Diabetes and cardiovascular disease in older adults: current status and future directions

The prevalence of diabetes increases with age, driven in part by an absolute increase in incidence among adults aged 65 years and older. Individuals with diabetes are at higher risk for cardiovascular disease, and age strongly predicts cardiovascular complications. Inflammation and oxidative stress appear to play some role in the mechanisms underlying aging, diabetes, cardiovascular disease, and other complications of diabetes. However, the mechanisms underlying the age-associated increase in risk for diabetes and diabetes-related cardiovascular disease remain poorly understood. Moreover, because of the heterogeneity of the older population, a lack of understanding of the biology of aging, and inadequate study of the effects of treatments on traditional complications and geriatric conditions associated with diabetes, no consensus exists on the optimal interventions for older diabetic adults. The Association of Specialty Professors, along with the National Institute on Aging, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Heart, Lung, and Blood Institute, and the American Diabetes Association, held a workshop, summarized in this Perspective, to discuss current knowledge regarding diabetes and cardiovascular disease in older adults, identify gaps, and propose questions to guide future research.

The medication appropriateness index at 20: where it started, where it has been, and where it may be going

Potentially inappropriate prescribing for older adults is a major public health concern. While there are multiple measures of potentially inappropriate prescribing, the medication appropriateness index (MAI) is one of the most common implicit approaches published in the scientific literature. The objective of this narrative review is to describe findings regarding the MAI's reliability, comparison of the MAI with other quality measures of potentially inappropriate prescribing, its predictive validity with important health outcomes, and its responsiveness to change within the framework of randomized controlled trials. A search restricted to English-language literature involving humans aged 65+ years from January 1992 to June 2013 was conducted using MEDLINE and EMBASE databases using the search term 'medication appropriateness index'. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. A total of 26 articles were identified for inclusion in this narrative review. The main findings were that the MAI has acceptable inter- and intra-rater reliability, it more frequently detects potentially inappropriate prescribing than a commonly used set of explicit criteria, it predicts adverse health outcomes, and it is able to demonstrate the positive impact of interventions to improve this public health problem. We conclude that the MAI may serve as a valuable tool for measuring potentially inappropriate prescribing in older adults.

Bloodstream infections in community hospitals in the 21st century: a multicenter cohort study

Background

While the majority of healthcare in the US is provided in community hospitals, the epidemiology and treatment of bloodstream infections in this setting is unknown.

Methods and Findings

We undertook this multicenter, retrospective cohort study to 1) describe the epidemiology of bloodstream infections (BSI) in a network of community hospitals and 2) determine risk factors for inappropriate therapy for bloodstream infections in community hospitals. 1,470 patients were identified as having a BSI in 9 community hospitals in the southeastern US from 2003 through 2006. The majority of BSIs were community-onset, healthcare associated (n = 823, 56%); 432 (29%) patients had community-acquired BSI, and 215 (15%) had hospital-onset, healthcare-associated BSI. BSIs due to multidrug-resistant pathogens occurred in 340 patients (23%). Overall, the three most common pathogens were S. aureus (n = 428, 28%), E. coli (n = 359, 24%), coagulase-negative Staphylococci (n = 148, 10%), though type of infecting organism varied by location of acquisition (e.g., community-acquired). Inappropriate empiric antimicrobial therapy was given to 542 (38%) patients. Proportions of inappropriate therapy varied by hospital (median = 33%, range 21–71%). Multivariate logistic regression identified the following factors independently associated with failure to receive appropriate empiric antimicrobial therapy: hospital where the patient received care (p<0.001), assistance with ≥3 ADLs (p = 0.005), Charlson score (p = 0.05), community-onset, healthcare-associated infection (p = 0.01), and hospital-onset, healthcare-associated infection (p = 0.02). Important interaction was observed between Charlson score and location of acquisition.

Conclusions

Our large, multicenter study provides the most complete picture of BSIs in community hospitals in the US to date. The epidemiology of BSIs in community hospitals has changed: community-onset, healthcare-associated BSI is most common, S. aureus is the most common cause, and 1 of 3 patients with a BSI receives inappropriate empiric antimicrobial therapy. Our data suggest that appropriateness of empiric antimicrobial therapy is an important and needed performance metric for physicians and hospital stewardship programs in community hospitals.

Effect of nosocomial bloodstream infections on mortality, length of stay, and hospital costs in older adults

OBJECTIVES

To quantify the effect of nosocomial bloodstream infection (BSI) on older adults, including mortality, length of stay (LOS), and costs attributed to BSI.

DESIGN

Retrospective cohort study.

SETTING

Eight acute care hospitals (7 community hospitals and 1 tertiary university-affiliated facility) belonging to the Duke Infection Control Outreach Network (DICON) from the states of North Carolina and Virginia.

PARTICIPANTS

Elderly patients over 65 years of age.

MEASUREMENTS

A multistate, multicenter, matched, retrospective cohort study was conducted from January 1994 through June 2002 in eight hospitals from the Southern-Central United States. Patients aged >65 years with nosocomial BSI were enrolled. Controls without bloodstream infection were matched to cases. Outcomes during the 90-day period following hospital discharge were evaluated to determine the association between BSI and mortality, hospital costs, and LOS.

RESULTS

Eight-hundred thirty cases and 830 matched controls were identified, all with a mean age of 74.4 years. Among cases, 81% of BSIs were central line-associated and Staphylococcus aureus was the most common pathogen accounting for 34.6% of infections (2/3 were methicillin resistant). The mortality rate of cases was 49.4%, compared to 33.2% for controls (OR = 2.1, P < .001), LOS was 29.2 days for cases and 20.2 days for controls (P < .001), and hospital charges were $102,276 for cases compared to $69,690 for controls (P < .001). The mean LOS and mean costs attributable to BSI were 10 days and $43,208, respectively.

CONCLUSION

Nosocomial BSI in older adults was significantly associated with increases in 90-day mortality, increased LOS, and increased costs of care. Preventive interventions to eliminate nosocomial BSIs in older adults would likely be cost effective.

Delays in appropriate antibiotic therapy for gram-negative bloodstream infections: a multicenter, community hospital study

Background

Gram-negative bacterial bloodstream infection (BSI) is a serious condition with estimated 30% mortality. Clinical outcomes for patients with severe infections improve when antibiotics are appropriately chosen and given early. The objective of this study was to estimate the association of prior healthcare exposure on time to appropriate antibiotic therapy in patients with gram-negative BSI.

Method

We performed a multicenter cohort study of adult, hospitalized patients with gram-negative BSI using time to event analysis in nine community hospitals from 2003-2006. Event time was defined as the first administration of an antibiotic with invitro activity against the infecting organism. Healthcare exposure status was categorized as community-acquired, healthcare-associated, or hospital-acquired. Time to appropriate therapy among groups of patients with differing healthcare exposure status was assessed using Kaplan-Meier analyses and multivariate Cox proportional hazards models.

Results

The cohort included 578 patients with gram-negative BSI, including 320 (55%) healthcare-associated, 217 (38%) community-acquired, and 41 (7%) hospital-acquired infections. 529 (92%) patients received an appropriate antibiotic during their hospitalization. Time to appropriate therapy was significantly different among the groups of healthcare exposure status (log-rank p=0.02). Time to first antibiotic administration regardless of drug appropriateness was not different between groups (p=0.3). The unadjusted hazard ratios (HR) (95% confidence interval) were 0.80 (0.65-0.98) for healthcare-associated and 0.72 (0.63-0.82) for hospital-acquired, relative to patients with community-acquired BSI. In multivariable analysis, interaction was found between the main effect and baseline Charlson comorbidity index. When Charlson index was 3, adjusted HRs were 0.66 (0.48-0.92) for healthcare-associated and 0.57 (0.44-0.75) for hospital-acquired, relative to patients with community-acquired infections.

Conclusions

Patients with healthcare-associated or hospital-acquired BSI experienced delays in receipt of appropriate antibiotics for gram-negative BSI compared to patients with community-acquired BSI. This difference was not due to delayed initiation of antibiotic therapy, but due to the inappropriate choice of antibiotic.

B cell responses to the 2011/12-influenza vaccine in the aged

Antibody and B cell responses to influenza A viruses were measured over a period of 2 months in 30 aged and 15 middle-aged individuals following vaccination with the 2011/12 trivalent inactivated influenza vaccine by micro-neutralization assays, ELISAs, ELISpot assays and cell surface staining with lineage-defining antibodies followed by multicolor flow cytometry. Both cohorts developed comparable antibody responses to the H3N2 virus of the vaccine while responses to the H1N1 virus were compromised in the aged. ELISpot assays of peripheral blood mononuclear cells (PBMCs) gave comparable results for the two cohorts. Analysis by flow cytometry upon staining of CD19+IgD-CD20- PBMCs with antibodies to CD27 and CD38 showed markedly reduced increases of such cells following vaccination in the aged. Additional analysis of cells from a subset of 10 younger and 10 aged individuals indicated that in the aged a portion of IgG producing cells lose expression of CD27 and reduce expression of CD38.

Health services use of older veterans treated and released from veterans affairs medical center emergency departments

OBJECTIVES

To determine predictors of repeat health service use in older veterans treated and released from the emergency department (ED).

DESIGN

Retrospective cohort study.

SETTING

Veterans Affairs Medical Center (VAMC) EDs.

PARTICIPANTS

Nationally representative sample of veterans aged 65 and older treated and released from one of 102 VAMC EDs between October 1, 2007, and June 30, 2008.

MEASUREMENTS

Logistic regression models were used to examine the association between independent variables and primary outcomes (30-day repeat ED visits and hospital admissions).

RESULTS

In 31,206 older veterans, ED diagnoses were commonly related to chronic conditions (22.5%), injuries and acute musculoskeletal conditions (19%), and infections (13.5%). Within 30 days, 22% of older veterans had returned to the ED (n = 4,779) or been hospitalized (n = 2,005). In adjusted models, factors associated with greater odds of repeat ED visits than injury were homelessness (odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.3-2.1), previous ED visits (OR = 1.7, 95% CI = 1.6-1.8), previous hospitalization (OR = 1.3, 95% CI = 1.2-1.4), and index ED visit related to infection (1.2, 95% CI = 1.1-1.3). Odds of subsequent hospital admission were higher in veterans with previous hospitalization (OR = 2.5, 95% CI = 2.2-2.8), who were homeless (OR = 1.5, 95% CI = 1.1-2.0), who had aid and attendance benefits (OR = 1.5, 95% CI = 1.2-1.8), who were unmarried (OR = 1.2, 95% CI = 1.1-1.3), and who had an ED visit related to a chronic condition (OR = 1.4, 95% CI = 1.2-1.6) than in those with injury.

CONCLUSION

A substantial proportion of older veterans treated and released from a VAMC ED returned to the ED or were hospitalized within 30 days. Intervening with high-risk older veterans after an ED visit may reduce unscheduled healthcare use.

Varicella-zoster virus-specific antibody responses in 50-59-year-old recipients of zoster vaccine

Prevaccination and 6-week postvaccination samples from the immunogenicity substudy (n = 2269) of the zoster vaccine (ZV) efficacy trial (N = 22 439) in 50-59-year-old subjects were examined for varicella-zoster virus-specific antibody responses to vaccination. The varicella-zoster virus geometric mean titer (GMT) and geometric mean fold rise were higher in ZV recipients than in placebo recipients (GMT, 660.0 vs 293.1 glycoprotein enzyme-linked immunosorbent assay units/mL [P < .001], respectively; geometric mean fold rise, 2.31 vs 1.00 [P < .025]). In each group there was a strong inverse correlation between postvaccination GMT and risk of subsequent herpes zoster. Although these data provide strong evidence that relates ZV-induced antibody and the risk of herpes zoster, a protective threshold was not determined. Clinical Trials Registration. NCT00534248.

Safety of zoster vaccine in elderly adults following documented herpes zoster

BACKGROUND

After completion of the Shingles Prevention Study (SPS; Department of Veterans Affairs Cooperative Studies Program Number 403), SPS participants who had initially received placebo were offered investigational zoster vaccine without charge. This provided an opportunity to determine the relative safety of zoster vaccine in older adults following documented herpes zoster (HZ).

METHODS

A total of 13 681 SPS placebo recipients who elected to receive zoster vaccine were followed for serious adverse events (SAE) for 28 days after vaccination. In contrast to the SPS, a prior episode of HZ was not a contraindication to receiving zoster vaccine. The SPS placebo recipients who received zoster vaccine included 420 who had developed documented HZ during the SPS.

RESULTS

The mean interval between the onset of HZ and the receipt of zoster vaccine in the 420 recipients with prior HZ was 3.61 years (median interval, 3.77 years [range, 3-85 months]); the interval was <5 years for approximately 80% of recipients. The proportion of vaccinated SPS placebo recipients with prior HZ who developed ≥ 1 SAE (0.95%) was not significantly different from that of vaccinated SPS placebo recipients with no prior history of HZ (0.66%), and the distribution of SAEs in the 2 groups was comparable.

CONCLUSIONS

These results demonstrate that the general safety of zoster vaccine in older persons is not altered by a recent history of documented HZ, supporting the safety aspect of the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices recommendation to administer zoster vaccine to all persons ≥ 60 years of age with no contraindications, regardless of a prior history of HZ.

Increased T-bet is associated with senescence of influenza virus-specific CD8 T cells in aged humans

Aged individuals have increased morbidity and mortality following influenza and other viral infections, despite previous exposure or vaccination. Mouse and human studies suggest increased senescence and/or exhaustion of influenza virus-specific CD8 T cells with advanced age. However, neither the relationship between senescence and exhaustion nor the underlying transcriptional pathways leading to decreased function of influenza virus-specific cellular immunity in elderly humans are well-defined. Here, we demonstrate that increased percentages of CD8 T cells from aged individuals express CD57 and KLRG1, along with PD-1 and other inhibitory receptors, markers of senescence, or exhaustion, respectively. Expression of T-box transcription factors, T-bet and Eomes, were also increased in CD8 T cells from aged subjects and correlated closely with expression of CD57 and KLRG1. Influenza virus-specific CD8 T cells from aged individuals exhibited decreased functionality with corresponding increases in CD57, KLRG1, and T-bet, a molecular regulator of terminal differentiation. However, in contrast to total CD8 T cells, influenza virus-specific CD8 T cells had altered expression of inhibitory receptors, including lower PD-1, in aged compared with young subjects. Thus, our data suggest a prominent role for senescence and/or terminal differentiation for influenza virus-specific CD8 T cells in elderly subjects.

Vaccination against herpes zoster in developed countries: state of the evidence

Although progress has been made in the treatment of herpes zoster (HZ) and postherpetic neuralgia (PHN), available therapeutic options are only partially effective. Given evidence that a live-attenuated varicella-zoster-virus vaccine is effective at reducing the incidence of HZ, PHN and the burden of illness, policymakers and clinicians are being asked to make recommendations regarding the use of the zoster vaccine. In this report, we summarize the evidence regarding the: (1) burden of illness; (2) vaccine efficacy and safety; and (3) cost-effectiveness of vaccination, to assist evidence-based policy making and guide clinicians in their recommendations. First, there is general agreement that the overall burden of illness associated with HZ and PHN is substantial. Second, the safety and efficacy of the zoster vaccine at reducing the burden of illness due to HZ and the incidence of PHN have been clearly demonstrated in large placebo-controlled trials. However, uncertainty remains about the vaccine's duration of protection. Third, vaccination against HZ is likely to be cost-effective when the vaccine is given at approximately 65 y of age, if vaccine duration is longer than 10 y.

Role of pain medications, consultants, and other services in improved pain control of elderly adults with cancer in geriatric evaluation and management units

OBJECTIVES

To determine whether pain medication use and inpatient consultations and services were associated with significantly better pain control.

DESIGN

Secondary data analysis from a randomized two-by-two factorial trial. Hospitalized, frail individuals aged 65 and older were randomized to receive care in a geriatric inpatient unit, a geriatric outpatient clinic, both, or neither.

SETTING

Eleven Veterans Affairs Medical Centers.

PARTICIPANTS

Ninety-nine individuals with a diagnosis of cancer, excluding nonmelanoma skin cancer; 44 received geriatric evaluation and management unit (GEMU) care and 55 usual care.

MEASUREMENTS

Pain medications were measured at baseline and discharge; consultations and other services were quantified for the entire admission.

RESULTS

Participants receiving GEMU care had a significantly higher number of consultations than those in usual care. Participants in GEMU care received psychiatry, endocrinology, and psychology consultations 12.7% (P = .004), 9.1% (P = .04), and 21.8% (P = .05) times more, respectively, and occupational and physical therapy 27.3% (P = .004) and 18.2% (P = .04) more, respectively. There were no significant differences in pain medication use between intervention and usual care.

CONCLUSION

Significantly greater use of psychology, psychiatry, physical and occupational therapy in the GEMU participants may have improved the effectiveness of pain management in individuals in inpatient GEMUs. Although analgesic use was not significantly different between the GEMU and usual care groups, small sample size may have limited the ability to detect these differences.

Persistence of the efficacy of zoster vaccine in the shingles prevention study and the short-term persistence substudy

BACKGROUND

The Shingles Prevention Study (SPS; Department of Veterans Affairs Cooperative Study 403) demonstrated that zoster vaccine was efficacious through 4 years after vaccination. The Short-Term Persistence Substudy (STPS) was initiated after the SPS to further assess the persistence of vaccine efficacy.

METHODS

The STPS re-enrolled 7320 vaccine and 6950 placebo recipients from the 38 546-subject SPS population. Methods of surveillance, case determination, and follow-up were analogous to those in the SPS. Vaccine efficacy for herpes zoster (HZ) burden of illness, incidence of postherpetic neuralgia (PHN), and incidence of HZ were assessed for the STPS population, for the combined SPS and STPS populations, and for each year through year 7 after vaccination.

RESULTS

In the STPS as compared to the SPS, vaccine efficacy for HZ burden of illness decreased from 61.1% to 50.1%, vaccine efficacy for the incidence of PHN decreased from 66.5% to 60.1%, and vaccine efficacy for the incidence of HZ decreased from 51.3% to 39.6%, although the differences were not statistically significant. Analysis of vaccine efficacy in each year after vaccination for all 3 outcomes showed a decrease in vaccine efficacy after year 1, with a further decline thereafter. Vaccine efficacy was statistically significant for the incidence of HZ and the HZ burden of illness through year 5.

CONCLUSIONS

Vaccine efficacy for each study outcome was lower in the STPS than in the SPS. There is evidence of the persistence of vaccine efficacy through year 5 after vaccination but, vaccine efficacy is uncertain beyond that point.

Department of Veterans Affairs Geriatric Research, Education and Clinical Centers: translating aging research into clinical geriatrics

Department of Veterans Affairs (VA) Geriatric Research, Education and Clinical Centers (GRECCs) originated in 1975 in response to the rapidly aging veteran population. Since its inception, the GRECC program has made major contributions to the advancement of aging research, geriatric training, and clinical care within and outside the VA. GRECCs were created to conduct translational research to enhance the clinical care of future aging generations. GRECC training programs also provide leadership in educating healthcare providers about the special needs of older persons. GRECC programs are also instrumental in establishing robust clinical geriatric and aging research programs at their affiliated university schools of medicine. This report identifies how the GRECC program has successfully adapted to changes that have occurred in VA since 1994, when the program's influence on U.S. geriatrics was last reported, focusing on its effect on advancing clinical geriatrics in the last 10 years. This evidence supports the conclusion that, after more than 30 years, the GRECC program remains a vibrant "jewel in the crown of the VA" and is poised to make contributions to aging research and clinical geriatrics well into the future.

Biological, clinical, and psychosocial correlates at the interface of cancer and aging research

In September 2010, the Cancer and Aging Research Group, in collaboration with the National Cancer Institute and the National Institute on Aging, conducted the first of three planned conferences to discuss research methodology to generate the highest quality research in older adults with cancer and then disseminate these findings among those working in the fields of cancer and aging. Conference speakers discussed the current level of research evidence in geriatric oncology, outlined the current knowledge gaps, and put forth principles for research designs and strategies that would address these gaps within the next 10 years. It was agreed that future oncology research trials that enroll older adults should include: (1) improved standardized geriatric assessment of older oncology patients, (2) substantially enhanced biological assessment of older oncology patients, (3) specific trials for the most vulnerable and/or those older than 75 years, and (4) research infrastructure that specifically targets older adults and substantially strengthened geriatrics and oncology research collaborations. This initial conference laid the foundation for the next two meetings, which will address the research designs and collaborations needed to enhance therapeutic and intervention trials in older adults with cancer.

Efficacy, safety, and tolerability of herpes zoster vaccine in persons aged 50-59 years

BACKGROUND

Herpes zoster (HZ) adversely affects individuals aged 50-59, but vaccine efficacy has not been assessed in this population. This study was designed to determine the efficacy, safety, and tolerability of zoster vaccine for preventing HZ in persons aged 50-59 years.

METHODS

This was a randomized, double-blind, placebo-controlled study of 22 439 subjects aged 50-59 years conducted in North America and Europe. Subjects were given 1 dose of licensed zoster vaccine (ZV) (Zostavax; Merck) and followed for occurrence of HZ for ≥1 year (mean, 1.3 years) postvaccination until accrual of ≥96 confirmed HZ cases (as determined by testing lesions swabs for varicella zoster virus DNA by polymerase chain reaction). Subjects were followed for all adverse events (AEs) from day 1 to day 42 postvaccination and for serious AEs (SAEs) through day 182 postvaccination.

RESULTS

The ZV reduced the incidence of HZ (30 cases in vaccine group, 1.99/1000 person-years vs 99 cases in placebo group, 6.57/1000 person-years). Vaccine efficacy for preventing HZ was 69.8% (95% confidence interval, 54.1-80.6). AEs were reported by 72.8% of subjects in the ZV group and 41.5% in the placebo group, with the difference primarily due to higher rates of injection-site AEs and headache. The proportion of subjects reporting SAEs occurring within 42 days postvaccination (ZV, 0.6%; placebo, 0.5%) and 182 days postvaccination (ZV, 2.1%; placebo, 1.9%) was similar between groups.

CONCLUSIONS

In subjects aged 50-59 years, the ZV significantly reduced the incidence of HZ and was well tolerated.

CLINICAL TRIALS REGISTRATION

NCT00534248.

Employment related productivity loss associated with herpes zoster and postherpetic neuralgia: a 6-month prospective study

We conducted a prospective multi-center study to assess productivity loss associated with herpes zoster (HZ) and postherpetic neuralgia (PHN). From 10/2005 to 07/2006, we recruited immunocompetent subjects aged ≥50 years with HZ within 14 days of rash onset across Canada. Of the 249 patients recruited, 88 were employed. Data on employment status, absences from work, reasons for absence and effectiveness at work were documented at recruitment, 7-14-21-30-60-90-120-150 and 180 days later. The majority (64%) of employed subjects missed work because of HZ and 76% reported decreased effectiveness at work (i.e. presenteeism) because of HZ/PHN. Mean hours of absenteeism and presenteeism per working individual were 27 and 34 h, respectively. Pain severity and duration were associated with greater productivity loss. These results provide new information about the burden of HZ and PHN, which is useful for public health planning and cost-effectiveness analyses of HZ vaccination among individuals of working age.

Emergency department visits in Veterans Affairs medical facilities

OBJECTIVE

To identify the frequency of, and risk factors for, repeat emergency department (ED) visits and hospitalizations following a treat-andrelease ED visit in patients from Veterans Affairs Medical Centers (VAMCs).

STUDY DESIGN

Retrospective cohort study.

METHODS

Subjects were veterans who visited 1 of 102 VAMC EDs between October 1, 2007, and June 30, 2008. Generalized estimating equations were used to identify factors related to repeat ED visits and hospitalizations within 30 days of the index ED visit.

RESULTS

At their index ED visit, 80% of veterans were treated and released. Of these, 15% returned to the ED and 5% were hospitalized in the next 30 days. In adjusted= models, factors associated with increased odds of repeat ED visits included homelessness (odds ratio [OR] 1.70; 95% confidence interval [CI] 1.59, 1.82) and having a previous ED visit (OR 1.66; 95% CI 1.58, 1.74). Odds of hospitalization were higher among older (OR 1.35; 95% CI 1.26, 1.46), homeless (OR 1.61; 95% CI 1.44,.,and functionally impaired (OR 1.52; 95% CI 1.35, 1.76) veterans, those with greater comorbidity (OR 1.31; 95% CI 1.27, 1.34), previous hospitalization (OR 2.48; 95% CI 2.28, 2.70), and an original ED visit related to a chronic condition (OR 1.30; 95% CI 1.23, 1.37). Among veterans who returned to the ED, 71.7% did not see another VA outpatient provider between their original and return visits.

CONCLUSIONS

A substantial proportion of veterans treated and released from VAMC EDs returned to the ED or were hospitalized within 30 days.