Medication effectiveness studies in the United States Veterans Administration health care system: a model for large integrated delivery systems

Prognostic Value in Preoperative Veterans RAND-12 Mental Component Score on Clinical Outcomes for Patients Undergoing Minimally Invasive Lateral Lumbar Interbody Fusion

OBJECTIVE

To evaluate the effect of Veterans RAND 12-item health survey mental composite score (VR-12 MCS) on postoperative patient-reported outcome measures (PROMs) after undergoing lateral lumbar interbody fusion.

METHODS

Retrospective data from a single-surgeon database created 2 cohorts: patients with VR-12 MCS ≥ 50 or VR-12 MCS < 50. Preoperative, 6-week, and final follow-up (FF)- PROMs including VR-12 MCS/physical composite score (PCS), 12-item Short Form health survey (SF-12) MCS/PCS, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), Patient Health Questionnaire-9 (PHQ-9), visual analogue scale (VAS)-back/leg pain (VAS-BP/LP), and Oswestry Disability Index (ODI) were collected. ∆6-week and ∆FF-PROMs were calculated. Minimal clinically important difference (MCID) achievement rates were determined from established cutoffs from the literature. For intercohort comparison, chi-square analysis was used for categorical variables, and Student t-test for continuous variables.

RESULTS

Seventy-nine patients were included; 25 were in VR-12 MCS < 50. Mean postoperative follow-up time was 17.12 ± 8.43 months. The VR-12 MCS < 50 cohort had worse VR-12 PCS, SF-12 MCS, PROMIS-PF, PHQ-9, VAS-BP, and ODI scores preoperatively (p ≤ 0.014, all), worse VR-12 MCS/PCS, SF-12 MCS, PROMIS-PF, PHQ-9, and ODI scores at 6-week postoperatively (p ≤ 0.039, all), and worse VR-12 MCS, SF-12 MCS, PROMIS-PF, PHQ-9, VAS-BP, VAS-LP, and ODI scores at FF (p ≤ 0.046, all). The VR-12 MCS < 50 cohort showed greater improvement in VR-12 MCS and SF-12 MCS scores at 6 weeks and FF (p ≤ 0.005, all). The VR-12 MCS < 50 cohort experienced greater MCID achievement for VR-12 MCS, SF-12 MCS, and PHQ-9 (p ≤ 0.006, all).

CONCLUSION

VR-12 MCS < 50 yielded worse mental health, physical function, pain and disability postoperatively, yet reported greater improvements in magnitude and MCID achievement for mental health.

Study protocol of a telephone problem-solving intervention for Spanish-speaking caregivers of veterans post-stroke: an 8-session investigator-blinded, two-arm parallel (intervention vs usual care), randomized clinical trial

BACKGROUND

Stroke is one of the leading causes of death and the main cause of long-term disability in the United States. The significant risk factors of stroke among Hispanics are well-documented. The majority of stroke survivors return home following a stroke and are cared for by family caregivers. Due to the abrupt nature of strokes, caregivers experience unexpected changes and demands that oftentimes lead to caregiver burden and depression. Given the significant risk factors for stroke in Hispanics and the influence of culture in family norms and family management, we developed a telephone and online problem-solving intervention for Spanish-speaking stroke caregivers. This study tests the impact of a telephone and online problem-solving intervention for Spanish-speaking stroke caregivers on caregiver outcomes.

METHODS

The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 290 caregivers from 3 Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a problem-solving intervention that uses telephone and online education and care management tools on the previously developed and nationally available RESCUE en Español Caregiver website. In the usual care group, participants receive the information and/or support caregivers of veterans with stroke normally receive through existing VA resources (e.g., stroke-related information and support). The primary outcome is change in caregiver's depressive symptoms at 1- and 12-weeks post-intervention. Secondary outcomes include changes in stroke caregivers' burden, self-efficacy, problem-solving, and health-related quality of life (HRQOL) and veterans' functional abilities. We will also determine the budgetary impact, the acceptability of the intervention and participation barriers and facilitators for Spanish-speaking stroke caregivers.

DISCUSSION

This is an ongoing study. It is the first known randomized controlled trial testing the effect of a telephone and online problem-solving intervention in Spanish for caregivers of veterans post-stroke. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post-stroke.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03142841- Spanish Intervention for Caregivers of Veterans with Stroke (RESCUE Español). Registered on February 23, 2018. Protocol version 8. 08.11.2022.

Two-year validation and minimal clinically important difference of the Veterans RAND 12 Item Health Survey Physical Component Score in patients undergoing minimally invasive transforaminal lumbar interbody fusion

OBJECTIVE

The Physical Component Score of the Veterans RAND 12 Item Health Survey (VR-12 PCS) has been assessed for use at short-term and intermediate-term time points for lumbar fusion populations. This study assesses the long-term validity and establishes minimal clinically important difference (MCID) values of VR-12 PCS in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

METHODS

A surgical registry was retrospectively reviewed for primary, elective, single-level MIS TLIF procedures with posterior instrumentation. Patients missing preoperative and 2-year postoperative VR-12 PCS survey data were excluded. VR-12 PCS, SF-12 Health Survey Physical Component Summary (SF-12 PCS), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), and Oswestry Disability Index (ODI) patient-reported outcome measures (PROMs) were recorded preoperatively and postoperatively. Responsiveness of the VR-12 measure was assessed in two ways. First, the mean postoperative PROM scores were compared with preoperative baseline values using a paired Student t-test. Second, MCID values were calculated using both distribution-based and anchor-based methods and used to assess improvement in VR-12 score at the 2-year time point. Discriminant validity of the VR-12 was assessed using cross-sectional and longitudinal anchors. Convergent validity of the VR-12 measure was assessed using Pearson's correlation coefficient and partial time-independent correlation. Floor and ceiling effects were assessed.

RESULTS

A total of 74 patients who underwent MIS TLIF were included. The VR-12 PCS demonstrated significant improvements at all time points from 12 weeks to 2 years (p < 0.001 for all). VR-12 PCSs were significantly different for patients classified using cross-sectional anchors (p < 0.001) and longitudinal anchors (p ≤ 0.005). Calculated MCID values ranged from 4.1 to 8.5, and 4.1 was selected as the optimal MCID, which 87.8% of patients achieved. Strong, significant correlations of the VR-12 PCS with SF-12 PCS and PROMIS PF were demonstrated at all time points (p < 0.001 for all). No significant floor or ceiling effects were detected.

CONCLUSIONS

The VR-12 PCS demonstrated excellent responsiveness, discriminant and convergent validity, and no significant floor or ceiling effects up to 2 years after MIS TLIF. Therefore, VR-12 PCS may serve as a valid measure of long-term physical function.

A 5-Year Follow-up of Patients Treated for Full-Thickness Rotator Cuff Tears: A Prospective Cohort Study

Background:

The evidence in support of operative versus nonoperative management of rotator cuff tears (RCTs) is limited, based primarily on observational studies of lower scientific merit.

Purpose:

To (1) compare the efficacy of operative versus nonoperative management of full-thickness RCTs across time and (2) detect variables that predict success within each group.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

We included patients with symptomatic full-thickness RCTs who were enrolled in an institutional shoulder registry. Patient enrollment began in 2009 and continued until early 2018. The following outcome measures were collected at baseline, then 6 months, 1 year, and annually up to 5 years postoperatively: Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) score, Veterans RAND 12-Item Health Survey (VR-12) mental and physical component subscales (MCS and PCS, respectively), 100-point Single Assessment Numeric Evaluation (SANE) rating, and 100-point visual analog scale (VAS) for pain and for patient satisfaction. We performed regression models for all outcome variables across all 5 years of follow-up and included the following predictor variables: treatment type (operative vs nonoperative), sex, age, symptom duration, smoking status, diabetes status, injury side, and obesity status.

Results:

A total of 595 patients were included. Longitudinal mixed-effects regression revealed that patients who received operative treatment did better across time on all outcomes. Women (n = 242; 40.7%) did not fare as well as did men on the ASES, WORC, or VR-12 PCS. Older patients tended to improve less on the VR-12 PCS and more on the VR12-MCS. Patients with longer symptom duration at baseline had better scores across time on the ASES, WORC, VAS for pain, and SANE. Current or recent smokers and patients with diabetes tended to have lower scores on all measures across time. For changes in scores from baseline, patients in the operative group improved to a larger degree out to 3 years compared with those in the nonoperative group.

Conclusion:

Patients with RCTs tended to improve regardless of whether they received operative or nonoperative treatment, but patients who underwent operative treatment improved faster. There appear to be several predictors of improved and worsened outcomes for patients with RCTs undergoing operative or nonoperative treatment.

Predictors of Cognitive Behavioral Therapy for Insomnia (CBTi) Outcomes in Active-Duty U.S. Army Personnel

Cognitive behavioral therapy for insomnia (CBTi) is well established as the first-line treatment for the management of chronic insomnia. Identifying predictors of response to CBTi should enable the field to efficiently utilize resources to treat those who are likely to respond and to personalize treatment approaches to optimize outcomes for those who are less likely to respond to traditional CBTi. Although a range of studies have been conducted, no clear pattern of predictors of response to CBTi has emerged. The purpose of this study was to examine the impact and relative importance of a comprehensive group of pretreatment predictors of insomnia outcomes in 99 active-duty service members who received in-person CBTi in a randomized clinical trial. Results indicated that higher levels of baseline insomnia severity and total sleep time predicted greater improvements on the Insomnia Severity Index (ISI) following treatment. Higher depression symptoms and a history of head injury predicted a worse response to treatment (i.e., smaller improvements on the ISI). Clinically meaningful improvements, as measured by the reliable change index (RCI), were found in 59% of the sample. Over and above baseline insomnia severity, only depressive symptoms predicted this outcome. Future studies should examine if modifications to CBTi based on these predictors of response can improve outcomes.

Health care insecurity in the underserved: Effect of a charitable pharmacy model

OBJECTIVES

The objectives of this study were to assess how a charitable pharmacy model affects patient perception of health care insecurity, physical and emotional functioning, and medication access in an underserved population.

METHODS

New patients presenting for medication at their initial pharmacy visit at Charitable Pharmacy of Central Ohio were screened for eligibility during a 12-week enrollment period. Participants completed a baseline survey containing the Health Care Insecurity Measure (HCIM), Veterans RAND 12-Item Health Survey (VR-12), and medication access questions. The follow-up survey, which contained the HCIM and VR-12 only, was administered during a pharmacy visit at least 14 days after the patient's initial visit. Survey data were analyzed with the use of descriptive statistics.

RESULTS

A total of 105 patients met eligibility criteria, and 17 patients declined to participate. Of the 88 remaining participants, 33 (38%) completed the study (both baseline and follow-up survey). Of the 33 participants who completed the study, there was a statistically significant decrease from the baseline health care insecurity score (23.2 ± 11.1) to the follow-up score (17.9 ± 8.5; P = 0.0031).

CONCLUSION

This study demonstrated that pharmacists working in a charitable pharmacy can have a positive impact on the sense of security patients feel about their health care and can better understand their medication-related needs.

Better with age? A comparison of geriatric and non-geriatric trauma patients' psychological outcomes 6 months post-injury

This is the first study to compare both physical and psychological outcomes in geriatric and non-geriatric patients (n = 268) at baseline and 6 months post-trauma. Demographic, clinical, and psychological data, including screens for alcohol use, depressive symptoms, and post-traumatic stress symptoms (PTSS) were collected from 67 geriatric patients (70.7 ± 8.0 years) and 201 non-geriatric patients (40.2 ± 12.8 years) admitted to a Level I trauma center for ≥ 24 h. Geriatric patients were significantly less likely to screen positive for alcohol use at baseline, and depression, PTSS, and alcohol use at follow-up. When not controlling for discharge to rehabilitation or nursing facility, geriatric patients had significantly lower odds of alcohol use at follow-up. There was no significant difference in injury severity, resilience, or pre-trauma psychological status between the two groups. Results indicate that geriatric trauma patients fare better than their younger counterparts at 6 months post-trauma on measures of alcohol use, depression, and PTSS. Screenings and interventions for both age groups could improve psychological health post-trauma, but younger patients may require additional attention.

Comprehensive Lifestyle Modification Intervention to Improve Chronic Disease Risk Factors and Quality of Life in Cancer Survivors

OBJECTIVES

Healthy lifestyle modifications, including weight management, regular physical activity, prudent diet, and stress relief, have been identified as key components of tertiary cancer prevention. In this study, we evaluate the effectiveness of a comprehensive, lifestyle medicine intervention, Lifestyle 180^®, on chronic disease risk factors and quality of life in cancer survivors.

DESIGN

Retrospective subgroup analysis of a clinical program.

SETTINGS/LOCATION

An outpatient medical facility.

SUBJECTS

Lifestyle 180 participants with a diagnosis of past cancer.

INTERVENTION

Sixty-four hours of intensive nutrition, culinary medicine, physical activity, and stress relief practices over a 6-month period, with 9- and 12-month follow-up.

OUTCOME MEASURES

Pre-postanalysis (baseline vs. 12 months) included biometrics: weight, body mass index (BMI), waist circumference, and blood pressure; standard laboratory tests: lipids, C-reactive protein, fasting insulin/glucose, and insulin resistance; and empirically validated questionnaires: perceived stress, depression, and quality of life.

RESULTS

Fifty-eight cancer survivors participated in Lifestyle 180. Average age was 63 years, roughly 75% of participants were female, and the greatest majority had a diagnosis of breast, prostate, or skin cancer. Diagnosis of hyperlipidemia, hypertension, diabetes, and prediabetes presented in 47%, 57%, 22%, and 50% of patients, respectively. Forty-five percent of patients were obese, 24% were overweight, and 16% were depressed. At 12 months, participants lost an average of 14 pounds (-6.6%, p < 0.001) and 2.6 inches off their waist (-5.9%, p < 0.001). BMI decreased significantly by an average of 2.4 kg/m² (-6.8%, p < 0.001). Significant decreases from well-managed baseline levels also occurred in most measured biomarkers (average change: high-density lipoprotein +3.3 mg/dL, p < 0.05; triglycerides -23.0 mg/dL, p < 0.01; C-reactive protein -1.3 mg/L, p < 0.01; fasting insulin -4.2 μU/mL, p < 0.05; and homeostasis model assessment-insulin resistance -1.5, p < 0.01; n = 40). Changes in psychosocial variables included significant improvements in perceived stress (-20%, p < 0.01) and quality of life (+54%, p < 0.001). We were unable to detect a difference in depressive symptoms.

CONCLUSIONS

Cancer survivors participating in a comprehensive intervention could employ the prescribed lifestyle modifications to produce clinically relevant health and quality-of-life benefits. These data support the American Cancer Society (ACS) and American Society of Clinical Oncology (ASCO) recommendations to incorporate healthy lifestyle modifications into long-term cancer survivorship care.

Clinical outcomes of remote asynchronous telerehabilitation are equivalent to traditional therapy following total knee arthroplasty: A randomized control study

Introduction Successful post-operative telerehabilitation following total knee replacement (TKR) has been documented using synchronous (real-time) video. Bandwidth and the need for expensive hardware are cited as barriers to implementation. Web-based asynchronous visual platforms promise to address these problems but have not been evaluated. We performed a randomized control study comparing an asynchronous video-based software platform to in-person outpatient physical therapy visits following TKR. Materials and methods Fifty-one patients were randomized to either the intervention group, using an asynchronous video application on a mobile device, or the traditional group undergoing outpatient physical therapy. Outcome data were collected using validated instruments prior to surgery and at a minimum three-month follow-up. Results Twenty-nine patients completed the study. There were no statistically significant differences in any clinical outcome between groups. The satisfaction with care was equivalent between groups. Overall utilization of hospital-based resources was 60% less than for the traditional group. Discussion We report that clinical outcomes following asynchronous telerehabilitation administered over the web and through a hand-held device were not inferior to those achieved with traditional care. Outpatient resource utilization was lower. Patient satisfaction was high for both groups. The results suggest that asynchronous telerehabilitation may be a more practical alternative to real-time video visits and are clinically equivalent to the in-person care model.

Linking Physical and Mental Health Summary Scores from the Veterans RAND 12-Item Health Survey (VR-12) to the PROMIS(®) Global Health Scale

BACKGROUND

Global health measures represent an attractive option for researchers and clinicians seeking a brief snapshot of a patient's overall perspective on his or her health. Because scores on different global health measures are not comparable, comparative effectiveness research (CER) is challenging.

OBJECTIVE

To establish a common reporting metric so that the physical and mental health scores on the Veterans RAND 12-Item Health Survey (VR-12 (©) ) can be converted into scores on the corresponding Patient Reported Outcomes Measurement Information System (PROMIS(®)) Global Health scores.

DESIGN

Following a single-sample linking design, participants from an Internet panel completed items from the PROMIS Global Health and VR-12 Health Survey. A common metric was created using analyses based on item response theory (IRT), producing score cross-walk tables for the mental and physical health components of each measure. The linking relationships were evaluated by calculating the standard deviation of differences between the observed and linked PROMIS scores and estimating confidence intervals by sample size.

PARTICIPANTS

Participants (N = 2025) were 49 % male and 73 % white; mean age was 46 years.

MAIN MEASURES

Mental and physical health subscales of the PROMIS Global Health and the VR-12. The mean VR-12 physical component and mental component scores were 45.2 and 46.6, respectively; the mean PROMIS physical and mental health scores were 48.3 and 48.5, respectively.

KEY RESULTS

We found evidence that the combined set of VR-12 and PROMIS items were relatively unidimensional and that we could proceed with linking. Linking worked better between the physical health than mental health scores using VR-12 item responses (vs. linking based on algorithmic scores). For each of the cross-walks, users can minimize the impact of linking error with modest increases in sample sizes.

CONCLUSIONS

VR-12 scores can be expressed on the PROMIS Global Health metric to facilitate the evaluation of treatment, including CER. Extending these results to other common measures of global health is encouraged.

Functional Status and Hospital Readmissions Using the Medical Expenditure Panel Survey

BACKGROUND

Hospital readmissions are expensive and they may signal poor quality of care. Whether functional status is related to hospital readmissions using a representative U.S sample remains unexplored .

OBJECTIVE

We aimed to assess the relationship between functional status and all-cause 30-day hospital readmissions using a representative sample of the US population.

DESIGN

This was a retrospective observational study (2003-2011).

PATIENTS

The study included 3,772 patients who completed the SF-12 before being hospitalized. Three hundred and eighteen (8.4%) were readmitted within 30 days after being discharged.

MEASUREMENTS

The Medical Expenditure Panel Survey (MEPS) was employed. Functional status was measured with the Short-Form 12-Item Health Survey Version 2® (SF-12). The probability of being readmitted was estimated using a logistic model controlling for demographic characteristics, comorbid conditions, insurance coverage, physical (PCS) and mental (MCS) summaries of the SF-12, reason for hospitalization, length of hospital stay, region, and residential area.

RESULTS

A one-unit difference in PCS reduced the odds of readmission by 2% (odds ratio 0.98 [95% CI, 0.97 to 0.99]; p < 0.001), which implies an 18% reduction in the odds of readmissions for a ten-unit difference (one standard deviation) in PCS. The c-statistic of the model was 0.72.

CONCLUSION

Baseline physical function is associated with hospital readmissions. The SF-12 improves the ability to identify patients at high risk of hospital readmission.

Patterns of initiation of second generation antipsychotics for bipolar disorder: a month-by-month analysis of provider behavior

BACKGROUND

Several second generation antipsychotics (SGAs) received FDA approval for bipolar disorder in the 2000s. Although efficacious, they have been costly and may cause significant side effects. Little is known about the factors associated with prescribers' decisions to initiate SGA prescriptions for this condition.

METHODS

We gathered administrative data from the Department of Veterans Affairs on 170,713 patients with bipolar disorder between fiscal years 2003-2010. Patients without a prior history of taking SGAs were considered eligible for SGA initiation during the study (n =126,556). Generalized estimating equations identified demographic, clinical, and comorbidity variables associated with initiation of an SGA prescription on a month-by-month basis.

RESULTS

While the number of patients with bipolar disorder using SGAs nearly doubled between 2003 and 2010, analyses controlling for patient characteristics and the rise in the bipolar population revealed a 1.2% annual decline in SGA initiation during this period. Most medical comorbidities were only modestly associated with overall SGA initiation, although significant differences emerged among individual SGAs. Several markers of patient severity predicted SGA initiation, including previous hospitalizations, psychotic features, and a history of other antimanic prescriptions; these severity markers became less firmly linked to SGA initiation over time. Providers in the South were somewhat more likely to initiate SGA treatment.

CONCLUSIONS

The number of veterans with bipolar disorder prescribed SGAs is rising steadily, but this increase appears primarily driven by a corresponding increase in the bipolar population. Month-by-month analyses revealed that higher illness severity predicted SGA initiation, but that this association may be weakening over time.

The association of PTSD with physical and mental health functioning and disability (VA Cooperative Study #569: the course and consequences of posttraumatic stress disorder in Vietnam-era veteran twins)

PURPOSE

To assess the relationship of posttraumatic stress disorder (PTSD) with health functioning and disability in Vietnam-era Veterans.

METHODS

A cross-sectional study of functioning and disability in male Vietnam-era Veteran twins. PTSD was measured by the Composite International Diagnostic Interview; health functioning and disability were assessed using the Veterans RAND 36-Item Health Survey (VR-36) and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). All data collection took place between 2010 and 2012.

RESULTS

Average age of the 5,574 participating Veterans (2,102 Vietnam theater and 3,472 non-theater) was 61.0 years. Veterans with PTSD had poorer health functioning across all domains of VR-36 and increased disability for all subscales of WHODAS 2.0 (all p < .001) compared with Veterans without PTSD. Veterans with PTSD were in poorer overall health on the VR-36 physical composite summary (PCS) (effect size = 0.31 in theater and 0.47 in non-theater Veterans; p < .001 for both) and mental composite summary (MCS) (effect size = 0.99 in theater and 0.78 in non-theater Veterans; p < .001 for both) and had increased disability on the WHODAS 2.0 summary score (effect size = 1.02 in theater and 0.96 in non-theater Veterans; p < .001 for both). Combat exposure, independent of PTSD status, was associated with lower PCS and MCS scores and increased disability (all p < .05, for trend). Within-pair analyses in twins discordant for PTSD produced consistent findings.

CONCLUSIONS

Vietnam-era Veterans with PTSD have diminished functioning and increased disability. The poor functional status of aging combat-exposed Veterans is of particular concern.

Off-label use of second generation antipsychotics for post-traumatic stress disorder in the Department of Veterans Affairs: time trends and sociodemographic, comorbidity, and regional correlates

PURPOSE

Second generation antipsychotics (SGAs) are widely used for post-traumatic stress disorder (PTSD), although without strong evidence base. With substantial numbers of veterans returning from Iraq/Afghanistan conflicts with PTSD, it is important to characterize the extent of SGA use and identify associated factors.

METHODS

We determined time trends and patient characteristics associated with the use of SGAs in veterans with PTSD, without comorbid schizophrenia or bipolar disorders, using the Department of Veterans Affairs national administrative data 2003-2010.

RESULTS

Among 732,085 veterans with PTSD, 27.6% received an intentional trial of an SGA in 2003-2010. The annual number treated with SGAs almost doubled (45,268 to 84,197, p < 0.001), while prescribing rates decreased (28.6% to 21.5%, p < 0.001). In multivariate analyses, African Americans (odds ratio (OR) = 1.07, 95%confidence interval (CI) = 1.06-1.09) and Hispanics (OR = 1.13, 95%CI = 1.10-1.17) were more likely to receive SGAs than Whites. Strongest clinical associations were with prior diagnosis of depression (OR = 1.96; 95%CI = 1.94-1.99), substance use disorders (OR = 1.86; 95%CI = 1.84-1.88), and other anxiety disorders (OR = 1.27; 95%CI = 1.26-1.29) (all p - < 0.0001) as well as cardiovascular risk factors. Veterans previously deployed to Iraq/Afghanistan had lower likelihood of SGA receipt. Substantial regional differences were demonstrated (South > Northeast; Midwest and West < Northeast; p < 0.0001); regional administrative units (veterans integrated service networks) contributed minimally to regional differences.

CONCLUSIONS

Post-traumatic stress disorder population growth is driving substantial increases in SGA use. Decreasing rates of the Department of Veterans Affairs prescribing may be due to integrated system-wide mechanisms (e.g., national practice guidelines), although regional variations remain prominent. These analyses provide foundational steps for identifying modifiable provider-level and organization-level determinants of SGA prescription in this growing population.

Monitoring outcomes for the Medicare Advantage program: methods and application of the VR-12 for evaluation of plans

The Veterans RAND 12-Item Health Survey (VR-12) is one of the major patient-reported outcomes for ranking the Medicare Advantage (MA) plans in the Health Outcomes Survey (HOS). Approaches for scoring physical and mental health are given using contemporary norms and regression estimators. A new metric approach for the VR-12 called the "VR-6D" is presented with case-mix adjustments for monitoring plans that combine utilities and mortality. Results show that the models for ranking health outcomes of the plans are robust and credible. Future directions include the use of utilities for evaluating and ranking of MA plans.

The American Burn Association/Shriners Hospitals for Children Burn Outcomes Program: a progress report at 15 years

The American Burn Association and the Shriners Hospitals for Children Outcomes Program has been in development for more than 15 years. Many of the tools and important findings are described in this special issue of The Journal of Trauma. This unique program in outcomes research introduces a model for outcome assessments from the patient-centered perspective with a cohort of 1,140 children with burn injury after hospitalization for up to 4 years. The findings represent a fundamental contribution to the field of burn care for monitoring outcomes from the perspective of the parent or child/adolescent. The Multi-Center Benchmarking Study of four burn centers serve as a model for collecting empiric scientific data on the variation and the expected trajectories of recovery in the most important domains of patient outcomes and can inform clinical decisions and the conduct of health service research. The dramatic progress in survival of children with severe burn injury and other advances in burn management can now move into a new phase of understanding the most cost-effective components of this care.

The risk of incident coronary heart disease among veterans with and without HIV and hepatitis C

BACKGROUND

Whether hepatitis C virus (HCV) confers additional coronary heart disease (CHD) risk among human immunodeficiency virus (HIV) infected individuals is unclear. Without appropriate adjustment for antiretroviral therapy, CD4 count, and HIV-1 RNA and substantially different mortality rates among those with and without HIV and HCV infection, the association between HIV, HCV, and CHD may be obscured.

METHODS AND RESULTS

We analyzed data on 8579 participants (28% HIV+, 9% HIV+HCV+) from the Veterans Aging Cohort Study Virtual Cohort who participated in the 1999 Large Health Study of Veteran Enrollees. We analyzed data collected on HIV and HCV status, risk factors for and the incidence of CHD, and mortality from January 2000 to July 2007. We compared models to assess CHD risk when death was treated as a censoring event and as a competing risk. During the median 7.3 years of follow-up, there were 194 CHD events and 1186 deaths. Compared with HIV-HCV- Veterans, HIV+HCV+ Veterans had a significantly higher risk of CHD regardless of whether death was adjusted for as a censoring event (adjusted hazard ratio, 2.03; 95% confidence interval, 1.28 to 3.21) or a competing risk (adjusted HR, 2.45; 95% confidence interval, 1.83 to 3.27 respectively). Compared with HIV+HCV- Veterans, HIV+HCV+ Veterans also had a significantly higher adjusted risk of CHD regardless of whether death was treated as a censored event (adjusted hazard ratio, 1.93; 95% confidence interval, 1.02 to 3.62) or a competing risk (adjusted hazard ratio, 1.46; 95% confidence interval, 1.03 to 2.07).

CONCLUSIONS

HIV+HCV+ Veterans have an increased risk of CHD compared with HIV+HCV- and HIV-HCV- Veterans.

Patient-provider language concordance and colorectal cancer screening

BACKGROUND AND OBJECTIVE

Patient-provider language barriers may play a role in health-care disparities, including obtaining colorectal cancer (CRC) screening. Professional interpreters and language-concordant providers may mitigate these disparities. DESIGN, SUBJECTS, AND MAIN MEASURES: We performed a retrospective cohort study of individuals age 50 years and older who were categorized as English-Concordant (spoke English at home, n = 21,594); Other Language-Concordant (did not speak English at home but someone at their provider's office spoke their language, n = 1,463); or Other Language-Discordant (did not speak English at home and no one at their provider's spoke their language, n = 240). Multivariate logistic regression assessed the association of language concordance with colorectal cancer screening.

KEY RESULTS

Compared to English speakers, non-English speakers had lower use of colorectal cancer screening (30.7% vs 50.8%; OR, 0.63; 95% CI, 0.51-0.76). Compared to the English-Concordant group, the Language-Discordant group had similar screening (adjusted OR, 0.84; 95% CI, 0.58-1.21), while the Language-Concordant group had lower screening (adjusted OR, 0.57; 95% CI, 0.46-0.71).

CONCLUSIONS

Rates of CRC screening are lower in individuals who do not speak English at home compared to those who do. However, the Language-Discordant cohort had similar rates to those with English concordance, while the Language-Concordant cohort had lower rates of CRC screening. This may be due to unmeasured differences among the cohorts in patient, provider, and health care system characteristics. These results suggest that providers should especially promote the importance of CRC screening to non-English speaking patients, but that language barriers do not fully account for CRC screening rate disparities in these populations.

Dissemination of Methods and Results From the Veterans Health Study

The Veterans Health Study (VHS) followed a cohort of patients receiving ambulatory care in the Veterans Affairs healthcare system for up to 5 years. One of the principal aims of this study was to develop a library of methodologies including general and disease-specific health outcome questionnaires for use in monitoring the quality of healthcare and for research purposes. The cornerstone for this work is the Veterans RAND 36 and 12 Item Health Surveys (VR-36 and VR-12), a general measure developed in the VHS for measuring the physical and psychologic well-being of the patient. A comprehensive set of disease-specific assessments has also been developed as part of this study for the purposes of monitoring specific chronic conditions more commonly seen in routine ambulatory care settings. Since 1996, more than 2 million questionnaires have been administered in the VA for quality monitoring purposes, using the VR-36 and VR-12. Research studies that have used these batteries span randomized clinical trials in the VA cooperative studies program and clinical effectiveness research. Health assessments using VHS batteries are being disseminated for widespread use outside the VA. Chief among the assessments used is the VR-12, which has recently been included in the 2006 Health Plan Employer Data and Information Set (HEDIS) as part of the Medicare Health Outcomes Survey for monitoring the Medicare Advantage Program. The methods and batteries developed in the VHS are in the public domain and provide a framework for future patient monitoring using standard measures of health.