- JGIM Supplement Features HSR&D/QUERI Research on the Importance of Implementation Science to
Sponsored by the Agency for Healthcare Research and
Quality (AHRQ), Kaiser Permanente, and VA, this supplemental issue of the Journal of General Internal Medicine (JGIM) on implementation science (IS) and
quality improvement (QI) marks the formal addition of IS/QI as an area of emphasis for JGIM. The supplement features innovative research that applied evidence across diverse delivery systems and settings, as well as a high-level overview of important contributions for implementation science with selected stories amplifying successes in the field. Editors discuss how the IS/QI research featured in this supplement can advance internal medicine care delivery and ensure that the foundational knowledge generated by internal medicine research finds its way into practice.
Date: November 10, 2020
- VA Policies to Establish National Dialysis Contracts Reduce Reimbursement Without Compromising Access or Survival
This study examined whether changes in VA reimbursement and contracting policies were associated with VA spending on dialysis, Veterans’ access to dialysis care, and mortality. Findings showed that VA policies to standardize payment and establish national dialysis contracts increased the value of community dialysis care by reducing costs without compromising access to care or survival. Over the time period that payment reforms went into effect, there was an estimated 44% reduction in average treatment prices for VA-financed community-based dialysis care. Over the same time period, there was an increase in the number of community dialysis facilities contracting with VA to deliver care to Veterans with end-stage kidney disease from 19 to 37 facilities (per VAMC), and there were no changes in either the
quality of community dialysis facilities or in the 1-year mortality rate of Veterans (12% vs. 11%). Standardization of payments to community dialysis providers did not appear to have unintended adverse effects on access to care or mortality, suggesting that national price setting may be a feasible approach for VA to improve the value of community care more broadly.
Date: September 22, 2020
- Low-Value Diagnostic Testing for Back Pain, Sinusitis, Headache, and Syncope Is Common and Varies Across VA Medical Centers
This study sought to determine the frequency and degree of variation in low-value diagnostic testing for four common conditions across 127 VAMCs. Findings showed that low-value diagnostic testing for four conditions was common; it affected 5-21% of Veterans, varied 2-to-5 fold across VAMCs, and was significantly correlated at the VAMC level. Applying sensitive criteria, the overall and VAMC-level of low-value testing frequency varied substantially across conditions: 5% (range 3-10%) for sinusitis, 13% (9-23%) for headache, 18% (11-25%) for low-back pain, and 20% (16-28%) for syncope. Applying specific criteria lowered the overall frequency and range of low-value testing across VAMCs: 2% (range 1-5%) for sinusitis, 9% (6-15%) for headache, 6% (4-8%) for low-back pain, and 13% (11-17%) for syncope. Findings reinforce the need to address low-value diagnostic testing, even in integrated health systems like VA, with robust utilization management practices.
Date: September 22, 2020
- Project Identifies and Validates Recommendations to Stop or Scale Back Unnecessary Routine Services in Primary Care
Investigators in this study conducted a focused review of existing guidelines and recommendations – concentrating primarily on those published between 2011 and 2016 – to identify potential deintensification recommendations related to routine primary care. Investigators reconfigured about 50 high-priority recommendations by explicitly defining and specifying the deintensification action and appropriate target population. Starting from a set of 86 guidelines, Choosing Wisely recommendations, and National
Quality Forum measures, investigators identified 409 recommendations – corresponding to 178 unique indications – that represented opportunities to stop or scale back routine services in primary care. After prioritization, specification, and expert panel revisions, the panel rated 37 of 44 deintensification recommendations as valid – and 32 of 44 as both valid and an important improvement opportunity (i.e., likely to affect many patients or substantially impact a smaller number of patients). This study builds on previous guidelines and lists of recommendations by making explicit when and for whom ongoing medical services should be stopped or scaled back. The approach used in this study in the first to systematically identify, specify, and validate actionable and measurable recommendations for deintensification in routine primary care.
Date: September 14, 2020
Quality Improvement Intervention Improves Outcomes for Veterans with New Ischemic Stroke Symptoms
The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention was developed to improve the
quality of VA care for Veterans experiencing transient ischemic attack (TIA). This trial evaluated the PREVENT intervention at six diverse VA medical centers and assessed temporal trends in care
quality among 36 matched control sites (six control sites matched to each intervention site on TIA patient volume, facility complexity, and
quality of care). Findings showed that over the course of a one-year implementation period, the mean without-fail rate (Veterans with TIA at a specific facility who received all of the processes of care for which they were eligible) improved substantially at the six VA sites utilizing PREVENT (37% to 54%; +17%) and improved only modestly at the 36 matched control sites (39% to 42%; +3%). Investigators observed a net improvement of 14% at PREVENT intervention sites compared with matched controls. At PREVENT sites, the observed 90-day all-cause mortality rate decreased from 2.5% to 1.6%; at matched control sites this rate declined similarly from 2.3% to 1.7%. Decreases in the 90-day stroke rate, combined 90-day stroke or death rate, and the recurrent event rate were modestly higher for PREVENT sites than for the matched control sites, but differences were not statistically significant. Based on observed improvements in
quality of care, PREVENT was deployed nationwide across the VA healthcare system in 2019.
Date: September 8, 2020
- VA/HSR&D Research on Complementary and Integrative Health Therapies within VA
Funded by HSR&D, this special issue of Medical Care highlights how research on complementary and integrative health (CIH) therapies in the VA healthcare system has progressed along the QUERI (
Quality Enhancement Research Initiative) Implementation Roadmap – from pre-implementation to implementation to sustainment. CIH approaches are becoming more available throughout VA, due to: 1) increased implementation of the Whole Health System of Care, which integrates allopathic and CIH care; and 2) development of the infrastructure for CIH implementation, which includes new standards for hiring CIH providers, the involvement of volunteers who teach CIH, and development of policy and guidance for providing CIH at VAMCs, via telehealth, and/or in the community. Conducting pre-implementation, implementation, and sustainment phases of research on CIH approaches in VA is yet another way to boost the scale-up and spread of these therapies to reach as many Veterans as possible.
Date: September 1, 2020
- Effectiveness of Deprescribing Interventions for Community-Dwelling Older Adults
This systematic review and meta-analysis evaluated the effectiveness, comparative effectiveness, and harms of deprescribing interventions in community-dwelling persons aged 65 or older. Findings showed that medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications. Comprehensive medication review may have reduced all-cause mortality but probably had little to no effect on falls, health-related
quality of life, or hospitalizations. Nine of thirteen trials reported fewer inappropriate medications in the intervention group. Among various educational initiatives, findings showed that they may reduce the use of inappropriate medications, but had uncertain effects on
quality of life and rates of hospitalizations and falls. Among computer decision support interventions, two studies reported a significant reduction in inappropriate medications and two studies reported no effect. No studies assessed the comparative effectiveness of the different deprescribing approaches.
Date: August 20, 2020
- Contextualized Care Planning Results in Improved Veteran Outcomes and Significant Cost Savings
Contextualizing care is the process of adapting research evidence to patient context. For example, recognizing that a patient is not managing their diabetes because they cannot afford the medication and switching them to a less costly alternative is a contextualized care plan. This study evaluated the effectiveness of a
quality improvement program in which providers receive ongoing feedback on their attention to patient contextual factors based on audio recordings of their clinical encounters. Findings showed that contextualized care planning was associated with a significantly greater likelihood of improved outcomes – and resulted in significant cost savings from avoided hospitalizations. At baseline, providers addressed 413 of out 618 contextual factors in their care plans (67%). Following either standard or enhanced feedback, they addressed 1,707 out of 2,367 contextual factors (72%), a significant improvement. In a budget impact analysis, estimated savings from avoided hospitalizations were $25.2 million at a cost of $337,000 for the intervention. Giving clinicians ongoing feedback on their attention to the life challenges that their patients face may be an effective strategy for heightening their awareness and attention to social determinants of health, which may significantly improve healthcare outcomes and reduce costs. QI programs may be well advised to consider routine incorporation of training in contextualizing care through audit and feedback.
Date: July 31, 2020
- VA Patients Have Fewer Potentially Avoidable Hospitalizations Post-Chemotherapy than Medicare Patients
The Centers for Medicare and Medicaid Services (CMS) released a new
quality measure to reduce potentially avoidable hospital admissions among patients receiving outpatient chemotherapy. In this study, investigators used this CMS measure to compare the
quality of care received by chemotherapy patients treated through traditional Fee-for-Service Medicare versus VA, using a cohort of dually-enrolled Veterans. Findings showed that Veterans with cancer receiving chemotherapy through VA have higher-
quality care with respect to avoidable hospitalizations than Veterans receiving chemotherapy through Medicare. Roughly 7% of Veterans treated through Medicare had potentially avoidable hospitalizations in the 30 days following chemotherapy compared with approximately 5% of Veterans treated by VA. In the entire cohort, the top reasons for an avoidable hospitalization were pneumonia (41%), sepsis (24%), anemia (21%), and pain (11%), though the order of frequency changed when evaluating Medicare versus VA treatment. This study was driven by recent legislation (Choice Act of 2014, MISSION Act of 2018) allowing Veterans to seek care in the private sector if VA care is difficult to access. As these policy changes are implemented, it is critical to understand whether this shift in system of care will impact care
quality, especially for conditions as serious as cancer.
Date: July 15, 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
- Nurse Practitioners as Primary Care Providers May Be a High-Value Solution to Increasing Access to Care for All Veterans
Investigators in this study assessed patient outcomes between primary care nurse practitioners (NPs) and MDs, including utilization, costs, and
quality of care – one year after patient reassignment to a new primary care provider (due to a Veteran’s prior MD PCP leaving VA). Findings showed that compared to Veterans newly assigned to MDs, those newly assigned to NPs were less likely to use primary care and specialty care services – and incurred fewer hospitalizations. Further, Veterans assigned to NPs achieved similar
quality of care in the management of chronic disease compared to those assigned to MDs. Differences in costs, clinical outcomes, and the receipt of diagnostic tests between NP and MD groups were not statistically significant. Findings suggest that the general use of nurse practitioners as primary care providers may be a high-value solution to increasing access to care for all Veterans. Also, comparable or better outcomes achieved at similar costs for patients across differing levels of comorbidity suggest NPs as primary care providers need not be limited to less complex patients.
Date: April 1, 2020
- Computer-Based Cognitive Behavioral Therapy with Peer Support Provides Greater Improvement of Depression Symptoms
This trial sought to determine whether computer-based cognitive behavioral therapy (cCBT) combined with peer support improved outcomes relative to enhanced usual care (EUC) for 330 primary care patients with depression who were treated at three Midwestern VA medical centers and two of their associated outpatient clinics. Findings showed that peer-supported cCBT as an add-on to usual primary care treatment for depression was associated with greater improvements in depression symptoms,
quality of life, and mental health recovery at three months compared to enhanced usual care alone. Improvements in mental health recovery, although not the other outcomes, were sustained up to six months. Remission rates were 14% for Veterans in the peer-supported cCBT group and 6% for Veterans in the EUC group at three months, and 22% and 11%, respectively, at six months. The more modest benefits found with peer-supported cCBT should be considered in the context that more than 50% of Veterans also received antidepressant medication with high levels of adherence and over 30% received some in-person psychotherapy. Computerized CBT with peer support should be considered for implementation and evaluation in primary care, and adaptations to the computer CBT and peer support components should be considered to further improve effectiveness.
Date: March 1, 2020
- Anti-MRSA Therapy Associated with Greater 30-day Mortality Compared with Standard Therapy for Veterans with Pneumonia
This study sought to determine the association of empirical anti-MRSA therapy with 30-day mortality for Veterans hospitalized with pneumonia. Findings showed that empirical anti-MRSA therapy was significantly associated with greater 30-day mortality compared with standard therapy alone. There was a significant increase in 30-day mortality associated with empirical anti-MRSA therapy plus standard therapy, compared with standard therapy alone, among patients admitted to the intensive care unit (ICU) and those with a high clinical risk for MRSA. Thus, investigators could establish no benefit of empirical anti-MRSA therapy, even when risk factors for MRSA were present or clinical severity warranted admission to the ICU. The use of anti-MRSA therapy also was associated with increased risk of kidney injury and secondary infections.
Date: February 17, 2020
- Payment Changes and Choosing Wisely Recommendations Affect Low-Value Lab Testing
This study examined the use of low-value lab testing, specifically, vitamin D screening and triiodothyronine (T3) level testing across three healthcare jurisdictions: Ontario, Canada; the VA healthcare system; and the U.S. employer-sponsored insurance market. In the three jurisdictions examined, Choosing Wisely recommendations were associated with only limited reductions in the use of low-value vitamin D screenings and were not associated with reduced use of low-value T3 testing. However, a December 2010 policy that eliminated reimbursement for low-value vitamin D screening in Ontario was associated with a 93% relative reduction in such screening. Corresponding Choosing Wisely recommendations were associated with smaller reductions: 5% in Ontario, 14% in VA, and 14% for U.S. employee-sponsored insurance. Thus, recommendations alone may not be enough to reduce the use of low-value services at a national or regional level – pairing recommendations with policy changes may be more effective.
Date: February 10, 2020
- Eight Organizational Target Areas for Improving Access to Primary Care
This study sought to identify priorities for improving healthcare organization management of patient access to primary care based on prior evidence and a stakeholder panel. Findings showed that optimal access to primary care for enrolled patient populations requires active ongoing management of at least eight diverse target areas (two organizational structure targets, four process improvements, and two outcomes): 1) Clearly identified group practice management structure; 2) Interdisciplinary primary care site leadership; 3) Patient telephone access to ensure patient safety, scheduling, and coordination; 4) Contingency staffing (planned minimal excess staffing to cover routine absences); 5) Nurse management of demand through care coordination; 6) Proactive demand management by optimizing provider visit schedules; 7)
Quality of patients’ experiences of access; and 8) Provider and staff morale in relationship to supply-demand mismatch (e.g., provider vacancies, panels exceeding recommended size).
Date: February 1, 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
- Few Disparities in Medical Treatment for Opioid Use Disorder after Non-Fatal Overdose
This study assessed the association between race and ethnicity and patterns of opioid prescribing before and after a non-fatal opioid overdose – and also assessed the receipt of medications for opioid use disorder (MOUD: buprenorphine, methadone, and naltrexone) following such events among VA patients. Findings showed that receipt of an opioid prescription decreased by 16-21 percentage points in the 30 days after overdose, but remained high, with no significant differences across racial and ethnic groups. After overdose, the frequency of receiving opioids was reduced by 18.3, 16.4, and 20.6 percentage points in whites, blacks, and Hispanics, respectively. Overall, MOUD prescribing in VA was very low in all racial groups in the 30 days after overdose, though statistically significantly higher in black and Hispanic patients. After overdose, 3% of patients received MOUDs (3% white, 5% black, and 6% Hispanic). Blacks and Hispanics had significantly larger odds of receiving MOUDs than whites. Findings demonstrate an opportunity to improve the
quality of care for all patients with opioid use disorder, particularly in the vulnerable period around a non-fatal overdose event.
Date: January 21, 2020
- Special Medical Care Supplement Features VA/HSR&D Research on Evidence Synthesis in a Learning Healthcare System
Titled “Evidence Synthesis in a Learning Health Care System,” this Medical Care supplement includes 14 original articles that present new insights and perspectives from HSR&D’s Evidence Synthesis Program (ESP). Articles discuss optimal evidence synthesis methods and applications in a learning healthcare system; some articles target the effect in one area (i.e., mental health, primary care), while others discuss a broader, system-wide effect. As the editors note, “The articles in this series demonstrate what can be accomplished when research synthesis is integrated with qualitative information from health system personnel and patients and quantitative data from health systems in the context of an overarching framework for health system learning."
Date: October 1, 2019
- Cardiovascular Benefits of Intensive Glucose Control in Veterans with Type 2 Diabetes Did Not Persist in Long-term Post-Trial Follow-Up
Long-term follow-up of glucose lowering in patients with type 2 diabetes may help clarify the duration of any potential cardiovascular disease (CVD) benefit. Investigators here report on the full 15-year follow-up of Veterans with type 2 diabetes who were randomly assigned to receive either intensive or standard glucose control as part of the Veterans Affairs Diabetes Trial. Findings showed that Veterans with type 2 diabetes at high CVD risk, with 5.6 years of intensive glucose lowering to a HbA1c of 6.9%, DID NOT experience reduced major cardiovascular events over 13.6 years of follow-up or reduced total mortality or improved
quality of life over 15 years of total follow-up. Although there was a 17% reduction in major CVD events during the approximate 10-year period when HbA1c levels were separated between the intensive and standard therapy groups, there was no evidence of a beneficial legacy effect in the subsequent 5-year period once levels equalized among the groups. Results suggest there are modest long-term cardiovascular benefits of intensive glucose lowering therapy in patients with more advanced diabetes, but that long-term maintenance of lower levels may be required to maintain these improvements.
Date: June 6, 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
- 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
- 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
- Women’s Health VA Stakeholders Discuss “Ideal” Care
As part of a multisite implementation trial of evidence-based
quality improvement for tailoring PACT to women Veterans’ healthcare needs, investigators conducted semi-structured interviews with 86 local leaders. At the conclusion of interviews about women’s primary care, participants were asked to describe their conceptualizations of “ideal care” for women Veterans. Respondents commonly discussed whether women Veterans should have separate primary care services from men; the need for childcare, expanded reproductive health services, resources, and staffing; geographic accessibility; the value of input from women Veterans; physical appearance of facilities; fostering active interest in women’s health across providers and staff; and the relative priority of women’s health at VA. Paths toward ideal care could include projecting and anticipating growth in women’s health programs; building on VA’s pilot program to provide childcare for patients’ children during visits; designing a hiring process to more consistently recruit providers with a strong interest in caring for women; and conducting listening sessions and creating other opportunities that allow senior VA leadership to hear women Veterans’ perspectives and preferences directly.
Date: January 1, 2019
- New VA Center for Innovation for Care and Payment to Test Novel Payment and Service Delivery Models
VA’s new Center for Innovation for Care and Payment will be staffed by VA employees and contractors with expertise in demonstrations and evaluations. Through this Center, VA will have the ability to test novel payment and service delivery models. The new Center also empowers VA to collaborate with other payers to drive improvements in
quality, costs, or efficiency.
Date: December 25, 2018
- Mobile Acute Care for Elders (MACE) Consultation Lowers Readmission and Mortality Rates
Underlying geriatric syndromes in hospitalized patients can lead to complications such as delirium, falls, and functional decline, which in turn may lead to increased morbidity, mortality, readmission, longer hospital stays, decreased
quality of life, and increased costs. Mobile Acute Care for Elders (MACE) has emerged as a way to provide dedicated geriatric care designed to prevent these complications, without the need for a physical inpatient unit. This study examined records of Veterans admitted to the Indianapolis VA Medical Center who were age 65 and older and were screened within 48 hours of admission for geriatric syndromes. For positive screens, admitting staff was offered MACE consultation and ongoing collaboration with a geriatrician and gerontological nurse practitioner. Although no results were statistically significant, Veterans receiving MACE had lower odds of 30-day readmission than those not receiving MACE (12% vs.15%) and lower odds of 30-day mortality (6% vs.9%). The group of Veterans receiving MACE had lower median costs for 30-day readmission than the group not receiving MACE ($16,000 vs. $18,000). The MACE consultation model for older Veterans with geriatric syndromes leverages the limited supply of clinicians with geriatrics expertise. It has the potential to improve care of older Veterans while achieving cost savings to the health system.
Date: December 21, 2018
- No Difference in Intermediate Outcomes for Veterans with Diabetes by Type of Primary Care Provider
This study examined whether intermediate diabetes outcomes differed among Veterans treated at one of 568 VA primary care facilities by a physician, nurse practitioner (NP), or physician assistant (PA) primary care provider. Findings showed that there were no clinically significant differences in intermediate diabetes outcomes – or the control of those outcomes – among patients with NP, PA, or physician primary care providers. There also was no clinically significant difference in the proportions of NP, PA, and physician-treated patients with diabetes who used endocrinology or specialty diabetes services during the year outcomes were calculated. This study provides further evidence that using NPs and PAs as primary care providers may represent a mechanism for expanding access to primary care while maintaining
Date: December 18, 2018
- Intervention Utilizing Community Health Workers Improves
Quality of Patient Care and Reduces Hospitalizations
Individualized Management for Patient-Centered Targets (IMPaCT) is a standardized intervention in which community health workers (CHWs) provide tailored social support, navigation, and advocacy to help low-income patients achieve health goals. This randomized trial assessed the scalability and effectiveness of IMPaCT in three primary care settings that provide treatment to low-income patients: one VA medical center, a federally-qualified health center, and an academic family practice clinic. Findings showed that compared to those in the control group, those in the intervention (CHW) group, including Veterans, had nearly twice the odds of reporting high-
quality primary care, were less likely to be re-hospitalized within 30 days of discharge (12% vs. 28%), and spent fewer total days in the hospital at 6 months. Patients in the CHW intervention group also had lower odds of repeat hospitalizations, including 30-day readmissions.
Date: December 1, 2018
- Veterans Receiving Prescriptions Through Both VA and Medicare Are More Likely to Be Taking Opioids and Benzodiazepines
This study sought to assess the association between receiving medications from both VA and Medicare Part D (dual use) and the receipt of overlapping opioid and benzodiazepine prescriptions. Findings showed that receiving prescription medications from both VA and Medicare Part D was associated with a 27% increased risk of overlapping opioids and benzodiazepines – and more than twice the risk of overlapping high-dose opioids with benzodiazepines – compared to receiving prescriptions from VA alone. Receipt of prescriptions from both VA and Medicare also was associated with a greater risk of opioid/benzodiazepine overlap compared to Medicare alone, although the difference was smaller. Receipt of medications from more than one healthcare system is a key risk factor for unsafe prescribing practices, highlighting the need to enhance coordination of care across healthcare systems to optimize the
quality and safety of prescribing.
Date: October 9, 2018
- Men Using VA More Likely to Receive Appropriate Prostate Cancer Imaging Tests Compared to Those Using Medicare
This study sought to assess the association between the
quality of healthcare within VA vs. Medicare, by comparing rates of guideline-concordant and guideline-discordant staging imaging among patients with newly diagnosed prostate cancer utilizing VA services only, Medicare only, or a combination of the two. Findings showed that among men with low-risk prostate cancer, the VA-only and VA-Medicare groups were most likely to receive guideline-concordant care (61% and 56%, respectively) compared with the Medicare-only group (53%). Among men with low-risk prostate cancer, more in the Medicare-only group received at least one inappropriate, guideline-discordant imaging test for staging (53%) compared with the VA-Medicare group (51%) and the VA-only group (46%). For men diagnosed with high-risk prostate cancer, guideline-concordance was similar across the 3 groups, with 71% of the VA-Medicare group, 69% of the VA-only group, and 67% of the Medicare-only group receiving guideline-concordant imaging. Findings suggest that Veterans using the Choice Act to seek care outside VA may experience more utilization of care with no guarantee of improved
quality of care.
Date: August 17, 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
- Systematic Review: Pay-for-Performance and VA Healthcare
Investigators sought to identify studies that examined the effects of pay-for-performance (P4P) on the
quality of care and health of Veterans, including potential unintended consequences, as well as program design features and implementation factors important to P4P both within VA and in the community. Findings showed that overall, evidence is insufficient to determine whether P4P results in durable improvements in the
quality of healthcare in VA settings. Only 1 controlled trial and 2 observational studies examined the effectiveness of P4P on intermediate clinical outcomes (e.g., blood pressure) in Veterans. Interviews with key informants were consistent with studies that identified the potential for overtreatment associated with performance metrics in VA. Key informants’ views on P4P in community settings included the need to: develop relationships with providers and strong-performing health systems; improve coordination by targeting documentation and data sharing processes, and troubleshoot the limited impact of P4P among practices where Veterans make up a small fraction of the patient population. Qualitative studies on P4P in VA found that participants felt performance measures may lead to unintended negative consequences, i.e., reduced focus on patient needs, un-incentivized areas of care, and/or healthier patient populations, and that they may negatively affect team dynamics. Key informants recognized the potential for unintended consequences of P4P, such as overtreatment in VA settings, and suggest that implementation of P4P in the community focus on relationship building – and target areas such as documentation and coordination of care.
Date: July 1, 2018
- No Decrease in Drinking among Veterans despite Alcohol-Related Nurse Care Management Intervention in Primary Care
The Choosing Healthier Drinking Options in Primary Care (CHOICE) intervention was designed to improve drinking outcomes by engaging Veterans at high risk for alcohol use disorders (AUDs) in patient-centered, alcohol-related care. Investigators in this study examined whether 12 months of alcohol care management via the CHOICE intervention – compared with usual primary care – improved drinking outcomes (abstinence was not a required goal). Findings showed that the CHOICE intervention did not decrease heavy drinking or alcohol-related problems at 12 months even though more Veterans engaged in alcohol-related care, including a four-fold increase in initiation of medications for alcohol use disorders. Primary outcomes improved at 12 months but did not differ between groups. The mean percentage of heavy drinking days decreased from 61% at baseline to 39% and 35% in the intervention and usual care groups, respectively. The percentage of Veterans with good drinking outcomes was 15% and 20% in the intervention and usual care groups, respectively. Current
quality measures for AUDs are based on the assumption that engagement in alcohol-related care emphasizing brief intervention and reduced drinking is sufficient to improve outcomes. This trial’s results, in addition to existing literature, suggest that more intensive measures, such as recommending abstinence (vs. reduction in drinking), engaging most patients in use of naltrexone, and/or offering effective behavioral treatment might be needed for alcohol care programs in primary care to be more effective.
Date: May 1, 2018
- Most Women Veterans Report Timely Access to Mental Healthcare, Leading to High Satisfaction with VA Care
This study evaluated access to mental healthcare by assessing women Veterans’ perceptions of the timeliness and
quality of care. Findings showed that of the 419 women Veterans in this study cohort, 59% reported "always" getting an appointment for mental healthcare as soon as needed, and another 22% reported “usually” getting an appointment as soon as needed. Two problems were negatively associated with timely access to mental healthcare: 1) medical appointments that interfere with other activities, and 2) difficulty getting questions answered between visits. Average ratings of the
quality of VA healthcare were high: 8.5 out of 10 regarding VA mental healthcare, 8.7 for VA primary care, and 8.2 for VA healthcare overall. Moreover, 93% of women Veterans reported that they would recommend VA healthcare to other women Veterans. This study highlights opportunities for addressing barriers to timely mental healthcare through practices such as non-traditional clinic hours, open access scheduling, telemedicine, and secure messaging.
Date: April 5, 2018
- Research Involvement Associated with Increased Satisfaction and Decreased Intent to Leave among VA Physicians
This study examined the influence of time spent on academic activities and perceived
quality of care in relation to job attitudes among inpatient medicine physicians from 36 VA medical centers. Findings showed that physicians’ ratings of perceived
quality of care and adequacy of physician staffing were the strongest predictors of overall job satisfaction and intent to leave. Adequacy of physician staffing was the strongest predictor of burnout. Among the job tasks that physicians spent their time on, research (involvement reported by 46% of respondents) was significantly associated with increased job satisfaction and decreased intent to leave. Research time showed a non-significant negative relation with burnout. Teaching involvement was reported by 72% of the respondents, and time spent in this activity showed a similar pattern with job attitudes as described above, but was not significant. Physicians’ perception of having sufficient registered nurse staffing also did not affect physicians’ attitudes about their job. Expanding opportunities for physician involvement with research may lead to more positive work experiences, which could potentially reduce turnover and improve system performance.
Date: April 5, 2018
- Then and Now: Medications for Opioid Use Disorder in VA
As the largest provider of substance use disorder treatment in the nation, VA has taken proactive steps to increase access to medications indicated for opioid use disorder (OUD), which is an essential component of evidence-based care. This article examines the history of those medications (methadone, buprenorphine, and injectable naltrexone) within VA, as well as early and ongoing efforts to increase access to and build capacity for the treatment of OUD, which included adding buprenorphine to the VA formulary in 2006, educational and
quality improvement initiatives, targeted resources, national policy, and “big data” initiatives. This article also summarizes research on barriers and facilitators to prescribing and medication receipt.
Date: March 29, 2018
- Intervention to Lessen Low-Value Electronic Health Record Notifications Reduces Workload for Primary Care Physicians
This study evaluated the impact of a national multi-component
quality improvement program to reduce low-value electronic health record notifications. Findings showed that the program potentially saved 1.5 hours per week per primary care physician to enable higher-value work (based on prior estimates of 85 seconds to process each notification). The mean number of daily notifications per PCP decreased significantly from 128 to 116, however, the number of daily notifications remained high, suggesting the need for additional multifaceted interventions and protected clinical time to help manage them. Program impact appeared to be achieved by reducing certain types versus just the sheer number of mandatory notifications, underscoring the complexity of addressing notification burden.
Date: March 5, 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 with Cancer Received Higher
Quality, Lower Intensity End-of Life Care in VA Compared to Medicare
This study evaluated the
quality of end-of-life cancer care provided by Fee-for-Service (FFS) Medicare and VA, using well-accepted
quality-of-care metrics. Findings showed that Veterans treated under FFS Medicare were more likely to get unduly intensive healthcare at end-of-life compared to those treated by VA. For example, Medicare-reliant Veterans were significantly more likely to receive chemotherapy, as well as experience a hospital stay, more hospital days, ICU admission, and death in hospital. Compared to Veterans in highly urban settings, Veterans living in rural areas were less likely to have a hospital admission or ICU stay, spend a greater number of their last 30 days of life in hospital, and were less likely to die in hospital. Compared with white Veterans, black Veterans were more likely to have two or more ED visits, a hospital admission, an ICU stay, or to die in hospital.
Date: January 1, 2018
- More Patient-Aligned Care Team Components Translates to Improved
Quality of Care for Veterans with Chronic Disease
This study examined whether the extent to which clinics had implemented PACT components was associated with improvements in the
quality of care for Veterans with chronic conditions over a four year period. Findings showed that over four years concurrent with PACT implementation, primary care clinics with the most PACT components in place had greater improvements in 5 of 7 chronic disease intermediate clinical outcome and 2 of 8 chronic disease process measures when compared to clinics with the least PACT components in place.
Quality measures that improved more among the clinics with highest PACT implementation included LDL< 100 in CAD and DM patients, and BP < 160/100 in DM and HTN patients. Improvements in percentage of clinic patient population meeting clinical outcome
quality measures over four years in the high PACT implementation clinics ranged from 1.3% to 5.2%. VA primary care clinics may be able to achieve improved
quality of care for patients with common chronic conditions through patient-centered medical home-aligned changes in care delivery across all patients, if those changes are extensively implemented.
Date: November 20, 2017
- Use of Evidence-Based Care Processes Decreases Mortality among Veterans with Staphylococcus aureus Bacteremia
This study sought to determine how increasing use of evidence-based care processes may have contributed to improving survival for Veterans with Staphylococcus aureus bacteremia (SAB). Findings showed that mortality associated with SAB declined significantly in VA hospitals, and a substantial portion of the declining mortality (57%) was attributable to increased use of evidence-based care processes. Further, mortality declined progressively as the number of care processes a patient received increased. Although the use of evidence-based processes substantially improved over the study period, approximately half (48%) of VA patients did not receive all three recommended evidence-based care processes in 2014.
Date: October 1, 2017
- Evidence-based Psychotherapy Template Use Associated with Treatment
Quality for Veterans with PTSD
This study measured the prevalence of evidence-based psychotherapy (EBP) templated notes in VA, testing the hypothesis that template use would be associated with
quality of care for Veterans with PTSD. Findings showed that facility-level EBP template use was associated with a greater proportion of PTSD-diagnosed patients treated in specialty clinics, greater facility-level rates of diagnostic assessment, and greater rates of psychotherapy adequacy (8 psychotherapy visits in 14 weeks). Overall, an average of 4% of Veterans with a PTSD diagnosis received at least one EBP template. Among Veterans receiving psychotherapy for PTSD, an average of 9% received an EBP template. VA facilities with a greater percentage of patients who were service-connected at 50% or higher administered EBP templates to a smaller proportion of Veterans diagnosed with PTSD. The overall reach of EBP template usage was low, indicating that greater efforts are needed to improve usage.
Date: September 30, 2017
- Medical Care Supplement Features Articles by VA Researchers on Improving the
Quality and Equity of Health and Healthcare
In 2016, HSR&D’s Center for Health Equity Research and Promotion (CHERP) and the Health Equity and Rural Outreach Innovation Center (HEROIC) hosted a state-of-the-science conference. This field-based meeting to “Engage Diverse Stakeholders and Operational Partners in Advancing Health Equity in the VA Healthcare System” brought together health equity investigators, representatives of vulnerable Veteran populations, and operational leaders to identify strategies to advance the implementation of evidence-based interventions to improve the
quality and equity of health and healthcare. The conference focused on three specific vulnerable Veteran populations: racial and ethnic minorities, homeless Veterans, and Veterans from the LGBT community. This supplement features several articles that emanated from this meeting.
Date: September 1, 2017
- Systematic Review: Patient Outcomes in Dose Reduction or Discontinuation of Long-term Opioid Therapy Suggest Utility of Multimodal Care
Investigators examined the evidence on the effectiveness of strategies to reduce or discontinue long-term opioid therapy (LTOT) prescribed for chronic pain – and the effect of dose reduction or discontinuation on important patient outcomes, including pain severity and pain-related function. Findings showed that there are multiple strategies to reduce or discontinue long-term opioid treatment for chronic pain, however the
quality of the evidence for effectiveness was very low. In 3 good-
quality trials of behavioral interventions and 11 fair-
quality studies of interdisciplinary pain programs, patients received multimodal care that emphasized non-pharmacologic and self-management strategies. Sixteen fair-
quality studies reported improvement in pain severity (8/8 studies), function (5/5 studies), and
quality of life (3/3 studies) following opioid dose reduction. However, few studies examined the potential risks of opioid dose reduction such as adverse events (i.e., opioid overdose), illicit substance abuse, or suicide.
Date: July 18, 2017
- Using Yelp, VA Hospitals Rated Higher than Affiliated Non-VA Hospitals
Online patient ratings of hospitals (e.g., Yelp) have been shown to correlate strongly with more conventional measures of patient satisfaction, as well as patient outcomes. Therefore, this study compared online hospital ratings from Yelp between VA hospitals and their local affiliated hospitals. Findings showed that VA hospitals had significantly higher Yelp ratings than non-VA-affiliated hospitals, suggesting better patient satisfaction. This was not explained by bed size or teaching status of the hospital. Although Yelp reviews describe patient experience, they also may be a marker of patient outcome. This study was not powered to detect differences in outcome; however, a different study found that high Yelp ratings were significantly associated with lower 30-day all-cause mortality following an admission for myocardial infarction or pneumonia – and lower 30-day all-cause readmissions following a discharge for myocardial infarction, heart failure, or pneumonia.
Date: June 28, 2017
- Delivery of Brief Cognitive Behavioral Therapy in Primary Care Improves Mental Health Symptoms in Chronically Ill Veterans
This trial sought to determine whether an integrated brief cognitive behavioral therapy (bCBT) intervention would improve depression, anxiety, and
quality of life for medically ill Veterans. Findings showed that integrated bCBT resulted in significant immediate and 12-month improvements related to depression and anxiety. Brief CBT also resulted in significant short-term improvements related to physical health
quality of life for Veterans with chronic lung conditions. Delivery of bCBT in VA primary care clinics resulted in Veterans receiving an average of 3.9 sessions with high levels of Veteran engagement (84% receiving care) and treatment completion (63% with 4 or more sessions). Veterans and VA providers reported very high satisfaction with bCBT.
Date: June 20, 2017
- Systematic Review on the Benefits and Harms of Spinal Manipulative Therapy for Acute Low Back Pain
This systematic review was conducted to provide updated estimates of the effectiveness and harms associated with spinal manipulative therapy (SMT) compared with other non-manipulative therapies for adults with acute low back pain. Findings showed that spinal manipulative therapy was associated with statistically significant benefits in both pain (15 randomized controlled trials [RCTs] with moderate
quality evidence) and function (12 RCTs with moderate
quality evidence) – of an average modest magnitude at up to six weeks. Minor transient adverse events (i.e., increased pain, muscle stiffness, and headache) were reported in more than half of the patients (67%) in the large case series.
Date: April 11, 2017
- Initiative Decreases Inappropriate Prescribing to Older Veterans Discharged from VA Emergency Department Care
This study evaluated the effectiveness and sustainability of the Enhancing
Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED) program to reduce the use of potentially inappropriate medications (PIMs). Findings showed that EQUiPPED was associated with a sustained reduction in inappropriate medication prescribing at all four VAMCs in the study. Post-intervention, the proportion of PIMs at site one decreased from 12% to 5%; at site two it decreased from 8% to 5%, at site three from 9% to 6%, and at site four from 7% to 6%. The implementation timeline for the initiative ranged from 6 to 14 months depending on the site. While the implementation timelines varied across sites, all VAMCs achieved a monthly PIM proportion between 5% and 6%. The EQUiPPED intervention led to safer prescribing and was sustainable across multiple VA sites. Implementation is currently underway at six additional VA emergency department sites, as well as three non-VA ED sites to evaluate broader dissemination.
Date: April 7, 2017
- Findings from an Evaluation of Partnerships within VA HSR&D’s
Quality Enhancement Research Initiative (QUERI)
This study sought to identify tensions that can undermine research/operations partnerships, as well as the positive behaviors that can enhance them. Two main themes were identified: 1) tensions in research/operations partnerships, and 2) key partnership building blocks that facilitate successful research/operations partnerships. Tensions in research/operations partnerships focused on two areas: differing incentives, and scientific rigor and integrity versus quick timelines. Partnership building blocks included: jointly designing the partnership up front; reducing the research bureaucracy burdens; prioritizing in-person communication and long-term relationships; understanding the importance of perspective-taking (mentioned by operations only); and overcoming the need for individual recognition (mentioned by researchers only).
Date: April 3, 2017
- Self-Management Intervention for Chronic Pain
Interactive voice response (IVR) – automated telephonic technology that allows patients to report symptoms, functioning, and pain coping skill use and to receive pre-recorded information and feedback – may improve access to cognitive behavioral therapy (CBT) for chronic pain. This randomized trial assessed the efficacy of interactive voice response-based CBT (IVR-CBT) as compared to in-person CBT among 125 Veterans who received treatment for chronic back pain in the VA Connecticut Healthcare System from June 2012 through July 2015. Findings showed that Veterans in both the IVR-CBT and in-person CBT groups experienced statistically significant reductions in average pain intensity at 3 and 6 months post-baseline, but not at 9 months. Veterans in both groups also experienced statistically significant improvements in physical functioning, sleep, and physical
quality of life at 3 months relative to baseline, with no advantage for either group. The treatment dropout rate was lower among Veterans in the IVR-CBT group, with patients completing an average 2.3 more sessions. IVR-CBT is a low-burden alternative that can increase access to CBT for patients with chronic pain; it also shows promise as a non-pharmacologic treatment option for chronic pain.
Date: April 3, 2017
- The Role of VA Research in a Learning Healthcare System
This overview discusses the ways in which VA research has contributed to improvements in care and health outcomes, reflects on ongoing challenges in getting new evidence taken up quickly in a diverse healthcare system, and offers suggestions about different roles for research in a learning healthcare system.
Date: March 20, 2017
- Systematic Review: Effects of Pay-for-Performance on Healthcare
This review updates and expands on a prior systematic review in order to summarize current understanding of the effects of pay-for-performance (P4P) programs on process of care and patient outcomes in ambulatory and outpatient settings in and outside the United States. Findings showed that overall, in the ambulatory setting there was low-strength evidence that P4P programs might improve process of care outcomes over the short term (2 to 3 years), but there were limited data on longer-term effects. Many of the studies reporting positive findings were conducted in the United Kingdom (where incentives are much larger than P4P programs in the U.S.), and the largest improvements were seen in areas where baseline performance was poor. There was low-strength evidence that P4P had little to no impact on intermediate health outcomes (e.g., changes in lab measures), though there were inconsistencies among study results. In addition, the evidence examining patient health outcomes was insufficient because few methodologically rigorous studies reported these outcomes. In the hospital setting, there was low strength evidence that P4P had a neutral effect on patient health outcomes and a positive effect on reducing hospital readmissions. Findings complement and add to prior reviews that have also generally found that P4P programs have not been consistently effective in improving patient outcomes. In addition, there is low-strength, contradictory evidence that these programs could improve processes of care. Thus, in the absence of strong evidence of benefit, the authors suggest that it may be particularly important to consider the potential harms and costs associated with P4P.
Date: March 7, 2017
- VA Pharmacy Use in the First Year of Choice Act
This study sought to describe pharmaceutical use during the first year of the Veterans Choice Program (VCP) and to understand barriers and facilitators for VA pharmacists to dispensing medications under the VCP. Findings showed that a majority of VCP pharmacy spending in the first year was for hepatitis C virus (HCV) medications, which accounted for only 5% of prescriptions but 90% of costs. However, in 2015, VA experienced greater than expected demand for HCV medications, which exceeded available funding, thus some patients obtained medications through the VCP. The impact of HCV medications on the VCP should be short-lived given broadened availability in VA in 2016. Topical eye drops and opioids represented the most commonly dispensed prescriptions: 16% and 9% of all prescriptions, respectively.
Most prescriptions dispensed (93%) were for formulary agents, but substantial efforts were required from VA pharmacists to work with non-VA providers to use formulary drugs. Challenges related to obtaining medications from VA pharmacies through VCP included requiring controlled substance prescriptions to be hand-delivered, a lack of access to lab data required to safely dispense medications, and substantial time required by pharmacists to communicate with non-VA providers. Safe use of opioids, efficient management of non-formulary medications, and unintended new barriers to access created by the VCP must be addressed, in addition to robust ongoing evaluations to identify new cost,
quality, and safety concerns.
Date: February 17, 2017
Quality Improvement Tool Shows Organizational Factors Related to Access and
Quality Measures in VA Mental Healthcare
This study analyzed performance on measures included in the Mental Health Management System (MHMS) – a performance data and
quality improvement tool used by VA to increase the value of mental healthcare for Veterans. The MHMS
quality improvement tool showed that organizational factors were associated with performance on key access and
quality measures related to VA mental healthcare. Better access was associated with higher staff-to-patient ratios for psychiatrists and other outpatient mental health providers, and with lower mental health provider staffing vacancies. Higher mental health staff-to-patient ratios were associated with higher performance on nearly all patient and provider satisfaction measures. Higher continuity of care was associated with lower no-show rates to appointments, better wait times, higher staff-to-patient ratios, lower mental health provider vacancies, and more space available for clinical work. Over the past decade, VA’s mental health population has grown rapidly compared to its overall patient population (71% vs. 21%, respectively), so these findings are important in showing that MHMS is a robust informatics and
quality improvement tool that can serve as a model for health systems planning to adopt a value perspective.
Date: February 1, 2017
- Lessons Learned from VA’s History of Transformation and Potential Future Scenarios
An article by O’Hanlon, et al presents an updated view of the evidence on VA’s
quality of care and a strong scientific case to support the conclusion that after its dramatic transformation in the 1990s, VA had
quality and safety measures that were as good, or better, than the private sector – and even top-rated healthcare organizations. However, does the controversy over wait times demonstrate that VA has reverted to its old ways? If so, how can the VA healthcare system find its way back? A return to VA’s earlier lessons of the value of decentralized decision-making, tight accountability for
quality and efficiency, and respect for two-way communication between the field and central management might result in a systematic review of VA 5 to 10 years from now that reaches the same conclusions as O’Hanlon, et al, but includes success in both
quality and access.
Date: January 1, 2017
- Intensive Outpatient Care for High-Need Patients Does Not Reduce Acute Care Use or Costs Compared to Standard VA Care
This study evaluated the effectiveness of augmenting VA’s Patient-Aligned Care Teams (PACTs) with an Intensive Management program (ImPACT). In February 2013, the Palo Alto VAMC launched an ImPACT multidisciplinary team that addressed healthcare needs and
quality of life through comprehensive patient assessments, intensive outpatient case management, care coordination, and social and recreational services. Findings showed that intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on healthcare experiences among Veterans who participated in ImPACT. During the first 16 months of the intervention period, the average number of primary care visits was 22 for ImPACT patients vs. 7 for PACT patients. However, after accounting for the cost of ImPACT encounters, the average baseline and follow-up person-level monthly costs declined at similar rates among ImPACT patients (21.0%) and PACT patients (20.7%). Implementing intensive outpatient programs in VA may offer high-need Veterans more comprehensive services. However, in settings with high-functioning PACTs, these programs may not prevent hospitalizations or achieve substantial cost savings.
Date: December 27, 2016
- Importance of VA’s
Quality Enhancement Research Initiative in the Choice Act Era
The Veterans Access, Choice and Accountability Act of 2014 (Choice Act) allows Veterans enrolled in VA healthcare who have waited longer than 30 days to see a provider – or who live more than 40 miles from a VA clinic – the option of seeking care from non-VA providers. The Choice Act also mandated an independent assessment of VA business and healthcare practices. This article describes how VA’s
Quality Enhancement Research Initiative (QUERI) is responding to the Choice Act, particularly through the implementation strategies that facilitate more rapid uptake of effective practices across different settings, and the rigorous evaluation of new VA programs and policies.
Date: December 16, 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
- Alternative Strategies to Inpatient Hospitalization for Acute Medical Conditions
This evidence review examined the effectiveness, safety, and cost of treating acute medical conditions in settings outside of a hospital inpatient unit. Findings showed that for low-risk patients with a range of acute medical conditions, evidence suggests that alternative management strategies to inpatient care can achieve comparable clinical outcomes and patient satisfaction at lower costs. Across all alternative management strategies, cost data were heterogeneous but showed near-universal savings when assessed.
Date: November 1, 2016
- Racial Disparities in HIV
Quality of Care that May Extend to Common Comorbid Conditions
To more fully understand patterns of racial disparities in the
quality of care for persons with HIV infection, this study examined a national cohort of Veterans in care for HIV in the VA healthcare system during 2013. Findings showed that racial disparities were identified in
quality of care specific to HIV infection – and in the care of common comorbid conditions. Blacks were less likely than whites to receive combination antiretroviral therapy (90% vs. 93%) or to experience viral control (85% vs. 91%), hypertension control (62% vs. 68%), diabetes control (86% vs. 90%), or lipid monitoring (82% vs. 85%). Although performance on
quality measures was generally high, racial disparities in HIV care for Veterans remain problematic and extend to comorbid conditions. Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.
Date: September 22, 2016
- VA Makes Significant Improvements in Surgical Care for Veterans
This study used VA Surgical
Quality Improvement Program data to examine post-operative outcomes for 704,901 Veterans who underwent inpatient general, vascular, thoracic, genitourinary, neurosurgical, orthopedic, or spine surgery from FY2000 through FY2014 at 143 VA hospitals. Findings showed that over the last 15 years, there have been decreases of 25%, 54%, and 41% in morbidity, mortality, and failure to rescue (respectively), with an ~40%-50% decrease in the odds of post-operative adverse events over that time among Veterans undergoing surgery in VA facilities. Notably, these improvements have occurred VA-wide and not only at the best-performing VA hospitals.
Date: September 21, 2016
- Similar Effectiveness and Costs of Elective Open vs. Endovascular Aortic Abdominal Aneurysm Repair in VA
This study compared the total and abdominal aortic aneurysm (AAA)-related use of healthcare resources, costs, and cost-effectiveness of the randomized groups to the end of the Open vs. Endovascular Repair trial, with 9 years of follow-up. Findings showed that survival,
quality of life, costs, and cost-effectiveness were not significantly different between elective open and endovascular AAA repair after a mean of 5.2 years of follow-up. Mortality was significantly lower with endovascular repair at 30 days after surgery – and 2 and 3 years after randomization, but not thereafter. Total mean healthcare costs did not differ significantly between the two groups: $142,745 for endovascular compared to $153,533 for open. Lower costs due to shorter hospitalization for initial endovascular repair were offset by increased costs from AAA-related secondary procedures and imaging studies. Thus, for patients with AAA who are candidates for both procedures, selection of either one remains reasonable and can be guided by patient and physician preference.
Date: September 14, 2016
- Barriers to Implementing Choosing Wisely® Recommendations
This study sought to determine whether particular Choosing Wisely® (CW) recommendations are perceived by primary care providers as difficult to follow, difficult for patients to accept, or both. Findings showed that while PCPs found many Choosing Wisely® recommendations easy to follow, they felt that some, especially those for symptomatic conditions, would be difficult for patients to accept. For 4 recommendations about not screening or testing in asymptomatic patients, e.g., avoiding colorectal screening for 10 years in patients with negative colonoscopy, less than 20% of PCPs found the CW recommendations difficult to accept (7%-17%) or difficult for patients to follow (12%-19%). For 5 recommendations about testing or treatment for symptomatic conditions, e.g., limiting the use of antibiotics for sinusitis, avoiding imaging tests for low back pain within the first six weeks, however, there was both variation in reported difficulty to follow (10%-32%) and a high level of reported difficulty for patients to accept (36%-87%). The most frequently reported barriers to reducing overuse included malpractice concern, patient requests for services, lack of time for shared decision-making, and the number of tests recommended by specialists.
Date: September 6, 2016
- Neuroimaging Overuse More Common among Medicare Patients Compared to VA Patients
This retrospective study sought to determine whether rates of inappropriate neuroimaging for headache and neuropathy differ between Veterans receiving VA care and a Medicare population enrolled in the Health and Retirement Study (HRS). Findings showed that while neuroimaging overuse was high in both populations, it was much less common for patients treated in VA compared to those who received care through Medicare coverage: 49% of all headache patients received neuroimaging in HRS-Medicare compared with 22% of VA patients, and 24% of all HRS-Medicare incident neuropathy patients received neuroimaging compared with 9% in VA.
Date: July 8, 2016
- New Guidelines May Significantly Decrease Cost for Testing Immune Function in Veterans with HIV
In 2012, the Department of Health and Human Services recommended CD4 testing in patients with HIV every 3 to 6 months – except in patients with consistently suppressed virus and sustained CD4 cell count, who could be tested every 6 to 12 months. In 2014, updated guidelines recommended that in individuals with viral suppression, CD4 testing be considered either optional or annual, depending on the cell count. This study evaluated how these recommendations might affect Veterans with HIV who receive care from the largest provider of HIV care in the United States – the VA healthcare system. Findings showed that VA providers decreased the frequency of CD4 testing by 11% between 2009 and 2012, reducing the direct cost of testing by $196,000 per year. While VA has made substantial progress in reducing the frequency of optional CD4 testing, it could be reduced a further 29% by full implementation of new treatment guidelines, with an expected annual savings of $600,000. Reduced CD4 monitoring also would likely reduce patient anxiety with little or no impact on
quality of care.
Date: July 1, 2016
- Pay-for-Performance Intervention Improves Blood Pressure Control among Black Veterans with Hypertension without Unintended Consequences
This study sought to evaluate the effect of a pay-for-performance intervention on the
quality of hypertension care provided to black Veterans. Findings showed that VA physicians who received performance incentives for meeting guideline-recommended hypertension
quality measures demonstrated better performance than control group physicians on a combined measure of BP control or appropriate clinical response to uncontrolled BP in black Veterans. The proportion of black patients who achieved BP control or received appropriate response to uncontrolled BP was 6% greater for physicians who received an incentive. There was no evidence found for risk selection, i.e., there was no difference between intervention and control groups in the proportion of Veterans who switched providers, and there were no differences in visit frequency or panel turnover, creating reassurance that the incentives did not have negative unintended effects on the care of black patients.
Date: June 22, 2016
- VA Captures More Complete
Quality Performance Data Compared to Medicare Advantage
Investigators in this study examined the agreement between VA and Medicare Advantage (MA)
quality assessments for a group of dually-enrolled Veterans, testing the hypothesis that private health plans under-report
quality of care relative to a fully integrated delivery system utilizing a comprehensive electronic health record. Findings showed that despite assessing the same Veterans using identical performance measure specifications, reported VA performance was significantly better than reported MA performance for all 12 HEDIS measures. For example, VA’s performance advantage ranged from 10 percentage points (46% for VA vs. 36% for MA) for HbA1c <7.0% in diabetes to 55 percentage points (80% for VA vs. 25% for MA) for blood pressure <140/90mmHg in diabetes. In analyses limited to Veterans having at least 10 MA outpatient encounters, VA reported better performance than MA for 11 of 12 measures – ranging from 10 percentage points to 36 percentage points. Findings suggest that neither Medicare Advantage plans nor VA fully capture
quality of care information for dually-enrolled Veterans. However, VA captures significantly more information than MA.
Date: March 31, 2016
- Impact of Evidence-based
Quality Improvement Strategy on VA Patient-Aligned Care Team Implementation
This study assessed changes in VA healthcare utilization and costs for Veterans from six practices in three different medical centers using an evidence-based
quality improvement (EBQI) approach to implement PACT and 28 comparison practices over a five-year period (FY2009 to FY2013). Findings showed that after PACT implementation, the overall use of primary care, specialty care, and mental health/substance abuse care decreased, while the use of telephone care increased. Decreased outpatient care use occurred more rapidly for VA practices that employed an EBQI approach to PACT implementation, including outpatient visits for primary care, specialty care, and mental health and substance abuse care that appeared to augment the effects of PACT. EBQI practice was significantly associated with a 15% reduction in primary care encounters over the study period. For specialty care, there was a 17% decrease in encounters associated with EBQI overall, but the rate of decrease slowed each year after the implementation of PACT. There was no significant effect of EBQI status on emergency department visits, all-cause hospitalizations, or prescription drugs. Total VA healthcare costs per patient decreased by 5% each year across all practices, but there was no effect of EBQI practice on costs.
Date: February 1, 2016
- Mental Health Conditions Common among Patients Seeking and Undergoing Bariatric Surgery
This systematic review had three aims: 1) to estimate the prevalence of mental health conditions among bariatric surgery candidates and recipients; 2) to evaluate the association between preoperative mental health conditions and weight loss after surgery; and 3) to evaluate the association between surgery and the clinical course of mental health conditions. Findings showed that mental health conditions are common among patients seeking and undergoing bariatric surgery, particularly depression and binge-eating disorder (BED). Prevalence estimates for mood disorders (22%), depression (19%), and BED (17%) were higher than published rates for the general U.S. population, (10%, 8%, and 1-5%, respectively) suggesting that special attention should be paid to these conditions among bariatric patients. There was moderate-
quality evidence to support an association between bariatric surgery and lower rates of depression post-operatively. Depression improved following surgery in 11 of the 12 studies, including two randomized controlled trials evaluating preoperative behavioral health interventions.
Date: January 12, 2016
- Career Development Programs Successfully Prepare Future Health Services Researchers, Particularly VA HSR&D
This evaluation compared the accomplishments of HSR&D, NIH, and AHRQ Career Development Awardees. Findings showed that all three programs are successfully selecting and mentoring awardees, ensuring additional health services research capacity to improve the
quality and delivery of high-value healthcare. VA HSR&D awardees had been PI on significantly more grants of $100,000+ than NIH awardees, and also had more major journal articles than NIH awardees. No significant differences emerged among HSR&D, NIH, and AHRQ awardees in tenure-track academic rank, number of grants as primary investigator, major journal articles and articles as first or sole author, or mentoring post-graduate researchers.
Date: November 9, 2015
- VA Hospital Observation Stays Increasing
When acutely ill patients present to the emergency department (ED) and neither inpatient admission nor ED treatment followed by discharge is clearly indicated, physicians are likely to place the patients in the hospital under “observation” status. This study sought to identify trends and variations in observation rates across 21 VISNs and 128 VA hospitals nationwide. Findings showed that of the 4,423,010 hospital admissions in this study, 392,939 (9%) were initiated in medical observation status. From 2005 through 2013, observation rates across VA hospitals more than doubled, with substantial variation across both hospitals and VISNs. There were 451,229 acute admissions in the first year (2005), of which 29,119 (6.5%) initiated in observation status compared to 517,248 acute admissions in the last year (2013), of which 71,124 (13.8%) initiated in observation status. While most hospitals in this study increased their observation rate, some reduced their rate. Overall, changes in the use of observation ranged from a 27 percentage-point decrease to a 43 percentage-point increase, with the average change being an increase of 7.1 percentage points. Findings suggest that trends in the use of observation stays are similar in VA and Medicare patients despite differing payment structures and financial incentives in the two systems. VA policymakers, like their Medicare counterparts, will need to examine the impact of the growing number of observation stays on patient outcomes and costs.
Date: October 1, 2015
- ICU Treatment for Medicare Patients with Pneumonia Associated with Better Outcomes without Increased Costs
This study sought to determine the association between ICU admission and outcomes, 30-day mortality, and costs among Medicare beneficiaries hospitalized for pneumonia. To account for unmeasured confounding between groups (ICU vs. general ward admission), an instrumental variable (IV) was used – the differential distance to a high-ICU use hospital. Findings showed that ICU admission of those patients for whom the decision appeared to be discretionary (those meeting the IV criteria above, approximately 13% of the total sample) was associated with improved survival and no significant difference in costs. Patients living closer (<3 miles) to a high-ICU hospital were significantly more likely to be admitted to the ICU than patients living farther away (36% vs. 23%) – this was the basis of the IV analysis. In the IV analysis, ICU admission was associated with significantly lower 30-day mortality compared to general ward admission (15% vs. 21%), with a reduction in 30-day mortality of 6%. In the IV analysis, ICU admission was not associated with significant differences in total payment to Medicare or total hospital costs.
Date: September 22, 2015
- Effectiveness of Mindfulness-Based Stress Reduction Therapy for Veterans with PTSD
This randomized clinical trial compared mindfulness-based stress reduction with present-centered group therapy, a treatment that addresses current life problems. Findings showed that mindfulness-based stress reduction therapy resulted in a greater decrease in PTSD symptom severity. However, the magnitude of the average improvement suggests a modest effect. Veterans in the mindfulness-based stress reduction group were more likely to show clinically significant improvement in self-reported PTSD symptom severity at two-month follow-up, but they were no more likely to have loss of PTSD diagnosis. Improvements in
quality of life made during treatment were maintained at 2-month follow-up for Veterans in the mindfulness-based stress reduction group, but reports of
quality of life returned to baseline levels for those in present-centered group therapy.
Date: August 4, 2015
- Wide Variation Documented Among VA Providers in Potential Overuse of Antibiotics for Acute Respiratory Infections
This study examined trends in antibiotic prescribing for acute respiratory infections (ARIs) within the VA healthcare system over an 8-year period – and identified patient, provider, and setting sources of variation. Findings showed that there was a persistently high prevalence of outpatient antibiotic prescriptions for ARIs among Veterans. Of more than one million ARI visits, the proportion resulting in antibiotic prescription increased from 67.5% in 2005 to 69.2% in 2012. Also, the proportion of antibiotic prescriptions that were macrolides increased from 37% to 47%. There was substantial variation in prescribing at the provider level. The 10% of VA providers who prescribed the most antibiotics did so during at least 95% of their ARI visits, while the 10% who prescribed the least did so during <40% of their ARI visits. Mid-level providers prescribed antibiotics slightly more frequently than physicians (70% vs. 68%). Subgroups associated with higher prevalence of antibiotic prescribing included: diagnosis of sinusitis (86%) or bronchitis (85%), presence of a high fever (78%), occurrence in an urgent care setting (75%), and Southern and Central regions of the U.S. (both 71%). Variation in ARI management seems to be strongly influenced by the prescribing patterns of individual providers. This is a ripe target for further research,
quality improvement, and antibiotic stewardship interventions.
Date: July 21, 2015
- Mortality among Veterans with Severe Sepsis Declines, but Significant Variation across VA Hospitals Persists
This study sought to determine the extent to which variation in short-term mortality following severe sepsis is explained by the VA hospital and regional VA healthcare network where a Veteran receives care. Findings showed that unadjusted 30-day mortality among hospitalized Veterans with severe sepsis declined from 18% in 2008 to 15% in 2012, despite very similar severity of illness between years. After severity-of-illness and case-mix adjustment, variation persisted in 30-day mortality across hospitals – and to a lesser extent, across regions. For example, the median hospital in the worst quintile of performers had a risk-adjusted 30-day mortality rate of 17% in 2012 compared with the best quintile with a rate of 13%, suggesting a 20% greater risk of death (4% absolute mortality difference) when treated at a hospital in the bottom versus the top quintile.
Date: July 1, 2015
- Effects of Primary Care Provider Turnover
This study measured the effect of PCP turnover on patient experiences of care and ambulatory care
quality. Findings showed that nearly 9% of Veterans in this study experienced a PCP turnover. Primary care turnover was associated with worse patient experiences of care. For example, 75% who experienced no PCP turnover had a positive rating of their personal doctor compared with 68% of Veterans who had experienced PCP turnover. Also, 38% of Veterans with no PCP turnover had a positive rating of getting care quickly compared with 36% of patients who had experienced PCP turnover. In contrast, PCP turnover was not associated with lower ambulatory care
quality. In 9 measures of ambulatory care
quality, the difference between patients who experienced no PCP turnover and those who had a PCP turnover was less than 1%.
Date: July 1, 2015
- Having a Diet Option Assigned vs. Choosing a Diet Leads to Greater Weight Loss among Obese Veterans
This randomized trial evaluated whether Veterans allowed the opportunity to choose between two diets would have greater weight loss than Veterans randomly assigned a diet. Findings showed that, contrary to popular opinion, the option of choosing a diet to follow, as opposed to being assigned a diet, did not improve weight loss among obese Veterans. At 48 weeks, the estimated mean weight loss was 5.7 kg for Veterans in the Choice group and 6.7 kg for Veterans in the Comparator group. Secondary outcomes of dietary adherence, physical activity, and weight-related
quality of life were similar between groups. Given that diverse diets have proven effective for weight loss, future research might examine matching patients to their optimal diet based on other characteristics (e.g., metabolic profile, genetics) instead of their preferences.
Date: June 16, 2015
- Electronic Health Record-Based Interventions for Reducing Inappropriate Imaging in the Clinical Setting
Given that adoption of electronic health records (EHRs) is expanding, investigators conducted a systematic review and meta-analysis of EHR-based interventions to improve the appropriateness of diagnostic imaging. Findings showed that Computerized clinical decision support that is integrated into the physician order entry system of an electronic health record can help improve the appropriate ordering of diagnostic imaging studies. Of the 23 studies in this review, 21 studies provided moderate-
quality evidence that EHR-based interventions can change appropriate test ordering by a moderate amount – and can reduce overall use by a small amount. Interventions that include a “hard stop” to prevent clinicians from ordering imaging tests classified as inappropriate, and implementation in an integrated care delivery setting may improve effectiveness. Potential harms of computerized clinical decision-support interventions have been rarely studied.
Date: April 21, 2015
- 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
- VA Maintains Access to Care as Need for Substance Use Treatment Grows
VA has enhanced funding of mental health programs and substance use disorder (SUD)-specific treatment and also has directed approximately $152 million toward hiring additional SUD staff. This study examined the relationship between dedicated SUD funding and SUD performance measures from 2005 and 2010 for VA medical centers. Findings showed that, overall, access and
quality of care kept pace with the demand for SUD services in the VA healthcare system. There was a statistically significant and generally positive correlation between additional, dedicated SUD resources and access and treatment intensity. The number of VA patients with an SUD diagnosis grew from about 310,000 in 2005 to 439,000 in 2010 – an increase of 42%. Average dedicated SUD funding per facility grew from $65,870 in 2005 to $324,416 in 2007, falling to $147,151 in 2009 and 2010. However, not all VAMCs received funding in each year.
Date: March 12, 2015
- Veterans Receiving Brief Alcohol Misuse Intervention Rate VA Providers and Care Higher than Veterans without Intervention
This study assessed the relationship between receipt of brief alcohol intervention and patient-reported indicators of care
quality. Findings showed that among Veterans who screened positive for unhealthy alcohol use, a higher proportion who reported receipt of a brief alcohol intervention, compared to those who did not, rated their provider (87% vs. 82%) and VA healthcare (83% vs. 76%) as high
quality. Sixty-one percent of Veterans in this study screened positive for mild unhealthy alcohol use, and 21%, 11%, and 8% screened positive for moderate, severe, and very severe unhealthy alcohol use, respectively. Of drinkers reporting unhealthy alcohol use, 44% of Veterans reported receipt of a brief intervention for unhealthy alcohol use in the previous year. Overall, 84% and 79% of Veterans rated their provider and VA healthcare as high
quality, respectively. Thus, although the literature suggests providers may be concerned that discussions of unhealthy alcohol use may negatively impact relationships with their patients, study findings do not support concerns that delivering alcohol-related advice adversely affects patients’ perceptions of care.
Date: February 18, 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
- Improved Performance on
Quality Measures is Accompanied by Increased Racial/Ethnic Equity in Care
This study examined the
quality and equity of hospital care during the six years following initiation of the Centers for Medicare & Medicaid Services (CMS) Inpatient
Quality Reporting (IQR) Program (2005 to 2010), focusing on 17 process-of-care
quality indicators publicly reported by the program for white, black, and Hispanic patients hospitalized for AMI, HF, and pneumonia in non-VA hospitals. Findings showed that improved performance on
quality measures for white, black, and Hispanic adults hospitalized with AMI, HF, and pneumonia was accompanied by increased racial/ethnic equity in performance rates both within and between U.S. hospitals. Over this time period, adjusted performance rates for the 17
quality measures improved by 3.4 to 57.6 percentage points for these patients. In 2010, unadjusted performance rates exceeded 90% for all subgroups for 14 of 17 measures. Declining racial/ethnic differences occurred through more equitable care for white and minority patients treated in the same hospital, as well as greater performance improvements among hospitals that disproportionately serve minority patients.
Date: December 11, 2014
- Poor Communication between VA and Non-VA Primary Care Providers co-Managing Rural Veterans
This study examined the perspectives of community-based, non-VA primary care providers (PCPs) regarding their experiences co-managing Veterans with VA providers. Findings showed that communication with VA was viewed as poor by 66% of non-VA primary care providers, and many non-VA PCPs (42%) believed this led to poor patient outcomes. They also felt that they interacted with VA as a system rather than with individual VA providers. While the majority of non-VA providers were dissatisfied with their communication with VA providers, this did not translate into a negative opinion of VA healthcare; most felt the overall
quality of VA care was high. Veterans were identified as the main medium for information transfer between VA and non-VA providers, which was viewed as undesirable. When non-VA PCPs were asked about their ideal method of communication, they most commonly identified electronic health records and fax that would occur automatically. They also identified the need for a VA point of contact to triage direct calls from non-VA providers.
Date: November 1, 2014
- Enrollment in VA Healthcare Most Likely in First Year after Return from Deployment for Army Reserve/National Guard Members
This study examined rates and predictors of Reserve Component (RC) members’ enrollment and use of VA healthcare services in the first year following demobilization from an index deployment. Findings showed that, of the Veterans in this study, 57% of Army National Guard (ARNG) members and 46% of Army Reserve (AR) members used VA care within 12 months of demobilization, suggesting that Reserve Component members are most likely to enroll in VA healthcare in the year following return from deployment. Female members were more likely to enroll in VA healthcare than male members, an important finding given that women are the fastest growing segment of the Veteran population. The percent of ARNG and AR members in each VA facility’s catchment area who received VA healthcare as an enrollee varied substantially – from as low as 25% to more than 85%, even after adjusting for driving time, demographics, and service-related factors. Investigators suggest that future research and QI efforts with VA and DoD should strive to better understand this variation and the extent to which it is explained by factors such as the availability of non-VA healthcare options, actual or perceived
quality of VA care, and/or availability of education and outreach interventions.
Date: October 1, 2014
- Systematic Frailty Screening may Lead to Reduced Post-Operative Mortality in Frail Veterans
Investigators in this study implemented a
quality improvement initiative to screen Veterans scheduled for elective surgery for frailty in order to identify those at high risk for post-operative mortality and morbidity. This systematic frailty-screening program effectively identified at-risk surgical patients and was associated with a significant reduction in mortality in Veterans undergoing palliative care consultation. Implementation of the screening program was associated with a 33% reduction in 180-day mortality even after controlling for age, frailty, and whether the patients had surgery. Further, given the high risk of dying in this frail cohort, study models suggest that for every four patients screened, one death was prevented or delayed at 180 days. After implementation of the frailty-screening program, palliative care consultations were more frequently ordered by surgeons, and they were more likely to take place before the index operation. Moreover, pre-operative palliative care consultations ordered by a surgeon were associated with the greatest reduction in mortality.
Date: September 10, 2014
- Measures of Patient Care Experiences Reflect Fair Hospital Assessments
There are concerns about the fairness of using Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey measures to compare healthcare facilities if some have more ”complex” patients that are harder to treat, and it has been argued that clinical variables should be included to adjust for such differences. Therefore, this study compared scores for different types of hospitals after making adjustments using only survey-reported patient characteristics – and then also using more complete clinical and hospital information. Findings showed that comparisons of composite patient-centered care (PCC) scores across types of hospitals that were adjusted only for patient-reported health status and sociodemographics were similar to those that also adjusted for patient clinical characteristics. Thus, study findings do not support concerns that measures of patient care experiences are unfair because commonly used models do not adjust adequately for potentially confounding patient clinical characteristics. The same was true when the various adjusted scores for specific dimensions of patient experience were compared across hospital types.
Date: July 1, 2014
- Most Patients with Type 2 Diabetes Obtain Little or No Benefit from Current Treatment for Tighter Glycemic Control
This study examined how considering treatment burden would affect the benefits of intensive versus moderate glycemic control in patients with type 2 diabetes. Findings showed that for most patients over the age of 50 with an A1c below 9% who were on metformin, further glycemic treatment usually offered, at most, modest benefits. Across all ages, patients who viewed treatment as modestly burdensome experienced a net loss in
quality of life years from treatments to lower A1c. The current approach of broadly advocating intensive glycemic control for millions of patients with diabetes should be reconsidered; instead, treating A1cs of less than 9% should be individualized based on estimates of benefit weighted against the patient’s view of treatment burden.
Date: June 30, 2014
- Outcomes Associated with VA Implementation of PACT
Investigators in this study created the PACT Implementation Progress Index (Pi2) to measure the extent and variation of PACT implementation, and then conducted an observational study to examine the association between the index and key outcomes (e.g., patient satisfaction, rates of hospitalization and emergency department use,
quality of care, and staff burnout. Findings showed that the extent of PACT implementation was highly associated with important outcomes for both patients and providers. Significant trends were observed in
quality of care in relation to the Pi2 score: 77 sites that achieved the most effective implementation exhibited higher clinical
quality outcome measures than less successful sites. The rate of emergency department visits was significantly lower in sites with more effective PACT implementation than in those with less effective implementation, and there were larger projected decreases in rates of ambulatory care sensitive condition admissions after the start of PACT. Patient satisfaction was significantly higher among sites that had effectively implemented PACT than among those that had not, and a similarly favorable pattern was observed for staff burnout.
Date: June 23, 2014
- Majority of Unplanned VA Hospital Readmissions Unrelated to Index Hospitalization
This study examined unplanned VA hospital readmissions – and compared the leading reasons for unplanned readmission between medical and surgical discharges. Findings showed that after excluding planned readmissions, 12% of all discharges were followed by an unplanned readmission within 30 days. Although nearly 42% of unplanned readmissions were identified as clinically related, the majority of unplanned VA hospital readmissions were unrelated to the index hospitalization for both surgical and medical discharges. The top five reasons for hospital readmission among medical discharges included: non-hypertensive heart failure (HF; 8%), pneumonia (5%), chronic obstructive pulmonary disease (5%), urinary tract infections (UTI, 3%), and fluid and electrolyte disorders (3%). Among surgical discharges, complications of surgical procedures or medical care (22%) or devices (7%) accounted for nearly 75% of the top five reasons for readmissions; the remaining three included HF, UTI, and pneumonia. These findings suggest that most hospital readmissions might reflect clinical and social factors, including the severity of the patient’s condition, inadequate social support, or post-discharge factors (e.g., lack of coordination between inpatient and outpatient settings). Thus,
quality improvement interventions should target those processes of care that may decrease related risks.
Date: March 1, 2014
- Underuse of Colorectal Cancer Screening among Healthy Veterans and Overuse among Unhealthy Veterans
This study examined whether the upper age cutoff of the colorectal cancer (CRC) screening
quality measure is associated with overuse of screening among 70- to 75-year-olds who are in poor health (limited life expectancy, but within the target age range of the measure) – and underuse in those older than age 75 who are in good health (longer life expectancy, but outside the target age range of the measure). Findings showed that screening rates were relatively stable for Veterans between ages 50-75, but dropped precipitously after age 75. On average, 39% of 75 year-old Veterans were screened, while only 21% of 76 year-old Veterans were screened. However, a Veteran who was 75 years of age and unhealthy – in whom life expectancy may be limited and screening is likely to result in net burden or harm – was significantly more likely to undergo screening than a Veteran who was 76 years of age and healthy (35% vs. 21%, respectively). Future patient-centered
quality measures should focus on clinical benefit rather than chronological age to ensure that patients who are likely to benefit from screening receive it (regardless of age), and that those who are are likely to incur harm are spared uncessary and costly care.
Date: February 26, 2014
- Health Information Technology
This review sought to examine recent evidence that relates health IT functionalities prescribed in meaningful use regulations to key aspects of healthcare, such as
quality, safety, and efficiency. Findings showed that most published IT evaluation studies report positive effects on
quality, safety, and efficiency. Strong evidence supports the use of clinical decision support (CDS) and computerized provider order entry (CPOE). Fifty-seven percent of the studies in this review evaluated CDS and CPOE, and most reported positive results. Insufficient reporting of implementation and context of use makes it impossible to determine why some health IT implementations are successful and others are not. Therefore, the most important improvement that can be made in health IT evaluations is increased reporting of the effects of implementation and context. Authors note that with the increasing adoption of electronic health records and other forms of health IT, it is no longer sufficient to ask whether health IT creates value, but rather the most useful studies will help us understand how to realize value from health IT.
Date: January 7, 2014
- Gaps in
Quality of Supportive VA Cancer Care for Veterans
This study evaluated non-hospice supportive VA cancer care in a nationally representative sample of Veterans with stage IV metastatic lung, colorectal, and prostate cancers who were diagnosed in 2008.
Quality of care was measured using the Cancer
Quality-Assessing Symptoms and Side Effects of Supportive Treatment (ASSIST)
quality indicators. Findings showed that, overall, Veterans received only about half (49%) of recommended care as measured by ASSIST
quality indicators. Gaps in
quality of cancer care included: inpatient pain screening was common (96%) but lacking for outpatients (58%); few Veterans had timely dyspnea evaluation (16%) or treatment (11%); only 4% of Veterans had a new diagnosis of depression identified; of patients at high risk for diarrhea from chemotherapy, 24% were offered antidiarrheals; only 18% of Veterans had their goals of care addressed in the month after a diagnosis of advanced cancer; and 64% of patients had timely discussion of goals ICU admission. Most Veterans who died (86%) were referred to palliative care or hospice before death and 72% had an advanced directive or surrogate decision maker documented in the medical record.
Date: December 9, 2013
- VA’s Online
Quality Improvement Toolkits
In 2009, VA/HSR&D’s
Quality Enhancement Research Initiative (QUERI) was tasked by VHA leadership to develop online toolkits that would facilitate the spread of locally developed innovations to improve
quality of care for Veterans. The QI Toolkit Series was designed as a two-year pilot project that would offer VHA staff access to innovations to help improve performance on specific performance measures across a variety of high-priority care conditions. The Toolkit Series is now an enhanced Intranet website, accessible by all staff using the VHA network. This article describes the general approach to creating such toolkits, aspects of implementation, and a brief evaluation.
Date: December 1, 2013
- “Tailored” Treatment of Blood Pressure May Prevent Many More Heart Attacks and Strokes than Current Guidelines
Most current blood pressure (BP) guidelines advocate a treat-to-target (TTT) strategy, which titrates treatment towards intermediate outcomes, notably a BP goal. Benefit-based tailored treatment (BTT) strategies estimate an individual’s net absolute benefit from treatment – taking into account the patient’s estimated risk reduction from treatment, as well as potential harms associated with treatment. This study sought to determine whether a BTT strategy for the treatment of hypertension would prove superior to a traditional TTT strategy. Findings showed that BTT was both more effective and required less antihypertensive medication than current guidelines based on treating to specific blood pressure goals. Over five years, BTT would prevent 900,000 more cardiovascular disease events and save 2.8 million more
quality-adjusted life years (QALYs), despite using 6% fewer medications, compared to TTT. While 55% of the 176 million “simulated” patients in this study would be treated identically under the two treatment approaches, in the 45% of the population treated differently by the strategies, BTT would save 159 QALYs per 1,000 treated versus 74 QALYs per 1,000 treated by the TTT approach.
Date: November 19, 2013
- Increase in Psychotherapy Since 2004 Corresponds with VA’s Efforts to Improve Access to Mental Health
This study examined longitudinal changes in VA psychotherapy use corresponding with widespread programmatic change targeting increased availability and
quality of mental healthcare. Findings showed that the number of Veterans newly diagnosed with depression, anxiety, or PTSD increased by nearly 40% between 2004 and 2010. Rates of PTSD grew most substantially, increasing by more than 2-fold. During this time, the proportion of Veterans with depression, anxiety, or PTSD receiving psychotherapy grew from 21% to 27%. In addition, psychotherapy dose increased – a growing proportion of Veterans received eight or more psychotherapy sessions. More Veterans engaged in individual than group psychotherapy across all study years. However, Veterans who engaged in group psychotherapy received more sessions of psychotherapy than those in individual psychotherapy. Treatment delays decreased across study time points. The median time between index diagnosis and psychotherapy dropped from 56 days in 2004 to 47 days in 2010. Although Veterans with PTSD consistently had shorter delays than Veterans with depression or anxiety, diagnostic disparities in time until treatment grew smaller across the study time points. Consistent with VA expansion efforts, more substantial increases in psychotherapy access, dose, and timeliness occurred between 2007 and 2010 relative to 2004 and 2007.
Date: October 1, 2013
- Receiving VA Care is Stronger Predictor of Appropriate Care for Veterans with Diabetes than Continuity of Care
This study examined whether
quality of diabetes care was associated with care continuity or Veterans’ usual source of primary care. Findings showed that reliance on VA primary care vs. Medicare fee-for-service (FFS) primary care was a stronger predictor of guideline-concordant diabetes care than continuity of care. When both over-provision (getting more tests than needed) and under-provision (getting fewer tests than needed) were examined for three diabetes
quality measures, reliance on VA care was a stronger predictor of appropriate care than continuity of care. For example, Veterans who relied only on Medicare FFS for primary care were more likely to be under-provided HbA1c testing than Veterans who relied only on VA primary care. However, dual users of VA and Medicare FFS primary care were significantly more likely to be over-provided HbA1c and microalbumin testing than Veterans who used only VA primary care. In both VA and Medicare FFS, under-provision of diabetes care was more common than over-provision during this period (from 2001 to 2004).
Date: October 1, 2013
- Individual Financial Incentives for VA Providers Result in Better Hypertension Treatment than Audit and Feedback Alone
This trial tested the effect of financial incentives to individual physicians and practice teams for the delivery of guideline-recommended care for hypertension. Findings showed that VA physicians randomized to the individual incentive group were more likely than controls to improve their treatment of hypertension. A physician in the individual incentive group caring for 1,000 patients with hypertension would have about 84 additional patients achieving blood pressure control or appropriate response after 1 year. The effect of the incentive was not sustained after the washout period. Although performance did not decline to pre-intervention levels, the decline was significant. None of the incentives resulted in increased incidence of hypotension compared with controls. While the use of guideline-recommended medications increased significantly over the course of the study in the intervention groups, there was no significant change compared to the control group.
Date: September 11, 2013
- Improvement in VA Patient Outcomes Related to Pay-for-Performance Remains after Removal of Incentives
This study sought to investigate the sustainability of performance levels following removal of performance-based incentives. Findings showed that performance improvements that occurred across 128 VA hospitals for three common conditions among Veterans – acute coronary syndrome, heart failure, and pneumonia – were sustained for up to three years after performance-based incentives were removed. For six of the seven performance measures, mean performance was over 90% prior to removal of the incentives. The only measure that did not demonstrate significant improvement over the study period was the heart failure measure for ACE-inhibitor/ARB therapy prior to admission.
Date: August 9, 2013
- Veterans with Prostate Cancer Living in Rural Settings have Less Access to Comprehensive Oncology Resources than Urban Veterans, but Receive Similar or Better
Quality of Care
This study sought to determine the degree to which access barriers impact the
quality of prostate cancer care for rural patients in the VA healthcare system. Findings showed that Veterans with prostate cancer living in rural settings traveled nearly 5-fold further for care and were less likely to be treated at facilities with comprehensive cancer resources, compared with Veterans living in urban settings. Despite differences in access to resources, rural patients received similar or better
quality of care for 4 of 5 measures (e.g., appropriate number of biopsies, no bone scan for low-risk disease, appropriate chemotherapy for progressive disease, and appropriate hormonal therapy for high-risk patients treated with radiation therapy). Time to prostate cancer treatment was similar for Veterans living in rural compared with urban settings (97 days vs. 106 days).
Date: July 30, 2013
- Changes in VA Care since PACT Implementation
This study evaluated interim changes in PACT-related care processes. Findings showed that VA achieved rapid progress in building a PACT infrastructure in the first 30 months of an extensive four-year implementation plan, and some interim changes in processes of care were observed: in-person PCP visit rates decreased slightly; healthcare via telephone and Internet increased dramatically (e.g., phone encounters increased 10-fold and patients using telehealth increased from 38,747 in 12/09 to 70,486 in 6/12); shared medical appointments increased slightly; appointment access and continuity improved slightly, but started at high levels; and post-hospitalization follow-up improved substantially but remains below goal (e.g., patients evaluated by primary care clinicians within 48 hrs of hospital discharge increased from 6% in 12/09 to 61% in 12/11). Facilities’ average overall score on the ACP Biopsy survey (assessing the presence of 127 PACT components via “yes” or “no” items in 7 categories) increased from 69% “yes” in 10/09 to 80% “yes” in 7/11.
Date: July 10, 2013
- Incentives to Impact Patient Engagement and Health Behavior
This essay discusses a range of efforts in implementing wellness programs and incentives intended to promote healthy behaviors by insurers, employers, and providers, and how they might be made more effective.
Date: July 1, 2013
- Issues for Sexual and Gender Minority Veterans Receiving VA Healthcare
This article summarizes emergent research findings regarding sexual and gender minority (SGM) Veterans, and the first initiatives that have been implemented by VA to promote
quality care. Being a member of both the Veteran and SGM communities may contribute to a higher level of risk for poor health than membership in just one of these populations. A recent VA study indicated that only 33% of SGM Veterans reported open communication about their sexual orientation with VA healthcare providers, while 25% reported avoiding certain VA services because of concerns about stigma. In another study of 202 VA providers and 58 SGM Veterans, less than one-third of all participants viewed VA as welcoming to SGM Veterans. To address these issues, VA has created new programs, such as the Office of Health Equity LGBT Workgroup, which works to address inequities in the healthcare environment for SGM Veterans. VA also created two new part-time LGBT Program Coordinator positions, through the Office of Patient Care Services, who advise leadership on policy and practice issues related to SGM Veterans. In June 2011, VA released the first national policy to describe the services that are available to transgender Veterans. Other recent VA policy changes include “sexual orientation” and “gender identity and expression” now being included in VA non-discrimination and caregiver policies. Educational resources and trainings have been developed for VA staff about culturally appropriate care for SGM Veterans. Further research is needed to better understand the SGM population, their healthcare needs, and how these needs vary in relation to gender, race/ethnicity, and other factors, as well as in evaluation of provider training and policies.
Date: July 1, 2013
- Cancer Genetics Toolkit Improves
Quality and Frequency of Family History Documentation among VA Primary Care Patients
Investigators in this study developed a cancer genetics toolkit designed to improve familial risk assessment and appropriate referrals for hereditary breast-ovarian cancer (HBOC) and Lynch syndrome. They then evaluated the impact of the toolkit by comparing clinician behaviors relating to documentation of cancer family history and referral for genetic consultation before and after its implementation in women’s primary care clinics. Findings showed that the toolkit increased the frequency and improved the
quality of cancer family history documented by primary care clinicians; increased recognition of high-risk Veterans; and increased the numbers of appropriate referrals for genetic consultation. A clinical reminder in the electronic health record was a key component of the toolkit; when used, it was associated with a two-fold increase in cancer family history documentation, and history was more complete. In addition, veterans whose clinicians completed the reminder were twice as likely to be referred for genetic consultation.
Date: June 13, 2013
Quality of VA Care for Veterans with Newly Diagnosed Lung Cancer is Markedly Higher than Previous Studies Suggest
This study sought to determine the proportion of Veterans who did not receive evidence-based care who had a documented refusal or contraindication to recommended lung cancer therapy. Findings showed that when accounting for refusals and contraindications, the
quality of care for newly diagnosed lung cancer was markedly higher than previous studies suggested. Adherence to
quality indicators ranged from 81% for adjuvant chemotherapy in resected stage II/III non-small cell lung cancer (NSCLC) to 98% for curative resection of stage I/II NSCLC. However, many Veterans met
quality indicator criteria without having received recommended therapy by having a refusal (0%-14%) or contraindication (1%-30%). Authors note that study results underscore the need for performance measurement systems that capture both patient refusals and medical contraindications. Using data that may not accurately capture
quality of care may result in allocation of resources to improve
quality where it is not indicated.
Date: June 10, 2013
- Readmission Rates are Limited in Measuring Hospital
This study assessed readmission rates as a hospital
quality measure. Findings showed that the change in readmission rates between 2009 and 2011 was inversely related to readmission rates in 2009: hospitals with higher readmission rates in 2009 tended to improve by 2011, while hospitals with lower readmission rates in 2009 tended to worsen by 2011. On average, readmission rates for the “worst” performing hospitals in 2009 decreased over time by between 2% and 4%, depending on the condition, while readmission rates for the “best” performing hospitals in 2009 increased by between 3% and 7%. Readmission rates were higher in teaching hospitals and were weakly correlated with the other indicators of hospital
Date: June 1, 2013
- Multimodal Intervention Increases HIV Testing in VA Primary Care
Investigators with VA/HSR&D’s HIV/Hepatitis
Quality Enhancement Research Initiative (QUERI) previously developed, implemented, and evaluated a multimodal program to promote HIV testing, which more than doubled testing among at-risk Veterans. These results prompted the current study that scaled up this intervention in a large number of diverse VA facilities. Investigators examined the effectiveness of promoting routine as well as risk-based HIV testing, and the effect of providing different levels of organizational support at study sites. Findings showed that the use of clinical reminders, provider feedback, education, and social marketing in this HIV-testing intervention significantly increased the frequency with which HIV testing was offered and performed within the VA healthcare system. Implementation of this intervention increased the rate of risk-based HIV testing two- to three-fold, and increased routine testing three- to four-fold. Risk-based and routine HIV testing increased in all facility-, provider-, and patient-level groups.
Date: April 19, 2013
- Prediction Model Using VA Data May Help Identify Primary Care Patients at Increased Risk for Hospitalization or Death
In an attempt to identify high-risk patients, investigators in this study developed statistical models using health information from VA’s clinical and administrative databases to predict the risk of hospitalization or death among all Veterans who were assigned to a primary care provider as of 10/1/10. Findings showed that prediction models using electronic clinical data accurately identified Veterans receiving VA primary care who were at increased risk of hospitalization or death. Of the top 5% of Veterans in terms of predicted risk, 51% were hospitalized or died within the following year. Predictors of death were quite different from predictors of hospitalization. In general, clinical and demographic characteristics (i.e., increasing age, metastatic cancer) were most predictive of death, while recent use of health services was most predictive of hospitalization. The authors suggest that in clinical settings, these values can be used to identify high-risk patients who might benefit from care coordination and special management programs, such as intensive case management, telehealth, home care, specialized clinics, and palliative care.
Date: April 1, 2013
- Racial Differences in Veterans’ Perception of the
Quality of PTSD Compensation Examinations
This study examined factors potentially associated with Veterans’ perceptions of the
quality of their PTSD compensation examination, including racial differences. Findings showed that the overall
quality of PTSD compensation examinations was predominantly rated as "excellent" or "very good" by both African American and Caucasian Veterans. However, compared to Caucasian Veterans, African American Veterans rated their examinations as having been of lower
quality. They also rated their examiners lower on interpersonal qualities but not on competence. Of Veterans participating in this study, 47% of Caucasian Veterans vs. 34% of African American Veterans rated the
quality of their examination as “excellent.” Ratings were not significantly related to the Veterans' age, gender, marital status, eventual diagnosis with PTSD, functioning score, the examiners’ perception of the prevalence of malingering, or the presence of a third party in the examination. The authors note that the Veterans’ perspective is only one component of the
quality of the PTSD compensation examination.
Date: April 1, 2013
- No Significant Association between Timing of Surgical Antibiotic Prophylaxis and Risk of Surgical Site Infection
This study sought to determine whether prophylactic antibiotic timing is associated with decreased surgical site infection (SSI). Findings showed that of the surgical procedures performed at VA hospitals included in this study, prophylactic antibiotics were administered at a median of 28 minutes prior to surgical incision; 92% of patients received antibiotics within the recommended time window. Of all patients, 5% of Veterans developed an SSI within 30 days of surgery. In adjusted models, no significant association between prophylactic antibiotic timing and SSI was observed. However, there was a significant association between choice of antibiotic and SSI for orthopedic and colorectal procedures: vancomycin hydrochloride was associated with higher SSI occurrence for orthopedic procedures, while cefazolin or quinolone in combination with an anaerobic agent were associated with fewer SSI events for colorectal procedures. While adherence to the timely prophylactic antibiotic measure is not bad care, there is little evidence to suggest that it is better care.
Date: March 20, 2013
- Journal Issue Highlights the State of Health Information Technology in VA Healthcare
This Medical Care Supplement focuses on the use and impact of health information technology (HIT) in
quality improvement research conducted within VHA. Articles in this Supplement highlight a range of specific HIT approaches, including innovative and interactive uses of VHA’s electronic health record, databases, and information systems, as well as applications of automated systems for intervention, evaluation, and tracking patient care.
Date: March 1, 2013
- Benzodiazepine Prescribing for Veterans with PTSD Remains Common and Varied across the VA Healthcare System
This study examined variation in benzodiazepine prescribing frequency across the VA healthcare system (by VAMC, VISN, and region), and evaluated differences in prescribing frequency among rural vs. urban residents, and between community-based outpatient clinics (CBOCs) relative to medical centers. Findings showed that benzodiazepine prescribing among Veterans with PTSD remains common despite guideline recommendations against their use, and the level of practice variation was extensive. While prescribing variation at the regional, network, and facility levels declined over the study period, facility-level benzodiazepine prescribing variation remains high at 15% to 57%. Rural veterans with PTSD received equivalent, if not higher,
quality of care (as reflected by benzodiazepine prescribing frequency) from community-based outpatient clinics compared to medical centers. The authors suggest that the wide variation in prescribing practices reflects uncertainty among providers regarding best practices, and is ultimately due to the limited number of effective PTSD treatments supported by a strong evidence base.
Date: January 1, 2013
- Previous Hospital Readmission Rates for Three Common Conditions are Poor Predictors for Future Readmission
This study sought to assess whether historic hospital readmission rates predict risk-adjusted patient readmission – and to measure the costs of readmission. Findings showed that previous hospital readmission rates are poor predictors of readmission for future individual patients, so policies using these meaures to guide subsequent reimbursement might prove problematic.
Patients who are readmitted do have substantially higher episode costs, even after conventional risk adjustment. Being readmitted increased total episode cost by 53% for Veterans with acute myocardial infarction, 83% for Veterans with community-acquired pneumonia, and 80% for Veterans with congestive heart failure.
Date: January 1, 2013
- Decreases in VA Hospital Length-of-Stay and Readmission Rates over 14 Years
This study sought to determine trends in hospital length of stay (LOS) and 30-day readmission rates in the VA healthcare system. Findings showed that VA hospitals demonstrated simultaneous improvements in hospital LOS and readmission rates from 1997 to 2010. This demonstrates that LOS reductions have not, thus far, adversely affected the likelihood of hospital readmission. For all medical diagnoses combined, the risk-adjusted mean hospital LOS decreased by 2% annually. Reductions in LOS also were observed for five specific common diagnoses, with the greatest reductions for acute myocardial infarction (2.9 days) and pneumonia (2.2 days). Risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 17% to 14%. Reductions also were observed for the five common diagnoses, with greatest reductions for AMI (23% to 20%) and COPD (18% to 15%). All-cause mortality 90 days after admission was reduced by 3% annually.
Date: December 18, 2012
- Protected Sleep Periods for Medical Interns Increase Overnight Sleep and Improve Morning Alertness
This study evaluated the feasibility and consequences of protected sleep periods among medical interns during extended duty. Findings showed that the implementation of a protected sleep period resulted in approximately a 50% increase in overnight sleep duration, a 200% reduction in nights without any sleep, a reduction of about 50% in disturbed sleep, and improved alertness the next morning. Interns with protected sleep, compared to those without protected sleep, were significantly less likely to have on-call nights with no sleep: 6% vs. 19% at the VAMC, and 6% vs. 14% at the University hospital. Interns with protected sleep also felt less sleepy after on-call nights. The proportion of interns who reported having disturbed sleep at the VAMC was 50% among interns with protected sleep periods compared to 85% among those without protected sleep periods.
Date: December 5, 2012
Quality of VA’s PTSD Disability Assessment Would Improve by Using Evidence-Based Assessment
This trial compared usual disability examiner practices with a standardized assessment that incorporates evidence-based assessments. Findings showed that administering a standardized disability assessment resulted in more complete diagnostic information on functional impairment and PTSD symptoms. Standardized assessments were 85% complete for diagnosis compared to 30% for non-standardized assessments; and for functional impairment, the rates were 76% compared to 3%. Standardized assessment elicited an increase in relevant information and nearly eliminated variation between examiners and medical centers. While the standardized examination was more sensitive than routine examination, it did not result in a significant change in the overall prevalence of diagnosed PTSD.
Date: December 1, 2012
- Determinants of Implementing Depression Care Improvement Models in VA Primary Care Practices
This study examined three VA-endorsed depression care models and tested the relationships between measures of organizational readiness and implementation of the models in VA primary care clinics. The three models include: 1) collocation of mental health specialists in primary care settings, 2) the Translating Initiatives in Depression (TIDES) model, and 3) the Behavioral Health Laboratory (BHL) model. Findings show that pre-existing demographic and readiness characteristics of primary care practices are associated with whether the practice chooses to implement a depression care improvement model – and with what type of model the practice chooses. Of the three approaches, primary care practices appear most ready to implement collocation, which had been present the longest (average 6 years) in practices adopting it. Moreover, the majority of practices that had not adopted it planned to do so. By 2007, 48% of clinics had implemented collocation, 17% had implemented TIDES, and 8% had implemented BHL. Having established
quality improvement processes or a depression clinician champion was associated with collocation. Being located in a VA regional network that endorsed TIDES was associated with TIDES implementation. The presence of psychologists or psychiatrists on primary care staff, greater financial sufficiency, or greater space sufficiency was associated with BHL implementation.
Date: October 5, 2012
- Construction of a Clinical Indicator for the Risk of Over-Treatment among Elderly Patients with Diabetes
The publication of three major trials, including the VA Diabetes Trial (VADT), has prompted greater attention to the potential harms of overly tight glycemic control among patients with diabetes, especially in the elderly and those with cardiovascular disease. The high frequency of risk factors for hypoglycemia and its adverse impact, the marginal benefits of tight control in individuals with short life expectancy, and potential for inaccurate measures suggest a need for a
quality measure to reduce over-treatment, particularly among elderly patients. This Commentary discusses these issues and explores the construction of a clinical indicator for the risk of over-treatment.
Date: September 10, 2012
- Increasing Duration of Resuscitation Might Improve Survival among Patients Suffering Cardiac Arrest
Despite several advances in resuscitation care, overall survival after in-hospital cardiac arrest remains poor. Of the 64,339 patients in this study, 49% achieved return of spontaneous circulation, and 15% survived to discharge. Patients who had cardiac arrests at hospitals with longer median resuscitation durations had higher overall survival than did those who arrested in hospitals with shorter median durations. For example, compared with patients at hospitals with the shortest median resuscitation attempts in non-survivors (16 minutes), patients at hospitals with the longest attempts (25 minutes) had a higher likelihood of return to spontaneous circulation and survival to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 minutes compared with 20 minutes for non-survivors. The likelihood of patients surviving to discharge with a favorable neurological status did not differ significantly between hospitals with shorter or longer resuscitation durations.
Date: September 5, 2012
- Veterans with Greater Clinical Complexity Receive Higher
Quality of Care for Diabetes
This study examined the impact of clinical complexity on three
quality indicators for diabetes care: glycemic, blood pressure (BP), and lipid control. Findings showed that of the Veterans in this study,18% were controlled for all three
quality indicators at index, and 19% were controlled at 90-day follow-up. Veterans with the greatest levels of clinical complexity received higher
quality of care for diabetes based on BP, glycemic, and lipid
quality indicators compared to less complex patients, regardless of the definition of complexity.
Date: September 1, 2012
- Despite Individual Hospital Performance, Pay-for-Performance Program May Result in Small Changes in Medicare Payments
Despite differences across hospitals in terms of performance, expected changes in payments from Medicare under the new hospital pay-for-performance program were small, even for hospitals with the best and worst performance scores. Almost two-thirds of hospitals would experience changes of just a fraction of 1%, and only eight hospitals would have a change of greater than 0.75%. Hospital performance varied substantially across states, which translated into regional differences in Medicare payments. For example, in New Hampshire, one of the states with the highest scores, average Medicare payments would increase by $66,948 (0.24%), while in Hawaii, one of the states with the lowest scores, average Medicare payments would decrease by $25,596 (0.20%). Changes in expected hospital payment also varied by most hospital characteristics. For example, the percentage of hospitals that would have an increase in Medicare payment by 0.25% or more varied by teaching status: 10% of hospitals with a major teaching affiliation were in this category compared to 20% of non-teaching hospitals. These results raise questions about whether the new pay-for-performance program will substantially alter the
quality of hospital care, and findings highlight the challenges of designing effective
quality improvement incentives.
Date: September 1, 2012
- New Anticoagulants are Viable Option for Patients Receiving Long-Term Anticoagulation
New oral anticoagulants are a viable option for patients receiving long-term anticoagulation. Direct thrombin inhibitors (DTIs) and factor Xa (FXa) inhibitors have the advantage of a more predictable anticoagulant effect, and fewer drug-drug interactions as well as equivalent or better mortality and vascular outcomes compared with warfarin. However, treatment benefits compared with warfarin are small and vary depending on the control achieved by warfarin treatment. Six good
quality randomized controlled trials comparing new oral anticoagulants (NOACs) with warfarin showed that in patients with atrial fibrillation (AF), NOACs decreased all-cause mortality. In patients with venous thromboembolism, NOACs did not differ for mortality or outcomes. Across indications, the risk of major and fatal bleeding was decreased with NOACs compared with warfarin. However, the bleeding risk with NOACs may be increased in individuals over the age of 75, and in those with renal impairment. Sub-group analyses suggest a higher risk for myocardial infarction or acute coronary events with dabigatran (DTI) compared with FXa inhibitors. Recent thromboprophylaxis guidelines conclude that patients with AF who are on good warfarin treatment control have little to gain by switching to dabigatran.
Date: August 28, 2012
- No Advantage in Collaborative Care vs. Usual Care for Veterans with PTSD
Over a 6-month period, primary care patients with PTSD in both the Three Component Model (3CM, collaborative care) and usual care groups showed small but clinically insignificant improvement in PTSD, depression, and functioning. No additional benefit was found for Veterans assigned to the 3CM treatment compared to those receiving usual care, despite the fact that 3CM patients were more likely to receive an antidepressant and had more mental health visits. Among Veterans who provided a numeric rating for PTSD care, half rated it as excellent or very good; however, 3CM was associated with lower perceived
quality of PTSD care. Almost two-thirds of Veterans rated their overall care as excellent or very good, and the groups did not differ. Costs were similar for both groups, except that Veterans assigned to 3CM had higher outpatient pharmacy costs.
Date: August 3, 2012
- QI Intervention for VA Programs Serving Homeless Veterans
Through the Getting To Outcomes (GTO) intervention, staff members at three homeless programs were able to make noticeable improvements in their programming. Although none of the improvements incorporated the wholesale adoption of a specific evidence-based program, most improvements involved programs becoming more evidence-based; e.g., using evidence-based guidelines to manage high-risk patients (i.e., Veterans at risk of suicide) and supporting additional substance abuse treatment for Veterans who had relapsed, while keeping them in their current VA housing. Many staff members experienced some challenges adding GTO activities to their already busy workload, and some felt the process could be more transparent and inclusive. Staff members stated that high levels of communication, commitment to the program, and technical assistance were critical to the success of the intervention.
Date: August 1, 2012
- Collaborative Care Models Improve Physical and Mental Health Outcomes for Individuals with Mental Disorders
Collaborative chronic care models (CCM)s can improve mental and physical outcomes for individuals with mental disorders across a wide variety of care settings and provide a robust clinical and policy framework for care integration. Meta-analysis of unadjusted outcomes demonstrated significant small-to-medium effects of CCMs across multiple disorders in clinical symptoms, mental and physical
quality of life, and social role function, with no net increase in total healthcare costs. Systematic review of a broader range of studies largely confirmed meta-analytic findings. The authors suggest that CCMs provide a framework of broad applicability for management for a variety of mental health conditions across a wide range of treatment settings, as they do for chronic medical illnesses.
Date: August 1, 2012
- Wide Variability among VA Hospitals Regarding ICU Admission Patterns
About half of all Veterans in this study (53%) who were admitted directly to the ICU had a 30-day predicted mortality of 2% or less. In more than half of cases, Veterans with a predicted mortality greater than 30% were not admitted to the ICU. At all levels of patient risk, hospitals varied widely in the proportion of Veterans admitted to the ICU. For example, the rate of admission for Veterans in the low-risk group (predicted mortality <2%) varied from 1% to 39%, while the rate of admission for Veterans in the high-risk group (predicted mortality >30%) varied from 11% to 50%. Investigators also found that for a one standard deviation increase in predicted mortality, the adjusted odds of ICU admission varied substantially across hospitals, ranging from a 15% decrease to a 122% increase.
Date: July 23, 2012
- Majority of OEF/OIF Veterans with PTSD Use VA Healthcare for PTSD-Related Treatment, and Users are Increasing
Approximately 58% of OEF/OIF Veterans with PTSD used VA healthcare services and received some PTSD-related treatment from 2002 through 2010. Moreover, OEF/OIF Veterans with PTSD have been increasingly likely to use VA services over time. There is insufficient information about the
quality of PTSD-related services. Developing a broader understanding of the concept of
quality as it relates to PTSD treatment may lead to a better understanding of the services that OEF/OIF Veterans with PTSD receive when they access VA care.
Date: July 1, 2012
- VA Hospitals Caring for Lower Volumes of Mechanically Ventilated Patients Do Not Have Worse Mortality
VA hospitals caring for lower volumes of mechanically ventilated patients do not have worse mortality compared to hospitals with higher volumes. The relationship between hospital volume of mechanical ventilation (MV) and 30-day mortality was not statistically significant: each 50-patient increase in volume was associated with a non-signicant 2% decrease in the odds of death within 30 days, By comparison, the published civilian hospital literature suggests a 10% decrease in odds per 50 patient increase over the same range of volume observed in the present study. There were no substantive differences in the primary results after excluding either repeat admissions or patients who were transferred into the VA from a non-VA facility.
Date: June 22, 2012
- VA Care May Be Sub-Optimal for Veterans with Cirrhosis-Related Ascites
quality of healthcare, measured according to whether Veterans received recommended services, was sub-optimal for cirrhosis-related ascites. For five of eight QIs of ascites care, Veterans in this study received the recommended care less than two-thirds of the time, even after accounting for possible justified exceptions.
Quality scores varied across individual QIs, ranging from 30% for secondary prophylaxis of spontaneous bacterial peritonitis to 90% for testing paracentesis fluid for cell count and differential. In general, care targeted at treatment was more likely to meet standards than preventive care. Veterans with no comorbidity, who saw a gastroenterologist, or who were seen in a VAMC with an academic affiliation received higher
quality of care.
Date: March 27, 2012
- Factors Associated with Increased VA Preventable Acute Care Use
Prior mental health diagnoses and medication use were independent risk factors for ambulatory care sensitive condition- (ACSC) related acute care. These risk factors will require focused attention if the full benefits of new primary care models, such as PACT, are to be achieved. The highest rate of ACSC admissions was among Veterans with drug use disorders (46 admissions per 1,000 patients), followed by those with depression (35 admissions per 1,000 patients), compared to 21 admissions per 1,000 patients for those with no mental health diagnoses. The rate of ED visits for ACSCs was also higher among those with mental health diagnoses (70 visits per 1,000 vs. 44 visits per 1,000 for those without mental health diagnoses). Patients without mental health conditions experienced significantly lower rates of both all-cause and ACSC admissions than patients with mental health conditions. The mean cost and length of stay of ACSC admissions, however, was similar and not statistically different between the two groups.
Date: March 20, 2012
- Meditation-Based Mantram Intervention Shows Potential as Adjunctive Therapy for Veterans with PTSD
The Mantram Repetition Program (MRP) shows potential when used as an adjunct to treatment as usual (TAU) for mitigating chronic PTSD symptoms in Veterans. In this study, twice as many Veterans in the MRP + TAU group had clinically meaningful reductions in PTSD symptoms compared to Veterans in the TAU alone group: 24% vs. 12%, respectively, and PTSD symptoms continued to improve in the MRP + TAU group at six-week follow-up. Compared to Veterans in the TAU alone group, Veterans in the MRP + TAU group also experienced significant reductions in depression and greater improvements in mental health-related
quality of life and spiritual well-being. Reductions in anxiety were equivalent between groups. Of Veterans in the MRP + TAU group, 97% reported moderate or high satisfaction with MRP, and dropout rates were equivalent and low (7%) in both groups.
Date: March 12, 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
- Publicly Reported
Quality Ratings have Small but Positive Effect on Patient Choice of Nursing Home for Post-Acute Care
Patients were more likely to choose facilities with higher reported post-acute care
quality related to resident pain control after public reporting was initiated; however, the magnitude of the effect was small. No changes in nursing home choice related to report card scores were seen in facilities not exposed to public reporting. A better pain score (less pain experienced by the patient) was associated with an increase in consumer demand after public reporting was initiated; for delirium, there was no significant effect, and for improved walking, the effect was unexpectedly negative. There was a differential response across patients by education level, which raises the possibility that the format and distribution of this information matters. Authors suggest that this information may be more influential if it is delivered to consumers in a more user-friendly format, or if it is delivered to patient advocates or surrogate decision-makers.
Date: January 10, 2012
- Chronic Disease Management Initiative Reduces Hospitalizations for Ambulatory Care Sensitive Conditions among Veterans
A chronic disease management (CDM) initiative in VISN 23 was associated with a significant reduction in hospitalizations for ambulatory care sensitive conditions (ACSCs) compared with other VA healthcare systems. The estimated annual effect of the CDM initiative is 2.9 fewer hospital admissions per 1,000 Veterans who have an ACSC. This is nearly 10% of the average of 30.8 ACSC admissions per 1,000 Veterans in the other networks in 2010. ACSC hospitalization ratios were nearly identical in 2006 (before CDM implementation) between VISN 23 and the other VISNs.
Date: January 1, 2012
- Relationship between Resources and
Quality of VA Primary Care
This study examined the relationship between resource use and care
quality in VA primary care clinics using the concept of organizational slack, which is defined as extra organizational resources (i.e., staff, budget, equipment) available to meet a given level of demand. Findings showed that Veterans seen in VA primary care clinics where staffing was below the recommended level were more likely to experience lower
quality of care. Although some level of organizational slack resource for staffing was associated with better
quality of care, additional staffing – beyond guideline recommendations – exhibited diminished returns. Thus, the addition of staffing resources in primary care clinics contributed to higher levels of
quality, but only to a point, at which more staff appeared to make only minimal contributions to
quality. Findings are relevant to understanding the cost and benefits of adding staff to new models of primary care, such as panel management and the Patient-Aligned Care Team (PACT). Also, staff cost and
quality trade-off issues may be an increasingly important issue in future policy discussions.
Date: December 20, 2011
- JGIM Special Supplement Highlights Access to VA Healthcare
The JGIM Supplement includes both the white papers commissioned as background for the September 2010 state-of-the-art (SOTA) conference on “Improving Access to VA Care” and manuscripts submitted in response to a post-SOTA solicitation for original research and reviews pertaining to improving access to VA care. Articles focus on a myriad of topics related to improving access to care for Veterans, including: eHealth technologies (e.g., Care Coordination Home Telehealth program, and My HealtheVet personal electronic health record); measuring the impact of access on healthcare utilization,
quality, and outcomes; and redefining access for 21st century healthcare.
Date: November 1, 2011
- Access to Healthcare and Framework for Reducing Hospital Readmissions
This Commentary discusses how a patient’s level of access to healthcare can influence readmission risk, and proposes a broader framework that can be used to identify alternative strategies to reduce readmissions – a framework in which readmission rates are determined by access, social determinants of health, and regulatory policies.
Date: October 26, 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
Quality Indicators may Lead to Unintended Harm in Elderly Patients with Complex Health Issues
This article highlights two ways that current
quality indicators may lead to unintended harms for older patients with complex medical problems and proposes ways to improve
quality indicators by minimizing or preventing those harms. For example, current
quality indicators are unbalanced, with many encouraging more appropriate care but few indicators discouraging inappropriate care, such as mammography screening for patients with pre-existing advanced cancer or advanced dementia, who are unlikely to benefit. The authors suggest that
quality indicators be refined and improved to drive real
quality improvement for the entire patient population.
Date: October 5, 2011
- Effect of Active versus Passive Monitoring of VA
Quality Performance Measures
This study compared the nature and rate of change in hospital outpatient clinical performance as a function of VA performance measures’ status (active vs. passive), and examined the mean time to stability of performance after changing status. Findings showed that performance measure monitoring status (active vs. passive) did not significantly impact performance over time. Structural organizational characteristics, including facility size, academic mission, and primary care structure, had no impact on this finding. There was variability in whether or not measures stabilized after a status change, suggesting the possibility that some measures may take more than two years to stabilize. However, performance scores for measures with short stability times were no higher or lower than scores for measures with longer stability times. All measures that stabilized did so immediately after the status change (e.g., time to stability was one quarter). Of the 6 measures that did not stabilize, 5 suggested continued improvement after the change.
Date: October 1, 2011
- Cognitive Processing Therapy Improves PTSD Symptoms More than Usual Care among Veterans in Residential Rehabilitation Program
This study examined one VA PTSD Residential Rehabilitation Program and compared clinical outcomes for two cohorts of male Veterans with PTSD that were treated with either cognitive processing therapy (CPT) or trauma-focused group treatment as usual (TAU). Findings showed that Veterans treated with CPT experienced more improvement of PTSD and depression symptoms, psychological
quality of life, coping, and psychological distress than Veterans who received TAU. In the CPT cohort, more Veterans reported PTSD symptoms that were classified as recovered or improved, compared to the TAU cohort.
Date: October 1, 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
Quality of VA Mental Health Care Following Psychiatric Hospitalization for Veterans with Depression
This study sought to assess the
quality of depression care (e.g., antidepressant treatment, psychotherapy) during the high-risk period following a psychiatric hospitalization. Findings show that less than half of Veterans hospitalized for major depression had outpatient mental health follow-up within 7 days of discharge (39%), which is similar to rates found in the general U.S. population among Medicare (38%) and Medicaid (43%) beneficiaries in 2008. Mental health follow-up within 30 days for Veterans in this study was substantially more common (76%). Many Veterans also received adequate psychopharmacologic treatment following a hospitalization for depression (59%), but relatively few received adequate psychotherapy post-discharge (13%).
Date: September 1, 2011
- Natural Language Processing with Electronic Medical Record Improves Identification of VA Post-Operative Complications
This study evaluated a natural language processing (NLP) search approach to detect post-operative surgical complications within VA’s electronic medical record (EMR). Findings showed that, among Veterans undergoing inpatient VA surgery, NLP using the EMR greatly improved the identification of post-operative complications compared to an administrative-code based algorithm. NLP correctly identified 82% of acute renal failure cases compared with 38% for patient safety indicators; 59% vs. 46% for venous thromboembolism; 64% vs. 5% for pneumonia; 89% vs. 34% for sepsis; and 91% vs. 89% for post-operative MI. An accompanying Editorial states that NLP has the potential to greatly enhance the EMR with new applications, such as automated
quality assessment to assist in the performance of comparative effectiveness research.
Date: August 24, 2011
- Co-Location of Primary Care in VA Mental Health Clinics Associated with Better Processes of Care for Veterans with Serious Mental Illness
This study sought to determine the association between the co-location of primary care services and
quality of medical care for patients with serious mental illness (SMI) receiving care in VA mental health clinics. Findings showed that the co-location of primary care services within VA mental health clinics was associated with better
quality of care for Veterans with serious mental illness, particularly for key processes of care. After adjusting for organizational and patient-level factors, Veterans from co-located clinics were more likely to receive diabetes foot exams and screening for colorectal cancer and alcohol misuse (process measures), and to have satisfactory blood pressure control (outcome measure). Co-location was not associated with better outcomes for hemoglobin A1C levels among Veterans with diabetes. Observed
quality of care in this sample exceeded national averages. Overall, integrated medical care may potentially provide an effective medical home model that can improve processes of medical care for Veterans with SMI.
Date: August 1, 2011
- Differences in Communication between Providers in VA Mental Health Clinics and General Medical Providers in Treating Veterans with Serious Mental Illness
Integrated care for co-occurring substance use and general medical disorders is considered essential for improving
quality of care for individuals with serious mental illness (SMI), and is one of VA’s priority goals. This study sought to describe the barriers and facilitators of integrated care (from the perspective of mental health providers) for nearly 20,000 Veterans with SMI. Findings show that mental health providers from VA mental health clinics with high versus low
quality of care scores differed in their ability to communicate with general medical providers regarding care for Veterans with SMI. Among mental health providers from low-performing sites, lack of communication with primary care providers was a key barrier. Barriers to communication included lack of opportunities to interact on a face-to-face basis and lack of opportunities to have team meetings. In addition, they were concerned that primary care providers did not want to see patients with SMI because of the perception that they were difficult to treat. Stigma was not mentioned as a problem for providers among the high-performing sites, with general medical providers viewed as sensitive to the needs of Veterans with SMI. The authors suggest that these findings indicate that efforts to improve communication between mental health and primary care providers, as well as delineating roles and responsibilities across both types of providers may potentially facilitate integrated medical care for Veterans with serious mental illness.
Date: July 7, 2011
- Updated Literature Review Examines Research and Findings on Women Veterans’ Health
Investigators conducted a systematic review of the scientific literature published from 2004-2008 and summarized major findings, as well as advancements and gaps in comparison to literature from an original synthesis (more research was published in this 5-year review than in the 25-year period of the previous review). High rates of PTSD symptoms and other mental health disorders (e.g., depression) were found among returning OEF/OIF military women. Also, as the number of OIF deployments increases, screening positive for mental health problems appears to increase. Military sexual trauma (MST) combined with combat exposure was associated with doubled rates of new onset PTSD in both women and men, and MST was associated with more readjustment difficulties in civilian life. In addition, the literature suggests the need for repeated PTSD/mental health screening in returning OEF/OIF Veterans. Local organizational culture and
quality of leadership support for women’s health were key factors in fostering gender-sensitive VA programs for women Veterans. Within VA healthcare, women Veteran’s satisfaction is positively affected by access to women’s clinics, gynecological services, and overall continuity of care. Women Veterans who do not use VA healthcare lack understanding of VA care and services. Among VA users, women and men had similar outpatient satisfaction ratings; however, women had consistently lower ratings for inpatient care (e.g., physical comfort, courtesy). While successes are evident in the breadth and depth of publications, remaining gaps in the literature include: post-deployment readjustment for women Veterans and their families, and
quality of care interventions/outcomes for physical and mental conditions affecting women Veterans.
Date: July 6, 2011
- Growing VA Research Agenda for Women Veterans
This paper reports on the 2010 VA Women’s Health Services Research Conference, as well as the resulting research agenda for moving forward on behalf of women who have served in the military. Recommendations for the future VA women’s health research agenda, resulting from this conference, included, to name a few: Address gaps in women Veterans’ knowledge and use of VA services (e.g., outreach/education, social marketing, telemedicine); Evaluate and improve
quality of transitions from military to VA care; Assess gender differences in the presentation and outcomes of chronic diseases; Determine reproductive health needs of women Veterans; Examine the structure and care models that support patient-aligned care teams; Evaluate variations in mental healthcare needs; Assess and reduce the risk of homelessness among women Veterans; Conduct research on post-deployment reintegration and readjustment among women Veterans; and Develop combat exposure measure(s) that reflect women Veterans’ experiences.
Date: July 6, 2011
- Women’s Health Issues Journal Focuses on Women Veterans
This special issue of Women’s Health Issues includes 18 peer-reviewed manuscripts summarizing health services research findings about women Veterans and women in the military, framed in the context of informing evidence-based practice and policy. Highlights include: VA has tailored primary care to women through the use of designated providers or separate women’s clinics. VA’s with these clinics were rated higher on most dimensions of care. These findings are particularly important to VA’s current implementation of patient-aligned care teams (PACTs). More than half of VA facilities now offer one or more mental healthcare services specifically for women Veterans, including services embedded within women’s primary care clinics, designation of women’s healthcare providers within general mental health clinics, and/or separate women’s mental health clinics. Recent data on VA care among men and women Veterans with histories of military sexual trauma (MST) show high satisfaction with care. Authors suggest that VA’s system-wide monitoring of MST-related care may be contributing to these positive results. PTSD among women Veterans is associated with poorer occupational functioning and satisfaction, but not employment status. Symptoms of depression have substantial effects across all components of work-related
quality of life, independent of PTSD symptoms. PTSD is the most common psychiatric condition among both women and men with traumatic brain injury (TBI). However, women with TBI are less likely than men to have a PTSD diagnosis, but more likely to have a depression or anxiety disorder diagnosis.
Date: July 6, 2011
- Most Veterans with Military Sexual Trauma Report High Satisfaction with VA Outpatient Care
This study examined the association of military sexual trauma (MST) to patient satisfaction with VA outpatient care. Findings showed that Veterans’ ratings of overall satisfaction with VA outpatient care (regardless of MST status) were high. The proportion of patients reporting very good or excellent overall satisfaction was 79% for male Veterans and 72% for female Veterans. After adjusting for patient characteristics, male and female Veterans’ MST status was not associated with satisfaction ratings of overall VA healthcare. However, female Veterans with a history of MST rated the patient satisfaction dimensions of overall coordination, as well as education and information, less favorably than female Veterans without a history of MST.
Date: July 6, 2011
Quality Improvement Program for Oral Anticoagulation has Potential to Save Lives and Millions in VA Healthcare Costs
Quality of anticoagulation can be measured by percent time in the therapeutic range (TTR). Because VA is considering a
quality improvement program to increase TTR, this study sought to determine whether a "business case" could be made for such a program, including whether or not it has the potential to save money in the short term. Findings showed that even after considering the cost of implementing the program, a
quality improvement program for oral anticoagulation therapy in Veterans with atrial fibrillation has the potential to save lives and millions in VA healthcare costs. In this study population, a modest improvement in TTR (5%) would be expected to avert 1,114 adverse events over two years, many of them fatal. Such an improvement would result in a savings of $15.9 million (minus the cost of the
quality improvement program). Improving TTR by 10% prevented 2,087 events and saved $29.7 million (again, minus the cost of the
quality improvement program).
Date: July 1, 2011
- Averaging Multiple Blood Pressure Measurements May Provide Optimal Assessment for Veterans with Hypertension
This study compared home, clinic, and research systolic blood pressure (SBP) measurements in Veterans with hypertension – and estimated the certainty with which an individual’s true BP can be determined. Findings showed that clinicians who want to be certain that they are correctly classifying patients’ blood pressure control should average multiple measurements. Hypertension
quality metrics based on a single clinic measurement potentially misclassify a large proportion of patients. The relationship between mean clinic and home SBP varied substantially, e.g., 52% had a mean clinic SBP that was at least 10 mm Hg greater than their mean home SBP. The within-individual variance declined markedly with increasing number of measurements and the relationship was similar across all three modes of measurement, with little added value of additional readings beyond 4-6 observed SBP measurements for all three modes. The proportion of patients with their SBP in control within the first 30 days (<140 mm Hg for clinic or research measurement; <135 mm Hg for home measurement) differed between mode of measurement: 28% were in control based on clinic measurement; 47% based on home measurement; and 68% based on research measurement.
Date: June 21, 2011
- Effect of Housing Vouchers on Homeless Veterans with Mental Illness
This study examined how homeless Veterans with mental illness obtain housing without a voucher, and whether greater employment earnings or better clinical outcomes were associated with such housing success. Findings showed that Veterans who obtained independent housing without a voucher worked more days and had higher employment income than those with a voucher, but they were less satisfied with their housing. Veterans who used vouchers lived in housing with the highest rent, but paid less of their own income toward rent because of their vouchers. They also reported the highest
quality of life with respect to their living situation, higher satisfaction with their housing, and higher safety scores. About one-third of Veterans who obtained independent housing without a voucher lived with others, most often with a family member, and reported lower total rent costs, but paid the greatest share of the rent themselves. Approximately 80% of participants were diagnosed with alcohol or drug dependency. There were no differences in psychiatric, substance abuse, or legal outcomes between groups at three months; however, data over all three years shows that Veterans who were not housed had higher psychiatric, substance abuse, and work problems over time than all other groups.
Date: May 1, 2011
- Despite Improved
Quality of VA Healthcare, Racial Disparity Persists for Important Clinical Outcome
This article reports on trends in the
quality of care and racial disparities in relation to 10 VA clinical performance measures that assessed cancer screening, cardiovascular care, and diabetes care from 2000 to 2009. Findings show that in the decade following VA’s organizational transformation,
quality of care improved and racial disparities were minimal for most process measures, such as glucose and LDL screening. However, these were not accompanied by meaningful reductions in racial disparity for important clinical outcomes, such as blood pressure, glucose, and cholesterol control. A gap in clinical outcomes of as much as nine percentage points was observed between African-American and white Veterans. Almost all of the disparity in outcomes was explained by within-facility disparity, which suggests that VA medical centers will need to measure and address racial gaps in care for their patient populations. Of the five performance measures with an absolute racial disparity of 5 percentage points or more in the initial year of the study, there were statistically significant reductions in racial disparity for three: glucose control, BP control, and CRC screening. However, the reductions in disparity were modest, and none were reduced by more than 2 percentage points.
Date: April 1, 2011
- Positive Effect of Pay-for-Performance May Not be Long Term
The Affordable Care Act of 2010 establishes a pay-for-performance program for hospitals. This program, which will take effect in 2013, includes all U.S. acute care hospitals and will be similar to an ongoing hospital pay-for-performance demonstration project sponsored by the Centers for Medicare and Medicaid Services (CMS). This study examined the results of the CMS demonstration project in non-VA hospitals in order to inform efforts to implement pay-for-performance across all U.S. hospitals through the Affordable Care Act. Findings showed that although hospital performance improved under the pay-for-performance demonstration project, the effect was short-lived. By the end of the five-year study period, performance in control hospitals matched that in pay-for-performance hospitals. Over the first three years of the pay-for-performance demonstration project, participating hospitals had better average overall performance than hospitals that did not participate for all three conditions (acute myocardial infarction, heart failure, pneumonia). However, non-pay-for-performance hospitals caught up by the fourth and fifth years of this study. Performance scores were highest among hospitals that were eligible for larger bonuses, were well-financed, or operated in less competitive markets.
Date: April 1, 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
- Article Challenges Process for Disseminating Diabetes Performance Measures
Pressure to develop more stringent measures for “optimal” control of risk factors in patients with diabetes has accelerated, despite the absence of new evidence from 1998 to 2008, and results from recent trials have cast new doubt on the benefits of achieving these “optimal” measures in many patients. This editorial suggests that an examination of Toyota, often portrayed as a leader in
quality, may provide some answers as to how diabetes performance measures got ahead of the evidence.
Date: February 16, 2011
- Intervention Targeting Trauma-Specific Sleep Disturbances Reduces PTSD Symptoms and Insomnia Severity among Veterans
This pilot study sought to determine whether or not the combined effects of cognitive behavioral therapy (CBT) for insomnia and imagery rehearsal therapy (IRT) for nightmares would produce significantly greater improvements in sleep disturbance than usual care alone. Findings show that the sleep intervention produced large short-term effects, including substantial reductions in PTSD symptoms, such as the frequency of nightmares and insomnia severity. In contrast, none of the participants in the usual care group responded or remitted from insomnia or PTSD, and did not improve from baseline on sleep
Date: February 15, 2011
- Using Administrative Data to Measure Treatment for Veterans with PTSD May Overestimate Delivery of Psychotherapy
This study sought to determine whether using administrative data to determine the number of psychotherapy sessions Veterans receive is equivalent to manual record review. Manually-classified notes were used to develop an automated coding protocol using the Automated Retrieval Console (ARC), a VA-developed natural language processing program. ARC was then used to independently code the notes, and the performance of the automated coding program was compared to manual coding. Findings showed that, of the notes that were administratively coded as individual psychotherapy for PTSD, 57% were coded as individual psychotherapy after manual review of records. Thus, nearly half of the encounters that would have been counted as the provision of psychotherapy in large administrative studies appeared to be records of services other than psychotherapy (e.g., intakes, psychological testing). Findings suggest that using counts of administrative codes over-estimates the amount of psychotherapy delivered to Veterans with PTSD. This suggests a potential limitation in current studies of the
quality of care for PTSD in VA. The ARC program replicated the performance of the manual coders in classifying psychotherapy notes very well. This suggests that ARC may help bridge the gap between the accuracy of manual coding and the scope of administrative coding.
Date: February 14, 2011
- Concepts for Evaluating High-Value, Cost-Conscious Healthcare
This article discusses three key concepts for understanding how to assess the value of healthcare interventions: 1) assessing the benefits, harms, and costs; 2) identifying the cost of the intervention as well as any potential downstream costs that will occur as a result of performing the intervention; and 3) estimating the incremental cost-effectiveness ratio. The authors suggest that the first step toward providing high-value healthcare is to reduce or eliminate the use of interventions that provide no benefit. A second step is to ensure that we provide interventions that are both effective and reduce costs. Finally, for interventions that provide additional benefit at additional cost, cost-effectiveness analysis is recommended, but should not be the sole determinant of use.
Date: February 1, 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
- Substantial Gaps in Processes of Care for Veterans with Bipolar Disorder
This study applied a comprehensive set of process of care measures that reflect the integration of psychosocial, patient preference, and continuum of care approaches to mental health – and evaluated whether Veterans with bipolar disorder received care concordant with these practices. Findings show substantial gaps in care for Veterans with bipolar disorder, especially for patient-centered processes such as symptom assessment and treatment experience. Only half of the patients received care in accordance with clinical practice guidelines. Moreover, only 17% had documented assessment of psychiatric symptoms, 28% had documented patient treatment preferences, 56% had documented assessment of substance abuse and psychiatric comorbidity, and 62% had documented assessment of cardiometabolics. Monitoring of weight gain was noted in 54% of the patient charts, and no-show visits were followed up only 20% of the time. However, 72% of the patients received appropriate anti-manic medication, and all patients were assessed for suicidal ideation. Overall, results suggest that in order to present a more patient-centered view of
quality, processes of care for bipolar disorder cannot be distilled into a single measure; but rather, a series of patient-centered composite indicators.
Date: November 1, 2010
- VA Performs Better than Non-VA Healthcare on
Quality Measures for Processes of Care
Since VA’s organizational transformation in the 1990’s, there have been both favorable and unfavorable reports of the
quality of VA care published in the peer-reviewed literature and lay media. In order to better understand the totality of the evidence, this systematic review compared the
quality of medical and other non-surgical care in VA and diverse non-VA healthcare settings. Findings show that VA outperforms non-VA healthcare on
quality measures assessing adherence to recommended processes of care. For example, studies of care processes after an acute myocardial infarction found greater rates of evidence-based drug therapy in VA settings. In addition, more VA patients than Medicare patients received beta-blockers, angiotensin-converting-enzyme inhibitors, or aspirin at discharge. Studies of diabetes care processes also demonstrated a performance advantage for VA; one study reported that VA outperformed commercial managed care plans on all seven measures of care processes examined. Most studies found no significant differences in mortality rates between VA and non-VA care.
Date: October 18, 2010
- VA Residency Training Program Rankings May Predict Cost of Care but not Hospital Readmission or Mortality Rates
Investigators in this natural experiment analyzed data from nearly 30,000 Veterans from one large, urban VA hospital who had been randomly assigned by standard hospital procedure to teams comprised of physicians affiliated with one of two medical/surgical residency training programs. One program was affiliated with one of the higher-ranked medical schools in the U.S., while the other program ranked lower. Findings show that Veterans treated by a team of VA physicians affiliated with a higher-ranked medical/surgical residency training program had 10% lower healthcare costs compared to Veterans at the same hospital who were treated by a team of VA physicians affiliated with a lower-ranked training program – and up to 25% lower costs for more complicated conditions (e.g., heart failure, COPD). Differences in cost largely were the result of diagnostic-testing rates: the physician team affiliated with the lower-ranked program took longer to order tests, and ordered more of them. Hospital readmission rates and mortality were unrelated to the physicians’ training program.
Date: October 1, 2010
- Threshold for Glycemic Control among Veterans with Diabetes
In 2009, the National Committee for
Quality Assurance (NCQA) – Healthcare Employer Information Data Set (HEDIS) measure for good (<7% A1c) glycemic control for individuals with diabetes was revised to apply only to persons younger than 65 years without cardiovascular disease, end-stage diabetes complications, or dementia. However, multiple guidelines recommend that glycemic control targets be individualized, especially in the presence of comorbid medical and mental health conditions. This retrospective study used the NCQA <7% measure to compare overall VA facility rankings with a subset of Veterans receiving complex glycemic treatment regimens (CGR). Findings show that the assessment of the
quality of good glycemic control among VA facilities differs using the NCQA-HEDIS measure for the overall study population compared to a subset of patients receiving CGR. For example, the overall top 10% performing facilities achieved a rate of 57% at the <7% A1c threshold compared to 34% for Veterans on CGR using the same measure. Therefore, the authors suggest that reliance upon a <7% A1c threshold measure as the “
quality standard” for public reporting or pay-for-performance could have the unintended consequence of adversely impacting patient safety. Moreover, they propose that rather than assessing “good glycemic control” by an all-or-none threshold, developers of measures should provide credit for an A1c result within an acceptable range (e.g. incremental credit for improvement between 7.9% and <7%) in order to balance the trade-offs of benefits, harms, and patient preferences.
Date: October 1, 2010
- VA’s Brief Alcohol Intervention Strategy Successful
This study evaluated the prevalence of documented brief interventions among VA outpatients with alcohol misuse before, during, and after implementation of a national performance measure linked to incentives and dissemination of an electronic clinical reminder for brief interventions. Findings show that VA’s strategy of implementing brief alcohol interventions with a performance measure supported by a clinical reminder meaningfully increased documentation of brief interventions over a one-year period. Among Veteran outpatients with alcohol misuse, the prevalence for brief interventions increased significantly over successive phases of implementation – from 5.5% at baseline – to 7.6% after announcement of the brief intervention performance measure – to 19.1% following implementation of the measure – to 29% following dissemination of the clinical reminder. Brief interventions increased among patients without prior alcohol use disorders or addictions treatment, as well as those with recognized drinking problems, with proportionately greater increases among the former group after clinical reminder dissemination.
Date: September 28, 2010
- Validated Alcohol Screening Questionnaire Not Enough to Ensure
Quality of Screening
This study evaluated the
quality of clinical alcohol screening among VA outpatients by comparing Alcohol Use Disorders Identification Test - Consumption Questions (AUDIT-C) results documented during routine clinical care to AUDIT-C results from a confidential mailed survey completed within 90 days of the clinical screen. Of the national sample, 61% of VA outpatients who screened positive for alcohol misuse with the AUDIT-C on mailed surveys screened negative during the same time period with the AUDIT-C in VA outpatient clinical settings. Overall, 11% of Veterans screened positive on the survey screen vs. only 6% on the clinical screen. Patients who screened positive on the AUDIT-C survey were much more likely to have discordant clinical screening results, e.g., among patients whose clinical screens indicated no alcohol use in the past year, 22% reported drinking on the survey screens. Discordance was significantly increased among African American Veterans compared with white Veterans. There were also differences across VA networks: the proportion of Veterans with positive survey screens who had negative clinical screens varied from 43% to 100% across different networks.
Date: September 22, 2010
- 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
- Rapid-Induction Group Clinic May Be Effective Method of Increasing Rates of Hypertension Control
This report describes the process of care and outcomes of a QI initiative that used group clinics to rapidly induce hypertension control among Veterans in a VA primary care setting at one VAMC. Findings show that among Veterans with chronically treated but persistently uncontrolled hypertension, more than half (54%) were able to rapidly lower their blood pressures to controlled levels within six weeks using a group clinic
quality improvement initiative. Moreover, Veterans maintained BP control over the follow-up period (10 months after QI protocol completion). Adherence to the QI protocol predicted hypertension control at follow-up, even after controlling for multiple baseline variables (e.g., diabetes, body mass index, medication compliance). Two-thirds of Veterans without diabetes achieved hypertension control, including more than 80% of those who adhered to the group-clinic protocol.
Date: September 1, 2010
- Measuring the
Quality of Mental Healthcare: Barriers and Strategies
This article discusses the barriers to mental health
quality measurement – and identifies strategies to enhance the development and use of
quality measures in order to improve outcomes for people with mental health disorders. The authors suggest that key reasons for the lag in mental health performance measurement include: lack of sufficient evidence regarding appropriate mental health care, poorly defined
quality measures, limited descriptions of mental health services from existing clinical data, and lack of linked electronic health information. The refinement of
quality measures and, ultimately, enhanced outcomes in mental health will require investment in information technology, additional studies to support the evidence base, and the development of a culture of measurement-based care. Sustaining efforts to improve mental health performance measurement will require rethinking how
quality measurement is used to promote the uptake of evidence-based mental healthcare across systems of care. In addition, measurement systems should cut across mental health disorders, physical disorders, and substance use disorders, which often co-occur.
Date: September 1, 2010
- Patients with Hepatitis C Benefit from Collaborative Care
This study evaluated the
quality of healthcare that patients (non-Veterans) with Hepatitis C (HCV) receive and factors associated with receipt of
quality care, using research data from one of the largest commercial health insurance carriers in the U.S. Findings show that collaboration between specialists and primary care physicians translates into better care for patients with HCV. Patients were less likely to receive any recommended care if they were being treated by specialists or generalists only, compared with being seen by both. Only about 19% of patients with HCV received all recommended care, and the proportion of patients who met
quality indicators varied substantially. For example, most patients (79%) received a genotype test before treatment, whereas relatively few (25%) received recommended vaccinations.
Date: August 17, 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
- Majority of National Guard Soldiers Recently Returned from Combat in Iraq Did Not Meet Criteria for Mental Health Disorder
This study provides the first known report of rates of mental health disorders and comorbidities diagnosed by structured clinical interviews, as opposed to self-report, in a sample of 348 National Guard troops who returned from Iraq. Findings show that a majority (62%) did not meet criteria for a mental health disorder. However, the soldiers had slightly higher rates than community and non-deployed military samples across all mental health diagnoses, with the exception of drug use disorders. Depressive disorders were the most common, followed by non-PTSD anxiety disorders. Mental health diagnoses were associated with poorer functioning and
quality of life, with PTSD having the strongest negative relationship with social functioning and
quality of life. Results also show that more than 85% of soldiers with a diagnosis of PTSD had at least one additional mental health diagnosis, with depressive disorders being the most common. In addition, female soldiers were significantly more likely to have a mental health diagnosis than male soldiers. Specifically, women were diagnosed with PTSD, depressive disorders, and non-PTSD anxiety disorders at twice the rate of men.
Date: June 9, 2010
- Self-Management Program for Veterans with Hepatitis C Improves Health, Independent of Antiviral Therapy
This randomized controlled trial sought to examine the effects of a Hepatitis C (HCV) self-management intervention on the
quality of life of Veterans with HCV who were not currently on or scheduled to start antiviral treatment. Findings show that the HCV Self-Management Program was well attended and produced significant improvements along a number of dimensions of
quality of life and other outcomes six weeks later. When compared to the information-only group, Veterans who attended the self-management workshop improved more on HCV knowledge, self-efficacy, and had more energy and vitality.
Date: May 31, 2010
- Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings
Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and
Date: May 11, 2010
- Processes of Care to Improve Stroke Outcomes
After adjusting for patient characteristics and other processes of care, three processes of care were independently associated with a reduction in the combined outcome: 1) swallowing evaluation, 2) deep vein thrombosis (DVT) prophylaxis, and 3) treating all episodes of hypoxia with supplemental oxygen. Two of the three processes (swallowing evaluation, DVT prophylaxis) are similar to existing stroke
quality measures, but the treatment of hypoxia is not a current performance measure. Thus, authors recommend that organizations that establish national performance measures add treatment of hypoxia to their assessment of stroke care
quality, and continue to measure DVT prophylaxis and swallowing assessment among stroke patients.
Date: May 10, 2010
- Communication Regarding Health-Related
Quality of Life between Cancer Patients and Providers
quality of life (HRQOL) discussions between oncologists and patients were common, but the emphasis was often on treatment (e.g., side effects) and symptoms (e.g., pain), even in patients with advanced disease. All provider/patient encounters included some talk of HRQOL, ranging from 3% to 75% of the total conversation, with the average HRQOL discussion taking up 25% of the conversation. An analysis of topics showed that 56% concerned treatment, 14% concerned disease, and 3% concerned testing. Talk of emotions, mental health, and psychological HRQOL was introduced into the conversations more frequently by patients than providers and occurred in only 9% of the audio segments studied. Spiritual HRQOL also was introduced into the conversations more frequently by patients than providers, and was discussed in only 1% of all audio segments. The authors suggest that given the often intense emotional experience of patients with advanced cancer, oncologists may need to pay more attention to psychological, social, and spiritual HRQOL concerns.
Date: May 1, 2010
- Obese and Overweight Patients Receive Equal or Better Care than Patients of Normal Weight
Among Medicare and VA patients, there was no evidence across eight
quality performance measures that obese and overweight patients received worse care than normal weight patients. In fact, obese and overweight patients received marginally better care on certain measures.
Date: April 7, 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
- Interactive Communication between Primary Care and Specialty Care Improves Patient Outcomes
This meta-analysis showed that interactive communications between collaborating PCPs and specialists were associated with improved patient outcomes. Interactive communication methods included: initial joint patient consultations, regular specialist attendance at primary care team meetings, telepsychiatry with primary care physicians, scheduled phone discussions, and shared electronic progress notes. The studies in this review all involved collaborations with psychiatrists for management of depression and other mental health disorders and with endocrinologists for management of diabetes; however, the consistency of the effects across different primary care-specialty collaborations, healthcare conditions, and study designs suggests the potential for improvement across other specialties and conditions. Effectiveness was enhanced by interventions to improve the
quality of information exchange (e.g., needs assessment, joint care planning).
Date: February 16, 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
- Costs and Outcomes Associated with Newer Medications for Glycemic Control in Type 2 Diabetes
Investigators in this study conducted a cost-effectiveness analysis to better understand the value of adding either of two newer medications (exenatide and sitagliptin) as second-line therapy to glycemic control strategies, compared to an older medication (glyburide), for new-onset type 2 diabetes in persons 25 to 64 years of age. Findings show that newer medications offer more options for glycemic control; however, they come at considerable costs. Exenatide and sitagliptin conferred 0.09 and 0.12 additional
quality-adjusted life years respectively, relative to glyburide as second-line therapy. Using sitagliptin as a second-line treatment is associated with additional costs of $20,213 per person over their lifetime compared to a baseline strategy using glyburide as second-line therapy. Using exenatide as a second-line treatment is associated with an additional cost of $23,849 per person over their lifetime compared to glyburide as second-line therapy.
Date: January 7, 2010
- Assessing New HEDIS Blood Pressure
Quality Measure for Diabetes
To encourage aggressive treatment of hypertension, the National Committee on
Quality Assurance recently adopted a new HEDIS blood pressure performance measure of <130/80 mm Hg for patients with diabetes. Although there is nearly universal agreement on the benefits of aggressive BP treatment (3-4 BP medications) for those with diabetes, the new HEDIS performance measure has generated considerable controversy. This study examined BP levels and medication treatment intensity in patients with diabetes, in order to assess the reasons for failing to meet the new HEDIS measure. Findings suggest that the new diabetes BP measure may not accurately identify poor
quality care and could promote overtreatment through its performance incentives. The new measure commonly mislabeled patients as being inadequately treated, especially elderly patients. Thus, the authors recommend that new BP measures be developed to encourage aggressive treatment of hypertension without unduly promoting overtreatment, especially among elderly patients.
Date: January 1, 2010
Quality of Care for Cardiometabolic Disease among Veterans with Mental Disorders, Regardless of Rural or Urban Dwelling
Mental disorders (MD) were associated with a decreased likelihood of obtaining
quality cardiometabolic care. When compared to those without MD, Veterans with MD were less likely to receive diabetes sensory foot exams, retinal exams, and renal tests. Rural residence was not associated with differences in
quality measures. Primary care visit volume was associated with a greater likelihood of obtaining diabetic retinal exam and renal testing, but did not explain disparities among patients with MD.
Date: January 1, 2010
- Validity of Mental Health Diagnosis Using VA Administrative Data
This study estimated the validity of eight ICD9-based algorithms for the identification of mental health disorders in administrative data among 124,716 Veterans with diabetes who used the VA healthcare system in 1998, and also participated in the 1999 Large Health Survey of Veteran Enrollees, which included questions about history of mental health diagnoses. Findings show that many Veterans with a diagnosed mental health disorder can be identified through VA administrative data; however, the choice of algorithm influenced conclusions. Since the limitations of administrative data cannot be fully eliminated with any algorithm, the authors suggest that investigators and
quality improvement programs also consider conducting sensitivity analyses in which they vary the algorithm, in order to indicate how different assumptions affect conclusions.
Date: January 1, 2010
Quality Measures for VA Alcohol Use Disorder Treatment
The goal of this study was to identify patterns of VA care that are associated with both facility- and patient-level outcomes in order to develop a new process-of-care measure for VA outpatient alcohol use disorder (AUD) treatment
quality. Findings show that nine candidate process measures of outpatient AUD treatment
quality can predict facility-level and patient-level improvement. The candidate measures with the strongest association with improvement in outcomes focused on Veterans who received 3 to 6 outpatient visits in the first month of care. Results also showed that while the literature indicates that longer duration of care should produce better patient outcomes, the investigators found no such link with overall outcomes.
Date: December 1, 2009
- Veterans’ Age and Disability Status Associated with Choice of Medicare Plans
Medicare-eligible Veterans may choose between care in VA or Medicare (or both), and they also have to choose between obtaining Medicare services in the fee-for-service (FFS) sector or in a Medicare Advantage (MA) plan. This study sought to assess factors associated with enrollment in an MA vs. FFS plan in 2000-2004 among this population. Findings show that age and disability status were both significantly associated with choice of MA vs. FFS plan. For example, age-eligible Veterans were more likely to be enrolled in an MA plan if aged 75 or older, female, able to receive free VA care, or not enrolled in Medicaid, while disability-eligible Veterans were more likely to be enrolled if they were married or elderly. Minority Veterans and Veterans with lower disease risk scores (better average health) were more likely to be enrolled in an MA plan than white Veterans or Veterans with higher risk scores. Overall, Veterans living in zip codes with greater population density and higher per capita income were also more likely to enroll in an MA plan. The authors suggest that future studies examine the Medicare health plan choice of disabled Veterans, particularly OEF/OIF Veterans who begin to qualify for Medicare, to better understand the possible impact of MA enrollment on continuity, duplication, cost, and
quality of care.
Date: November 1, 2009
- Use of Medicare and VA Healthcare among Veterans with Dementia
This study sought to characterize healthcare use among Veterans with dementia over a four-year period (1998-2001), and to determine predictors of whether a Veteran will be a VA-only, dual, or Medicare-only user. Findings show that during the four-year study period, Medicare-only use increased while VA-only use decreased. Results also show that an increased likelihood of some Medicare use was associated with being older, white, married, and having higher education, private insurance or Medicaid, and low VA priority level. Further, the number of functional limitations was associated with an increased likelihood of Medicare-only use and a decreased likelihood of VA-only use, while higher comorbidities were associated with a higher likelihood of dual use as opposed to any single system use. The authors suggest that these results imply that different aspects of Veterans’ needs have differential effects on where Veterans seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure patients receive high
quality care, particularly among those with multiple comorbidities.
Date: October 1, 2009
- Special Issue of Pain Medicine Highlights VA Research on Pain among OEF/OIF Veterans
This publication is in follow-up to a Pain Research Summit held in September 2007 by VA’s Rehabilitation R&D Service and VA/HSR&D’s Polytrauma and Blast-Related Injury
Quality Enhancement Research Initiative (PT/BRI-QUERI). This Special Issue begins with four articles that build on the growing epidemiological literature on the prevalence and correlates of pain among OEF/OIF Veterans, and considers the evidence for the assessment and management of pain in this population. The Issue also includes several original articles that provide a sample of the relatively large and growing body of research on pain, including research that focuses on the most prevalent and challenging of pain conditions observed among OEF/OIF Veterans, such as neuropathic pain, chronic widespread pain, musculoskeletal/joint pain, and pain secondary to spinal cord injury.
Date: October 1, 2009
- Delays in Initiating Antibiotic Therapy for Veterans Hospitalized with Pneumonia
Time to first antibiotic dose (TFAD) is an important
quality indicator for pneumonia care. Findings from this study, which included 20 VA hospitals, show that of the 82 survey participants, 72% perceived that ordering and performing chest X-ray was the most frequent step resulting in TFAD delays. Additional steps reported to cause TFAD delays were medical provider assessment, chest X-ray interpretation, ordering/obtaining blood cultures, and ordering/administering initial antibiotic therapy. The most commonly perceived barriers were patient and X-ray equipment transportation delays and communication delays between providers. The most frequently used strategies to reduce TFAD were stocking antibiotics in the emergency department and physician education. Focus groups emphasized the importance of multi-faceted
quality improvement approaches and a top-down hospital leadership style to improve performance on this pneumonia
Date: October 1, 2009
- “Rights” of Safe Electronic Health Record Use
This JAMA Commentary proposes eight “Rights” of safe electronic health record (EHR) use, which are grounded in an engineering model that addresses work-system design for patient safety. The authors recommend the use of the eight “Rights,” in order to address the complex interaction of organizational, technical, and cognitive factors that affect the safety and effectiveness of EHRs.
Date: September 9, 2009
- Federal Investment in Electronic Medical Records
The American Recovery and Reinvestment Act (ARRA) includes $19 billion in incentives for the adoption of electronic medical records (EMRs) and $50 billion to promote health information technology. Medicare physicians adopting and making “meaningful use” of EMRs in 2011 and 2012 will be eligible for an initial payment of up to $18,000, with reduced payments in 2013 and 2014. However, current EMR systems’ inability to learn from aggregated health data has led to implementations and hospital information technology departments that can actually obstruct
quality improvement. For example, much of the information contained in EMRs is formatted as unstructured free text – useful for essential individual communication but unsuitable for detecting quantifiable trends. This commentary suggests that the Department of Health and Human Services capitalize on the opportunity to mandate EMRs that have the potential to learn from data in the EMR system.
Date: September 9, 2009
- Chronic Care Model Improves VA Care, with Opportunities for More Progress within and Outside VA
The Chronic Care Model (CCM) has been embraced by many healthcare systems including VA, whose reorganization in 1995 encouraged the type of organizational commitment that the CCM views as vital to providing high
quality care for patients with chronic illness. The return on VA’s investment in the CCM is reflected in significant improvements in
quality of care. Comparisons of the
quality of chronic illness and preventive care between VA and the private sector generally show that VA provides superior
quality of care. Looking ahead, the American Recovery and Reinvestment Act (ARRA) contains several provisions with the potential to support the widespread adoption of CCM processes throughout the US healthcare system.
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
- Guideline Concordant Care Improves Outcomes for Veterans with Venous Ulcers
Using VA data, investigators identified 155 Veterans with 400 venous ulcers who were treated in the VA Puget Sound Healthcare system between 10/03 and 9/07. Using the 2006 Wound Healing Society guidelines for venous ulcers, guideline-concordant care was defined as adherence during at least 80% of patient visits with the use of: dressings creating a moist wound-healing environment, use of a multi-layer compression device (excluding monolayer devices like ace wraps and compression stockings), and ulcer debridement. Findings show that guideline concordant venous ulcer care was significantly associated with venous ulcer healing, when provided at 80% or more of patient visits. The likelihood of ulcer healing increased when compression therapy or a moist wound-healing environment were provided during at least 80% of the visits; debridement alone was not significantly associated with ulcer healing. Veterans who received all three treatments during at least 80% of their visits were more likely to heal than those who received less than 80%. For this cohort of Veterans, a majority of ulcers (n=362) healed, with an average time to healing of 18.1 weeks, which is much better than the reported average of 36 weeks.
Date: September 1, 2009
- Focus Groups Recommend Strategies to Decrease Missed Test Results
This paper reports on the efforts of two focus groups that formed as part of the Diagnostic Error in Medicine – A National Conference, which was held by the American Medical Informatics Association in 2008. Clinicians who were part of the focus groups were asked to develop interventions that might decrease the risk of diagnostic delay due to missed test results in the future. The focus groups concluded that while the electronic medical record helps to improve access to test results, eliminating all missed test results would be difficult to achieve. However, they did recommend several strategies that might decrease the rates of missed test results, including: improving standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow-up of test results, and systems re-engineering to improve the management and presentation of data. They also suggest that healthcare organizations focus initial
quality improvement efforts on specific tests that have been identified as high-risk for adverse impact on patient outcomes, such as tests associated with a possible malignancy or acute coronary syndrome.
Date: September 1, 2009
- Study Questions Validity of HEDIS
Quality Measures for Substance Use Disorder Specialty Care
Healthplan Employer Data and Information Set (HEDIS) is the most widely used set of
quality measures, thus many healthcare systems now track HEDIS measures of Initiation and Engagement in Alcohol and Other Drug Dependence Treatment. Using VA data, this study identified 320,238 Veterans who received at least one of the HEDIS-specified substance use disorder (SUD) diagnoses during FY06. Investigators then developed a model to determine their progression through Initiation and Engagement, with a focus on clinical setting and care specialty. Findings show that Veterans who have contact with SUD specialty treatment have higher rates of advancing from diagnosis to Initiation – and from Initiation to Engagement – compared to Veterans who are diagnosed with substance use disorders in psychiatric or other medical locations. For example, outpatients who were diagnosed in SUD specialty treatment settings were much more likely to “initiate” than those who were diagnosed in psychiatric and other specialty settings. Results also showed that 85% of the Veterans who received an SUD diagnosis in FY06 did so first in an outpatient setting, and that more than 40% of “engagement” occurred outside of SUD specialty care. Therefore, the usual combining of inpatient and outpatient performance on these measures into overall facility scores may affect measurement and interpretation. The authors suggest that these particular
quality measures be considered measures of facility performance rather than measures of the
quality of SUD specialty care.
Date: August 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
- Drugs-to-Avoid Criteria for the Elderly have Limited Value
Drugs-to-avoid criteria are lists of drugs considered to be potentially inappropriate for the elderly due to adverse effects, limited effectiveness, or both. For example, the Centers for Medicare and Medicaid Services use a version of the criteria of Beers et al. in nursing homes, and the National Committee for
Quality Assurance uses the criteria of Zhan et al. to compare the
quality of U.S. health plans. This study compared the Beers and Zhan criteria with individualized expert assessment of patients’ medications in 256 elderly Veterans from the Iowa City VAMC who were taking five or more medications. Findings show that the drugs-to-avoid criteria performed poorly when used as
quality measures to assess the current state of a patient’s drug therapy. For example, half or more of the drugs flagged by the Beers and Zhan criteria were not considered problematic upon individualized expert review. In addition, the Beers and Zhan criteria identified only 8-15% of drugs that experts judged to be problematic. Therefore, authors suggest that while these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures for the
quality of prescribing.
Date: July 27, 2009
- Significant Proportion of New Abdominal Aortic Aneurysms are not Recorded in VA’s Electronic Medical Record
This study examined the frequency with which newly identified abdominal aortic aneurysms were accompanied by evidence of clinician recognition of the abnormality in VA’s electronic medical record. Of the 91 Veterans with abdominal aortic aneurysms newly identified by CT, 60% lacked documentation in their VA electronic medical record within three months of CT detection, and 18% were never documented during an average follow-up of more than three years. Radiologists infrequently notified the clinical teams of aortic abnormalities, and notification did not appear more common for larger as opposed to smaller abnormalities. More than 40% of Veterans with new aortic aneurysms identified on CT scan had no follow-up contact with the provider who ordered the test, suggesting a potential mechanism for missed results. There was no evidence that any of the aneurysms ruptured or that deaths resulted from the delayed follow-up.
Date: July 7, 2009
- Standard-Based Method is Preferred Measure of Treatment Intensity for BP Control
One possible measure of the
quality of hypertension care is the intensity of clinical management when blood pressure (BP) is uncontrolled, thus there is increasing interest in measuring treatment intensification (TI). This study compared different TI measures in predicting BP control among 819 outpatients with hypertension. The three TI scores/measures evaluated were: 1) any/none score, which divides patients into those who had any therapy increase during the study vs. none; 2) Norm-Based Method (NBM), which scores each patient based on whether they received more or fewer medication increases than predicted at each visit; and 3) Standard-Based Method (SBM), which is similar to NBM but expects a medication increase whenever the BP is uncontrolled. Findings show that the SBM score was an excellent predictor of the final systolic blood pressure, thus the authors suggest that SBM serve as the basis for research and
quality improvement efforts for better hypertension care. The any/none measure produced paradoxical results (therapy increases were associated with a higher final BP), while the NBM was not predictive of BP control.
Date: July 1, 2009
- Resident Duty Hour Reform has No Systematic Impact on Patient Safety in Teaching Hospitals
This observational study focused on patients admitted to VA and Medicare acute-care hospitals, examining changes in patient safety events in more vs. less teaching-intensive hospitals before (2000-2003) and after (2003-2005) duty hour reform. Findings show that the implementation of duty hour regulations did not have an overall systematic impact on potential safety-related events in either VA or non-VA (Medicare) hospitals of different teaching intensity. In the few cases where there were statistically significant increases in the relative odds of developing a patient safety event, the increases were too small to be clinically meaningful.
Date: July 1, 2009
- Veterans with Hypertension and Comorbidities Receive Better Care than Veterans with Hypertension Alone
This study sought to determine the impact of different types of co-existing chronic diseases on
quality of care for hypertension, as well as patient perceptions of
quality. Findings show that Veterans with hypertension and comorbid conditions had greater odds of receiving good
quality of care. Moreover, as the number of chronic conditions increased, so did the odds of receiving appropriate overall care for hypertension. No relationship was found between the provision of guideline-recommended care for hypertension and Veterans’ perception of
quality of care, nor did Veterans’ assessment of
quality of care vary by the presence of co-existing conditions.
Date: June 16, 2009
- HSR&D Investigators Propose New Measure to Assess Diabetes Care
This article discusses a conceptual framework for assessing the efficiency of pharmacologic control of three important risk factors for diabetes (glucose, blood pressure, and cholesterol) because of their central role in diabetes management, and policy implications related to higher medication costs. The authors note that a growing body of evidence indicates a need for more flexible measures of diabetes
quality of care. Thus, rather than a single optimal threshold approach, they suggest a new framework for measuring
quality of care that incorporates the benefit of incremental improvement among multiple populations that differ by age, diabetes duration, and co-existing illness. The new paradigm would assess pharmaceutical efficiency using
quality-adjusted life years (QALYs), calculated separately within multiple age/risk categories, as the output (numerator) and acquisition costs of medications as the input (denominator). The QALYs/cost ratio will provide an assessment of the efficiency of pharmacologic utilization. Therefore, measuring efficiency in the treatment of glucose, blood pressure, and cholesterol in persons with diabetes would incorporate the evaluation of a future healthcare benefit that is “purchased” by direct pharmaceutical costs, linking expected healthcare benefits to actual costs.
Date: June 1, 2009
- Comparative Effectiveness Research Initiatives Fall Short without Commitment to Implementation
President Obama recently signed into law an initiative providing $1.1 billion to support research on the comparative effectiveness of drugs, medical devices, surgical procedures, and other treatments for various conditions. Although comparative effectiveness research (CER) funding has increased, the translation of this investment into practice is very slow, and little attention has been paid to a critical question: Will CER results significantly improve the
quality and safety of the healthcare received by the average patient? This Editorial focuses on the issue of translating evidence into practice, as well as existing programs that can serve as models for achieving important implementation research objectives. Authors note that Federal (CER) initiatives will fall short unless they include a commitment to implementation research to help translate findings into high-
quality health care. An implementation research and development program could fulfill three important objectives: 1) accelerate the translation of evidence into everyday care; 2) enhance opportunities for healthcare providers and patients to define value (balancing expected benefits with costs); and 3) provide the means for providers and patients to communicate with researchers and policymakers about clinically important issues earlier in the research process. Three programs already exist as models for achieving the aforementioned objectives: 1) VA’s
Quality Enhancement Research Initiative (QUERI), 2) VA’s Center for Implementation Practice and Research Support, and 3) the Agency for Healthcare Research and
Quality’s (AHRQ) John M. Eisenberg Clinical Decisions and Communications Science Center.
Date: May 7, 2009
- Establishing Appropriate Peer Group Method for Comparing Healthcare
Measuring and reporting healthcare facility performance via clinical measures of
quality has become a major strategic initiative in improving the
quality of healthcare. Establishing appropriate peer groups can help make equitable comparisons across hospital or healthcare systems. This study sought to develop a new methodology for constructing customized peer groups for VA medical centers by identifying the “nearest neighbor” medical centers, according to distance from each other and selected characteristics for comparison. Findings show that one of the advantages of the nearest-neighbor method is that the peer groups are more refined, reflecting the multi-dimensional diversity of healthcare providers. Moreover, the nearest-neighbor method incorporates the practical consideration that healthcare facilities or systems may have structural and patient-based differences that cannot be changed, but do affect financial or
quality outcomes. Authors suggest that nearest-neighbor peer groups may be more appealing to some researchers and administrators than standard cluster analysis, and thus may strengthen organizational buy-in for financial and
Date: April 1, 2009
- New Process for
Quality Improvement Suggests Local Focus on Improving, in Addition to Measuring
Authors suggest reforming
quality improvement (QI) so that instead of a focus on measures with national benchmarks, there is a focus on rewarding local actions that improve
quality of care using local norms to guide progress.
Quality improvement efforts should be tied to local actions and local results rather than national norms, acknowledging that QI efforts are not generalizable – one size does not fit all. Measures would be tailored to each institution to reflect local core causes. Measurement could remain a key part of local QI initiatives, however, the measurement of core causes and incentives to improve would be conducted at the local sites.
Date: April 1, 2009
Quality Improvement Intervention Improves Follow-up Colonoscopy for Veterans with Positive Colorectal Cancer Screening Test
Inadequate follow-up of abnormal fecal occult blood test (FOBT) screening for colorectal cancer (CRC) may be related to patient, provider, or system-level factors. Thus, in calendar years 2004 and 2005 the Houston VAMC implemented multi-faceted
quality improvement (QI) activities to improve follow-up of positive FOBT results. This study examined the effects of these activities on timeliness and appropriateness of positive-FOBT follow-up for 800 Veterans, and also identified factors that affect colonoscopy performance. Findings show that in cases where a colonoscopy was indicated, the proportion of Veterans who received timely referral and performance was significantly higher after the implementation of the QI activities. In addition, there was a significant decrease in median times to colonoscopy referral and performance. However, colonoscopy was not indicated in more than one-third of Veterans with positive FOBTs, raising concerns about current screening practices and the appropriate performance measures related to CRC screening.
Date: April 1, 2009
- Taking Stock:
Quality Enhancement Research Initiative and Implementation Science
Quality Enhancement Research Initiative (QUERI) program and implementation research emerged at the same time – about 10 years ago. This Editorial takes stock of how much both QUERI and implementation science have grown in the intervening decade, and reflects on the opportunities and challenges ahead.
Date: March 6, 2009
Quality Enhancement Research Initiative Advances Implementation Science
This Editorial offers a perspective from implementation researchers outside the U.S. about VA/HSR&D’s
Quality Enhancement Research Initiative (QUERI) and its impact on and contributions to implementation science.
Date: March 6, 2009
- Costs and Benefits of Health Information Technology
The use of health information technology (HIT) has been promoted as having tremendous promise in improving the efficiency, cost-effectiveness,
quality, and safety of medical care delivery. Findings from this literature review show a proliferation of patient-focused HIT applications, many of which are designed for use by patients without significant oversight by healthcare providers. Investigators believe that accelerating the adoption of HIT will require greater public-private partnerships, new policies to address the misalignment of financial incentives, and a more robust evidence base regarding HIT implementation.
Date: March 1, 2009
- Improving Audit and Feedback Strategies
Audit and feedback (A&F) furnishes providers with summaries of clinical performance over a specified period of time, offering providers current information and motivation to improve. This study found that A&F has a modest but significant positive effect on
quality outcomes. A&F reports containing specific suggestions for performance improvements – delivered in writing, rather than verbally or graphically, and delivered frequently – can noticeably improve the effectiveness of audit and feedback. Also, providing combined group- and individual-level feedback appeared to positively impact feedback effectiveness; however, definitive conclusions could not be made.
Date: March 1, 2009
- Research Agenda for Oral Anticoagulation
Efforts to measure the
quality of oral anticoagulation care have focused disproportionately on the identification of ideal candidates for warfarin therapy, with little effort in measuring the
quality of oral anticoagulation once therapy has begun. To address this knowledge gap, investigators propose a research agenda to advance our understanding of how to measure the
quality of care in oral anticoagulation. Authors propose that valid
quality indicators will provide a framework for
quality improvement that will maximize the effectiveness of therapy and minimize patient harm.
Date: March 1, 2009
- Evaluating Profiling Program and New
Quality Indicators for Diabetes Care
This study evaluated the addition of new
quality indicators to an ongoing clinician feedback initiative that profiles diabetes care and suggests that rather than relying on benchmarks with high and consistent attainment, profiling programs may want to target indicators that demonstrate low and variant performance to better differentiate care across sites.
Date: March 1, 2009
- Costs Associated with Providing Depression Care in the Primary Care Setting
This study reports on organizational costs associated with depression care
quality improvement, specifically introducing an evidence-based depression model – Translating Initiatives in Depression into Effective Solutions (TIDES) Project – into VA primary care settings. Findings show that organizational costs for the TIDES project (in the locations studied) were significant, and should be accounted for in planning the implementation of evidence-based depression care.
Date: February 1, 2009
Quality Improvement Approach May Be Best
There is a growing consensus that a hybrid of two common approaches to
quality improvement (QI) – local participatory QI and central expert QI – might be the best method for achieving
quality care across a variety of conditions. This study examined preferences of frontline staff and managers participating in HSR&D’s Translating Initiatives for Depression into Effective Solutions (TIDES) project regarding how to engage in QI dialogue and provide practical suggestions for implementation. Many study participants believed that a hybrid of participatory and expert QI models might provide the best formula for improving the
quality of care.
Date: February 1, 2009
- 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
- Spaced Education May Improve Teaching by Surgical Residents
This randomized trial investigated whether feedback given by surgery residents to students could improve using a spaced-education program delivering succinct weekly e-mails. Findings show that succinct e-mails using spaced education methods are an effective tool to significantly improve both the frequency and
quality of feedback given by surgical residents to medical students. Authors suggest that spaced-education techniques may help educate busy residents, for whom service and education responsibilities are often at odds with effective teaching strategies.
Date: February 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
- Hospital Readmission More Likely Following VA vs. non-VA Hospitalization for Older Veterans Living in Rural and Urban Settings
Regardless of where veterans lived (urban or rural setting), readmission after a VA hospitalization was more common than readmission after a non-VA hospitalization (20.7% vs. 16.8% for rural veterans; 21.2% vs. 16.1% for urban veterans). Authors suggest that VA consider using unplanned 30-day readmission rates as a component of
Date: January 1, 2009
- Assessing Accuracy and Completeness of Research Data
VA benefits from one of the most highly developed health information systems in the world, which includes the Immunology Case Registry (ICR) that was designed to monitor costs and
quality of HIV care, and the Decision Support System (DSS) that was developed to monitor utilization and costs of Veterans in care. This study compared ICR and DSS datasets, which share overlapping laboratory data from the same VA electronic record system. Findings show that six of the laboratory tests for HIV patients that were studied demonstrated remarkably similar amounts of overlap (68% to 72%) between the two datasets, showing that ICR and DSS are both good sources of data for these tests. However, several other tests demonstrated much lower proportions of overlap (between 20% and 31%). These findings indicate that validation of laboratory data should be conducted prior to its use in
quality and efficiency projects.
Date: January 1, 2009
- Factors Associated with VA Employee Participation in
Quality Improvement Program to Reduce Patient Wait Times
Perceived group norms and attitudes were related to greater individual participation in the Advanced Clinic Access program, but perceived behavioral control was not found to be significant to participation. Overall, survey respondents typically engaged in just under half of the change behaviors. Employees with greater responsibility (e.g., nurse practitioners, RNs, and physicians) participated in more activities compared to other clinic employees. Team size, academic affiliation, and job satisfaction were not significant predictors of participation.
Date: November 1, 2008
- Clinically Complex Veterans have Higher Rates of Performance Measurement and Higher Satisfaction with Care
Veterans with higher clinical complexity had higher measured performance on common process measures used to assess the
quality of outpatient care. In addition, satisfaction with care was higher among clinically complex patients with high measured performance, suggesting that compliance with performance measures does not crowd out unmeasured care.
Date: November 1, 2008
Quality Improvement Collaborative Improves ICU Care for Veterans
This study focused on two “bundles” (ventilator bundle and central line insertion bundle) – tools designed to facilitate the application of best practices and evidence-based care at the bedside. Using these bundles, the goals were to increase adherence with specific evidence-based ICU practices, and to determine whether this would promote additional and sustained
quality improvement across VISN 23. Adherence with all five elements of the ventilator bundle improved to 82% in the final three months of the intervention. The use of a central line insertion checklist to monitor adherence with the central line bundle increased to 74% in the final three months of the intervention. In addition, the implementation of the ventilator and central line bundles was associated with a reduction in rates of ventilator-associated pneumonias and catheter-related blood stream infections, respectively.
Date: November 1, 2008
- Healthcare Providers Should Adopt Principles of Both Patient Centeredness and Cultural Competence to Meet the Needs of All Patients
Authors suggest that healthcare organizations and providers should adopt principles of both patient centeredness and cultural competence so that services are aligned to meet the needs of all patients. Moreover, health services researchers should develop measures of cultural competence and patient centeredness and explore the impact of their unique and overlapping components on patient outcomes.
Date: November 1, 2008
Quality Indicators to Help Treat Veterans with HIV and Depression
Quality indicators were developed based on a review of the existing clinical guidelines for depression, particularly depression related to HIV, in addition to a review of the literature. Authors suggest that
quality indicators identified in this study provide a useful tool for measuring and informing the
quality of HIV depression care.
Date: October 1, 2008
- Variation in Care for Recurrent Non-Melanoma Skin Cancer in a University-Based vs. VA Practice
Treatment choices differed significantly between the two sites: after adjusting for patient, tumor, and clinician characteristics that may have affected treatment choice, tumors treated at the university-based site remained significantly more likely to be treated with Mohs surgery. There was no evidence that the
quality of care varied at the two sites.
Date: September 1, 2008
- Demographic and Clinical Factors Affect Ostomy Complications
Demographic factors (age) and clinical factors (marking the stoma pre-operatively and provider explanation of the ostomy prior to surgery) are potential risk factors for the development of ostomy complications. In addition, the four
quality of life domains measured in this study (physical, psychological, social, and spiritual) were strongly related to all three ostomy complications evaluated.
Date: September 1, 2008
- Veterans with Spinal Cord Injury Report Frequent Physical and Mental Health Concerns
Overall, veterans with spinal cord injury (SCI) were much more likely to experience frequent physically and mentally unhealthy days, and frequent days with depression than what has been reported for the general population. In addition, both chronic illnesses and smoking had a substantial effect on health-related
quality of life for persons with SCI.
Date: July 1, 2008