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Publication Briefs
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  • 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
  • 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
  • Evidence Review Identifies Modest Mortality Disparities among Racial and Ethnic Minority Groups in VA Healthcare
    To support VA’s efforts to better understand the scale and determinants of disparities in racial and ethnic mortality – and to develop interventions to reduce disparities, investigators from the VA Evidence-based Synthesis Program (ESP) Coordinating Center in Portland, OR conducted an evidence review of mortality disparities specific to VA. Findings showed that although VA’s equal access healthcare system has reduced many racial/ethnic mortality disparities still present in the private sector, modest mortality disparities persist mainly for black Veterans with conditions that include: stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, and stroke. There also were modest disparities in mortality for American Indian and Alaska Native Veterans undergoing major non-cardiac surgery, and for Hispanic Veterans with HIV or traumatic brain injury.
    Date: March 1, 2018
  • 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
  • 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
  • Study Compares Stroke Care in VA Community Living Centers with Private, VA-Contracted Nursing Homes
    This study is part of a larger investigation comparing the use and functional outcomes between Veterans in VA community living centers (CLCs) and VA-contracted community nursing homes (CNHs). Findings showed that compared with Veterans residing at CNHs, Veterans residing at CLCs had fewer average rehabilitation therapy days (both adjusted and unadjusted), but were significantly more likely to receive restorative nursing care. For rehabilitation therapy, Veterans in CLCs had lower user rates (75% vs. 76%) and fewer observed therapy days (4.9 vs. 6.4) compared to Veterans in CNHs. For restorative nursing care, Veterans in CLCs had higher user rates (34% vs. 31%), more observed average care days (9.4 vs. 5.9), and more adjusted days for restorative nursing care.
    Date: March 1, 2016
  • Incident Stroke Associated with Accelerated and Persistent Cognitive Decline Over Six Years Post- Stroke
    This prospective study measured changes in cognitive function among survivors of incident stroke, controlling for their pre- stroke cognitive trajectories. Findings showed that incident stroke was associated with an acute decline in cognitive function and accelerated and persistent cognitive decline over a median follow-up of six years. Incident stroke was associated with significant acute declines in new learning and verbal memory after the event. Executive function (e.g., remembering details, managing time) also declined significantly faster post- stroke compared to pre- stroke.
    Date: July 7, 2015
  • 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
  • Penetrating Traumatic Brain Injury Strongly Associated with Risk of Epilepsy among OEF/OIF Veterans
    This study examined the association between epilepsy and TBI, including penetrating TBI (pTBI), in OEF/OIF Veterans. Findings showed that epilepsy was associated with previous TBI diagnosis. The estimated risk of epilepsy among Veterans with pTBI was nearly 18 times greater than among those without TBI, even after controlling for other factors. When examined separately, risk for epilepsy was also elevated among Veterans with severe, moderate, and mild TBI. Even among this relatively young group of Veterans, stroke was one of the strongest risk factors for epilepsy. Veterans with epilepsy also were more likely to be younger than 50 years and white, and were more likely to have previously diagnosed substance use disorder, depression, anxiety, bipolar disorder, schizophrenia, and PTSD than those without epilepsy. Headache, cardiac conditions, cerebrovascular disease, and cognitive impairment/dementia were also epilepsy risk factors. An increasing burden of epilepsy in this Veteran population is likely. These Veterans should be followed closely, and systems of care, such as VA Epilepsy Centers of Excellence, should be prepared to provide epilepsy specialty care.
    Date: April 1, 2014
  • Veterans with Multiple Chronic Conditions Account for Disproportionate Share of VA Healthcare Costs
    This study examined the association between number of chronic conditions and costs of care for non-elderly (<65 years) and elderly Veterans (=65 years) within the VA healthcare system – and estimated VA expenditures for the most prevalent and costly combinations of three conditions (triads). Findings showed that Veterans with multiple chronic conditions account for a disproportionate share of VA healthcare costs. Almost one-third of non-elderly and slightly more than one-third of elderly VA patients had >3 conditions, but they accounted for 65% and 67% of total VA healthcare costs, respectively. The most common triad of chronic conditions for both non-elderly and elderly Veterans was diabetes, hyperlipidemia, and hypertension (24% and 29%, respectively). Conditions present in the most costly triads included: spinal cord injury, heart failure, renal failure, ischemic heart disease, peripheral vascular disease, stroke, and depression. While patients with the most costly triads had average costs that were three times higher than average costs of patients in other triads, the prevalence of these costly triads was extremely low (0.1 to 0.4%). These findings highlight the need for interventions that target the sickest patients who have high resource use to provide more cost-effective care.
    Date: March 1, 2014
  • “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
  • 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
  • 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
  • TeleRehab Improves Physical Function in Veterans with Stroke
    This trial sought to determine the effects of a multi-faceted Stroke Tele-Rehabilitation (STeleR) intervention on physical function, and secondarily on disability, in community-dwelling Veterans who had experienced a stroke within the past two years. The STeleR intervention significantly improved lower body physical functioning in Veterans with stroke. Most gains in physical functioning and other improvements occurred during the initial 3 months of the study, but were maintained during the subsequent 3 months during which no STeleR services were provided. The STeleR intervention also improved Veterans’ ability to perform life tasks such as “take part in regular fitness program” and management of social tasks that involve minimal mobility or physical activity, such as “take care of own health.” The authors suggest the STeleR intervention could be a useful supplement to traditional post- stroke rehabilitation given the limited resources available for in-home rehabilitation for stroke survivors.
    Date: May 24, 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
  • Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008
    This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care.
    Date: December 1, 2011
  • 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
  • Dementia More Prevalent among Older Veterans with PTSD
    This study sought to determine the association between PTSD and dementia in older Veterans. Findings show that older Veterans with PTSD had twice the incidence and prevalence of dementia diagnoses, even after accounting for confounding illnesses, combat-related trauma (measured by receipt of a Purple Heart), and number of primary care visits. Rates of TBI were highest in the group with PTSD and a Purple Heart, while rates of stroke were slightly higher among all groups with PTSD (regardless of Purple Heart receipt). The prevalence of drug dependence and abuse and the rates of alcohol dependence and abuse were highest in the group with PTSD, but without a Purple Heart. The mechanism for the observed increased incidence and prevalence of dementia among Veterans with PTSD is unknown. Possibilities include a common risk factor underlying PTSD and dementia, or PTSD being a risk factor for dementia. Regardless, the authors suggest that veterans over 65 years of age with PTSD be considered for dementia screening.
    Date: September 1, 2010
  • Processes of Care to Improve Stroke Outcomes
    After adjusting for patient characteristics and other processes of care, three processes of care were independently associated with a reduction in the combined outcome: 1) swallowing evaluation, 2) deep vein thrombosis (DVT) prophylaxis, and 3) treating all episodes of hypoxia with supplemental oxygen. Two of the three processes (swallowing evaluation, DVT prophylaxis) are similar to existing stroke quality measures, but the treatment of hypoxia is not a current performance measure. Thus, authors recommend that organizations that establish national performance measures add treatment of hypoxia to their assessment of stroke care quality, and continue to measure DVT prophylaxis and swallowing assessment among stroke patients.
    Date: May 10, 2010
  • Strategies to Reduce Sodium Intake Likely to Decrease Stroke and Heart Disease, and Save Billions in Costs
    Using a mathematical model, investigators examined the cost-effectiveness of two governmental strategies to reduce sodium intake in the U.S.: 1) government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience; and 2) a tax on sodium. Findings show that strategies to reduce sodium intake on a population level are likely to substantially reduce the incidence of stroke and myocardial infarction, saving billions of dollars in medical expenses.
    Date: March 1, 2010
  • VA Provides Broader Variety of Assistive Technologies for Veterans with Stroke at Lower Cost
    Findings from this study suggest that VA provides a broader variety of assistive technology devices (ATDs) at a lower cost than Medicare. In specific ATD comparisons, VA costs were substantially lower than Medicare for purchased items, and slightly lower than Medicare for capped rental payments. More than half of the ATDs provided by VA were ADL-related, compared to only 11% provided by Medicare. Findings also showed that 39% of the cohort had not received an ATD of any kind, while 56% received ATDs from VA only, 3% received ATDs from both systems, and 1% received an ATD from Medicare only. Analyses suggest that VA policy in providing ATDs is driven by Veterans’ needs, whereas Medicare policy may be driven, in part, by cost-containment needs associated with increases in fraudulent claims.
    Date: February 1, 2010
  • Review Suggests PTSD Negatively Impacts Physical Health but More Research Needed
    In this systematic review, investigators searched case reports, comparative studies, meta-analyses, and review articles that examined the relationship between PTSD and specific physical-health diagnoses. Findings suggest that PTSD can have negative effects on physical health, but evidence regarding its association with specific physical disorders is lacking. Evidence suggests a significant association between PTSD and musculoskeletal disorders, especially participant report of arthritis, in the general population – but not in Veterans. There also was an association between PTSD and digestive disorders, particularly ulcers, among non-Veterans. The rest of the associations were either found in single studies or are conflicting, particularly in regard to diabetes, congestive heart failure, and stroke. Authors suggest that large, prospective epidemiological trials are needed to examine the relationship between PTSD and physical illness.
    Date: June 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
  • Using VA Medical Data Alone May Underestimate Post- Stroke Depression and Geographic Variation in this Condition
    When VA medical data alone were used, investigators found no significant geographic variation in the detection of post- stroke depression (PSD). But when VA medical data were used along with Medicare and VA pharmacy data, significant geographic variation (nearly double – 39.1% vs. 20.0%) was observed. This suggests that to gain a comprehensive view of PSD detection in VA patients, investigators must evaluate non-VA data sources because 70% of VA stroke patients were multiple health program users.
    Date: December 1, 2008
  • Early Invasive Strategy Associated with Improved Clinical Outcomes for Patients with STEMI after Fibrinolytic Therapy
    An early invasive strategy was associated with significant reductions in mortality and re-infarction for patients with ST-segment elevation myocardial infarction (STEMI) compared with ischemia-guided management. There were no significant differences in the risk of stroke or major bleeding.
    Date: September 1, 2008

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