Publication Briefs

Publication Briefs
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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 Team-Based Palliative Telecare Led to Improved Quality of Life in Veterans with Chronic Lung Disease and Heart Failure This clinical trial determined the effect of a nurse and social worker palliative telecare team on quality of life in outpatient Veterans with COPD, heart failure (HF), or interstitial lung disease (ILD) compared to usual care. Findings showed that Veterans who received the palliative telecare team intervention reported significantly improved quality of life at six months compared with Veterans who received usual care (mean quality of life score improvement of six points vs. one point; a clinically meaningful difference is four points). The positive intervention effect on quality of life began early, at 4 months, and persisted at 12 months. The intervention also improved COPD and HF health status, and depression and anxiety at six months. The virtual and population approach of this intervention can improve the reach of palliative care services in traditionally under-resourced areas. Date: January 16, 2024 Individualized Provider Reminders Improve Statin Use and Adherence among Veterans with Atherosclerotic Cardiovascular Disease This multi-site trial compared usual care to personalized reminders to providers in improving the use of high-intensity statins in Veterans with atherosclerotic cardiovascular disease (ASCVD). Findings showed that centrally processed individualized reminders to providers led to a significant increase in high-intensity statin (HIS) use and statin adherence among Veterans with ASCVD. In the intervention arm, the absolute change in HIS was +10% for those who received a reminder versus a -0.18% decrease among those who did not receive a reminder. Baseline HIS use at intervention and usual care sites was 54% and 56%, respectively. At the end of the study, HIS use at intervention and usual care sites was 55% and 54%, respectively. Centrally controlled reminders allowed rapid upscaling of the intervention to several sites. Date: March 5, 2023 Home-Based Cardiac Rehabilitation May Decrease Mortality This study evaluated all Veterans referred to home-based cardiac rehabilitation (HBCR) at one VA Medical Center and compared outcomes for those who participated in the program and those who did not. Findings showed that Veterans who underwent HBCR had 36% lower risk of mortality after 4 median years of follow-up compared to non-participants, suggesting that participation in HBCR may benefit patients who cannot attend traditional CR programs. However, even when home-based cardiac rehabilitation was offered at the time and place of their choosing, only 44% of eligible Veterans chose to participate. Findings are especially relevant given that COVID-19 has caused many CR programs to offer HBCR as a temporary intervention. Date: March 1, 2023 Traumatic Brain Injury May Be a Potentially Novel Risk Factor for Cardiovascular Disease in Veterans This study sought to determine the association between TBI and subsequent cardiovascular disease (CVD) in post-9/11 era Veterans. Findings showed that post-9/11 Veterans with mild TBI, moderate to severe TBI, and penetrating TBI were more likely to develop CVD compared to Veterans without TBI. Although the risk was highest shortly after injury, TBI remained significantly associated with CVD for years after the initial injury. All TBI categories increased the risk of stroke, coronary artery disease, and peripheral artery disease. Mild and moderate to severe TBI categories were also associated with an increased risk of CVD mortality. Veterans with TBI were more likely to have a history of smoking, substance use disorder, obesity, obstructive sleep apnea, insomnia, PTSD, depression, and anxiety. Conversely, hyperlipidemia, kidney disease, hypertension, and diabetes were more common in Veterans without TBI. Date: September 6, 2022 Predictive Tool Associated with 22% Lower Odds of All-Cause Mortality among High-Risk Veterans Taking Opioids In 2018, VA mandated a case review intervention that targeted patients who had been prescribed opioid analgesics and who were at high risk of adverse outcomes. The Stratification Tool for Opioid Risk Mitigation (STORM), a provider-facing dashboard that uses predictive analytics to stratify patients prescribed opioids based on their risk for overdose/suicide, was developed to identify these patients and assist providers in determining whether a patient needed a revised treatment plan or augmented care. Investigators then evaluated the impact of the case review mandate on serious adverse events (SAEs) and all-cause mortality among Veterans designated as high-risk between 2018-2020. Findings showed that identifying high-risk patients and mandating they receive an interdisciplinary case review was associated with 22% lower odds of all-cause mortality relative to control patients. This kind of impact is on par with interventions such as common medications for heart disease. Mandated review patients were five times more likely to receive a case review than non-mandated patients with similar risk – and they received more risk mitigation strategies. Date: May 2, 2022 Increased Risk for Cardiovascular Conditions among Veterans for Up to One Year Following COVID-19 Infection This study evaluated the risks and 12-month burdens of cardiovascular outcomes among Veterans who survived the first 30 days of COVID compared to VA healthcare users with no COVID and Veterans who used VA healthcare before the COVID pandemic. Findings showed that COVID-19 increased the risk of developing cardiovascular conditions – spanning several categories – within the first month to one year after infection. The risk increased even in Veterans without previous heart conditions and in those with mild COVID-19 infection. Overall, heart disease was seen in 4% more people who contracted COVID-19 than in those without. COVID-19 patients were 72% more likely to suffer from coronary artery disease, 63% more likely to have a heart attack, and 52% more likely to have a stroke. Health systems should prepare for a significant contribution of COVID-19 to a rise in the burden of cardiovascular diseases and the potential long-lasting consequences for patients and the health system. Date: February 7, 2022 Marginal Improvements and Significant Variation in Optimal Treatment for Veterans with Heart Failure This study sought to evaluate trends in guideline-directed medical therapy, implantable cardioverter-defibrillator (ICD) use, and risk-adjusted mortality among VA patients with recent-onset heart failure with reduced ejection fraction (HFrEF). Findings showed only marginal improvements between 2013 and 2019 in guideline-recommended therapy and mortality rates among Veterans with recent-onset HFrEF. Substantial variation in medical therapy rates across VA facilities was observed, e.g., for guideline-recommended ß-blocker use, 8 facilities had rates less than 55%, and 19 facilities exceeded 75%. Risk-adjusted mortality decreased over the study period from 20% in 2013 to 18% in 2019. Facility-level, 1-year risk-adjusted mortality rates ranged from 14% to 23%. Among patients with an ICD indication, use rates were 41% at 6 months but decreased over time. Thus, despite the availability of multiple therapies that are associated with reduced mortality among VA patients with HFrEF, treatment rates remained suboptimal, suggesting the need for new approaches to increase the uptake of evidence-based treatment. Date: November 10, 2021 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 Women Veterans with Premature Cardiovascular Disease Less Likely than Men to Receive Secondary Prevention Therapy This study sought to evaluate sex-based differences in antiplatelet use, any statin and high-intensity statin (HIS) therapy, and statin adherence among patients with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD). Findings showed that women Veterans with premature (age < 55 years) and extremely premature (age < 40 years) ASCVD were less likely to receive antiplatelet agents or statins than men. Premature ASCVD women, compared with men, were significantly less likely to receive antiplatelets (61% vs. 79%), any statin (58% vs. 75%), or HIS therapy (24% vs. 38%). Women with premature ischemic heart disease were comparatively less statin adherent. Relative to women of other races, Black women were less likely to receive some therapies but also more likely to receive others. There was no heterogeneity observed regarding statin adherence. Overall, both sexes received sub-optimal aspirin and statin therapy and had poor statin adherence. Date: April 21, 2021 Many Veterans Unnecessarily Take Low-Dose Aspirin to Prevent Cardiovascular Disease The goal of this study was to investigate the suitability of electronic health records (EHR) to identify patients for deprescribing aspirin based on updated guidelines. Findings showed that many Veterans unnecessarily take low-dose aspirin to prevent cardiovascular disease. Between 2% to 5% of Veterans in this study took low-dose aspirin outside of the guidelines and qualify for the definition of medication overuse as defined by the Institute of Medicine. The percentage of Veterans with low-dose aspirin use was especially high in those aged 50-79. True numbers are likely even higher given the incomplete capture of aspirin use in the EHR. Date: December 15, 2020 New Tool Using Electronic Health Records Can Reliably Detect Infections after Cardiac Device Procedures This study sought to develop and validate an electronic detection tool that accurately and reliably flags cardiovascular implantable electronic device (CIED) cases with true post-procedure cardiac device infection, leveraging the strengths of VA’s electronic health record. Findings showed that combining structured data, such as microbiology results, with text note searches was highly efficient for identifying true post-procedural infection. Among all 19,212 cardiac device procedures performed within VA in FY16-17, investigators reviewed 744 cases and identified 154 true procedure-related infections. The positive predictive validity of the tool was 44%, and overall sensitivity and specificity were 94% and 49%, respectively, indicating that the tool is useful for flagging cardiac device infection cases. This novel measurement tool, which adds data collected in clinical notes to flag cardiac device infections, has the potential to significantly reduce the burden of manual review for infection surveillance. Similar tools that combine structured data and key words from clinical notes could be developed to enhance infection detection, improve early event reporting, and support infection control efforts for other types of infections. Date: September 21, 2020 Higher Mortality for Veterans Choosing Community Hospitals Rather than VA for Percutaneous Coronary Intervention This study compared the clinical outcomes of Veterans undergoing elective percutaneous coronary revascularization (PCI) at VA and community hospitals after the significant expansion of the community care program. Findings showed that Veterans receiving elective PCI in the community were at higher risk of dying—especially within the first month—than those treated at a VA medical center. There was a 33% increase in death risk for Veterans treated at community hospitals versus within VA, with an absolute risk difference of 1.4%. Restricting the analysis to just the first month after the procedure showed an even sharper increase in relative risk—143%, with an absolute difference of 0.7%—for the community-hospital setting. Two-thirds (67%) of Veterans received elective PCI within VA, while 33% received PCI in community facilities. However, over the period of 2015 to 2018, the probability of having PCI performed at a non-VA hospital rose from 39% to 52%. Date: September 1, 2020 VA Achieves Reduction in Heart Failure Readmissions – Without Change in Mortality – Despite Non-Financial Incentives This study sought to evaluate trends in heart failure readmissions and mortality over the past decade in the VA healthcare system, which prioritized reducing readmissions without introducing financial penalties. Findings showed that over a 10-year period in which VA worked to reduce hospital readmissions for Veterans with heart failure (e.g., through public reporting and QI programs), a steady decline in readmissions was seen with no increase in mortality. Between January 2007 and September 2017 there was a 2% decline in 30-day readmissions and a 1% decline in 1-year readmissions. Mortality rates at 30 days decreased by 0.5%, while mortality rates at 1-year increased by 1.3%. Date: June 17, 2020 Palliative Care During VA Hospitalization for Heart Failure Reduces Readmissions and Mechanical Ventilation This study examined the association of palliative care during heart failure hospitalizations with transitions (i.e., multiple readmissions or intensive care admissions) and procedures (i.e., mechanical ventilation, pacemaker implantation, or defibrillator implantation) in the six months following hospital admission. Findings showed that palliative care during hospital admissions for heart failure was associated with fewer multiple readmissions (31% versus 40%), less mechanical ventilation (3% versus 5%), and less defibrillator implantation (2% versus 4%). Hospice use in the six months after discharge was significantly higher among Veterans in the palliative cohort vs those in the non-palliative cohort (35% vs 18%). These findings add to an increasing number of analyses that found associations between palliative care and positive outcomes for patients experiencing heart failure. As health systems develop population health approaches to care, palliative care for heart failure patients should be considered as an adjunct to improve patient quality of life, symptom management, and goal setting – and to potentially reduce rehospitalizations and mechanical ventilation. Date: June 2, 2020 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 Little Correlation between VA Spending and Survival among Veterans with Chronic Heart Failure This study sought to determine the association between healthcare spending and survival in VA patients with chronic heart failure (CHF). Findings showed that there was a modest but statistically significant association between VA spending and survival among patients with CHF; however, the general relationship indicated little correlation. Mean annual expenditures varied from $21,300 to $52,800 per patient (annual expenditures at the highest-cost VAMC were about 2.5 times greater than expenditures at the lowest-cost VAMC)—and annual survival varied between 81% and 89%. Thirteen VAMCs in the lowest quartile for cost were also in the highest quartile for survival, whereas 10 VAMCs in the highest quartile for cost were also in the lowest quartile for survival. The relationship between VA spending and outcomes was minimally affected by differences in VAMCs’ local labor costs, structural capacity, or the fraction of healthcare provided by non-VA sources. Thus, VA medical centers with high expenditures for patients with CHF may have opportunities to improve efficiencies and reduce costs while still aiming for optimal health outcomes. Date: July 3, 2019 Veterans with PTSD and/or Depression More Likely to Participate in Cardiac Rehabilitation than Veterans without These Disorders This study sought to determine whether Veterans with depression and/or PTSD were more or less likely than those without depression or PTSD to participate in cardiac rehabilitation (CR) programs following hospitalization for heart attack or coronary revascularization. Findings showed that Veterans with PTSD and/or depression were more likely to participate in CR than Veterans without these mental health disorders. Between 2010 and 2014, cardiac rehabilitation participation rates were consistently higher in patients with PTSD or depression (9-12%) than in those without either condition (7-11%). Investigators found that in comparison to Veterans without PTSD or depression, the odds of participation in CR were 24% greater in patients with depression alone, 38% greater in patients with PTSD alone, and 57% greater in patients with both PTSD and depression. Investigators were not able to determine why patients with mental disorders were more likely to participate in cardiac rehabilitation. Overall participation in cardiac rehabilitation is low in patients with coronary heart disease, but the presence of PTSD or depression does not reduce participation further. Date: June 4, 2019 How Do VA’s Frontline Cardiovascular Clinicians Engage with Concepts of Healthcare Outcomes and Value in their Clinical Work? This study assessed VA clinicians’ familiarity with and attitudes toward VA’s efforts to measure and improve quality-of-care processes, clinical outcomes, and healthcare value at their medical centers. Findings showed that, regardless of their medical center's healthcare value performance, most VA cardiovascular providers used feedback from process-of-care data (for example, appropriate use of aspirin or beta-blockers) to inform their practice. However, clinical outcomes data (for example, adverse events or 30-day readmissions) were used more rarely, and value-of-care data were almost never used. While two-thirds of participants reported that process data were regularly shared with providers, only about one-third of participants were aware of who was responsible for reviewing, analyzing, and disseminating their facility’s outcomes and cost data. In addition, half of the participants stated that they did not receive any feedback on costs of care, and they were not aware whether their facility measured the cost of care in relation to processes and outcomes. Fewer respondents reported clinical outcome measures influencing their practice, and virtually no participants used value data to inform their practice, although several described administrative barriers limiting high-cost care. Providers expressed general enthusiasm for VA’s quality measurement/improvement efforts, with few criticisms about workload or opportunity costs inherent in clinical performance data collection. This study identifies an opportunity for outcomes and value information to be more frequently measured and more commonly used in routine clinical care settings. Date: May 7, 2019 Cardiovascular Care and Research for Women Veterans This review presents important information on five areas of cardiovascular disease (CVD) care for women Veterans: 1) rapidly changing demographics; 2) prevalence of traditional risk factors; 3) prevalence of less traditional risk factors (i.e., homelessness, military sexual trauma, and mental health disorders); 4) treatment and outcomes of CVD; and 5) the current state and future directions of women’s health research. The rapidly growing population of women Veterans represents a specific at-risk population with characteristics that set them apart from their male counterparts as well as civilian women regarding CVD risk factors and CVD recognition, diagnosis, treatment, and possibly outcomes. Significant advancements have been made over the past decade in better characterizing CVD in women Veterans, but there remains a large gender gap and paucity of prospective, randomized, interventional clinical trials. Date: February 19, 2019 Higher Statin Adherence Associated with Lower Mortality in Veterans with Atherosclerotic Cardiovascular Disease This analysis sought to determine whether statin adherence is associated with mortality in stable patients with atherosclerotic cardiovascular disease (ASCVD). Findings showed that higher statin adherence was associated with lower mortality in a national sample of Veterans with ACSVD. Also, ischemic heart disease or stroke hospitalizations in the VA healthcare system were more frequent in Veterans who were less adherent to statins. Overall, statin adherence in this cohort on a stable statin intensity was high (88%). Veterans on moderate-intensity statin therapy were more adherent than Veterans on high-intensity statin therapy. Veterans with peripheral artery disease and cerebrovascular disease were less adherent than those with coronary artery disease. Women and minority groups were less adherent to statin therapy, with adherence lowest among black patients. Younger and older patients were less adherent, compared with adults aged 65-74. Date: February 13, 2019 Brief Cognitive Behavioral Therapy Reduces Suicidal Ideation among Veterans with Chronic Illness Brief cognitive behavioral therapy (bCBT) intervention delivered by VA mental health providers in primary care settings is effective for depression, anxiety, and improves physical health quality of life. Investigators in the current study determined the effect of bCBT on suicidal ideation among Veterans with cardiopulmonary chronic illness receiving mental health treatment in a VA primary care setting. Findings showed that bCBT in primary care reduced suicidal ideation in Veterans with chronic medical illness. Veterans in the bCBT group were less likely to have high suicidal ideation than Veterans in the EUC group post-treatment and at 8-month follow-up after accounting for baseline suicidal ideation. Results suggest that exposure to a brief evidence-based psychotherapy intervention in primary care may significantly reduce distress and suicidal ideation over a prolonged period of time, potentially reducing future suicide-related distress and/or attempts among a high-risk Veteran population. Date: February 8, 2019 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 Echocardiography Testing Can Be Redesigned to Answer Focused Diagnostic Questions While Reducing Costs In 2006, the VA Palo Alto Health Care System (PAVA) added an alternative to the standard transthoracic echocardiogram (TTE; cost= $240) that evaluated only the left ventricle (LV-TTE; cost = $60). Evaluation of left ventricular ejection fraction is one of the most common indications for a TTE. Investigators in this study evaluated the use of this new option and its association with the overall use of TTE. Findings showed that the volume of TTEs, number of outpatient visits, and mean age of patients were similar at the PAVA and the 118 control hospitals in 2005. But between 2011 and 2015, limited TTEs – as a percentage of total TTEs – increased to 19.5% at the PAVA (from a baseline of 0.8% in 2005) compared to 2% at the control hospitals. With multivariable regression, the introduction of LV-TTEs was associated with 349.5 more limited TTEs, but no significant change in total TTEs. Study results suggest that LV-TTE was substituted in place of a full TTE and that echocardiography testing can be redesigned to answer focused questions important to clinicians while reducing healthcare costs. Date: July 23, 2018 Substantial Variation in Cardiovascular Mortality Rates across the VA Healthcare System This study sought to determine whether there are substantial differences in cardiovascular outcomes across 138 VA medical centers. Findings showed that there is substantial variation in risk-standardized cardiovascular mortality rates across the VA healthcare system, suggesting differences in the quality of cardiovascular healthcare. Ischemic heart disease (IHD) annual death rates at the VAMC with the highest mortality were 3.9 percentage points larger than at the VAMC with the lowest mortality, translating into 1 excess death per year on average among every 26 IHD patients at the highest-mortality VAMC. Similarly, chronic heart failure (CHF) annual death rates were 7.8 percentage points larger, translating into1 excess death per year among every 13 CHF patients at the highest-mortality VAMC compared with CHF patients at the lowest mortality VAMC. Twenty-nine VAMCs had IHD mortality rates that significantly exceeded the national mean, while 35 VAMCs had CHF mortality rates that significantly exceeded the national mean. Cardiovascular mortality in VA medical centers’ chronic cardiovascular disease populations was only modestly correlated with post-hospitalization 30-day outcomes – or with VA’s 5-star quality ratings system. Date: July 1, 2018 Telephone Intervention Improves Cardiovascular Risk Factors This study assessed the effectiveness of a health risk assessment (HRA) coupled with a brief health coaching intervention to encourage Veterans to enroll and participate in a cardiovascular risk factor prevention program chosen based on their needs and preferences. Findings showed that brief telephone health coaching increased patient activation and increased enrollment in structured prevention programs to improve health behaviors among Veterans at cardiovascular risk. From baseline to six months, compared to controls, Veterans participating in the intervention reported higher rates of enrollment in a prevention program (51% vs 29%) and higher rates of program participation (40% vs 23%). Date: May 7, 2018 Veterans with Heart Disease More Likely to Participate in Cardiac Rehabilitation (CR) When Home-Based CR Program is Available This study examined whether the implementation of new home-based cardiac rehabilitation (HBCR) programs is associated with improved cardiac rehabilitation (CR) participation among Veterans. Findings showed that Veterans hospitalized with ischemic heart disease were more likely to participate in CR when a home-based program was available. Implementation of HBCR increased participation from 6% to 25%, and was associated with four-fold greater odds of participation. Overall, participation in at least one CR session increased from 8% to 13%. Veterans offered HBCR were less likely to drop out after the first session than were those for whom HBCR was not available. Home-based cardiac rehabilitation may be an effective tool for increasing CR participation among Veterans who would otherwise decline participation, thereby improving patient outcomes. Date: January 22, 2018 Study Compares VA Care to Community Care for Veterans Receiving Elective Coronary Revascularization This observational study compared access, quality, and cost of elective coronary revascularization procedures between VA and community care (CC) hospitals. Findings showed that compared to CC hospitals, Veterans who underwent PCI in VA hospitals had lower mortality (1.5% vs. 0.65%), lower costs ($22,025 vs. $15,683), and similar readmission rates. Compared to CC hospitals, Veterans who underwent CABG in VA hospitals had similar mortality, similar readmission rates, but higher cost ($55,526 vs. $63,144). Compared to VA-only care, Community Care reduced net travel distance for PCI by 54 miles, and CABG by 73 miles, on average. CC care also was associated with significantly lower travel costs – an average of $156 less for PCI and $690 less for CABG. One in five coronary revascularizations for VA patients was performed at CC sites. Findings demonstrate that, on average, Veterans seeking high-quality care with low mortality and readmission rates are well-served by VA. As VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimizing outcomes and costs. Date: January 3, 2018 Veterans are Commonly Prescribed Statins for Indications Unsupported by Guidelines for Managing High Cholesterol This study of new statin prescriptions in the VA healthcare system examined concordance with ATP-III guidelines (in force in 2102) and ACC-AHA guidelines (updated in 2013). Findings showed that Veterans were commonly prescribed statins for indications not supported by either the ATP-III or the ACC-AHA 2013 guidelines. Of Veterans receiving new statins for primary prevention, 48% did not meet ATP III guidelines; 20% did not fulfill the new ACC-AHA guidelines. Of the Veterans included in the study, 68% of new statins were prescribed for primary prevention and 32% were for secondary prevention of atherosclerotic cardiovascular disease. Nineteen percent of Veterans receiving statins did not meet either set of guidelines. Date: September 19, 2017 Maximal Doses of High-Intensity Statins Confer Greatest Survival Advantage for Those with Atherosclerotic Cardiovascular Disease This study sought to determine one-year cardiovascular mortality for VA patients with atherosclerotic cardiovascular disease by statin intensity – and to assess whether any differences in mortality related to statin intensity, if present, were observed in selected patient sub-groups (i.e., age, gender). Findings showed that high-intensity statins conferred a small but significant survival advantage over moderate intensity statins, even among older adults. Moreover, the maximal doses of high intensity statins conferred a further survival benefit. For example, when the sample was limited to Veterans on high-intensity statins, those treated with maximal doses had a 10% lower mortality when compared with those on sub-maximal doses. There was significant underuse of high-intensity statins and a graded relationship between statin intensity and mortality among Veterans in this study. Only 20% of Veterans received a high-intensity statin, while 43% were on moderate-intensity statins. Older adults (>75 years), women, and some minority groups were less likely to be on a high-intensity statin at baseline. Findings have significant implications for future lipid management practice guidelines. Date: November 9, 2016 VA Diabetes and Cardiovascular Care Quality Comparable between Physicians and Advanced Practice Providers This study assessed the effectiveness of diabetes and cardiovascular disease (CVD) care provided to Veterans in VA primary care by advanced practice providers (APPs) compared to physicians. Findings showed that the quality of diabetes and CVD care delivered in VA primary care settings was mostly comparable between physicians and APPs. However, a majority of Veterans with diabetes and CVD – irrespective of their provider type – did not meet performance measures geared toward control of multiple risk factors. Only 27% and 28% of Veterans with diabetes and 54% and 55% of Veterans with CVD receiving care from physicians and APPs, respectively, met all eligible measures. Thus, regardless of provider type, there is a need to improve performance on all eligible measures among these Veterans. Date: November 1, 2016 Incorporating Health Status into Routine Care This article describes the early efforts of VA’s Patient Reported Health Status Assessment (PROST) system to capture, report, and initiate clinical action in response to patient-reported health status measures, thereby improving the value of care delivered to Veterans undergoing elective percutaneous coronary intervention. Findings suggest that refocusing performance measures on health outcomes that reflect the patient’s perspective may reduce measurement burden and incentivize care delivery improvements that directly improve patient health. Integrating data from patient-reported health status measures such as PROST could lead to efficient and targeted interventions for specific patient populations. Date: August 2, 2016 Use of Contraindicated Medications among Veterans Undergoing Percutaneous Coronary Intervention This study examined the use of contraindicated antiplatelet medications for 64,294 Veterans who underwent a PCI between 2007 and 2013. Findings showed that 18% had a known contraindication to at least 1 of 5 antiplatelet medications. Among these patients, 7% received a contraindicated medication in either the periprocedural setting or upon hospital discharge. Patients on contraindicated antiplatelet therapy showed a non-significant trend for greater risk of 30-day mortality and periprocedural major bleeding. Thus, use of contraindicated antiplatelet medications persists, though the rate of contraindicated medication use is lower in VA compared with U.S. community practice. Date: July 1, 2016 Use of Oral Anticoagulant Therapy for Veterans with Atrial Fibrillation Declines over 10-Year Period in VA Healthcare Among patients with atrial fibrillation (AF), oral anticoagulants (OACs) are recommended when the risk of stroke is moderate or high, but not when the risk of stroke is low. This study sought to quantify trends and evaluate guideline adherence with OACs in Veterans with newly diagnosed AF over a ten-year period within the VA healthcare system. Findings showed that among Veterans with new AF and additional risk factors for stroke, only about half received an oral anticoagulant, and the proportion is declining, including among patients with higher risks for stroke. Overall, initiation of an OAC fell from 51% in 2002 to 43% in 2011. The decline in oral anticoagulant use shown in these results is concerning because patients with AF who fail to receive recommended OAC therapy have high rates of preventable stroke. This study, as well as others, shows an opportunity to improve rates of guideline adherence. Date: June 21, 2016 Significant Decrease in Rates of Non-Acute Percutaneous Coronary Intervention since Release of Appropriate Use Criteria This study sought to examine the trends in percutaneous coronary intervention (PCI) utilization, patient selection, and procedural appropriateness following the introduction of Appropriate Use Criteria to critically examine and improve patient selection for PCI, as well as address concerns about potential overuse. Findings showed that since the publication of the Appropriate Use Criteria in 2009, there have been significant reductions in non-acute PCI volume. Among patients undergoing PCI between July 2009 and December 2014, the volumes of non-acute PCIs declined significantly – from 89,704 in 2010 to 59,375 in 2014, while the volume of acute PCIs remained stable – 377,540 in 2010 to 374,543 in 2014. There also were significant reductions in the proportion of non-acute PCIs classified as being inappropriate – from 26% in 2009 to 13% in 2014. However, there was persistent hospital-level variation in the rate of inappropriate PCIs, ranging from 6% to 23% in 2014. Date: November 17, 2015 Long-Term Follow-Up of VADT Study Suggests Cardiovascular Benefits of Tight-Glucose Control in Diabetes Veterans Affairs Diabetes Trial (VADT) participants were randomly assigned to receive either intensive or standard glucose control. The study ended on May 29, 2008, with a median follow-up of 5.6 years. This study analyzed an additional five years of observational follow-up data on VADT participants (through December 2013), thus achieving a total follow-up of 11.8 years for most study measures. Findings showed that Veterans with type 2 diabetes randomized to intensive glucose control for a median of 5.6 years had a significant 17% relative reduction in major cardiovascular events after almost 10 years of total follow-up (8.6 events prevented per 1,000 person-years) compared to Veterans who received standard glucose therapy. However, intensive glucose control was not associated with a significant decrease in all-cause mortality after almost 12 years of follow-up. Results provide further evidence that improved glycemic control can reduce major cardiovascular events. This potential benefit may be considered in conversations with patients, but balanced with the burdens and safety data for the specific glucose-lowering treatment being considered. Date: June 4, 2015 Pharmacist Support Key in Medication Adherence for Veterans Prescribed Dabigatran for Atrial Fibrillation This study assessed site-level variation in dabigatran adherence and identified practices associated with higher dabigatran adherence within the VA healthcare system. Findings showed that among VA patients who were treated with dabigatran, there was significant site-level variation in medication adherence across VAMCs – with the site average ranging from 42% to 93%. Veterans were more likely to be adherent and without missing doses when they were monitored by VA pharmacists. Longer duration of pharmacist-led monitoring and providing more intensive care to non-adherent patients, in collaboration with the clinician, also improved medication adherence. Findings suggest extra patient support (i.e., pharmacist availability) may significantly improve adherence to dabigatran. These data affirm that VA’s rich infrastructure of pharmacist-led, specialized anticoagulation care may continue to have an important role in maximizing safety, effectiveness, and appropriate use of these new agents, even as warfarin use continues to decline. Date: April 14, 2015 Study Shows No Evidence that Dual Use of VA and Medicare Advantage Results in Worse Patient Outcomes This study assessed characteristics of Veterans who were dually enrolled in both VA and Medicare Advantage (MA) – managed care plans administered by private health insurance companies that contract with the Centers for Medicare and Medicaid Services. This study also compared quality of care using intermediate quality outcomes among Veterans exclusively receiving outpatient care in VA with Veterans receiving outpatient care in both systems. No evidence was found that Veterans with dual use of VA and Medicare Advantage experienced either improved or worsened intermediate outcomes compared with Veterans who exclusively used VA healthcare. Outcomes were marginally better for VA-only users on the measures related to hypertension control and CHD control. Conversely, dual VA-MA users experienced slightly better outcomes on measures relating to diabetes control. Dually-enrolled Veterans with fewer VA outpatient visits had comparable outcomes to Veterans with many VA outpatient visits, suggesting the absence of a threshold number of VA visits for achieving better intermediate outcomes in diabetes, hypertension, and heart disease. Date: April 6, 2015 Patient Outcomes for Multi-faceted Intervention for Veterans with Heart Failure Comparable to Usual Care Investigators in this study developed the Patient-Centered Disease Management (PCDM) intervention for patients with heart failure (HF) that combines multidisciplinary collaborative care by a nurse coordinator, cardiologist, psychiatrist and primary care provider, home tele-monitoring, and depression management. The primary aim of the study was to determine whether or not Veterans enrolled in the intervention experienced better health status (i.e., symptom burden, functional status, and quality of life) compared with Veterans enrolled in usual care. Findings showed that the PCDM intervention did not improve HF health status for Veterans compared with usual care. While there was significant improvement in overall summary scores in both groups after one year (mean increase of 13.5 points in each group), there was no significant difference between Veterans in the intervention group compared to Veterans in the usual care group. Among secondary outcomes, there were significantly fewer deaths at one year among Veterans in the intervention group (8 of 187, or 4%) than in the usual care group (19 of 197, or 10%). Among Veterans who screened positive for depression, there also was greater improvement in depression scores after one year for Veterans in the intervention group compared to Veterans in the usual care group. There was no significant difference in 1-year hospitalization rates between groups (29% vs. 30%). Date: March 30, 2015 Sleep Difficulties Associated with Risk Factors for Cardiovascular Disease among Younger Veterans and Active Duty Personnel This study examined the relationship between sleep difficulties and several cardiovascular (CVD) risk factors (i.e., smoking status, body mass index, self-reported hypertension, hypertension medication use, clinic-based blood pressure readings, symptoms of depression and PTSD, and diagnosis of depression and PTSD) among relatively younger (mean age, 37 years) Veterans and active duty personnel of the Iraq and Afghanistan wars. Findings showed that 8% of the Veterans in this study endorsed only sleep onset difficulties, 9% endorsed only sleep maintenance difficulties, and 41% endorsed both sleep onset and sleep maintenance difficulties. Study participants with both sleep onset and maintenance difficulties had greater odds of being a current smoker, having a diagnosis of PTSD, having clinically significant PTSD symptoms, having a diagnosis of depression, and having clinically significant depression symptoms. The odds for these risk factors did not differ by race or age. Having the combination of sleep onset and maintenance difficulties also was associated with elevated systolic blood pressure readings and increased likelihood of reporting a hypertension diagnosis among younger white Veterans. Overall, study participants with sleep maintenance difficulties were older, while those having both sleep onset and maintenance difficulties were younger and reported more tours of duty. Veterans reporting sleep difficulties of any kind reported more symptoms of depression and PTSD. Authors note that since sleep difficulties are associated with several CVD risk factors, improving sleep in this younger population may reduce the progression of disease and avert the increased incidence of CVD found in older Veterans. Date: March 27, 2015 Differences between Men and Women Veterans Undergoing Cardiac Catheterization in VA This study sought to determine whether there were gender differences in clinical characteristics and comorbidities, coronary anatomy and treatment, and procedural complications and long-term outcomes after diagnostic catheterization. Findings showed that female Veterans were younger (57 vs 63 years), with fewer traditional cardiovascular risk factors, but had more obesity, depression, and PTSD than male Veterans. Compared to male Veterans, female Veterans had lower rates of obstructive coronary artery disease (CAD) (23% vs 53%), similar or lower rates of procedural complications, and lower rates of all-cause rehospitalization. Women Veterans had lower mortality at one year, even when adjusted for age, presence of obstructive disease, and multiple comorbidities. Findings suggest that a significant portion of women Veterans treated in VA catheterization labs have chest pain not related to obstructive CAD. This may represent a complex interplay of psychological stressors and somatic disease, but further research is needed. Date: March 1, 2015 Female Veterans with CVD Less Likely to Receive Statin and High-Intensity Statin Therapy Compared to Male Veterans with CVD This study sought to identify the proportion of male and female Veterans with cardiovascular disease (CVD) who received care in any of 130 VA facilities between 10/1/10 and 9/30/11, and who received any statin and high-intensity statin. Findings showed that while evidence-based use of both statin and high-intensity statin therapy remains low in both genders, female Veterans with CVD were less likely to receive evidence-based statins (58% vs. 65%) and high-intensity statins (21% vs. 24%) compared with male Veterans. In fully adjusted analyses, female gender was independently associated with a 32% lower likelihood of receiving any statin therapy and a 24% lower likelihood of receiving high-intensity statin therapy. Mean low-density lipoprotein cholesterol levels were higher in female compared with male Veterans (99 vs. 85 mg/dl) with CVD. The use of statin and high-intensity statin therapy among female Veterans with CVD showed substantial facility-level variation. With the “statin dose-based approach” proposed by the recent cholesterol guidelines, these results highlight areas for quality improvement. It is important to note that despite the observed gender disparity noted in this study, statin and high-intensity statin use remain low in both genders. This is concerning, as the patient population studied in these analyses (i.e., those with established CVD) is the one that derives the most benefit from statin and high-intensity statin therapy. Date: January 1, 2015 Veterans with Non-Obstructive Coronary Artery Disease at Significantly Greater Risk of MI and Mortality This study compared incidence of myocardial infarction (MI) and mortality between patients with non-obstructive coronary artery disease (CAD), obstructive CAD, and no apparent CAD in a national cohort of Veterans receiving VA care. Findings showed that compared to Veterans with no apparent CAD, Veterans with non-obstructive CAD were at significantly greater risk of MI and all-cause mortality at one year. The one-year risk of MI progressively increased by extent of CAD, rather than abruptly increasing between non-obstructive and obstructive CAD. For example, among Veterans with no apparent CAD, the one-year MI rate was 0.11%, while the one-year MI rate for 1-vessel non-obstructive CAD was 0.24%, increasing to 0.59% for 3-vessel non-obstructive CAD. One-year mortality rates also were associated with increasing extent of CAD, ranging from 1.4% among Veterans with no apparent CAD to 4% for Veterans with 3-vessel or LM (left main) obstructive CAD. After risk adjustment, there was no significant association between 1- or 2-vessel non-obstructive CAD and mortality, but there were significant associations with mortality for 3-vessel non-obstructive CAD and 1-, 2-, and 3-vessel or LM obstructive CAD. Age and cardiovascular risk factors (e.g., hypertension, hyperlipidemia, and diabetes) all increased with increasing extent of CAD. The frequency of prescriptions for post-angiography cardiovascular medications and rates of coronary revascularization also increased with CAD extent. Findings suggest that non-obstructive CAD is common, confers significant risk for MI and mortality, and warrants immediate consideration of preventative therapies for patients with this condition. Date: November 5, 2014 Delays in Filling Clopidogrel Prescription Associated with Increased Major Adverse Events Following PCI This study assessed the frequency of delays in filling an initial clopidogrel prescription after hospital discharge for Veterans who underwent percutaneous coronary intervention (PCI) with stent implantation between 1/05 and 9/10 at any of 60 VA hospitals. Findings showed that approximately 1 in 14 Veterans delayed filling clopidogrel prescriptions after PCI. Moreover, delays were associated with increased risk of major adverse events; specifically, patients with a delay in filling their clopidogrel prescription more often suffered MI (12% vs. 6%) and death (2.2% vs. 1.5%) compared to those without delay. The percentage of Veterans with delays varied by VA hospital, ranging from 0% to nearly 44%. This large variation suggests a need to identify best practices that allow hospitals to optimize prescription filling at discharge to potentially improve patient outcomes. In the VA healthcare system, delayed filling of clopidogrel prescription occurred less than half as often as in a prior study conducted with a Medicare population, which found that 20% of patients delayed filling their clopidogrel prescription after hospital discharge. Therefore, it is possible that the lower rate of delayed prescription filling within VA (7%) may be attributable to greater coordination of care, since inpatient and outpatient prescriptions are managed by a single VA pharmacy service. Date: September 1, 2014 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 Digoxin Significantly Associated with Increased Risk of Death among Veterans with Atrial Fibrillation This study investigated the association of digoxin therapy with mortality in a large cohort of Veterans with atrial fibrillation (AF). Findings showed that among Veterans with newly diagnosed AF, treatment with digoxin was significantly and independently associated with increased risk of death, regardless of age, gender, kidney function, heart failure status, concomitant therapies, or drug adherence. Of the Veterans in the study, 23% received digoxin. Compared with non-recipients, digoxin recipients had a higher prevalence of heart failure (HF) and receipt of beta-blockers, angiotensin receptor blockers, antiplatelet therapy, diuretic agents, and warfarin. Digoxin increased the risk of death by 1.21 times compared to comparable patients treated with other therapies for AF. While these findings challenge current cardiovascular society recommendations, the implication is not that every patient should come off this drug and every doctor should stop using it. Rather, physicians should consider alternatives to digoxin in managing patients with AF as it may still have a useful role under specific and carefully monitored conditions. Date: August 19, 2014 Under-utilization of Cardiac Rehabilitation for Veterans Hospitalized for Ischemic Heart Disease This study sought to determine: 1) the proportion of Veterans with ischemic heart disease (IHD) who participate in cardiac rehabilitation (CR); 2) whether the presence of an onsite CR program was associated with greater participation; and 3) patient characteristics associated with participation. Findings showed that only 8% of the Veterans in this study who had been hospitalized for MI, PCI, or CABG participated in one or more sessions of outpatient cardiac rehabilitation. Overall, Veterans were more likely to participate in CR if they had been hospitalized at a VA facility with an onsite CR program versus without one (11% vs. 7%). However, participation was extremely low regardless of the presence or absence of an onsite program. Characteristics associated with greater participation in CR included: younger age, being married, higher BMI, living closer to a VA facility, hyperlipidemia, absence of heart failure, absence of chronic kidney disease, and hospitalization for CABG (vs. PCI or MI). After controlling for these variables, the presence of an onsite CR program was associated with 75% greater odds of attending a CR program. Date: August 18, 2014 Combat Deployments Associated with New-Onset Coronary Heart Disease among Young U.S. Service Members and Veterans This study sought to determine whether specific deployment experiences and PTSD symptoms are associated with newly reported coronary heart disease (CHD) among a young cohort (mean age = 34 years at baseline) of U.S. military personnel (active duty) from all service branches. Findings showed that combat deployments were associated with new-onset CHD among young U.S. service members and Veterans. Service members who reported combat experiences had nearly twice the odds of having a diagnosis code for new-onset CHD than service members without combat exposure. This suggests that experiences of intense stress may increase the risk for CHD over a relatively short period among young adults. Screening positive for PTSD symptoms was associated with self-reported CHD prior to – but not after adjusting for depression and anxiety, and was not associated with a new diagnosis of CHD. Date: March 11, 2014 Veterans with Multiple Chronic Conditions Account for Disproportionate Share of VA Healthcare Costs This study examined the association between number of chronic conditions and costs of care for non-elderly (<65 years) and elderly Veterans (=65 years) within the VA healthcare system – and estimated VA expenditures for the most prevalent and costly combinations of three conditions (triads). Findings showed that Veterans with multiple chronic conditions account for a disproportionate share of VA healthcare costs. Almost one-third of non-elderly and slightly more than one-third of elderly VA patients had >3 conditions, but they accounted for 65% and 67% of total VA healthcare costs, respectively. The most common triad of chronic conditions for both non-elderly and elderly Veterans was diabetes, hyperlipidemia, and hypertension (24% and 29%, respectively). Conditions present in the most costly triads included: spinal cord injury, heart failure, renal failure, ischemic heart disease, peripheral vascular disease, stroke, and depression. While patients with the most costly triads had average costs that were three times higher than average costs of patients in other triads, the prevalence of these costly triads was extremely low (0.1 to 0.4%). These findings highlight the need for interventions that target the sickest patients who have high resource use to provide more cost-effective care. Date: March 1, 2014 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 Multifaceted Intervention Improves Medication Adherence for Veterans following Hospitalization for Acute Coronary Syndrome This study tested a multifaceted intervention to improve adherence to cardiac medications in the year after acute coronary syndrome (ACS) hospital discharge. Findings showed that, based on the four classes of cardio-protective medications in the study, a greater proportion of Veterans in the intervention group were adherent to medications in the year following hospitalization for ACS compared to Veterans in the usual care group: 89% vs. 74%, respectively. For the secondary prevention measures, there were no differences in the proportion of patients who achieved BP and LDL goals. There were no significant differences between Veterans in the intervention and usual care groups for rehospitalization for myocardial infarction (7% vs. 4%), revascularization (12% vs. 18%), or death (9% vs. 8%). Date: November 18, 2013 Normal Coronary Rates for Elective Angiography This study sought to determine if VA is selective and consistent in the use of angiography, as reflected by rates of normal coronaries found in patients undergoing angiography. Findings showed that among Veterans undergoing elective coronary angiography in the VA healthcare system, about 1 in 5 patients (21%) had normal coronaries. This is a lower average rate of normal coronaries, compared with previous findings from other U.S. hospitals (39%). Across VA hospitals, the median proportion of normal angiograms among Veterans who had undergone elective coronary angiography ranged from 6% to 49%. Veterans at hospitals with lower normal coronary rates were more likely to undergo stress testing prior to angiography compared with hospitals with higher rates of normal results, and rates of obstructive coronary artery disease and subsequent revascularization were higher at hospitals with lower rates of normal coronaries. Date: October 18, 2013 Risk Factors for Adverse Cardiac Events after non-Cardiac Surgery in Veterans with Coronary Stents This study examined the risk factors for major adverse cardiac events (MACE) in Veterans undergoing non-cardiac surgery following coronary stent implantation, including the relationship between stent type and time from stent to surgery. Findings showed that the three most significant risk factors associated with MACE following non-cardiac surgery in Veterans with recent coronary stent implantation were non-elective surgical admission, history of MI in the six months preceding surgery, and a revised cardiac risk index greater than 2. Stent type and timing of surgery beyond 6 months following stent implantation were not associated with MACE. Also, no association between APT cessation and MACE was observed. Investigators suggest that a more comprehensive approach to perioperative risk assessment and management among Veterans with coronary stents that emphasizes cardiac and surgical risk factors, rather than stent type, may be warranted. Date: October 9, 2013 Veterans with PTSD or Major Depression Less Likely to Undergo Four Major Invasive Procedures This study examined whether PTSD, after controlling for major depression, was associated with the likelihood of having four common types of major invasive procedures. Findings showed that Veterans with PTSD only and with depression only were less likely to undergo all types of procedures examined in this study. Having both PTSD and depression was associated with lower odds of hip/knee, CABG/PCI, and vascular procedures, but not digestive procedures. Vascular procedures had the strongest effect. The odds of undergoing CABG/PCI or vascular procedures for patients with depression only were 35% to 40% lower than for patients with neither PTSD nor depression, while patients with PTSD only were about 25% less likely to receive the procedures. African American and women at-risk patients (those with a pre-existing condition likely to be alleviated by a procedure) were less likely to undergo hip/knee, vascular, and CABG/PCI procedures. Given that African-Americans are more likely than non-Hispanic whites to die of heart disease, their reduced odds of receiving CABG/PCI or vascular procedures could be problematic. Date: October 1, 2013 Redundant Lipid Testing in Veterans with CHD Repeat lipid testing for coronary heart disease (CHD) patients who have already attained guideline-recommended LDL-C treatment targets and receive no treatment intensification may represent overutilization and possibly waste of healthcare resources. This study sought to determine the frequency and correlates of repeat lipid testing in Veterans with CHD who had already attained the LDL-C treatment target, and who received no treatment intensification. Findings showed that one-third of the Veterans with CHD who had attained guideline-recommended LDL-C levels had additional lipid testing performed without treatment intensification in the 11 months following their initial lipid panel. Collectively, these patients had 12,686 additional lipid panels performed, with an annual extra cost of $203,990 for the one VA network included in the study. This does not include the cost of the patients’ time to undergo testing, or the providers’ time to manage results and notify the patient. Veterans with concomitant diabetes, hypertension, and higher illness burden, and those who had more frequent primary care visits were more likely to undergo repeat lipid testing, while Veterans with good medication adherence were less likely to undergo repeat testing. Date: July 1, 2013 Comparing Cardiovascular Outcomes for Two Common Anti-Diabetes Drugs among Veterans This study compared cardiovascular disease (CVD) outcomes and all-cause mortality in a cohort of Veterans who received regular VA healthcare and were prescribed metformin or sulfonylureas – the two most commonly used anti-diabetic drugs. Findings showed a modest but clinically important 21% increased risk of hospitalization for heart attack or stroke, or death from any cause associated with the initiation of sulfonylurea compared with metformin therapy. The sulfonylurea group had higher rates of hospitalizations and deaths due to cardiovascular disease: 18 per 1,000 person years for those taking a sulfonylurea and 10 per 1,000 person years for those taking metformin. These findings suggest that for 1,000 patients who are initiating treatment for diabetes using metformin rather than sulfonylureas, there are 2 fewer heart attacks, strokes, or deaths per year of treatment. The findings do not clarify whether the difference in CVD risk is due to harm from sulfonylureas, benefit from metformin, or both. Date: November 6, 2012 Treatment Intensification for Hypertension Not Significantly More Likely to Occur in Veterans with Diabetes and at Higher CV Risk Treatment intensification for hypertension was not significantly more likely to occur in Veterans with diabetes and at higher CV risk, compared with patients at low to medium risk. However, physicians were more likely to advance therapy in patients with higher and more consistently elevated blood pressures. Several individual risk factors were associated with higher rates of treatment intensification: systolic BP, mean BP in the prior year, and higher hemoglobin A1c, while self-reported home BP <140/90 was associated with lower rates of TI. The authors suggest that incorporating CV risk into TI decision algorithms could prevent an estimated 38% of cardiac events without increasing the number of patients being treated. Date: August 1, 2012 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 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 Non-Cardiac Surgery Soon after Cardiac Revascularization with Stents Decreasing among Veterans In November 2007, American College of Cardiology/American Heart Association (ACC/AHA) guidelines were released that recommended delay of elective non-cardiac surgery for 12 months after cardiac revascularization with drug eluting stents (DES), compared with six weeks for bare metal stents (BMS). In this study, 12% of Veterans in the BMS cohort had early surgery (less than 6 weeks) compared with 47% of Veterans in the DES cohort who had early surgery (less than 12 months). Rates of non-cardiac surgery within the first year after a DES placement have steadily declined (15% to 8%), suggesting that the ACC/AHA guidelines are being adopted into practice across the VA healthcare system. The authors note that nearly half of operations after a DES, including major procedures, were performed within the first 12 months. Thus, many Veterans are still undergoing high-risk non-cardiac procedures during the high-risk time period after cardiac stent placement. Date: February 15, 2012 Veterans with Serious Mental Illness Using Co-Located/Integrated Primary Care and Outpatient Mental Health Clinic Care have Reduced Cardiovascular Risk Veterans with serious mental illness (SMI) were more likely to attain cardiovascular risk goals after being enrolled in a primary care clinic co-located and integrated into an outpatient mental health clinic. Compared to prior to enrollment, Veterans enrolled in SMIPCC had significantly more primary care visits over six months – and significantly improved BP, LDL, triglycerides, and BMI. There were no significant differences in the attainment of goals for HDL or HbA1c. Prior to enrollment, 49% of primary care visits were on the same day as any scheduled mental health visit; this increased to 86% post-enrollment. Among the 28 Veterans in this study with coronary artery disease and/or diabetes, SMIPCC enrollment was associated with a significant improvement in BP goal attainment, but not with any other measures. Date: February 1, 2012 Top Performing VA Anticoagulation Clinics Share Characteristics The top performing VA anticoagluation clinics shared six characteristics: 1. Adequate pharmacist staffing and effective use of non-pharmacist personnel; 2. Innovation to standardize clinical practice around evidence-based guidelines; 3. Presence of a quality champion for the anticoagulation clinic (ACC); 4. Higher staff qualifications (e.g., all pharmacists had completed pharmacy residencies); 5. Climate of ongoing group learning; and 6. Internal efforts to measure performance. No low-outlier ACC had more than two of these characteristics. Therefore, the authors suggest that efforts to improve performance should focus on the six common domains. At least five domains were not associated with ACC performance, including use of the electronic medical record, and configuration of the clinic (e.g., face-to-face patient contact vs. telephone care). Date: February 1, 2012 Increased Risk of Mortality Following Heart Attack for Veterans Insufficiently Treated for Major Depressive Disorder This study sought to determine if mortality following acute MI was associated with treatment-resistant depression (TRD). Findings show that all-cause mortality following an acute MI is greatest in Veterans with depression that is insufficiently treated – and is a risk in Veterans with treatment-resistant depression. Veterans who were insufficiently treated were 3.04 times more likely to die than those who received treatment. Veterans with TRD were 1.71 times more likely to die; however, this risk was partly explained by comorbid disorders. Date: January 12, 2012 Investigators Provide Rationale for New LDL Guidelines Updated guidelines for cholesterol testing and management from the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults are due to be published in 2012. A primary focus of the previous version of the guidelines was treating patients to low-density lipoprotein (LDL) cholesterol level targets, with the primary goals of therapy and the cut-points for initiating treatment stated in terms of LDL. However, the authors of this commentary believe this reasoning diverges from clinical evidence and present three primary reasons that justify a major change in the next generation of guidelines: 1) There is no scientific basis to support treating to LDL targets, 2) The safety of treating to LDL targets has never been proven, and 3) Tailored treatment is a simpler, safer, more effective, and more evidence-based approach. This perspective is synergistic with recent activities in VA, in which a multidisciplinary group of leaders provided input that led to the suspension of VA’s Performance Measure that was strictly focused on achievement of lipid targets. They are now working to substitute a performance measure that emphasizes the prescription of statin medications. Date: January 1, 2012 Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008 This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care. Date: December 1, 2011 Caregivers of Veterans with Chronic Illness This study sought to identify predictors of caregiver strain and satisfaction associated with caring for Veterans with chronic illness. Findings showed that although 76% of caregivers reported feeling very self-confident in their caregiving role, more than one-third (37%) reported high strain. Overall, the mean caregiving satisfaction score indicated a moderate level of satisfaction. Caregiver characteristics that predicted strain included having less support, having depressive symptoms, and using paid help. Veteran characteristics that predicted caregiver strain included greater need for caregiving assistance in IADL (instrumental activities of daily living), and greater levels of depression. Predictors of lower caregiver satisfaction included less social support, older age, depression, and poor Veteran health status. Predictors of higher caregiver satisfaction included helping the Veteran with medical equipment and the coping style of “taking medication.” Both caregivers and Veterans reported similar levels of assistance provided, which were relatively low for ADL (activities of daily living) and IADL. However, caregivers reported providing a mean of 43 hours per week in assistance. Investigators suggest this may be due to the higher percentage of spouse caregivers in this sample, who are available for caregiving around the clock. A majority of caregivers expressed a need to know more about the Veteran’s medication. Date: November 22, 2011 Missed Opportunities for Providers to Discuss Advance Care Planning with Veterans with Heart Failure This study sought to identify and characterize potential opportunities for physicians to engage in advance care planning (ACP) discussions – and to examine their responses to opportunities during follow-up with Veterans recently hospitalized for heart failure. Findings showed that in 13 of 71 outpatient consultations, Veterans expressed concerns, questions, and thoughts regarding their future care that gave providers opportunities to engage in an ACP discussion. The majority of these opportunities (84%) were missed by physicians. Instead, physicians changed the subject back to the routine biomedical aspects of the visit; hedged their response about prognosis; denied or contradicted the patient’s expressed emotion or preference; or inadequately acknowledged the question or sentiment underlying the patient’s statement. In order to successfully leverage opportunities to engage in ACP discussions, authors suggest that communication training efforts should focus on helping physicians identify patient openers and providing a toolbox to encourage appropriate physician responses. Date: October 25, 2011 Health of Gulf War Veterans Worsened in 10-Year Study Since the 1991 Gulf War, initial concerns regarding health consequences of participation in the war have turned to requests for longitudinal evaluation of how the health of Gulf War Veterans has changed over time. To help in this evaluation, investigators conducted health surveys of deployed and non-deployed Gulf War-era Veterans in 1995 and again in 2005. Findings showed that the health of deployed Gulf War Veterans worsened during the 10-year period from 1995 to 2005 in comparison with non-deployed Gulf War Veterans. Perceived health of fair or poor was more likely to persist among deployed Veterans, and relatively more deployed Veterans reported that their health status had worsened over the 10-year follow-up. Deployed Veterans were less likely to recover from any prior functional impairment, limitation of activities, or PTSD that they had in 1995 – and were more likely to report new onset of these adverse health outcomes in 2005 compared with non-deployed Veterans. Authors note that the extent to which any of the health problems experienced by Gulf War Veterans were due to the effects of military service in the Gulf War is difficult to determine. Date: October 1, 2011 Collaborative Care Intervention for Veterans with Ischemic Heart Disease Treated in VA Primary Care Setting The Collaborative Cardiac Care Project sought to determine whether a multi-faceted intervention using a collaborative care model ? directed through primary care providers ? would improve symptoms of angina, self-perceived health, and concordance with practice guidelines for managing chronic stable angina among Veterans with ischemic heart disease (IHD). Findings showed that the collaborative care intervention had no significant effects on symptoms or self-perceived health, but significantly improved receipt of guideline-concordant care in Veterans with stable angina. Although concordance with guidelines improved 4.5% more among Veterans receiving collaborative care than those receiving usual care, this was mainly due to increased use of diagnostic testing rather than recommended medications. The collaborative care model was well received by primary care providers, who implemented 92% of 701 recommendations made by collaborative care teams. Nearly half of the recommendations were related to medications, e.g., adjustments to beta blockers, long-acting nitrates, and statins. Date: September 12, 2011 Veterans with Diabetes and Major Depressive Disorder at Significantly Increased Risk of Myocardial Infarction This study sought to determine if major depressive disorder (MDD) complicates the course of type 2 diabetes and is associated with increased risk of myocardial infarction (MI) and mortality. Findings showed that Veterans with comorbid MDD and type 2 diabetes were 82% more likely to experience a MI compared to Veterans without MDD and type 2 diabetes. Veterans with MDD alone were 29% more likely to have a MI, and Veterans with type 2 diabetes alone were at 33% increased risk of MI. The incidence of MI increased in a step-wise fashion, from unaffected Veterans (2.6% incidence of MI) to those with depression only (3.5%) to those with diabetes only (5.9%) to Veterans with both conditions (7.4%). Veterans with PTSD, anxiety, and panic disorder were more likely to have a MI, as were Veterans with hypertension, hyperlipidemia, obesity, and nicotine dependence. Date: August 1, 2011 Racial and Ethnic Differences in Blood Pressure Control among Veterans with Type 2 Diabetes This study examined racial/ethnic differences in blood pressure control among Veterans with type 2 diabetes and uncontrolled BP at baseline. Findings showed that the adjusted proportion of Veterans with uncontrolled BP (>=140/90 mmHg) decreased in all groups over the study period. However, ethnic minority Veterans had significantly increased odds of poor BP control over a mean follow-up of 5 years compared to non-Hispanic White Veterans, independent of socio-demographic factors and comorbidity patterns. Compared to non-Hispanic Whites (45%), 54% of non-Hispanic Black Veterans, 48% of Hispanic Veterans, and 49% of Veterans with unknown race had poor blood pressure control. In using a more stringent BP cutoff (>=130/80 mmHg) to define poor BP control, 74% of non-Hispanic White Veterans had poor blood pressure control over the 5 years compared to 82% of non-Hispanic Black Veterans, 75% of Hispanic Veterans, and 79% of Veterans with unknown race/ethnicity. The presence of a hypertension diagnosis at the time of study entry appears to be associated with higher odds of achieving BP control over time. Among other comorbidities, cancer, coronary heart disease, congestive heart failure, and substance use disorders were all associated with increased odds of good BP control over time. Date: June 14, 2011 Nurse Case Management Decreases Cardiovascular Risk Factors among Veterans with Diabetes Compared to Usual Care This study sought to determine if nurse case management could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia among Veterans with diabetes compared to usual care. Findings showed that involving a nurse case manager in the care of patients with diabetes can significantly improve the number of individuals achieving target values for glycemia, lipids, and blood pressure compared to usual care. In this study, a greater number of Veterans in the intervention group had all three outcome measures under control compared to Veterans in the usual care group. In addition, a greater number of Veterans in the nurse case management group achieved individual treatment goals for blood pressure, lipids, and blood sugar compared to Veterans receiving usual care. Observed differences between groups were likely mediated both by enhanced lifestyle changes and a greater intensity of pharmacological treatment among Veterans in the intervention group. Date: June 2, 2011 VA Healthcare Outperforms Private-Sector, Medicare-Managed Care among Older Patients This study compared clinical performance between VA and Medicare-managed care plans, known as Medicare Advantage (MA). Findings show that VA outperformed MA health plans on 10 out of 11 widely used clinical performance indicators assessing diabetes, cardiovascular, and cancer screening care among patients ages 65 and older in the initial study year – and on all 12 measures by the final year. Moreover, for 10 of the 12 measures studied, even the best-performing MA plans lagged behind the lowest-performing VAMCs. The performance advantage for VA was substantial. For example, in 2006 and 2007, adjusted differences between VA and MA ranged from 4.3 percentage points for cholesterol testing in coronary heart disease to 30.8 percentage points for colorectal cancer screening. VA delivered care that was less variable by site, geographic region, and socioeconomic status. For 9 of the 12 measures, socioeconomic disparities were lower in VA than in MA. Date: March 18, 2011 Newly FDA-Approved Dabigatran May Be Cost-Effective Alternative to Warfarin for Patients at Increased Risk of Stroke Atrial fibrillation (AF) is the second most common cardiovascular condition in the U.S. – and the second most common condition affecting Veterans. AF also increases the risk of ischemic stroke by five-fold. Research shows that anticoagulation therapy with warfarin and other vitamin K antagonists can reduce the relative risk of stroke in AF by two-thirds. Dabigatran – a newer anticoagulant and the first such drug approved by the FDA in 20 years – produces similar or reduced rates of ischemic stroke and hemorrhage compared with warfarin and requires no blood testing. This study evaluated the quality-adjusted survival, costs, and cost-effectiveness of dabigatran compared with warfarin for the prevention of ischemic stroke in patients >65 years with non-valvular AF. Findings show that dabigatran could be a cost-effective alternative to adjusted dose warfarin. High-dose dabigatran was the most effective and the most cost-effective therapy examined. The quality-adjusted life expectancy was 10.28 quality-adjusted life years (QALYs) with warfarin, 10.70 QALYs with low-dose dabigatran, and 10.84 QALYs with high-dose dabigatran. Thus, high-dose dabigatran yielded an additional half year of quality-adjusted life compared to warfarin. With dabigatran given at 150 mg twice daily – the approved dosage for most patients – the incremental cost compared with using warfarin is under the conventional cost-effectiveness threshold of $50,000 per QALY gained. Total costs were $143,193 for warfarin, $164,576 for low-dose dabigatran, and $168,398 for high-dose dabigatran. Date: January 4, 2011 Risk-Adjusted Time in Therapeutic Range Can Be Used as Quality Indicator for Outpatient Oral Anticoagulation This study examined the suitability of risk-adjusted time in therapeutic range (TTR) as a potential quality indicator for anticoagulation therapy among VA patients. Findings show that TTR can be used to profile the quality of outpatient oral anticoagulation in a large, integrated healthcare system. Thus, this measure can serve as the basis for quality measurement and quality improvement efforts. TTR differed among VA anticoagulation clinics – from 38% to 69%, or from poor to excellent. Risk-adjustment did not alter performance rankings for many sites, but for other sites it made an important difference. For example, the anticoagulation clinic that was ranked 27th out of 100 before risk adjustment was ranked as one of the best (7th) after risk-adjustment. Risk-adjusted site rankings were consistent between the first and second years of the study, suggesting that risk-adjusted TTR measures a construct (quality of care) that is stable over time. Date: January 1, 2011 Use of Automated External Defibrillators on Hospitalized Patients Not Associated with Improved Survival The use of automated external defibrillators (AEDs) has been proposed as a strategy to reduce times to defibrillation and improve survival from cardiac arrests that occur in the hospital setting. This study evaluated the association of AED use and survival for patients with cardiac arrests in general hospital wards. Findings show that the use of AEDs to assess and treat hospitalized patients with cardiac arrest was not associated with improved survival. Overall, the use of an AED in this study population was associated with a lower rate of survival after in-hospital cardiac arrest compared with no AED use (16% vs. 19%). Among cardiac arrests due to non-shockable heart rhythms (e.g., asystole, pulseless electrical activity), AED use was associated with lower survival (10% vs. 15%). In contrast, for cardiac arrests due to shockable heart rhythms (e.g., ventricular fibrillation, pulseless ventricular tachycardia), AED use was not associated with survival (38% vs. 40%).There were no differences by age or gender, but there was a slightly higher rate of AED use among African Americans. Date: November 17, 2010 Model Used for Cholesterol Guidelines May Lead to Misclassification of Risk for Heart Attack and Coronary Death National cholesterol guidelines use the “Framingham model” to calculate a person’s 10-year risk of myocardial infarction or coronary death. Based on this risk, patients are categorized into different risk groups, which are used to guide treatment decisions. Both original and point-based versions of the model are in use and endorsed by national guidelines. Given that approximately 36 million persons in the U.S. are eligible for lipid-lowering therapy, differences in risk classification depending on which model is used could result in millions receiving different lipid-lowering therapy. This study compared differences in predicted risk between the original and point-based Framingham calculations. Findings show that compared with the original Framingham model, the point-based version of the tool misclassifies millions of Americans into different risk groups, with 25-46% of affected individuals experiencing potential impacts on drug treatment recommendations for cholesterol control. Date: November 1, 2010 Using One Classification System for Estimates of Urban/Rural Impact on AMI Outcomes among Veterans May Not Be Adequate This study examined whether: 1) two different rural classification systems identify differential rates of Veterans admitted for AMI; 2) rural-urban disparities exist for risk-adjusted AMI outcomes (measured by mortality and receipt of coronary revascularization); and 3) whether hospital transfer rates differ for patients admitted with AMI. Findings showed no observed differences between rural-dwelling and urban-dwelling Veterans in risk-adjusted 30-day mortality, regardless of the urban-rural classification system used. However, rural-dwelling Veterans were less likely to receive revascularization compared to urban-dwelling Veterans, but risk estimations were dependent upon the urban-rural classification system used. Regardless of classification system, Veterans residing in rural settings were transferred more often and were more likely to be admitted to VA hospitals without revascularization facilities. This study demonstrates that using a single rural classification system for estimating the effects of living in a rural setting on AMI outcomes among Veterans may not be adequate. Date: September 1, 2010 Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains. Date: August 1, 2010 Heart Failure Mortality Decreases While Rehospitalization Increases among Veterans Heart failure is the number one reason for admission among Veterans enrolled in the VA healthcare system. In order to improve care for this chronic disease, VA has incorporated the use of guideline-recommended treatments; however, it is unclear if the increased performance on process of care measures for hospitalized Veterans has led to improvements in outcomes. This study sought to determine if recent mortality and readmission rates have improved within VA. Findings show that mortality and rehospitalization rates for Veterans with a first hospitalization for heart failure in the VA healthcare system or in a non-VA hospital that was paid for by VA trended in opposite directions between 2002 and 2006. Mortality rates at 30 days decreased (7.1% to 5.0%), while rehospitalization rates for heart failure at 30 days increased (5.6% to 6.1%). Over the same time period, use of guideline recommended therapy increased. During the six months prior to hospital admission and during the three months following admission, there were large increases in the use of beta-blockers. The use of angiotensin-receptor blockers also increased. Examination of patient characteristics showed that most comorbid diagnoses increased significantly from 2002 to 2006, suggesting that Veterans hospitalized in 2006 were more ill. The authors suggest that the use of rehospitalization for heart failure as a marker of poor care may be flawed. Further studies to determine the reasons for the decline in mortality and the portion of hospitalizations that are preventable are recommended. Date: July 27, 2010 History of Depression Remains a Risk Factor for Heart Disease after Accounting for Other Contributing Factors among Twin Veterans A history of depression remained a risk factor for incident heart disease even after adjusting for numerous covariates including: sociodemographics, co-occurring psychopathology, smoking, obesity, diabetes, hypertension, and social isolation. Moreover, twins with both high genetic and phenotypic expression of depression were at greatest risk of ischemic heart disease (IHD). Results also show that twins with hypertension and twins with diabetes were more likely to have IHD, as were twins who reported no social support. Age, race, education, and marital status were not associated with IHD status. Date: May 1, 2010 Additional Evidence of Clustering of Cardiovascular Events Following Cessation of Clopidogrel in Patients with ACS In multivariable analysis, including adjustment for total duration of clopidogrel treatment, the 0-90 day interval after stopping clopidogrel was associated with significantly increased risk of death/MI compared to the 91-360 day interval among a non-VA population. There was a similar trend of increased adverse events after stopping clopidogrel for various subgroups (women vs. men, medical therapy vs. percutaneous coronary intervention, stent type, and = or <6 months of clopidogrel treatment). This clustering of adverse events was not present among patients stopping ACE-inhibitors, suggesting that the events are not a general effect of stopping medications. There was no association between the 91-360 day interval after stopping clopidogrel and adverse outcomes compared to patients remaining on clopidogrel. Date: May 1, 2010 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 Strategies to Reduce Sodium Intake Likely to Decrease Stroke and Heart Disease, and Save Billions in Costs Using a mathematical model, investigators examined the cost-effectiveness of two governmental strategies to reduce sodium intake in the U.S.: 1) government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience; and 2) a tax on sodium. Findings show that strategies to reduce sodium intake on a population level are likely to substantially reduce the incidence of stroke and myocardial infarction, saving billions of dollars in medical expenses. Date: March 1, 2010 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 Comparing Treat-to-Target Strategies to Tailored Approach for Statin Therapy This study examined how a simple Tailored Treatment strategy for statin therapy compared with a Treat-to-Target strategy based on National Cholesterol Education Program (NCEP) III treatment recommendations. Findings show that a simple Tailored Treatment strategy was more efficient and prevented substantially more coronary artery disease morbidity and mortality than any of the currently recommended Treat-to-Target approaches. The Tailored Treatment approach was predicted to save 520,000 more quality-adjusted life years among Americans aged 30-75 than the best NCEP III Treat-to-Target approach for every five years of treatment, even though fewer people were treated with high doses of statins. The authors indicate that these results suggest that a Tailored Treatment approach to medicine can substantially improve care, while also reducing unnecessary treatment and costs. Thus, they recommend that given its potential to better tailor treatments to individual patients, the principles underlying a Tailored Treatment approach should be considered during deliberations about guidelines and performance measures. Date: January 19, 2010 Veterans with Psychosis More Likely to Die from Heart Disease This study assessed whether Veterans with mental disorders receiving care in the VA healthcare system were more likely to die from heart disease than Veterans without these disorders, and whether modifiable factors may explain mortality risks. Findings show that compared to Veterans without a mental health diagnosis, Veterans with psychosis (schizophrenia or other psychotic disorder diagnoses) were more likely to die from heart disease. Smoking and physical inactivity were the behavioral factors most strongly associated with mortality related to heart disease. Veterans with schizophrenia were the most likely to be current smokers, and those with bipolar disorder were the least likely to report adequate physical activity. Controlling for behavioral factors (e.g., smoking and physical inactivity) diminished but did not eliminate the impact of psychosis on mortality. The authors suggest that to reduce mortality related to heart disease, early interventions that promote smoking cessation and physical activity among Veterans with psychotic disorders are warranted. Date: November 1, 2009 Effect of Medicare Pharmacy Benefit Coverage on VA Healthcare Users This study examined the influence of Medicare pharmacy benefit coverage on VA pharmacy use among Veterans using the VA healthcare system during 2002, who had diabetes mellitus, ischemic heart disease, or chronic heart failure. Overall, results showed that Veterans dually enrolled in VA and Medicare fee-for-service (FFS) were less likely to receive condition-related medications from VA compared with Veterans enrolled in HMOs with lower levels of prescription drug coverage. One implication of the overall study findings is that VA will become less the healthcare system of choice for Veteran beneficiaries if Medicare pharmacy services become more affordable. Moreover, Veterans with chronic conditions that require many medications and who hit a coverage gap in Medicare Part D or have difficulty making the Medicare co-payments may turn to VA as a safety net at intermittent times rather than using VA pharmacy services more steadily. Date: October 1, 2009 Mental Health Diagnoses Associated with Cardiovascular Risk Factors among OEF/OIF Veterans Studies of Veterans from prior wars found that those with PTSD are at increased risk of developing and dying from cardiovascular disease, but this risk had not yet been evaluated in OEF/OIF Veterans. This article discusses findings from a study on the association between mental health disorders, including PTSD, and cardiovascular risk factors. Findings show that OEF/OIF Veterans (male and female) with mental health diagnoses had a significantly higher prevalence of cardiovascular risk factors (e.g., hypertension, obesity, diabetes, tobacco use). The association between mental health diagnoses and cardiovascular risk factors remained after adjusting for demographics and military factors. The most common mental health diagnosis was PTSD (24%). The majority of Veterans with PTSD had comorbid mental health diagnoses: depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), as well as other psychiatric diagnoses (33%). Date: August 5, 2009 Improving Adherence to Cardiovascular Medications This article focuses on cardiovascular medication adherence and discusses studies that address: 1) different methods of measuring adherence, 2) prevalence of non-adherence, 3) association between non-adherence and outcomes, 4) reasons for non-adherence, and 5) interventions to improve medication adherence. Findings show that while there are many different methods for assessing medication adherence, non-adherence to cardiovascular medications is common and associated with adverse outcomes. The authors also found that non-adherence is not solely a patient problem but is impacted by both providers and the healthcare system. To date, interventions targeting medication adherence have produced only modest success. Multi-modal interventions have shown the most promise in improving adherence, but require the clinical personnel to manage and coordinate multiple intervention components. Date: June 16, 2009 Men and Women Veterans Receive Equal Care for AMI in VA Hospitals This study sought to describe the clinical characteristics, treatment, and survival in women Veterans compared with men admitted to VA hospitals for AMI between 10/03 and 3/05. Findings show that after adjusting for clinical characteristics, men and women Veterans treated for AMI in VA hospitals had similar levels of care and survival. There were no significant differences in the treatment provided to men and women Veterans, and cardiac catheterization was provided at equal rates (34.9% for men vs. 36.9% for women). Men did have higher mortality rates, but after adjusting for clinical characteristics this difference was no longer significant. In addition, significantly more men were prescribed aspirin and angiotensin-converting enzyme inhibitors, but there were no differences with regard to other platelet inhibitors, beta-blockers, or lipid-lowering medications. Date: May 1, 2009 Neither Warfarin nor Clopidogrel Superior to Aspirin as Antiplatelet Therapy for Chronic Heart Failure The Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) Trial was conducted to determine the optimal anti-thrombotic agent for heart failure patients with reduced ejection fraction who are in sinus rhythm. WATCH Trial findings do not support the primary hypotheses that warfarin or clopidogrel is superior to aspirin. For the primary combined outcome of mortality, non-fatal MI, or non-fatal stroke, major differences between anticoagulation with warfarin and anti-platelet therapy with aspirin or clopidogrel are unlikely. Warfarin was associated with fewer non-fatal strokes than aspirin or clopidogrel, but also was associated with more frequent bleeding episodes compared to clopidogrel, and a non-significant excess of bleeding compared to aspirin. Date: March 31, 2009 Study Compares PCI Strategies to Medical Therapy in Patients with Non-Acute CAD This study compared medical therapy (e.g., lifestyle modifications, medication) to various percutaneous coronary intervention (PCI) strategies in the treatment of patients with non-acute coronary artery disease (CAD). Findings show that while bare metal stents and drug-eluting stents yielded increased improvements in diminishing the need for revascularization, innovations in PCI technologies have not improved outcomes (i.e., incidence of myocardial infarction, mortality) compared to medical therapy. Date: March 14, 2009 Concomitant Use of Clopidogrel and Proton-Pump Inhibitors after ACS is Associated with Higher Risk of Adverse Outcomes Proton-pump inhibitors (PPI) were frequently prescribed with clopidogrel (63.9%) for Veterans following hospitalization for acute coronary syndrome (ACS); the concomitant use of clopidogrel and PPI was associated with a higher risk of adverse outcomes compared to the use of clopidogrel alone. The combined primary outcome of mortality or re-hospitalization occurred in 20.8% of Veterans prescribed clopidogrel only, and in 29.8% of Veterans prescribed clopidogrel and PPI. Among secondary outcomes, Veterans taking clopidogrel and PPI also had a higher risk of recurrent hospitalization for ACS and revascularization procedures. Longer duration of clopidogrel plus PPI treatment was associated with adverse outcomes, suggesting that time on combination treatment is important. Pending further studies to confirm results and prospectively assess cardiovascular outcomes for Veterans taking clopidogrel and PPI versus clopidogrel alone, these results may suggest that PPIs should be used for patients with a clear indication for the medication, rather than prophylactically. Date: March 4, 2009 Cardiovascular Risk Reduction Clinic for Veterans with Diabetes The Cardiovascular Risk Reduction Clinic (CRRC) is a pharmacist-coordinated clinic at the Providence VAMC designed to treat the four traditional cardiovascular risk factors (diabetes, dyslipidemia, hypertension, and smoking) to attain goals set forth by national guidelines for patients with diabetes or documented cardiovascular disease. Veterans are discharged from the CRRC when guideline-recommended goals for hemoglobin A1c, low-density lipoprotein cholesterol, blood pressure, and smoking are achieved or mostly achieved. This study evaluated the maintenance of these goals for two to three years after discharge from the CRRC. Findings show that Veterans who completed the program maintained two goals – HbA1c and LDL-C – over three years of observation. The effect on blood pressure was less durable, with half of the Veterans who were at target levels at discharge from the CRRC reaching systolic BP >130 within six months after discharge. Results also show that the most important factor to consider for risk of failure after successful attainment of a cardiovascular goal is how poorly controlled the goal was at baseline. Date: March 1, 2009 Increase in VA Prescription Co-Pay Leads to Decrease in Adherence to Statins for Veterans at Risk of Heart Disease VA’s increase in drug co-payments from $2 to $7 adversely affected lipid-lowering medication adherence among Veterans, including those at high risk of coronary heart disease. After the increase in medication co-payments, the percent of Veterans who were adherent to lipid-lowering therapy declined significantly, even for Veterans with no co-pay. The co-payment increase was also accompanied by a significant increase in the likelihood of having continuous gaps in lipid-lowering medication use. Date: January 27, 2009 Improving Treatment Adherence for Veterans with Coronary Artery Disease Nearly 40% of the veterans in this study did not keep their appointments for testing or treatment for coronary artery disease, indicating that non-attendance in this particular patient population is a significant problem. Several factors associated with non-attendance were: slightly younger age, lower income, unemployment, and longer wait times for appointments (136 vs. 54 days for non-attenders compared to attenders). Veterans who missed appointments also reported fewer cardiac symptoms and were more likely to attribute them to something other than heart disease. Other reasons given for non-attendance were fear of diagnostic procedures (22.3%), as well as dissatisfaction with VA care and lack of trust in the physicians or hospital (16.5%). Date: December 1, 2008 Reducing Cardiovascular Risk for Veterans with Diabetes and Depression The Cardiovascular Risk Reduction Clinic (CRRC) is an ongoing clinical, multi-disciplinary, disease management program at the Providence VAMC. Veterans with and without a depression diagnosis had a significant improvement in cardiovascular risk reduction after participation in the CRRC program. Veterans with a diagnosis of depression had significantly higher cardiovascular risk than those with no mental health condition, but they had greater improvement after participating in the program. Date: October 1, 2008 Early Invasive Strategy Associated with Improved Clinical Outcomes for Patients with STEMI after Fibrinolytic Therapy An early invasive strategy was associated with significant reductions in mortality and re-infarction for patients with ST-segment elevation myocardial infarction (STEMI) compared with ischemia-guided management. There were no significant differences in the risk of stroke or major bleeding. Date: September 1, 2008
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