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Back AL, Li YF, Sales AE. Impact of Palliative Care Case Management on Resource Use by Patients Dying of Cancer at a Veterans Affairs Medical Center. J Palliat Med 2005; 8:26-35. [PMID: 15662171 DOI: 10.1089/jpm.2005.8.26] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The VA Puget Sound Health Care System (VAPSHCS) started a palliative care service (PCS) in October 2001 to provide case management for patients with advanced cancer. OBJECTIVE To examine resource use during the last 60 days of life for patients dying of cancer who received PCS compared to patients receiving usual care (non-PCS) during the same time period. DESIGN Retrospective nonrandomized comparison of resource use using administrative data. SETTING Tertiary care Veterans Affairs medical center. PARTICIPANTS All patients who died of cancer between October 1, 2001 and October 31, 2002 at VAPSHCS. RESULTS Two hundred sixty-five patients died of cancer during the specified time period, including 82 PCS and 183 non-PCS patients. PCS patients received case management for a mean of 79 days, and were younger, had more comorbid conditions, and were more likely to have had chemotherapy in the last 60 days of life than non-PCS patients. Variables associated with more acute care bed days in the last 60 days of life included: chemotherapy in the last 60 days of life, and a length of stay on PCS less than 60 days. Variables associated with fewer acute care bed days within the last 60 days of life included: being married, and a length of stay on PCS 60 days or more. Compared to non-PCS patients, the place of death for PCS patients was less likely to be acute care. CONCLUSION PCS for 60 or more days prior to death was associated with decreased use of acute care hospital resources for patients dying of cancer.
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Sales AE, Pineros SL, Magid DJ, Every NR, Sharp ND, Rumsfeld JS. The association between clinical integration of care and transfer of veterans with acute coronary syndromes from primary care VHA hospitals. BMC Health Serv Res 2005; 5:2. [PMID: 15649313 PMCID: PMC545996 DOI: 10.1186/1472-6963-5-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2004] [Accepted: 01/13/2005] [Indexed: 11/22/2022] Open
Abstract
Background Few studies report on the effect of organizational factors facilitating transfer between primary and tertiary care hospitals either within an integrated health care system or outside it. In this paper, we report on the relationship between degree of clinical integration of cardiology services and transfer rates of acute coronary syndrome (ACS) patients from primary to tertiary hospitals within and outside the Veterans Health Administration (VHA) system. Methods Prospective cohort study. Transfer rates were obtained for all patients with ACS diagnoses admitted to 12 primary VHA hospitals between 1998 and 1999. Binary variables measuring clinical integration were constructed for each primary VHA hospital reflecting: presence of on-site VHA cardiologist; referral coordinator at the associated tertiary VHA hospital; and/or referral coordinator at the primary VHA hospital. We assessed the association between the integration variables and overall transfer from primary to tertiary hospitals, using random effects logistic regression, controlling for clustering at two levels and adjusting for patient characteristics. Results Three of twelve hospitals had a VHA cardiologist on site, six had a referral coordinator at the tertiary VHA hospital, and four had a referral coordinator at the primary hospital. Presence of a VHA staff cardiologist on site and a referral coordinator at the tertiary VHA hospital decreased the likelihood of any transfer (OR 0.45, 95% CI 0.27–0.77, and 0.46, p = 0.002, CI 0.27–0.78). Conversely, having a referral coordinator at the primary VHA hospital increased the likelihood of transfer (OR 6.28, CI 2.92–13.48). Conclusions Elements of clinical integration are associated with transfer, an important process in the care of ACS patients. In promoting optimal patient care, clinical integration factors should be considered in addition to patient characteristics.
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Sales AE, Plomondon ME, Magid DJ, Spertus JA, Rumsfeld JS. Assessing response bias from missing quality of life data: the Heckman method. Health Qual Life Outcomes 2004; 2:49. [PMID: 15373945 PMCID: PMC521693 DOI: 10.1186/1477-7525-2-49] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2004] [Accepted: 09/16/2004] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The objective of this study was to demonstrate the use of the Heckman two-step method to assess and correct for bias due to missing health related quality of life (HRQL) surveys in a clinical study of acute coronary syndrome (ACS) patients. METHODS We analyzed data from 2,733 veterans with a confirmed diagnosis of acute coronary syndromes (ACS), including either acute myocardial infarction or unstable angina. HRQL outcomes were assessed by the Short-Form 36 (SF-36) health status survey which was mailed to all patients who were alive 7 months following ACS discharge. We created multivariable models of 7-month post-ACS physical and mental health status using data only from the 1,660 survey respondents. Then, using the Heckman method, we modeled survey non-response and incorporated this into our initial models to assess and correct for potential bias. We used logistic and ordinary least squares regression to estimate the multivariable selection models. RESULTS We found that our model of 7-month mental health status was biased due to survey non-response, while the model for physical health status was not. A history of alcohol or substance abuse was no longer significantly associated with mental health status after controlling for bias due to non-response. Furthermore, the magnitude of the parameter estimates for several of the other predictor variables in the MCS model changed after accounting for bias due to survey non-response. CONCLUSION Recognition and correction of bias due to survey non-response changed the factors that we concluded were associated with HRQL seven months following hospital admission for ACS as well as the magnitude of some associations. We conclude that the Heckman two-step method may be a valuable tool in the assessment and correction of selection bias in clinical studies of HRQL.
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Ho PM, Masoudi FA, Peterson ED, Grunwald GK, Sales AE, Hammermeister KE, Rumsfeld JS. Cardiology management improves secondary prevention measures among patients with coronary artery disease. J Am Coll Cardiol 2004; 43:1517-23. [PMID: 15120805 DOI: 10.1016/j.jacc.2003.12.037] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2003] [Revised: 12/08/2003] [Accepted: 12/15/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The goal of this study was to determine if cardiology subspecialty involvement improves the attainment of recommended low-density lipoprotein (LDL) cholesterol and blood pressure (BP) targets in coronary artery disease (CAD) patients. BACKGROUND The impact of physician specialty on secondary prevention measures for CAD in ambulatory care is unknown. METHODS This was a retrospective cohort study of 13,995 patients with CAD seen at eight ambulatory care Veteran Affairs facilities from 1998 to 2000. Patients with cardiology involvement were defined as those seen in cardiology clinic in addition to primary care. The main outcomes of interest were LDL cholesterol < or =100 mg/dl and BP < or =130/85 mm Hg. Multivariable hierarchical regression analyses were used to determine the independent association of cardiology involvement with improved LDL cholesterol and BP control. RESULTS Overall, 3,771 (27.0%) patients had cardiology involvement. A higher proportion of patients with cardiology involvement achieved LDL cholesterol (55.6% vs. 45.6%; p < 0.01) and BP (45.3% vs. 35.9%; p < 0.01) goals. In multivariable hierarchical regression analysis, cardiology involvement was independently associated with better LDL cholesterol (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.40 to 1.82) and BP (OR, 1.52; 95% CI, 1.32 to 1.77) control. The benefit of cardiology involvement was consistent across a range of LDL and BP targets, in analysis of LDL and BP as continuous outcomes, and among subgroups of high-risk patients, including diabetic patients, the elderly, and those with prior revascularization. CONCLUSIONS Cardiology involvement is associated with better LDL cholesterol and BP control among CAD patients. However, significant room for improvement in secondary prevention measures remains, irrespective of physician specialty.
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Liu CF, Sales AE, Sharp ND, Fishman P, Sloan KL, Todd-Stenberg J, Nichol WP, Rosen AK, Loveland S. Case-mix adjusting performance measures in a veteran population: pharmacy- and diagnosis-based approaches. Health Serv Res 2003; 38:1319-37. [PMID: 14596393 PMCID: PMC1360949 DOI: 10.1111/1475-6773.00179] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To compare the rankings for health care utilization performance measures at the facility level in a Veterans Health Administration (VHA) health care delivery network using pharmacy- and diagnosis-based case-mix adjustment measures. DATA SOURCES/STUDY SETTING The study included veterans who used inpatient or outpatient services in Veterans Integrated Service Network (VISN) 20 during fiscal year 1998 (October 1997 to September 1998; N = 126,076). Utilization and pharmacy data were extracted from VHA national databases and the VISN 20 data warehouse. STUDY DESIGN We estimated concurrent regression models using pharmacy or diagnosis information in the base year (FY1998) to predict health service utilization in the same year. Utilization measures included bed days of care for inpatient care and provider visits for outpatient care. PRINCIPAL FINDINGS Rankings of predicted utilization measures across facilities vary by case-mix adjustment measure. There is greater consistency within the diagnosis-based models than between the diagnosis- and pharmacy-based models. The eight facilities were ranked differently by the diagnosis- and pharmacy-based models. CONCLUSIONS Choice of case-mix adjustment measure affects rankings of facilities on performance measures, raising concerns about the validity of profiling practices. Differences in rankings may reflect differences in comparability of data capture across facilities between pharmacy and diagnosis data sources, and unstable estimates due to small numbers of patients in a facility.
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Beinart SC, Sales AE, Spertus JA, Plomondon ME, Every NR, Rumsfeld JS. Impact of angina burden and other factors on treatment satisfaction after acute coronary syndromes. Am Heart J 2003; 146:646-52. [PMID: 14564318 DOI: 10.1016/s0002-8703(03)00256-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE Although of great importance to clinicians, hospitals, and health care systems, little is known about factors that influence treatment satisfaction after acute coronary syndromes (ACS). The objective of this study was to identify potentially modifiable factors associated with treatment satisfaction 7 months after ACS. METHODS The study population included 1957 patients with ACS who were enrolled in the multicenter, prospective Veterans' Health Administration Access to Cardiology Study. The primary outcome was treatment satisfaction 7 months after ACS as measured by the Seattle Angina Questionnaire. Multivariable regression models were developed to determine the association between treatment satisfaction and patient characteristics, physician-patient communication, and current angina frequency. RESULTS Patient characteristics associated with reduced treatment satisfaction included a history of depression, atrial fibrillation, prior heart surgery, arthritis, hypertension, younger age, and a discharge diagnosis of unstable angina (as opposed to myocardial infarction). After adjusting for patient characteristics, patient-reported inability to reach one or more of their physicians (OR, 2.40; 95% CI, 1.47 to 3.91), being given confusing information (OR, 3.48; 95% CI, 2.08 to 5.83), and poor overall communication with one or more of their physicians (OR, 4.94; 95% CI, 2.93 to 8.34) were all associated with reduced satisfaction. Finally, after adjustment for both patient characteristics and physician communication, weekly (OR, 3.52; 95% CI, 2.28 to 5.45) and daily angina (OR, 3.88; 95% CI, 2.23 to 6.75) were associated with worse treatment satisfaction. CONCLUSIONS Current angina symptoms and aspects of physician communication are independently associated with treatment satisfaction after ACS. These results suggest that treatment satisfaction may be improved through better communication and better control of angina symptoms.
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Miller RR, Li YF, Sun H, Kopjar B, Sales AE, Piñeros SL, Fihn SD. Underuse of cardioprotective medications in patients prior to acute myocardial infarction. Am J Cardiol 2003; 92:209-11. [PMID: 12860227 DOI: 10.1016/s0002-9149(03)00541-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Maynard C, Sales AE. Changes in the use of coronary artery revascularization procedures in the Department of Veterans Affairs, the National Hospital Discharge Survey, and the Nationwide Inpatient Sample, 1991-1999. BMC Health Serv Res 2003; 3:12. [PMID: 12852792 PMCID: PMC183850 DOI: 10.1186/1472-6963-3-12] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2002] [Accepted: 07/10/2003] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There have been dramatic increases in the number of coronary artery bypass surgeries (CABS) and percutaneous coronary interventions (PCI) performed during the last decade. Whether this finding is true for revascularization procedures performed in Department of Veterans Affairs (VA) medical centers is the subject of this paper. METHODS This study compared the number of revascularization procedures and rates of use in the VA, the National Hospital Discharge Survey, and the Nationwide Inpatient Sample. Included were men who underwent isolated CABS and/or PCI, including stenting, between 1991 and 1999, although data for the Nationwide Inpatient Sample were available only between 1993 and 1997. Age adjusted use rates were calculated with the direct method of standardization. RESULTS The percent of users of VA healthcare 75 years and older increased from 10% in 1991 to 20% in 1999. In the VA, the number of isolated CABS declined from 6227 in 1991 to 6147 in 1999, whereas age adjusted rates declined from 167.6 per 100,000 in 1991 to 107.9 per 100,000 in 1999. In the 2 national surveys, both the estimated numbers of procedures and use rates increased over time. In all 3 settings, there were increases in both numbers and rate of PCI from 1993, although in the VA, use rates decreased from 191.2 per 100,000 in 1996 to 139.7 per 100,000 in 1999. VA use rates for both CABS and PCI were lower than those in the 2 national surveys. CONCLUSION Age adjusted rates of CABS and PCI were lower in the VA than in 2 national surveys. Since 1996, there has been a decrease in the rate of use of revascularization procedures in the VA.
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Gray SL, Hedrick SC, Rhinard EE, Sales AE, Sullivan JH, Tornatore JB, Curtis MP. Potentially inappropriate medication use in community residential care facilities. Ann Pharmacother 2003; 37:988-93. [PMID: 12841805 DOI: 10.1345/aph.1c365] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe the prevalence of potentially inappropriate medication use in community residential care (CRC) facilities at baseline, describe exposure to potentially inappropriate drugs during the 1-year follow-up, and examine characteristics associated with potentially inappropriate use. DESIGN A cohort study was conducted using 282 individuals aged >/=65 years entering a CRC facility in a 3-county area in the Puget Sound region of Washington State between April 1998 and December 1998 on Medicaid funding. MAIN OUTCOME MEASURE Use of potentially inappropriate medications as defined by explicit criteria (e.g., drugs that should generally be avoided in the elderly because potential risks outweigh any potential benefits). RESULTS Sixty-two (22%) residents took a total of 75 potentially inappropriate medications at baseline. The most common agents used at baseline were oxybutynin (3.5%) and amitriptyline (3.5%). The incidence of new use of potentially inappropriate medications was 0.1/100 person-days during the follow-up period. Potentially inappropriate use was related to self-reported fair or poor health (adjusted OR 1.42; 95% CI 1.05 to 1.92) and number of prescription drugs (adjusted OR 1.12; 95% CI 1.05 to 1.19). In the Cox proportional hazard model, no characteristics predicted new potentially inappropriate medication use during the follow-up. CONCLUSIONS Potentially inappropriate medication use is common among residents in CRC facilities. A comprehensive periodic review may be beneficial for reducing potentially inappropriate use, especially for patients taking multiple drugs.
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Sloan KL, Sales AE, Liu CF, Fishman P, Nichol P, Suzuki NT, Sharp ND. Construction and characteristics of the RxRisk-V: a VA-adapted pharmacy-based case-mix instrument. Med Care 2003; 41:761-74. [PMID: 12773842 DOI: 10.1097/01.mlr.0000064641.84967.b7] [Citation(s) in RCA: 164] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Assessment of disease burden is the key to many aspects of health care management. Patient diagnoses are commonly used for case-mix assessment. However, issues pertaining to diagnostic data availability and reliability make pharmacy-based strategies attractive. Our goal was to provide a reliable and valid pharmacy-based case-mix classification system for chronic diseases found in the Veterans Health Administration (VHA) population. OBJECTIVE To detail the development and category definitions of a VA-adapted version of the RxRisk (formerly the Chronic Disease Score); to describe category prevalence and reliability; to check category criterion validity against ICD-9 diagnoses; and to assess category-specific regression coefficients in concurrent and prospective cost models. RESEARCH DESIGN Clinical and pharmacological review followed by cohort analysis of diagnostic, pharmacy, and utilization databases. SUBJECTS 126,075 veteran users of VHA services in Washington, Oregon, Idaho, and Alaska. METHODS We used Kappa statistics to evaluate RxRisk category reliability and criterion validity, and multivariate regression to estimate concurrent and prospective cost models. RESULTS The RxRisk-V classified 70.5% of the VHA Northwest Network 1998 users into an average of 2.61 categories. Of the 45 classes, 33 classes had good-excellent 1-year reliability and 25 classes had good-excellent criterion validity against ICD-9 diagnoses. The RxRisk-V accounts for a distinct proportion of the variance in concurrent (R2 = 0.18) and prospective cost (R2 = 0.10) models. CONCLUSIONS The RxRisk-V provides a reliable and valid method for administrators to describe and understand better chronic disease burden of their treated populations. Tailoring to the VHA permits assessment of disease burden specific to this population.
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Sales AE, Liu CF, Sloan KL, Malkin J, Fishman PA, Rosen AK, Loveland S, Paul Nichol W, Suzuki NT, Perrin E, Sharp ND, Todd-Stenberg J. Predicting costs of care using a pharmacy-based measure risk adjustment in a veteran population. Med Care 2003; 41:753-60. [PMID: 12773841 DOI: 10.1097/01.mlr.0000069502.75914.dd] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although most widely used risk adjustment systems use diagnosis data to classify patients, there is growing interest in risk adjustment based on computerized pharmacy data. The Veterans Health Administration (VHA) is an ideal environment in which to test the efficacy of a pharmacy-based approach. OBJECTIVE To examine the ability of RxRisk-V to predict concurrent and prospective costs of care in VHA and compare the performance of RxRisk-V to a simple age/gender model, the original RxRisk, and two leading diagnosis-based risk adjustment approaches: Adjusted Clinical Groups and Diagnostic Cost Groups/Hierarchical Condition Categories. METHODS The study population consisted of 161,202 users of VHA services in Washington, Oregon, Idaho, and Alaska during fiscal years (FY) 1996 to 1998. We examined both concurrent and predictive model fit for two sequential 12-month periods (FY 98 and FY 99) with the patient-year as the unit of analysis, using split-half validation. RESULTS Our results show that the Diagnostic Cost Group /Hierarchical Condition Categories model performs best (R2 = 0.45) among concurrent cost models, followed by ADG (0.31), RxRisk-V (0.20), and age/sex model (0.01). However, prospective cost models other than age/sex showed comparable R2: Diagnostic Cost Group /Hierarchical Condition Categories R2 = 0.15, followed by ADG (0.12), RxRisk-V (0.12), and age/sex (0.01). CONCLUSIONS RxRisk-V is a clinically relevant, open source risk adjustment system that is easily tailored to fit specific questions, populations, or needs. Although it does not perform better than diagnosis-based measures available on the market, it may provide a reasonable alternative to proprietary systems where accurate computerized pharmacy data are available.
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Silverstein M, Sales AE, Koepsell TD. Health care utilization and expenditures associated with child care attendance: a nationally representative sample. Pediatrics 2003; 111:e371-5. [PMID: 12671154 DOI: 10.1542/peds.111.4.e371] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Participation in center-based child care among preschool-aged children is associated with an increased incidence of communicable illness. Although estimates of health care utilization and costs associated with child care attendance exist in other countries with different health care systems, nationally representative data for the United States are lacking. The objective of this study was to determine the patterns of health care utilization and costs associated with attendance at different types of child care, among a nationally representative sample of preschool-aged children. METHODS A nationally representative sample of children aged 0 to 5 years enrolled in the Medical Expenditure Panel Survey, 1997 Cohort were studied. Data were analyzed by cross-sectional analysis within a single calendar year. The Rand Health Insurance experiment 2-part multivariate regression model was used to accommodate skewed expenditure data. RESULTS A total of 871 children were included in the study. A total of 484 (56%) attended no child care provided by anyone other than their primary caregiver; 134 (15%) attended center-based child care; 76 (9%) attended friend or neighbor care; and 170 (20%) attended in-home or relative care. In a weighted multivariate model, children in center-based child care were more likely than those not in child care to have attended at least 1 office-based visit (adjusted odds ratio [aOR]: 2.8; 95% confidence interval [CI]: 1.0-7.9) and emergency department visit (aOR: 2.0; 95% CI: 1.1-3.6) and to have received a medication prescription (aOR: 2.8; 95% CI: 1.2-6.1). The adjusted 2-part model predicted total health care expenditures for those not attending child care to be 642 dollars (95% CI: 508-813), versus 985 dollars (95% CI: 714-1336) for a similar population in center-based child care. Expenditure data for office-based visits and medication prescriptions mirrored these trends. CONCLUSION In the immediate term, children in center-based child care tend to use more health care services. This increased utilization translates into modest per-child differences in health care expenditures. We hypothesize that this pattern of utilization and expenditure is attributable primarily to a higher incidence of minor, self-limited, communicable illness among children in center-based child care.
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Rumsfeld JS, Magid DJ, Plomondon ME, Westfall JM, Peterson LA, Sales AE. The impact of admission to primary versus tertiary care VA medical centers on outcomes following acute coronary syndromes: The VA access to cardiology study. J Am Coll Cardiol 2003. [DOI: 10.1016/s0735-1097(03)82855-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Rumsfeld JS, Magid DJ, Plomondon ME, Sales AE, Grunwald GK, Every NR, Spertus JA. History of depression, angina, and quality of life after acute coronary syndromes. Am Heart J 2003; 145:493-9. [PMID: 12660673 DOI: 10.1067/mhj.2003.177] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Depression has been associated with higher mortality and morbidity rates after acute coronary syndromes (ACS), but little is known about the association between depression, angina burden, and quality of life. We evaluated the association between a history of depression and patient-reported angina frequency, physical limitation, and quality of life 7 months after discharge from the hospital for ACS. METHODS Patients were enrolled in the Department of Veterans Affairs Access to Cardiology Study, a cohort study of all patients with acute myocardial infarction or unstable angina who were discharged from 24 Veterans Affairs medical centers between March 1998 and February 1999. Data from 1957 patients who completed a 7-month postdischarge Seattle Angina Questionnaire were analyzed. Multivariate logistic regression was used to evaluate a history of depression as an independent predictor of angina frequency, physical limitation, and quality of life 7 months after ACS, as measured with the Seattle Angina Questionnaire. RESULTS A total of 526 patients (26.7%) had a history of depression. After adjustment for a wide array of demographic, cardiac, and comorbid factors, a history of depression was significantly associated with more frequent angina (odds ratio [OR] 2.40, 95% CI 1.86-3.10, P <.001), greater physical limitation (OR 2.89, 95% CI 2.17-3.86, P <.001), and worse quality of life (OR 2.84, 95% CI 2.16-3.72, P <.001) after ACS. CONCLUSION We found a strong association between a history of depression and both heavier angina burden and worse health status after ACS. These findings further support the importance of depression as a risk marker for adverse outcomes after ACS.
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Sloan KL, Sales AE, Willems JP, Every NR, Martin GV, Sun H, Pineros S, Sharp N. Frequency of serum low-density lipoprotein cholesterol measurement and frequency of results < or=100 mg/dl among patients who had coronary events (Northwest VA Network Study). Am J Cardiol 2001; 88:1143-6. [PMID: 11703960 DOI: 10.1016/s0002-9149(01)02050-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This population-based, cross-sectional analysis targeted all veterans with coronary heart disease (CHD) who were active patients in primary care or cardiology clinics in the Veterans Health Administration Northwest Network from July 1998 to June 1999. We report guideline compliance rates, including whether low-density lipoprotein (LDL) was measured, and if measured, whether the LDL was < or=100 mg/dl. In addition, we utilized multivariate logistic regression to determine patient characteristics associated with LDL measurements and levels. Of 13,891 active patients with CHD, 5,552 (40.0%) did not have a current LDL measurement. Of those with LDL measurements, 39.1% were at the LDL goal of < or =100 mg/dl, whereas 26.5% had LDL > or =130 mg/dl. Male gender, younger age, history of angioplasty or coronary artery bypass grafting, current hypertension, diabetes mellitus, and angina pectoris were associated with increased likelihood of LDL measurement. Older age and current diabetes and angina were associated with increased likelihood of LDL being < or =100 mg/dl, if measured. Although these rates of guideline adherence in the CHD population compare well to previously published results, they continue to be unacceptably low for optimal clinical outcomes. Attention to both LDL measurement and treatment (if elevated) is warranted.
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Rumsfeld JS, Magid DJ, Plomondon ME, O'Brien MM, Spertus JA, Every NR, Sales AE. Predictors of quality of life following acute coronary syndromes. Am J Cardiol 2001; 88:781-4. [PMID: 11589849 DOI: 10.1016/s0002-9149(01)01852-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Every NR, Fihn SD, Sales AE, Keane A, Ritchie JR. Quality Enhancement Research Initiative in ischemic heart disease: a quality initiative from the Department of Veterans Affairs. QUERI IHD Executive Committee. Med Care 2000; 38:I49-59. [PMID: 10843270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Despite the dramatic fall in ischemic heart disease (IHD) mortality rates over the last 3 decades, it remains the number one cause of death in the United States, and one of the most frequent indications for care by the US Department of Veterans Affairs. National practice guidelines have been developed and disseminated both by societies that specialize in cardiology and within the Veterans Health Administration. Despite these efforts, a substantial minority remains of patients with IHD who are not treated with guideline-recommended therapies. The Quality Enhancement Research Initiative in IHD is a Veterans Health Administration-sponsored initiative to address the gap between guideline-recommended therapies and actual Department of Veterans Affairs practice. Because guideline development for patients with IHD is relatively mature, the Quality Enhancement Research Initiative in IHD will concentrate on measuring existing practices, implementing interventions, and evaluating outcomes in veterans with IHD. Measurement of existing practices will be evaluated through analyses of existing Veterans Affairs databases developed for the Continuous Improvement in Cardiac Surgery Program, as well as data collected at the Center for the Study of Practice Patterns in veterans with acute myocardial infarction. To measure existing practices in outpatients with IHD, we plan to develop a new database that extracts electronic data from patient laboratory and pharmacy records into a relational database. Interventions to address gaps between guideline recommendations and actual practice will be solicited and implemented at individual medical centers. We plan to emphasize point-of-care electronic reminders as well as online decision support as methods for improving guideline compliance.
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