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Weeda ER, Ward R, Gebregziabher M, Axon RN, Taber DJ. Medication Safety Events After Acute Myocardial Infarction Among Veterans Treated at VA Versus Non-VA Hospitals. Med Care 2024; 62:72-78. [PMID: 37796198 DOI: 10.1097/mlr.0000000000001935] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Fragmentation of health care across systems can contribute to mistakes in prescribing and filling medications among patients treated for myocardial infarction (MI). We sought to compare omissions, duplications, and delays in outpatient medications used for secondary prevention among veterans treated for MI at Veterans Affairs (VA) versus non-VA hospitals. METHODS We utilized national VA and Centers for Medicare and Medicaid Services data (2012-2018) to identify veterans 65 years or older hospitalized for MI and measured the use of outpatient medications for secondary prevention in the 30 days after MI among those treated at VA versus non-VA hospitals. RESULTS A total of 118,456 veterans experiencing MI were included; of which 102,209 were hospitalized at non-VA hospitals. An omission in any medication class occurred more frequently among veterans treated at non-VA versus VA hospitals (82.8% vs 67.8%, P < 0.001). In multivariable modeling, the odds of omissions in any medication class were higher among those treated at non-VA versus VA hospitals (odds ratio: 3.04; 95% CI: 2.88-3.20). Duplications occurred more frequently in veterans treated at non-VA versus VA hospitals: 1.9% versus 1.6% had 1 or more for non-VA versus VA hospitals ( P < 0.001). Veterans treated at non-VA hospitals were more likely to have delays of 3 days or more in prescription fills after hospital discharge (88.4% vs 70.6% across all classes, P < 0.001). CONCLUSIONS Omissions, duplications, and delays in outpatient prescribing of secondary prevention medications were more common among 118,456 veterans treated at non-VA versus VA hospitals for MI. Interventions aimed at improving care transitions and optimizing medication use among veterans treated at non-VA hospitals should be implemented.
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Affiliation(s)
- Erin R Weeda
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Healthcare System, Charleston, SC
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, Medical University of South Carolina, Charleston, SC
| | - Ralph Ward
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Healthcare System, Charleston, SC
- Department of Public Health Science, Medical University of South Carolina, Charleston, SC
| | - Mulugeta Gebregziabher
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Healthcare System, Charleston, SC
- Department of Public Health Science, Medical University of South Carolina, Charleston, SC
| | - Robert N Axon
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Healthcare System, Charleston, SC
- Department of General Internal Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - David J Taber
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Healthcare System, Charleston, SC
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC
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Rogal SS, Taddei TH, Monto A, Yakovchenko V, Patton H, Merante M, Spoutz P, Chia L, Yudkevich J, Aytaman A, Rabiee A, John BV, Blechacz B, Cai CX, Gilles H, Shah AS, McCurdy H, Puri P, Jou J, Mazhar K, Dominitz JA, Anwar J, Morgan TR, Ioannou GN. Hepatocellular Carcinoma Diagnosis and Management in 2021: A National Veterans Affairs Quality Improvement Project. Clin Gastroenterol Hepatol 2024; 22:324-338. [PMID: 37460005 PMCID: PMC10788380 DOI: 10.1016/j.cgh.2023.07.002] [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] [Received: 04/12/2023] [Revised: 06/16/2023] [Accepted: 07/02/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND & AIMS The coronavirus disease-2019 pandemic profoundly disrupted preventative health care services including cancer screening. As the largest provider of cirrhosis care in the United States, the Department of Veterans Affairs (VA) National Gastroenterology and Hepatology Program aimed to assess factors associated with hepatocellular carcinoma (HCC) stage at diagnosis, treatment, and survival. METHODS Veterans with a new diagnosis of HCC in 2021 were identified from electronic health records (N = 2306). Structured medical record extraction was performed by expert reviewers in a 10% random subsample of Veterans with new HCC diagnoses. Factors associated with stage at diagnosis, receipt of treatment, and survival were assessed using multivariable models. RESULTS Among 199 patients with confirmed HCC, the average age was 71 years and most (72%) had underlying cirrhosis. More than half (54%) were at an early stage (T1 or T2) at diagnosis. Less-advanced liver disease, number of imaging tests adequate for HCC screening, HCC diagnosis in the VA, and receipt of VA primary care were associated significantly with early stage diagnosis. HCC-directed treatments were administered to 145 (73%) patients after a median of 37 days (interquartile range, 19-54 d) from diagnosis, including 70 (35%) patients who received potentially curative treatments. Factors associated with potentially curative (vs no) treatments included HCC screening, early stage at diagnosis, and better performance status. Having fewer comorbidities and better performance status were associated significantly with noncurative (vs no) treatment. Early stage diagnosis, diagnosis in the VA system, and receipt of curative treatment were associated significantly with survival. CONCLUSIONS These results highlight the importance of HCC screening and engagement in care for HCC diagnosis, treatment, and survival while demonstrating the feasibility of developing a national quality improvement agenda for HCC screening, diagnosis, and treatment.
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Affiliation(s)
- Shari S Rogal
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Tamar H Taddei
- VA Connecticut Healthcare System, West Haven, Connecticut; Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alexander Monto
- San Francisco VA Health Care System, San Francisco, California
| | - Vera Yakovchenko
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Heather Patton
- Gastroenterology Section, Jennifer Moreno VA San Diego Healthcare System, San Diego, California
| | - Monica Merante
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Patrick Spoutz
- Pharmacy Benefits Management, Veterans Integrated Service Network 20, Vancouver, Washington
| | - Linda Chia
- Pharmacy Benefits Management, Veterans Integrated Service Network 20, Vancouver, Washington
| | - Jennifer Yudkevich
- VA New York Harbor Healthcare System, Brooklyn Campus, Brooklyn, New York
| | - Ayse Aytaman
- VA New York Harbor Healthcare System, Brooklyn Campus, Brooklyn, New York; SUNY Health Science Center Brooklyn, Brooklyn, New York
| | - Atoosa Rabiee
- Washington DC VA Medical Center, Washington, District of Columbia
| | - Binu V John
- Division of Gastroenterology and Hepatology, Miami VA Healthcare System, Miami, Florida; Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Boris Blechacz
- Department of Gastroenterology and Hepatology, VA South Texas Health Care System, San Antonio, Texas
| | - Cindy X Cai
- Department of Gastroenterology and Hepatology, VA Loma Linda Healthcare System, Loma Linda, California; Loma Linda University, Loma Linda, California; Department of Internal Medicine, University of California, Riverside, Riverside, California
| | - HoChong Gilles
- Division of Gastroenterology and Hepatology, Central Virginia VA Healthcare System, Richmond, Virginia
| | - Anand S Shah
- Division of Gastroenterology, Joseph Maxwell Cleland Atlanta VA Medical Center, Decatur, Georgia; Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Puneet Puri
- Division of Gastroenterology and Hepatology, Central Virginia VA Healthcare System, Richmond, Virginia; Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Janice Jou
- VA Portland Healthcare System, Portland, Oregon; Division of Gastroenterology and Hepatology, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Khurram Mazhar
- VA North Texas Health Care System, Dallas, Texas; Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, Washington; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
| | - Jennifer Anwar
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, California
| | - Timothy R Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, California; Division of Gastroenterology, Department of Medicine, University of California, Irvine, California
| | - George N Ioannou
- VA Puget Sound Health Care System, Seattle, Washington; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
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Apaydin EA, Paige NM, Begashaw MM, Larkin J, Miake-Lye IM, Shekelle PG. Veterans Health Administration (VA) vs. Non-VA Healthcare Quality: A Systematic Review. J Gen Intern Med 2023:10.1007/s11606-023-08207-2. [PMID: 37076605 PMCID: PMC10361919 DOI: 10.1007/s11606-023-08207-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/07/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND The Veterans Health Administration (VA) serves Veterans in the nation's largest integrated healthcare system. VA seeks to provide high quality of healthcare to Veterans, but due to the VA Choice and MISSION Acts, VA increasingly pays for care outside of its system in the community. This systematic review compares care provided in VA and non-VA settings, and includes published studies from 2015 to 2023, updating 2 prior systematic reviews on this topic. METHODS We searched PubMed, Web of Science, and PsychINFO from 2015 to 2023 for published literature comparing VA and non-VA care, including VA-paid community care. Records were included at the abstract or full-text level if they compared VA medical care with care provided in other healthcare systems, and included clinical quality, safety, access, patient experience, efficiency (cost), or equity outcomes. Data from included studies was abstracted by two independent reviewers, with disagreements resolved by consensus. Results were synthesized narratively and via graphical evidence maps. RESULTS Thirty-seven studies were included after screening 2415 titles. Twelve studies compared VA and VA-paid community care. Most studies assessed clinical quality and safety, and studies of access were second most common. Only six studies assessed patient experience and six assessed cost or efficiency. Clinical quality and safety of VA care was better than or equal to non-VA care in most studies. Patient experience in VA care was better than or equal to experience in non-VA care in all studies, but access and cost/efficiency outcomes were mixed. DISCUSSION VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety. Access, cost/efficiency, and patient experience between the two systems are not well studied. Further research is needed on these outcomes and on services widely used by Veterans in VA-paid community care, like physical medicine and rehabilitation.
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Affiliation(s)
- Eric A Apaydin
- Evidence Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- RAND Corporation, Santa Monica, CA, USA.
| | - Neil M Paige
- Evidence Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Meron M Begashaw
- Evidence Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | | | - Isomi M Miake-Lye
- Evidence Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Paul G Shekelle
- Evidence Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Abstract
Rationale: The development of novel therapies for idiopathic pulmonary fibrosis (IPF) has brought increased attention to the population burden of disease. However, little is known about the epidemiology of IPF among U.S. Veterans. Objectives: This study examines temporal trends in incidence and prevalence, patient characteristics, and risk factors associated with IPF among a national cohort of U.S. Veterans. Methods: We used data from the Veterans Health Administration (VHA) electronic health record system to describe the incidence, prevalence, and geographic distribution of IPF between January 1, 2010, and December 31, 2019. We evaluated patient characteristics associated with IPF using multivariate logistic regression. Results: Among 10.7 million Veterans who received care from the VHA between 2010 and 2019, 139,116 (1.26%) were diagnosed with IPF. Using a narrow case definition of IPF, the prevalence increased from 276 cases per 100,000 in 2010 to 725 cases per 100,000 in 2019. The annual incidence increased from 73 cases per 100,000 person-years in 2010 to 210 cases per 100,000 person-years in 2019. Higher absolute incidence and prevalence rates were noted when a broader case definition of IPF was used. Risk factors associated with IPF among Veterans included older age, White race, tobacco use, and rural residence. After accounting for interactions, the average marginal difference in IPF prevalence between males and females was small. There was significant geographic heterogeneity of disease across the United States. Conclusions: This study is the first comprehensive epidemiologic analysis of IPF among the U.S. Veteran population. The incidence and prevalence of IPF among Veterans has increased over the past decade. The effect of sex on risk of IPF was attenuated once accounting for other risk factors. The geographic distribution of disease is heterogeneous across the United States with rural residence associated with higher odds of IPF. The reasons for these trends deserve further study.
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Schleiden LJ, Zickmund SL, Roman KL, Kennedy K, Thorpe JM, Rossi MI, Niznik JD, Springer SP, Thorpe CT. Caregiver and provider perspectives on dual VA and Medicare Part D medication use in veterans with suspected dementia or cognitive impairment. Am J Health Syst Pharm 2021; 79:94-101. [PMID: 34453437 DOI: 10.1093/ajhp/zxab343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Many older veterans with dementia fill prescriptions through both Veterans Affairs (VA) and Medicare Part D benefits. Dual VA/Part D medication use may have unintended negative consequences on prescribing safety and quality. We aimed to characterize benefits and drawbacks of dual VA/Part D medication use in veterans with dementia or cognitive impairment from the perspectives of caregivers and providers. METHODS This was a qualitative study based on semistructured telephone interviews of 2 group: (1) informal caregivers accompanying veterans with suspected dementia or cognitive impairment to visits at a VA Geriatric Evaluation and Management clinic (n = 11) and (2) VA healthcare providers of veterans with dementia who obtained medications via VA and Part D (n = 12). We conducted semistructured telephone interviews with caregivers and providers about benefits and drawbacks of dual VA/Part D medication use. Interview transcripts were subjected to qualitative content analysis to identify key themes. RESULTS Caregivers and providers both described cost and convenience benefits to dual VA/Part D medication use. Caregivers reported drawbacks including poor communication between VA and non-VA providers and difficulty managing medications from multiple systems. Providers reported potential safety risks including communication barriers, conflicting care decisions, and drug interactions. CONCLUSION Results of this study allow for understanding of potential policy interventions to better manage dual VA/Part D medication use for older veterans with dementia or cognitive impairment at a time when VA is expanding access to non-VA care.
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Affiliation(s)
- Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Susan L Zickmund
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, and Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Katie Lynn Roman
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Kayla Kennedy
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, and Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Michelle I Rossi
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, and Division of Geriatrics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, and Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Sydney P Springer
- University of New England School of Pharmacy Westbrook College of Health Professions, Portland, ME, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, and Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
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Essien UR, Sileanu FE, Zhao X, Liebschutz JM, Thorpe CT, Good CB, Mor MK, Radomski TR, Hausmann LRM, Fine MJ, Gellad WF. Racial/Ethnic Differences in the Medical Treatment of Opioid Use Disorders Within the VA Healthcare System Following Non-Fatal Opioid Overdose. J Gen Intern Med 2020; 35:1537-1544. [PMID: 31965528 PMCID: PMC7210353 DOI: 10.1007/s11606-020-05645-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/30/2019] [Accepted: 01/03/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND After non-fatal opioid overdoses, opioid prescribing patterns are often unchanged and the use of medications for opioid use disorder (MOUDs) remains low. Whether such prescribing differs by race/ethnicity remains unknown. OBJECTIVE To assess the association of race/ethnicity with the prescribing of opioids and MOUDs after a non-fatal opioid overdose. DESIGN Retrospective cohort study. PARTICIPANTS Patients prescribed ≥ 1 opioid from July 1, 2010, to September 30, 2015, with a non-fatal opioid overdose in the Veterans Health Administration (VA). MAIN MEASURES Primary outcomes were the proportion of patients prescribed: (1) any opioid during the 30 days before and after overdose and (2) MOUDs within 30 days after overdose by race and ethnicity. We conducted difference-in-difference analyses using multivariable regression to assess whether the change in opioid prescribing from before to after overdose differed by race/ethnicity. We also used multivariable regression to test whether MOUD prescribing after overdose differed by race/ethnicity. KEY RESULTS Among 16,210 patients with a non-fatal opioid overdose (81.2% were white, 14.3% black, and 4.5% Hispanic), 10,745 (66.3%) patients received an opioid prescription (67.1% white, 61.7% black, and 65.9% Hispanic; p < 0.01) before overdose. After overdose, the frequency of receiving opioids was reduced by 18.3, 16.4, and 20.6 percentage points in whites, blacks, and Hispanics, respectively, with no significant difference-in-difference in opioid prescribing by race/ethnicity (p = 0.23). After overdose, 526 (3.2%) patients received MOUDs (2.9% white, 4.6% black, and 5.5% Hispanic; p < 0.01). Blacks (adjusted OR (aOR) 1.6; 95% CI 1.2, 1.9) and Hispanics (aOR 1.8; 95% CI 1.2, 2.6) had significantly larger odds of receiving MOUDs than white patients. CONCLUSIONS In a national cohort of patients with non-fatal opioid overdose in VA, there were no racial/ethnic differences in changes in opioid prescribing after overdose. Although blacks and Hispanics were more likely than white patients to receive MOUDs in the 30 days after overdose, less than 4% of all groups received such therapy.
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Affiliation(s)
- Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas R Radomski
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Hynes DM, Maciejewski ML, Atkins D. HSR Commentary: Linking VA and Non-VA Data to Address Important US Veteran Health Services Research Issues. Health Serv Res 2019; 53 Suppl 3:5133-5139. [PMID: 30430570 DOI: 10.1111/1475-6773.13081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE This commentary summarizes the methods and topics addressed in the special issue of HSR focused on linkage of United States Department of Veterans Affairs (VA) and non-VA datasets. The issue illustrates that researchers are increasingly linking diverse datasets as a valuable method for obtaining outcomes, treatments, and covariates to evaluate and examine health care delivery that includes non-VA services. The issue serves as a reference to VA and non-VA investigators alike who employ data linkage methods to address high-impact clinical and health policy evaluations that span different care systems and different datasets.
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Affiliation(s)
- Denise M Hynes
- Center to Improve Veteran Involvement in Care, Veterans Affairs Portland VA Health Care System, Portland, OR.,Veterans Affairs Information Resource Center, Hines, IL.,College of Public Health and Human Sciences, Oregon State University, Corvallis, OR
| | - Matthew L Maciejewski
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, NC.,Department of Department of Population Health Sciences, Duke University, Durham, NC
| | - David Atkins
- Department of Veterans Affairs, Office of Research and Development, Washington, DC
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Moyo P, Zhao X, Thorpe CT, Thorpe JM, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Donohue JM, Hausmann LRM, Hanlon JT, Good CB, Fine MJ, Gellad WF. Dual Receipt of Prescription Opioids From the Department of Veterans Affairs and Medicare Part D and Prescription Opioid Overdose Death Among Veterans: A Nested Case-Control Study. Ann Intern Med 2019; 170:433-442. [PMID: 30856660 PMCID: PMC6736692 DOI: 10.7326/m18-2574] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND More than half of enrollees in the U.S. Department of Veterans Affairs (VA) are also covered by Medicare and can choose to receive their prescriptions from VA or from Medicare-participating providers. Such dual-system care may lead to unsafe opioid use if providers in these 2 systems do not coordinate care or if prescription use is not tracked between systems. OBJECTIVE To evaluate the association between dual-system opioid prescribing and death from prescription opioid overdose. DESIGN Nested case-control study. SETTING VA and Medicare Part D. PARTICIPANTS Case and control patients were identified from all veterans enrolled in both VA and Part D who filled at least 1 opioid prescription from either system. The 215 case patients who died of a prescription opioid overdose in 2012 or 2013 were matched (up to 1:4) with 833 living control patients on the basis of date of death (that is, index date), using age, sex, race/ethnicity, disability, enrollment in Medicaid or low-income subsidies, managed care enrollment, region and rurality of residence, and a medication-based measure of comorbid conditions. MEASUREMENTS The exposure was the source of opioid prescriptions within 6 months of the index date, categorized as VA only, Part D only, or VA and Part D (that is, dual use). The outcome was unintentional or undetermined-intent death from prescription opioid overdose, identified from the National Death Index. The association between this outcome and source of opioid prescriptions was estimated using conditional logistic regression with adjustment for age, marital status, prescription drug monitoring programs, and use of other medications. RESULTS Among case patients, the mean age was 57.3 years (SD, 9.1), 194 (90%) were male, and 181 (84%) were non-Hispanic white. Overall, 60 case patients (28%) and 117 control patients (14%) received dual opioid prescriptions. Dual users had significantly higher odds of death from prescription opioid overdose than those who received opioids from VA only (odds ratio [OR], 3.53 [95% CI, 2.17 to 5.75]; P < 0.001) or Part D only (OR, 1.83 [CI, 1.20 to 2.77]; P = 0.005). LIMITATION Data are from 2012 to 2013 and cannot capture prescriptions obtained outside the VA or Medicare Part D systems. CONCLUSION Among veterans enrolled in VA and Part D, dual use of opioid prescriptions was independently associated with death from prescription opioid overdose. This risk factor for fatal overdose among veterans underscores the importance of care coordination across health care systems to improve opioid prescribing safety. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
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Affiliation(s)
- Patience Moyo
- Brown University School of Public Health, Providence, Rhode Island (P.M.)
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - Carolyn T Thorpe
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina (C.T.T., J.M.T.)
| | - Joshua M Thorpe
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina (C.T.T., J.M.T.)
| | - Florentina E Sileanu
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - John P Cashy
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - Jennifer A Hale
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - Maria K Mor
- VA Pittsburgh Healthcare System and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (M.K.M., J.M.D.)
| | - Thomas R Radomski
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F.)
| | - Julie M Donohue
- VA Pittsburgh Healthcare System and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (M.K.M., J.M.D.)
| | - Leslie R M Hausmann
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F.)
| | - Joseph T Hanlon
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania; VA Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, Pennsylvania (J.T.H.)
| | - Chester B Good
- VA Pittsburgh Healthcare System, University of Pittsburgh School of Medicine, and UPMC Health Plan, Pittsburgh, Pennsylvania (C.B.G.)
| | - Michael J Fine
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F.)
| | - Walid F Gellad
- VA Pittsburgh Healthcare System, and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (W.F.G.)
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9
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Schleiden LJ, Thorpe CT, Cashy JP, Gellad WF, Good CB, Hanlon JT, Mor MK, Niznik JD, Pleis JR, Van Houtven CH, Thorpe JM. Characteristics of dual drug benefit use among veterans with dementia enrolled in the Veterans Health Administration and Medicare Part D. Res Social Adm Pharm 2018; 15:701-709. [PMID: 30236896 DOI: 10.1016/j.sapharm.2018.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/29/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Obtaining prescription medications from multiple health systems may complicate coordination of care. Older Veterans who obtain medications concurrently through Veterans Affairs (VA) benefits and Medicare Part D benefits (dual users) are at higher risk of unintended negative outcomes. OBJECTIVE To explore characteristics predicting dual drug benefit use from both VA and Medicare Part D in a national sample of older Veterans with dementia. METHODS Administrative data were obtained from the VA and Medicare for a national sample of 110,828 Veterans with dementia ages 68 and older in 2010. Veterans were classified into three drug benefit user groups based on the source of all prescription medications they obtained in 2010: VA-only, Part D-only, and Dual Use. Multinomial logistic regression was used to examine predictors of drug benefit user group. The source of prescriptions was described for each of the ten most frequently used drug classes and opioids. RESULTS Fifty-six percent of Veterans received all of their prescription medications from VA-only, 28% from Part D-only, and 16% from both VA and Part D. Veterans who were eligible for Medicaid or who had a priority group score conferring less generous drug benefits within the VA were more likely to be Part D-only or dual users. Nearly one fourth of Veterans taking opioids concurrently received opioid prescriptions from dual sources (24.7%). CONCLUSIONS Medicaid eligibility and Veteran priority group status, which largely decrease copayments for drugs obtained outside versus within the VA, respectively, were the main factors predicting drug user benefit group. Policies to encourage single-system prescribing and enhance communication across health systems are crucial to preventing negative health outcomes related to care fragmentation.
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Affiliation(s)
- Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, United States.
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, United States
| | - John P Cashy
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of General Internal Medicine, School of Medicine, University of Pittsburgh, University of Pittsburgh Medical Center Montefiore Hospital, Suite W933, Pittsburgh, PA, 5213, United States
| | - Chester B Good
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, United States; Division of General Internal Medicine, School of Medicine, University of Pittsburgh, University of Pittsburgh Medical Center Montefiore Hospital, Suite W933, Pittsburgh, PA, 5213, United States; Center for Value Based Pharmacy Initiatives, University of Pittsburgh Medical Center, 600 Grant St, Pittsburgh, PA, 15219, United States
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, 3471 Fifth Ave, Kaufmann Medical Building, Suite 500, Pittsburgh, PA, 15213, United States
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, 130 De Soto St, Pittsburgh, PA, 15261, United States
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, United States; Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, 3471 Fifth Ave, Kaufmann Medical Building, Suite 500, Pittsburgh, PA, 15213, United States
| | - John R Pleis
- National Center for Health Statistics, Centers for Disease Control and Prevention, Division of Research and Methodology, 3311 Toledo Road, Hyattsville, MD, 20782, United States
| | - Courtney H Van Houtven
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, VA Medical Center (152), 508 Fulton St., Durham, NC, 27705, United States; Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Imperial Center, Durham, NC, 27713, United States
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, United States; Veterans Experience Center, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Annex Suite 202, Philadelphia, PA, 19104, United States
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