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Veterans’ Perceptions of VA Healthcare by Race and Sex
Investigators in this qualitative study focused on examining how Veterans’ perceptions of VA healthcare may differ by race and sex. Findings showed that, overall, there were differences in the perceived quality of interactions within the VA healthcare system by race and sex, with more positive experiences more likely to be reported by Veterans of White race and male sex. Some positive responses were salient across race and sex, including “good medical care” and telehealth as a “comfortable/great option,” as were some negative items, including “long waits/delays in getting care” and “transportation/traffic challenges.” Associations of VA with anxiety, stress, and fear were salient for all groups. However, it is unclear whether these were responses to extraordinary circumstances during the pandemic or were more deeply rooted experiences with VA care. Courtesy and respect were salient for White but not Black Veterans – and men but not women. While telehealth was seen as a good option, the perception of technology problems differed by race (reported by Black Veterans) and sex (reported by men), suggesting a digital divide. Divergent experiences of interpersonal care by race and sex provide insights for improving equitable, patient-centered VA healthcare.
Date: February 19, 2024
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Wide VA Facility-Level Variation in Anticoagulation for Veterans with Atrial Fibrillation, Including by Race
This study sought to assess variation in anticoagulant initiation by race across 82 VA facilities. Findings showed that there was large (>28 percentile point) facility-level variation in any anticoagulant and direct oral anticoagulant therapy initiation, overall and by race. Overall unadjusted rates of any anticoagulant therapy ranged from 57% to 87% across facilities; corresponding rates for Black and White patients were 48% to 91% and 58% to 87%, respectively. Racial disparities in anticoagulation in excess of 10 percentile points were found in nearly one-quarter of VA facilities, though most facilities did not demonstrate a statistically significant difference in prescribing between Black and White Veterans. These findings may represent a target to reduce prescribing inequities and improve atrial fibrillation care.
Date: February 2, 2024
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Veterans with a Racial/Ethnic Minority Background, Rural Residence, or Mental Health Disability History Were Less Likely to Complete Preoperative Goals of Care Documentation
This study assessed factors – including race, ethnicity, rurality, history of mental health disability, and VA facility type – that are known or hypothesized to be linked with disparities in preoperative life-sustaining treatment (LST) documentation. The study also described the COVID-19 pandemic’s effect on completion of preoperative LST. Findings showed that Veterans with a racial or ethnic minority background, rural residence, mental health disability history, or who were seen at low-complexity, low-volume facilities were significantly less likely to complete preoperative LST compared to Veterans who were white or non-Hispanic, urban residents, without a mental health disability history, or who had access to a high-complexity, high-volume facility. Of the 229,737 Veterans in the cohort, 13,408 (6%) completed preoperative LST documentation within 30 days prior to surgery. With each passing year, Veterans undergoing surgical procedures had greater likelihoods of completing LST before surgery, including during the COVID-19 pandemic. Findings suggest there is continued need for interventions that target Veteran groups at risk of not engaging in serious illness communication.
Date: December 19, 2023
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Study Suggests Racial Inequalities in VA Pancreatic Cancer Care
This study examined whether there were significant racial disparities in the continuum of pancreatic cancer care in the VA system, hypothesizing that there would be no racial disparities in the receipt of pancreatic cancer care among Black and White Veterans. Findings showed that even in a healthcare system with equal access to care, racial inequalities exist in the timing of pancreatic cancer diagnosis and receipt of treatment. Black Veterans were 19% more likely to have late-stage disease and 25% less likely to undergo surgical resection. After adjusting for sociodemographic characteristics and medical comorbidities, Black Veterans had 13% higher mortality risk compared to White Veterans. However, this was no longer statistically significant after additionally adjusting for cancer stage and receipt of potentially curative treatment.
Date: November 13, 2023
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Equal-Access Healthcare Is Associated with Significantly Improved Clinical Outcomes in Black and Hispanic Veterans with Prostate Cancer
This study examined clinical outcomes by race and ethnicity in Veterans with nonmetastatic castration-resistant prostate cancer (nmCRPC). Findings showed that among patients with nmCRPC in VA—an equal-access system—self-identified Black and Hispanic men had better clinical outcomes than White or other patients, including time to metastasis and overall survival. Median time elapsed from nmCRPC to metastasis or death was 5.96 years for Black Veterans, 5.62 years for Hispanic Veterans, 4.11 years for White Veterans, and 3.59 years for other Veterans. Median unadjusted overall survival was 6.26 years among all Veterans, 8.36 years for Black Veterans, 8.56 years for Hispanic Veterans, 5.48 years for White Veterans, and 4.48 years for other Veterans. Findings provide evidence that the racial and ethnic disparities long observed in prostate cancer might stem from systemic socioeconomic inequity rather than molecular or genetic factors. Black and Hispanic men may have considerably improved outcomes when treated in an equal-access setting.
Date: October 11, 2023
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Despite Equal Access and Use of VA Care, Black Veterans are More Likely to Experience Postpartum Rehospitalization and Low-Birthweight Infants
This study sought to determine whether Black/white racial disparities in access, use, and outcomes are present among pregnant and postpartum Veterans and their infants using VA maternity care. Findings showed no statistically significant racial disparities in access or use of care during the perinatal period; nevertheless, Black Veterans were more likely than white Veterans to experience postpartum rehospitalization and to have a low-birthweight infant. After adjusting for age, rurality, and parity, Black Veterans were 67% more likely than white Veterans to have a postpartum rehospitalization and 67% more likely to have a low-birthweight infant. No other racial disparities in outcomes for birthing Veterans or their infants were detected. Approximately one-third of both Black and white Veterans reported needing mental healthcare during pregnancy. However, one in five Veterans were unable to access needed mental healthcare indicating there may be a persistent unmet need for perinatal mental healthcare. Study findings underscore the idea that access is necessary but not sufficient for ensuring health equity.
Date: July 1, 2023
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Significant Racial Disparities Found in VA Uterine Fibroid Treatment
This study examined differences in uterine fibroid (UF) treatment among Black and White Veterans in VA, including variation by UF severity as indicated by anemia. Findings showed that there were significant Black-White disparities in receipt of any treatment for symptomatic UF. Across age and UF severity subgroups, Black Veterans were less likely than White Veterans to receive any treatment. Racial disparities were most pronounced among Veterans with severe UF as indicated by anemia (<45 years: 60% of Black Veterans vs 71% of White Veterans received any treatment; >45 years: 46% of Black Veterans vs 67% of White Veterans received any treatment). Across age groups, among those who received any treatment, Black Veterans were less likely than White Veterans to have hysterectomy and more likely to have a fertility-sparing treatment as their first treatment. These disparities may indicate delays in care among Black Veterans, differential ability to access desired treatments, and/or differential or biased care.
Date: July 1, 2023
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Early Months of Pandemic Increased Overall Death Rates Comparably for General Population and Veterans
This study sought to quantify excess all-cause mortality during the first nine months of the COVID-19 pandemic among Veterans compared with the general US population. Findings showed that in 2020, 85% of the overall increase in the US death rate was directly associated with COVID-19. Comparable data are not yet available for VA. Veterans receiving VA healthcare had similar relative increases in mortality compared with the general US population during the first 9 months of the COVID-19 pandemic. However, the absolute pre-pandemic death rate was higher among VA patients, which translated to higher absolute excess death rates among Veterans. The relative increase in deaths was smaller among the White population than in other racial and ethnic groups. These patterns were consistent between the general and VA populations, but the disparities were less pronounced in VA, particularly among young age groups.
Date: May 8, 2023
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Most Veterans Support Integration of Standardized Suicide Risk Assessment into Routine Primary Care Visits
This study sought to characterize VA primary care patients’ perspectives regarding population-based suicide risk screening through the Risk ID program – a multi-stage suicide risk assessment process, which includes initial screening (the focus of this analysis) and subsequent evaluation when indicated (following a positive screen). Findings showed that most Veterans support integration of standardized suicide risk assessment into routine primary care visits. More than 90% of Veterans reported that it is appropriate for primary care providers or nurses/medical assistants to ask Veterans about suicidal thoughts during these visits. And approximately half indicated that Veterans should be asked about suicidal thoughts at every visit. Qualitative findings revealed that while most Veterans were generally supportive of VA screening for suicidal thoughts, they also expressed concern for the potential for inadvertent harm (i.e., repeated screening could turn into “white noise”). They also noted that question wording, body language, and care team role affected whether the process was a positive or negative experience. Additional guidance or training for staff conducting suicide risk screening may be warranted to ensure Veterans feel heard (e.g., eye contact, expressing empathy) and increase patient understanding of the purpose of the screening and potential outcomes.
Date: March 20, 2023
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Black and Hispanic Veterans Experienced Greater Access Barriers to VA Care During Pandemic
This study sought to determine whether wait times increased differentially for Black and Hispanic compared with White Veterans for VA outpatient orthopedic and cardiology services from the pre–COVID-19 to COVID-19 periods. Findings showed that national wait time disparities increased significantly for Black and Hispanic Veterans for orthopedic services. During the COVID-19 period, Black and Hispanic Veterans’ mean wait times exceeded those of White Veterans by 2.45 days for Black Veterans and 1.98 days for Hispanic Veterans. There were only modest national disparities for cardiology services (<1-day difference). There was variation in wait times across the 140 VA facilities. For example, pre-COVID, there were Black/White differences for cardiology at 6 facilities (Black Veterans waited longer at 4 facilities, White Veterans waited longer at 2 facilities). During COVID, 21 facilities had Black/White differences for cardiology (Black Veterans waited longer at 14 facilities, while White Veterans waited longer at 7 facilities). Although differences in wait times were only a few days, any wait time disparity is concerning. It will be important for future work to monitor these trends, understand their sources, and implement appropriate interventions as needed. Findings also underscore the critical importance of facility-level analyses for highlighting opportunities to reduce disparities and target quality improvement efforts.
Date: January 23, 2023
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QUERI Investigators Develop and Refine Evidence Assessment Checklist to Help VA Comply with Evidence Act Requirements
In January 2021, the White House released the Memorandum on Restoring Trust in Government Through Scientific Integrity and Evidence-Based Policymaking, which directed federal cabinet-level agencies to establish scientific integrity policies and procedures – and provided guidance for supporting policy decisions with evidence, as required by the Foundations for Evidence-based Policymaking Act of 2018 (Evidence Act). QUERI was tasked with assisting VHA leadership with implementing the Evidence Act – and focused on the processing and approval of legislative and budget proposals. Through this, QUERI investigators learned that no systematic process existed to evaluate the supporting evidence base for proposals. To address this gap, investigators created a checklist to assess the strength of evidence included in VHA legislative and budget proposals. This article describes the development, refinement, and use of the checklist to assess the strength of evidence included in VHA legislative and budget proposals.
Date: November 1, 2022
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Increased Access to VA-Paid Community Care Resulted in Shift in Location of Surgery but No Difference in Outcomes for Veterans
VA’s Veterans Choice Program (VCP) expanded access to healthcare in community settings outside VA for eligible Veterans, but little is known about the effect of VCP on access to surgery and post-operative outcomes. This study explored the healthcare use of Veterans undergoing either VA-provided or VA-paid surgery (i.e., community care) between October 1, 2014, to June 1, 2019, when VCP ended. Findings showed that expanded access to VA healthcare resulted in a shift in the location of surgical procedures but had no measurable effect on surgical outcomes. Investigators found no difference in post-operative ED visits, inpatient readmissions, or mortality between VA-provided and VA-paid surgical procedures done in a community setting. Patients who underwent VA-paid vs. VA-provided procedures were significantly more likely to be female (13% vs. 9%), younger than 65 (49% vs. 46%), and White (74% vs. 73%), and they had a significantly lower comorbidity burden. Overall, 15% of the procedures were VA-paid (community care), and the proportion of VA-paid procedures varied by procedure type (e.g., spinal fusion and knee prosthesis had higher proportions of VA-paid care). Results emphasize the importance of access to community care and help assuage concerns of worsened outcomes due to care fragmentation. However, study results are less applicable to some select procedures (i.e., transplant, gastric bypass, or transcatheter aortic valve replacement), and VA should continue to make these decisions on a case-by-case basis.
Date: October 12, 2022
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Pulse Oximetry More Likely to Miss Hypoxemia in Black Veterans than White Veterans Among General and Surgical Inpatients
The objective of this study was to evaluate measurement discrepancies by race between pulse oximetry and arterial oxygen saturation as measured in arterial blood gas among inpatients not in the intensive care unit. Findings showed a significant difference in the ability of pulse oximetry to detect clinically relevant hypoxemia in patients of different races. Black Veterans had higher odds than white Veterans of having occult hypoxemia noted on arterial blood gas but not detected by pulse oximetry (unadjusted rates of 20% vs 16%, respectively). The absolute adjusted probability of occult hypoxemia was 4% higher in Black Veterans than in White Veterans. Measurements of racial differences in occult hypoxemia were not sensitive to differences in the timing of the arterial blood gas and the recorded pulse oximeter readings, up to at least 10 minutes apart. There may be a role for large integrated health systems, such as VA, to use only pulse oximeters proven to provide equivalent accuracy in Black patients rather than devices of unproven equity.
Date: July 6, 2022
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Documented Clinical Diagnoses Underestimate Prevalence of Substance Use Disorders in Younger, Hispanic, and Women Veterans
This study compared clinical diagnosis rates of alcohol use disorder (AUD), drug use disorder (DUD), and total SUD (AUD and/or DUD) to survey-based prevalence among a random sample of VA patients from 30 VA healthcare facilities. Findings showed that the survey-based prevalence of AUD, DUD, and SUD was generally higher than clinical diagnosis rates among all Veterans: 10% vs 6% for AUD, 4.7% vs 4.6% for DUD, and 13% vs 9% for SUD. The survey-based prevalence of AUD and SUD exceeded clinical diagnosis rates in every demographic subgroup. For DUD, the greatest levels of clinical underdiagnosis/under-recognition were seen in the youngest age group and among those reporting White race/ethnicity. For SUD overall, the greatest levels of under-recognition were for women, youngest and oldest age groups, and those reporting Hispanic ethnicity. For AUD, the greatest levels of under-recognition were among women, youngest and oldest age groups, persons of “other” race/ethnicity, and White persons. Documented clinical diagnoses are insufficient to capture the prevalence of SUD, particularly for women, younger, and Hispanic/Latinx patients, the latter of whom may often experience the greatest consequences of SUD.
Date: June 30, 2022
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Black Veterans with Chronic Kidney Disease Experience Racism in the Healthcare Setting, Resulting in Stress and Distrust
This study investigated the healthcare experiences of Black Veterans with chronic kidney disease to assess any discrimination faced by this vulnerable population. Findings showed that these Veterans experienced racism in the healthcare setting resulting in physical and emotional stress and distrust in the healthcare system. Some Veterans also expressed a need to be hypervigilant during the clinical encounter. Veteran comments included: “…it seemed like everything I asked her about, ‘Oh, don’t worry about that. Don’t worry.’ I said, “What do you mean don’t worry about that? I’m concerned about it.” ‘But I tell you when you need to worry.’ “So, I got rid of her.” (patient switched to a different provider) “I just watch how… the interaction with other patients that are White. They may spend time with them, talking with them, this or that… less time with me or the other African Americans that are in the clinic.” When encountering racism, Veterans described both negative (e.g., hypervigilance) and positive (e.g., faith) coping strategies. Talking and sharing stressful events with family was also a major source of support for respondents.
Date: May 12, 2022
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Genetic Consultation Provided by VA Facilities or Centralized VA Virtual Care More Timely and Better Coordinated than Community Care Options
This study assessed care coordination and equity in the delivery of genetic care for the care models available to VA patients (i.e., VA-traditional, centralized VA-telehealth, and non-VA care). Findings showed that VA genetic care models – both traditional and centralized telehealth – had better care coordination than non-VA care. Veterans referred to non-VA care completed their consult only 57% of the time compared with 75% if referred to the VA-traditional model and 73% with the centralized VA-telehealth model. Completion of a genetic consultation if referred to non-VA care was almost 3 times longer than with either VA model (140 days vs 55 days for VA-traditional and 45 days for VA-telehealth). The centralized VA-telehealth model was associated with exacerbated healthcare disparities based on self-reported race or ethnicity and gender compared with the VA traditional model. Veterans reporting their race as Asian, American Indian, Alaskan Native, Hawaiian and other Pacific Islander, and unknown were 46% less likely to be referred to the centralized VA-telehealth model compared to the VA-traditional model. Black Veterans were significantly less likely to complete a consultation compared to White Veterans, but only if referred to the centralized VA-telehealth model. Women Veterans were 50% more likely to be referred to the centralized VA-telehealth model than the VA traditional model. VA should assess structural barriers to using centralized telehealth services and the needs and preferences of vulnerable subpopulations in order to find solutions that mitigate health disparities and improve access.
Date: April 11, 2022
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Rapid Response to Executive Order by HSR&D Investigators Leads to Widespread Adoption of Suicide Prevention Strategies
As part of the response to Presidential Executive Order #13861, this study analyzed a large body of text responses collected as a federal Request for Information (RFI) to uncover gaps in policy and practice across the U.S. in order to more effectively address and prevent suicide among Veterans. Findings identified unique barriers to care, in addition to ways in which data and research could be better aligned to improve outcomes. For example, Veterans need a greater connection to the community when they transition from military service and they want healthcare professionals who understand and/or have experience with military culture. Metrics for evidence-based risk prevention and treatment methods need to incorporate Veterans’ perspectives to ensure suicide prevention efforts address their needs and concerns. VA used the findings and policy opportunities identified from this RFI analysis to contribute to the development of The PREVENTS Roadmap with recommendations and implementation steps for suicide prevention. Thus far, the governors of 42 states and territories have submitted state proclamations to support the PREVENTS campaign and follow strategies outlined within the report. The HSR&D “QUICk: A Qualitative Interdisciplinary Collaboration” method developed for this study has been submitted for VA invention disclosure and could be useful for other researchers to address similar public requests for information or to help analyze other types of qualitative data to fulfill research mandates.
Date: March 3, 2022
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Changes in the Association between Race and Urban Residence with COVID-19 Outcomes among Veterans
This study examined whether key sociodemographic and clinical risk factors for COVID-19 infection and mortality changed between February 2020 and March 2021 among more than 9 million Veterans enrolled in VA healthcare. Findings showed that strongly positive associations of Black race, American Indian/Alaska Native (AI/AN) race, and urban residence with COVID-19 infection, mortality, and case fatality that were observed early in the pandemic attenuated over time. The magnitude of the association between Black (vs. White) race and COVID-19 infection or mortality declined steadily from February/March 2020 to November 2020, when it was no longer significant. The association between AI/AN (vs. White) race and COVID-19 infection declined steadily over time to a negative association in March 2021. Similarly, the association between urban vs. rural location and COVID-19 infection or mortality also declined steadily over time, shifting from a positive association in February/March 2020 to a negative association in September/October 2020 and to a non-significant association in March 2021. Throughout the study period, high comorbidity burden, younger age, Hispanic ethnicity, and obesity were consistently associated with COVID-19 infection, while high comorbidity burden, older age, Hispanic ethnicity, obesity, and male sex were consistently associated with mortality. Understanding changing patterns of risk factors could be important in informing population-based approaches to prevent infection and reduce mortality by targeting those at highest risk at any given time during the course of an evolving pandemic.
Date: October 21, 2021
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Receipt of COVID-19 Vaccine is Higher among Racial/Ethnic Minorities than Whites within VA Healthcare System
VA began administering COVID-19 vaccinations shortly after the US rollout began, allowing for an examination of vaccination rates among racial/ethnic minorities in an integrated healthcare system with few barriers to access. Findings showed that in contrast to disparities reported in the general population, COVID-19 vaccine receipt in the VA healthcare system was higher among most racial/ethnic minority groups than in Whites, suggesting reduced vaccination barriers compared with non-VA care. Overall, 24% of the cohort received at least one vaccine dose as of 2/23/21. Black (29%), Hispanic (27%), and Asian (27%) Veterans were significantly more likely than White (24%) Veterans to receive a vaccination through VA, while American Indian and Alaska Native (AI/AN) Veterans were less likely. Only AI/ANs in Contract Health Service Delivery Area counties, which indicates residence in/adjacent to federally reserved tribal lands were less likely than Whites to be vaccinated. Since AI/AN Veterans were less likely to obtain COVID-19 vaccinations through VA when close to a tribal area, the Indian Health Service may provide a safety net that is effective at reaching this population despite disparities in other contexts. Influenza vaccination history was positively associated with COVID-19 vaccine uptake.
Date: October 21, 2021
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Best Practices for Equitable COVID-19 Vaccination Drive
In collaboration with HSR&D investigators, the Interdisciplinary Vaccine Team at the VA Puget Sound Healthcare System worked to develop an equitable, coordinated, and data-driven COVID-19 vaccination drive for Veterans (carried out from December 21, 2020 to May 30, 2021). As of July 28, 2021, the VA Puget Sound facility had administered 79,643 vaccinations to 41,386 Veterans, representing 42% of its total population, and including 42% of Black enrollees, 29% of American Indian/Native Alaskan enrollees, and 35% of white enrollees. Key takeaways include: develop an intentional vaccine delivery strategy in conjunction with experts in population-level barriers to vaccination; explicitly include demographic and social determinants of health data to prioritize vulnerable populations in accessing vaccination; utilize multiple communication channels to reach patients in different formats.
Date: September 15, 2021
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Racial and Ethnic Disparities Persist in the Management of VA Patients with Atrial Fibrillation
This study compared the initiation of any anticoagulant therapy by race/ethnicity for Veterans with atrial fibrillation (AF). Findings showed that 62% of Veterans in this study initiated any anticoagulant therapy (OAC), varying 10.5 percentage points by race/ethnicity; initiation was lowest in Asian (52%) and Black (60%) patients and highest in White patients (63%). After adjusting for clinical, sociodemographic, provider, and facility factors, Black and Asian patients were significantly less likely than White patients to initiate OAC, with 10-18% lower odds of such therapy. Also, among those who initiated OAC, Black, Hispanic, and American Indian/Alaska Native patients were significantly less likely to initiate direct oral anticoagulants (DOACs), with 21-26% lower odds of such therapy. While overall OAC initiation and DOAC use increased significantly over time, there were no significant differences by race/ethnicity in the initiation of these treatments. Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial/ethnic minority patients managed in VA.
Date: July 28, 2021
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Gender Differences in Relationship between Civility and Burnout among VA Primary Care Providers
This study analyzed gender differences in civility, burnout, and the relationship between civility and burnout among male and female primary care providers (PCPs). Findings showed that greater workplace civility was significantly associated with lower odds of burnout for women, reflecting that in workplaces with higher civility, women were less impacted by burnout. However, workplace civility was not significantly related to burnout among men. Almost half of the sample reported burnout (48%), but this difference was not significant between the genders. Across occupational groups, female nurse practitioners reported lower burnout compared to female physicians. Female supervisors also reported lower burnout rates. Black male and Asian female providers reported lower burnout compared to white male and female providers, respectively. Overall, burnout was lowest among employees with less than or equal to one year of tenure. Interventions tailored to gender- and primary care-specific needs should be employed to increase civility and reduce burnout among primary care providers.
Date: April 26, 2021
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Veterans of Color Are More Likely to be Tested for COVID-19 at VA than White Veterans and are More Likely to Test Positive
This analysis evaluated the characteristics associated with obtaining a COVID-19 test within the VA healthcare system – and receiving a positive test result from February 8 through December 28, 2020. Findings showed that VA is testing a significantly higher proportion of traditionally disenfranchised patient groups for COVID-19 than other healthcare systems. However, Black and Hispanic/Latino Veterans have an increased risk of receiving a positive test result for COVID-19, despite receiving more tests than White and non-Hispanic/Latino Veterans. Overall, Veterans who were female, Black/African American, Hispanic/Latino, lived in urban settings, had a low income, or had a disability had an increased likelihood of obtaining a COVID-19 test, while Veterans who were Asian had a decreased likelihood. Compared with Veterans who were White, Veterans who were Black/African American were 23% more likely and Native Hawaiian/Other Pacific Islander 13% more likely to receive a positive test result. Hispanic/Latino Veterans had a 43% higher risk of receiving a positive test result than non-Hispanic/Latino Veterans. Veterans with disabilities or who were low-income were more likely to obtain a COVID-19 test but had a lower risk of receiving a positive test. Although disparities are significantly smaller at VA, the test positivity differences suggest that Veterans are not immune to the negative external effects of SDH. Results suggest that other factors (e.g., external social inequities) are driving disparities in COVID-19 prevalence.
Date: April 7, 2021
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Important IT Issues Impede Implementation of VA Mobile Teledermatology Application
To improve access to teledermatology for Veterans, VA created the web-based VA Telederm application (app), which interfaces with the EHR (electronic health record). This study evaluated the initial implementation process for the VA Telederm app – and assessed organizational readiness for change (ORC). Findings showed that at all sites, technical issues including sub-optimal information technology infrastructure negatively affected adoption, leading to the inoperability of the app at two sites. There also were technical inefficiencies related to users’ unfamiliarity with new devices and inconsistent Internet access. Each site had a high level of organizational commitment for change, including support from leadership and clinical champions, but this was insufficient to surmount the technological barriers. Communication and early-user involvement encouraged individual and system-wide adoption. Thus, information obtained from users at an early stage of implementation provided an understanding of needed communication strategies. Leadership support, commitment to change, staff perceptions about the value of a change and their ability to implement it, and a clinical champion were important for implementation effectiveness, but were not enough to overcome technological barriers.
Date: March 1, 2021
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Inequities in Enhanced Pension Benefit for Veterans
This study examined sociodemographic, medical, and healthcare use characteristics associated with receipt of the Aid and Attendance (A&A) benefit among Veterans receiving pension. Findings identified potential inequities in Veterans’ receipt of the A&A enhanced pension. Among 89,845 Veterans who received a pension but not the A&A enhanced benefit in FY2016, 8,724 Veterans (10%) newly received the A&A enhanced pension in FY2017. Veteran pensioners who received A&A were significantly older and more likely to be white and married than those who did not receive A&A. Pensioners who were black, Hispanic, or other non-white race had a lower probability of receiving A&A than white Veterans after adjusting for indicators of need. Most indicators of need for assistance (e.g., home health use, dementia, stroke) were associated with significantly higher probabilities of receiving A&A, with notable exceptions: pensioners with PTSD or enrolled in Medicaid had lower probabilities of receiving A&A. Among Veterans receiving pension, receipt of A&A varied by medical center. While provider education and wider dissemination of information about A&A may help reduce observed inequities, action is required at the system level that will eliminate the possibility of bias in which some eligible pensioners are able to access this enhanced pension benefit and others are not.
Date: February 25, 2021
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Significantly Higher Rates of Suicide among Sexual Minority Veterans Compared to Other Veterans and the General Public
This study assessed suicide mortality among Veterans who had documentation of sexual minority sexual orientation status recorded in VA’s electronic health record (EHR). Findings showed that risk of death from suicide was more than four-fold higher for sexual minority Veterans compared to the general US population – and more than twice as high as what has been found among the general Veteran population. The most common method of suicide was by firearm (40%) with men more likely than women (41% vs. 35%, respectively) to use firearms. For both sexual minority men and women, suicide was the most common cause of death among those 18–29 years of age, accounting for approximately 40% of all deaths.
Date: December 28, 2020
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Geographic and Racial/Ethnic Variation in Glycemic Control and Treatment among Veterans with Diabetes
Geography is a well-known determinant of health and an improved understanding of the relationships between geographic factors (social and environmental) and diabetes outcomes may lead to targeted interventions. This retrospective cohort study sought to answer the following questions: 1) Do rates of metabolic control exhibit geographic patterning or “hotspots”? and 2) Does patterning vary by race-ethnicity? Findings showed that after adjusting for age, gender, race-ethnic group, service-connected disability, marital status and comorbidities, the prevalence of uncontrolled diabetes varied by VA catchment area, with values ranging from 19% to 29%. These differences persisted after further adjustment for medication use and adherence, as well as use and access metrics. Disparities in sub-optimal control appeared consistent across most but not all catchment areas, with Black and Hispanic Veterans having higher odds of sub-optimal control than White Veterans. Prevalence of uncontrolled diabetes in the VA catchment area with the poorest control rates was estimated as high as 28% for Whites, 30% for Blacks, and 35% for Hispanics. Patterns of uncontrolled diabetes within VA did not mirror patterns of diabetes prevalence across the country. While high diabetes prevalence in the general population overlapped with sub-optimal diabetes control in parts of Appalachia, Georgia, Alabama, Mississippi, and Tennessee, parts of the Diabetes Belt had lower than average rates of uncontrolled diabetes in VA, indicating that areas of high diabetes prevalence can have below average rates of uncontrolled diabetes. Geographic as well as racial-ethnic differences in diabetes control rates were not explained by adjustment for demographics, comorbidity burden, use or type of diabetes medication, healthcare use, access metrics, or medication adherence, suggesting there is a geographic component to diabetes control that needs to be further explored.
Date: October 1, 2020
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Racial Differences in Conservative Management of Low- to Intermediate-Risk Prostate Cancer among Veterans
This study sought to determine whether there are any racial differences in the receipt and duration of conservative management among Veterans treated in the VA healthcare system. Findings showed that African American Veterans were slightly less likely to receive conservative management than White Veterans with localized prostate cancer. Further, among patients receiving conservative management, African American Veterans had a higher risk of receiving definitive therapy within five years of diagnosis than White Veterans. The median time to definitive treatment was 719 days for African American Veterans and 787 days for White Veterans. Compared to White Veterans, African American Veterans were more likely to have intermediate-risk disease (58% vs. 52%). Conservative management for low- and intermediate-risk prostate cancer may be less durable for African American Veterans compared to White Veterans.
Date: September 28, 2020
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Blacks and Hispanics Twice as Likely as White Veterans to Test Positive for COVID-19
This study examined racial and ethnic disparities in patterns of COVID-19 testing (i.e., who received testing and who tested positive) and subsequent 30-day mortality for Veterans receiving VA healthcare (all testing and services in this study were provided within VA). Findings showed that Black Veterans were more likely to be tested (rate per 1,000 patients, 60.0) than Hispanic (52.7) or White Veterans (38.6). Among those tested, both Black and Hispanic Veterans were twice as likely to test positive than White Veterans, even after accounting for all adjusting variables. The disparity between Black and White Veterans in testing positive slightly decreased over the study period – and was highest in the Midwest compared to other regions. The disparity between Hispanic and White Veterans was consistent across time, geographic region, and outbreak pattern. Among those who tested positive for COVID-19, there were no other observed differences in 30-day mortality by race/ethnicity group.
Date: September 22, 2020
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Use of Community Outpatient Providers During the Choice Program was Associated with Less Attrition from VA Care
This study examined the characteristics of patients and practices that used Choice outpatient care in the first year of implementation – and whether using Choice outpatient care was associated with attrition from VA primary care over a two-year period. Findings showed that overall, the attrition rate from VA primary care was low (4.4%), and Veterans who used Choice outpatient care were less likely to leave VA primary care than VA-only users. Compared to Veterans who used only VA outpatient care, those using Choice care were more likely to be female, white, or Hispanic, to live in the Continental or Pacific region, to have a higher service-connected disability rating, to have longer driving distances to all VA care, to not have a mental health condition, and to have greater primary care and total healthcare costs at baseline. Practices that sent more patients out for Choice care had lower mean scores for patient-centered medical home implementation, especially regarding access, and longer mean waiting times for appointments. Findings suggest that the use of community care more often supplements rather than replaces VA primary care, especially for practices that experience more difficulty in providing timely patient-centered primary care.
Date: September 10, 2020
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VA HIT-Related Outpatient Diagnostic Delays
This study evaluated the role of health information technology (HIT) in the root cause analyses (RCAs) of outpatient diagnostic delays submitted to the VA National Center for Patient Safety, which leads patient safety initiatives and uses RCAs of adverse events and close calls to promote learning across the VA healthcare system. Findings showed that of the 214 RCAs included in this study, 88 involved HIT-related safety factors in diagnostic delays. In the majority of these RCAs (n=64), the primary process breakdown was due to inadequate follow-up of one or more abnormal test results. Delays involved the diagnosis of serious conditions, including cancers, infections, and cardiovascular disease. Most safety concerns (83%) involved problems with the safe use of HIT, mainly sociotechnical factors associated with workflow and communication, people, and a poorly designed human-computer interface. Five key high-risk areas for diagnostic delays emerged: 1) managing electronic health record inbox notifications and communication, 2) gathering diagnostic information, 3) technical problems, 4) data entry problems, and 5) failure of a system to track test results. Study findings suggest multiple interventions to reduce outpatient diagnostic delays through improved design, configuration, and use of HIT. Interventions should aim to: 1) Redesign EHR inboxes and message workflow; 2) Develop safety nets to identify missed results; 3) Improve the display of diagnostic information; 4) Track referrals; 5) Optimize order entry design; and 6) Pursue interoperability between VA and non-VA care settings.
Date: June 25, 2020
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One-third of Reproductive-Age Women Veterans Perceive Gender-based Discrimination in VA Healthcare System
This study examined the prevalence of perceived gender-based discrimination – and factors with which it is associated – among reproductive-aged women Veterans seeking VA healthcare. Findings showed that among 2,294 women Veterans, 34% perceived gender-based discrimination when receiving VA care. However, the mean perceived discrimination score was 8 on a 24-point scale, indicating a relatively low frequency of perceived discrimination in VA among those who do encounter it. Of the women Veterans perceiving gender-based discrimination in VA, odds were higher among women with medical or mental illness, or with a history of military sexual trauma. Odds of perceiving gender-based discrimination were lower among women who received most of their care from the same VA primary care provider – or whose VA had a women’s health clinic. Of note, compared to non-Hispanic White women, Hispanic and non-Hispanic African American women perceived less gender-based discrimination. Efforts to enhance patient experiences to prevent exposure to gender-based discrimination may be needed among women with more health concerns and/or a history of military sexual trauma.
Date: May 1, 2020
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Significant Duplicative Spending on Coronary Revascularization Procedures among VA and Medicare Dual Enrollees
This study sought to describe where dually-enrolled VA-Medicare Advantage (MA) Veterans receive coronary revascularization and the associated costs. Findings showed that a significant share of VA healthcare users, concurrently enrolled in a Medicare Advantage plan, received coronary revascularization procedures through VA, incurring significant duplicative federal healthcare spending of nearly $215 million from 2010 through 2013. Over the study period, 22% of patients received either CABG or PCI through VA, 75% through MA, and 3% through both payers. Among this cohort, younger, non-white Veterans living in urban and rural counties were more likely to receive CABG or PCI through VA, whereas distance to a VA hospital did not independently influence the choice of VA versus MA for coronary revascularization. Findings suggest that the growing number of Medicare beneficiaries opting into Medicare Advantage is likely to lead to an increase in duplicative billing.
Date: April 6, 2020
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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
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All-Cause Deaths and Those Due to Poisoning, Suicide, and Alcoholic Liver Disease Higher among White Veterans Ages 55-64
After years of declining mortality rates across all age groups in the United States, increasing rates in White non-Hispanic Americans ages 45–54 were reported. This study sought to determine whether White non-Hispanic middle-aged male Veterans enrolled in VA primary care experienced similar increases in all-cause and select-cause death rates as was observed in the general population. Findings showed that White non-Hispanic male Veterans ages 55-64 had a significant increase in all-cause death rates from 2003 through 2014, accompanied by increases in deaths due to suicide, poisoning, and alcoholic liver disease. Changes were not evident in the younger (45-54) Veteran age group. For White non-Hispanic males ages 55–64 who were not Veterans, all-cause mortality decreased slightly from 2003-2014. However, there were increases in death rates due to poisoning, alcoholic liver disease, and suicide. For all three race/ethnicity groups in the 55–64 age category, trends in death rates for alcoholic liver disease, poisoning, and suicide did not differ according to rural or urban location. Findings suggest the critical importance of suicide prevention programs, as well as the importance of high-quality integrated healthcare, for both Veteran and non-Veteran white men.
Date: January 31, 2020
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VA Healthcare Benefits May Reduce Racial/Ethnic Disparities in Seeking Mental Health Treatment among Veterans
This study assessed whether racial/ethnic disparities in mental health treatment seeking for psychiatric conditions common in the Veteran population (PTSD, major depressive disorder, alcohol-use disorder or AUD) were attenuated for military Veterans compared to civilians, and whether attenuation was more pronounced among Veterans who had VA healthcare coverage in the past 12 months. Findings showed that unlike civilians, racial/ethnic minority Veterans did not differ from whites in time to initiate treatment for PTSD and depression, and showed a shorter time to initiate treatment for AUD. Racial/ethnic minority Veterans with past year VA healthcare coverage were the most likely to seek treatment for all three disorders, whereas racial/ethnic minority civilians were the least likely to seek treatment for all three disorders. Among racial/ethnic minority patients, shortened time to treatment initiation for Veterans relative to civilians remained significant after adjusting for additional demographic and clinical covariates for PTSD and major depressive disorder, but not alcohol use disorder. Findings suggest that military service and benefits available to Veterans may reduce racial/ethnic disparities in seeking mental health treatment seen in the civilian population.
Date: January 27, 2020
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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
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No Difference in Intermediate Outcomes for Veterans with Diabetes by Type of Primary Care Provider
This study examined whether intermediate diabetes outcomes differed among Veterans treated at one of 568 VA primary care facilities by a physician, nurse practitioner (NP), or physician assistant (PA) primary care provider. Findings showed that there were no clinically significant differences in intermediate diabetes outcomes – or the control of those outcomes – among patients with NP, PA, or physician primary care providers. There also was no clinically significant difference in the proportions of NP, PA, and physician-treated patients with diabetes who used endocrinology or specialty diabetes services during the year outcomes were calculated. This study provides further evidence that using NPs and PAs as primary care providers may represent a mechanism for expanding access to primary care while maintaining quality standards.
Date: December 18, 2018
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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
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Women Veterans with Pain More Likely to Use Complementary and Integrative Therapies
This study sought to examine complementary and integrative health (CIH) therapy use by gender among Veterans with chronic musculoskeletal pain, and variations in gender differences by race/ethnicity and age. Findings showed that of Veterans with chronic musculoskeletal pain, more women than men used CIH therapies (36% vs. 26%). Black women, regardless of age, were least likely to use CIH therapies compared to other women. Among men, White and Black Veterans were less likely to use CIH therapies, irrespective of age, than men of Hispanic or other race/ethnicities. Among both women and men, CIH therapies were least likely to be used by younger Black or White Veterans. Given the disparities in CIH therapy use, tailoring CIH therapy engagement to gender, race/ethnicity, and age may increase CIH therapy use among Veterans.
Date: September 1, 2018
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Medical Records Flag for Suicide Risk Increases VA Healthcare Visits among Veterans with Substance Use Disorder
VA has identified suicide prevention as a top priority and established policies to include high-risk suicide patient record flags (PRFs) in the electronic medical record to alert providers of patient risk and increase healthcare contacts. This study sought to identify predictors of new PRFs and to describe healthcare use before and after PRF initiation among VA patients who had received a substance use disorder (SUD) diagnosis. Findings showed that consistent with VA policy, 62% of Veterans with new suicide risk flags attended the recommended number of visits in months 1 to 3, with an additional 14% meeting recommended targets in month 1 only. Further, outpatient contacts in mental health and substance use disorder clinics increased 2 and 4 times, respectively, over the three-month follow-up period, with mean contacts in these services exceeding the minimum required one contact per week in month one. ED visits decreased by 45% in the three months following initiation of a PRF. Demographic predictors of PRF initiation included being younger than 35, White, and homeless. Clinical predictors were cocaine, opioid and sedative use disorders, PTSD, psychotic, bipolar, and depressive disorders, and suicide-attempt diagnoses. Suicide risk PRFs in an electronic medical record and subsequent follow-up increased service use for those Veterans with flags initiated.
Date: June 8, 2018
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While the Numbers of Homeless Veterans Continue to Decrease, their Needs Remain Unchanged
For more than two decades, VA’s Project Community Homelessness Assessment, Local Education and Networking Groups (CHALENG) has conducted an annual national survey to assess the needs of homeless Veterans. This study compiled five years of CHALENG survey data (available since the 2011 report) and examined changes in the characteristics of geographically diverse homeless Veteran respondents and their ratings on unmet needs. Findings showed that while the sociodemographic characteristics of homeless Veterans have changed over time (i.e., increasing number of aging, female, and white Veterans), their needs have largely remained unchanged. Across years 2012-2016, there were slight increases in unmet needs related to case management, food, emergency shelter, and medical services, but the highest-rated unmet needs that affected the most homeless Veterans were related to credit, utilities, furniture, dental care, and disability income. The need for legal assistance regarding evictions and foreclosures also was reported as one of the top unmet needs for all five years. Over four of the five years, legal assistance for child support – and in three of the five years, child care also were reported as common unmet needs. Homeless Veterans have begun to identify other needs beyond obtaining housing that pertain to sustaining housing and improving social functioning. Findings highlight numerous areas that may need further attention and intervention as VA continues to prioritize ending homelessness among Veterans.
Date: May 3, 2018
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Veterans with Cancer Received Higher Quality, Lower Intensity End-of Life Care in VA Compared to Medicare
This study evaluated the quality of end-of-life cancer care provided by Fee-for-Service (FFS) Medicare and VA, using well-accepted quality-of-care metrics. Findings showed that Veterans treated under FFS Medicare were more likely to get unduly intensive healthcare at end-of-life compared to those treated by VA. For example, Medicare-reliant Veterans were significantly more likely to receive chemotherapy, as well as experience a hospital stay, more hospital days, ICU admission, and death in hospital. Compared to Veterans in highly urban settings, Veterans living in rural areas were less likely to have a hospital admission or ICU stay, spend a greater number of their last 30 days of life in hospital, and were less likely to die in hospital. Compared with white Veterans, black Veterans were more likely to have two or more ED visits, a hospital admission, an ICU stay, or to die in hospital.
Date: January 1, 2018
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PACT Initiative Did Not Reduce Most Disparities in Improved Hypertension or Diabetes Control among VA Patients
This study sought to determine whether PACTs helped mitigate national racial/ethnic disparities in VA clinical outcomes, after adjusting for variable implementation and social determinants of health. Findings showed that improvements in clinical outcomes for hypertension and diabetes control had not been achieved for whites or most racial/ethnic groups four years into VA’s system-wide roll-out of the PACT initiative. Greater PACT implementation was associated with higher percentages of Veterans who achieved hypertension or diabetes control, but most racial/ethnic disparities in achieving control persisted. Authors suggest that to promote health equity, healthcare innovations such as patient-centered medical homes should incorporate tailored strategies that account for determinants of racial/ethnic variations.
Date: June 1, 2017
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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
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Racial Disparities in HIV Quality of Care that May Extend to Common Comorbid Conditions
To more fully understand patterns of racial disparities in the quality of care for persons with HIV infection, this study examined a national cohort of Veterans in care for HIV in the VA healthcare system during 2013. Findings showed that racial disparities were identified in quality of care specific to HIV infection – and in the care of common comorbid conditions. Blacks were less likely than whites to receive combination antiretroviral therapy (90% vs. 93%) or to experience viral control (85% vs. 91%), hypertension control (62% vs. 68%), diabetes control (86% vs. 90%), or lipid monitoring (82% vs. 85%). Although performance on quality measures was generally high, racial disparities in HIV care for Veterans remain problematic and extend to comorbid conditions. Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.
Date: September 22, 2016
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Application of Triggers on VA “Big Data” may Help Identify Patients Experiencing Delays in Diagnostic Evaluation of Chest Imaging
Triggers offer one method to use big electronic health record (EHR) data to prevent and mitigate the impact of delays in care related to missed test results. Triggers consist of computerized algorithms that can scan thousands of patient records to flag those with clues suggestive of patient safety events. This study tested the application of a trigger within VA’s EHR to help identify delays in patient follow-up related to abnormal chest imaging results. Findings showed that the trigger identified delays in patient follow-up with a reasonable accuracy for use in the clinical setting, suggesting that triggers are able to identify almost all delays related to abnormal lung imaging follow-up, and cost-effectively minimize the amount of effort providers spend reviewing false-positive results.
Date: September 1, 2016
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VA National Transplant System Shows No Racial/Ethnic Disparities in Evaluating Veterans for Kidney Transplant
This study examined VA patients of diverse racial/ethnic backgrounds with end-stage kidney disease (ESKD) who underwent the evaluation process for kidney transplantation (KT). Findings showed that in comparing African American Veterans with white Veterans and other minority Veterans, the VA National Transplant System did not exhibit the racial/ethnic disparities in evaluation for kidney transplant that have been found in non-VA transplant centers. Moreover, VA kidney transplant centers are successfully bringing ESKD patients through the evaluation process without race disparities at a time when non-VA transplant centers are unable to do so, while achieving a median time to complete evaluation similar to other published rates in non-VA settings.
Date: August 1, 2016
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Racial and Ethnic Differences in Primary Care Experiences for Veterans with Mental Health and Substance Use Disorders
This study examined racial and ethnic differences in positive and negative experiences in VA Patient-Centered Medical Home (PCMH) settings among Veterans with mental health or substance use disorders (MHSUDs) who completed VA’s 2013 PCMH Survey of Healthcare Experiences of Patients. Findings showed that positive experiences were reported least often for access. Negative experiences were reported most often for self-management support and comprehensiveness, defined as provider attention to MHSUD concerns. One or more racial/ethnic minority groups reported more negative and/or fewer positive experiences than Whites in the following 4 domains: access, communication, office staff helpfulness/courtesy, and comprehensiveness. Solutions are needed to improve access to care for all Veterans with MHSUDs, with additional attention on improving access for Black, Hispanic, and AI/AN Veterans.
Date: June 20, 2016
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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
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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
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Consequences of Notifying VA Patients about Potential Exposure to Large-Scale Adverse Events
This study sought to determine the intended and unintended consequences of patient notification following a large-scale adverse event (LSAE) within the VA healthcare system, which systematically looks for LSAEs, tracks potentially exposed patients, and communicates with them after LSAE notification. Findings showed that more than two-thirds of potentially exposed patients returned for HCV, HBV, and HIV testing following the receipt of an LSAE notification letter, which was associated with a 72 to 76 percentage point increase in testing.
Among Veterans who sought testing, 57% were tested in the 30 days following notification, and 74% were tested within 60 days. The vast majority (>98%) completed testing in a VA facility; less than 2% were tested at a non-VA facility paid by purchased care or Medicare (when eligible). Among older Veterans, notification was associated with higher odds of increased VA outpatient use in the following 3 months, but decreased odds of using VA healthcare in the subsequent 9 months. Compared to white Veterans, African American Veterans were significantly less likely to return to VA for follow-up testing.
Date: May 1, 2015
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Electronic Health Record-Based Interventions for Reducing Inappropriate Imaging in the Clinical Setting
Given that adoption of electronic health records (EHRs) is expanding, investigators conducted a systematic review and meta-analysis of EHR-based interventions to improve the appropriateness of diagnostic imaging. Findings showed that Computerized clinical decision support that is integrated into the physician order entry system of an electronic health record can help improve the appropriate ordering of diagnostic imaging studies. Of the 23 studies in this review, 21 studies provided moderate-quality evidence that EHR-based interventions can change appropriate test ordering by a moderate amount – and can reduce overall use by a small amount. Interventions that include a “hard stop” to prevent clinicians from ordering imaging tests classified as inappropriate, and implementation in an integrated care delivery setting may improve effectiveness. Potential harms of computerized clinical decision-support interventions have been rarely studied.
Date: April 21, 2015
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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
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Having Dependent Children Associated with Increased Risk of PTSD among OEF/OIF Veterans
This is the first study to examine whether being the parent of a dependent child was, in itself, associated with the likelihood of post-deployment PTSD diagnosis among Veterans. Findings showed that after controlling for demographics, mental healthcare use, and other serious mental illness, OEF/OIF Veterans with dependent children were about 40% more likely to carry a diagnosis of PTSD. This association was stronger among men than women. Other variables associated with increased odds of PTSD diagnosis included male gender, white race, Hispanic ethnicity, younger age, Priority 1 status, more than one dependent child, depression or SUD diagnosis, greater use of mental health services, and more medical comorbidities. Veterans with dependent children had greater VA mental healthcare utilization, including inpatient psychiatric admissions and mental health counseling visits. Thus, it may be of value for clinicians to consider parental status when treating Veterans with PTSD.
Date: January 19, 2015
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Improved Performance on Quality Measures is Accompanied by Increased Racial/Ethnic Equity in Care
This study examined the quality and equity of hospital care during the six years following initiation of the Centers for Medicare & Medicaid Services (CMS) Inpatient Quality Reporting (IQR) Program (2005 to 2010), focusing on 17 process-of-care quality indicators publicly reported by the program for white, black, and Hispanic patients hospitalized for AMI, HF, and pneumonia in non-VA hospitals. Findings showed that improved performance on quality measures for white, black, and Hispanic adults hospitalized with AMI, HF, and pneumonia was accompanied by increased racial/ethnic equity in performance rates both within and between U.S. hospitals. Over this time period, adjusted performance rates for the 17 quality measures improved by 3.4 to 57.6 percentage points for these patients. In 2010, unadjusted performance rates exceeded 90% for all subgroups for 14 of 17 measures. Declining racial/ethnic differences occurred through more equitable care for white and minority patients treated in the same hospital, as well as greater performance improvements among hospitals that disproportionately serve minority patients.
Date: December 11, 2014
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Use of Electronic Health Information Exchange may Reduce Emergency Department Utilization
Investigators in this study conducted a systematic review of the health information exchange (HIE) literature, specifically examining the evidence of effect on health outcomes, healthcare use and efficiency, evidence of clinicians’ use of HIE, and the financial sustainability of HIE organizations. Investigators also evaluated evidence about patient and provider attitudes toward HIE, as well as barriers and facilitators to its use. Findings showed that using HIE may reduce emergency department (ED) usage and costs. The effects of HIE on other healthcare outcomes are uncertain. The use of HIE is low relative to the estimated potential need, with most studies reporting use in 2% to 10% of healthcare encounters. However, some sites reported much greater HIE use, and specifics of the context and implementation may be responsible for these differences. All stakeholders claim to value HIE, but many barriers to acceptance and sustainability exist, including workflow and interface issues, privacy and security of patient health information, and the lack of a compelling business case for sustainability.
Date: December 2, 2014
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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
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Characteristics Associated with Suicide among Male Veterans Treated in VA Primary Care
This study sought to identify characteristics of Veterans who received VA primary care in the six months prior to suicide (in 2009) – and compare these to control patients who also received primary care at the same 41 VA facilities in 11 geographically diverse states. Findings showed that compared to controls, Veterans who died by suicide were significantly more likely to be unmarried, white, and to have major depression, bipolar disorder, anxiety disorder other than PTSD, and/or an alcohol or other substance use disorder diagnosis. Veterans who died by suicide also were more likely to have documented functional decline, sleep disturbance, expressions of anger, and suicidal ideation. The odds of dying by suicide were greatest among Veterans with anxiety disorder diagnoses and functional decline. A diagnosis of PTSD was not significantly associated with suicide, nor was a pain diagnosis or general medical comorbidity. Also, non-white race and a VA service-connected disability rating were associated with decreased odds of suicide. The assessment of anxiety disorders and functional decline, in particular, may be important for determining suicide risk among Veterans. The authors suggest continued development of interventions that support identifying and addressing these conditions in primary care.
Date: December 1, 2014
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Racial/Ethnic Disparities in Treatment Retention for Veterans with PTSD
This study of Veterans recently diagnosed with PTSD sought to determine whether the odds of premature mental health treatment termination varied by patient race/ethnicity and, if so, whether such variation is due to differential access to services or beliefs about mental health treatment, or whether there is a disparity in the provision of treatment. Findings showed that compared to White Veterans, African-American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy and, overall, African-Americans were less likely to receive a minimal trial of any treatment in the six months after being diagnosed with PTSD. Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino Veterans but not African-American Veterans. As expected, positive beliefs about psychotherapy or pharmacotherapy facilitated treatment retention. Access barriers did not contribute to treatment retention disparities. They significantly impacted psychotherapy participation, but equally across the entire sample. To improve treatment equity, clinicians may need to directly address patients’ treatment beliefs and preferences.
Date: November 24, 2014
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Electronic Health Record-based Alerting Systems Can be Source of Turnover for Clinical Practices
The use of certain components of electronic health records (EHRs), such as EHR-based alerting systems (EAS), might reduce provider satisfaction – a strong precursor to turnover. This study examined how providers’ perceptions of the use of EAS (known within the VA CPRS as View Alert notifications) may impact their satisfaction, intention to quit, and turnover. Findings showed that providers’ perceptions of the value of EAS predicted both provider satisfaction and facility-level turnover. For example, perceptions of the degree of monitoring and feedback received regarding EAS were significantly associated with intention to quit, with high levels of monitoring and feedback associated with increased intention to quit. Monitoring/feedback on EAS practices, training on the use of EAS, and the extent to which colleagues used/valued EAS had little impact on provider satisfaction.
Date: November 1, 2014
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Women Veterans, Particularly Black Veterans, Have Worse Risk Factor Control for Cardiovascular Disease than Male Veterans
This study compared gender and racial differences in three risk factors that predispose individuals to cardiovascular disease: diabetes, hypertension, and hyperlipidemia. Findings showed that overall, female Veterans had significantly higher LDL cholesterol levels than male Veterans, despite being almost ten years younger, on average. These differences are similar to gender disparities previously reported both within and outside VHA and represent a clinically significant difference. African-American women Veterans had worse blood pressure control than White women Veterans, and among Veterans with diabetes, male African-Americans had worse control of higher blood pressure, LDL, and HbA1c levels than White males.
Date: September 1, 2014
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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
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“Virtual” Hope Box Smartphone App Delivers Patient-Tailored Coping Tools to Help Veterans at Risk for Suicide
Tools that assist patients in accessing and affirming their reasons for living can enable them to mitigate suicidal thoughts. One such tool has been labeled a “hope box”: a physical representation of the patient’s reasons for living, reminders of individual accomplishments and future aspirations, or things the individual finds soothing, e.g., a worry stone, family photographs, or letters. However, a conventional hope box can by physically unwieldy and inconvenient; thus, the investigators in this study developed a “Virtual” Hope Box (VHB) for service members and Veterans that expands the reach of the hope box modality to a smartphone app. This study compared the VHB with a Conventional Hope Box (CHB) integrated into VA behavioral health treatment. Compared with a CHB, more Veterans used the Virtual Hope Box regularly and found it to be beneficial, helpful, and easy to set up. Veterans stated that they would recommend the VHB to their peers, and twice as many preferred the VHB over the CHB for future use. Written comments from Veterans cited the helpfulness of the VHB with managing distress, negativity, hopelessness, anger, and various other symptoms. Moreover, mental health clinicians were unanimous in their praise for the VHB as an eminently usable therapeutic tool.
Date: May 15, 2014
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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
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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
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VA’s “Housing First” Approach to Helping Homeless Veterans Presents Several Challenges
Over the past three years VA has shifted toward a Housing First (HF) approach to its HUD-VASH program, pivoting away from the traditional approach (often termed “Treatment First”), which emphasized housing readiness prior to awarding rental vouchers. This study examined the experiences of eight VA facilities that were at varying stages of HF adoption in 2012. Findings showed that front-line staff faced challenges in rapidly housing homeless Veterans due to difficult rental markets, the need to coordinate with local public housing authorities, and a lack of available funds for move-in costs. Finding interim sheltering options for Veterans waiting for housing (i.e., with no expectations of sobriety or treatment participation) also presented a significant challenge to the implementation of HF. Staff struggled to balance the time spent on housing search activities with intensive case management of highly vulnerable Veterans; this tension is acute immediately after the release of vouchers, when facilities are closely monitored on the speed with which the vouchers are used. Facility leadership supported HF implementation through resource allocation, performance monitoring, and reliance on mid-level managers to meet the challenges of implementation. The authors suggest that HF cannot successfully proceed unless VA is able to secure housing in discrete geographies and markets. Moreover, securing housing while simultaneously advancing the recovery agenda for each Veteran remains an ambitious undertaking.
Date: January 15, 2014
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Health Information Technology
This review sought to examine recent evidence that relates health IT functionalities prescribed in meaningful use regulations to key aspects of healthcare, such as quality, safety, and efficiency. Findings showed that most published IT evaluation studies report positive effects on quality, safety, and efficiency. Strong evidence supports the use of clinical decision support (CDS) and computerized provider order entry (CPOE). Fifty-seven percent of the studies in this review evaluated CDS and CPOE, and most reported positive results. Insufficient reporting of implementation and context of use makes it impossible to determine why some health IT implementations are successful and others are not. Therefore, the most important improvement that can be made in health IT evaluations is increased reporting of the effects of implementation and context. Authors note that with the increasing adoption of electronic health records and other forms of health IT, it is no longer sufficient to ask whether health IT creates value, but rather the most useful studies will help us understand how to realize value from health IT.
Date: January 7, 2014
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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
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Electronic Patient Portals and their Effect on Health Outcomes
Investigators conducted a systematic review of the relevant literature evaluating peer-reviewed articles on patient portals tied to existing electronic medical record systems, specifically looking at whether or not these systems improve health outcomes, patient satisfaction, healthcare utilization and efficiency, and adherence. Findings showed that the evidence is insufficient as to the effects of patient portals on health outcomes. A limited number of studies and variations in study design, portal functionalities, and implementation processes make it difficult to draw strong conclusions or generalizations about this relatively new technology. Examples were identified in which portal use was associated with improved outcomes for patients with chronic diseases (i.e., diabetes, hypertension, depression), but these were generally studies that used the portal in conjunction with case management. Evidence was mixed about the effect of portals on healthcare utilization and efficiency. Some findings included more acceptance of portals by patients who were younger and had more computer literacy or trust in the Internet, and more enthusiasm for portals among patients than physicians. Administrative and human factors in the interface were cited as barriers to use. Thus, the jury is still out on whether patient portals such as MyHealtheVet improve health outcomes or increase healthcare efficiency, although patients seem to value the ability to access their own medical records. While patients’ attitudes on portals are generally positive, more widespread use may require efforts to overcome racial, ethnic, and literacy barriers.
Date: November 19, 2013
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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
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Veterans with PTSD or Major Depression Less Likely to Undergo Four Major Invasive Procedures
This study examined whether PTSD, after controlling for major depression, was associated with the likelihood of having four common types of major invasive procedures. Findings showed that Veterans with PTSD only and with depression only were less likely to undergo all types of procedures examined in this study. Having both PTSD and depression was associated with lower odds of hip/knee, CABG/PCI, and vascular procedures, but not digestive procedures. Vascular procedures had the strongest effect. The odds of undergoing CABG/PCI or vascular procedures for patients with depression only were 35% to 40% lower than for patients with neither PTSD nor depression, while patients with PTSD only were about 25% less likely to receive the procedures. African American and women at-risk patients (those with a pre-existing condition likely to be alleviated by a procedure) were less likely to undergo hip/knee, vascular, and CABG/PCI procedures. Given that African-Americans are more likely than non-Hispanic whites to die of heart disease, their reduced odds of receiving CABG/PCI or vascular procedures could be problematic.
Date: October 1, 2013
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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
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VA Primary Care Physicians Using Electronic Health Records May Miss Important Information Due to Information Overload
This study examined potential predictors of missed test results in the setting of electronic health record (EHR)-based alerts. Findings showed that the median number of alerts VA PCPs reported receiving each day was 63; 87% of PCPs perceived the quantity of alerts to be excessive, and 70% reported receiving more alerts than they could effectively manage (marker of information overload). More than half (56%) of the PCPs reported that the EHR notification system, as currently implemented, made it possible for them to miss test results. Almost a third (30%) reported having personally missed results that led to delays in care for their patients. Further analyses showed that the perceived ease of EHR use by PCPs was related to a lower likelihood of both study outcomes: 1) the perception of potentially missing results, and 2) reporting missed results that led to delays in patient care. Greater concern over electronic hand-offs (i.e., routing alerts to the EHR of a surrogate covering-practitioner) was also related to the potential for and personal history of missed test results. PCPs who reported receiving more alerts than is manageable (information overload) were more likely to report having missed results that led to delayed patient care. Notably, the number of alerts that respondents reported they received per day was unrelated to either outcome.
Date: April 22, 2013
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Journal Issue Highlights the State of Health Information Technology in VA Healthcare
This Medical Care Supplement focuses on the use and impact of health information technology (HIT) in quality improvement research conducted within VHA. Articles in this Supplement highlight a range of specific HIT approaches, including innovative and interactive uses of VHA’s electronic health record, databases, and information systems, as well as applications of automated systems for intervention, evaluation, and tracking patient care.
Date: March 1, 2013
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Primary Care Practitioners’ Views on VA’s Electronic Health Record System and Test Result Notification
This study examined the broad range of social and technical factors that affect test result management in the VA healthcare system, based on a web-based survey of primary care practitioners (PCPs) at 142 VA facilities nationwide. Findings showed that despite an advanced electronic health record (EHR) system, VA PCPs reported both social and technical challenges in ensuring notification of test results to practitioners and Veterans. The vast majority of PCPs in this study had considerable experience with VA’s EHR, but less than half (46%) reported receiving sufficient training on the “View Alert” system. Nevertheless, the majority believed they had knowledge (74%) and proficiency (82%) to use the View Alert system. Just over one-third of the PCPs reported having the help needed for notifying patients of test results. Almost half of the PCPs reported that they did not immediately notify patients of normal test results and relied on patients’ next visit to notify them, whereas about one-fifth relied on the next visit to report abnormal results. A majority of PCPs (86%) stayed after hours or came in on weekends to address patient notifications, and less than one-third (30%) reported receiving protected time for alert management. Nearly half of the PCPs (47%) had prior experience using a non-VA EHR. Of these, 55% indicated that VA’s CPRS was superior to other commercially-available EHRs they had used, 19% thought that the non-VA EHR they used was superior, and 26% perceived them to be the same. PCPs endorsed several new features to improve test result management, including better tracking and visualization of result notifications.
Date: December 25, 2012
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Many OEF/OIF Veterans Delay Initiating Mental Health Care and Completing Effective Mental Health Treatment
This study sought to describe time to initiation (and predictors of time to initiation) of first primary care visit, mental health outpatient visit, and minimally adequate mental healthcare among Veterans with mental health diagnoses seeking VA healthcare post-deployment. Findings indicate delays in initiating and completing minimally adequate mental healthcare among OEF/OIF/OND Veterans using VA services. Among these Veterans, the median time to engagement in mental healthcare was more than two years from the end of the last deployment. Further, after more than three years post-deployment, 75% of Veterans with mental health diagnoses – who were in the VA healthcare system for at least one year – had still not engaged in minimally adequate mental healthcare. There was a median lag time of 7.5 years between coming in for an initial mental health treatment session and beginning a course of minimally adequate mental healthcare. All of the mental health diagnoses, as well as number of comorbid mental health diagnoses, were associated with an increased chance of initiating minimally adequate mental health outpatient care sooner. PTSD had the strongest association with early initiation. Male Veterans waited nearly two years longer to initiate minimally adequate mental healthcare compared to female Veterans. Younger Veterans (<25 years of age) took longer to initiate and seek minimally adequate care; racial/ethnic minorities also took longer than their White counterparts.
Date: December 1, 2012
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Design and Implementation of a VA Hospital-Based Usability Laboratory for Health Information Technology
This article describes the HSR&D Human-Computer Interaction & Simulation Laboratory, housed within one VAMC, which was intended to provide research-level findings about health information technology (HIT) design and was developed to investigate the usability of HIT toward transforming VA’s health information system. Investigators provide insight about the Laboratory’s design and implementation, and the use of a usability laboratory in the healthcare setting.
Date: December 1, 2012
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Equitable Rates of Pain Assessment among African American and White Veterans
This study sought to determine whether African American Veterans were less likely to be screened for pain than their White counterparts – and to determine the factors associated with differences in screening rates. Findings showed that VA’s mandate for pain screening has resulted in high and relatively equitable rates of pain assessment among both African American and White Veterans. Although rates of pain screening were lower among African Americans compared to Whites (78% vs.82%), this disparity was reduced by half after controlling for prior healthcare use, in which African American Veterans had a greater number of outpatient visits, which was associated with lower rates of pain screening at the index visit. Overall, Veterans were less likely to be screened for pain if they were African American, female, and married; if they had a diagnosis of deficiency anemia; if they had a greater number of outpatient visits; and if they were an established (vs. new) patient. Veterans were more likely to be screened if they had prior diagnoses of chronic joint, neck, or back pain; opioid abuse, anemia, and pulmonary circulation disorders; and if they had a non-opioid analgesic prescription and/or greater number of inpatient admissions in the previous two years.
Date: November 21, 2012
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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
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Review Supports One-to-One Peer Mentorship among Veterans
Across a broad range of populations, peer mentors appeared to be acceptable, credible sources of information. This may be particularly true among current and former members of the Armed Forces, who are accustomed to a culture of mutual support. The literature suggests that peers are capable of conducting assessment and triage, coaching and teaching, and providing direct social support. A White Paper identified three areas where peer mentorship (PM) might play a unique role for military/Veteran populations: coping with combat and operational stress, suicide prevention, and recovery-related issues downstream from combat/injury. In addition, the review suggests PM might play a role in reducing stigma, improving treatment adherence, increasing knowledge of treatment resources, and augmenting or teaching self-management skills.
Date: July 1, 2012
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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
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Perceived Discrimination Associated with Risk of Severe Coronary Obstruction among African American Veterans
Compared to white Veterans, African American Veterans with abnormal cardiac nuclear imaging studies had greater perceptions of racial discrimination that were related to increased risk for severe coronary obstruction – and to angiographic coronary obstruction, after controlling for clinical and psychosocial factors related to cardiovascular health. Based on their nuclear imaging studies, 44% of Veterans (both whites and African Americans) were at high risk for severe coronary obstruction. Among both African American and white Veterans, prior myocardial infarction (MI) and smoking were associated with high (vs. low/moderate) risk for severe coronary obstruction, while optimism was related to a decreased risk of severe obstruction. No significant associations between social support, negative affect, or religiosity and results from nuclear imaging or coronary angiography were found.
Date: April 1, 2012
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Relationship between Perceived Racial Discrimination and Wait Times for Kidney Transplant
Compared to whites, African Americans took significantly longer to get accepted for transplant.
There were also significant racial differences on several cultural factors in patients as they began the evaluation process for kidney transplantation. Compared to white patients, African Americans reported experiencing more discrimination in healthcare, more perceptions of racism in healthcare, higher medical mistrust, and more religious objections to living donor kidney transplantation. Comorbidity, dialysis status, and availability of potential living donors were not associated with length of time to be accepted for kidney transplant. Thus, medical factors alone did not explain racial disparities. In analyses to identify which factors predicted racial disparities, the authors found that perceived discrimination in healthcare, less transplant knowledge, more religious objection to transplantation, and lower income explained the racial disparities observed in the time it took to be accepted for transplant. Moreover, after adjusting for demographics, psychosocial, and cultural factors, the association of race with longer time for listing for transplant was no longer significant. Authors suggest these findings indicate that perceived discrimination in healthcare can be as much of a risk factor as race, income, or low transplant knowledge.
Date: February 27, 2012
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Majority of Veterans Interested in Sharing Personal Health Record Information with Caregivers and non-VA Healthcare Providers
This study explored patient preferences regarding shared access to electronic health information by surveying individuals who used VA’s personal health record, My HealtheVet. Findings showed that a majority (79%) of My HealtheVet users were interested in sharing access to their personal health record with someone outside the VA healthcare system: 62% with a spouse/partner, 23% with a child, 15% with another family member, and 25% with a non-VA healthcare provider. Preferences regarding degree of access varied based on the type of information being shared, the type of activity being performed, and the respondent’s relationship with the person. Interest in sharing access to My HealtheVet was modestly, but significantly, greater among older Veterans and men, but did not vary by health status.
Date: December 20, 2011
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Telemedicine-Based Collaborative Care Intervention for Depression has Greater Effect on Minority vs. White Veterans
The Telemedicine Enhanced Antidepressant Management (TEAM) study was a randomized trial of telemedicine-based collaborative care tailored for small, rural primary care practices. Investigators in the current study evaluated racial differences in clinical outcomes among 360 Veterans with depression who were randomized to usual care or the TEAM intervention. Findings showed that in the usual care group, minority Veterans had a lower treatment response rate (8%) than Caucasians (18%), but this was not significant. In contrast, minority Veterans in the TEAM intervention group had a significantly higher treatment response rate (42%) than Caucasians (19%) in the intervention group. Veterans in the minority group were significantly less likely to report that antidepressants were an acceptable form of treatment, and were significantly less likely to have had prior or current depression treatment. However, none of these variables were significantly related to treatment outcomes. Thus, the study was not able to determine why minorities responded better to the intervention than Caucasians.
Date: November 1, 2011
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JGIM Special Supplement Highlights Access to VA Healthcare
The JGIM Supplement includes both the white papers commissioned as background for the September 2010 state-of-the-art (SOTA) conference on “Improving Access to VA Care” and manuscripts submitted in response to a post-SOTA solicitation for original research and reviews pertaining to improving access to VA care. Articles focus on a myriad of topics related to improving access to care for Veterans, including: eHealth technologies (e.g., Care Coordination Home Telehealth program, and My HealtheVet personal electronic health record); measuring the impact of access on healthcare utilization, quality, and outcomes; and redefining access for 21st century healthcare.
Date: November 1, 2011
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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
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Depression and Race may Independently Affect Receipt of Some Surgeries
This study examined race and ethnicity as factors potentially associated with surgeries experienced by Veterans with and without major depressive disorder (MDD). Findings show that Veterans with pre-existing MDD were less likely to undergo digestive, hip/knee, vascular, or CABG surgeries than Veterans without MDD. Minority Veterans were slightly less likely to receive vascular operations compared to white Veterans, but were more likely to undergo digestive system procedures. The effect of depression was independent of race and ethnicity; thus, depression and race would have an additive but not synergistic effect on the odds of receiving surgery. In addition, a gender effect was noted: women Veterans were more likely to have digestive procedures but were less likely to undergo CABG or vascular operations. Authors note that the lack of information regarding severity of illness makes it difficult to determine whether or not diagnostic differences explain differences in surgery.
Date: October 1, 2011
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Natural Language Processing with Electronic Medical Record Improves Identification of VA Post-Operative Complications
This study evaluated a natural language processing (NLP) search approach to detect post-operative surgical complications within VA’s electronic medical record (EMR). Findings showed that, among Veterans undergoing inpatient VA surgery, NLP using the EMR greatly improved the identification of post-operative complications compared to an administrative-code based algorithm. NLP correctly identified 82% of acute renal failure cases compared with 38% for patient safety indicators; 59% vs. 46% for venous thromboembolism; 64% vs. 5% for pneumonia; 89% vs. 34% for sepsis; and 91% vs. 89% for post-operative MI. An accompanying Editorial states that NLP has the potential to greatly enhance the EMR with new applications, such as automated quality assessment to assist in the performance of comparative effectiveness research.
Date: August 24, 2011
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Veterans in Favor of Internet-Provided HIV Screening Information
This study examined patient and provider perceptions of Internet-based outreach to increase HIV screening among Veterans who use the VA healthcare system. Findings showed that both Veterans and providers thought that HIV screening outreach provided electronically via the personal health record (PHR – MyHealtheVet) would improve patient access to health information, with important educational value. Providers believed that it would reinforce messages they give to their patients. Veterans could envision instances in which information provided electronically might be better than verbal information from their doctor because it would be in lay language and readily available. Veterans also believed that electronic outreach would motivate them to be proactive about their health. Most felt that electronic messages would remind them to be screened, or at least contemplate getting screened. Regarding stigma attached to an electronic message about HIV, providers expressed substantially more concerns than Veterans. Providers also expected increased workload from the electronic outreach, and suggested adding primary care resources and devising methods to smooth the flow of patients getting screened.
Date: August 15, 2011
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Racial and Ethnic Differences in Blood Pressure Control among Veterans with Type 2 Diabetes
This study examined racial/ethnic differences in blood pressure control among Veterans with type 2 diabetes and uncontrolled BP at baseline. Findings showed that the adjusted proportion of Veterans with uncontrolled BP (>=140/90 mmHg) decreased in all groups over the study period. However, ethnic minority Veterans had significantly increased odds of poor BP control over a mean follow-up of 5 years compared to non-Hispanic White Veterans, independent of socio-demographic factors and comorbidity patterns. Compared to non-Hispanic Whites (45%), 54% of non-Hispanic Black Veterans, 48% of Hispanic Veterans, and 49% of Veterans with unknown race had poor blood pressure control. In using a more stringent BP cutoff (>=130/80 mmHg) to define poor BP control, 74% of non-Hispanic White Veterans had poor blood pressure control over the 5 years compared to 82% of non-Hispanic Black Veterans, 75% of Hispanic Veterans, and 79% of Veterans with unknown race/ethnicity. The presence of a hypertension diagnosis at the time of study entry appears to be associated with higher odds of achieving BP control over time. Among other comorbidities, cancer, coronary heart disease, congestive heart failure, and substance use disorders were all associated with increased odds of good BP control over time.
Date: June 14, 2011
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Despite Improved Quality of VA Healthcare, Racial Disparity Persists for Important Clinical Outcome
This article reports on trends in the quality of care and racial disparities in relation to 10 VA clinical performance measures that assessed cancer screening, cardiovascular care, and diabetes care from 2000 to 2009. Findings show that in the decade following VA’s organizational transformation, quality of care improved and racial disparities were minimal for most process measures, such as glucose and LDL screening. However, these were not accompanied by meaningful reductions in racial disparity for important clinical outcomes, such as blood pressure, glucose, and cholesterol control. A gap in clinical outcomes of as much as nine percentage points was observed between African-American and white Veterans. Almost all of the disparity in outcomes was explained by within-facility disparity, which suggests that VA medical centers will need to measure and address racial gaps in care for their patient populations. Of the five performance measures with an absolute racial disparity of 5 percentage points or more in the initial year of the study, there were statistically significant reductions in racial disparity for three: glucose control, BP control, and CRC screening. However, the reductions in disparity were modest, and none were reduced by more than 2 percentage points.
Date: April 1, 2011
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No Racial Disparities in Adherence to CRC Screening among Veterans Receiving VA Care
This study examined the contribution of demographic/health-related factors, cognitive factors, and environmental factors to racial disparities in colorectal cancer (CRC) screening in a nationally representative survey of Veterans ages 50 to 75. The effect of race on adherence to CRC screening guidelines was non-significant after adjusting for demographic/health-related factors and environmental factors. Adherence in both African American and White groups was substantially higher than the national average. The high rates of CRC screening are likely, in part, a result of various VA efforts initiated over the past decade to increase screening adherence. There were no racial differences in physician recommendations for CRC screening: 84% for African Americans and 85% for Whites. Among those who were adherent to CRC screening, African American Veterans had significantly lower rates of colonoscopy compared with White Veterans (47% vs. 57%) and significantly higher rates of fecal occult blood testing (60% vs. 53%).
Date: March 1, 2011
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Electronic Record Intervention Improves Follow-Up of Veterans with Positive Colorectal Cancer Screening
This randomized trial of eight VAMCs evaluated an electronic record intervention for follow-up of Veterans with a positive fecal occult blood test (FOBT). Findings show that a simple electronic intervention involving an automatic GI consult for Veterans with a positive FOBT result improved follow-up and reduced the time between a positive FOBT and GI evaluation, as well as complete diagnostic evaluation (CDE). The 30, 90, and 180 day GI consult rates improved 21% to 33% among intervention sites, but did not change in the usual care sites. Thirty, 90, and 180 day CDE rates improved 9% to 31% in intervention sites, but did not significantly change in usual care sites. Time to GI consult and CDE decreased significantly over time in the intervention sites, but remained unchanged in the usual care sites.
Date: February 15, 2011
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Collaborative Care Intervention Improves Depression in Veterans with HIV
The goal of this study was to adapt an evidence-based primary care model of depression collaborative care for HIV clinic settings (HIV Translating Initiatives for Depression into Effective Solutions [HITIDES])) – and to evaluate its effectiveness. Findings show that the HITIDES intervention was successfully implemented in HIV settings and improved both depression and HIV symptom outcomes. Veterans who participated in the intervention were more likely to report treatment response and remission compared to Veterans in usual care at 6-month follow-up but not at 12-month follow-up. Improved depression response and remission outcomes at 6 but not 12 months suggest that depression symptoms improved more rapidly in the intervention group compared to usual care. Intervention participants also reported more depression-free days over 12 months. Compared to usual care, significant intervention effects also were observed for lowered HIV symptom severity at 6 and 12 months. The authors suggest that the HITIDES intervention may serve as a model for collaborative care interventions in other specialty physical healthcare settings.
Date: January 10, 2011
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VA Patient-Provider Communication Does Not Contribute to Racial Disparities in Use of Total Joint Replacement
This study examined whether there were racial differences in patient-provider communication about treatment of chronic knee/hip osteoarthritis in African American and white Veterans referred to two VA orthopedic clinics over a 3-year period. Findings show that communication between VA orthopedic surgeons and patients regarding the management of chronic knee/hip osteoarthritis did not, for the most part, vary by patient race. No racial differences were observed with regard to length of visit, overall amount of dialogue, discussion of psychosocial issues, Veteran activation/engagement statements, physician verbal dominance, display of positive affect by Veterans or providers, or discussion related to informed decision-making. However, visits with African American Veterans contained less discussion of biomedical topics and more rapport-building statements than visits with white Veterans. These findings diminish the potential role of communication in VA orthopedic settings as an explanation for racial disparities in the use of total joint replacement.
Date: January 10, 2011
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Electronic Health Information’s Effect on Clinical Workflow
This study sought to assess aspects of health information technology (HIT) that impact clinical workflow – and to identify a set of HIT characteristics that support patient care processes. Investigators identified many examples of how HIT affects workflow, but characteristics were strongest within four primary domains: 1) Trustworthy and reliable (e.g., inconsistent incomplete, incorrect information in the electronic health record (EHR); 2) Ubiquitous (e.g., poor accessibility due to lack of computer workstations or lengthy secure login processes, but good information availability ); 3) Effectively displayed (e.g., problems locating scanned documents in the EHR, lack of searchability , information not well-organized or prioritized); and 4) Adaptable to work demands (e.g., EHR is not portable or customizable, difficult to modify information). The findings from this study underscore the value of obtaining input from healthcare employees and may be used to enhance HIT design, clinical practice, and patient safety.
Date: December 1, 2010
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Validated Alcohol Screening Questionnaire Not Enough to Ensure Quality of Screening
This study evaluated the quality of clinical alcohol screening among VA outpatients by comparing Alcohol Use Disorders Identification Test - Consumption Questions (AUDIT-C) results documented during routine clinical care to AUDIT-C results from a confidential mailed survey completed within 90 days of the clinical screen. Of the national sample, 61% of VA outpatients who screened positive for alcohol misuse with the AUDIT-C on mailed surveys screened negative during the same time period with the AUDIT-C in VA outpatient clinical settings. Overall, 11% of Veterans screened positive on the survey screen vs. only 6% on the clinical screen. Patients who screened positive on the AUDIT-C survey were much more likely to have discordant clinical screening results, e.g., among patients whose clinical screens indicated no alcohol use in the past year, 22% reported drinking on the survey screens. Discordance was significantly increased among African American Veterans compared with white Veterans. There were also differences across VA networks: the proportion of Veterans with positive survey screens who had negative clinical screens varied from 43% to 100% across different networks.
Date: September 22, 2010
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Disparities in Healthcare Coverage and Access among American Indian/Alaska Native Veterans
American Indian/Alaska Native (AIAN) Veterans have considerable disparities in healthcare coverage and access to care compared to non-Hispanic white Veterans. For example, AIAN Veterans are nearly twice as likely to be uninsured, even after adjusting for sociodemographic and economic characteristics. AIAN Veterans are significantly less likely to report private coverage and significantly more likely to report public coverage, military coverage, and be uninsured. Regarding barriers to healthcare, AIAN Veterans were significantly more likely to delay healthcare due to not getting timely appointments, not getting through on the telephone, and having transportation problems.
Date: June 1, 2010
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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
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Patient Treatment Preferences Play Important Role in Racial Disparities in Knee/Hip Total Joint Replacement
Overall, 10.3% of Veterans treated for knee/hip osteoarthritis at two VA orthopedic clinics underwent total joint replacement (TJR) within six months of study enrollment. TJR was less likely for African-American Veterans compared to white Veterans of similar age and disease severity, but this difference was not significant after adjusting for whether patients had received a recommendation for the procedure from their orthopedic surgeon. African-American Veterans were less likely to receive a recommendation for TJR than white Veterans of similar age and disease severity. However, this difference was not significant after controlling for Veterans’ willingness to undergo TJR, as assessed prior to the visit with their surgeon. This suggests that the observed race differences in recommendations about joint replacement may result from orthopedic surgeons being responsive to patient preferences regarding the procedure.
Date: May 28, 2010
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Lower Mortality Rates for African American Compared with White Patients Hospitalized for Heart Failure
This study examined research reporting mortality by race after hospitalization for heart failure (HF), and combined the results using meta-analyses. Adjusted mortality rates were 32% lower in short-term follow-up (0-30 days) and 16% lower in long-term follow-up (after 30 days) for African American compared with white patients. Authors suggest that differences in mortality imply unmeasured differences by race in clinical severity of illness at hospital admission and may lead to biased hospital mortality profiles.
Date: March 1, 2010
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Male OEF/OIF Veterans with PTSD More Likely to Perpetrate and Experience Aggressive Behavior toward/from Female Partners
This study examined the nature and frequency of self-reported partner aggression among three male cohorts recruited from one large VAMC outpatient PTSD clinic: OEF/OIF Veterans with PTSD, OEF/OIF Veterans without PTSD, and Vietnam Veterans with PTSD. Findings show that OEF/OIF Veterans with PTSD were significantly more likely to report psychologically abusing their partners than OEF/OIF Veterans without PTSD. Although other comparisons did not reach significance, results suggested that OEF/OIF Veterans with PTSD were about two to three times more likely than the other two groups to report perpetrating or sustaining violence. OEF/OIF Veterans with PTSD also were six times more likely to report sustaining injury from their female partners than OEF/OIF Veterans without PTSD. Significant correlations among reports of violence perpetrated and sustained suggest many men may have been in mutually violent relationships. In terms of family functioning, 63% of OEF/OIF Veterans with PTSD reported having children in the home. These results emphasize the importance of assessing partner aggression in VA clinical settings in order to provide a more complete psychological picture of Veterans and their families’ potential treatment considerations.
Date: February 2, 2010
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Fixing an Electronic Communication Problem that Reduced Follow-Up of Positive Cancer Screens at One VAMC
This study sought to determine if technical and/or workflow-related aspects of automated communication in VA’s electronic health record could lead to the lack of response to a positive fecal occult blood test (FOBT). A problem with software configuration at one VA medical center intended to alert VA primary care physicians about positive FOBT results led to breakdowns in transmission of a subset of test results. About one-third of the 490 positive FOBTs examined for this study were not directly reported to PCPs as CPRS alerts. Upon correction of the technical problem, lack of timely follow-up of test results decreased from 29.9% to 5.4% -- and was sustained for four months following the intervention. The authors recommend that electronic communication of positive FOBT results should be monitored to avoid limiting the benefits of colorectal cancer screening. They are currently investigating whether this problem exists in other VA facilities, or if this was an isolated event.
Date: December 9, 2009
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Veteran Minorities Equally Likely to Receive PTSD Treatment
This study sought to determine the rates of mental health use in the six months after Veterans received a PTSD diagnosis – and to examine whether service use varied by race or ethnicity. Findings show that minority Veterans were similar to Whites in the likelihood of receiving VA mental health treatment in the six months following a diagnosis of PTSD. Of the 20,284 Veterans with PTSD in this study, 50% received psychotropics, 39% received counseling, and 64% received at least one of these forms of treatment. However, only 24% who received any counseling had at least eight sessions, and most had only one session. These findings indicate that possible treatment preferences exist. The authors suggest that incorporating preferences into treatment planning may facilitate treatment retention and help to maximize treatment outcomes for all Veterans with PTSD.
Date: December 1, 2009
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Veterans’ Age and Disability Status Associated with Choice of Medicare Plans
Medicare-eligible Veterans may choose between care in VA or Medicare (or both), and they also have to choose between obtaining Medicare services in the fee-for-service (FFS) sector or in a Medicare Advantage (MA) plan. This study sought to assess factors associated with enrollment in an MA vs. FFS plan in 2000-2004 among this population. Findings show that age and disability status were both significantly associated with choice of MA vs. FFS plan. For example, age-eligible Veterans were more likely to be enrolled in an MA plan if aged 75 or older, female, able to receive free VA care, or not enrolled in Medicaid, while disability-eligible Veterans were more likely to be enrolled if they were married or elderly. Minority Veterans and Veterans with lower disease risk scores (better average health) were more likely to be enrolled in an MA plan than white Veterans or Veterans with higher risk scores. Overall, Veterans living in zip codes with greater population density and higher per capita income were also more likely to enroll in an MA plan. The authors suggest that future studies examine the Medicare health plan choice of disabled Veterans, particularly OEF/OIF Veterans who begin to qualify for Medicare, to better understand the possible impact of MA enrollment on continuity, duplication, cost, and quality of care.
Date: November 1, 2009
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Ethnic Disparities in Treatment for Chronic Pain
This study sought to identify racial and ethnic differences in patient-reported rates of treatment for chronic pain and ratings of pain-treatment effectiveness among 255,522 Veterans who were treated at more than 800 VA healthcare facilities in FY05. Findings show that 35% of male Veterans and 44% of female Veterans reported receiving treatment for chronic pain. Male and female Veterans who were Hispanic or non-Hispanic black were more likely to report receiving treatment for chronic pain compared to non-Hispanic white Veterans. Among the Veterans who received treatment for chronic pain, non-Hispanic black men were one-fifth less likely to rate pain treatment effectiveness as very good or excellent compared to non-Hispanic white male Veterans.
Date: October 1, 2009
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Use of Medicare and VA Healthcare among Veterans with Dementia
This study sought to characterize healthcare use among Veterans with dementia over a four-year period (1998-2001), and to determine predictors of whether a Veteran will be a VA-only, dual, or Medicare-only user. Findings show that during the four-year study period, Medicare-only use increased while VA-only use decreased. Results also show that an increased likelihood of some Medicare use was associated with being older, white, married, and having higher education, private insurance or Medicaid, and low VA priority level. Further, the number of functional limitations was associated with an increased likelihood of Medicare-only use and a decreased likelihood of VA-only use, while higher comorbidities were associated with a higher likelihood of dual use as opposed to any single system use. The authors suggest that these results imply that different aspects of Veterans’ needs have differential effects on where Veterans seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure patients receive high quality care, particularly among those with multiple comorbidities.
Date: October 1, 2009
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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
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Federal Investment in Electronic Medical Records
The American Recovery and Reinvestment Act (ARRA) includes $19 billion in incentives for the adoption of electronic medical records (EMRs) and $50 billion to promote health information technology. Medicare physicians adopting and making “meaningful use” of EMRs in 2011 and 2012 will be eligible for an initial payment of up to $18,000, with reduced payments in 2013 and 2014. However, current EMR systems’ inability to learn from aggregated health data has led to implementations and hospital information technology departments that can actually obstruct quality improvement. For example, much of the information contained in EMRs is formatted as unstructured free text – useful for essential individual communication but unsuitable for detecting quantifiable trends. This commentary suggests that the Department of Health and Human Services capitalize on the opportunity to mandate EMRs that have the potential to learn from data in the EMR system.
Date: September 9, 2009
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“Rights” of Safe Electronic Health Record Use
This JAMA Commentary proposes eight “Rights” of safe electronic health record (EHR) use, which are grounded in an engineering model that addresses work-system design for patient safety. The authors recommend the use of the eight “Rights,” in order to address the complex interaction of organizational, technical, and cognitive factors that affect the safety and effectiveness of EHRs.
Date: September 9, 2009
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African Americans and Whites Equally Appropriate Candidates for Total Joint Arthroplasty
This study sought to determine if racial differences in clinical appropriateness for surgery existed among a sample of primary care patients (425 whites and 260 African Americans) with moderate to severe symptomatic knee or hip osteoarthritis (OA) treated at one VA hospital and one county hospital between 3/03 and 9/06. Findings show that African Americans and whites were equally appropriate candidates for total joint arthroplasty (TJA). There were no significant ethnic differences found between the proportion of those deemed appropriate for TJA and those deemed inappropriate.
Date: September 1, 2009
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Focus Groups Recommend Strategies to Decrease Missed Test Results
This paper reports on the efforts of two focus groups that formed as part of the Diagnostic Error in Medicine – A National Conference, which was held by the American Medical Informatics Association in 2008. Clinicians who were part of the focus groups were asked to develop interventions that might decrease the risk of diagnostic delay due to missed test results in the future. The focus groups concluded that while the electronic medical record helps to improve access to test results, eliminating all missed test results would be difficult to achieve. However, they did recommend several strategies that might decrease the rates of missed test results, including: improving standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow-up of test results, and systems re-engineering to improve the management and presentation of data. They also suggest that healthcare organizations focus initial quality improvement efforts on specific tests that have been identified as high-risk for adverse impact on patient outcomes, such as tests associated with a possible malignancy or acute coronary syndrome.
Date: September 1, 2009
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Lower Mortality for African American Veterans with COPD Exacerbation not Explained by More Aggressive Care
This study sought to determine the potential impact of racial differences in ICU admission and the use of ventilator support on mortality among African American and white Veterans admitted to VA hospitals with COPD (chronic obstructive pulmonary disease) exacerbation. Findings show that mortality was lower in African American Veterans compared to white Veterans, even after adjusting for differences in ICU admission rates and ventilator support. However, mortality was similar for African Americans and whites receiving mechanical ventilation (28.8% vs. 31.4%), thus the lower risk-adjusted mortality among African Americans was not explained by more aggressive care.
Date: July 1, 2009
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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
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Alcohol Misuse and Counseling among Minority Veterans
This study sought to describe alcohol consumption across race and ethnicity groups among Veterans treated in VA during FY05, and examine associations between race and ethnicity and receipt of alcohol-related advice by clinicians. Findings show that overall, less than one-third of patients who drank at all and one-third of patients with positive alcohol misuse screens reported receiving alcohol-related advice. After adjusting for demographics, health status, and alcohol consumption, Veterans who self-identified as black, Hispanic, or American Indian/Alaska Native were more likely to report receiving alcohol-related advice from their VA healthcare providers compared to non-Hispanic whites. In addition, women and older Veterans were less likely to receive alcohol-related advice than their male and younger counterparts, respectively.
Date: May 1, 2009
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Costs and Benefits of Health Information Technology
The use of health information technology (HIT) has been promoted as having tremendous promise in improving the efficiency, cost-effectiveness, quality, and safety of medical care delivery. Findings from this literature review show a proliferation of patient-focused HIT applications, many of which are designed for use by patients without significant oversight by healthcare providers. Investigators believe that accelerating the adoption of HIT will require greater public-private partnerships, new policies to address the misalignment of financial incentives, and a more robust evidence base regarding HIT implementation.
Date: March 1, 2009
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Ethnic Differences in Self-Reported Cancer Screening
Several studies suggest that non-whites may be more likely than whites to over-report screening behavior, which may have considerable implications for research on racial and ethnic disparities in cancer screening. Findings from this study show that racial and ethnic minorities may be less likely to provide accurate reports of their cancer screening behavior and that over-reporting may be particularly problematic. Research suggests that this might be rectified by changing how screening questions are worded and developing different methods for data collection. A conceptual framework offered by study investigators has the potential to guide exploration of where and why possible bias may be occurring and suggests ways in which these biases might be reduced.
Date: February 1, 2009
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Need for Better Self-Management Education to Address Cultural Differences among Veterans with Diabetes
Although non-white Veterans have documented disparities in the quality of some diabetes care processes and intermediate outcome measures, racial disparities in foot care examinations have not been widely explored. Findings from this study show that there are significant differences in self-reported foot care and education across racial and ethnic groups among Veterans with diabetes. Authors suggest the need for better self-management education to address culture, knowledge, preferences, and unique barriers to care.
Date: January 1, 2009
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African-American Veterans More Likely than White Veterans to Receive Mechanical Ventilation for COPD
African-American Veterans with COPD exacerbation in VA hospitals are more likely than white Veterans to receive mechanical ventilation, and this difference is not explained by available clinical or demographic variables. By contrast, African-American and white Veterans are equally likely to receive non-invasive ventilation (NIV) when being treated for COPD exacerbation. Authors suggest that there is no underuse of mechanical ventilation and NIV in the treatment of racial minorities in this patient population; however, unmeasured factors, such as patient preferences or disease severity may be affecting the use of mechanical ventilation, and thus warrant further investigation.
Date: January 1, 2009
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Racial Differences in Coping with Chronic Osteoarthritis Pain
Compared to white veterans, African American veterans were much more likely to perceive prayer as helpful (85% vs. 66%) and were more likely to have tried it for hip or knee pain (73% vs. 55%). Race was not associated with arthritis pain self-efficacy, arthritis function self-efficacy, or any other coping strategies.
Date: December 1, 2008
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Students Attending Racially and Ethnically Diverse Medical Schools Report Being Better Prepared to Care for Patients in Diverse Society
White students who attend racially diverse medical schools report feeling better prepared than students at less diverse schools to care for racial and ethnic minority patients. They also are more likely to endorse access to adequate health care as a right. However, investigators found no association between the diversity of a medical school and whether white students intended to provide care in underserved areas.
Date: September 10, 2008
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Association between Nurse Staffing Levels and Patient Mortality in VA Hospitals
RN staffing was not significantly associated with in-hospital mortality for veterans with an ICU stay; however, increased RN staffing was significantly associated with decreased mortality among non-ICU patients. Continuing to estimate the effect of RN staffing and skill mix on patient outcomes using hospital-level data will provide poor estimates of outcome associations, such as in-hospital mortality.
Date: September 1, 2008
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Perceived Racial Discrimination in U.S Healthcare More Prevalent among African Americans and Associated with Worse Health Outcomes
The prevalence of perceived discrimination in U.S. healthcare is considerably higher for African Americans compared to Whites and Hispanics. [These results were not based on VA data.] Perceived discrimination was associated with worse health for both African Americans and Whites. Health care coverage was not significantly related to perceived discrimination for any of the racial/ethnic groups. However, not obtaining medical care due to cost was associated with a greater likelihood of perceiving discrimination for all groups.
Date: September 1, 2008
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