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Medication Risks for Veterans of Child-bearing Age
This study investigated medication use and the role of comorbidity among pregnant Veterans receiving VA care – and where patient education or provider-to-provider communication is needed. Findings showed that, based on prescriptions filled within VA only, women Veterans were prescribed numerous medications during pregnancy and discontinued antidepressants at a substantial rate. The median number of drug classes prescribed during pregnancy was five. Use of SSRI/SNRI antidepressants dropped from 36% preconception to 26% during pregnancy, including new starts, and 15% of pregnant Veterans discontinued SSRI/SNRI treatment. Predictors of discontinuing SSRI/SNRI antidepressants during pregnancy were examined, and only Black race was identified as a predictor. Veterans of childbearing age should receive counseling about medication use before pregnancy. Their non-VA obstetricians and VA providers should share information to optimize outcomes.
Date: March 23, 2022
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VA Mental Health Use During Pregnancy/Postpartum Periods Remained Strong among Women with Prepregnancy Depression, PTSD, and Anxiety Diagnoses
This study examined how prepregnancy psychiatric diagnoses could impact mental health treatment use during pregnancy and postpartum, given there is increased risk of symptom recurrence and/or medication discontinuation during pregnancy. Findings showed that there was a strong correlation between a prepregnancy diagnosis of major depressive disorder (MDD), PTSD, or anxiety and use of mental healthcare during pregnancy and the postpartum period. For women with these pre-pregnancy diagnoses, there was an increase in the use of psychotherapy during pregnancy and postpartum, while the percentage of women using antidepressants only or antidepressants plus therapy decreased during the same time periods; 42% of women reported stopping their antidepressants at the onset of the pregnancy.
Date: November 18, 2020
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VA Successfully Implements Interferon-free Treatment for Hepatitis C Virus in Previously Undertreated Patient Populations
This study examined the adoption of interferon-free treatment for hepatitis C virus (HCV) in VA to learn who received this therapy and whether the limitations of interferon-containing treatments have been overcome, including low rates of use among VA healthcare users who are African American or Hispanic, and among those with HCV-HIV co-infection. Findings showed that with the advent of interferon-free regimens, the percentage of VA patients with HCV infection that was treated increased from 2% in 2010 to 18% in 2015, an absolute increase of 16%. There were large treatment gains realized by groups of patients that had been less likely to be treated in 2010. Large absolute increases in the percentage treated were achieved in Veterans with HIV co-infection (19%), alcohol use disorder (12%), and drug use disorder (13%), and in Veterans who were African-American (14%) or Hispanic (14%). Veterans with mental illnesses exacerbated by interferon, depression, PTSD, and bipolar disorder, had absolute increases in treatment that were larger than the overall increase.
Date: March 7, 2018
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Evidence Review Identifies Modest Mortality Disparities among Racial and Ethnic Minority Groups in VA Healthcare
To support VA’s efforts to better understand the scale and determinants of disparities in racial and ethnic mortality – and to develop interventions to reduce disparities, investigators from the VA Evidence-based Synthesis Program (ESP) Coordinating Center in Portland, OR conducted an evidence review of mortality disparities specific to VA. Findings showed that although VA’s equal access healthcare system has reduced many racial/ethnic mortality disparities still present in the private sector, modest mortality disparities persist mainly for black Veterans with conditions that include: stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, and stroke. There also were modest disparities in mortality for American Indian and Alaska Native Veterans undergoing major non-cardiac surgery, and for Hispanic Veterans with HIV or traumatic brain injury.
Date: March 1, 2018
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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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New Guidelines May Significantly Decrease Cost for Testing Immune Function in Veterans with HIV
In 2012, the Department of Health and Human Services recommended CD4 testing in patients with HIV every 3 to 6 months – except in patients with consistently suppressed virus and sustained CD4 cell count, who could be tested every 6 to 12 months. In 2014, updated guidelines recommended that in individuals with viral suppression, CD4 testing be considered either optional or annual, depending on the cell count. This study evaluated how these recommendations might affect Veterans with HIV who receive care from the largest provider of HIV care in the United States – the VA healthcare system. Findings showed that VA providers decreased the frequency of CD4 testing by 11% between 2009 and 2012, reducing the direct cost of testing by $196,000 per year. While VA has made substantial progress in reducing the frequency of optional CD4 testing, it could be reduced a further 29% by full implementation of new treatment guidelines, with an expected annual savings of $600,000. Reduced CD4 monitoring also would likely reduce patient anxiety with little or no impact on quality of care.
Date: July 1, 2016
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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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Pilot Study Implements HIV Rapid-Testing in Homeless Shelters
Investigators in this pilot study developed and implemented an HIV rapid-testing/linkage-to-care initiative between VA and local government in Los Angeles County (LAC) to provide rapid testing in homeless shelters – and to link individuals with HIV to care. The initiative was considered a success, with stakeholders noting that the collaboration had prompted their participation in testing within homeless shelters. For example, stakeholders stated that once VA investigators were able “to solidify and secure those shelters, it was easy for us to come in… all that groundwork was done,” showing that different levels of government (i.e., federal, county, city) can work collaboratively to implement HIV testing. During the 26-month duration of the initiative, counselors made 189 visits and administered 817 tests (4.5% were to Veterans), identifying seven preliminary HIV-positive individuals. Five were confirmed and linked to care, one did not return for results, and the other refused linkage to care. Cost analysis showed that the cost per HIV-positive individual was $5,714, with costs highest during the first six months. The initiation and support provided by VA was a catalyst in allowing other agencies to concentrate resources. Investigators note this model can be adapted as a “plug and play” intervention, for the most part.
Date: January 1, 2015
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Multimodal Intervention Increases HIV Testing in VA Primary Care
Investigators with VA/HSR&D’s HIV/Hepatitis Quality Enhancement Research Initiative (QUERI) previously developed, implemented, and evaluated a multimodal program to promote HIV testing, which more than doubled testing among at-risk Veterans. These results prompted the current study that scaled up this intervention in a large number of diverse VA facilities. Investigators examined the effectiveness of promoting routine as well as risk-based HIV testing, and the effect of providing different levels of organizational support at study sites. Findings showed that the use of clinical reminders, provider feedback, education, and social marketing in this HIV-testing intervention significantly increased the frequency with which HIV testing was offered and performed within the VA healthcare system. Implementation of this intervention increased the rate of risk-based HIV testing two- to three-fold, and increased routine testing three- to four-fold. Risk-based and routine HIV testing increased in all facility-, provider-, and patient-level groups.
Date: April 19, 2013
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Post-deployment Health Outcomes Associated with Multiple Deployment-Related Factors
This study examined the unique contributions of various deployment-related exposures and injuries to current post-deployment physical, psychological, and general health outcomes in National Guard members. Findings showed that various deployment-related experiences increased the risk for post-deployment adverse mental and physical health outcomes, individually and in combination. Most adverse outcomes had associations with multiple deployment-related factors. Deployment-related mild traumatic brain injury (TBI) was associated with post-deployment depression, anxiety, PTSD, and post-concussive symptoms such as headaches and dizziness. Combat exposures with and without physical injury were associated not only with PTSD, but also with numerous post-concussive and non-post-concussive symptoms (e.g., chest pain, indigestion). Associations between blast exposure and abdominal pain, pain on deep breathing, shortness of breath, hearing loss, and tinnitus suggested residual barotrauma. The experience of seeing others wounded or killed, or experiencing the death of a buddy or leader, was associated with indigestion and headaches, but not with depression, anxiety, or PTSD. Findings indicate that an integrated interdisciplinary healthcare approach would be beneficial for Veterans with multiple deployment-related health issues. Such a system of care is currently being used within the VA Polytrauma programs.
Date: November 1, 2012
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Construction of a Clinical Indicator for the Risk of Over-Treatment among Elderly Patients with Diabetes
The publication of three major trials, including the VA Diabetes Trial (VADT), has prompted greater attention to the potential harms of overly tight glycemic control among patients with diabetes, especially in the elderly and those with cardiovascular disease. The high frequency of risk factors for hypoglycemia and its adverse impact, the marginal benefits of tight control in individuals with short life expectancy, and potential for inaccurate measures suggest a need for a quality measure to reduce over-treatment, particularly among elderly patients. This Commentary discusses these issues and explores the construction of a clinical indicator for the risk of over-treatment.
Date: September 10, 2012
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Pain and PTSD Common Comorbidities among OEF/OIF Veterans with Spinal Cord Injury Undergoing Inpatient Rehabilitation
Pain and PTSD were more likely to manifest as comorbidities than as isolated conditions during inpatient rehabilitation for spinal cord injury. Comorbid pain and PTSD symptoms were more common than either condition alone, and nearly as common as not having either condition. Veterans with pain at the beginning of rehabilitation showed declines in pain ratings over the course of rehabilitation. In contrast, Veterans in the “PTSD Alone” group showed increasing pain over the course of rehabilitation. Factors not associated with pain and PTSD status were: demographic and SCI characteristics, number of comorbid traumatic injuries, and the prevalence of individual comorbid injuries.
Date: August 1, 2012
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Wide Variability among VA Hospitals Regarding ICU Admission Patterns
About half of all Veterans in this study (53%) who were admitted directly to the ICU had a 30-day predicted mortality of 2% or less. In more than half of cases, Veterans with a predicted mortality greater than 30% were not admitted to the ICU. At all levels of patient risk, hospitals varied widely in the proportion of Veterans admitted to the ICU. For example, the rate of admission for Veterans in the low-risk group (predicted mortality <2%) varied from 1% to 39%, while the rate of admission for Veterans in the high-risk group (predicted mortality >30%) varied from 11% to 50%. Investigators also found that for a one standard deviation increase in predicted mortality, the adjusted odds of ICU admission varied substantially across hospitals, ranging from a 15% decrease to a 122% increase.
Date: July 23, 2012
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Gastric Bypass Surgery among Veterans Not Associated with Reduced Healthcare Expenditures Three Years Later
Gastric bypass surgery does not appear to be associated with reduced healthcare expenditures three years after the procedure. Total expenditures trended higher for bariatric surgical cases in the year leading up to the procedure and then converged back to the lower expenditure levels of non-surgical controls one year after the procedure. Health expenditures were similar two and three years before the surgical procedure because surgical patients and non-surgical controls had similar weight and healthcare use trajectories several years before giving serious consideration to bariatric surgery. These results are notable because they contrast with results from several prior observational studies that found costs among post-surgical cases to be lower than those of non-surgical controls two to four years after the procedures. This may be explained by important differences in the populations examined (e.g., Veterans are generally older and sicker than the general population) and the methods of analysis.
Date: July 1, 2012
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Dramatic Improvement in Blood Pressure Management among Veterans with Diabetes, with Potential Over-Treatment
Clinical action measures that reward clinical actions that are strongly tied to evidence might better capture the complexity of clinical decision making about blood pressure management among patients with diabetes. In this study, 713,790 Veterans were eligible for a newly developed clinical action measure. Of these, 94% (n=668,210) met the clinical action measure for BP measurement (82% had a BP <140/90; an additional 12% had BP >=140/90 but appropriate management). This represents a dramatic improvement in BP management over the past decade. Among all Veterans in this study, 197,291 (20%) had a BP <130/65; of these, 80,903 (41% - or slightly more than 8% of the cohort) had potential over-treatment. Facility rates of potential over-treatment varied from 3% to 20%. Facilities with higher rates of meeting the current threshold measure (<140/90) had higher rates of potential over-treatment. Veterans with potential over-treatment were older, had lower mean index BP, and were more likely to be men and have ischemic heart disease.
Date: June 25, 2012
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VA HIV and Hepatitis C Telemedicine Clinics Improve Patient Outcomes among Rural Veterans
Among a rural-dwelling study sample, HIV and hepatitis C telemedicine clinics were associated with improved access, high patient satisfaction, and a reduction in health visit-related time. Clinic completion rates (proxy for access) were higher for telemedicine (76%) than for in-person visits (61%). Of the 43 Veterans in the study, 30 (70%) completed a telemedicine-facilitated survey. More than 95% of these Veterans rated telemedicine at the highest level of satisfaction and preferred telemedicine to in-person visits. Veterans estimated that total health visit time was 340 minutes less for telemedicine compared to in-person visits. The majority of perceived time reduction was related to travel.
Date: April 1, 2012
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Intervention to Increase HIV Testing Can Be Successfully Implemented by Non-Research Staff
This study reports on the one-year results of implementing a program that doubled HIV testing rates in at-risk Veterans receiving care at two VAMCs in two other VA facilities where the research team played a much smaller part in the intervention implementation. Findings showed that the annual rate of HIV testing among at-risk Veterans increased by 6% and 16% after the end of the first year for the two sites to which the project was newly exported, and where non-research staff were responsible for implementation. In contrast, for the original two implementation sites where research staff played a major role, testing rates increased by 9% and 12%. There was no change in the rate of testing at the one control site that did not participate in the project. Authors note that even with differences between the original and “export” sites (e.g., strength of academic affiliations, emphasis on specialized services), the successful implementation and similar increases in HIV testing rates across patient and sub-facility levels provides further support for the generalizability of the intervention.
Date: December 1, 2011
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Veterans Receiving PTSD Disability Benefits May Experience Fewer Symptoms, Less Poverty and Homelessness over Long Term
This study sought to examine long-term outcomes associated with receiving and not receiving VA disability benefits for PTSD. Findings showed that compared to Veterans not receiving VA PTSD disability benefits, Veterans receiving benefits continued to report more severe PTSD symptoms 10 years after applying for benefits, but were more likely to have had a clinically meaningful reduction in PTSD symptoms. Beneficiaries also had reduced odds of poverty and homelessness compared to denied claimants. Employment was low in both groups, and mortality was similar. On average, Veterans who had been awarded PTSD benefits and Veterans who had been denied them both experienced meaningful improvements of similar magnitude in work, role, and social functioning; however, overall functioning remained poor nonetheless. Findings counter common concerns that PTSD disability benefits impede recovery by incentivizing Veterans to remain ill, and suggest that such benefits may be helpful.
Date: October 1, 2011
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Collaborative Care Intervention for Veterans with Ischemic Heart Disease Treated in VA Primary Care Setting
The Collaborative Cardiac Care Project sought to determine whether a multi-faceted intervention using a collaborative care model ? directed through primary care providers ? would improve symptoms of angina, self-perceived health, and concordance with practice guidelines for managing chronic stable angina among Veterans with ischemic heart disease (IHD). Findings showed that the collaborative care intervention had no significant effects on symptoms or self-perceived health, but significantly improved receipt of guideline-concordant care in Veterans with stable angina. Although concordance with guidelines improved 4.5% more among Veterans receiving collaborative care than those receiving usual care, this was mainly due to increased use of diagnostic testing rather than recommended medications. The collaborative care model was well received by primary care providers, who implemented 92% of 701 recommendations made by collaborative care teams. Nearly half of the recommendations were related to medications, e.g., adjustments to beta blockers, long-acting nitrates, and statins.
Date: September 12, 2011
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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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Behavioral and Medication Management Interventions Improve Blood Pressure Control for Veterans
This randomized clinical trial evaluated three nurse-led, home tele-monitoring interventions that were developed to improve blood pressure (BP) – and also tested which intervention was most effective among Veterans treated in VA primary care. Findings showed that overall, the behavioral and medication management intervention groups had a greater increase in the proportion of Veterans with BP measurements within target, relative to the usual care group, at 12 months. These findings were not sustained at 18 months; however, among Veterans with poor baseline BP control, the combined intervention significantly decreased blood pressure at both 12 and 18 months.
Date: July 11, 2011
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Long-Term Outcomes Following Positive Colorectal Screening
Despite persistently low rates of follow-up colonoscopy in older adults with positive fecal occult blood test (FOBT) results, the long-term outcomes of screening and follow-up practices have not been described. This study examined outcomes following a positive screening FOBT result for 212 Veterans ages 70 years or older at four VA facilities in 2001. Both Veterans who did receive a follow-up colonoscopy and Veterans who did not were followed through 2008. Findings showed that, over a 7-year period, a little more than half of the older Veterans in this study received a follow-up colonoscopy after a positive FOBT. Among Veterans who received follow-up colonoscopy, more than 25% had significant adenomas or cancer detected, were treated, and survived for more than five years. Approximately 59% of Veterans who received follow-up colonoscopy had no significant findings, and 10% experienced complications from colonoscopy or cancer treatment. Among Veterans who did not receive follow-up colonoscopy, 57% underwent some form of follow-up other than colonoscopy (e.g., repeat FOBT or sigmoidoscopy) and 59% had more than one non-colonoscopy follow-up test. Nearly half of the non-colonoscopy group died of other causes within five years, and 3% ultimately died of colorectal cancer. Veterans with the best predicted life expectancy were less likely to experience net burden from screening than Veterans with the worst predicted life expectancy. These findings support guidelines that recommend using life expectancy to guide colorectal cancer screening decisions in older adults, and argue against one-size-fits-all interventions that simply aim to increase overall screening and follow-up rates.
Date: May 9, 2011
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Medication Reconciliation Reduces Adverse Drug Events Related to Some Hospital Admission Prescribing Changes
This study estimated the effectiveness of inpatient medication reconciliation at the time of hospital admission on adverse drug events (ADEs) caused by admission prescribing changes. Findings showed that medication reconciliation at the time of hospital admission reduced ADEs caused by admission prescribing changes that were classified as errors by 43%, but it did not reduce ADEs caused by all admission prescribing changes. Non-error-related ADEs would not be averted by one-time medication reconciliation on admission, but they might be averted by improved provider awareness and monitoring of admission prescribing changes during the hospital stay. The potential impact of such an intervention is large, as 50% of the ADEs in this study were caused by admission medication changes that were not errors.
Date: May 9, 2011
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Telemedicine ICU Coverage Lowers ICU Mortality but Not In-Hospital Mortality
Because many hospitals lack the patient volume or financial resources to hire dedicated specialists trained to care for critically ill patients (intensivists) – and because of a shortage of these trained specialists – hospitals are increasingly adopting telemedicine ICU (tele-ICU) coverage. This systematic review of the literature examined the impact of tele-ICU coverage on mortality and length of stay in non-VA hospitals. Findings showed that tele-ICU coverage was associated with a significant 20% reduction in ICU mortality, but did not significantly reduce in-hospital mortality for patients admitted to an ICU. Tele-ICU coverage was associated with a 1.26 day mean reduction in ICU length of stay, which translates into a 10%-30% relative reduction in ICU length of stay. Tele-ICU was not associated with a reduction in the patient’s length of stay in the hospital.
Date: March 28, 2011
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Improvements Using Patient-Aligned Group Clinics for Diabetes Care
This study evaluated the comparative effectiveness of two group self-management interventions for glycemic control among Veterans with treated but uncontrolled diabetes. Findings show that Veterans who participated in the primary care-based “Empowering Patients in Care” (EPIC) intervention had significantly greater improvements in HbA1c levels immediately following the active intervention; these differences remained at one-year follow-up. Thus, primary care-based diabetes group clinics that include patient-aligned approaches to goal-setting (e.g., action plan) for medication management, and diet and exercise changes can significantly improve HbA1c levels. Diabetes self-efficacy measures improved immediately after the intervention in both the EPIC and comparison intervention groups, but were significantly higher in the EPIC group. Self-efficacy was associated with individual changes in HbA1c levels. At 1 year, differences in HbA1c levels between groups remained the same (i.e., there was no return to baseline, but also no further improvements). Self-efficacy levels dropped in both groups at 1 year; but the drop in the EPIC intervention participants was less than the diabetes education participants, resulting in modest (non-significant) differences between the groups at one year.
Date: March 14, 2011
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Successful Translation of Behavioral Intervention for Caregivers of Veterans with Dementia
This study assessed the translation of the NIA/NINR Resources for Enhancing Alzheimer’s Caregivers Health (REACH II) intervention into REACH VA – a behavioral intervention for caregivers of Veterans with dementia that ran from 9/07 through 8/09. Findings show that the REACH VA intervention provided clinically significant benefits for caregivers of Veterans with progressive dementia. Caregivers reported significantly decreased burden, depression, impact of depression on daily life, frustrations associated with caregiving, and number of troubling dementia-related behaviors. Also, a decrease of two hours per day “on duty” trended toward significance. Of the caregivers who participated in the REACH VA intervention, 96% believed that the program should be provided by VA to caregivers.
Date: February 28, 2011
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Routine, Oral, Rapid HIV Testing in VA Emergency Departments Financially Equivalent to Usual Care
Using a dynamic decision analysis model, this study examined the budget impact of implementing a routine oral HIV rapid-testing program in a VA emergency department (ED) versus the impact of following ‘usual’ care. Findings show that a routine oral HIV screening program using a rapid testing approach is financially equivalent to following a usual care approach within the VA healthcare system. Assuming a 1% prevalence of the disease and an 80% acceptance of testing, the total cost of HIV rapid-testing was $1,418,088 versus $1,320,338 for ‘usual care.’ While the HIV rapid-testing program had substantial screening costs, they were offset by lower inpatient expenses associated with earlier identification of disease. The higher treatment costs for ‘usual care’ patients were largely due to inpatient stays, reflecting more hospitalizations for these patients due to opportunistic infections. Given that early detection of HIV and linkage to treatment is associated with better health outcomes – and non-targeted testing does not result in a greater budget impact than usual care – the authors suggest that this analysis provides support for the implementation of a routine oral rapid testing program within VA.
Date: January 27, 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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Concussion/mild TBI During Deployment Does Not Result in Significant Post-Deployment Health Effects Separate from PTSD
This study assessed the longitudinal associations between concussion/mild TBI (mTBI) and PTSD symptoms reported in-theater and longer-term psychosocial outcomes in 953 combat-deployed National Guard soldiers. Findings show that the rate of self-reported concussion/mTBI was 9% at Time 1 (one month before returning home from Iraq) and 22% at Time 2 (one year later). Differences may be explained by recall bias and/or poor reliability of the TBI screening instrument. Prevalence of probable PTSD at Times 1 and 2 was 8% and 14%, respectively; and for probable depression was 9% and 18%, respectively. At Time 2, 42% screened positive for problematic drinking and 29% endorsed clinically-significant non-specific somatic complaints. Self-reported post-concussive symptoms at Time 2 were common. For example, among those who reported neither mTBI nor PTSD, 23% reported balance problems, 57% reported tinnitus, 60% reported memory problems, and 64% reported concentration problems and irritability. Post-concussive symptom prevalences were even higher among those who reported mTBI and/or PTSD. The increased post-concussive symptoms reported by soldiers who also reported concussion/mTBI were no longer statistically significant after adjusting for post-deployment PTSD symptoms, suggesting that post-concussion symptoms may be largely explained by PTSD. Findings suggest that early identification and evidence-based treatment of PTSD may be important to the management of post-concussive symptoms following deployment.
Date: January 1, 2011
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Rates of Liver Cancer and Cirrhosis Increase Significantly among Veterans with Hepatitis C Virus
This study identified all Veterans with hepatitis C virus (HCV) who visited any of 128 VA medical centers over a 10-year period to examine the prevalence of cirrhosis, hepatic decompensation, and hepatocellular cancer, as well as risk factors that may be associated with an accelerated progression to cirrhosis. The number of Veterans diagnosed with HCV increased over the ten years from 17,261 to 106,242. Over the same time period, among HCV patients, the prevalence of cirrhosis increased from 9% to 18.5%, while the prevalence of liver cancer increased approximately 19-fold (from 0.07% to 1.3%). Regarding risk factors among HCV-infected Veterans, the proportion of patients with co-existing diabetes increased from 12% in to 23%, while the number of patients with HIV, hepatitis B virus, or a diagnosis of alcohol use declined slightly.
Date: December 22, 2010
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Link between Psychiatric Diagnosis and Higher Risk of Suicide among Veterans
As part of VA’s ongoing evaluation of suicide risk among Veterans being treated in VA facilities, this study examined the impact of different psychiatric diagnoses on the risk of suicide. Findings show that a clinical diagnosis of a psychiatric disorder increased the risk of subsequent suicide by 160%. Psychiatric diagnoses were an especially strong risk factor for suicide among women, increasing their risk of suicide more than 5-fold. Bipolar disorder was the least common diagnosis (only 3% of all Veterans studied), but was diagnosed in approximately 9% of all Veterans who died by suicide. A diagnosis of bipolar disorder increased the risk of suicide nearly 3-fold in men and 6-fold in women. Authors suggest this makes bipolar disorder particularly appropriate for targeted interventions (e.g., improving medication adherence). Overall, suicides were more than three times as common in men than in women and were 37% to 77% more common in Veterans ages 30 and older than among those ages 18 to 29.
Date: November 1, 2010
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Processes of Care to Improve Stroke Outcomes
After adjusting for patient characteristics and other processes of care, three processes of care were independently associated with a reduction in the combined outcome: 1) swallowing evaluation, 2) deep vein thrombosis (DVT) prophylaxis, and 3) treating all episodes of hypoxia with supplemental oxygen. Two of the three processes (swallowing evaluation, DVT prophylaxis) are similar to existing stroke quality measures, but the treatment of hypoxia is not a current performance measure. Thus, authors recommend that organizations that establish national performance measures add treatment of hypoxia to their assessment of stroke care quality, and continue to measure DVT prophylaxis and swallowing assessment among stroke patients.
Date: May 10, 2010
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Assessment Tool for Elderly Adults’ Capacity to Live Independently
An interdisciplinary team of clinicians developed the Capacity Assessment and Intervention (CAI) model to evaluate vulnerable patients – and to assess their capacity for safe and independent living. Despite some challenges, the authors suggest that the CAI model provides a systematic approach to initiating, conducting, and following through an assessment of an older adult’s capacity to make and execute decisions regarding safe and independent living in the community.
Date: May 1, 2010
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Nurse-Initiated Rapid HIV Testing was Cost-Effective and Increased Screening Rates among Veterans
Nurse-initiated routine screening (i.e. recommending HIV testing to all Veterans) with rapid HIV testing and streamlined counseling increased rates of testing and receipt of test results among Veterans – and was cost-effective compared with traditional risk-based HIV testing strategies. When benefits to sexual partners from reduced transmission was considered, rapid testing with streamlined counseling was even more favorable. Traditional risk-based HIV counseling and testing resulted in the lowest costs and effectiveness.
Date: March 4, 2010
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Relationship between Cost of Care and Quality of Care for Two Conditions in Non-VA Hospitals
The relationship between (non-VA) hospitals’ cost of care and quality of care for a particular condition was small and differed by condition. However, evidence did not support the hypothesis that low-cost hospitals discharge patients with congestive heart failure (CHF) or pneumonia earlier, only to increase readmission rates and incur greater inpatient cost of care over time. Low-cost hospitals had similar or slightly higher 30-day readmission rates compared with high-cost hospitals. Hospitals in the highest-cost quartile for CHF care had higher quality-of-care scores and lower mortality. For pneumonia, the opposite was true: high-cost hospitals had lower quality-of-care scores and higher mortality. Risk-adjusted costs of care for CHF and pneumonia varied widely between hospitals, although hospital cost-of-care patterns seemed stable over time.
Date: February 22, 2010
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Chronic Kidney Failure Associated with Increased Mortality among Veterans with HIV and Hepatitis C Virus
Compared with their mono-infected counterparts, Veterans with HIV who were co-infected with HCV had significantly higher rates of chronic kidney disease (14% vs. 11%) and mortality. HCV co-infection independently increased the likelihood of death by nearly 25%, after adjusting for other important HIV- and HCV-related factors. Co-infected Veterans also were less likely to have received highly active antiretroviral therapy (HAART) at baseline. Authors suggest that efforts should be targeted toward optimizing medical care for mono- and co-infected Veterans, including HAART therapy, HCV antiviral therapy, and treatment of comorbid medical conditions.
Date: February 1, 2010
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Comparing Two Weight Loss Therapies in Overweight/Obese Veterans
This study compared a low-carbohydrate, ketogenic diet (LCKD) to orlistat combined with a low-fat, reduced-calorie diet (O+LFD). Findings show that a low-carbohydrate diet led to similar improvements as O+LFD for weight, serum lipid, and glycemic parameters – and was more effective for lowering blood pressure. While weight loss was significant and similar for both diet interventions, and decrease in waist circumference also was similar, the LCKD had a more beneficial impact than the O+LFD on systolic (-5.9 vs. 1.5 mm Hg) and diastolic (-4.5vs. 0.4 mm Hg) blood pressure. Study results also show that participants who attended 80% or more of the group counseling sessions lost considerably more weight, regardless of treatment assignment. The authors suggest that efforts be made to incorporate similarly intensive weight loss programs into medical practice.
Date: January 25, 2010
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Predictors Associated with Use of Complementary/Alternative Medicine in Men with HIV
This study sought to describe the types, frequency, and intensity of complementary/alternative medicine (CAM) use among men living with HIV infection in southern California and northern Florida/southern Georgia, and to identify predictors of CAM use and intensity. Findings show that the majority of men with HIV infection in this study (69%) reported some CAM use. The most frequently cited types of CAM use were drug or dietary supplements (71%) and spiritual therapies (66%). CAM use was almost three times higher in California compared to Florida/Georgia, and was also greater in men who reported depression or more health-promoting behaviors. The odds of CAM use intensity increased with greater symptom frequency and more health-promoting behaviors. In addition, vitamins, dietary supplements, and herbs were used by the majority of men in this study. The authors suggest that high levels of CAM use among men with HIV infection should alert healthcare providers to assess CAM use and to incorporate CAM-related patient education into their clinical practices.
Date: November 1, 2009
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Team-Based Care Led by Pharmacists or Nurses Improves Blood Pressure Control
Investigators in this study conducted a systematic review of the literature to evaluate the effectiveness of team-based BP care involving pharmacists and nurses. Findings indicate that team-based interventions involving nurses or pharmacists were associated with significantly improved blood pressure control, with community pharmacists having the greatest impact. In addition, counseling on lifestyle modification and providing free BP medications had a significant impact on lowering systolic BP. Results also show that intervention strategies that provided medication education were the most effective, but this strategy cannot be evaluated on its own merit because it was usually provided with additional strategies.
Date: October 26, 2009
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“Super-obesity” Associated with Risk of Death Among Veterans Following Bariatric Surgery
This retrospective study of 856 bariatric surgical cases conducted in 12 VAMCs between 2000 and 2006 sought to define the risk of death among Veterans with a body mass index (BMI) of 40 or greater – and to identify patient-level factors associated with mortality. Findings show that Veterans classified as “super-obese” (BMI of 50 or higher) and those with a higher chronic disease burden appear more likely to die within one year of having bariatric surgery. Authors recommend that the risks of bariatric surgery in patients with significant comorbidities should be carefully weighed against potential benefits in older male Veterans and those with super-obesity.
Date: October 1, 2009
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Improving Provider-Patient Communication about Routine HIV Testing in VA
This study sought to understand patient and provider perspectives on the adoption of routine HIV testing within the VA healthcare system. Findings show that Veterans and providers agreed that the implementation of routine HIV testing, treating HIV like other chronic diseases, and removing requirements for written informed consent and pre-test counseling would benefit both Veterans and public health. Veterans wished to have HIV testing routinely offered by providers so that they could decide whether or not to be tested; they also believed that routine testing would help de-stigmatize HIV. Six steps for providers to use in communicating about routine testing also were identified, such as raising the topic of HIV testing, reassuring the Veteran that he/she is not showing clinical signs of the disease, and responding to Veteran questions about HIV.
Date: October 1, 2009
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Low Rates of HIV Screening among Veterans with Substance Use Disorders
This study sought to determine the rate of HIV screening among Veterans with substance use disorders. Findings show that among the 371,749 Veterans with substance use disorders in this study, only 20% had evidence of ever having been screened for HIV. HIV screening was lowest among Veterans with alcohol use disorders alone (11%), and highest among Veterans treated in substance use programs (28%) or receiving inpatient care (28%). Authors suggest that these findings support the need for more widespread interventions to expand routine voluntary HIV screening nationally – within and outside VA.
Date: October 1, 2009
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Improving Acute Care for Elders at Risk for Poor Hospital Outcomes
For patients older than age 65, traditional hospital care frequently results in adverse outcomes that increase their risk of mortality, functional dependency, and institutionalization. There are several alternative models to traditional hospital care that have been shown to address these problems and improve outcomes for older patients. One such model is VA’s Geriatric Evaluation and Management (GEM) program, which was launched in 1976 to provide interdisciplinary, multi-dimensional evaluations for elderly Veterans in need of geriatric treatment, rehabilitation, health promotion, and social service interventions. However, alternative models are not widely disseminated. This Editorial challenges healthcare providers to think outside the traditional hospital box. They suggest broadening the implementation and availability of programs such as GEM and Hospital at Home (non-VA program providing hospital-level care of elders in their own homes) for those patients who would benefit from acute care outside a hospital setting.
Date: September 28, 2009
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Drugs-to-Avoid Criteria for the Elderly have Limited Value
Drugs-to-avoid criteria are lists of drugs considered to be potentially inappropriate for the elderly due to adverse effects, limited effectiveness, or both. For example, the Centers for Medicare and Medicaid Services use a version of the criteria of Beers et al. in nursing homes, and the National Committee for Quality Assurance uses the criteria of Zhan et al. to compare the quality of U.S. health plans. This study compared the Beers and Zhan criteria with individualized expert assessment of patients’ medications in 256 elderly Veterans from the Iowa City VAMC who were taking five or more medications. Findings show that the drugs-to-avoid criteria performed poorly when used as quality measures to assess the current state of a patient’s drug therapy. For example, half or more of the drugs flagged by the Beers and Zhan criteria were not considered problematic upon individualized expert review. In addition, the Beers and Zhan criteria identified only 8-15% of drugs that experts judged to be problematic. Therefore, authors suggest that while these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures for the quality of prescribing.
Date: July 27, 2009
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Effective Clinical Decision Support Tool for HIV Symptom Management
This pilot study produced a clinical decision support tool called TEMS that was developed to: elicit information about symptoms at routine clinic visits; organize information to emphasize what is most useful for clinical care; present information at the point-of-care; and recommend clinical responses based on that information. TEMS was implemented as part of VA’s electronic medical record at one VA medical center, to increase provider awareness of and response to common HIV symptoms. Investigators then studied the tool’s feasibility in routine care within a weekly HIV clinic, comparing a 4-week intervention period with a 4-week control period. Findings show that TEMS was accepted by Veterans and their providers and did not substantially impede workflow. In addition, there was a trend toward including a greater number of symptoms in the progress notes documented during the intervention period compared to the control period.
Date: July 1, 2009
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Smoking Cessation Services for Veterans in VA Psychiatric Facility
This study had two goals: 1) determine staff characteristics that are associated with attitudes about providing smoking cessation services to Veterans who are psychiatric patients, and 2) seek suggestions from staff about what would be important to include in a tobacco cessation program. Findings show that nearly 75% of staff in this study thought that VA should do more to assist Veterans to quit smoking, yet only about 25% said that they personally provide cessation services. However, more than 50% felt moderately, very, or extremely confident in providing cessation services. Interestingly, nurses were less likely than other staff to feel that it was important to provide cessation services, which could be because of competing job demands. The most common reasons given by all respondents for not providing services were not enough time and lack of training. When asked how VA could best assist smokers to quit, most responses focused on educating Veterans about tobacco use and how they can quit, as well as providing tobacco cessation medications.
Date: June 1, 2009
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Improving Wheelchair Appropriateness for Adults with Spinal Cord Injury
This study integrated and expanded upon previously published models of wheelchair service delivery to provide a preliminary framework for developing more comprehensive, descriptive models for adults with spinal cord injury (SCI). In this article, ‘wheelchair service delivery’ includes the process of justifying wheelchair selection, approving the selected wheelchair, delivering it to the client, fitting and customizing the wheelchair, and providing follow-up care and consultation. Findings show that most experts stress the importance of having both patients and providers play a key role in the process. For example, the primary patient factors identified were: wheelchair funding source, ability to pay out of pocket, decision-making capacity, self-awareness of needs, familiarity with products, and family influences. Suppliers also play an integral role and may significantly influence the appropriateness of the wheelchair provided. In addition, the authors identified a number of system-level factors (e.g., facility standards, policies, and regulations) that influence wheelchair service delivery.
Date: June 1, 2009
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Veterans with HIV Treated at Clinics with Integrated Specialty Services More Likely to Achieve Better Outcomes
The most common way HIV clinics address patients with comorbidities is by integrating non-infectious disease providers (e.g., psychiatrists and social workers) into HIV primary care. This retrospective cohort study evaluated the association between Integrated HIV Care and patient outcomes among 1018 Veterans with HIV who received care at five VA facilities from 2000-2006. Findings show that Veterans who visited HIV clinics with more integrated specialty services were more likely to achieve viral suppression. In particular, Veterans visiting clinics that offered hepatitis, psychiatric, psychological, and social services in addition to primary care and HIV specialty services were three times more likely to achieve viral suppression than Veterans visiting clinics that offered only primary care and HIV specialty services. Results also showed that 93% of Veterans in this study had one or more comorbid conditions, with a mean of 3.2 comorbidities. Authors suggest that resources should be allocated to integrate sub-specialty services into HIV primary care clinics, and that providers should direct patients toward these clinics and retain them in care.
Date: May 1, 2009
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Diffusion of New Drug Therapy for PTSD Lessens with Distance
This study sought to evaluate the pace and reach of the passive dissemination of a novel, but as yet un-established treatment with the drug prazosin for post-traumatic stress disorder (PTSD) within the VA health care system. Investigators used geographic surveillance data to track the diffusion of prazosin to treat Veterans diagnosed with PTSD in the VA Puget Sound Healthcare System (where the treatment was developed), and at VAMCs ranging up to 2500 miles or farther from Puget Sound. Findings show that the passive diffusion of a new treatment can be rapid in the immediate area in which it is developed, but the geographic gradient of use seems to be steep and changed little during a two-year period, even when cost and organizational barriers were minimal. Veterans with PTSD treated in the area nearest to Puget Sound (<499 miles) were about 63% less likely in 2004 and about 49% less likely in 2006 to be prescribed prazosin than their counterparts treated within Puget Sound. These results suggest that if and when new treatments are definitively demonstrated to be effective, more active dissemination is likely to be needed, especially in geographically remote areas.
Date: April 1, 2009
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OEF/OIF Veterans with Spinal Cord Injury and Additional Problems Require Timely Intervention to Avoid Rehabilitation Delays
Soldiers returning from Iraq and Afghanistan with spinal cord injury often have additional medical and psychosocial problems that require timely intervention to avoid significant delays in rehabilitation. Rehabilitation was often delayed because other problems needed to be addressed first.
Date: March 1, 2009
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Assessing Accuracy and Completeness of Research Data
VA benefits from one of the most highly developed health information systems in the world, which includes the Immunology Case Registry (ICR) that was designed to monitor costs and quality of HIV care, and the Decision Support System (DSS) that was developed to monitor utilization and costs of Veterans in care. This study compared ICR and DSS datasets, which share overlapping laboratory data from the same VA electronic record system. Findings show that six of the laboratory tests for HIV patients that were studied demonstrated remarkably similar amounts of overlap (68% to 72%) between the two datasets, showing that ICR and DSS are both good sources of data for these tests. However, several other tests demonstrated much lower proportions of overlap (between 20% and 31%). These findings indicate that validation of laboratory data should be conducted prior to its use in quality and efficiency projects.
Date: January 1, 2009
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Quality Indicators to Help Treat Veterans with HIV and Depression
Quality indicators were developed based on a review of the existing clinical guidelines for depression, particularly depression related to HIV, in addition to a review of the literature. Authors suggest that quality indicators identified in this study provide a useful tool for measuring and informing the quality of HIV depression care.
Date: October 1, 2008
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Physicians May Lack Empathy in Treating Veterans with Lung Cancer
Physicians rarely responded empathically to lung cancer patients’ concerns and generally responded more consistently with empathy when patients presented concrete and positive, rather than abstract or negative concerns. The authors note that there may be several reasons why physicians may not display empathy; for example, they may be too busy to recognize opportunities, or they may believe that biomedical information is more reassuring.
Date: September 22, 2008
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Variation in Care for Recurrent Non-Melanoma Skin Cancer in a University-Based vs. VA Practice
Treatment choices differed significantly between the two sites: after adjusting for patient, tumor, and clinician characteristics that may have affected treatment choice, tumors treated at the university-based site remained significantly more likely to be treated with Mohs surgery. There was no evidence that the quality of care varied at the two sites.
Date: September 1, 2008
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