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Vanneman ME, Rosen AK, Wagner TH, Shwartz M, Gordon SH, Greenberg G, Zheng T, Cook J, Beilstein-Wedel E, Greene T, Kelley AT. Differences Between VHA-Delivered and VHA-Purchased Behavioral Health Care in Service and Patient Characteristics. Psychiatr Serv 2023; 74:148-157. [PMID: 36039555 PMCID: PMC10069743 DOI: 10.1176/appi.ps.202100730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Federal legislation has expanded Veterans Health Administration (VHA) enrollees' access to VHA-purchased "community care." This study examined differences in the amount and type of behavioral health care delivered in VHA and purchased in the community, along with patient characteristics and area supply and demand factors. METHODS This retrospective cross-sectional study examined data for 204,094 VHA enrollees with 448,648 inpatient behavioral health stays and 3,467,010 enrollees with 55,043,607 outpatient behavioral health visits from fiscal years 2016 to 2019. Standardized mean differences (SMDs) were calculated for patient and provider characteristics at the outpatient-visit level for VHA and community care. Linear probability models assessed the association between severity of behavioral health condition and site of care. RESULTS Twenty percent of inpatient stays were purchased through community care, with severe behavioral health conditions more likely to be treated in VHA inpatient care. In the outpatient setting, community care accounted for 3% of behavioral health care visits, with increasing use over time. For outpatient care, veterans receiving community care were more likely than those receiving VHA care to see clinicians with fewer years of training (SMD=1.06). CONCLUSIONS With a large portion of inpatient behavioral health care occurring in the community and increased use of outpatient behavioral health care with less highly trained community providers, coordination between VHA and the community is essential to provide appropriate inpatient follow-up care and address outpatient needs. This is especially critical given VHA's expertise in providing behavioral health care to veterans and its legislative responsibility to ensure integrated care.
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Affiliation(s)
- Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Amy K Rosen
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Todd H Wagner
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Michael Shwartz
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Sarah H Gordon
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Greg Greenberg
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Tianyu Zheng
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - James Cook
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Erin Beilstein-Wedel
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - Tom Greene
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
| | - A Taylor Kelley
- Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs (VA) Salt Lake City Health Care System (Vanneman, Zheng, Kelley), and Department of Internal Medicine (Vanneman, Greene, Kelley) and Department of Population Health Sciences (Zheng, Greene), University of Utah School of Medicine, Salt Lake City; Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System (Rosen, Shwartz, Beilstein-Wedel), and Department of Surgery, Boston University School of Medicine, Boston (Rosen); Department of Operations and Technology Management, Boston University Questrom School of Business, Boston (Shwartz); Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, and Department of Surgery, Stanford University School of Medicine, Stanford, California (Wagner); Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, and Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston (Gordon); Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Greenberg); Health Catalyst, Salt Lake City (Cook)
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Leung LB, Ziobrowski HN, Puac-Polanco V, Bossarte RM, Bryant C, Keusch J, Liu H, Pigeon WR, Oslin DW, Post EP, Zaslavsky AM, Zubizarreta JR, Kessler RC. Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration. J Gen Intern Med 2022; 37:3235-3241. [PMID: 34613577 PMCID: PMC8493943 DOI: 10.1007/s11606-021-07136-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Physician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes. OBJECTIVE To examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment. DESIGN Patient self-report surveys at treatment initiation linked to medical records. SETTING Veterans Health Administration (VA) clinics nationally, 2018-2020. PARTICIPANTS A total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White) MAIN MEASURES: Patient self-reported preferences for medication and psychotherapy on 0-10 self-anchoring visual analog scales (0="completely unwilling"; 10="completely willing"). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables. KEY RESULTS More patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ21=175.3, p<0.001). A total of 32.1% of patients who preferred (7-10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5-24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0-3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4-7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence. CONCLUSIONS Mismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.
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Affiliation(s)
- Lucinda B Leung
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Division of General Internal Medicine, and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
| | | | - Victor Puac-Polanco
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Robert M Bossarte
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV, USA.,Center of Excellence for Suicide Prevention, Canandaigua VAMC, Canandaigua, NY, USA
| | - Corey Bryant
- VA Ann Arbor, Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Janelle Keusch
- VA Ann Arbor, Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Howard Liu
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.,Center of Excellence for Suicide Prevention, Canandaigua VAMC, Canandaigua, NY, USA
| | - Wilfred R Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VAMC, Canandaigua, NY, USA.,Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - David W Oslin
- Cpl Michael J Crescenz VA Medical Center, VISN 4 Mental Illness Research Education and Clinical Center, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward P Post
- VA Ann Arbor, Center for Clinical Management Research, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Jose R Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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3
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Cai S, Bakerjian D, Bang H, Mahajan SM, Ota D, Kiratli J. Data acquisition process for VA and non-VA emergency department and hospital utilization by veterans with spinal cord injury and disorders in California using VA and state data. J Spinal Cord Med 2022; 45:254-261. [PMID: 32543354 PMCID: PMC8986188 DOI: 10.1080/10790268.2020.1773028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Context: To identify VA and non-VA Emergency Department (ED) and hospital utilization by veterans with spinal cord injury and disorders (SCI/D) in California.Design: Retrospective cohort study.Setting: VA and Office of Statewide Health Planning and Development (OSHPD) in California.Participants: Total 300 veterans admitted to the study VA SCI/D Center for initial rehabilitations from 01/01/1999 through 08/17/2014.Interventions: N/A.Outcome Measures: Individual-level ED visits and hospitalizations during the first-year post-rehabilitation.Results: Among 145 veterans for whom ED visit data available, 168 ED visits were identified: 94 (55.2%) at non-VA EDs and 74 (44.8%) at the VA ED, with a mean of 1.16 (±2.21) ED visit/person. Seventy-seven (53.1%) veterans did not visit any ED. Of 68 (46.9%) veterans with ≥ one ED visit, 20 (29.4%) visited the VA ED only, 34 (50.0%) visited non-VA EDs only, and 14 (20.6%) visited both VA and non-VA EDs. Among 212 Veterans for whom hospitalization data were available, 247 hospitalizations were identified: 82 (33.2%) non-VA hospitalizations and 165 (66.8%) VA hospitalization with a mean of 1.17 (±1.62) hospitalizations/person. One hundred-seven (50.5%) veterans had no hospitalizations. Of 105 veterans with ≥ one hospitalization, 58 (55.2%) were hospitalized at the study VA hospital, 15 (14.3%) at a non-VA hospital, and 32 (30.5%) at both VA and non-VA hospitals.Conclusion: Non-VA ED and hospital usage among veterans with SCI/D occurred frequently. The acquisition of non-VA healthcare data managed by state agencies is vital to accurately and comprehensively evaluate needs and utilization rates among veteran populations.
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Affiliation(s)
- Sujuan Cai
- Department of the Veterans Affairs, Palo Alto Health Care System, Palo Alto, California, USA,The Betty Irene Moore School of Nursing, University of California at Davis, Sacramento, California, USA,Correspondence to: Sujuan Cai, 3801 Miranda Ave. Building 7, VA Palo Alto Health Care System, Spinal Cord Injury/Disorder, Palo Alto, California94304, USA; Ph: 408-832-4205.
| | - Debra Bakerjian
- The Betty Irene Moore School of Nursing, University of California at Davis, Sacramento, California, USA
| | - Heejung Bang
- Division of Biostatistics, Department of Public Health Sciences, University of California at Davis, Davis, California, USA
| | - Satish M. Mahajan
- Department of the Veterans Affairs, Palo Alto Health Care System, Palo Alto, California, USA
| | - Doug Ota
- Department of the Veterans Affairs, Palo Alto Health Care System, Palo Alto, California, USA
| | - Jenny Kiratli
- Department of the Veterans Affairs, Palo Alto Health Care System, Palo Alto, California, USA
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Sjoberg H, Liu W, Rohs C, Ayele RA, McCreight M, Mayberry A, Battaglia C. Optimizing care coordination to address social determinants of health needs for dual-use veterans. BMC Health Serv Res 2022; 22:59. [PMID: 35022053 PMCID: PMC8754195 DOI: 10.1186/s12913-021-07408-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 12/13/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Veterans increasingly utilize both the Veteran's Health Administration (VA) and non-VA hospitals (dual-users). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health (SDOH). We developed a Veteran-informed social worker-led Advanced Care Coordination (ACC) program to decrease fragmented care and provide longitudinal care coordination addressing SDOH for dual-users accessing non-VA emergency departments (EDs) in two communities. METHODS ACC had four core components: 1. Notification from non-VA ED providers of Veterans' ED visit; 2. ACC social worker completed a comprehensive assessment with the Veteran to identify SDOH needs; 3. Clinical intervention addressing SDOH up to 90 days post-ED discharge; and 4. Warm hand-off to Veteran's VA primary care team. Data was documented in our program database. We performed propensity matching between a control group and ACC participants between 4/10/2018 - 4/1/2020 (N- = 161). A joint survival model using Markov Chain Monte Carlo technique was employed for 30-day outcomes. We performed Difference-In-Difference analyses on number of ED visits, admissions, and primary care physician (PCP) visits 120-day pre/post discharge. RESULTS When compared to a matched control group ACC had significantly lower risk of 30-day ED visits (Hazard Ratio (HR) = 0.61, 95% Confidence Interval (CI) = (0.42, 0.92)) and a higher probability of PCP visits at 13-30 days post-ED visit (HR = 1.5, 95% CI = (1.01, 2.22)). Veterans enrolled in ACC were connected to VA PCP visits (50%), VA benefits (19%), home health care (10%), mental health and substance use treatment (7%), transportation (7%), financial assistance (5%), and homeless resources (2%). CONCLUSION We developed and implemented a program addressing dual-users' SDOH needs post non-VA ED discharge. Social workers connected dual-users to needed follow-up care and resources which reduced fragmentation and adverse outcomes.
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Affiliation(s)
- Heidi Sjoberg
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.
| | - Wenhui Liu
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Carly Rohs
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Roman A Ayele
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
- Anschutz Medical Campus Colorado School of Public, University of Colorado, 13001 E. 17th Pl, Aurora, CO, 80045, USA
| | - Marina McCreight
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Ashlea Mayberry
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Catherine Battaglia
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
- Anschutz Medical Campus Colorado School of Public, University of Colorado, 13001 E. 17th Pl, Aurora, CO, 80045, USA
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Koufacos NS, May J, Judon KM, Franzosa E, Dixon BE, Schubert CC, Schwartzkopf AL, Guerrero VM, Traylor M, Boockvar KS. Improving Patient Activation among Older Veterans: Results from a Social Worker-Led Care Transitions Intervention. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2022; 65:63-77. [PMID: 34053407 PMCID: PMC8982469 DOI: 10.1080/01634372.2021.1932003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/14/2021] [Accepted: 05/16/2021] [Indexed: 06/12/2023]
Abstract
Older veterans enrolled in the Veterans Health Administration (VHA) often use both VHA and non-VHA providers for their care. This dual use, especially around an inpatient visit, can lead to fragmented care during the time of transition post-discharge. Interventions that target patient activation may be valuable ways to help veterans manage complex medication regimens and care plans from multiple providers. The Care Transitions Intervention (CTI) is an evidence-based model that helps older adults gain confidence and skills to achieve their health goals post-discharge. Our study examined the impact of CTI upon patient activation for veterans discharged from non-VHA hospitals. In total, 158 interventions were conducted for 87 veterans. From baseline to follow-up there was a significant 1.7-point increase in patient activation scores, from 5.4 to 7.1. This association was only found among those who completed the intervention. The most common barriers to completion were difficulty reaching the veteran by phone, patient declining the intervention, and rehospitalization during the 30 days post-discharge. Care transitions guided by social workers may be a promising way to improve patient activation. However, future research and practice should address barriers to completion and examine the impact of increased patient activation on health outcomes.
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Affiliation(s)
- Nicholas S Koufacos
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Justine May
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Kimberly M Judon
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Emily Franzosa
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian E Dixon
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
- Department of Epidemiology, Indiana University, Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Center for Biomedical Informatics, Regenstrief Institute, Center for Biomedical Informatics, Indianapolis, Indiana, USA
| | - Cathy C Schubert
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
- Department of Medicine, Indiana University, School of Medicine, Indianapolis, Indiana, USA
| | - Ashley L Schwartzkopf
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Vivian M Guerrero
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Morgan Traylor
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Kenneth S Boockvar
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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6
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Howren MB, Kazmerzak D, Pruin S, Barbaris W, Abrams TE. Behavioral Health Screening and Care Coordination for Rural Veterans in a Federally Qualified Health Center. J Behav Health Serv Res 2021; 49:50-60. [PMID: 34036516 PMCID: PMC8148401 DOI: 10.1007/s11414-021-09758-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/27/2022]
Abstract
Many rural veterans receive care in community settings but could benefit from VA services for certain needs, presenting an opportunity for coordination across systems. This article details the Collaborative Systems of Care (CSC) program, a novel, nurse-led care coordination program identifying and connecting veterans presenting for care in a Federally Qualified Health Center to VA behavioral health and other services based upon the veteran’s preferences and eligibility. The CSC program systematically identifies veteran patients, screens for common behavioral health issues, explores VA eligibility for interested veterans, and facilitates coordination with VA to improve healthcare access. While the present program focuses on behavioral health, there is a unique emphasis on assisting veterans with the eligibility and enrollment process and coordinating additional care tailored to the patient. As VA expands its presence in community care, opportunities for VA-community care coordination will increase, making the development and implementation of such interventions important.
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Affiliation(s)
- M Bryant Howren
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Health Care System, Iowa City, IA, USA.
- Department of Behavioral Sciences & Social Medicine, College of Medicine, Florida State University, 1115 W. Call Street, Tallahassee, FL, 32306, USA.
- Florida Blue Center for Rural Health Research & Policy, College of Medicine, Florida State University, Tallahassee, FL, USA.
- Center for Access Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.
| | | | - Sheryl Pruin
- Community Health Centers of Southeastern Iowa, West Burlington, IA, USA
| | - Wendy Barbaris
- Community Health Centers of Southeastern Iowa, West Burlington, IA, USA
| | - Thad E Abrams
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Health Care System, Iowa City, IA, USA
- Center for Access Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- Carver College of Medicine, The University of Iowa, Iowa City, IA, USA
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7
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Vest BM, Kulak JA, Homish DL, Hoopsick RA, Homish GG. Mental and physical health factors related to dual use of veterans affairs and non-veterans affairs healthcare among U.S. reserve soldiers. PSYCHOL HEALTH MED 2020; 27:976-986. [PMID: 32997548 DOI: 10.1080/13548506.2020.1828945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This study examined the association between mental and physical health factors and dual use of Veterans' Affairs (VA) and non-VA healthcare among previously deployed male Reserve/National Guard (R/NG) soldiers (N = 214). Participants completed online annual surveys on a range of topics, including validated measures of mental and physical health, as well as questions about past-year healthcare utilization. Multinomial logistic regression models separately examined the association between mental health symptoms (PTSD, anxiety, depression, emotional role limitations), physical health symptoms (bodily pain, physical role limitations), and healthcare use (single use and dual use compared to no use), controlling for geography, trust in the VA, age, and race. Anxiety (aRR: 1.13; 95% Confidence Interval (CI): 1.02, 1.26; p<.05), depression (aRR: 1.23; 95% CI: 1.06, 1.43; p<.01), and PTSD (aRR: 1.05; 95% CI: 1.01, 1.10; p<.05) symptoms were all related to past year dual use of VA and non-VA healthcare, even after controlling for known demographic factors. Bodily pain and emotional and physical role limitations were not related to healthcare outcomes. This suggests that mental health symptoms themselves may be a primary factor driving healthcare use. Further study is needed to examine whether dual use of VA and non-VA healthcare is duplicative or complementary.
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Affiliation(s)
- Bonnie M Vest
- Department of Family Medicine, University at Buffalo, Buffalo, NY, USA
| | - Jessica A Kulak
- Department of Health, Nutrition, & Dietetics, Buffalo State College, Buffalo, NY, USA
| | - D Lynn Homish
- Department of Community Health & Health Behavior, University at Buffalo, Buffalo, NY, USA
| | - Rachel A Hoopsick
- Department of Family Medicine, University at Buffalo, Buffalo, NY, USA.,Department of Community Health & Health Behavior, University at Buffalo, Buffalo, NY, USA
| | - Gregory G Homish
- Department of Community Health & Health Behavior, University at Buffalo, Buffalo, NY, USA
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8
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Miller LB, Sjoberg H, Mayberry A, McCreight MS, Ayele RA, Battaglia C. The advanced care coordination program: a protocol for improving transitions of care for dual-use veterans from community emergency departments back to the Veterans Health Administration (VA) primary care. BMC Health Serv Res 2019; 19:734. [PMID: 31640673 PMCID: PMC6805730 DOI: 10.1186/s12913-019-4582-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Veterans who access both the Veterans Health Administration (VA) and non-VA health care systems require effective care coordination to avoid adverse health care outcomes. These dual-use Veterans have diverse and complex needs. Gaps in transitions of care between VA and non-VA systems are common. The Advanced Care Coordination (ACC) quality improvement program aims to address these gaps by implementing a comprehensive longitudinal care coordination intervention with a focus on Veterans' social determinants of health (SDOH) to facilitate Veterans' transitions of care back to the Eastern Colorado Health Care System (ECHCS) for follow-up care. METHODS The ACC program is an ongoing quality improvement study that will enroll dual-use Veterans after discharge from non-VA emergency department (EDs), and will provide Veterans with social worker-led longitudinal care coordination addressing SDOH and providing linkage to resources. The ACC social worker will complete biopsychosocial assessments to identify Veteran needs, conduct regular in-person and phone visits, and connect Veterans back to their VA care teams. We will identify non-VA EDs in the Denver, Colorado metro area that will provide the most effective partnership based on location and Veteran need. Veterans will be enrolled into the ACC program when they visit one of our selected non-VA EDs without being hospitalized. We will develop a program database to allow for continuous evaluation. Continuing education and outreach including the development of a resource guide, Veteran Care Cards, and program newsletters will generate program buy-in and bridge communication. We will evaluate our program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, supported by the Practical, Robust Implementation and Sustainability Model, Theoretical Domains Framework, and process mapping. DISCUSSION The ACC program will improve care coordination for dual-use Veterans by implementing social-work led longitudinal care coordination addressing Veterans' SDOH. This intervention will provide an essential service for effective care coordination.
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Affiliation(s)
- Lindsay B Miller
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Heidi Sjoberg
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.
| | - Ashlea Mayberry
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Marina S McCreight
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Roman A Ayele
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.,University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, 13001 E. 17th Pl, Aurora, CO, 80045, USA
| | - Catherine Battaglia
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.,University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, 13001 E. 17th Pl, Aurora, CO, 80045, USA
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9
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Taber DJ, Ward R, Axon RN, Walker RJ, Egede LE, Gebregziabher M. The Impact of Dual Health Care System Use for Obtaining Prescription Medications on Nonadherence in Veterans With Type 2 Diabetes. Ann Pharmacother 2019; 53:675-682. [PMID: 30724092 DOI: 10.1177/1060028019828681] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Dual health system use may provide increased access to physicians, medications, and other health care resources but may also increase the complexity and coordination of medication regimens. Thus, it is important to elucidate the impact of dual use on medication adherence. OBJECTIVE The objective of this study was to evaluate the impact on medication adherence for veterans with dual health care system use (VA and Medicare) when obtaining prescription antihyperglycemic medications to treat diabetes. METHODS This was a longitudinal cohort study using VA and Medicare data from 2006 to 2010. Medication adherence was estimated by calculating annualized drug class-level proportion of days covered (PDC), where PDC >80% was considered adherent. Generalized linear models were used for estimations, accounting for correlation over time. RESULTS In total, 254 267 veterans with diabetes were included, with 71 057 (27.9%) defined as pharmacy system dual users. Mean age was 77.5 years, and nearly all had multiple comorbidities (mean count 10.2). During follow-up, 75% of VA-only users were deemed adherent to diabetes prescriptions, compared with 63% of dual users. In adjusted models, dual prescription benefit use from VA/Medicare was associated with 39% lower odds of medication adherence (odds ratio [OR] = 0.61; 95% CI = 0.60-0.61). Medication adherence significantly worsened with each additional diabetes medication (OR = 0.65; 95% CI = 0.64-0.65) and significantly decreased over time (OR = 0.95 per year; 95% CI = 0.95-0.96). Conclusion and Relevance: These data suggest that veterans utilizing VA and Medicare to obtain diabetes prescriptions are significantly less likely to be adherent.
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Affiliation(s)
- David J Taber
- 1 Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA.,2 Medical University of South Carolina, Charleston, SC, USA
| | - Ralph Ward
- 1 Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA
| | - R Neal Axon
- 1 Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA
| | | | | | - Mulugeta Gebregziabher
- 1 Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA.,2 Medical University of South Carolina, Charleston, SC, USA
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10
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Nelson RE, Ma J, Crook J, Knippenberg K, Nyman H, Paul D, Esker S, LaFleur J. Health Care Costs in a Cohort of HIV-Infected U.S. Veterans Receiving Regimens Containing Tenofovir Disoproxil Fumarate/Emtricitabine. J Manag Care Spec Pharm 2018; 24:1052-1066. [PMID: 30247099 PMCID: PMC10397780 DOI: 10.18553/jmcp.2018.24.10.1052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Tenofovir disoproxil fumarate (TDF), a key component in many human immunodeficiency virus (HIV) treatment regimens, is associated with increased renal and bone toxicities. The contributions of such toxicities to treatment costs, as well as the relative differences in treatment costs for various TDF/emtricitabine (FTC) regimens, remains unexplored. OBJECTIVE To estimate and compare mean overall and renal- and bone-specific costs, including total, inpatient, outpatient, and pharmacy costs in patients treated with TDF/FTC+efavirenz (EFV) compared with several non-EFV-containing TDF/FTC regimens. METHODS We conducted a national cohort study of treatment-naive HIV-infected U.S. veterans who initiated treatment from 2003 to 2015 with TDF/FTC in combination with EFV, elvitegravir/cobicistat, rilpivirine, or ritonavir-boosted protease inhibitors (atazanavir, darunavir, or lopinavir). Outcomes of interest were quarterly total, inpatient, outpatient, and pharmacy costs using data from the Veterans Health Administration (VHA) electronic medical record and Managerial Cost Accounting System (an activity-based accounting system that allocates VHA expenditures to patient encounters). We controlled for measured confounders using inverse probability of treatment (IPT) weights and assessed differences using standardized mean differences (SMDs). For comparisons where SMDs exceeded 0.1 after IPT weighting, we used the more conservative matching weights in sensitivity analyses. For hypothesis testing, we compared IPT-adjusted differences in quarterly costs between treatment groups using Mann-Whitney U-tests and generalized estimating equation (GEE) regression models. RESULTS Of 33,048 HIV-positive veterans, 7,222 met eligibility criteria, including 4,172 TDF/FTC + EFV recipients; mean (SD) age of the cohort was 50.0 (10.0) years; 96.7% were male; 60.1% were black; and 30.1% were white. Quarterly periods of exposure to EFV-containing regimens were 22,499 and of exposure to non-EFV-containing regimens were 11,633. After IPT weighting, absolute SMDs were < 0.1 except for a few covariates in the rilpivirine comparison. The per-patient adjusted mean total quarterly costs were $7,145 for EFV versus $8,726 for non-EFV (P < 0.001; Mann-Whitney U-test) and the per-patient adjusted mean difference in total quarterly costs was $1,419 lower for EFV versus all non-EFV combined (P < 0.001; GEE model). Corresponding values for outpatient costs ($2,656 vs. $2,942; P < 0.001; difference, -$254; P = 0.001), inpatient costs ($2,009 vs. $2,614; P < 0.001), radiology costs ($213 vs. $276; P < 0.001), and pharmacy costs ($2,480 vs. $3,170; P < 0.001; difference, -$600; P < 0.001) were all lower for EFV versus all non-EFV combined. Findings based on matching weights were qualitatively similar. Contributions of renal and bone costs to the total costs of treatment were very small, ranging between $52 and $94 per patient per quarter for renal outcomes and between $6 and $114 for bone outcomes. CONCLUSIONS Among 7,222 HIV-treated veterans over an average follow-up of 1.2 years per patient, those patients receiving TDF/FTC + EFV had lower overall health care costs compared with those receiving non-EFV regimens. DISCLOSURES This study was funded by Bristol-Myers Squibb. Nelson, Ma, Crook, Knippenberg, Nyman, and LaFleur are employees of the University of Utah, which received a grant from Bristol-Myers Squibb to conduct this study. Nyman also discloses honoraria for consulting from Otsuka and for writing a book chapter from Fresenius. La Fleur reports advisory board and consulting fees from Bristol-Myers Squibb outside of this study. Paul and Esker are employees of, and own stock in, Bristol-Myers Squibb.
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Affiliation(s)
- Richard E Nelson
- 1 Salt Lake City Health Care System, and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Junjie Ma
- 2 Salt Lake City Health Care System, and Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City
| | - Jacob Crook
- 1 Salt Lake City Health Care System, and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Kristin Knippenberg
- 2 Salt Lake City Health Care System, and Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City
| | - Heather Nyman
- 3 Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City
| | - Damemarie Paul
- 4 Research and Development, Bristol-Myers Squibb, Plainsboro, New Jersey
| | - Stephen Esker
- 4 Research and Development, Bristol-Myers Squibb, Plainsboro, New Jersey
| | - Joanne LaFleur
- 2 Salt Lake City Health Care System, and Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City
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11
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Pope CA, Davis BH, Wine L, Nemeth LS, Haddock KS, Hartney T, Axon RN. Perceptions of U.S. Veterans Affairs and community healthcare providers regarding cross-system care for heart failure. Chronic Illn 2018; 14:283-296. [PMID: 28906129 DOI: 10.1177/1742395317729887] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study explores perceptions of US Veterans Affairs (VA) and non-VA healthcare providers caring for Veterans with heart failure (HF) regarding Veteran knowledge and motivations for dual use, provider roles in recommending and coordinating dual use, systems barriers and facilitators, and suggestions for improving cross-system care. METHODS Twenty VA and 11 non-VA providers participated in semi-structured interviews, which were analyzed using parallel qualitative content and discourse analysis. RESULTS VA and non-VA providers described variable HF knowledge and self-management among Veterans, and both groups described the need for improved education addressing medication adherence, self-care, and management of acute symptoms. Both groups described highly limited roles for providers in shaping choices surrounding dual use. VA and non-VA providers had significantly different perceptions regarding the availability, quality, and effectiveness of VA HF services. Multiple non-VA providers expressed frustration with and difficulty in contacting VA providers, accessing records, and making referrals into the VA system. Suggestions for improved care focused on patient education and care coordination. DISCUSSION Dual healthcare system use for Veterans is increasingly common. Similarities and contrasts in perceptions of VA and non-VA providers are instructive and should be incorporated into future policy and program initiatives.
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Affiliation(s)
- Charlene A Pope
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA.,2 Division General Pediatrics, Department of Pediatrics, College of Medicine, Medical University of South Carolina (MUSC), Charleston, USA
| | - Boyd H Davis
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA.,3 University of North Carolina-Charlotte, Charlotte, NC, USA
| | - Leticia Wine
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA
| | - Lynne S Nemeth
- 4 College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - K Sue Haddock
- 5 William J.B. Dorn VA Medical Center, Columbia, SC, USA
| | - Tom Hartney
- 6 Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - R Neal Axon
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA.,7 Department of Internal Medicine, College of Medicine, Medical University of South Carolina (MUSC), Charleston, SC, USA
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12
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Axon RN, Gebregziabher M, Everett CJ, Heidenreich P, Hunt KJ. Dual Healthcare System Use During Episodes of Acute Care Heart Failure Associated With Higher Healthcare Utilization and Mortality Risk. J Am Heart Assoc 2018; 7:e009054. [PMID: 30371248 PMCID: PMC6201461 DOI: 10.1161/jaha.118.009054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/11/2018] [Indexed: 01/04/2023]
Abstract
Background Individuals receiving cross-system care (dual users) have higher rates of healthcare utilization and worse outcomes for heart failure ( HF ) and other conditions. Individuals can be dual users or single-system users at different times, though, and little is known about utilization and mortality within discrete episodes of care. Methods and Results A retrospective cohort of 3439 patients with 5231 discrete episodes of HF exacerbation were identified between 2007 and 2011. Episodes encompassed the period from 2 weeks before an initial HF emergency department ( ED ) visit or hospitalization, included any acute care visits within 30 days after initial visit, and ended 30 days after the last acute care visit in the episode chain. All-cause and HF -specific ED visits and hospitalization within 30 days of index visit were analyzed using generalized estimating equations with robust variance. Hazard for death within episodes of acute illness was analyzed using Cox proportional hazards models. In adjusted analyses, dual use acute HF episodes were associated with higher odds of all-cause ED visits (odds ratio 1.61, 95% confidence interval [ CI ], 1.33, 1.95), HF -specific ED visits, (odds ratio 1.54, 95% CI , 1.12, 2.13), all-cause hospitalization (odds ratio 1.89, 95% CI , 1.50, 2.38), and HF -specific hospitalization (odds ratio 1.62, 95% CI , 1.15-2.30) as compared with Veterans Health Administration-only episodes of acute HF care. Dual use episodes of care were associated with higher hazard for mortality (hazard ratio=1.52, 95% CI 1.07, 2.16) as compared with all-Veterans Health Administration episodes of care. Conclusions Episodes of acute HF care spanning across healthcare systems appear to be associated with higher risk of subsequent ED visits, hospitalization, and mortality.
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Affiliation(s)
- R. Neal Axon
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
- Division of General Internal MedicineDepartment of MedicineThe Medical University of South CarolinaCharlestonSC
| | - Mulugeta Gebregziabher
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
- Department of Public Health SciencesThe Medical University of South CarolinaCharlestonSC
| | - Charles J. Everett
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
| | - Paul Heidenreich
- Division of CardiologyVA Palo Alto Healthcare SystemStanford University Medical CenterPalo AltoCA
| | - Kelly J. Hunt
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
- Department of Public Health SciencesThe Medical University of South CarolinaCharlestonSC
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13
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Vaughan Sarrazin M, Rosenthal GE, Turvey CL. Empirical-Based Typology of Health Care Utilization by Medicare Eligible Veterans. Health Serv Res 2018; 53 Suppl 3:5181-5200. [PMID: 29896771 DOI: 10.1111/1475-6773.12995] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Up to 70 percent of patients who receive care through Veterans Health Administration (VHA) facilities also receive care from non-VA providers. Using applied classification techniques, this study sought to improve understanding of how elderly VA patients use VA services and complementary use of non-VA care. METHODS The study included 1,721,900 veterans age 65 and older who were enrolled in VA and Medicare during 2013 with at least one VA encounter during 2013. Outpatient and inpatient encounters and medications received in VA were classified, and mutually exclusive patient subsets distinguished by patterns of VA service use were derived empirically using latent class analysis (LCA). Patient characteristics and complementary use of non-VA care were compared by patient subset. RESULTS Five patterns of VA service use were identified that were distinguished by quantity of VA medical and specialty services, medication complexity, and mental health services. Low VA Medical users tend to be healthier and rely on non-VA services, while High VA users have multiple high cost illnesses and concentrate their care in the VA. CONCLUSIONS VA patients distinguished by patterns of VA service use differ in illness burden and the use of non-VA services. This information may be useful for framing efforts to optimize access to care and care coordination for elderly VA patients.
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Affiliation(s)
- Mary Vaughan Sarrazin
- Iowa City VA Health Care System, Iowa City, IA.,Department of Internal Medicine, University of Iowa, Iowa City, IA
| | - Gary E Rosenthal
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Carolyn L Turvey
- Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA.,Department of Psychiatry, University of Iowa, Iowa City, IA
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14
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McManus MC, Cramer RJ, Boshier M, Akpinar-Elci M, Van Lunen B. Mental Health and Drivers of Need in Emergent and Non-Emergent Emergency Department (ED) Use: Do Living Location and Non-Emergent Care Sources Matter? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E129. [PMID: 29342846 PMCID: PMC5800228 DOI: 10.3390/ijerph15010129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 01/10/2018] [Accepted: 01/11/2018] [Indexed: 11/16/2022]
Abstract
Emergency department (ED) utilization has increased due to factors such as admissions for mental health conditions, including suicide and self-harm. We investigate direct and moderating influences on non-emergent ED utilization through the Behavioral Model of Health Services Use. Through logistic regression, we examined correlates of ED use via 2014 New York State Department of Health Statewide Planning and Research Cooperative System outpatient data. Consistent with the primary hypothesis, mental health admissions were associated with emergent use across models, with only a slight decrease in effect size in rural living locations. Concerning moderating effects, Spanish/Hispanic origin was associated with increased likelihood for emergent ED use in the rural living location model, and non-emergent ED use for the no non-emergent source model. 'Other' ethnic origin increased the likelihood of emergent ED use for rural living location and no non-emergent source models. The findings reveal 'need', including mental health admissions, as the largest driver for ED use. This may be due to mental healthcare access, or patients with mental health emergencies being transported via first responders to the ED, as in the case of suicide, self-harm, manic episodes or psychotic episodes. Further educating ED staff on this patient population through gatekeeper training may ensure patients receive the best treatment and aid in driving access to mental healthcare delivery changes.
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Affiliation(s)
- Moira C McManus
- Community and Environmental Health, College of Health Sciences, Old Dominion University; Norfolk, VA 757-683-4259, USA.
| | - Robert J Cramer
- Community and Environmental Health, College of Health Sciences, Old Dominion University; Norfolk, VA 757-683-4259, USA.
| | - Maureen Boshier
- Community and Environmental Health, College of Health Sciences, Old Dominion University; Norfolk, VA 757-683-4259, USA.
| | - Muge Akpinar-Elci
- Community and Environmental Health, College of Health Sciences, Old Dominion University; Norfolk, VA 757-683-4259, USA.
| | - Bonnie Van Lunen
- Physical Therapy and Athletic Training, College of Health Sciences, Old Dominion University; Norfolk, VA 757-683-4519, USA.
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15
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Radomski TR, Zhao X, Thorpe CT, Thorpe JM, Naples JG, Mor MK, Good CB, Fine MJ, Gellad WF. The Impact of Medication-Based Risk Adjustment on the Association Between Veteran Health Outcomes and Dual Health System Use. J Gen Intern Med 2017; 32:967-973. [PMID: 28462490 PMCID: PMC5570738 DOI: 10.1007/s11606-017-4064-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/29/2017] [Accepted: 04/10/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Veterans commonly receive care from both Veterans Health Administration (VA) and non-VA sources (i.e., dual use). A major challenge in comparing health outcomes between dual users and VA-predominant users is applying an accurate method of risk adjustment. OBJECTIVE To determine how different comorbidity indices affect the association between patterns of dual use and health outcomes. DESIGN Retrospective cohort. PARTICIPANTS A total of 316,775 community-dwelling Veterans (≥65 years) with type 2 diabetes who were enrolled in VA and fee-for-service Medicare from 2008 to 2010. METHODS We determined the associations between dual use and death or diabetes-related hospitalization in FY 2010 using multivariable models incorporating claims-based (Elixhauser) or medication-based (RxRisk-V) risk adjustment. Dual use was classified using four previously identified groups of health services users: 1) VA-predominant, 2) VA + Medicare visits and labs, 3) VA + Medicare test strips, and 4) VA + Medicare medications. KEY RESULTS Controlling for Elixhauser comorbidities, dual-use groups 2-4 had significantly decreased odds of death or hospitalization compared to VA-predominant users. Controlling for RxRisk-V comorbidities, groups 2-4 had increased odds of death compared to VA-predominant users, but variable odds of hospitalization, with group 2 having increased odds (OR 1.06, CI 1.04-1.09), while groups 3 (OR 0.96, CI 0.94-0.99) and 4 (OR 0.93, CI 0.89-0.97) had decreased odds. CONCLUSIONS The method of risk adjustment drastically influences the direction of effect in health outcomes among dual users of VA and Medicare. These findings underscore the need for standardized and reliable risk adjustment methods that are not susceptible to measurement differences across different health systems.
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Affiliation(s)
- Thomas R Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA.
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Jennifer G Naples
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
- Division of Geriatrics, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
- Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, IL, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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16
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Coordinating Care Across Health Care Systems for Veterans With Gynecologic Malignancies. Med Care 2017; 55 Suppl 7 Suppl 1:S53-S60. [DOI: 10.1097/mlr.0000000000000737] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Attributable Mortality of Healthcare-Associated Infections Due to Multidrug-Resistant Gram-Negative Bacteria and Methicillin-Resistant Staphylococcus Aureus. Infect Control Hosp Epidemiol 2017; 38:848-856. [DOI: 10.1017/ice.2017.83] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVEThe purpose of this study was to quantify the effect of multidrug-resistant (MDR) gram-negative bacteria and methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections (HAIs) on mortality following infection, regardless of patient location.METHODSWe conducted a retrospective cohort study of patients with an inpatient admission in the US Department of Veterans Affairs (VA) system between October 1, 2007, and November 30, 2010. We constructed multivariate log-binomial regressions to assess the impact of a positive culture on mortality in the 30- and 90-day periods following the first positive culture, using a propensity-score–matched subsample.RESULTSPatients identified with positive cultures due to MDR Acinetobacter (n=218), MDR Pseudomonas aeruginosa (n=1,026), and MDR Enterobacteriaceae (n=3,498) were propensity-score matched to 14,591 patients without positive cultures due to these organisms. In addition, 3,471 patients with positive cultures due to MRSA were propensity-score matched to 12,499 patients without positive MRSA cultures. Multidrug-resistant gram-negative bacteria were associated with a significantly elevated risk of mortality both for invasive (RR, 2.32; 95% CI, 1.85–2.92) and noninvasive cultures (RR, 1.33; 95% CI, 1.22–1.44) during the 30-day period. Similarly, patients with MRSA HAIs (RR, 2.77; 95% CI, 2.39–3.21) and colonizations (RR, 1.32; 95% CI, 1.22–1.50) had an increased risk of death at 30 days.CONCLUSIONSWe found that HAIs due to gram-negative bacteria and MRSA conferred significantly elevated 30- and 90-day risks of mortality. This finding held true both for invasive cultures, which are likely to be true infections, and noninvasive infections, which are possibly colonizations.Infect Control Hosp Epidemiol 2017;38:848–856
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Comparing VA and Non-VA Quality of Care: A Systematic Review. J Gen Intern Med 2017; 32:105-121. [PMID: 27422615 PMCID: PMC5215146 DOI: 10.1007/s11606-016-3775-2] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/28/2016] [Accepted: 06/07/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND The Veterans Affairs (VA) health care system aims to provide high-quality medical care to veterans in the USA, but the quality of VA care has recently drawn the concern of Congress. The objective of this study was to systematically review published evidence examining the quality of care provided at VA health care facilities compared to quality of care in other facilities and systems. METHODS Building on the search strategy and results of a prior systematic review, we searched MEDLINE (from January 1, 2005, to January 1, 2015) to identify relevant articles on the quality of care at VA facilities compared to non-VA facilities. Articles from the prior systematic review published from 2005 and onward were also included and re-abstracted. Studies were classified, analyzed, and summarized by the Institute of Medicine's quality dimensions. RESULTS Sixty-nine articles were identified (including 31 articles from the prior systematic review and 38 new articles) that address one or more Institute of Medicine quality dimensions: safety (34 articles), effectiveness (24 articles), efficiency (9 articles), patient-centeredness (5 articles), equity (4 articles), and timeliness (1 article). Studies of safety and effectiveness indicated generally better or equal performance, with some exceptions. Too few articles related to timeliness, equity, efficiency, and patient-centeredness were found from which to reliably draw conclusions about VA care related to these dimensions. DISCUSSION The VA often (but not always) performs better than or similarly to other systems of care with regard to the safety and effectiveness of care. Additional studies of quality of care in the VA are needed on all aspects of quality, but particularly with regard to timeliness, equity, efficiency, and patient-centeredness.
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Lam CA, Sherbourne C, Gelberg L, Lee ML, Huynh AK, Chu K, Strauss JL, Metzger ME, Post EP, Rubenstein LV, Farmer MM. Differences in Depression Care for Men and Women among Veterans with and without Psychiatric Comorbidities. Womens Health Issues 2016; 27:206-213. [PMID: 28007391 DOI: 10.1016/j.whi.2016.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 10/31/2016] [Accepted: 11/07/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Depression is common among primary care patients, affecting more women than men. Women veterans are an extreme but growing minority among patients seeking care from the Department of Veterans Affairs (VA), an organization historically designed to serve men. Little is known about gender differences in depression care quality within the VA primary care population. PURPOSE This works assesses the gender differences in depression care among veterans using longitudinal electronic measures. METHODS We undertook a cross-sectional study of all veteran VA primary care users with a new episode of depression from federal fiscal year 2010, covering nine geographically diverse regions. We assessed the quality of depression care based on receipt of minimally appropriate depression treatment within 1 year of a new episode of depression and on receipt of depression-related follow-up visits within 180 days. Minimally appropriate treatment and follow-up were operationalized as meeting or exceeding a minimally appropriate threshold for care, based on national quality measures and expert panel consensus. Regression models were used to produce predicted probabilities for each process outcome accounting for the presence or absence of other psychiatric comorbidities. All models were adjusted for model covariates and clinic clusters (404 sites). MAIN FINDINGS In 2010, 110,603 veterans with a primary care visit had a new episode of depression; 10,094 (9%) were women. In multivariate analyses, women had modest yet significantly higher rates of minimally appropriate depression treatment than men, whether patients had depression only (79% of women vs. 76% of men; p < .001) or depression along with other psychiatric comorbidities (92% of women vs. 91% or men; p < .001). There were no significant gender differences for rate of receipt of follow-up for depression at 180 days. Interactions between gender and other psychiatric comorbidities were not significant. CONCLUSIONS Our findings suggest that the VA is achieving comparable depression care between genders at minimally appropriate thresholds.
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Affiliation(s)
- Christine A Lam
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California; Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California.
| | | | - Lillian Gelberg
- Department of Family Medicine, UCLA David Geffen School of Medicine, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California; Office of Healthcare Transformation and Innovation, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Martin L Lee
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California; Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, California
| | - Alexis K Huynh
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California
| | - Karen Chu
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California
| | - Jennifer L Strauss
- Mental Health Services, Department of Veterans Affairs, Washington, DC; Department of Psychiatry, Duke University Medical Center, Durham, North Carolina
| | - Maureen E Metzger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, Michigan
| | - Edward P Post
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, Michigan; University of Michigan Medical School, Ann Arbor, Michigan
| | - Lisa V Rubenstein
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California; Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California; RAND Corporation, Santa Monica, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | - Melissa M Farmer
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Sepulveda, California
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Gorman LA, Sripada RK, Ganoczy D, Walters HM, Bohnert KM, Dalack GW, Valenstein M. Determinants of National Guard Mental Health Service Utilization in VA versus Non-VA Settings. Health Serv Res 2016; 51:1814-37. [PMID: 26840993 PMCID: PMC5034208 DOI: 10.1111/1475-6773.12446] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine associations between need, enabling, and predisposing factors with mental health service use among National Guard soldiers in the first year following a combat deployment to Iraq or Afghanistan. DATA SOURCES/STUDY SETTING Primary data were collected between 2011 and 2013 from 1,426 Guard soldiers representing 36 units. STUDY DESIGN Associations between Guard soldier factors and any mental health service use were assessed using multivariable logistic regression models in a cross-sectional study. Further analysis among service users (N = 405) assessed VA treatment versus treatment in other settings. PRINCIPAL FINDINGS Fifty-six percent of Guard soldiers meeting cutoffs on symptom scales received mental health services with 81 percent of those reporting care from the VA. Mental health service use was associated with need (mental health screens and physical health) and residing in micropolitan communities. Among service users, predisposing factors (middle age range and female gender) and enabling factors (employment, income above $50,000, and private insurance) were associated with greater non-VA services use. CONCLUSION Overall service use was strongly associated with need, whereas sector of use (non-VA vs. VA) was insignificantly associated with need but strongly associated with enabling factors. These findings have implications for the recent extension of veteran health coverage to non-VA providers.
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Affiliation(s)
| | - Rebecca K Sripada
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Dara Ganoczy
- VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Heather M Walters
- VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Kipling M Bohnert
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Gregory W Dalack
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Marcia Valenstein
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
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Radomski TR, Zhao X, Thorpe CT, Thorpe JM, Good CB, Mor MK, Fine MJ, Gellad WF. VA and Medicare Utilization Among Dually Enrolled Veterans with Type 2 Diabetes: A Latent Class Analysis. J Gen Intern Med 2016; 31:524-31. [PMID: 26902242 PMCID: PMC4835371 DOI: 10.1007/s11606-016-3631-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 12/04/2015] [Accepted: 02/05/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many Veterans treated within the VA Healthcare System (VA) are also enrolled in fee-for-service (FFS) Medicare and receive treatment outside the VA. Prior research has not accounted for the multiple ways that Veterans receive services across healthcare systems. OBJECTIVE We aimed to establish a typology of VA and Medicare utilization among dually enrolled Veterans with type 2 diabetes. DESIGN This was a retrospective cohort. PARTICIPANTS 316,775 community-dwelling Veterans age ≥ 65 years with type 2 diabetes who were dually enrolled in the VA and FFS Medicare in 2008-2009. METHODS Using latent class analysis, we identified classes of Veterans based upon their probability of using VA and Medicare diabetes care services, including patient visits, laboratory tests, glucose test strips, and medications. We compared the amount of healthcare use between classes and identified factors associated with class membership using multinomial regression. KEY RESULTS We identified four distinct latent classes: class 1 (53.9%) had high probabilities of VA use and low probabilities of Medicare use; classes 2 (17.2%), 3 (21.8%), and 4 (7.0%) had high probabilities of VA and Medicare use, but differed in their Medicare services used. For example, Veterans in class 3 received test strips exclusively through Medicare, while Veterans in class 4 were reliant on Medicare for medications. Living ≥ 40 miles from a VA predicted membership in classes 3 (OR 1.1, CI 1.06-1.15) and 4 (OR 1.11, CI 1.04-1.18), while Medicaid eligibility predicted membership in class 4 (OR 4.30, CI 4.10-4.51). CONCLUSIONS Veterans with diabetes can be grouped into four distinct classes of dual health system use, representing a novel way to characterize how patients use multiple services across healthcare systems. This classification has applications for identifying patients facing differential risk from care fragmentation.
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Affiliation(s)
- Thomas R Radomski
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Chester B Good
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA.,Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, IL, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA.,Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael J Fine
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA
| | - Walid F Gellad
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, 151C, Pittsburgh, PA, 15240, USA.
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Stroupe KT, Bailey L, Gellad WF, Suda K, Huo Z, Martinez R, Burk M, Cunningham F, Smith BM. Veterans’ Pharmacy and Health Care Utilization Following Implementation of the Medicare Part D Pharmacy Benefit. Med Care Res Rev 2016; 74:328-344. [DOI: 10.1177/1077558716643887] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We examined associations between enrollment in Medicare Part D pharmacy benefits and changes in medication acquisition from Department of Veterans Affairs (VA) pharmacies. We included all women and a random 10% sample of men who were VA enrollees, ≥65 years old as of January 1, 2004, and alive through December 2007. We used difference-in-differences models with propensity score weighting to examine changes in medication acquisition between 2005 (before Part D was implemented) and 2007 (after Part D implementation) for veterans who were or were not Part D enrolled. Of 231,716 veterans meeting inclusion criteria, 49,881 (21.5%) were enrolled. While 30-day medication supplies decreased from 26.2 to 23.4 for enrolled veterans, they increased from 36.6 to 37.4 for nonenrolled veterans (difference-in-differences: −4.0, p < .001). Reductions in 30-day supplies were greater among veterans who were required to pay VA copayments for some or all medications and who used VA and Medicare outpatient services.
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Affiliation(s)
- Kevin T. Stroupe
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, USA
- Loyola University Chicago Department of Public Health Sciences, Maywood, IL, USA
| | - Lauren Bailey
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, USA
- University of Illinois at Chicago, Chicago, IL, USA
| | - Walid F. Gellad
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katie Suda
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, USA
- University of Illinois at Chicago, Chicago, IL, USA
| | - Zhiping Huo
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, USA
| | - Rachael Martinez
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, USA
| | - Muriel Burk
- Veterans Affairs Pharmacy Benefit Management Services, Edward Hines Jr. VA Hospital, Hines IL
| | - Francesca Cunningham
- Veterans Affairs Pharmacy Benefit Management Services, Edward Hines Jr. VA Hospital, Hines IL
| | - Bridget M. Smith
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, USA
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Northwestern University, Chicago IL, USA
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Dual health care system use is associated with higher rates of hospitalization and hospital readmission among veterans with heart failure. Am Heart J 2016; 174:157-63. [PMID: 26995383 DOI: 10.1016/j.ahj.2015.09.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 09/26/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Heart failure (HF) frequently causes hospital admission and readmission. Patients receiving care from multiple providers and facilities (dual users) may risk higher health care utilization and worse health outcomes. METHODS To determine rates of emergency department (ED) visits, hospitalizations, and hospital readmissions relative to dual use among HF patients, we analyzed a retrospective cohort of 13,977 veterans with HF hospitalized at the Veterans Affairs (VA) or non-VA facilities from 2007 to 2011; we analyzed rates of acute health care utilization using zero-inflated negative binomial regression. RESULTS Compared to VA-only users and dual users, individuals receiving all of their ED and hospital care outside the VA tended to be older, more likely to be non-Hispanic white and married, and less likely to have high levels of service connected disability. Compared to VA-only users, dual users had significantly higher rates of ED visits for HF as a primary diagnosis (adjusted rate ratio 1.15, 95% CI 1.04-1.27), hospitalization for HF (adjusted rate ratio 1.4, 95% CI 1.26-1.56), hospital readmission after HF hospitalization (all cause) (1.46, 95% CI 1.30-1.65), and HF-specific hospital readmission after HF hospitalization (1.46, 95% CI 1.31-1.63). With the exception of hospitalization for any primary diagnosis, non-VA-only users had significantly lower rates of ED visits, hospitalization, and readmission compared to VA-only users. CONCLUSIONS Dual use is associated with higher rates of health care utilization among patients with HF. Interventions should be devised to encourage continuity of care where possible and to improve the effectiveness and safety of dual use in instances where it is necessary or desired.
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Nelson RE, Xie Y, DuVall SL, Butler J, Kamauu AWC, Knippenberg K, Schuerch M, Foskett N, LaFleur J. Multiple Sclerosis and Risk of Infection-Related Hospitalization and Death in US Veterans. Int J MS Care 2015; 17:221-30. [PMID: 26472943 DOI: 10.7224/1537-2073.2014-035] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study estimated the risk of infection-related hospitalizations and death in patients with and without multiple sclerosis (MS). METHODS We identified adults with MS in the US Department of Veterans Affairs (VA) system between 1999 and 2010. Each veteran with MS was matched, on age and sex, with up to four veterans without MS. Multivariable Cox proportional hazards regression models were performed to assess the influence of MS on the development of serious and fatal infections. RESULTS The cohort included 7743 veterans with MS and 30,972 veterans without MS. Mean (SD) age was 53.8 (13.3) years, and 80.8% were male. The incidence per 1000 person-years of overall serious infections was 19.2 (95% confidence interval [CI], 17.6-20.8) for those with MS and 10.3 (95% CI, 9.8-10.9) for those without MS. Fatal infection incidence rates were 1.2 (95% CI, 0.8-1.7) for patients with MS and 0.5 (95% CI, 0.3-0.6) for patients without MS. Regression models showed that veterans with MS were at greater risk for overall serious (hazard ratio [HR] = 1.52, P < .01) and fatal (HR = 1.85, P = .03) infections and serious respiratory (HR = 1.31, P = .01), urinary tract (HR = 4.44, P < .01), and sepsis-related infections (HR = 2.56, P < .01). CONCLUSIONS This study provides evidence that VA patients with MS are more likely than those without MS to be hospitalized and die of infection.
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Affiliation(s)
- Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Yan Xie
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Scott L DuVall
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Jorie Butler
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Aaron W C Kamauu
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Kristin Knippenberg
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Markus Schuerch
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Nadia Foskett
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
| | - Joanne LaFleur
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA (REN, SLD, JB, KK, JL); University of Utah School of Medicine, Salt Lake City, UT, USA (REN, SLD, JB, YX); AbbVie, Inc, Chicago, IL, USA (YX); University of Utah College of Pharmacy, Salt Lake City, UT, USA (SLD, KK, JL); Anolinx LLC, Salt Lake City, UT, USA (AWCK); and F. Hoffman-La Roche Ltd, Basel, Switzerland (MS, NF)
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West AN, Charlton ME, Vaughan-Sarrazin M. Dual use of VA and non-VA hospitals by Veterans with multiple hospitalizations. BMC Health Serv Res 2015; 15:431. [PMID: 26416176 PMCID: PMC4587652 DOI: 10.1186/s12913-015-1069-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 08/26/2015] [Indexed: 11/23/2022] Open
Abstract
Background Veterans who are hospitalized in both VA and non-VA hospitals within a short timespan may be at risk for fragmented or conflicting care. To determine the characteristics of these “dual users,” we analyzed administrative hospital discharge data for VA-enrolled veterans of any age in seven states, including any VA or non-VA hospitalizations they had in 2004–2007. Method For VA enrollees in Arizona, Iowa, Louisiana, Florida, South Carolina, Pennsylvania, or New York in 2007, we merged 2004–2007 discharge data for all VA hospitalizations and all non-VA hospitalizations listed in state health department or hospital association databases. For patients hospitalized in 2007, we compared those younger or older than 65 years who had one or multiple hospitalizations during the year, split into users of VA hospitals, non-VA hospitals, or both (“dual users”), on demographics, priority for VA care, travel times, principal diagnoses, co-morbidities, lengths of stay, and prior (2004–2006) hospitalizations, using chi-square analysis or ANOVA. Multiply hospitalized patients were compared with multinomial logistic regressions to predict non-VA and dual use. Payers for non-VA hospitalizations also were compared across groups. Results Of unique inpatients in 2007, 38 % of those 65 or older were hospitalized more than once during the year, as were 32 % of younger patients; 3 and 8 %, respectively, were dual users. Dual users averaged the most index-year (3.7) and prior (1.5) hospitalizations, split evenly between VA and non-VA. They also had higher rates of admission for circulatory diseases, symptoms/signs/ill-defined conditions, and injury and poisoning, and more admissions for multiple diagnostic categories; among younger patients they had the highest rate of mental disorders admissions. Higher income, non-rural residence, greater time to VA care, lower VA priority, prior non-VA hospitalization, no prior VA hospitalization, and several medical categories predicted greater non-VA use. Among younger patients, however, mental disorders predicted more dual use but less exclusively non-VA use. Dual users’ non-VA admissions were more likely than others’ to be covered by payers other than Medicare or commercial insurance. Conclusions Younger dual users require more medical and psychiatric treatment, and rely more on government funding sources. Effective care coordination for these inpatients might improve outcomes while reducing taxpayer burden.
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Affiliation(s)
- Alan N West
- Research Service, VA Medical Center (10A5A), 215 N. Main St., White River Junction, Vermont, 05009, USA. .,Geisel Medical School (formerly Dartmouth Medical School), Hanover, New Hampshire, USA. .,Veterans Rural Health Resource Center - Eastern Region, White River Junction, Vermont, USA.
| | - Mary E Charlton
- Iowa City VA Health Care System, Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City, Iowa, USA. .,Department of Epidemiology, The University of Iowa College of Public Health, Iowa City, Iowa, USA.
| | - Mary Vaughan-Sarrazin
- Iowa City VA Health Care System, Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City, Iowa, USA. .,Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
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Nelson RE, Grosse SD, Waitzman NJ, Lin J, DuVall SL, Patterson O, Tsai J, Reyes N. Using multiple sources of data for surveillance of postoperative venous thromboembolism among surgical patients treated in Department of Veterans Affairs hospitals, 2005-2010. Thromb Res 2015; 135:636-42. [PMID: 25666908 PMCID: PMC4453876 DOI: 10.1016/j.thromres.2015.01.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/10/2015] [Accepted: 01/20/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are limitations to using administrative data to identify postoperative venous thromboembolism (VTE). We used a novel approach to quantify postoperative VTE events among Department of Veterans Affairs (VA) surgical patients during 2005-2010. METHODS We used VA administrative data to exclude patients with VTE during 12 months prior to surgery. We identified probable postoperative VTE events within 30 and 90 days post-surgery in three settings: 1) pre-discharge inpatient, using a VTE diagnosis code and a pharmacy record for anticoagulation; 2) post-discharge inpatient, using a VTE diagnosis code followed by a pharmacy record for anticoagulation within 7 days; and 3) outpatient, using a VTE diagnosis code and either anticoagulation or a therapeutic procedure code with natural language processing (NLP) to confirm acute VTE in clinical notes. RESULTS Among 468,515 surgeries without prior VTE, probable VTEs were documented within 30 and 90 days in 3,931 (0.8%) and 5,904 (1.3%), respectively. Of probable VTEs within 30 or 90 days post-surgery, 47.8% and 62.9%, respectively, were diagnosed post-discharge. Among post-discharge VTE diagnoses, 86% resulted in a VA hospital readmission. Fewer than 25% of outpatient records with both VTE diagnoses and anticoagulation prescriptions were confirmed by NLP as acute VTE events. CONCLUSION More than half of postoperative VTE events were diagnosed post-discharge; analyses of surgical discharge records are inadequate to identify postoperative VTE. The NLP results demonstrate that the combination of VTE diagnoses and anticoagulation prescriptions in outpatient administrative records cannot be used to validly identify postoperative VTE events.
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Affiliation(s)
- Richard E. Nelson
- Veterans Affairs Salt Lake City Health Care System, USA
- University of Utah Department of Internal Medicine, Salt Lake City, UT, USA
| | - Scott D. Grosse
- National Center on Birth Defects and Developmental Disabilities, Office of the Director, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Junji Lin
- Veterans Affairs Salt Lake City Health Care System, USA
- University of Utah Department of Pharmacotherapy, Salt Lake City, UT, USA
| | - Scott L. DuVall
- Veterans Affairs Salt Lake City Health Care System, USA
- University of Utah Department of Internal Medicine, Salt Lake City, UT, USA
- University of Utah Department of Pharmacotherapy, Salt Lake City, UT, USA
| | - Olga Patterson
- Veterans Affairs Salt Lake City Health Care System, USA
- University of Utah Department of Internal Medicine, Salt Lake City, UT, USA
| | - James Tsai
- Office on Smoking and Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nimia Reyes
- National Center on Birth Defects and Developmental Disabilities, Division of Blood Disorders, Centers for Disease Control and Prevention, Atlanta, GA, USA
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The Impact of Healthcare-Associated Methicillin-Resistant Staphylococcus Aureus Infections on Post-Discharge Healthcare Costs and Utilization. Infect Control Hosp Epidemiol 2015; 36:534-42. [DOI: 10.1017/ice.2015.22] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVEHealthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) infections are a major cause of morbidity, mortality, and cost among hospitalized patients. Little is known about their impact on post-discharge resource utilization. The purpose of this study was to estimate post-discharge healthcare costs and utilization attributable to positive MRSA cultures during a hospitalization.METHODSOur study cohort consisted of patients with an inpatient admission lasting longer than 48 hours within the US Department of Veterans Affairs (VA) system between October 1, 2007, and November 30, 2010. Of these patients, we identified those with a positive MRSA culture from microbiology reports in the VA electronic medical record. We used propensity score matching and multivariable regression models to assess the impact of positive culture on post-discharge outpatient, inpatient, and pharmacy costs and utilization in the 365 days following discharge.RESULTSOur full cohort included 369,743 inpatients, of whom, 3,599 (1.0%) had positive MRSA cultures. Our final analysis sample included 3,592 matched patients with and without positive cultures. We found that, in the 12 months following hospital discharge, having a positive culture resulted in increases in post-discharge pharmacy costs ($776, P<.0001) and inpatient costs ($12,167, P<.0001). Likewise, having a positive culture increased the risk of a readmission (odds ratio [OR]=1.396, P<.0001), the number of prescriptions (incidence rate ratio [IRR], 1.138; P<.0001) and the number of inpatient days (IRR, 1.204; P<.0001,) but decreased the number of subsequent outpatient encounters (IRR, 0.941; P<.008).CONCLUSIONSThe results of this study indicate that MRSA infections are associated with higher levels of post-discharge healthcare cost and utilization. These findings indicate that financial benefits resulting from infection prevention efforts may extend beyond the initial hospital stay.Infect Control Hosp Epidemiol 2015;00(0): 1–9
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Johnson CE, Bush RL, Harman J, Bolin J, Evans Hudnall G, Nguyen AM. Variation in Utilization of Health Care Services for Rural VA Enrollees With Mental Health-Related Diagnoses. J Rural Health 2015; 31:244-53. [PMID: 25599892 DOI: 10.1111/jrh.12105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Rural-dwelling Department of Veterans Affairs (VA) enrollees are at high risk for a wide variety of mental health-related disorders. The objective of this study is to examine the variation in the types of mental and nonmental health services received by rural VA enrollees who have a mental health-related diagnosis. METHODS The Andersen and Aday behavioral model of health services use and the Agency for Healthcare Research and Quality Medical Expenditure Panel Survey (MEPS) data were used to examine how VA enrollees with mental health-related diagnoses accessed places of care from 1999 to 2009. Population survey weights were applied to the MEPS data, and logit regression was conducted to model how predisposing, enabling, and need factors influence rural veteran health services use (measured by visits to different places of care). Analyses were performed on the subpopulations: rural VA, rural non-VA, urban VA, and urban non-VA enrollees. FINDINGS For all types of care, both rural and urban VA enrollees received care from inpatient, outpatient, office-based, and emergency room settings at higher odds than urban non-VA enrollees. Rural VA enrollees also received all types of care from inpatient, office-based, and emergency room settings at higher odds than urban VA enrollees. Rural VA enrollees had higher odds of a mental health visit of any kind compared to urban VA and non-VA enrollees. CONCLUSIONS Based on these variations, the VA may want to develop strategies to increase screening efforts in inpatient settings and emergency rooms to further capture rural VA enrollees who have undiagnosed mental health conditions.
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Affiliation(s)
- Christopher E Johnson
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Ruth L Bush
- College of Medicine, Texas A&M Health Science Center, Round Rock, Texas
| | - Jeffrey Harman
- Department of Health Services Research, Management, and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Jane Bolin
- Southwest Rural Health Research Center, Texas A&M Health Science Center, College Station, Texas
| | - Gina Evans Hudnall
- South Central Mental Illness, Research, Education and Clinical Center and Houston Center for Quality of Care and Utilization Studies, Michael E. Debakey VA Medical Center, Houston, Texas.,Health Services Research and Development Section, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Ann M Nguyen
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
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Farmer MM, Rose DE, Rubenstein LV, Canelo IA, Schectman G, Stark R, Yano EM. Challenges facing primary care practices aiming to implement patient-centered medical homes. J Gen Intern Med 2014; 29 Suppl 2:S555-62. [PMID: 24715394 PMCID: PMC4070226 DOI: 10.1007/s11606-013-2691-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND While the potential of patient-centered medical homes (PCMH) is promising, little is known empirically about the frontline challenges that primary care (PC) leaders face before making the decision to implement PCMH, let alone in making it a reality. OBJECTIVE Prior to the design and implementation of the Veterans Health Administration's (VA) national PCMH model--Patient Aligned Care Teams (PACT)--we identified the top challenges faced by PC directors and examined the organizational and area level factors that influenced those challenges. DESIGN AND PARTICIPANTS A national cross-sectional key informant organizational survey was fielded to the census of PC directors at VA medical centers and large community-based outpatient clinics (final sample n = 229 sites). MAIN MEASURES PC directors were asked to rate the degree to which they faced 48 management challenges in eight PCMH-related domains (access, preventive care, chronic diseases requiring care in PC, challenging medical conditions, mental health/substance abuse, special populations, PC coordination of care, and clinical informatics). Responses were dichotomized as moderately-to-extremely challenging versus somewhat-slightly-not at all challenging. Items were rank ordered; chi square or regression techniques were used to examine variations in facility size, type, urban/rural location, and region. KEY RESULTS On average, VA PC directors reported 16 moderate-to-extreme challenges, and the top 20 challenges spanned all eight PCMH domains. Four of the top 20 challenges, including the top two challenges, were from the clinical informatics domain. Management of chronic non-malignant pain requiring opiate therapy was the third most reported challenge nationwide. Significant organizational and area level variations in reported challenges were found especially for care coordination. CONCLUSIONS Better understanding of PC challenges ahead of PCMH implementation provides important context for strategic planning and redesign efforts. As a national healthcare system, the VA provides a unique opportunity to examine organizational and area determinants relevant to other PCMH models.
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Affiliation(s)
- Melissa M Farmer
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Sepulveda Campus (Mailcode 152), 16111 Plummer Street, Sepulveda, CA, 91343, USA,
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Shi J, Peng Y, Erdem E, Woodbridge P, Fetrick A. Communication Enhancement and Best Practices for Co-Managing Dual Care Rural Veteran Patients by VA and Non-VA Providers: A Survey Study. J Community Health 2013; 39:552-61. [DOI: 10.1007/s10900-013-9797-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Pfeiffer PN, Kim HM, Ganoczy D, Zivin K, Valenstein M. Treatment-resistant depression and risk of suicide. Suicide Life Threat Behav 2013; 43:356-65. [PMID: 23510005 DOI: 10.1111/sltb.12022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 12/26/2012] [Indexed: 01/18/2023]
Abstract
We evaluated whether treatment-resistant depression (TRD) as measured by the Massachusetts General Hospital (MGH) staging method was associated with suicide in a large U.S. health system. Data from the Veterans Health Administration and the National Death Index were used to conduct a case-control study of patients newly diagnosed with depression who received antidepressant treatment between 2003 and 2006. Suicide cases (N = 499) were matched with nonsuicide controls (N = 1994). Conditional logistic regression was used to assess whether MGH stage at time of suicide (or matched date) was associated with case status, adjusting for patient demographic characteristics, comorbidity, and service use. Results indicated 11.6% of suicide cases had MGH stage 3 or greater (indicating at least two antidepressant trials) compared to 6.4% of controls (p < .001). In adjusted analyses, suicide was not significantly more likely among patients with stage 3 or greater (OR 1.52; 95% CI: 0.98, 2.37) or stages 1.5-2.5 (OR 1.19; 95% CI: 0.91, 1.55) compared to patients with stage 1 or less (<10 weeks of antidepressant medication). Staging TRD using MGH criteria is unlikely to substantially improve suicide risk assessment of depressed patients beyond existing measures contained in health system records.
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Affiliation(s)
- Paul N Pfeiffer
- Department of Veterans Affairs, National Serious Mental Illness Treatment Resource and Evaluation Center and Health Services Research and Development HSR&D Center for Clinical Management Research, Ann Arbor, MI, USA.
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Nayar P, Yu F, Apenteng B. Improving Care for Rural Veterans: Are High Dual Users Different? J Rural Health 2013; 30:139-45. [DOI: 10.1111/jrh.12038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Preethy Nayar
- College of Public Health; University of Nebraska Medical Center; Omaha Nebraska
| | - Fang Yu
- College of Public Health; University of Nebraska Medical Center; Omaha Nebraska
| | - Bettye Apenteng
- College of Public Health; University of Nebraska Medical Center; Omaha Nebraska
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Horowitz S. Treating Veterans’ Chronic Pain and Mental Health Disorders: An Integrative, Patient-Centered Approach. ACTA ACUST UNITED AC 2013. [DOI: 10.1089/act.2013.19305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Wong ES, Liu CF. The relationship between local area labor market conditions and the use of Veterans Affairs health services. BMC Health Serv Res 2013; 13:96. [PMID: 23496888 PMCID: PMC3607916 DOI: 10.1186/1472-6963-13-96] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 02/27/2013] [Indexed: 11/16/2022] Open
Abstract
Background In the U.S., economic conditions are intertwined with labor market decisions, access to health care, health care utilization and health outcomes. The Veterans Affairs (VA) health care system has served as a safety net provider by supplying free or reduced cost care to qualifying veterans. This study examines whether local area labor market conditions, measured using county-level unemployment rates, influence whether veterans obtain health care from the VA. Methods We used survey data from the Behavioral Risk Factor Surveillance System in years 2000, 2003 and 2004 to construct a random sample of 73,964 respondents self-identified as veterans. VA health service utilization was defined as whether veterans received all, some or no care from the VA. Hierarchical ordered logistic regression was used to address unobserved state and county random effects while adjusting for individual characteristics. Local area labor market conditions were defined as the average 12-month unemployment rate in veterans’ county of residence. Results The mean unemployment rate for veterans receiving all, some and no care was 5.56%, 5.37% and 5.24%, respectively. After covariate adjustment, a one percentage point increase in the unemployment rate in a veteran’s county of residence was associated with an increase in the probability of receiving all care (0.34%, p-value = 0.056) or some care (0.29%, p-value = 0.023) from the VA. Conclusions Our findings suggest that the important role of the VA in providing health care services to veterans is magnified in locations with high unemployment.
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Affiliation(s)
- Edwin S Wong
- Northwest Center for Outcomes Research in Older Adults, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA.
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Tarlov E, Lee TA, Weichle TW, Durazo-Arvizu R, Zhang Q, Perrin R, Bentrem D, Hynes DM. Reduced overall and event-free survival among colon cancer patients using dual system care. Cancer Epidemiol Biomarkers Prev 2012; 21:2231-41. [PMID: 23064003 DOI: 10.1158/1055-9965.epi-12-0548] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Many veterans have dual Veterans Administration (VA) and Medicare healthcare coverage. We compared 3-year overall and cancer event-free survival (EFS) among patients with nonmetastatic colon cancer who obtained substantial portions of their care in both systems and those whose care was obtained predominantly in the VA or in the Medicare fee-for-service system. METHODS We conducted a retrospective observational cohort study of patients older than 65 years with stages I to III colon cancer diagnosed from 1999 to 2001 in VA and non-VA facilities. Dual use of VA and non-VA colon cancer care was categorized as predominantly VA use, dual use, or predominantly non-VA use. Extended Cox regression models evaluated associations between survival and dual use. RESULTS VA and non-VA users (all stages) had reduced hazard of dying compared with dual users [e.g., for stage I, VA HR 0.40, 95% confidence interval (CI): 0.28-0.56; non-VA HR 0.54, 95% CI: 0.38-0.78). For EFS, stage I findings were similar (VA HR 0.47, 95% CI: 0.35-0.62; non-VA HR 0.64, 95% CI: 0.47-0.86). Stage II and III VA users, but not non-VA users, had improved EFS (stage II: VA HR 0.74, 95% CI: 0.56-0.97; non-VA HR 0.92, 95% CI: 0.69-1.22; stage III: VA HR 0.73, 95% CI: 0.56-0.94; non-VA HR 0.81, 95% CI: 0.62-1.06). CONCLUSIONS Improved survival among VA and non-VA compared with dual users raises questions about coordination of care and unmet needs. IMPACT Additional study is needed to understand why these differences exist, why patients use both systems, and how systems may be improved to yield better outcomes in this population.
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Affiliation(s)
- Elizabeth Tarlov
- Center for Management of Complex Chronic Care, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave., 151H, Hines, IL 60141, USA.
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Williams LS, Ofner S, Yu Z, Beyth RJ, Plue L, Damush T. Pre-post evaluation of automated reminders may improve detection and management of post-stroke depression. J Gen Intern Med 2011; 26:852-7. [PMID: 21499827 PMCID: PMC3138982 DOI: 10.1007/s11606-011-1709-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Post-stroke depression (PSD) occurs in at least one-third of stroke survivors, is associated with worse functional outcomes and increased mortality, and is frequently underdiagnosed and undertreated. OBJECTIVE To evaluate the effectiveness of an electronic medical record-based system intervention to improve the proportion of veterans screened and treated for PSD. DESIGN Quasi-experimental study comparing PSD screening and treatment among veterans receiving post-stroke outpatient care one year prior to the intervention (the control group) to those receiving outpatient care during the intervention period (the intervention group); contemporaneous data from non-study sites included to assess temporal trends in depression diagnosis and treatment. PARTICIPANTS Veterans hospitalized for ischemic stroke and/or receiving primary care (PC) or neurology outpatient follow-up within six months post-stroke at two (Veterans Affairs) VA Medical Centers. INTERVENTIONS We formed clinical improvement teams at both sites. Teams developed PSD screening and treatment reminders and designed tailored implementation strategies for reminder use in PC and neurology clinics. MAIN MEASURES Proportion screened for PSD within 6 months post-stroke; proportion screening positive for PSD who received an appropriate treatment action within 6 months post-stroke. KEY RESULTS In unadjusted analyses, PSD screening was performed within 6 months for 85% of intervention (N = 278) vs. 50% of control (N = 374) patients (OR 6.2 , p < 0.001), and treatment action was received by 83% of intervention vs. 73% of control patients who screened positive (OR 1.8 p = 0.13). After adjusting for intervention, site and number of follow-up visits, intervention patients were more likely to be screened (OR 4.8, p < 0.001) and to receive a treatment action if screened positive (OR 2.45, p = 0.05). Analyses of temporal trends in non-study sites revealed no trend toward general increase in PSD detection or treatment. CONCLUSIONS Automated depression screening in primary and specialty care can improve detection and treatment of PSD.
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Liu CF, Chapko M, Bryson CL, Burgess JF, Fortney JC, Perkins M, Sharp ND, Maciejewski ML. Use of outpatient care in Veterans Health Administration and Medicare among veterans receiving primary care in community-based and hospital outpatient clinics. Health Serv Res 2010; 45:1268-86. [PMID: 20831716 DOI: 10.1111/j.1475-6773.2010.01123.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients. DATA SOURCES/STUDY SETTING VA administrative and Medicare claims data from 2001 to 2004. STUDY DESIGN Retrospective cohort study of outpatient service use by 8,964 community-based and 6,556 hospital-based VA primary care patients. PRINCIPAL FINDINGS A significant proportion of VA patients used Medicare-reimbursed primary care (>30 percent) and specialty care (>60 percent), but not mental health care (3-4 percent). Community-based patients had 17 percent fewer VA primary care visits (p<.001), 9 percent more Medicare-reimbursed visits (p<.001), and 6 percent fewer total visits (p<.05) than hospital-based patients. Community-based patients had 22 percent fewer VA specialty care visits (p<.0001) and 21 percent more Medicare-reimbursed specialty care visits (p<.0001) than hospital-based patients, but no difference in total visits (p=.80). CONCLUSIONS Medicare-eligible VA primary care patients followed over 4 consecutive years used significant primary care and specialty care outside of VA. Community-based patients offset decreased VA use with increased service use paid by Medicare, suggesting that increasing access to VA primary care via community clinics may fragment veteran care in unintended ways. Coordination of care between VA and non-VA providers and health care systems is essential to improve the quality and continuity of care.
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Affiliation(s)
- Chuan-Fen Liu
- Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, HSR&D, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA.
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Sy LS, Liu ILA, Solano Z, Cheetham TC, Lugg MM, Greene SK, Weintraub ES, Jacobsen SJ. Accuracy of influenza vaccination status in a computer-based immunization tracking system of a managed care organization. Vaccine 2010; 28:5254-9. [PMID: 20554065 DOI: 10.1016/j.vaccine.2010.05.061] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 05/06/2010] [Accepted: 05/26/2010] [Indexed: 12/01/2022]
Abstract
Influenza vaccine safety and effectiveness studies conducted using electronic medical records rely on accurate assessment of influenza vaccination status. However, influenza immunization in non-traditional settings (e.g., the workplace) may not be captured in patient immunization tracking systems. We compared influenza vaccination status from electronic records with self-reported vaccination status for five hundred and two 50-79 years olds enrolled in a large managed care organization. Influenza vaccination status in the medical record had a high positive predictive value and specificity (both >99%). The negative predictive value was 80% and sensitivity was 78%. These data suggest that an electronic record of influenza vaccination reliably indicates immunization, while the absence of such a record is only moderately accurate, partly due to vaccines received in non-traditional settings.
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Affiliation(s)
- Lina S Sy
- Kaiser Permanente Southern California, 100 South Los Robles Ave., Pasadena, CA 91101, USA.
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