- Methods of Suicide Differ Between Stably and Unstably Housed Veterans
This study examined whether Veterans’ methods of suicide varied by housing status. Findings showed that across the study period, 3% of Veterans in the study population were unstably housed. Among the 7,005 Veterans who died by suicide, 4% were unstably housed. After accounting for demographic and health factors, unstably housed Veterans had an 86% increased hazard of suicide from self-poisoning from exposure to drugs and other biological substances, compared to stably housed Veterans. Unstably housed Veterans also were more than 3 times more likely to die by suicide from jumping from a height and more than 2.5 times more likely to die by suicide from unspecified means than stably housed Veterans. Among stably housed Veterans, nearly 3 of 4 suicides involved firearms; in contrast, for unstably housed Veterans, less than half of suicides involved firearms. Understanding methods of suicide can inform prevention and intervention efforts, allowing VA to tailor suicide prevention programs for unstably housed Veterans. In particular, lethal means safety efforts (i.e., counseling and public health approaches) to suicide prevention should consider unstably housed Veterans at greater risk for using different means of suicide.
Date: April 12, 2020
- Possible Impact of Measures to Curb COVID-19 Spread on Suicide Prevention Efforts
Social distancing and other public health actions intended to curb the spread of COVID-19 have the potential for adverse outcomes on suicide risk. However, concerns about negative secondary outcomes of COVID-19 prevention efforts should not imply that that these public health actions should not be taken. Implementation should include a comprehensive approach that considers the public health priority of suicide prevention as well.
Date: April 10, 2020
- All-Cause Deaths and Those Due to Poisoning, Suicide, and Alcoholic Liver Disease Higher among White Veterans Ages 55-64
After years of declining mortality rates across all age groups in the United States, increasing rates in White non-Hispanic Americans ages 45–54 were reported. This study sought to determine whether White non-Hispanic middle-aged male Veterans enrolled in VA primary care experienced similar increases in all-cause and select-cause death rates as was observed in the general population. Findings showed that White non-Hispanic male Veterans ages 55-64 had a significant increase in all-cause death rates from 2003 through 2014, accompanied by increases in deaths due to suicide, poisoning, and alcoholic liver disease. Changes were not evident in the younger (45-54) Veteran age group. For White non-Hispanic males ages 55–64 who were not Veterans, all-cause mortality decreased slightly from 2003-2014. However, there were increases in death rates due to poisoning, alcoholic liver disease, and suicide. For all three race/ethnicity groups in the 55–64 age category, trends in death rates for alcoholic liver disease, poisoning, and suicide did not differ according to rural or urban location. Findings suggest the critical importance of suicide prevention programs, as well as the importance of high-quality integrated healthcare, for both Veteran and non-Veteran white men.
Date: January 31, 2020
- Health is the Main Concern of Newly Separated Veterans
This large study is the first in-depth investigation of U.S. Veterans’ health and well-being as they leave military service. Findings showed that health concerns were the most salient for newly separated Veterans, with many reporting that they had chronic physical (53%) or mental (33%) health conditions – and that they were less satisfied with their health than either their work or social relationships. Chronic pain, sleep problems, anxiety, and depression were most commonly reported by Veterans. Men were more likely to report a hearing condition, high blood pressure, and high cholesterol, while women were more likely to report anxiety and depression at both survey timepoints. Compared with officers, enlisted personnel reported consistently poorer health, vocational, and social outcomes, and deployed Veterans reported poorer health than non-deployed Veterans. Veterans’ work functioning declined in the first year after leaving military service. Findings suggest several important directions for future prevention and early intervention efforts (i.e., health concerns such as chronic pain, sleep, and anxiety), which, if implemented, have the potential to put Veterans on the path to more successful and fulfilling post-military lives.
Date: December 28, 2019
- Social Stressors Strongly Associated with Suicide Ideation and Attempt among Veterans
This study examined documented social stressors in VA’s electronic health record (EHR) and how these stressors were associated with suicidal ideation and suicide attempt. Seven types of social stressors were included: 1) experiences of violence, 2) housing instability, 3) employment or financial problems, 4) legal problems, 5) social or familial problems, 6) lack of access to care or transportation, and 7) non-specific psychological needs. Findings showed that social stressors were strongly associated with suicidal ideation and suicide attempt. For example, compared with Veterans who had no social stressors, those with one social stressor had nearly 2.5 times the odds of suicidal ideation, two social stressors had over four times the odds, three social stressors had nearly five times the odds, and four or more social stressors had over eight times the odds – after adjusting for numerous socio-demographic factors and mental illness diagnoses. Social stressors are as relevant as biological factors (e.g., depression) for suicide prevention and treatment. Systematic assessment of a more complete set of these stressors may improve the ability to identify patients at highest risk of suicide.
Date: November 19, 2019
- Increase in Opioid Overdose Deaths among Veterans Attributed to Increased Overdoses from Heroin and Synthetic Opioids
This study examined trends in VA opioid overdose rates and receipt of prescription opioids among Veterans receiving VA care who died from opioid overdose from 2010 through 2016. Findings showed that the overall rate of fatal opioid overdose among Veterans increased from 14.47 per 100,000 person years in 2010 to 21.08 per 100,000 person years in 2016. There was a decline in methadone overdose and no significant change in natural/semisynthetic opioid overdose, however the synthetic opioid overdose rate and heroin overdose rate increased substantially. Among all opioid overdose decedents, prescription opioid receipt within 3 months before death declined from 54% in 2010 to 26% in 2016. Fatal opioid overdose rates among Veterans receiving VA care increased because of increases in heroin and synthetic opioid overdose rates. Risk of overdose from heroin and synthetic opioids may need to be considered separately from risk from prescription opioids, and prevention efforts must broaden beyond Veterans actively receiving opioids.
Date: July 1, 2019
- Post 9/11 Veterans Less Likely to Delay Mental Health Treatment
This study compared delay of treatment for PTSD, major depressive disorder (MDD), and/or alcohol-use disorder (AUD) among post-9/11 Veterans relative to pre-9/11 Veterans and civilians. Findings showed that post-9/11 Veterans were less likely than both pre-9/11 Veterans and civilians to delay mental health treatment for PTSD and depression. Median time to PTSD treatment was 2.5 years for post-9/11 Veterans compared to 16 years and 15 years, for pre-9/11 Veterans and civilians, respectively. Median time to depression treatment was 1 year for post-9/11 Veterans compared to 7 years and 5 years, for pre-9/11 Veterans and civilians, respectively. No differences in treatment delay were observed between post-9/11 Veterans and pre-9/11 Veterans or civilians for alcohol-use disorder. Increased engagement in PTSD and depression treatment for post- vs. pre-9/11 Veterans could be attributable to a host of recent historic, cultural, and policy changes, including: DoD’s universal post-deployment mental health screening; educational public health initiatives; enhanced eligibility for VA benefits for post-9/11 Veterans; VA’s suicide prevention hotline; VA mobile health resources (e.g., PTSD Coach); and VA’s integration of mental health services into primary care settings.
Date: March 7, 2019
- Links Between Opioid Use and Suicide
This review describes what is known about the links between suicide and overdoses, with a focus on pathways through opioid use, issues of intent, risk factors, prevention strategies, and unresolved issues. Many factors promote the initiation and persistence of opioid use, but several specific pathways toward vulnerability to overdose and suicide are highlighted. Interventions that address shared causes and risk factors, such as programs to improve the quality of pain care, expanding access to psychotherapy, and increasing access to medication-assisted treatment for opioid use disorders, have the potential to be high-value investments by addressing both problems.
Date: January 3, 2019
- Medical Records Flag for Suicide Risk Increases VA Healthcare Visits among Veterans with Substance Use Disorder
VA has identified suicide prevention as a top priority and established policies to include high-risk suicide patient record flags (PRFs) in the electronic medical record to alert providers of patient risk and increase healthcare contacts. This study sought to identify predictors of new PRFs and to describe healthcare use before and after PRF initiation among VA patients who had received a substance use disorder (SUD) diagnosis. Findings showed that consistent with VA policy, 62% of Veterans with new suicide risk flags attended the recommended number of visits in months 1 to 3, with an additional 14% meeting recommended targets in month 1 only. Further, outpatient contacts in mental health and substance use disorder clinics increased 2 and 4 times, respectively, over the three-month follow-up period, with mean contacts in these services exceeding the minimum required one contact per week in month one. ED visits decreased by 45% in the three months following initiation of a PRF. Demographic predictors of PRF initiation included being younger than 35, White, and homeless. Clinical predictors were cocaine, opioid and sedative use disorders, PTSD, psychotic, bipolar, and depressive disorders, and suicide-attempt diagnoses. Suicide risk PRFs in an electronic medical record and subsequent follow-up increased service use for those Veterans with flags initiated.
Date: June 8, 2018
- 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
- Journal Features VA Research on Combating Multi-drug Resistant Organisms Posing Public Health Threat
As an integrated healthcare system with acute care, community living centers, and community-based outpatient clinics, VA provides an ideal setting in which to study multi-drug resistant organism prevention and make a significant impact. Thus, a group of HSR&D infectious disease researchers and operations partners convened in Iowa City, IA, in September 2016. Conference participants included experts in hospital epidemiology, antimicrobial stewardship, medical anthropology, clinical medicine, infection prevention, pharmacy, and sociology. The participants were divided into four subgroups, to work together to identify key knowledge gaps and important targets for future investigation. Articles resulting from this collaboration are highlighted in this journal issue.
Date: February 8, 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
- Systematic Review of Suicide Risk Assessment and Prevention
This systematic review evaluated studies assessing the accuracy of methods to identify individuals at increased risk for suicide, and the effectiveness and adverse effects of healthcare interventions relevant to Veteran and military populations in reducing suicide and suicide attempts. Findings showed that suicide rates were reduced in 6 of 8 observational studies of various types of multiple-component population-level interventions, including two studies in Veteran and military populations. Only 2 of 10 trials of individual-level psychotherapy reported statistically significant differences between treatment and usual care, however, most trials were inadequately designed to detect differences. No studies described the adverse effects of risk assessment methods or interventions for suicide prevention. Risk assessment methods are sensitive predictors of subsequent suicide and suicide attempts in studies, but the frequency of false positives limits their clinical utility. Future research should continue to refine these methods and examine their clinical applications.
Date: June 15, 2017
- Meta-Analysis of Interventions to Prevent Suicide
This study conducted a meta-analysis of randomized controlled trials (RCTs) that compared the efficacy of various interventions versus control to prevent death by suicide among adults. Of the studies included in this review, 29 RCTs reported on complex psychosocial interventions, with 3 reporting on the WHO Brief Intervention and Contact (BIC) intervention, which includes an educational session on suicide prevention followed by regular contact with a trained provider (phone or in-person) for up to 18 months. The WHO BIC intervention was associated with significantly lower odds of death by suicide. No other suicide prevention intervention showed a statistically significant effect in reducing death by suicide.
Date: June 1, 2017
- Male Veterans at Greater Risk of Sexually Transmitted Infections Compared to Non-Veterans
In this study, investigators compared sexual behaviors and history of sexually transmitted infections (STIs) between male Veterans and non-Veterans, including men aged 18-44 who had reported ever having sex with a man or woman. Findings showed that male Veterans were significantly more likely than male non-Veterans to have STI risk factors. In models adjusted for age, race/ethnicity, education, income, and marital status, Veterans had greater odds than non-Veterans of having =6 lifetime female partners, of having had sex with both female and male partners in the past year, and of having had gonorrhea in the past 12 months. For other sexual behaviors and STIs examined in the study, Veterans trended toward greater risk, although associations were statistically non-significant. Findings indicate that healthcare providers need to be aware that male Veterans may be at higher risk for STIs and routinely assess their sexual behaviors, screen for STIs accordingly, and perform risk reduction counseling during clinical encounters.
Date: March 22, 2017
- VA and Non-VA Nursing Homes Differ in CAUTI Prevention Methods
This study sought to compare infection prevention resources and practices between VA and non-VA nursing homes from 41 states that were participating as part of a national initiative to reduce catheter-associated urinary tract infections (CAUTIs), enhance frontline healthcare professional knowledge about infection prevention, and improve the safety culture in nursing homes. Findings showed that VA and non-VA nursing homes differed in their approach to CAUTI prevention: VA nursing homes reported more hours/week devoted to infection prevention-related activities (31 vs. 12 hours), and were more likely to have committees that reviewed healthcare-associated infections; VA nursing homes had substantially higher physician and nurse staffing to bed ratios compared with non-VA nursing homes; a higher percentage of VA nursing homes reported having 24-hour registered nurse supervision compared to non-VA nursing homes (96% vs. 56%); and most VA nursing home infection prevention programs were integrated within their VA acute care infection prevention programs, and they had more infection prevention related resources. In addition, a higher percentage of VA nursing homes reported tracking CAUTI rates (94% vs. 66%) and sharing CAUTI data with leadership and nursing personnel.
Date: December 5, 2016
- Organizational Factors Associated with Successful Campaign to Increase Influenza Vaccination among VA Healthcare Providers
VA’s Office of Public Health commissioned a study to characterize organizational factors and practices associated with vaccination campaign success among health care providers (HCPs) in the VA healthcare system. Findings showed that successful HCP flu campaigns shared several recognizable characteristics, many of which are amenable to adoption or emulation by programs hoping to improve their vaccination rates. Three factors distinguished sites with high flu vaccination rates from those with low rates: 1) High levels of executive leadership involvement that demonstrated visible support, fostered new ideas, facilitated resources, and empowered flu team members; 2) Positive flu team characteristics, including: high levels of collaboration, sense of campaign ownership, sense of empowerment to meet challenges, and adequate time and staffing dedicated to the campaign; and 3) Several concrete strong practices, such as: advance planning, easy access to the vaccine, ability to track employee vaccination status, use of innovative methods to educate staff, and use of audit and feedback to promote targeted efforts to reach unvaccinated employees.
Date: July 4, 2016
- MRSA Prevention Initiative Results in Additional Significant Decline in Other Bacteremia Rates across 130 VHA Facilities
VA introduced the Methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative in 2007. Although the Initiative was perceived as only targeting MRSA, it also expanded infection prevention and control programs and resources, which could result in lower rates of infection with other pathogenic bacteria. This study assessed the effect of the MRSA Initiative on hospital-onset gram-negative rod (GNR) bacteremia at 130 VA facilities. Findings showed that over the 11-year study period, the nationwide infection control program expansion that was part of the MRSA Initiative was strongly associated with a sustained and statistically significant 43% decline in hospital-onset (HO) GNR bacteremia rates. Findings suggest that the non MRSA-specific components of the Initiative (e.g., increased infection-control staffing, emphasis on hand hygiene compliance) had collateral benefits in reducing rates of HO GNR bacteremia among Veterans.
Date: June 28, 2016
- Higher Risk of Suicidal Ideation among Veterans Seeking Mental Health Treatment from both VA and non-VA Facilities
VA researchers developed the Veterans Health Module (VHM) to be implemented within the Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS). This report presents data from the 2011-2012 VHM telephone survey. Findings showed that after adjusting for sociodemographic and VHM variables, Veterans who sought mental health treatment from both VA and non-VA facilities had more than four-fold increased odds of suicidal ideation than Veterans who sought mental health treatment from VA facilities only. Overall, 5% of the study cohort reported recent suicidal ideation, and 1% reported attempting suicide. There were no sex differences in prevalence of suicidal ideation or attempt. In the overall sample, lifetime diagnosis of depression, anxiety, or PTSD was the strongest correlate of both suicidal ideation and attempt.
Date: June 24, 2016
- National Program to Prevent Catheter-Associated Urinary Tract Infection is Successful in Non-ICU Settings
The National Implementation of Comprehensive Unit-based Program (CUSP) to reduce catheter-associated urinary tract infection (CAUTI) focused on both the technical and socio-adaptive aspects of implementation of prevention guidelines. This study examined CAUTI and catheter utilization outcomes in 926 units (non-VA) within 603 hospitals in 30 states. Findings showed that participation in the program led to reduced CAUTI rates. Reductions occurred mainly in non-ICU settings, where CAUTI rates showed a 32% reduction. Rates did not significantly change in ICU settings. Catheter utilization also decreased significantly in adjusted analysis in non-ICUs (20% to 19%), but did not significantly change in ICUs (63% to 62%). The reason ICUs have had less success in CAUTI prevention is unclear. Authors suggest that it could be related to the belief that if a patient is ill enough to require ICU admission, they are unstable enough to need a urinary catheter for close urine output monitoring. The frequent occurrence of fever in critically ill patients, coupled with routine urine culturing to determine possible infectious sources could also lead to higher CAUTI rates in ICUs compared to non-ICUs.
Date: June 2, 2016
- Bundled Intervention Associated with Lower Rates of Surgical Site Infections following Cardiac or Orthopedic Operations
This study evaluated whether the implementation of an evidence-based bundle is associated with a lower risk of S. aureus surgical site infections (SSIs) in patients undergoing cardiac operations or hip or knee arthroplasties. Findings showed that implementation of an SSI prevention bundle was associated with reduced S. aureus SSI rates. During the pre-intervention period, there were 101 complex S. aureus SSIs compared with 29 during the intervention period. Also, the number of months without any complex S. aureus SSIs increased from 2 of 39 (5%) to 8 of 22 (36%). After a 3-month phase-in period, bundle adherence was 83%. The complex S. aureus SSI rates decreased significantly among patients in the fully adherent group compared with the pre-intervention period, but rates did not decrease significantly in the partially adherent or non-adherent group.
Date: June 2, 2015
- Comparing High-Dose Influenza Vaccine to Standard-Dose Vaccine among Elderly Veterans
This study assessed the relative effectiveness of high-dose (HD) influenza vaccination compared to standard-dose (SD) vaccination among Veterans 65 years and older who received either HD or SD vaccine during the 2010-2011 flu season. Findings showed that high-dose influenza vaccine was not more effective than standard-dose vaccine in protecting against hospitalization for influenza or pneumonia in Veterans = 65 years of age; however, subgroup analysis found that it was more effective in Veterans =85 years of age. The rate of hospitalization for influenza or pneumonia was 0.3% for Veterans in both the HD and SD groups during the influenza season. There were no significant differences in all-cause hospitalization and mortality between Veterans in the HD and SD groups.
Date: March 31, 2015
- Rates of Suicide Higher among Transgender Veterans
This study sought to document all-cause and suicide mortality among VA healthcare users with an ICD-9-CM diagnosis consistent with transgender status. Findings showed that the crude suicide rate among Veterans with transgender-related diagnoses across the 10-year study period was approximately 82/100,000 person-years, which approximated the crude suicide death rates for Veterans with serious mental illness (e.g., depression, schizophrenia). However, this rate was higher than in both the general VA and U.S. populations. Comparisons of age at time of death suggest Veterans with transgender-related diagnoses may be dying by suicide at younger ages than Veterans without such diagnoses. The average age of transgender Veterans at the time of death by suicide was 49 years compared with studies that show the average age of death among non-transgender Veterans who die from suicide was between 55 and 60 years.
Diseases of the circulatory system and neoplasms were the first and second leading causes of death among transgender Veterans, however, the other ranked causes of death differed somewhat from patterns among the general U.S. population for the same time period. For example, certain infectious and parasitic diseases were the 6th leading cause of death among transgender Veterans, whereas they ranked 9th among the general U.S. population. Authors suggest future research is needed to examine how transgender Veterans seek or receive mental health services and that programs aimed at suicide prevention may benefit from clinical education and training about transgender populations.
Date: December 1, 2014
- JGIM Supplement Highlights VA’s Partnered Research
In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management, suicide prevention, homelessness, medical home models, and communication of adverse events.
Date: November 1, 2014
- Cardiovascular Outcomes after Addition of Insulin Versus Sulfonylureas in Veterans with Diabetes Taking Metformin
This study compared time to a combined outcome of acute myocardial infarction (AMI), stroke, or death among Veterans with diabetes that were initially treated with metformin, and subsequently added either insulin or sulfonylurea. Compared to those who added a sulfonylurea, Veterans who added insulin to metformin therapy had a 30% higher risk of the combined outcome of heart attack, stroke, and all-cause mortality. Although new heart attacks and strokes occurred at similar rates in both groups, mortality was higher in patients who added insulin. Although sulfonylurea use predominated as add-on therapy, there was increasing use of insulin intensification over the study years (increasing by an average of 17% per year). Reasons may include a growing prevalence of obesity and insulin resistance, emphasis on metrics such as glycemic targets, increasing comfort with newer analog insulins, and/or the benefit in microvascular outcome prevention.
Date: June 11, 2014
- Proactive Tobacco Treatment More Successful than Usual Care among Veterans Attempting to Quit Smoking
This randomized controlled trial – the Veterans Victory over Tobacco Study – compared the effects of a proactive tobacco cessation care model versus a traditional cessation care model on the use of tobacco treatment and subsequent population-level smoking cessation rates. Findings showed that proactive tobacco cessation care that connected smokers to evidence-based telephone or in-person smoking cessation services is effective for increasing long-term, population-level cessation rates. The six-month prolonged smoking abstinence rate at one year was 14% for Veterans in the proactive care group, a significant increase compared to 11% for Veterans in the usual care group, and much higher than the 6% population-level cessation rate of the total US population. The proactive care group reported significantly higher rates of behavioral counseling combined with medication treatment compared to usual care (13% versus 5%). There was also a significant increase in receipt of a smoking cessation medication from VA providers among proactive care compared to usual care (35% versus 30%). About 85% of the usual care group and 83% of the proactive care group were daily smokers.
Date: March 10, 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
- Testosterone Therapy Associated with Adverse Cardiovascular Outcomes among Veterans
This study evaluated the association between the use of testosterone therapy and all-cause mortality, myocardial infarction (MI), and/or stroke among male Veterans who underwent coronary angiography in VA and had low testosterone levels between 2005 and 2011. Findings showed that the use of testosterone therapy was associated with increased risk of mortality, MI, and/or ischemic stroke. This association was consistent among patients with and without coronary artery disease. The absolute rate of events was 26% in the testosterone therapy group and 20% in the no-testosterone therapy group at 3 years after angiography, corresponding to one additional event for every 17 Veterans begun on testosterone. The increased risk of adverse outcomes associated with testosterone therapy use was not related to differences in risk factor control or rates of secondary prevention medication use since patients in both groups had similar blood pressure, LDL levels, and use of secondary prevention medications. Authors suggest that while physicians should continue to discuss the symptomatic benefits of testosterone therapy with patients, it is also important to inform them that long-term risks are unknown and that there is a possibility that testosterone therapy might be harmful.
Date: November 6, 2013
- Musculoskeletal Conditions, Injuries, and Pain More Prevalent among Patients Using Statins
This study sought to determine whether statin use was associated with musculoskeletal conditions, including arthropathy (joint disease) and injury. Findings showed that musculoskeletal conditions, injuries, and pain were more common among statin users than similar non-users. In addition, arthropathy was found to be more common among statin users than non-users. Authors note that these findings are concerning, since starting statins at a young age for primary prevention of cardiovascular diseases has been widely advocated.
Date: July 22, 2013
- Adoption of PACT Features is Significantly Associated with Lower Risk of Avoidable Hospitalization
The primary outcome measured in this study was potentially avoidable hospitalizations for ambulatory care sensitive conditions (ACSC) that included: asthma, angina without procedure, pneumonia, dehydration, COPD, congestive heart failure, complications related to diabetes, hypertension, perforated appendix, and urinary tract infection. In addition, the total number and costs of ACSC hospitalizations were measured for each Veteran during a 12-month follow-up period. Findings showed that greater adoption of medical home features by VA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations. Veterans in clinics with the highest medical home adoption had significantly lower ACSC rates (20 per 1,000) compared to Veterans in clinics with the lowest (25 per 1,000) and medium (26 per 1,000) adoption of medical home features. If clinics were transformed from the mean level of medical home adoption to the maximum level, the reduction in hospitalization costs in an average-sized clinic with 3,500 Veterans could be as much as $83,000 annually. Two PACT features were independently related to lower risk of ACSC hospitalization: access and scheduling, and care coordination/transitions in care. For example, Veterans in clinics with the highest scores on access and scheduling had 17% lower odds of having an ACSC admission compared to the lowest scoring clinics.
Date: March 26, 2013
- Review Supports One-to-One Peer Mentorship among Veterans
Across a broad range of populations, peer mentors appeared to be acceptable, credible sources of information. This may be particularly true among current and former members of the Armed Forces, who are accustomed to a culture of mutual support. The literature suggests that peers are capable of conducting assessment and triage, coaching and teaching, and providing direct social support. A White Paper identified three areas where peer mentorship (PM) might play a unique role for military/Veteran populations: coping with combat and operational stress, suicide prevention, and recovery-related issues downstream from combat/injury. In addition, the review suggests PM might play a role in reducing stigma, improving treatment adherence, increasing knowledge of treatment resources, and augmenting or teaching self-management skills.
Date: July 1, 2012
- PTSD Symptom Severity Predicts Aggression after Treatment
Post-treatment PTSD severity predicted aggression at the end of treatment and 4 months after treatment. Patients who experienced greater PTSD symptom severity at the end of treatment were more likely to be aggressive after treatment completion, regardless of their aggression history before treatment. Results suggest that severity of each PTSD symptom cluster is associated with aggression four months after treatment completion. Of the PTSD symptom clusters, hyper-arousal had the largest correlation with concurrent aggression before and after treatment. The authors suggest that this research could inform the development of aggression prevention and intervention efforts, as well as the development of clinical recommendations for post-treatment safety for patients with PTSD.
Date: March 1, 2012
- Despite Guidelines to the Contrary, High Rates of PSA Screening Found among Older Veterans with Limited Life Expectancy
This study sought to identify medical center characteristics associated with prostate-specific antigen (PSA) screening among men with limited life expectancy. Findings showed that high rates of PSA screening were found among older Veterans with life expectancy of less than 10 years, with substantial variation across VAMCs. Among Veterans with limited life expectancy, 45% received PSA screening in 2003. Across 104 VAMCs, the PSA screening rate for this population ranged from 25-79%. VA medical center characteristics associated with higher PSA screening rates included: no academic affiliation, a ratio of mid-level providers to physicians >3:4, and location in the South. Use of incentives and high scores on performance measures did not significantly affect screening practices. The percentages of men screened with limited and favorable life expectancies were highly correlated, indicating that screening is being poorly targeted. As a result of this and other studies, VHA’s National Center for Health Promotion and Disease Prevention has developed a set of goals to reduce over-screening in older adults starting in FY12.
Date: December 17, 2011
- Systematic Review Shows Most Current Readmission Risk Prediction Models have Poor Predictive Ability
This systematic review was performed to synthesize the available literature on validated readmission risk prediction models, describe their performance, and assess their suitability for clinical or administrative use. Findings showed that most current readmission risk prediction models that were designed for either comparing hospital performance or clinical purposes have poor predictive ability. Although in certain settings such models may prove useful, better approaches are needed to assess hospital performance in discharging patients, as well as to identify patients at greater risk of preventable readmission. Most models incorporated variables for medical comorbidity and use of prior medical services, but few examined variables associated with overall health and function, illness severity, or social determinants of health. The variable performance of predictive models in different populations suggests that the best choice of a model may depend on the setting and population in which it is being used. Even though the overall predictive ability of the clinical models was poor, investigators found that high- and low-risk scores were associated with a clinically meaningful gradient of readmission rates. Thus, even limited ability to identify a proportion of patients at highest risk for readmission could increase the cost-effectiveness of hospital interventions aimed at improving the discharge process and post-hospital follow-up.
Date: October 19, 2011
- Article Recommends Role of “Patient Safety Professional” to Increase Patient Safety
This article recommends consideration of a new type of clinical role in the hospital setting – the Patient Safety Professional (PSP) – to ensure that each patient receives individualized prevention strategies to minimize the hazards of hospitalization. Authors suggest the PSP be an advanced practice registered nurse, who would: 1) assess assigned patients for hospital-acquired complications (e.g., pressure ulcers, falls, pain) following explicit protocols relevant to a short list of safety targets; 2) prioritize identified complications based on morbidity, mortality, and hospital costs; and 3) develop and implement plans to decrease hospital-acquired complications, in consultation with physicians and staff nurses. The PSP might also provide additional benefits to the organization, i.e., he/she could serve as an educational resource or consultant to other clinicians and take responsibility for staying up to date on new advances and recommendations in the area of patient safety.
Date: September 8, 2011
- Adherence to National Prevention Measures for Surgical Site Infection Does Not Impact VA Surgical Outcomes
This study evaluated whether the Surgical Care Improvement Project (SCIP) improved surgical site infection (SSI) rates at the VA patient or hospital level. Findings showed that none of the 5 SCIP infection prevention measures were significantly associated with lower odds of SSI among Veterans after adjusting for variables known to predict SSI and procedure type. Individual hospital SCIP performance also was not associated with hospital SSI rates. While adherence to SCIP measures improved, risk-adjusted SSI rates remained stable. For Veterans with all measures assessed, the composite rate of adherence was 81%. Although SCIP measures are best practices and should continue, they may not discriminate hospital quality. Mandatory SCIP reporting without improvement in care may lead to health professional skepticism and fatigue with quality improvement measures.
Date: September 1, 2011
- Long-Term Outcomes Following Positive Colorectal Screening
Despite persistently low rates of follow-up colonoscopy in older adults with positive fecal occult blood test (FOBT) results, the long-term outcomes of screening and follow-up practices have not been described. This study examined outcomes following a positive screening FOBT result for 212 Veterans ages 70 years or older at four VA facilities in 2001. Both Veterans who did receive a follow-up colonoscopy and Veterans who did not were followed through 2008. Findings showed that, over a 7-year period, a little more than half of the older Veterans in this study received a follow-up colonoscopy after a positive FOBT. Among Veterans who received follow-up colonoscopy, more than 25% had significant adenomas or cancer detected, were treated, and survived for more than five years. Approximately 59% of Veterans who received follow-up colonoscopy had no significant findings, and 10% experienced complications from colonoscopy or cancer treatment. Among Veterans who did not receive follow-up colonoscopy, 57% underwent some form of follow-up other than colonoscopy (e.g., repeat FOBT or sigmoidoscopy) and 59% had more than one non-colonoscopy follow-up test. Nearly half of the non-colonoscopy group died of other causes within five years, and 3% ultimately died of colorectal cancer. Veterans with the best predicted life expectancy were less likely to experience net burden from screening than Veterans with the worst predicted life expectancy. These findings support guidelines that recommend using life expectancy to guide colorectal cancer screening decisions in older adults, and argue against one-size-fits-all interventions that simply aim to increase overall screening and follow-up rates.
Date: May 9, 2011
- Targeting Infection Prevention: JAMA Commentary on Methods for Comparative Effectiveness Research
This Commentary focuses on three complementary methods for comparative effectiveness research in infection prevention: cluster randomized trials, quasi-experimental studies, and mathematical models. The authors suggest that the focused and coordinated use of well-designed quasi-experiments, cluster-randomized trials, and mathematical models offer significant potential opportunities for targeting infection prevention efforts.
Date: April 13, 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
- Targeted Cost-Saving Method for MRSA and VRE Surveillance in VA Hospitals
Emerging antibiotic-resistant bacteria, including MRSA (methicillin-resistant Staphylococcus aureus) and VRE (vancomycin-resistant enterococcus), are leading causes of infections in hospitalized patients that result in significant costs, morbidity, and mortality. This prospective study investigated alternative methods for targeted active surveillance (using a prediction rule to identify a group of patients at high risk for MRSA or VRE among general hospital admissions) among 585 Veterans admitted to the medical and surgical wards of one VA hospital between 8/07 and 10/09 (non-ICU patients only). Findings show that antibiotic exposure documented by VA’s electronic medical record (EMR) in the year prior to admission was the best prediction rule for MRSA and VRE infections, identifying 84% of MRSA exposure risk and 98% of VRE exposure risk, while culturing only 51% of inpatients. During the 26-month study period, active surveillance for MRSA (culturing all patients at hospital admission) on all non-ICU inpatients would cost $86,773. Targeted active surveillance with EMR documentation of antibiotics would cost $45,255, resulting in a 48% savings. Active surveillance for VRE would cost $77,275 compared to $42,468 for targeted active surveillance, resulting in a 45% savings. An overall cost savings of 47% would result if targeted surveillance for both MRSA and VRE were included.
Date: December 1, 2010
- Prostate Screening Does Not Reduce Prostate Cancer or All-Cause Mortality
In a 2006 review of the evidence, authors identified insufficient evidence to either support or refute the use of routine screening for prostate cancer. This article presents findings from their updated study, in which investigators sought to determine whether population-based screening reduces prostate cancer-specific mortality and/or all-cause mortality. They also examined its impact on quality of life, including adverse events (e.g., harms of screening from false-positive or false-negative results). Findings show that prostate cancer screening did not result in a statistically significant reduction in prostate cancer-specific or all-cause mortality. One of the studies in this review showed a marginally significant benefit for prostate cancer screening among a subgroup of men aged 55 to 69. Among this group, it was reported that 1,410 men would need to be screened, with 48 men needing prostate cancer treatment, to prevent one additional death from prostate cancer during a 9-year period. Any benefits from prosate cancer screening may take up to 10 years to accrue; therefore, the authors suggest that men with a life expectancy of less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. None of the studies reviewed provided detailed assessment of the effect of screening on quality of life or costs associated with screening.
Date: September 1, 2010
- Responding to Decline in MRSA Infection
This JAMA Editorial reports on the current status of MRSA (methicillin-resistant S aureus) infection rates – and what it may mean for the future. Using data from 2005-2008, the CDC’s surveillance system showed a continuous decline of invasive MRSA disease. This includes an estimated 9.4% annual decrease in hospital onset and an estimated 5.7% annual decrease in healthcare-associated community-onset infections. There are a variety of theories for these decreases, such as general infection control efforts (e.g., wider use of alcohol-based hand rubs). However, it may be presumptuous to assume that hospital-based prevention efforts have a major effect on the natural history of such a wide-spread pathogen. Natural biologic trends are likely to override the best-laid attempts at infection control. Therefore, only by improving existing surveillance and prevention research programs can clinicians and infection control researchers begin to explain the decrease in MRSA disease.
Date: August 11, 2010
- Surveillance Colonoscopy is Cost-Effective for Patients at High Risk for Developing Colorectal Cancer
A modeling study examining different surveillance strategies for patients who have adenomas on their initial screening colonoscopy found that costs and benefits differed widely depending on the characteristics of the adenomas and the surveillance intervals. Performing routine screening colonoscopies every ten years in patients at low risk of developing colorectal cancer and surveillance colonoscopy every three years in patients at high risk was more costly, but also more effective than a “no surveillance” strategy where everyone got routine screening every ten years. Compared to no surveillance, this “3/10” strategy was highly cost-effective. Compared to the 3/10 strategy, a “3/5”strategy which conducted surveillance every 5 years on low-risk patients was considerably more costly, but only marginally more effective. A “3/3” strategy was cost-ineffective and potentially harmful in comparison to less intensive surveillance. Based on these results, the authors suggest that the 3/10 strategy is the optimal strategy under the vast majority of clinical circumstances for patients with adenomas on screening colonoscopy.
Date: March 10, 2010
- Implementation of a VA Quality Improvement Initiative Improves Knowledge and Perceptions Regarding MRSA Prevention
Implementation of the initiative at 17 VAMCs was associated with temporal improvements in knowledge and perceptions regarding MRSA prevention. Between baseline and follow-up, there were increases in the number of respondents who: correctly identified that alcohol-based hand rub is more effective at inactivating MRSA than soap and water, reported cleaning their hands when entering and exiting a patient room in the past 30 days, reported using alcohol-based hand rub over soap and water when cleaning their hands, and felt comfortable reminding others about proper hand hygiene.
Date: February 3, 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
- Implementing a Successful Fall Prevention Program for Elderly Veterans
This article discusses the implementation of a Telecare fall prevention program at the VA Greater Los Angeles Healthcare System (VAGLAHS) that was designed to be sustainable. Findings show that leadership and workgroup meetings led to the development of a functional program. The Telecare fall prevention program screened its first Veteran in October 2008 and is ongoing. The program uses an existing telephone nurse advice line to: 1) place outgoing calls to Veterans at high risk of falling, 2) assess the Veterans’ risk factors, and 3) triage Veterans to the appropriate services. Because Telecare operates via the telephone, it can accept referrals from anywhere in VAGLAHS, thus reaching Veterans in geographically remote areas. The authors suggest that another potential advantage of the Telecare fall prevention program is the opportunity to unburden primary care providers of additional responsibilities by helping assess patients’ needs and arranging the appropriate services.
Date: November 16, 2009
- Electronic Reminder Increases Follow-Up Rates for Positive Fecal Occult Blood Tests
Screening with fecal occult blood tests (FOBT) reduces colorectal cancer mortality by 15-33% and decreases the incidence of the disease by 20%; however, as many as 46-66% of patients with an abnormal FOBT do not receive proper diagnostic testing (e.g., follow-up colonoscopy). This study sought to determine the impact of an electronic reminder on the timeliness and proportion of Veterans referred to gastroenterology (GI) for evaluation after a positive FOBT. Findings show that the electronic reminder was associated with a significant improvement in the proportion and timeliness of follow-up for Veterans with a positive FOBT. The intervention was associated with a 20.3% increase in GI consultations within 14 days, and the median time to colonoscopy decreased by 38 days (105 vs. 143 days).
Date: September 1, 2009
- Toyota Production System Methodology Leads to Improved Peri-Operative Care in One VAMC
In the Toyota Production System (TPS) industrial engineering approach, front-line work groups identify problems, experiment with possible solutions, measure the results, and implement strategies to improve quality, resulting in a “ground-up” rather than “top-down” approach to solving system problems. Beginning in 2001, one VAMC instituted TPS methods to reduce Methicillin Resistant Staphylococcus Aureus (MRSA) infections on a general surgical floor. The intervention then evolved to address other areas for QI on the surgical unit, such as increasing appropriate prophylactic peri-operative antibiotic therapy. The aims of this study were to determine: 1) whether the QI intervention for peri-operative antibiotic therapy was associated with improvements in selection and duration of prophylactic therapy; and 2) if the overall MRSA prevention initiative was associated with decreased hospital stay (LOS). Findings show that use of the TPS methodology resulted in a QI intervention that was associated with an increase in appropriate peri-operative antibiotic therapy among surgical patients. The proportion of all surgical admissions in this study (n=2,550) receiving appropriate peri-operative antibiotics was significantly higher in 2004 after initiation of the TPS intervention (44.0%) compared to the previous four years (range 23.4% to 29.8%). Results also showed no statistically significant decrease in LOS over time.
Date: September 1, 2009
- Strategies to Improve Follow-Up for Positive Colorectal Cancer Screening
In 2006, VA launched a national effort to increase the proportion of patients receiving a colonoscopy within 60 days of a positive fecal occult blood test (FOBT). This study sought to determine the proportion of VA patients with a positive FOBT between March and June of 2007 that received a colonoscopy within 60 days. Investigators also examined data from a 2007 web-based survey that was completed by 132 VAMCs on their FOBT follow-up quality improvement strategies. Results show that only 1 in 4 Veterans received follow-up colonoscopies within 60 days of a positive FOBT for colorectal cancer screening. Findings also show that developing QI infrastructure appears to be an effective strategy for improving FOBT follow-up, when this work is followed by process improvements (e.g., strategies to decrease cancellations, revise colonoscopy prep education protocols). On average, facilities indicated that they had fully implemented 6.84 of 16 improvement strategies. The number of strategies fully implemented was positively associated with 60-day follow-up. The most commonly cited barriers to improvement involved capacity constraints, e.g., sites listing insufficient gastroenterology staff as a barrier had a lower percentage of Veterans receiving timely follow-up. However, none of the improvement strategies designed to address gastroenterology capacity constraints were associated with timely follow-up, suggesting that this barrier may be more difficult or take more time to address than process inefficiencies.
Date: August 1, 2009
- High Rates of Violence among Substance Abusers
This study examined violence related to SUD, as well as potential violence prevention treatment needs for men and women patients (non-Veterans) in SUD treatment settings. Investigators looked specifically at violence resulting in injury toward partners and non-partners, as well as against individuals in treatment. Findings show that rates of injury across relationship types were substantial, with more than 54.8% reporting injuring another person, and 55.4% reporting being injured. Further, there was a strong association between injuring others and being injured. Overall, those reporting injuring others had significant psychosocial challenges in terms of low rates of employment, low household income, relatively few prior SUD treatment visits on average, and most participants did not have prior “anger-management/domestic violence” treatment. Moreover, those injuring or reporting injury by others had higher rates of problems (e.g., binge drinking, opiate use, depression) than those in the non-injury groups.
Date: July 1, 2009
- Spinal Cord Injury and Alcohol Use are Risk Factors for Osteoporosis Hospitalization
Spinal cord injury (SCI) is associated with severe osteoporosis, increasing the risk of low-impact fractures that occur in the absence of trauma. Findings from this study show that hospitalization for low-impact fractures was more common in motor complete SCI (no motor function below the neurological level of injury) and was associated with greater alcohol use after injury. Osteoporosis diagnosis, prevention, and management were not included in the treatment plans for any of the Veterans hospitalized with fractures. These findings suggest that future studies should address prevention and treatment of bone loss among Veterans with motor complete SCI.
Date: March 1, 2009
- Need for Better Self-Management Education to Address Cultural Differences among Veterans with Diabetes
Although non-white Veterans have documented disparities in the quality of some diabetes care processes and intermediate outcome measures, racial disparities in foot care examinations have not been widely explored. Findings from this study show that there are significant differences in self-reported foot care and education across racial and ethnic groups among Veterans with diabetes. Authors suggest the need for better self-management education to address culture, knowledge, preferences, and unique barriers to care.
Date: January 1, 2009
- Low Rates of Hepatitis Vaccination among Veterans with HCV
Among veterans diagnosed with HCV between 2000 and 2005, approximately 8% overall received hepatitis vaccination and 7% of those with cirrhosis were vaccinated. In veterans with HCV who did not receive hepatitis vaccinations, 66%-96% had hepatitis A or B serology checked and about one-third had negative serology indicating susceptibility to co-infection and missed opportunity for vaccination.
Date: November 1, 2008
- Fall Prevention and Management for Older Adults
This article describes fall prevention and management activities from a chronic care perspective that may help researchers, practitioners, and policymakers better understand existing programs and services. The authors propose a "no wrong door" approach to fall prevention and management, in which older adults at risk of falls are evaluated across three domains -- physical activity, medical risks, and home safety. Trained providers would then connect the patients and their caregivers to programs and services that address the identified risk in the most appropriate manner.
Date: August 1, 2008