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Initiation of Antihypertensives in Older VA Nursing Home Residents Increases Risk of Fractures and Falls
This study sought to determine whether initiating antihypertensive treatment increases fracture risk in older VA long-term nursing home residents. Findings showed that initiation of antihypertensives was associated with a >2-fold increase in risk of fractures and falls. In the matched cohort of 64,710 older Veterans (mean age 78 years), the incidence rate of fractures per 100 person-years in residents initiating antihypertensives was 5.4 compared to 2.2 in the control arm. Use of an antihypertensive was also associated with an increased risk of severe falls necessitating emergency department visits or hospitalizations. Risks of fractures and falls were numerically higher among Veterans with dementia, higher baseline blood pressure values, and those who had not used antihypertensives recently, but did not reach statistical significance. Caution and additional monitoring are advised when initiating antihypertensives in older Veterans residing in nursing homes.
Date: April 22, 2024
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Early Temperature Trends May Identify COVID-19 Infection in Pre-Symptomatic Long-Term Care Residents
Pre-symptomatic COVID-19 transmission in nursing homes is common and older patients often have blunted febrile response to infection. As a result, current clinical screening for temperature above 38°C may not identify infected subclinical cases that risk transmission until later. This study sought to determine whether early temperature trends in the course of COVID-19 infection could identify pre-symptomatic Veterans in nursing homes. Findings showed that a change in temperature of 0.4°C from baseline identified 47% of VA nursing home residents who became COVID positive, earlier than standard testing by an average of 42 hours. Temperature variability of 0.5°C over three days, when paired with a 37.2°C temperature cutoff (instead of the VA standard of 38°C), identified 55% of VA nursing home residents who became COVID positive earlier than standard testing by an average of 44 hours. A change from baseline temperature of 0.4°C, when combined with temperature variability of 0.7°C over three days, identified 52% of VA nursing home residents who became COVID positive, earlier than standard testing by an average of 40 hours, and by more than 3 days in 22% of Veterans.
Date: August 4, 2022
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Inequities in Enhanced Pension Benefit for Veterans
This study examined sociodemographic, medical, and healthcare use characteristics associated with receipt of the Aid and Attendance (A&A) benefit among Veterans receiving pension. Findings identified potential inequities in Veterans’ receipt of the A&A enhanced pension. Among 89,845 Veterans who received a pension but not the A&A enhanced benefit in FY2016, 8,724 Veterans (10%) newly received the A&A enhanced pension in FY2017. Veteran pensioners who received A&A were significantly older and more likely to be white and married than those who did not receive A&A. Pensioners who were black, Hispanic, or other non-white race had a lower probability of receiving A&A than white Veterans after adjusting for indicators of need. Most indicators of need for assistance (e.g., home health use, dementia, stroke) were associated with significantly higher probabilities of receiving A&A, with notable exceptions: pensioners with PTSD or enrolled in Medicaid had lower probabilities of receiving A&A. Among Veterans receiving pension, receipt of A&A varied by medical center. While provider education and wider dissemination of information about A&A may help reduce observed inequities, action is required at the system level that will eliminate the possibility of bias in which some eligible pensioners are able to access this enhanced pension benefit and others are not.
Date: February 25, 2021
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Strategy in a VA Skilled Nursing Facility Minimizes Both Asymptomatic and Pre-Symptomatic Transmission of COVID-19
Universal and serial COVID-19 testing in skilled nursing facilities can identify cases during an outbreak, and rapid isolation and cohorting can minimize ongoing transmission. This outbreak report demonstrates the utility of universal serial laboratory screening to identify cases to rapidly isolate or cohort to reduce transmission in a VA skilled nursing facility. This strategy limited potential asymptomatic and pre-symptomatic transmission of COVID-19, allowing for successful containment. The outbreak in one ward was suppressed within 1 week, the outbreak in a second ward was suppressed within 2 weeks, and no cases occurred in a third ward.
Date: May 29, 2020
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Practical Recommendations for the Care of Older Individuals at Highest Risk from COVID-19
The risk of COVID-19 transmission in the coming months may be high long-term care facilities, requiring focused attention and preparedness efforts. Adding to this healthcare challenge, long-term care residents often have medical conditions associated with an increased risk of morbidity and mortality from COVID-19. Appropriate preparedness includes five key elements: 1) Reduce morbidity and mortality among those infected; 2) Minimize transmission; 3) Ensure protection of healthcare workers; 4) Maintain healthcare system functioning, and 5) Maintain communication with worried residents and family members. Airborne disease protocols should be activated and put into action. Environmental services should be engaged to perform at least daily cleaning with Environmental Protection Agency (EPA) registered hospital-grade disinfectants, particularly in high-traffic areas (e.g., dining halls, treatment areas, living spaces, etc.). Training staff and visitors on how to minimize their risk for picking up COVID-19 in the community and in long-term care facilities, and transmitting it to others, will remain the most important tools to stop the spread of the virus. Executing a communication strategy that keeps residents, family members, and the public informed also will be critical during this rapidly evolving crisis.
Date: March 13, 2020
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Antihypertensive Deintensification Associated with Fewer Falls among Older VA Nursing Home Residents
This study sought to: 1) describe the frequency of antihypertensive de-intensification during scenarios suggesting over-aggressive treatment, 2) identify characteristics of residents associated with antihypertensive de-intensification, and 3) examine the association between antihypertensive de-intensification and subsequent falls. Findings showed that among Veterans with possibly over-aggressive antihypertensive treatment, just 11% underwent antihypertensive de-intensification. Among Veterans with low systolic blood pressure (SBP 80-100), antihypertensive de-intensification was associated with a lower risk of falling, but was not associated with risk of hospitalization or death. Among Veterans with possibly low SBP (101-120), antihypertensive de-intensification was associated with a higher risk of death, but not with risk of falling or hospitalization. In frail older adults, clinicians should repeatedly re-evaluate intensity of blood pressure management, taking into account the individual’s prognosis, goals of care, and an individualized estimate of the benefits and harms associated with the intensity of antihypertensive medication.
Date: December 1, 2018
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Impact of Comprehensive Caregiver Support Program on VA Healthcare Utilization and Cost
The Program of Comprehensive Assistance for Family Caregivers (PCAFC) supports caregivers of Veterans from the post-9/11 era who need assistance with activities of daily living (ADLs) or supervision or protection because of the residual effect of injuries sustained during their service. A monthly stipend is provided to caregivers based on Veterans’ care needs. In this study, investigators examined the early impact of PCAFC on VA healthcare utilization and costs. Findings showed that Veterans in PCAFC had similar acute care utilization when compared with those in the control group, but significantly greater primary, specialty, and mental health outpatient care use at least 30 – and up to 36 months post-application. Compared with Veterans in the control group, over time, Veterans in the PCAFC group had about a 10 percentage point higher probability of receiving any VA primary care. In the first six months, Veterans in the PCAFC group had an increased probability of using any VA specialty care (75% vs. 64%). Veterans in the treatment group also had an increased probability of using mental healthcare in the first 6 months (84% vs. 77%) and this increase was sustained through 31-36 months. Estimated total healthcare costs for Veterans in the PCAFC group were $1,500 to $3,400 higher per Veteran per 6-month interval than for Veterans in the control group. Findings suggest that comprehensive supports for family caregivers can increase patient engagement in outpatient care in the short term, which may enhance long-term health outcomes.
Date: April 1, 2017
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Stewardship Intervention Reduces Overuse of Antibiotics in the Treatment of Asymptomatic Bacteriuria among Veterans
The Kicking CAUTI: The No Knee-Jerk Antibiotics Campaign intervention to reduce asymptomatic bacteriuria (ASB) overtreatment features case-based audit and feedback and an actionable algorithm to distinguish ASB from catheter-associated urinary tract infection (CAUTI). This study evaluated the effectiveness of the Kicking CAUTI intervention in two VAMCs between July 2010 and June 2013. Findings showed that, at the intervention site, the Kicking CAUTI intervention successfully decreased inappropriate screening for ASB and decreased ASB overtreatment with antimicrobials, without increasing the undertreatment of CAUTI. In stratified analysis, the effect of the intervention was more significant in long-term care wards and was modest on acute medicine wards. The overall rate of ordering urine cultures decreased during the intervention period – from 41.2 to 23.3 per 1000 bed-days, and even further during the maintenance period – to 12.0 per 1000 bed-days. At the comparison site, cultures ordered did not change significantly across periods. Overtreatment of ASB at the intervention site fell significantly during the intervention period from 1.6 to 0.6 per 1000 bed-days, and these reductions persisted during the maintenance period – to 0.4 per 1000 bed-days. Overtreatment of ASB at the comparison site was similar across all periods.
Date: July 1, 2015
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Some VA Polytrauma Team Members Caring for Veterans with Traumatic Brain Injury at Risk for Job Burnout
This study sought to examine the extent of job burnout among VA polytrauma team members engaged in the diagnosis and treatment of traumatic brain injury – and to identify their coping strategies for dealing with job-related stress. Findings showed that VA polytrauma team members experienced moderate levels of emotional exhaustion, low levels of depersonalization, and high levels of personal accomplishment. However, 24% of participants in this study reported high levels of emotional exhaustion, which may be a precursor to job burnout. Polytrauma team members who reported caring for Veterans with TBI >50% of their time experienced higher levels of emotional exhaustion than those who spent <50% of their time caring for Veterans with TBI. Coping strategies included: connecting with others (e.g., relating to family, friends, and coworkers); promoting a healthy lifestyle (e.g., healthy diet, exercise); pursuing outside interests (e.g., hobbies); managing the work environment (e.g., staying organized); and maintaining positive thinking. No significant differences in participant characteristics for any of the subscales that were measured (emotional exhaustion, depersonalization, and personal accomplishment) were found for age category, race, years in practice, years at VA, primary role, or percent of time providing direct care.
Date: March 1, 2013
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Significant Financial Burden for Caregivers of Veterans with Polytrauma and Traumatic Brain Injury
This study (conducted prior to the implementation of stipends from the Caregivers and Veterans Omnibus Health Services Act) evaluated the prevalence of financial strain as measured by asset depletion and/or debt accumulation, and labor force exit among caregivers of Veterans with polytrauma and traumatic brain injury (TBI). Findings showed that financial strain is common for caregivers: 62% reported depleted assets and/or accumulated debt, and 41% reported leaving the labor force. The latter finding stands in sharp contrast to studies in other populations internationally, where between 2% to 27% of caregivers left the labor force. If a severely injured Veteran needed intensive help with activities of daily living, the primary caregiver faced 4.6 higher odds of leaving the labor force, and used $27,576 more assets and/or debt to help care for the Veteran compared to caregivers of Veterans needing little or no help. Male caregivers, those providing care since the time of injury, and those providing care to Veterans with high-intensity needs and with the lowest overall functioning at time of discharge experienced significantly higher amounts of asset depletion and/or debt accumulation compared to female caregivers, caregivers relatively new to their role, and those providing care to higher functioning Veterans with low-intensity care needs. Spouses did not face higher financial strain compared to parents; financial strain was no higher for caregivers of those injured in Iraq, Afghanistan or the Middle East compared to those injured in the U.S., and the timing of injury was not associated with greater financial strain.
Date: February 1, 2013
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Unintended Consequences of Advance Directive Law
This study sought to identify the unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences. Findings show that unintended negative consequences of advance directive legal restrictions may prevent all patients, vulnerable patients in particular, from making and communicating their end-of-life wishes and having them honored. Five overarching legal and content-related barriers were identified: poor readability (i.e., laws in all states were written above a 12th-grade reading level); restrictions on who may serve as a healthcare agent; execution requirements (steps needed to make forms legally valid); inadequate reciprocity (acceptance of advance directives between states); and religious, cultural, and social inadequacies. These restrictions have rendered advance directives less clinically useful. Advance directive statues meant to protect patients’ right of self-determination may instead better protect physicians from punitive action. For example, many states have provisions that enable physicians to presume the validity of an advance directive in the absence of actual knowledge that the directive is invalid. Author recommendations include improving readability (e.g., older persons read at a 5th-grade level), allowing oral advance directives, and eliminating witness or notary requirements. They also suggest that patients be allowed and encouraged to document their values, cultural traditions, and other socially or culturally important information.
Date: January 18, 2011
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Bloodstream Infections in Veterans with Spinal Cord Injury May Require Different Treatment Strategies
Bloodstream infections (BSIs) are a common type of infection in people with spinal cord injury. Bloodstream infections that occur in healthcare settings (e.g., acute care, long-term care) have been traditionally classified as community-acquired, but recent evidence suggests that these infections are distinct and may have a unique epidemiology. This retrospective review assessed characteristics associated with bloodstream infections that were: hospital-acquired (HA BSI), from healthcare contact outside the hospital (HCA BSI), or were community-acquired (CA BSI). Results show that HCA bloodstream infections accounted for 25% of all BSIs in hospitalized Veterans with spinal cord injury. Antibiotic resistance was more common in Veterans with HA BSI (65.5%) compared to those with HCA (49.1%) and CA BSI (22.2%). Methicillin-resistance in Staphylococcus aureus (MRSA) was highly prevalent: 84.5% in Veterans with HA BSI, 60.6% in Veterans with HCA BSI, and 33.3% in Veterans with CA BSI. Because several differences in medical characteristics and causal micro-organisms were found, the authors suggest that treatment and management strategies for HCA and CA infections may need to vary.
Date: August 1, 2009
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Prescribing Discrepancies during Patient Transfer May Result in Adverse Drug Events
The objective of this study was to examine medication discrepancies related to adverse drug events (ADEs) in nursing home patients transferred to and from the hospital. Findings show that less than 5% of discrepancies caused ADEs, which is consistent with reviews that suggest only a small fraction of errors result in harm. Authors note that information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients, and inform the development of decision-support tools at the time of patient transfer.
Date: February 1, 2009
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Physicians May Need More Education about Long-Term Care Options for Veterans
The purpose of this study was to obtain information about VA long-term care (LTC) referrals that could be used to develop interventions that increase the likelihood of referrals to home and community-based services (HCBS) instead of institutional care. Findings indicate that physicians are often seen as having limited familiarity with HCBS options and tend to refer Veterans with LTC needs to nursing homes. Training physicians about LTC referral options, with particular focus on how HCBS can be used to meet Veteran and caregiver needs, may help to increase those referrals.
Date: February 1, 2009
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Veterans Using Home Healthcare have Higher Rates of Outpatient, Inpatient, and Nursing Home Care
Veterans receiving VA home health care in 2002 increased their absolute chance of using VA outpatient care by 3%, inpatient care by nearly 12%, and nursing home care by 5% in 2003. Moreover, although utilization rates were low, VA HHC users were about 10 times more likely to have used hospice, adult day health care, or respite care in the VA system than non-users.
Date: October 1, 2008
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