly associated with suicide-related behavior, even after controlling for psychiatric comorbidity and prior SRB. Individuals who received AEDs were significantly more likely to have prior diagnoses of suicide-related behavior, depression, anxiety, bipolar disorder, PTSD, schizophrenia, substance abuse/dependence, conditions associated with chronic pain, and dementia. Veterans who received prescriptions for several specific AEDs – valproate, gabapentin, lamotrigine, levetiracetam, phenytoin, and topiramate – were at greater risk of diagnosed suicide-related behavior than Veterans with no AED exposure. Findings indicated that suicide-related behavior may occur as early as one week following AED use.
Date: October 30, 2012
- Perceptions of Coercive Treatment and Satisfaction with Care among Veterans Hospitalized for Severe Mental Illness
This study examined associations between perceptions of coercive treatment and satisfaction with care among psychiatric inpatients at one VAMC. Findings show that both involuntary commitment status and perceptions of coercion were independently and negatively associated with patient satisfaction with psychiatric inpatient hospitalization. Among the Veterans who were psychiatric inpatients in this study, 15% were involuntarily admitted, 40% reported prior involuntary admissions, and nearly half endorsed the perception of some coercion during their index admission. In addition, self-reported history of being denied a requested medication during psychiatric hospitalization (a potentially coercive treatment) may influence appraisal of care during the current hospitalization. Self-reported lifetime rates of other coercive treatment experiences ranged from 22% reporting being forced to take medications to 46% reporting ever being transported to the ER or hospital by law enforcement.
Date: September 28, 2012
- Veterans’ Communication Preferences for Primary Care Needs
Overall, 54% of the Veterans in this study reported being regular computer users (daily, 2-3 times per week, or once per week). On average, a greater proportion of infrequent users (2-3 times per month, less than once per month, or do not typically use a computer) were male, older, and in fair/poor health compared to regular users. Among Veteran primary care patients, telephone communication was preferred for the majority of primary care issues, including general medical questions, medication questions and refills, as well as preventive care reminders, scheduling, and test results. In-person visits were preferred for new medical conditions, concerns about ongoing conditions, treatment instructions, and information about next steps in care. Of regular computer users, about 1/3 preferred electronic communication (email or Internet portal, including MyHealtheVet) for preventive care reminders (37%), test results (34%), and prescription refills (32%). Veterans who used the Internet did so for a variety of reasons, with e-mail (85%) and accessing health information (39%) among the top two.
Date: September 1, 2012
- New Anticoagulants are Viable Option for Patients Receiving Long-Term Anticoagulation
New oral anticoagulants are a viable option for patients receiving long-term anticoagulation. Direct thrombin inhibitors (DTIs) and factor Xa (FXa) inhibitors have the advantage of a more predictable anticoagulant effect, and fewer drug-drug interactions as well as equivalent or better mortality and vascular outcomes compared with warfarin. However, treatment benefits compared with warfarin are small and vary depending on the control achieved by warfarin treatment. Six good quality randomized controlled trials comparing new oral anticoagulants (NOACs) with warfarin showed that in patients with atrial fibrillation (AF), NOACs decreased all-cause mortality. In patients with venous thromboembolism, NOACs did not differ for mortality or outcomes. Across indications, the risk of major and fatal bleeding was decreased with NOACs compared with warfarin. However, the bleeding risk with NOACs may be increased in individuals over the age of 75, and in those with renal impairment. Sub-group analyses suggest a higher risk for myocardial infarction or acute coronary events with dabigatran (DTI) compared with FXa inhibitors. Recent thromboprophylaxis guidelines conclude that patients with AF who are on good warfarin treatment control have little to gain by switching to dabigatran.
Date: August 28, 2012
- Age Differences in PTSD Diagnoses and Treatment Seeking among Veterans
Among the Veterans in this study sample who screened positive for PTSD, the percentage of positive screens decreased as age increased: 17% for Veterans aged 18-29 years, 13% for Veterans ages 30-44, 13% for Veterans ages 45-59, 6% for Veterans ages 60-74, and 2% for those ages 75 years and older. While older Veterans were less likely to screen positive for PTSD, they also were less likely to initiate specialty mental health treatment when they had positive screens. For example, 66% of Veterans ages 18-29 had mental health visits compared to 19% of Veterans ages 75 years and older. There also were significant differences by age in types of treatment received. Veterans ages 18-29 years received the most diagnostic visits, while Veterans ages 45-59 and 60-74 years received more visits for group psychotherapy than other age groups. Veterans ages 75 years and older received the fewest visits involving psychotherapy and medications or phone contact. The authors suggest that future research is needed to examine whether alternative approaches to PTSD in primary care settings may improve specialty treatment initiation rates, particularly among older Veterans.
Date: August 13, 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
- No Significant Cost Increase for Telephone-based BP Intervention for Veterans with Hypertension
Average intervention costs were similar in the three study arms, and at 18 months there were no significant differences in direct VA medical costs or total VA costs between treatment arms and usual care. Mean total VA costs per patient in the treatment arms were $14,441 for behavioral management; $14,453 for medication management; $13,009 for combined treatment; and $12,328 for usual care. The combined intervention resulted in observed net savings in outpatient care and overall medical care, as well as the lowest mean cost difference and total cost, but these differences were not statistically significant relative to the other intervention arms. Patients in all three intervention arms incurred $289 to $1,127 less in outpatient care compared to those treated under usual care, but these savings were not statistically significant.
Date: June 1, 2012
- IRB Process for Multisite, Minimal-Risk VA Trial
Complying with IRB requirements for a minimal-risk randomized controlled trial involved 115 submissions, consumed more than 6,700 staff hours, and lasted nearly two years longer than planned. The IRB approval process had a profound financial impact on the project, costing close to $170,000 in staff salaries. Delays in approval affected participant recruitment and retention; for example, seven physician participants had left their primary care settings before all IRB approvals were received. One IRB’s concern about incentivizing a medication recommended by national guidelines prompted a protocol modification (broadening study inclusion criteria beyond uncomplicated hypertension) at all sites in order to preserve the study’s internal validity. Requirements for local site principal investigators and for IRB and R&D committee approvals resulted in the inclusion of more highly-affiliated, urban sites that were treating more complex patients, potentially affecting the external validity (generalizability) of the study findings.
Date: May 15, 2012
- The Importance of Testing Interventions in Real-World Settings
Using the best evidence from efficacy trials to improve BP control among patients with diabetes and persistent hypertension, investigators in this study designed a pharmacist-led care management program – the Adherence and Intensification of Medications (AIM) intervention. In examining three-month intervals, the AIM program lowered systolic BP among patients more rapidly than usual care did for patients in the control group. However, usual care patients achieved equally low systolic BP (SBP) levels by six months after the intervention. Thus, by six months and throughout the remainder of follow-up, control team patients’ mean SBP were indistinguishable from those of the intervention group participants. There were no differences in health services utilization between eligible intervention and control patients during the 14-month intervention period. Patients in the AIM intervention group were more likely than patients in the control group to undergo medication changes during the 6-month period following their start date, although both groups had high rates of medication changes. Authors note that these findings emphasize the importance of evaluating programs that are found to be effective in efficacy trials in real-life clinical settings before urging widespread adoption.
Date: May 8, 2012
- Clinically-Guided Approach for Improving Performance Measurement for Hypertension
This study tested a novel performance measurement system for BP control that was designed to mimic clinical reasoning. Using an algorithm that replicates clinical decision-making, this approach focuses on: 1) exempting Veterans for whom tight BP control may not be appropriate or feasible, and 2) assessing BP over time. Nearly one in three Veterans with hypertension would be exempted from BP performance measurement based on clincially-guided criteria. The most common reasons for exemption were inadequate opportunity for clinicians to manage Veterans’ BP, and the patient’s use of four or more anti-hypertensive medications. After accounting for clinically-guided exemptions and methods of BP assessment, only 15 of 72 Veterans (21%) whose last BP was >140/90 mm Hg were classified as problematic by the clinically-guided approach, i.e., eligible for performance assessment and defined as having uncontrolled BP.
Date: May 1, 2012
- Anti-Hypertensive Medication May Reduce Risk of Dementia among Veterans with Diabetes
Comorbid hypertension was associated with increased risk of dementia; however, anti-hypertensive medications, particularly ACE inhibitors and ARBs, were associated with reduced risk of dementia, even among Veterans without hypertension. The most protective effect was associated with ARB use (approximately 24% lower risk of dementia), followed by diuretics (14%), ACE inhibitors (11%), CCBs (7%), and beta blockers (4%). Factors associated with higher incidence of dementia included: increasing age (Veterans >85 had more than three times greater risk compared to Veterans age 65), as well as duration of diabetes and higher comorbidity. Also, African Americans and other non-white races were more likely to have dementia. These findings suggest that ARBs and ACE inhibitors be considered when prescribing medication for the control of hypertension among patients with diabetes.
Date: April 20, 2012
- Factors Associated with Increased VA Preventable Acute Care Use
Prior mental health diagnoses and medication use were independent risk factors for ambulatory care sensitive condition- (ACSC) related acute care. These risk factors will require focused attention if the full benefits of new primary care models, such as PACT, are to be achieved. The highest rate of ACSC admissions was among Veterans with drug use disorders (46 admissions per 1,000 patients), followed by those with depression (35 admissions per 1,000 patients), compared to 21 admissions per 1,000 patients for those with no mental health diagnoses. The rate of ED visits for ACSCs was also higher among those with mental health diagnoses (70 visits per 1,000 vs. 44 visits per 1,000 for those without mental health diagnoses). Patients without mental health conditions experienced significantly lower rates of both all-cause and ACSC admissions than patients with mental health conditions. The mean cost and length of stay of ACSC admissions, however, was similar and not statistically different between the two groups.
Date: March 20, 2012
- Increase in Proportion of Veterans with PTSD Prescribed Guideline-Concordant Medications
The number of Veterans being treated for PTSD in the VA healthcare system increased nearly 3-fold – from 170,685 in FY1999 to 498,081 in FY2009. The majority of these Veterans (80%) received one of the medications recommended in the clinical practice guideline (CPG) for the treatment of this disorder. The proportion of Veterans receiving either of the two CPG-recommended first-line pharmacotherapy treatments for PTSD – selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) – increased from 50% in 1999 to 59% in 2009. This increase represents more than 46,000 Veterans receiving first-line, guideline recommended medications. The overall frequency of antipsychotic use declined by 6% – from 20% in 1999 to 14% in 2009, and there also was a reduction in benzodiazepine prescriptions (the CPG cautions against prescribing benzodiazepines to manage core PTSD symptoms). However, non-benzodiazepine hypnotic drug prescribing tripled when zolpidem (Ambien) was added to the VA national formulary. Prazosin use increased more than 6-fold, from 1% in 1999 to 9% in 2009, suggesting that it is now more widely prescribed to Veterans with PTSD.
Date: March 1, 2012
- Veterans that Use Cigarette Smoking to Cope with Chronic Pain Experience Worse Pain-Related Outcomes
Veterans who reported smoking as a coping strategy for chronic pain scored significantly worse compared to Veterans who did not smoke and those who denied using cigarettes to cope with pain on the majority of measures of pain-related outcomes. After controlling for demographics and clinical factors, smoking as a coping strategy for pain was significantly and positively associated with pain intensity, pain interference, and fear of pain. There were no significant differences between the three groups on current symptoms of depression or anxiety, indicating that comorbid psychopathology likely did not contribute to poorer pain-related outcomes in the group who used cigarettes to cope with pain. The two smoking groups did not differ with respect to the frequency or severity of nicotine dependence, use of opioid medications, or on other clinical factors, suggesting that impairment in pain-related variables may be due to reliance on cigarettes as a coping strategy for chronic pain.
Date: March 1, 2012
- Study Compares Effectiveness of Oral Anti-diabetic Drugs on Kidney Function for Veterans with Type 2 Diabetes
Among Veterans with type 2 diabetes, initiation of sulfonylureas compared to metformin was associated with an increased risk of clinically significant decline in kidney function, diagnosis of ESRD, or death. Compared to metformin, the use of rosiglitazone was not significantly associated with any outcomes. Compared to sulfonylureas, the use of rosiglitazone was associated with a decreased risk for all three outcomes. Authors suggest that these findings support the current recommendations of metformin as first-line therapy for patients with type 2 diabetes who are in earlier stages of kidney disease.
Date: February 1, 2012
- Few Veterans Receive Appropriate Thrombolysis Following Stroke
This study examined the use and misuse of thrombolytic therapy with tissue plasminogen activator (tPA) in a national sample of Veterans with acute ischemic stroke who were admitted to one of 129 VA medical centers in FY07. Findings show that VA treatment of Veterans with acute ischemic stroke who are eligible for thrombolytic therapy is similar to that in non-stroke center hospitals in the private sector. Among the 532 Veterans with ischemic stroke presenting to VA within three hours of symptom onset, 33% were eligible for tPA, and 11% received it. Considering only the 135 Veterans who arrived within two hours of symptom onset (allowing adequate time for testing and evaluation), 14% received tPA. Among the 30 Veterans who received tPA (whether eligible to receive it or not), 17% received the wrong dose. Eligible Veterans receiving tPA were similar to eligible Veterans who did not receive tPA in terms of clinical conditions and time to brain imaging.
Date: January 1, 2012
- Investigators Provide Rationale for New LDL Guidelines
Updated guidelines for cholesterol testing and management from the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults are due to be published in 2012. A primary focus of the previous version of the guidelines was treating patients to low-density lipoprotein (LDL) cholesterol level targets, with the primary goals of therapy and the cut-points for initiating treatment stated in terms of LDL. However, the authors of this commentary believe this reasoning diverges from clinical evidence and present three primary reasons that justify a major change in the next generation of guidelines: 1) There is no scientific basis to support treating to LDL targets, 2) The safety of treating to LDL targets has never been proven, and 3) Tailored treatment is a simpler, safer, more effective, and more evidence-based approach. This perspective is synergistic with recent activities in VA, in which a multidisciplinary group of leaders provided input that led to the suspension of VA’s Performance Measure that was strictly focused on achievement of lipid targets. They are now working to substitute a performance measure that emphasizes the prescription of statin medications.
Date: January 1, 2012
- Low Proportion of Veterans Are Using My HealtheVet to Transfer or Share Information with Others
Of the 25,898 Veterans who participated in Wave One of the study (asking about the transfer of information from My HealtheVet to other places/persons), 40% reported printing information, 21% reported saving information electronically, and 4% sent information from My HealtheVet to another person. Of the 18,471 Veterans who participated in Wave Two of the study (asking about using and sharing the My HealtheVet medication information list), 30% reported self-entering medication information into My HealtheVet, with 60% of those reporting sharing their complete medication list with their VA providers and 32% with their non-VA providers.
The authors suggest that although some Veterans are transferring important medical information from their personal health records, increased education and awareness is needed to help them use this information to improve continuity of care with their providers, both VA and non-VA.
Date: January 1, 2012
- Adverse Drug Reactions Associated with Polypharmacy are Common Cause of Unplanned Hospitalizations among Older Veterans
This study sought to describe the prevalence of unplanned hospitalizations caused by adverse drug reactions (ADRs) among older Veterans. Findings showed that adverse drug reactions are a common cause of unplanned hospitalization among older Veterans, are frequently preventable, and are associated with polypharmacy (overall, 45% of Veterans took >9 outpatient medications and 35% took 5 to 8). The most common ADRs that occurred were bradycardia, hypoglycemia, falls, and mental status changes. Of the 678 unplanned hospitalizations that occurred during the study period, 70 ADRs involving 113 drugs occurred in 68 older Veterans, of which 37% were preventable. Extrapolating to a population of more than 2.4 million older Veterans receiving care during this time, 8,000 hospitalizations costing about $110 million (using FY04 dollars) may have been unnecessary. The most common reason for a preventable ADR was suboptimal prescribing (52%), followed by patient non-adherence (28%), and suboptimal monitoring (12%). In addition, 4 medication classes (cardiovascular, central nervous system, anti-thrombotic, and endocrine) accounted for almost 80% of all the drugs implicated in ADRs.
Date: December 8, 2011
- Diabetes Managed More Intensively in Older Veterans with Dementia and Cognitive Impairment
This study sought to examine and compare anti-glycemic medication use, glycemic control, and risk of hypoglycemia in older Veterans with and without dementia or cognitive impairment. Findings showed that diabetes was managed more intensively in older Veterans with dementia or cognitive impairment than in those with no impairment, with more patients on insulin (30% vs. 24%) among those with cognitive problems. These conditions were independently associated with a greater risk of hypoglycemia. Of all Veterans taking insulin, the incidence of hypoglycemia was higher among those with dementia (27%) or cognitive impairment (20%) than among those with neither condition (14%). Veterans with dementia or cognitive impairment also had a greater decline in HbA1c over the 2-year study period. These findings suggest that providers were less likely to pursue individualized glycemic goals, as recommended by VA-DoD clinical practice guidelines (updated in 2010), when patients had cognitive problems.
Date: December 8, 2011
- Decreased Use of Benzodiazepines among Veterans with PTSD
This study examined trends in benzodiazepine prescribing among Veterans with PTSD. Findings show that the overall proportion of Veterans receiving a benzodiazepine decreased from 37% in 1999 to 31% in 2009. In addition, the proportion of long-term users (>90 days) decreased from 69% to 64%, and the mean daily dose declined by nearly 15%. The likelihood of receiving benzodiazepines was influenced by time since first VA PTSD diagnosis. For example, in 2009, patients newly diagnosed with PTSD were the least likely to receive a benzodiazepine (21%) compared to patients with a history of three or more years of treatment (36%). Clonazepam was the most commonly prescribed benzodiazepine across all study years.Despite decreasing frequency of use, the absolute number of Veterans with PTSD who received benzodiazepines increased nearly 250% due to the increasing numbers of Veterans receiving care for PTSD in the VA healthcare system. Therefore, the authors suggest that minimizing benzodiazepine exposure will remain a vital policy issue.
Date: November 29, 2011
- 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
- Unintended Consequences of Local Implementation of VA Performance Measures
This study explored the possible relationships between a centralized primary care clinical performance measurement (PM) system, facility-level practices to implement the PM system into daily care, and unintended negative consequences for Veterans. Findings showed that primary care staff described several ways in which PMs may lead to inappropriate care (e.g., over-prescribing of medication), decrease focus on Veterans’ concerns and patient service (e.g., inconveniencing patients for little benefit), and may make it more difficult for Veterans to make informed, value-consistent decisions (e.g., performance system doesn’t acknowledge when a patient makes an informed refusal of a recommended intervention). Staff also described unintended consequences on primary care team dynamics, e.g., requiring nurses to check on providers to be sure they completed and documented PMs, and providing performance bonuses based on PMs to physicians, but not to nurses. In many instances, problems originated from local implementation strategies developed in response to national PM definitions and policies. Some noted benefits of PMs included feedback from the system helping some clinic staff feel more confident that their care was thorough, and performance scores as a source of pride and positive competition. VA is currently making changes to the national PM system based on this and other research, e.g., developing new PMs that reward clinically appropriate action, even if the patient has not achieved specific targets, and developing clinical reminders that facilitate patient-centered decisions.
Date: October 13, 2011
- Evidence-Based Staffing Methodology to Predict Nurse Staffing Needs
This article describes a process used to identify indicators of nursing workload and develop an evidence-based nurse-staffing methodology that could be used to predict staffing needs and eventually link to nursing outcomes in the VA healthcare system. The final set of indicators included: 1) average length of stay (surrogate marker for patient severity of illness); 2) average number of medication doses administered daily; 3) percentage of patients with age >70; 4) percentage of patients with a BMI >25; 5) top three diagnostic categories on the unit (surrogate for complexity/scope of care required); 6) average daily census (patient volume and nursing workload); and 7) daily patient turnover (admissions, transfers, discharges). Following successful evaluation, the Office of Nursing Services introduced a national VA policy that directed all facilities to implement the new evidence-based, nationally standardized staffing methodology by September 2011. A formal evaluation will begin in October 2011.
Date: October 1, 2011
- Collaborative Care Intervention for Veterans with Ischemic Heart Disease Treated in VA Primary Care Setting
The Collaborative Cardiac Care Project sought to determine whether a multi-faceted intervention using a collaborative care model ? directed through primary care providers ? would improve symptoms of angina, self-perceived health, and concordance with practice guidelines for managing chronic stable angina among Veterans with ischemic heart disease (IHD). Findings showed that the collaborative care intervention had no significant effects on symptoms or self-perceived health, but significantly improved receipt of guideline-concordant care in Veterans with stable angina. Although concordance with guidelines improved 4.5% more among Veterans receiving collaborative care than those receiving usual care, this was mainly due to increased use of diagnostic testing rather than recommended medications. The collaborative care model was well received by primary care providers, who implemented 92% of 701 recommendations made by collaborative care teams. Nearly half of the recommendations were related to medications, e.g., adjustments to beta blockers, long-acting nitrates, and statins.
Date: September 12, 2011
- 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
- VA Travel Reimbursement Increases Outpatient Visits
This study examined the effects of a February 2008 policy change to increase Veterans’ mileage reimbursement rate (from 11 cents per mile to 28.5 cents per mile) on utilization of outpatient, inpatient, and pharmacy services in the 10.5 months before the reimbursement rate increase and the 10.5 months after the rate increase. Findings showed that after the reimbursement rate increase, eligible Veterans at all distances were 7% more likely to have at least one VA outpatient visit and had 3% more outpatient visits compared to Veterans who were not eligible for the travel reimbursement. The increased reimbursement was associated with slightly larger increases in outpatient costs to provide care to Veterans who lived farther away from VA facilities compared to those who lived closer. The odds of having a prescription filled at a VA pharmacy increased by at least 4% for Veterans across all distance definitions, with patients living farther than 50 miles away experiencing the largest increase at 9%. The reimbursement rate also was associated with a significant increase in pharmacy costs to provide medications to Veterans living farther than 50 and 75 miles from a VA facility. Inpatient visits remained generally unaffected, and there was no significant increase in cost.
Date: August 24, 2011
- Potential Problems with the Use of Antidepressants among Older Veterans Residing in VA Nursing Homes
This study examined the prevalence and patient/site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants among Veterans aged 65 years and older that were admitted to any one of 133 VA Community Living Centers (CLC, previously called Nursing Home Care Units). Findings suggest potential problems with the use of antidepressants in older Veterans that reside in VA CLCs. Overall, only 18% of antidepressant use was optimal. Of the 877 Veterans with depression, 25% did not receive an antidepressant, suggesting potential underuse. Among depressed Veterans who received antidepressants, 43% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. In addition, of the 2,815 Veterans who did not have depression, 42% were prescribed one or more antidepressants; of these, only 4% had an FDA-approved labeled indication, suggesting potential overuse. Also, the co-prescribing of antipsychotics (in patients without schizophrenia) among those without depression was associated with an increased risk of antidepressant overuse.
Date: August 1, 2011
- Behavioral and Medication Management Interventions Improve Blood Pressure Control for Veterans
This randomized clinical trial evaluated three nurse-led, home tele-monitoring interventions that were developed to improve blood pressure (BP) – and also tested which intervention was most effective among Veterans treated in VA primary care. Findings showed that overall, the behavioral and medication management intervention groups had a greater increase in the proportion of Veterans with BP measurements within target, relative to the usual care group, at 12 months. These findings were not sustained at 18 months; however, among Veterans with poor baseline BP control, the combined intervention significantly decreased blood pressure at both 12 and 18 months.
Date: July 11, 2011
- Quality Improvement Program for Oral Anticoagulation has Potential to Save Lives and Millions in VA Healthcare Costs
Quality of anticoagulation can be measured by percent time in the therapeutic range (TTR). Because VA is considering a quality improvement program to increase TTR, this study sought to determine whether a "business case" could be made for such a program, including whether or not it has the potential to save money in the short term. Findings showed that even after considering the cost of implementing the program, a quality improvement program for oral anticoagulation therapy in Veterans with atrial fibrillation has the potential to save lives and millions in VA healthcare costs. In this study population, a modest improvement in TTR (5%) would be expected to avert 1,114 adverse events over two years, many of them fatal. Such an improvement would result in a savings of $15.9 million (minus the cost of the quality improvement program). Improving TTR by 10% prevented 2,087 events and saved $29.7 million (again, minus the cost of the quality improvement program).
Date: July 1, 2011
- Medication Reconciliation Reduces Adverse Drug Events Related to Some Hospital Admission Prescribing Changes
This study estimated the effectiveness of inpatient medication reconciliation at the time of hospital admission on adverse drug events (ADEs) caused by admission prescribing changes. Findings showed that medication reconciliation at the time of hospital admission reduced ADEs caused by admission prescribing changes that were classified as errors by 43%, but it did not reduce ADEs caused by all admission prescribing changes. Non-error-related ADEs would not be averted by one-time medication reconciliation on admission, but they might be averted by improved provider awareness and monitoring of admission prescribing changes during the hospital stay. The potential impact of such an intervention is large, as 50% of the ADEs in this study were caused by admission medication changes that were not errors.
Date: May 9, 2011
- Veterans Receiving Higher-Dose Opioid Prescriptions for Pain at Increased Risk of Death from Overdose
This study examined the association of maximum prescribed daily opioid dose and dosing schedule (“as needed,” regularly scheduled, or both) with risk of opioid overdose death among Veterans with cancer, chronic pain, acute pain, and substance use disorders. Findings showed that among Veterans receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of death from opioid overdose. The frequency of fatal overdose among Veterans treated with opioids was rare – estimated to be 0.04% - and was directly related to the maximum prescribed daily dose of opioid medication. There was no significant increased risk of opioid overdose among Veterans who were treated with both “as-needed” and regularly scheduled opioids – a strategy for treating pain exacerbations – after adjusting for maximum daily dose and patient characteristics. Veterans who died from opioid overdose were significantly more likely to have chronic or acute pain, substance use disorders, and other psychiatric disorders, but they were less likely to have cancer. This study highlights the importance of implementing strategies for reducing opioid overdose among patients being treated for pain, for example, ascertaining history of substance abuse, using treatment contracts, and scheduling frequent follow-up visits and toxicological screens for patients at special risk.
Date: April 6, 2011
- Patient Self-Testing/Management May Decrease Mortality and Thromboembolic Events among Patients on Long-Term Anticoagulation
This evidence review sought to determine whether patient self-testing (PST), either alone or in combination with self-dose adjustment (patient self-management, PSM), is associated with fewer thromboembolic complications and all-cause mortality – without an increase in major bleeding – compared to usual care. Findings showed that PST with or without PSM is associated with significantly fewer deaths and thromboembolic events – without an increased risk of serious bleeding – for a highly select group of motivated adult patients requiring long-term anticoagulation with Vitamin K antagonists. Patients randomized to PST/PSM had a 26% lower risk of death and a 42% reduction in major thromboembolism without any increased risk of major bleeding events. Whether or not this care model is cost-effective and can be implemented successfully in typical U.S. healthcare settings is unknown.
Date: April 5, 2011
- Rates of Accidental Poisoning among VA Patients Higher than General Population
This study describes the rate of accidental poisoning mortality among Veterans who used VA healthcare services, compares this rate to the general U.S. population, and describes the drugs/medications involved. Findings show that for FY05, VA patients had nearly twice the rate of fatal accidental poisoning compared to adults in the general population. Among VA patients who died from accidental poisoning, opioid medications (including methadone) made up 32% of the reported deaths; cocaine also was common at 23%. In both the VA and U.S. general populations, the rate of accidental poisoning mortality was higher for men than women, and higher for individuals ages 30 to 64 as compared to those ages 18 to 29, or ages 65 and older. Although VA patients have a greater risk of suicide than death by accidental poisoning, their risk for accidental poisoning death relative to the general population is larger than that of suicide.
Date: April 1, 2011
- Excessive Caution in Prescribing to Veterans with Geriatric Conditions May Be Unnecessary
This study evaluated whether common geriatric conditions were associated with risk of adverse drug events (ADEs). Findings show that over the one-year study period, 126 Veterans suffered a total of 167 ADEs, but there was no association between the presence of various geriatric conditions and ADEs. However, in exploratory analyses investigators found that the use of new medications (present at 12-month follow-up) was associated with a higher risk of ADEs. The authors suggest that while it is important to consider the unique circumstances of each patient, excessive caution in prescribing to elders with geriatric conditions may not be warranted.
Date: April 1, 2011
- Improvements Using Patient-Aligned Group Clinics for Diabetes Care
This study evaluated the comparative effectiveness of two group self-management interventions for glycemic control among Veterans with treated but uncontrolled diabetes. Findings show that Veterans who participated in the primary care-based “Empowering Patients in Care” (EPIC) intervention had significantly greater improvements in HbA1c levels immediately following the active intervention; these differences remained at one-year follow-up. Thus, primary care-based diabetes group clinics that include patient-aligned approaches to goal-setting (e.g., action plan) for medication management, and diet and exercise changes can significantly improve HbA1c levels. Diabetes self-efficacy measures improved immediately after the intervention in both the EPIC and comparison intervention groups, but were significantly higher in the EPIC group. Self-efficacy was associated with individual changes in HbA1c levels. At 1 year, differences in HbA1c levels between groups remained the same (i.e., there was no return to baseline, but also no further improvements). Self-efficacy levels dropped in both groups at 1 year; but the drop in the EPIC intervention participants was less than the diabetes education participants, resulting in modest (non-significant) differences between the groups at one year.
Date: March 14, 2011
- Newly FDA-Approved Dabigatran May Be Cost-Effective Alternative to Warfarin for Patients at Increased Risk of Stroke
Atrial fibrillation (AF) is the second most common cardiovascular condition in the U.S. – and the second most common condition affecting Veterans. AF also increases the risk of ischemic stroke by five-fold. Research shows that anticoagulation therapy with warfarin and other vitamin K antagonists can reduce the relative risk of stroke in AF by two-thirds. Dabigatran – a newer anticoagulant and the first such drug approved by the FDA in 20 years – produces similar or reduced rates of ischemic stroke and hemorrhage compared with warfarin and requires no blood testing. This study evaluated the quality-adjusted survival, costs, and cost-effectiveness of dabigatran compared with warfarin for the prevention of ischemic stroke in patients >65 years with non-valvular AF. Findings show that dabigatran could be a cost-effective alternative to adjusted dose warfarin. High-dose dabigatran was the most effective and the most cost-effective therapy examined. The quality-adjusted life expectancy was 10.28 quality-adjusted life years (QALYs) with warfarin, 10.70 QALYs with low-dose dabigatran, and 10.84 QALYs with high-dose dabigatran. Thus, high-dose dabigatran yielded an additional half year of quality-adjusted life compared to warfarin. With dabigatran given at 150 mg twice daily – the approved dosage for most patients – the incremental cost compared with using warfarin is under the conventional cost-effectiveness threshold of $50,000 per QALY gained. Total costs were $143,193 for warfarin, $164,576 for low-dose dabigatran, and $168,398 for high-dose dabigatran.
Date: January 4, 2011
- Risk-Adjusted Time in Therapeutic Range Can Be Used as Quality Indicator for Outpatient Oral Anticoagulation
This study examined the suitability of risk-adjusted time in therapeutic range (TTR) as a potential quality indicator for anticoagulation therapy among VA patients. Findings show that TTR can be used to profile the quality of outpatient oral anticoagulation in a large, integrated healthcare system. Thus, this measure can serve as the basis for quality measurement and quality improvement efforts. TTR differed among VA anticoagulation clinics – from 38% to 69%, or from poor to excellent. Risk-adjustment did not alter performance rankings for many sites, but for other sites it made an important difference. For example, the anticoagulation clinic that was ranked 27th out of 100 before risk adjustment was ranked as one of the best (7th) after risk-adjustment. Risk-adjusted site rankings were consistent between the first and second years of the study, suggesting that risk-adjusted TTR measures a construct (quality of care) that is stable over time.
Date: January 1, 2011
- Possible Hypertension Medication Gaps in Veterans Switching Healthcare Systems
This study sought to measure the relationship between switching healthcare systems (VA and Medicaid) when filling prescriptions and gaps in medication adherence for Veterans with a diagnosis of hypertension. Findings show a significant and positive relationship between switching healthcare systems where prescriptions are filled and medication gaps when all drug classes are combined. Veterans who switched between healthcare systems were predicted to significantly increase their percent of days without drugs by 7% compared to individuals who received their drugs in one system. The authors suggest that healthcare policymakers and providers pay particular attention to patients who are switching payers for drug coverage because their medication regime may be compromised.
Date: January 1, 2011
- Substantial Gaps in Processes of Care for Veterans with Bipolar Disorder
This study applied a comprehensive set of process of care measures that reflect the integration of psychosocial, patient preference, and continuum of care approaches to mental health – and evaluated whether Veterans with bipolar disorder received care concordant with these practices. Findings show substantial gaps in care for Veterans with bipolar disorder, especially for patient-centered processes such as symptom assessment and treatment experience. Only half of the patients received care in accordance with clinical practice guidelines. Moreover, only 17% had documented assessment of psychiatric symptoms, 28% had documented patient treatment preferences, 56% had documented assessment of substance abuse and psychiatric comorbidity, and 62% had documented assessment of cardiometabolics. Monitoring of weight gain was noted in 54% of the patient charts, and no-show visits were followed up only 20% of the time. However, 72% of the patients received appropriate anti-manic medication, and all patients were assessed for suicidal ideation. Overall, results suggest that in order to present a more patient-centered view of quality, processes of care for bipolar disorder cannot be distilled into a single measure; but rather, a series of patient-centered composite indicators.
Date: November 1, 2010
- Link between Psychiatric Diagnosis and Higher Risk of Suicide among Veterans
As part of VA’s ongoing evaluation of suicide risk among Veterans being treated in VA facilities, this study examined the impact of different psychiatric diagnoses on the risk of suicide. Findings show that a clinical diagnosis of a psychiatric disorder increased the risk of subsequent suicide by 160%. Psychiatric diagnoses were an especially strong risk factor for suicide among women, increasing their risk of suicide more than 5-fold. Bipolar disorder was the least common diagnosis (only 3% of all Veterans studied), but was diagnosed in approximately 9% of all Veterans who died by suicide. A diagnosis of bipolar disorder increased the risk of suicide nearly 3-fold in men and 6-fold in women. Authors suggest this makes bipolar disorder particularly appropriate for targeted interventions (e.g., improving medication adherence). Overall, suicides were more than three times as common in men than in women and were 37% to 77% more common in Veterans ages 30 and older than among those ages 18 to 29.
Date: November 1, 2010
- Model Used for Cholesterol Guidelines May Lead to Misclassification of Risk for Heart Attack and Coronary Death
National cholesterol guidelines use the “Framingham model” to calculate a person’s 10-year risk of myocardial infarction or coronary death. Based on this risk, patients are categorized into different risk groups, which are used to guide treatment decisions. Both original and point-based versions of the model are in use and endorsed by national guidelines. Given that approximately 36 million persons in the U.S. are eligible for lipid-lowering therapy, differences in risk classification depending on which model is used could result in millions receiving different lipid-lowering therapy. This study compared differences in predicted risk between the original and point-based Framingham calculations. Findings show that compared with the original Framingham model, the point-based version of the tool misclassifies millions of Americans into different risk groups, with 25-46% of affected individuals experiencing potential impacts on drug treatment recommendations for cholesterol control.
Date: November 1, 2010
- VA Increases Prescriptions for Smoking Cessation Medications among Veterans
Since 2002, VA has implemented a range of policies and programs to increase evidence-based treatment for smoking. This study examined the change in rates of dispensing cessation-related medications to Veterans in the VA healthcare system to assess the impact of these policy changes. Findings show that VA policy initiatives instituted since 2002 have greatly increased prescriptions for smoking cessation medications among Veterans, while decreasing costs. The number of Veterans filling a prescription for nicotine replacement therapy (NRT) increased 63% from FY04 through FY08. Thirty-day-equivalent NRT prescriptions rose nearly 50% over the same period. Bupropion prescribing also rose sharply; the four-year growth rate among Veterans also prescribed a NRT was 61% greater than the 35% growth rate among all Veterans receiving bupropion prescriptions. While prescriptions for NRT and bupropion rose, spending per treated patient fell by 39% for bupropion and by 24% across all NRT formats (e.g., patch, gum).
Date: September 24, 2010
- Rapid-Induction Group Clinic May Be Effective Method of Increasing Rates of Hypertension Control
This report describes the process of care and outcomes of a QI initiative that used group clinics to rapidly induce hypertension control among Veterans in a VA primary care setting at one VAMC. Findings show that among Veterans with chronically treated but persistently uncontrolled hypertension, more than half (54%) were able to rapidly lower their blood pressures to controlled levels within six weeks using a group clinic quality improvement initiative. Moreover, Veterans maintained BP control over the follow-up period (10 months after QI protocol completion). Adherence to the QI protocol predicted hypertension control at follow-up, even after controlling for multiple baseline variables (e.g., diabetes, body mass index, medication compliance). Two-thirds of Veterans without diabetes achieved hypertension control, including more than 80% of those who adhered to the group-clinic protocol.
Date: September 1, 2010
- Medication Management for Veterans with Schizophrenia
This study examined medication management for a random sample of Veterans who received drug therapy for schizophrenia at any one of three VA mental health clinics in Southern California between 2002 and 2003. Overall, 67% of Veterans had inappropriate management at baseline: 32% had inappropriate management of psychotic symptoms, 45% had inappropriate management of weight, and 8% had inappropriate management of tardive dyskinesia (TD). Further, 11% had depression that was moderately severe or worse. At one year, the appropriateness of management for psychotic and depressive symptoms had not changed. The appropriateness of management of TD also did not change over time, but the management of elevated weight improved modestly. There were no significant differences between the three clinics in the prevalence of symptoms or side effects, or in the appropriateness of medication management. However, psychiatrists with more than 12 patients were significantly more likely to improve their patients’ care over time.
Date: July 1, 2010
- Inappropriate Non-Steroidal Anti-Inflammatory Drug Use is Prevalent among Veterans
This study examined the prevalence of inappropriate non-steroidal anti-inflammatory drug (NSAID) use among Veterans– and identified patient and clinical characteristics associated with inappropriate use. The inappropriate use of NSAIDs was prevalent and was associated with more GI symptoms and higher levels of pain. Of the 1,250 Veterans who reported NSAID use, approximately 32% used NSAIDs inappropriately, including taking two or more NSAIDs, exceeding the highest daily recommended dosage, or both. Veterans classified as using NSAIDs inappropriately were more likely to be non-white and were more likely to have an income of less than $20,000.
Date: June 1, 2010
- Aggression May Be Linked to Psychosis in Elderly Persons with Dementia
This literature review examined the evidence on whether delusions or hallucinations contribute to the development of agitation or aggression in persons aged 65 and older with dementia. Most studies showed a statistically significant association between psychosis and aggression. Findings also showed that the use of antipsychotic medications in the setting of agitation/aggression and psychosis among patients with dementia is not uniformly supported. Authors note that given the multifactorial etiology of psychosis and aggression with other comorbid symptoms in dementia, it is important to understand the various contributing factors to facilitate more effective treatment interventions with least possible risk.
Date: June 1, 2010
- All Antipsychotics May Not Increase Short-Term Risk for Mortality among Veterans with Dementia
Commonly prescribed doses of haloperidol, olanzapine, and risperidone, but not quetiapine, were associated with short-term increases in mortality. During the first 30 days, there was a significant increase in mortality in subgroups prescribed a daily low dose of haloperidol, olanzapine, or risperidone, after adjusting for demographics, comorbidities, and medication history. However, increased mortality was not seen when quetiapine was prescribed. No antipsychotic was associated with increased mortality after the first 30 days. Therefore, the authors suggest that all antipsychotics might not pose the same degree of risk in all patient groups as implied by the general warnings that have been issued.
Date: May 7, 2010
- Additional Evidence of Clustering of Cardiovascular Events Following Cessation of Clopidogrel in Patients with ACS
In multivariable analysis, including adjustment for total duration of clopidogrel treatment, the 0-90 day interval after stopping clopidogrel was associated with significantly increased risk of death/MI compared to the 91-360 day interval among a non-VA population. There was a similar trend of increased adverse events after stopping clopidogrel for various subgroups (women vs. men, medical therapy vs. percutaneous coronary intervention, stent type, and = or <6 months of clopidogrel treatment). This clustering of adverse events was not present among patients stopping ACE-inhibitors, suggesting that the events are not a general effect of stopping medications. There was no association between the 91-360 day interval after stopping clopidogrel and adverse outcomes compared to patients remaining on clopidogrel.
Date: May 1, 2010
- Article Suggests Achieving Blood Pressure Control within Three Months Should be New Therapy Goal
The authors argue that to improve cardiovascular outcomes, evidence now indicates that a new paradigm emphasizing the rapid achievement of blood pressure control is required. Central to this paradigm is an explicit expectation of the timeframe in which blood pressure control should be achieved. Higher rates of control in shorter time periods have been seen in more recent clinical trials, and rapid blood pressure control is safe and associated with few side effects. Thus, the authors believe that the balance of the evidence supports changing the paradigm of hypertension treatment and implementing an expectation that blood pressure control should be achieved within three months of starting medication therapy.
Date: May 1, 2010
- Pharmacotherapy May Be Underused for Veterans with Alcohol Addiction
In FY06 and FY07, only about 3% of more than a quarter of a million VA patients with alcohol use disorders received treatment with one of four drugs specifically approved for treating alcohol dependence. [This apparent underutilization is not unique to VA, as utilization rates are within the range of rates reported in other settings.] Receipt of pharmacotherapy was more likely among Veterans receiving specialty addiction care, Veterans with alcohol dependence (vs. abuse), Veterans younger than 55 years old, and women. SSRI antidepressants were used about five times as often as alcohol use disorder medications in Veterans with an alcohol use disorder but without a psychiatric indication for SSRIs.
Date: April 1, 2010
- Aggression is Common among Veterans with Dementia
Findings showed that 41% of Veterans with newly diagnosed dementia became aggressive within 24 months, corroborating the findings of previous studies that aggression is common in persons with dementia. The use of antipsychotic medications increased significantly in Veterans after they became aggressive, and this group also had a ten-fold greater occurrence of injuries. In addition, almost twice as many aggressive Veterans were admitted to nursing homes. There were no differences in rates of restraint use or in- and outpatient visits between Veterans who became aggressive and those who did not.
Date: March 1, 2010
- VA Care for Obese Veterans
Of those Veterans identified as obese, only 27.7% had an obesity diagnosis in FY02; by 2006, 53.5% had an obesity diagnosis. Although suboptimal, these rates are comparable or better than those recently reported in the public sector. Results also show that an obesity diagnosis, and not BMI per se, was the strongest predictor of receiving obesity-related education. Only about 10-13% of obese Veterans received individual or group outpatient education in nutrition, exercise, or weight management on an annual basis, and only about one-third received any obesity-related education over the five-year study period. Obese Veterans who were older than 65 years, prescribed fewer types of medications, or lacking an EMR diagnosis of obesity or diabetes were less likely to have outpatient obesity-related education. Investigators also found limited utilization of weight loss medications and bariatric surgery, which may be partially due to system barriers such as access to surgery and medications.
Date: February 24, 2010
- Mental Health Treatment Seeking among OIF National Guard Soldiers
This study sought to determine the rate of reported mental health treatment-seeking in 424 returning OIF National Guard soldiers – and to examine potential barriers to and facilitators of treatment-seeking. Findings show that approximately one-third of the soldiers in this study reported post-deployment mental health treatment through military, VA, or other sources; however, 51% of soldiers who screened positive for PTSD and 40% who screened positive for depression did not report involvement in mental health treatment. Of the 34.7% who reported receiving mental health services, 22.9% had received psychotherapy only, 4.5% received psychiatric medications only, and 7.3% had received both. Reported treatment-seeking was more common among soldiers who screened positive for either PTSD or depression. Injury in-theater, illness-based need (e.g. presence and severity of mental illness), and mental health treatment in-theater were significantly associated with both self-reported psychotherapy and medication treatment-seeking. More positive attitudes regarding mental health treatment were associated with greater reported utilization of both psychotherapy and medication. Findings also indicate that while concerns about stigma were present, they were not associated with reported treatment-seeking behavior.
Date: February 1, 2010
- Comparing Treat-to-Target Strategies to Tailored Approach for Statin Therapy
This study examined how a simple Tailored Treatment strategy for statin therapy compared with a Treat-to-Target strategy based on National Cholesterol Education Program (NCEP) III treatment recommendations. Findings show that a simple Tailored Treatment strategy was more efficient and prevented substantially more coronary artery disease morbidity and mortality than any of the currently recommended Treat-to-Target approaches. The Tailored Treatment approach was predicted to save 520,000 more quality-adjusted life years among Americans aged 30-75 than the best NCEP III Treat-to-Target approach for every five years of treatment, even though fewer people were treated with high doses of statins. The authors indicate that these results suggest that a Tailored Treatment approach to medicine can substantially improve care, while also reducing unnecessary treatment and costs. Thus, they recommend that given its potential to better tailor treatments to individual patients, the principles underlying a Tailored Treatment approach should be considered during deliberations about guidelines and performance measures.
Date: January 19, 2010
- Affective Disorders Strongest Predictor of Suicidal Behavior in Elderly Veterans Receiving Anti-Epileptic Medication
In January 2008, the FDA issued an alert indicating that anti-epileptic drug (AED) treatment is associated with increased risk for suicidal ideation, attempt, and completion. This study sought to assess variation in suicide-related behaviors in a population not well-represented by the data used for the FDA analysis – individuals 66 years and older with new exposure to AEDs. Findings show that in older Veterans who were started on AED monotherapy, the strongest reliable predictor of suicide-related behaviors was the diagnosis of an affective disorder prior to AED treatment. Increased suicide-related behaviors were not associated with individual AEDs. However, while most Veterans in this study received AED prescriptions for gabapentin (76.8%), a trend for increased suicide-related behaviors was found among those prescribed levetiracetam or lamotrigine, but interpretation was difficult since few Veterans received either drug (0.6%). The associations between suicide-related behaviors and chronic pain or chronic disease burden were not statistically significant, but dementia was significantly associated with suicide-related behaviors (42.2% with dementia vs. 25.8% without).
Date: January 11, 2010
- Costs and Outcomes Associated with Newer Medications for Glycemic Control in Type 2 Diabetes
Investigators in this study conducted a cost-effectiveness analysis to better understand the value of adding either of two newer medications (exenatide and sitagliptin) as second-line therapy to glycemic control strategies, compared to an older medication (glyburide), for new-onset type 2 diabetes in persons 25 to 64 years of age. Findings show that newer medications offer more options for glycemic control; however, they come at considerable costs. Exenatide and sitagliptin conferred 0.09 and 0.12 additional quality-adjusted life years respectively, relative to glyburide as second-line therapy. Using sitagliptin as a second-line treatment is associated with additional costs of $20,213 per person over their lifetime compared to a baseline strategy using glyburide as second-line therapy. Using exenatide as a second-line treatment is associated with an additional cost of $23,849 per person over their lifetime compared to glyburide as second-line therapy.
Date: January 7, 2010
- Assessing New HEDIS Blood Pressure Quality Measure for Diabetes
To encourage aggressive treatment of hypertension, the National Committee on Quality Assurance recently adopted a new HEDIS blood pressure performance measure of <130/80 mm Hg for patients with diabetes. Although there is nearly universal agreement on the benefits of aggressive BP treatment (3-4 BP medications) for those with diabetes, the new HEDIS performance measure has generated considerable controversy. This study examined BP levels and medication treatment intensity in patients with diabetes, in order to assess the reasons for failing to meet the new HEDIS measure. Findings suggest that the new diabetes BP measure may not accurately identify poor quality care and could promote overtreatment through its performance incentives. The new measure commonly mislabeled patients as being inadequately treated, especially elderly patients. Thus, the authors recommend that new BP measures be developed to encourage aggressive treatment of hypertension without unduly promoting overtreatment, especially among elderly patients.
Date: January 1, 2010
- Increase in VA Drug Co-Payment Resulted in Decrease in Veterans’ Adherence to Some Medications
This study examined the impact of the VA medication co-payment increase on adherence to diabetes, hypertension, and hyperlipidemic medications by Veterans with diabetes or hypertension at 4 VAMCs during a 35-month period (2/01--12/03). Findings showed that a medication co-payment increase from $2 to $7 adversely impacted adherence to statins and anti-hypertensives by Veterans subject to the co-payment, but the impact was greatest among Veterans taking oral hypoglycemic medication. Adherence to all medications increased in the short term for all Veterans (12 months after co-payment increase), but then declined in the longer term (subsequent 11-month period). The impact of the co-payment increase was particularly adverse for Veterans with diabetes who were responsible for co-payments. Their adherence to oral hypoglycemic medication in the period 13-23 months after the co-payment increase was 10.3% lower than their pre-period adherence – and 9% lower than comparable Veterans who were exempt from co-payments.
Date: January 1, 2010
- Importance of Communicating Drug Information to Clinicians
The most direct way that the Food and Drug Administration (FDA) communicates prescribing information to clinicians is through the drug label. However, critical information that the FDA has at the time of drug approval may not appear on the drug label or in relevant journal articles. This commentary reviews several instances of information not included on drug labels and suggests the importance of better communicating this information to clinicians.
Date: October 29, 2009
- Team-Based Care Led by Pharmacists or Nurses Improves Blood Pressure Control
Investigators in this study conducted a systematic review of the literature to evaluate the effectiveness of team-based BP care involving pharmacists and nurses. Findings indicate that team-based interventions involving nurses or pharmacists were associated with significantly improved blood pressure control, with community pharmacists having the greatest impact. In addition, counseling on lifestyle modification and providing free BP medications had a significant impact on lowering systolic BP. Results also show that intervention strategies that provided medication education were the most effective, but this strategy cannot be evaluated on its own merit because it was usually provided with additional strategies.
Date: October 26, 2009
- Delays in Initiating Antibiotic Therapy for Veterans Hospitalized with Pneumonia
Time to first antibiotic dose (TFAD) is an important quality indicator for pneumonia care. Findings from this study, which included 20 VA hospitals, show that of the 82 survey participants, 72% perceived that ordering and performing chest X-ray was the most frequent step resulting in TFAD delays. Additional steps reported to cause TFAD delays were medical provider assessment, chest X-ray interpretation, ordering/obtaining blood cultures, and ordering/administering initial antibiotic therapy. The most commonly perceived barriers were patient and X-ray equipment transportation delays and communication delays between providers. The most frequently used strategies to reduce TFAD were stocking antibiotics in the emergency department and physician education. Focus groups emphasized the importance of multi-faceted quality improvement approaches and a top-down hospital leadership style to improve performance on this pneumonia quality measure.
Date: October 1, 2009
- Effect of Medicare Pharmacy Benefit Coverage on VA Healthcare Users
This study examined the influence of Medicare pharmacy benefit coverage on VA pharmacy use among Veterans using the VA healthcare system during 2002, who had diabetes mellitus, ischemic heart disease, or chronic heart failure. Overall, results showed that Veterans dually enrolled in VA and Medicare fee-for-service (FFS) were less likely to receive condition-related medications from VA compared with Veterans enrolled in HMOs with lower levels of prescription drug coverage. One implication of the overall study findings is that VA will become less the healthcare system of choice for Veteran beneficiaries if Medicare pharmacy services become more affordable. Moreover, Veterans with chronic conditions that require many medications and who hit a coverage gap in Medicare Part D or have difficulty making the Medicare co-payments may turn to VA as a safety net at intermittent times rather than using VA pharmacy services more steadily.
Date: October 1, 2009
- Veterans Using VA Pharmacy Services are More Ill than their Counterparts
This study compared users and non-users of VA pharmacy services separately by age group – Veterans ages 18-64 (non-elderly) vs. age 65 and older (elderly). Findings suggest that Veterans who use VA pharmacy services appear to be more ill than their counterparts who do not use the VA pharmacy benefit. Among younger Veterans, users of the VA pharmacy were more than twice as likely to report fair or poor general health status and more than three times as likely to report fair or poor mental health status. Moreover, both non-elderly and elderly users of VA pharmacy services reported more medical conditions and were more disabled. Overall results show a higher proportion of Veterans who use VA pharmacy services are African American and have no alternative insurance. Compared to non-users, VA pharmacy users also were more likely to be unemployed or out of the labor force, and living in a poor or low income family.
Date: October 1, 2009
- Appropriate Prescription of Proton-Pump Inhibitors among Elderly Veterans Using NSAIDs
Using VA data, this observational study assessed VA provider awareness of NSAID gastro-protection and the therapeutic intent of proton-pump inhibitor (PPI) prescription among 1,491 elderly Veterans at one VAMC. In other words, investigators sought to better understand why VA physicians were prescribing these drugs. Findings show that among elderly Veterans who were prescribed a PPI, a therapeutic intent was documented in 71% of the cases, and of these prescriptions, 88.8% were considered appropriate. However, practitioner recognition of the need for gastro-protection in elderly patients was remarkably low (10%). Results also show that poor rates of appropriate therapeutic intent were noted when the PPI was initiated by the inpatient service, by certain sub-specialties (e.g., cardiology, otolaryngology), and for Veterans using the VA for medication refill only.
Date: September 15, 2009
- Toyota Production System Methodology Leads to Improved Peri-Operative Care in One VAMC
In the Toyota Production System (TPS) industrial engineering approach, front-line work groups identify problems, experiment with possible solutions, measure the results, and implement strategies to improve quality, resulting in a “ground-up” rather than “top-down” approach to solving system problems. Beginning in 2001, one VAMC instituted TPS methods to reduce Methicillin Resistant Staphylococcus Aureus (MRSA) infections on a general surgical floor. The intervention then evolved to address other areas for QI on the surgical unit, such as increasing appropriate prophylactic peri-operative antibiotic therapy. The aims of this study were to determine: 1) whether the QI intervention for peri-operative antibiotic therapy was associated with improvements in selection and duration of prophylactic therapy; and 2) if the overall MRSA prevention initiative was associated with decreased hospital stay (LOS). Findings show that use of the TPS methodology resulted in a QI intervention that was associated with an increase in appropriate peri-operative antibiotic therapy among surgical patients. The proportion of all surgical admissions in this study (n=2,550) receiving appropriate peri-operative antibiotics was significantly higher in 2004 after initiation of the TPS intervention (44.0%) compared to the previous four years (range 23.4% to 29.8%). Results also showed no statistically significant decrease in LOS over time.
Date: September 1, 2009
- Drugs-to-Avoid Criteria for the Elderly have Limited Value
Drugs-to-avoid criteria are lists of drugs considered to be potentially inappropriate for the elderly due to adverse effects, limited effectiveness, or both. For example, the Centers for Medicare and Medicaid Services use a version of the criteria of Beers et al. in nursing homes, and the National Committee for Quality Assurance uses the criteria of Zhan et al. to compare the quality of U.S. health plans. This study compared the Beers and Zhan criteria with individualized expert assessment of patients’ medications in 256 elderly Veterans from the Iowa City VAMC who were taking five or more medications. Findings show that the drugs-to-avoid criteria performed poorly when used as quality measures to assess the current state of a patient’s drug therapy. For example, half or more of the drugs flagged by the Beers and Zhan criteria were not considered problematic upon individualized expert review. In addition, the Beers and Zhan criteria identified only 8-15% of drugs that experts judged to be problematic. Therefore, authors suggest that while these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures for the quality of prescribing.
Date: July 27, 2009
- Computerized Patient Hand-Off Tool Shows Promise in Increasing Patient Safety
Clinicians at the Indianapolis VAMC use a computerized patient hand-off tool (PHT) that extracts information from the electronic health record to populate a form that is printed and given to the cross-over physician. This study sought to: 1) evaluate the rate at which data were extracted from VA’s electronic medical record into the PHT; 2) assess the frequency for needing information beyond that contained in the PHT; and 3) assess physicians’ perceptions of the PHT, as well as opportunities for improvement. Overall, findings show that the PHT reliably extracts information from the electronic health record. However, while patient identifiers and medications were reliably extracted (>98%), other types of information were more variable (e.g., allergies and code status, <50%). Residents preferred PHT content that included: patient medication list, assessment and plan from the most recent physician note, and list of anticipated problems and recommendations for treatment. The primary suggestion for improving the PHT form was that it be organized by patient location (e.g., ward patients grouped together). Authors suggest that the PHT, which is marked for dissemination to other VAMCs, has considerable potential for improving patient safety.
Date: July 1, 2009
- Standard-Based Method is Preferred Measure of Treatment Intensity for BP Control
One possible measure of the quality of hypertension care is the intensity of clinical management when blood pressure (BP) is uncontrolled, thus there is increasing interest in measuring treatment intensification (TI). This study compared different TI measures in predicting BP control among 819 outpatients with hypertension. The three TI scores/measures evaluated were: 1) any/none score, which divides patients into those who had any therapy increase during the study vs. none; 2) Norm-Based Method (NBM), which scores each patient based on whether they received more or fewer medication increases than predicted at each visit; and 3) Standard-Based Method (SBM), which is similar to NBM but expects a medication increase whenever the BP is uncontrolled. Findings show that the SBM score was an excellent predictor of the final systolic blood pressure, thus the authors suggest that SBM serve as the basis for research and quality improvement efforts for better hypertension care. The any/none measure produced paradoxical results (therapy increases were associated with a higher final BP), while the NBM was not predictive of BP control.
Date: July 1, 2009
- Improving Adherence to Cardiovascular Medications
This article focuses on cardiovascular medication adherence and discusses studies that address: 1) different methods of measuring adherence, 2) prevalence of non-adherence, 3) association between non-adherence and outcomes, 4) reasons for non-adherence, and 5) interventions to improve medication adherence. Findings show that while there are many different methods for assessing medication adherence, non-adherence to cardiovascular medications is common and associated with adverse outcomes. The authors also found that non-adherence is not solely a patient problem but is impacted by both providers and the healthcare system. To date, interventions targeting medication adherence have produced only modest success. Multi-modal interventions have shown the most promise in improving adherence, but require the clinical personnel to manage and coordinate multiple intervention components.
Date: June 16, 2009
- HSR&D Investigators Propose New Measure to Assess Diabetes Care Quality
This article discusses a conceptual framework for assessing the efficiency of pharmacologic control of three important risk factors for diabetes (glucose, blood pressure, and cholesterol) because of their central role in diabetes management, and policy implications related to higher medication costs. The authors note that a growing body of evidence indicates a need for more flexible measures of diabetes quality of care. Thus, rather than a single optimal threshold approach, they suggest a new framework for measuring quality of care that incorporates the benefit of incremental improvement among multiple populations that differ by age, diabetes duration, and co-existing illness. The new paradigm would assess pharmaceutical efficiency using quality-adjusted life years (QALYs), calculated separately within multiple age/risk categories, as the output (numerator) and acquisition costs of medications as the input (denominator). The QALYs/cost ratio will provide an assessment of the efficiency of pharmacologic utilization. Therefore, measuring efficiency in the treatment of glucose, blood pressure, and cholesterol in persons with diabetes would incorporate the evaluation of a future healthcare benefit that is “purchased” by direct pharmaceutical costs, linking expected healthcare benefits to actual costs.
Date: June 1, 2009
- Smoking Cessation Services for Veterans in VA Psychiatric Facility
This study had two goals: 1) determine staff characteristics that are associated with attitudes about providing smoking cessation services to Veterans who are psychiatric patients, and 2) seek suggestions from staff about what would be important to include in a tobacco cessation program. Findings show that nearly 75% of staff in this study thought that VA should do more to assist Veterans to quit smoking, yet only about 25% said that they personally provide cessation services. However, more than 50% felt moderately, very, or extremely confident in providing cessation services. Interestingly, nurses were less likely than other staff to feel that it was important to provide cessation services, which could be because of competing job demands. The most common reasons given by all respondents for not providing services were not enough time and lack of training. When asked how VA could best assist smokers to quit, most responses focused on educating Veterans about tobacco use and how they can quit, as well as providing tobacco cessation medications.
Date: June 1, 2009
- Factors Associated with Antibiotic Prescribing for Likely Non-Bacterial Respiratory Infections
This study sought to identify patient and provider factors associated with prescribing antibiotics for emergency department (ED) outpatients with acute respiratory infections of likely non-bacterial etiology. Findings show that antibiotic use varied substantially between the two VAMCs studied and was particularly high for acute bronchitis (97% and 65%). Overall, 26% of the Veterans with upper respiratory infections (URIs) and/or acute bronchitis received antibiotics: 78% for acute bronchitis only, 57% for both infections, and 16% for URIs only. The following factors were associated with prescribing antibiotics for infections of likely non-bacterial etiology: presence of one or more comorbidities, fever, purulent sputum, shortness of breath, altered breath sounds, diagnosis of acute bronchitis, as well as non-internal medicine provider specialty and provider age older than 30.
Date: June 1, 2009
- Physicians More Likely than Mid-Level Providers to Initiate Treatment Change for Veterans with Diabetes and Elevated Blood Pressure
This study sought to examine whether treatment change for Veterans with diabetes and elevated blood pressure (BP) differed between physicians and mid-level providers (nurse practitioners, physician assistants), and to determine reasons for any observed differences. Findings show that mid-level providers were significantly less likely than physicians to change BP treatment for Veterans with diabetes and multiple chronic conditions, even after controlling for a number of patient, provider, and organizational characteristics. For example, after controlling for visit factors, provider practice style, measurement and organizational factors, mid-level providers were still less likely than physicians to initiate treatment change (37.5% vs. 52.5%) for elevated BP. Investigators also note that a fairly comprehensive set of potential explanatory variables did not account for any of the differences between physicians and mid-level providers.
Date: June 1, 2009
- Inhaled Corticosteroids Associated with Higher Glucose Levels in Veterans with Diabetes, but Effect was Dose-Dependent
This study examined the association between inhaled corticosteroids and glucose concentration among Veterans who received care at seven VA primary care clinics between 12/96 and 5/01. Of the 1,698 Veterans in this study, 19% also had self-reported diabetes. Findings show that after controlling for systemic corticosteroid use and other potential confounders, no association was found between inhaled corticosteroids and serum glucose for Veterans without diabetes. However, among Veterans with diabetes, every additional 100 mcg of inhaled corticosteroid dose was associated with increased glucose concentration. Given this association, authors suggest that clinicians anticipate an increase in serum glucose for patients with diabetes who are using inhaled corticosteroids and adjust serum glucose monitoring accordingly.
Date: May 1, 2009
- Men and Women Veterans Receive Equal Care for AMI in VA Hospitals
This study sought to describe the clinical characteristics, treatment, and survival in women Veterans compared with men admitted to VA hospitals for AMI between 10/03 and 3/05. Findings show that after adjusting for clinical characteristics, men and women Veterans treated for AMI in VA hospitals had similar levels of care and survival. There were no significant differences in the treatment provided to men and women Veterans, and cardiac catheterization was provided at equal rates (34.9% for men vs. 36.9% for women). Men did have higher mortality rates, but after adjusting for clinical characteristics this difference was no longer significant. In addition, significantly more men were prescribed aspirin and angiotensin-converting enzyme inhibitors, but there were no differences with regard to other platelet inhibitors, beta-blockers, or lipid-lowering medications.
Date: May 1, 2009
- Diffusion of New Drug Therapy for PTSD Lessens with Distance
This study sought to evaluate the pace and reach of the passive dissemination of a novel, but as yet un-established treatment with the drug prazosin for post-traumatic stress disorder (PTSD) within the VA health care system. Investigators used geographic surveillance data to track the diffusion of prazosin to treat Veterans diagnosed with PTSD in the VA Puget Sound Healthcare System (where the treatment was developed), and at VAMCs ranging up to 2500 miles or farther from Puget Sound. Findings show that the passive diffusion of a new treatment can be rapid in the immediate area in which it is developed, but the geographic gradient of use seems to be steep and changed little during a two-year period, even when cost and organizational barriers were minimal. Veterans with PTSD treated in the area nearest to Puget Sound (<499 miles) were about 63% less likely in 2004 and about 49% less likely in 2006 to be prescribed prazosin than their counterparts treated within Puget Sound. These results suggest that if and when new treatments are definitively demonstrated to be effective, more active dissemination is likely to be needed, especially in geographically remote areas.
Date: April 1, 2009
- Adapting Pharmaceutical Company Strategies to Improve Physician NSAID Prescribing Behaviors
This study sought to describe the social and communicative strategies that pharmaceutical companies use to influence non-steroidal anti-inflammatory drug (NSAID) prescribing behaviors – and to elicit physicians’ perceptions and counterbalances to these strategies. Physicians described several strategies used by pharmaceutical companies to influence their NSAID prescribing behaviors, including detailing and direct contact with pharmaceutical representatives, requests from patients inspired by direct-to-consumer advertisements, and marketing during formative medical school and residency training. Practice guidelines and peer-reviewed evidence, as well as local physician experts were viewed as important counterbalances to the influence of pharmaceutical companies.
Date: April 1, 2009
- Neither Warfarin nor Clopidogrel Superior to Aspirin as Antiplatelet Therapy for Chronic Heart Failure
The Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) Trial was conducted to determine the optimal anti-thrombotic agent for heart failure patients with reduced ejection fraction who are in sinus rhythm. WATCH Trial findings do not support the primary hypotheses that warfarin or clopidogrel is superior to aspirin. For the primary combined outcome of mortality, non-fatal MI, or non-fatal stroke, major differences between anticoagulation with warfarin and anti-platelet therapy with aspirin or clopidogrel are unlikely. Warfarin was associated with fewer non-fatal strokes than aspirin or clopidogrel, but also was associated with more frequent bleeding episodes compared to clopidogrel, and a non-significant excess of bleeding compared to aspirin.
Date: March 31, 2009
- Primary Care-Based Collaborative Care for Chronic Pain May Be More Effective than Usual Care
A primary care-based collaborative care intervention for chronic pain was significantly more effective than usual care across a variety of outcome measures, including pain disability and intensity. However, these improvements were generally modest. Depression severity and pain disability and intensity improved among Veterans in the intervention group who reported both chronic pain and depression. Greater use of adjunctive pain medications and long-term opioids among the intervention group suggested that the intervention contributed to the delivery of guideline-concordant care.
Date: March 25, 2009
- Study Compares PCI Strategies to Medical Therapy in Patients with Non-Acute CAD
This study compared medical therapy (e.g., lifestyle modifications, medication) to various percutaneous coronary intervention (PCI) strategies in the treatment of patients with non-acute coronary artery disease (CAD). Findings show that while bare metal stents and drug-eluting stents yielded increased improvements in diminishing the need for revascularization, innovations in PCI technologies have not improved outcomes (i.e., incidence of myocardial infarction, mortality) compared to medical therapy.
Date: March 14, 2009
- Concomitant Use of Clopidogrel and Proton-Pump Inhibitors after ACS is Associated with Higher Risk of Adverse Outcomes
Proton-pump inhibitors (PPI) were frequently prescribed with clopidogrel (63.9%) for Veterans following hospitalization for acute coronary syndrome (ACS); the concomitant use of clopidogrel and PPI was associated with a higher risk of adverse outcomes compared to the use of clopidogrel alone. The combined primary outcome of mortality or re-hospitalization occurred in 20.8% of Veterans prescribed clopidogrel only, and in 29.8% of Veterans prescribed clopidogrel and PPI. Among secondary outcomes, Veterans taking clopidogrel and PPI also had a higher risk of recurrent hospitalization for ACS and revascularization procedures. Longer duration of clopidogrel plus PPI treatment was associated with adverse outcomes, suggesting that time on combination treatment is important. Pending further studies to confirm results and prospectively assess cardiovascular outcomes for Veterans taking clopidogrel and PPI versus clopidogrel alone, these results may suggest that PPIs should be used for patients with a clear indication for the medication, rather than prophylactically.
Date: March 4, 2009
- Research Agenda for Oral Anticoagulation Quality Measurement
Efforts to measure the quality of oral anticoagulation care have focused disproportionately on the identification of ideal candidates for warfarin therapy, with little effort in measuring the quality of oral anticoagulation once therapy has begun. To address this knowledge gap, investigators propose a research agenda to advance our understanding of how to measure the quality of care in oral anticoagulation. Authors propose that valid quality indicators will provide a framework for quality improvement that will maximize the effectiveness of therapy and minimize patient harm.
Date: March 1, 2009
- Panel Reaches Consensus on Oral Dosing for Primarily Renally Cleared Medications in Older Adults
Chronic kidney disease (CKD) is a growing public health problem that disproportionately affects older adults. Medications are the most frequently used therapy for the management of CKD-related problems in older adults, but they are often prescribed in inappropriate doses. This study sought to establish consensus dosing guidelines for primarily renally cleared oral medications commonly taken by older adults with renal insufficiency. An expert panel was able to reach consensus agreement on 18 oral medications that are primarily renally cleared, including anti-infectives and central nervous system medications.
Date: February 1, 2009
- Prescribing Discrepancies during Patient Transfer May Result in Adverse Drug Events
The objective of this study was to examine medication discrepancies related to adverse drug events (ADEs) in nursing home patients transferred to and from the hospital. Findings show that less than 5% of discrepancies caused ADEs, which is consistent with reviews that suggest only a small fraction of errors result in harm. Authors note that information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients, and inform the development of decision-support tools at the time of patient transfer.
Date: February 1, 2009
- Increase in VA Prescription Co-Pay Leads to Decrease in Adherence to Statins for Veterans at Risk of Heart Disease
VA’s increase in drug co-payments from $2 to $7 adversely affected lipid-lowering medication adherence among Veterans, including those at high risk of coronary heart disease. After the increase in medication co-payments, the percent of Veterans who were adherent to lipid-lowering therapy declined significantly, even for Veterans with no co-pay. The co-payment increase was also accompanied by a significant increase in the likelihood of having continuous gaps in lipid-lowering medication use.
Date: January 27, 2009
- Transparency Standards for Diabetes Performance Measures
The development and adoption of performance measures must be transparent. Transparency has been defined as “a process by which information about existing conditions, decisions and actions is made accessible, visible and understandable.” This JAMA Commentary discusses several examples of transparency that might help guide the development of hemoglobin A1c performance measures in the future. Authors suggest that, considering the potential effect on millions of patients and the high cost of antiglycemic medications alone, the upfront investment in ensuring evidence-based, transparently developed performance measures would be worthwhile to protect the public health and restore public and professional confidence.
Date: January 14, 2009
- Lessons Learned from Deceptive Marketing of Neurontin™
Recent lawsuits alleging injury from the illegal marketing of gabapentin (Neurontin™) have yielded remarkable discoveries about the structure and function of pharmaceutical marketing. This article summarizes the marketing tactics used and offers actions to prevent similar occurrences.
Date: January 8, 2009
- Study Suggests Changes Needed in Warfarin Dosing
The lack of evidence regarding optimal management strategies for warfarin probably contributes to limited success in maintaining patients within the target International Normalized Ratio (INR) range (system used to report testing for coagulation). Findings from this study show that providers vary widely in their dose change thresholds in similar clinical situations and that the INR value was by far the most important predictor of dose change. Authors suggest that in addition to offering warfarin to as many optimal candidates as possible, we also need to optimize warfarin dose management to fully realize the benefits of anticoagulation.
Date: January 1, 2009
- Controlling Medicare Costs: Study Suggests VA-Administered Drug-Only Benefit for Veterans Enrolled in Medicare
This article discusses the role of interest groups in drug-plan policy differences between Medicare and VA. Authors suggest a partnership between Medicare and VA that could provide access to the VA drug benefit to a large number of Medicare-enrolled veterans who do not currently have it.
Date: December 1, 2008
- ACE Inhibitors May Benefit Patients with Pneumonia
Prior outpatient use of lipophilic, but not hydrophilic ACE inhibitors was associated with decreased 30-day mortality for patients hospitalized with community-acquired pneumonia. Study results also provide further support demonstrating that ACE inhibitor use, in general, is associated with decreased mortality for patients with pneumonia.
Date: December 1, 2008
- Treatments for Co-Occurring Schizophrenia and Substance Use Disorders
While studies to date suggest better outcomes with second-generation antipsychotics (SGAs), for example, olanzapine and risperidone, the available evidence does not clearly demonstrate an advantage for any particular SGA; thus investigators recommend that clinicians select the medication that balances efficacy and side effects for each individual patient.
Date: October 1, 2008
- Mortality Risk Associated with Respiratory Medications in Veterans with Newly Diagnosed COPD
Inhaled corticosteroids and long-acting beta-agonists were associated with a reduction in the odds of all-cause death. Ipratropium was associated with an 11% increase in the risk of death.
Date: September 16, 2008
- Veteran Perceptions of In-Home Medication Dispensing Devices
No significant differences were found across types of devices in the perceived likelihood that using the device would improve medication adherence. Moreover, even if VA paid for the devices, patient participants reported that they would be unlikely to use them.
Date: July 1, 2008