Quality of ambulatory care for women and men in the Veterans Affairs Health Care System

Long-Term Outcomes and Duration of Dual Antiplatelet Therapy After Coronary Intervention With Second-Generation Drug-Eluting Stents: The Veterans Affairs Extended DAPT Study

Background Recent guidelines on dual antiplatelet therapy (DAPT) duration after percutaneous coronary intervention (PCI) balance the subsequent risks of major bleeding with ischemic events. Although generally favoring shorter DAPT duration with second-generation drug-eluting stents, the effects on long-term outcomes in the wider population are uncertain. Methods and Results We tracked all patients having PCI with second-generation drug-eluting stents in the Veterans Affairs Healthcare System between 2006 and 2016 for death, myocardial infarction, stroke, and major bleeding up to 13 years. We compared these outcomes with 4 DAPT durations of 1 to 5, 6 to 9, 10 to 12, and 13 to 18 months after the index PCI using hazard ratios (HRs) and 95% CIs from Cox proportional hazards models adjusted by inverse probability weighting. A total of 40 882 subjects with PCI were followed up for a median of 4.3 (25%-75%: 2.4-6.5) years. DAPT discontinuation was rare early after PCI (5.8% at 1-5 months and 6.3% at 6-9 months) but increased (19% and 44%) >9 months. The risk of cardiovascular and noncardiovascular death was higher (HR, 2.03-3.41) with DAPT discontinuation <9 months, likely reflecting premature cessation from factors related to early death. DAPT discontinuation after 9 months following PCI was associated with lower risks of death (HR, 0.93 [95% CI, 0.88-0.99]), cardiac death (HR, 0.79 [95% CI, 0.70-0.90]), myocardial infarction (HR, 0.75 [95% CI, 0.69-0.82]), and major bleeding (HR, 0.82 [95% CI, 0.74-0.91]). Results were similar with an index PCI for an acute coronary syndrome. Conclusions Stopping DAPT after 9 months is associated with lower long-term risks of adverse ischemic and bleeding events and supports recent guidelines of shorter duration DAPT after PCI with second-generation drug-eluting stents.

Cardiovascular Risk Screening among Women Veterans: Identifying Provider and Patient Barriers and Facilitators to Develop a Clinical Toolkit

INTRODUCTION

Cardiovascular (CV) disease is the leading cause of death among women in the United States, making CV risk screening and management a women's health priority. Objectives were to elicit barriers and facilitators to CV risk identification and reduction among women veterans, and iteratively cocreate clinical tools to identify CV risk factors and promote goal-setting for lifestyle changes.

METHODS

We conducted three exploratory focus groups with 21 Veterans Health Administration primary care team members and piloted patient CV screeners with brief interviews with 19 patients from two Veterans Health Administration women's clinics to inform toolkit development. We then conducted two focus groups and one interview for feedback from a total of 12 staff on the proposed toolkit components. Transcripts were summarized, and a matrix analysis was used to synthesize qualitative findings.

RESULTS

Provider-identified barriers included difficulties disseminating CV information in clinic, limited patient knowledge, and lack of organized resources for provider communication and available referrals. Women's complex health needs were notable challenges to CV risk reduction. Facilitators included having a single place to track patient CV risks (e.g., an electronic template note), a patient screening worksheet, and aids to complete referrals. Patient-identified barriers included difficulties balancing health, finances, and physical and mental health concerns. Facilitators included resources for accountability and gender-specific information about CV risks and complications. Providers requested easy, accessible tools in the electronic record with gender-specific CV data and resources linked. Patients requested lifestyle change supports, including trustworthy sources vetted by providers.

CONCLUSIONS

Iteratively eliciting end-users' perspectives is critical to developing user-friendly, clinically relevant tools. CV risk reduction among women veterans will require multilevel tools and resources that meet providers' and women's needs.

Premature Discontinuation of Dual Antiplatelet Therapy After Coronary Stenting in Veterans: Characteristics and Long-Term Outcomes

Background Premature discontinuation of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention is related to higher short-term risks of adverse outcomes. Whether these risks persist in the long-term is uncertain. Methods and Results We assessed all patients having percutaneous coronary intervention with coronary second- or first-generation drug-eluting stents in the Veterans Affairs healthcare system between 2006 and 2012 who were free of major ischemic or bleeding events in the first 12 months. The characteristics of patients who stopped DAPT prematurely (1-9 months duration), compared with >9 to 12 months, or extended duration (>12 months) were assessed by odds ratios (ORs) from multivariable logistic models. The risk of adverse clinical outcomes over a mean 5.1 years in patients who stopped DAPT prematurely was assessed by hazard ratios (HRs) and 95% CIs from Cox regression models. A total of 14 239 had second-generation drug-eluting stents, and 8583 had first-generation drug-eluting stents. Premature discontinuation of DAPT was more likely in Black patients (OR, 1.54; 95% CI, 1.40-1.68), patients with greater frailty (OR, 1.04; 95% CI, 1.03-1.05), and patients with higher low-density lipoprotein cholesterol, and less likely in patients on statins (OR, 0.87; 95% CI, 0.80-0.95). Patients who stopped DAPT prematurely had higher long-term risks of death (second-generation drug-eluting stents: HR, 1.35; 95% CI, 1.19-1.56), myocardial infarction (second-generation drug-eluting stents: HR, 1.46; 95% CI, 1.22-1.74), and repeated coronary revascularization (second-generation drug-eluting stents: HR, 1.24; 95% CI, 1.08-1.41). Conclusions Patients who stop DAPT prematurely have features that reflect greater frailty, poorer medication use, and other social factors. They continue to have higher risks of major adverse outcomes over the long-term and may require more intensive surveillance many years after percutaneous coronary intervention.

Inverse relationship between nonadherence to original GOLD treatment guidelines and exacerbations of COPD

Background

Prescriber disagreement is among the reasons for poor adherence to COPD treatment guidelines; it is yet not clear whether this leads to adverse outcomes. We tested whether undertreatment according to the original Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines led to increased exacerbations.

Methods

Records of 878 patients with spirometrically confirmed COPD who were followed from 2005 to 2010 at one Veterans Administration (VA) Medical Center were analyzed. Analysis of variance was performed to assess differences in exacerbation rates between severity groups. Logistic regression analysis was performed to assess the relationship between noncompliance with guidelines and exacerbation rates.

Findings

About 19% were appropriately treated by guidelines; 14% overtreated, 44% under-treated, and in 23% treatment did not follow any guideline. Logistic regression revealed a strong inverse relationship between undertreatment and exacerbation rate when severity of obstruction was held constant. Exacerbations per year by GOLD stage were significantly different from each other: mild 0.15, moderate 0.27, severe 0.38, very severe 0.72, and substantially fewer than previously reported.

Interpretation

The guidelines were largely not followed. Undertreatment predominated but, contrary to expectations, was associated with fewer exacerbations. Thus, clinicians were likely advancing therapy primarily based upon exacerbation rates as was subsequently recommended in revised GOLD and other more recent guidelines. In retrospect, a substantial lack of prescriber adherence to treatment guidelines may have been a signal that they required re-evaluation. This is likely to be a general principle regarding therapeutic guidelines. The identification of fewer exacerbations in this cohort than has been generally reported probably reflects the comprehensive nature of the VA system, which is more likely to identify relatively asymptomatic (ie, nonexacerbating) COPD patients. Accordingly, these rates may better reflect those in the general population. In addition, the lower rates may reflect the more complete preventive care provided by the VA.

Long-term outcomes in patients with acute coronary syndromes related to prolonging dual antiplatelet therapy more than 12 months after coronary stenting

OBJECTIVES

To assess the impact of stent type on the risk of death or myocardial infarction (MI) related to dual antiplatelet therapy (DAPT) more than 12 months (prolonged DAPT) versus 12 or less months after PCI for an acute coronary syndrome (ACS).

BACKGROUND

The recent DAPT study reported lower recurrent ischemic events from prolonged DAPT in patients treated with PCI for an ACS, but was underpowered to determine the impact of stent type.

METHODS

We determined clinical outcomes after PCI for an ACS (median follow-up: DES = 26 months, BMS = 46 months) in 18,484 patients in the Veterans Affairs system treated with first generation drug-eluting stents (DES) or bare-metal stents (BMS). We used landmark analyses starting 1 year after the index PCI to assess the risk of prolonged DAPT on the primary endpoint of death or MI. Multivariable and propensity models adjusted for confounding.

RESULTS

There was a significant interaction between stent type and prolonged DAPT for death and MI (P = 0.0036), death (P = 0.054), and major bleeding (P = 0.0013). Patients treated with prolonged DAPT had lower risks of death or MI (HR = 0.71, 95% CI = 0.61, 0.82) and death (HR = 0.74, 95%CI = 0.62, 0.89) with DES, but not BMS, and higher risks of major bleeding, particularly with BMS (HR = 1.67, P < 0.001) than DES (HR = 1.24, p = 0.01).

CONCLUSIONS

Prolonging DAPT more than 12 months after PCI for ACS only associated with a lower risk of ischemic events in the 1-4 years after PCI in those receiving first generation DES. Stent type may influence the benefit of prolonged DAPT. © 2016 Wiley Periodicals, Inc.

Long-Term Outcomes in Patients With Diabetes Mellitus Related to Prolonging Clopidogrel More Than 12 Months After Coronary Stenting

BACKGROUND

Recent large clinical trials show lower rates of late cardiovascular events by extending clopidogrel >12 months after percutaneous coronary revascularization (PCI). However, concerns of increased bleeding have elicited support for limiting prolonged treatment to high-risk patients.

OBJECTIVES

The aim of this analysis was to determine the effect of prolonging clopidogrel therapy >12 months versus ≤12 months after PCI on very late outcomes in patients with diabetes mellitus (DM).

METHODS

Using the Veterans Health Administration, 28,849 patients undergoing PCI between 2002 and 2006 were categorized into 3 groups: 1) 16,332 without DM; 2) 9,905 with DM treated with oral medications or diet; and 3) 2,612 with DM treated with insulin. Clinical outcomes, stratified by stent type, ≤4 years after PCI were determined from the Veterans Health Administration and Medicare databases and risk was assessed by multivariable and propensity score analyses using a landmark analysis starting 1 year after the index PCI. The primary endpoint of the study was the risk of all-cause death or myocardial infarction (MI).

RESULTS

In patients with DM treated with insulin who received drug-eluting stents (DES), prolonged clopidogrel treatment was associated with a decreased risk of death (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.42 to 0.82) and death or MI (HR: 0.67; 95% CI: 0.49 to 0.92). Similarly, in patients with noninsulin-treated DM receiving DES, prolonged clopidogrel treatment was associated with less death (HR: 0.61; 95% CI: 0.48 to 0.77) and death or MI (HR: 0.61; 95% CI: 0.5 to 0.75). Prolonged clopidogrel treatment was not associated with a lower risk in patients without DM or in any group receiving bare-metal stents.

CONCLUSIONS

Extending the duration of clopidogrel treatment >12 months may decrease very late death or MI only in patients with DM receiving first-generation DES. Future studies should address this question in patients receiving second-generation DES.

Outcomes with prolonged clopidogrel therapy after coronary stenting in patients with chronic kidney disease

OBJECTIVES

Patients with chronic kidney disease (CKD) are at high risk of death or myocardial infarction (MI) after percutaneous coronary interventions (PCI). We assessed whether prolonged dual antiplatelet therapy beyond the recommended 12 months may prevent adverse outcomes in patients with CKD receiving drug-eluting stents (DES) or bare-metal stents (BMS).

METHODS

We studied all Veterans receiving PCI with BMS or first-generation DES in the Veterans Affairs (VA) Healthcare System between 2002 and 2006, classified by CKD (estimated glomerular filtration rate <60 mL/min) or normal renal function. We used landmark analyses from 12 months after PCI with Cox proportional hazards multivariable and propensity-adjusted models to assess the effect of prolonged clopidogrel (more than 12  months) versus 12 months or less after PCI on clinical outcomes from 1 year to 4 years after PCI.

RESULTS

Of 23 042 eligible subjects receiving PCI, 4880 (21%) had CKD. Compared with normal renal function, patients with CKD had higher risks of death or MI 1-4 years after DES (21% vs 12%, HR=1.75; 95% CI 1.51 to 2.04) or BMS (28% vs 15%, HR=2.10; 95% CI 1.90 to 2.32). In patients with CKD receiving DES, clopidogrel use of more than 12 months after PCI was associated with lower risks of death or MI (18% vs 24%, HR=0.74; 95% CI 0.58 to 0.95), and death (15% vs 23%, HR=0.61; 95% CI 0.47 to 0.80), but had no effect on repeat revascularisation 1-4 years after PCI.

CONCLUSIONS

In patients with CKD, prolonging clopidogrel beyond 12 months after PCI may decrease the risk of death or MI only in patients receiving first-generation DES. These results support a patient-tailored approach to prolonging clopidogrel after PCI.

Associations between provider designation and female-specific cancer screening in women Veterans

BACKGROUND

In 2010, the Department of Veterans Affairs Healthcare System (VA) implemented policy to provide Comprehensive Primary Care (for acute, chronic, and female-specific care) from designated Women's Health providers (DWHPs) at all VA sites. However, since that time no comparisons of quality measures have been available to assess the level of care for women Veterans assigned to these providers.

OBJECTIVES

To evaluate the associations between cervical and breast cancer screening rates among age-appropriate women Veterans and designation of primary-care provider (DWHP vs. non-DWHP).

RESEARCH DESIGN

Cross-sectional analyses using the fiscal year 2012 data on VA women's health providers, administrative files, and patient-specific quality measures.

SUBJECTS

The sample included 37,128 women Veterans aged 21 through 69 years.

MEASURES

Variables included patient demographic and clinical factors (ie, age, race, ethnicity, mental health diagnoses, obesity, and site), and provider factors (ie, DWHP status, sex, and panel size). Screening measures were defined by age-appropriate subgroups using VA national guidelines.

RESULTS

Female-specific cancer screening rates were higher among patients assigned to DWHPs (cervical cytology 94.4% vs. 91.9%, P<0.0001; mammography 86.3% vs. 83.3%, P<0.0001). In multivariable models with adjustment for patient and provider characteristics, patients assigned to DWHPs had higher odds of cervical cancer screening (odds ratio, 1.26; 95% confidence interval, 1.07-1.47; P<0.0001) and breast cancer screening (odds ratio, 1.24; 95% CI, 1.10-1.39; P<0.0001).

CONCLUSIONS

As the proportion of women Veterans increases, assignment to DWHPs may raise rate of female-specific cancer screening within VA. Separate evaluation of sex neutral measures is needed to determine whether other measures accrue benefits for patients with DWHPs.

Improving care of chronic conditions for women veterans: identifying opportunities for comparative effectiveness research

This article aims to critically analyze research focused on the findings for five chronic conditions: chronic pain, diabetes, cardiovascular disease, HIV and cancer among women veterans to identify opportunities for comparative effectiveness research. We provide a descriptive analysis from the relevant articles in prior systematic reviews. In order to identify potential gaps in research for these specific conditions, we also conducted a literature search to highlight studies focusing on women veterans published since the last systematic review. While the scientific knowledge base has grown for these chronic conditions among women veterans, the vast majority of the published literature remains descriptive and/or observational, with only a few studies examining gender differences and even fewer clinical trials. There is a need to conduct comparative effectiveness research on chronic conditions among women veterans to improve health and healthcare.

Accounting for clinical action reduces estimates of gender disparities in lipid management for diabetic veterans

BACKGROUND

Women with diabetes have higher low-density lipoprotein (LDL) levels than men, resulting in apparent disparities between genders on quality indicators tied to LDL thresholds.

OBJECTIVE

To investigate whether gender disparities persist when accounting for clinical action with statins or cardiovascular risk.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Veterans Health Administration patients (21,780 women and 646,429 men) aged 50-75 with diabetes.

MAIN MEASURES

Threshold measure: LDL < 100 mg/dL; clinical action measure: LDL < 100 mg/dL; or LDL ≥ 100 mg/dL and the patient was prescribed a moderate or high-dose statin at the time of the test; or LDL ≥ 100 mg/dL and the patient received other appropriate clinical action within 90 days; adherence: continuous multiple interval measure of gaps in dispensed medication (CMG).

KEY RESULTS

Women were much less likely to have LDL < 100 mg/dL than were men (55 % vs. 68 %). This disparity narrowed from 13 % to 6 % for passing the clinical action measure (79 % vs. 85 %). These gender differences persisted among those with ischemic heart disease (IHD). Women had a lower odds of passing the clinical action measure (odds ratio 0.68, 95 % confidence interval 0.66-0.71). Among those with IHD, the gender gap increased with age. Differences in pass rates were explained by women's higher LDL levels, but not by their slightly worse adherence (3 % higher CMG).

CONCLUSIONS

Women and men veterans receive more similar quality of care for lipids in diabetes than previously indicated. Less reassuringly, the remaining gender differences appear to be as common in women at high cardiovascular risk as in those at low risk. Rather than focus on simply improving LDL levels in all women with diabetes, future efforts should ensure that patients with high cardiovascular risk are appropriately treated with statins when clinically indicated, feasible, and concordant with patient preferences.

Prolonged clopidogrel use after bare metal and drug-eluting stent placement: the Veterans Administration drug-eluting stent study

BACKGROUND

Current guidelines recommend combining clopidogrel with aspirin for up to 1 year after coronary stenting, but the value of clopidogrel beyond this time is uncertain.

METHODS AND RESULTS

We evaluated all patients in the Veterans Administration healthcare system receiving either drug-eluting or bare metal stents from 2002 to 2006. The Veterans Administration National Patient Care and Pharmacy databases were used to extract patient characteristics, duration of clopidogrel use, and outcomes for up to 4 years after the index procedure. We used Cox proportional hazards to estimate hazard ratios for death, myocardial infarction, revascularization, and bleeding from a 12-month landmark after stenting that excluded patients with events within the first 12 months. Of 42,254 patients, 29,175 met the study inclusion criteria. Compared with ≤12 months of clopidogrel, prolonged clopidogrel (>12 months) was associated with a lower adjusted risk of death for both drug-eluting stents (hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.61, 0.82; P<0.01) and bare metal stents (HR, 0.85; 95% CI, 0.76, 0.96; P=0.01) as well as for death and myocardial infarction but was unrelated to stroke or major bleeding. The effect of prolonged clopidogrel on death or myocardial infarction was significantly greater among patients receiving drug-eluting (HR, 0.70; 95% CI, 0.64, 0.84) compared with bare metal stents (HR, 0.88; 95% CI, 0.79, 0.98; interaction P=0.024).

CONCLUSIONS

Patients receiving clopidogrel beyond 12 months had a lower risk of death or myocardial infarction compared patients receiving clopidogrel ≤12 months. The risk reduction was greater for drug-eluting stents. These data support longer durations of dual antiplatelet therapy for patients receiving a stent, particularly for those receiving a drug-eluting stent.

Effect of patient selection method on provider group performance estimates

BACKGROUND

Performance measurement at the provider group level is increasingly advocated, but different methods for selecting patients when calculating provider group performance have received little evaluation.

OBJECTIVE

We compared 2 currently used methods according to characteristics of the patients selected and impact on performance estimates.

RESEARCH DESIGN, SUBJECTS, AND MEASURES

We analyzed Medicare claims data for fee-for-service beneficiaries with diabetes ever seen at an academic multispeciality physician group in 2003 to 2004. We examined sample size, sociodemographics, clinical characteristics, and receipt of recommended diabetes monitoring in 2004 for the groups of patients selected using 2 methods implemented in large-scale performance initiatives: the Plurality Provider Algorithm and the Diabetes Care Home method. We examined differences among discordantly assigned patients to determine evidence for differential selection regarding these measures.

RESULTS

Fewer patients were selected under the Diabetes Care Home method (n=3558) than the Plurality Provider Algorithm (n=4859). Compared with the Plurality Provider Algorithm, the Diabetes Care Home method preferentially selected patients who were female, not entitled because of disability, older, more likely to have hypertension, and less likely to have kidney disease and peripheral vascular disease, and had lower levels of predicted utilization. Diabetes performance was higher under Diabetes Care Home method, with 67% versus 58% receiving >1 A1c tests, 70% versus 65% receiving ≥1 low-density lipoprotein (LDL) test, and 38% versus 37% receiving an eye examination.

CONCLUSIONS

The method used to select patients when calculating provider group performance may affect patient case mix and estimated performance levels, and warrants careful consideration when comparing performance estimates.

Variation in prescription use and spending for lipid-lowering and diabetes medications in the Veterans Affairs Healthcare System

OBJECTIVES

To examine variation in outpatient prescription use and spending for hyperlipidemia and diabetes mellitus in the Veterans Affairs Healthcare System (VA) and its association with quality measures for these conditions.

STUDY DESIGN

Cross-sectional.

METHODS

We compared outpatient prescription use, spending, and quality of care across 135 VA medical centers (VAMCs) in fiscal year 2008, including 2.3 million patients dispensed lipid-lowering medications and 981,031 patients dispensed diabetes medications. At each facility, we calculated VAMC-level cost per patient for these medications, the proportion of patients taking brand-name drugs, and Healthcare Effectiveness Data and Information Set (HEDIS) scores for hyperlipidemia (low-density lipoprotein cholesterol level <100 mg/dL) and for diabetes (glycosylated hemoglobin level >9% or not measured).

RESULTS

The median cost per patient for lipid-lowering agents in fiscal year 2008 was $49.60 and varied from $39.68 in the least expensive quartile of VAMCs to $69.57 in the most expensive quartile (P < .001). For diabetes agents, the median cost per patient was $158.34 and varied from $123.34 in the least expensive quartile to $198.31 in the most expensive quartile (P < .001). The proportion of patients dispensed brand-name oral drugs among these classes in the most expensive quartile of VAMCs was twice that in the least expensive quartile (P < .001). There was no correlation between VAMC-level prescription spending and performance on HEDIS measures for lipid-lowering drugs (r = 0.12 and r = 0.07) or for diabetes agents (r = -0.10).

CONCLUSIONS

Despite the existence of a closely managed formulary, significant variation in prescription spending and use of brand-name drugs exists in the VA. Although we could not explicitly risk-adjust, there appears to be no relationship between prescription spending and quality of care.

Gender influence in influenza vaccine uptake in Spain: time trends analysis (1995-2006)

This study aims to analyze gender differences in influenza vaccine coverage and predictors of vaccine uptake in Spain from year 1995 to 2006. We used data obtained from the Spanish National Health Surveys (NHSS) conducted in 1995, 1997, 2001, 2003 and 2006. Only subjects for whom the vaccine was recommended in Spain (age >or=65 years and <65 years with an associated chronic condition) during the entire study period were analyzed. Influenza vaccination status was self-reported. Independent variables included: year of survey, age, marital status, educational level, size of town, physician visits and chronic conditions. The study population included 26,653 (15,973 women and 10,680 men) individuals and 54.9% (CI 95% 54.3-55.5) were vaccinated. Vaccination coverage was higher among men than women in each and all of the NHSS analyzed. Positive predictors of vaccine uptake were the same among women and men including: higher age, being married, lower educational level, "Physician visits in last four weeks"; and the presence of associated chronic condition. Time trends 1995/1997-2006 showed that the coverage has improved for women (OR 1.12 CI 95% 1.09-1.16) and men (OR 1.11 CI 95% 1.06-1.15). Over the whole study period men had 12% greater probability of having received the vaccine. We conclude that in Spain there are significant gender differences in influenza vaccine uptake with lower coverage among women. These differences have remained throughout all years studied. We suggest that possible explanations for the lower uptake among women could include less social support, differences in the health status and provider bias.

An evaluation of gender equity in different models of primary care practices in Ontario

BACKGROUND

The World Health Organization calls for more work evaluating the effect of health care reforms on gender equity in developed countries. We performed this evaluation in Ontario, Canada where primary care models resulting from reforms co-exist.

METHODS

This cross sectional study of primary care practices uses data collected in 2005-2006. Healthcare service models included in the study consist of fee for service (FFS) based, salaried, and capitation based. We compared the quality of care delivered to women and men in practices of each model. We performed multi-level, multivariate regressions adjusting for patient socio-demographic and economic factors to evaluate vertical equity, and adjusting for these and health factors in evaluating horizontal equity. We measured seven dimensions of health service delivery (e.g. accessibility and continuity) and three dimensions of quality of care using patient surveys (n = 5,361) and chart abstractions (n = 4,108).

RESULTS

Health service delivery measures were comparable in women and men, with differences

CONCLUSIONS

The observed differences in the type of health promotion subjects discussed are likely an appropriate response to the differential healthcare needs between genders. Chronic disease care is non equitable in FFS but not in capitation based models. We recommend that efforts to monitor and address gender based differences in the delivery of chronic disease management in primary care be pursued.

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MESH Headings

• Chronic Disease/therapy
• Cross-Sectional Studies
• Delivery of Health Care/organization & administration
• Delivery of Health Care/statistics & numerical data
• Female
• Humans
• Male
• Models, Organizational
• Ontario
• Prejudice
• Primary Health Care/organization & administration
• Primary Health Care/statistics & numerical data
• Quality of Health Care
• Sex Factors

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Affiliation(s)

Simone Dahrouge C.T. Lamont Primary Health Care Research Centre, Élisabeth Bruyère Research Institute, 43 Bruyère Street, Ottawa, Ontario, Canada
William Hogg C.T. Lamont Primary Health Care Research Centre, Élisabeth Bruyère Research Institute, 43 Bruyère Street, Ottawa, Ontario, Canada University of Ottawa, Department of Family Medicine, 43 Bruyère St, Ottawa, Ontario, Canada University of Ottawa, Department of Epidemiology and Community Medicine, 451 Smyth Road, Ottawa, Ontario, Canada
Meltem Tuna C.T. Lamont Primary Health Care Research Centre, Élisabeth Bruyère Research Institute, 43 Bruyère Street, Ottawa, Ontario, Canada
Grant Russell C.T. Lamont Primary Health Care Research Centre, Élisabeth Bruyère Research Institute, 43 Bruyère Street, Ottawa, Ontario, Canada University of Ottawa, Department of Family Medicine, 43 Bruyère St, Ottawa, Ontario, Canada University of Ottawa, Department of Epidemiology and Community Medicine, 451 Smyth Road, Ottawa, Ontario, Canada
Rose Anne Devlin University of Ottawa, Department of Epidemiology and Community Medicine, 451 Smyth Road, Ottawa, Ontario, Canada
Peter Tugwell University of Ottawa, Department of Epidemiology and Community Medicine, 451 Smyth Road, Ottawa, Ontario, Canada University of Ottawa, Institute of Population Health, 1 Stewart St, Room 300, Ottawa, Ontario, Canada
Elisabeth Kristjansson University of Ottawa, Institute of Population Health, 1 Stewart St, Room 300, Ottawa, Ontario, Canada

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Patient- and system-related barriers for the earlier diagnosis of colorectal cancer

Background

A cohort of colorectal cancer (CRC) patients represents an opportunity to study missed opportunities for earlier diagnosis. Primary objective: To study the epidemiology of diagnostic delays and failures to offer/complete CRC screening. Secondary objective: To identify system- and patient-related factors that may contribute to diagnostic delays or failures to offer/complete CRC screening.

Methods

Setting: Rural Veterans Administration (VA) Healthcare system. Participants: CRC cases diagnosed within the VA between 1/1/2000 and 3/1/2007. Data sources: progress notes, orders, and pathology, laboratory, and imaging results obtained between 1/1/1995 and 12/31/2007. Completed CRC screening was defined as a fecal occult blood test or flexible sigmoidoscopy (both within five years), or colonoscopy (within 10 years); delayed diagnosis was defined as a gap of more than six months between an abnormal test result and evidence of clinician response. A summary abstract of the antecedent clinical care for each patient was created by a certified gastroenterologist (GI), who jointly reviewed and coded the abstracts with a general internist (TW).

Results

The study population consisted of 150 CRC cases that met the inclusion criteria. The mean age was 69.04 (range 35-91); 99 (66%) were diagnosed due to symptoms; 61 cases (46%) had delays associated with system factors; of them, 57 (38% of the total) had delayed responses to abnormal findings. Fifteen of the cases (10%) had prompt symptom evaluations but received no CRC screening; no patient factors were identified as potentially contributing to the failure to screen/offer to screen. In total, 97 (65%) of the cases had missed opportunities for early diagnosis and 57 (38%) had patient factors that likely contributed to the diagnostic delay or apparent failure to screen/offer to screen.

Conclusion

Missed opportunities for earlier CRC diagnosis were frequent. Additional studies of clinical data management, focusing on following up abnormal findings, and offering/completing CRC screening, are needed.

Does sex influence immunization status for influenza and pneumonia in older veterans?

OBJECTIVES

To compare the prevalence of influenza and pneumococcal immunization rates according to sex in a national sample of older veterans in the Department of Veterans Affairs (VA) healthcare system.

DESIGN

Retrospective, cross-sectional.

SETTING

VA healthcare system.

PARTICIPANTS

Current VA healthcare system users aged 65 and older eligible for immunization in fiscal years 2001 to 2003 (N=48,424 patient records).

MEASUREMENTS

Generalized estimating equations were performed to analyze combined chart review and administrative data to determine effect of sex on receipt of influenza and pneumococcal immunizations.

RESULTS

Unadjusted immunization rates were higher for men than women for influenza (73% vs 69%) and pneumococcal (87% vs 83%) vaccine. Adjusting for demographics, clinical comorbidities, use, and region, women had significantly lower odds of influenza (odds ratio (OR)=0.85, 95% confidence interval (CI=0.79-0.92) and pneumococcal (OR=0.77, 95% CI=0.71-0.84) immunization.

CONCLUSION

Older female veterans have lower rates of immunization than older male veterans in VA settings. Although VA remains above community levels for immunization, older female veterans will benefit from targeted efforts to increase immunization prevalence.

Use of preventive care by elderly male veterans receiving care through the Veterans Health Administration, Medicare fee-for-service, and Medicare HMO plans

OBJECTIVES

We compared use of preventive care among veterans receiving care through the Veterans Health Administration (VHA), Medicare fee-for-service (FFS) plans, and Medicare health maintenance organizations (HMOs).

METHODS

Using both the Costs and Use, and Access to Care files of the Medicare Current Beneficiary Survey (2000-2003), we performed a cross-sectional analysis examining self-reported use of influenza vaccination, pneumococcal vaccination, serum cholesterol screening, and serum prostate-specific antigen measurement among male veterans 65 years or older. Veterans' care was categorized as received through VHA, Medicare FFS, Medicare HMOs, VHA and Medicare FFS, or VHA and Medicare HMOs.

RESULTS

Veterans receiving care through VHA reported 10% greater use of influenza vaccination (P<.05), 14% greater use of pneumococcal vaccination (P<.01), a nonsignificant 6% greater use of serum cholesterol screening (P=.1), and 15% greater use of prostate cancer screening (P<.01) than did veterans receiving care through Medicare HMOs. Veterans receiving care through Medicare FFS reported less use of all 4 preventive measures (P<.01) than did veterans receiving care through Medicare HMOs.

CONCLUSIONS

Receiving care through VHA was associated with greater use of preventive care.

Severe mental illness and mortality of hospitalized ACS patients in the VHA

BACKGROUND

Severe mental illness (SMI) has been associated with more medical co-morbidity and less cardiovascular procedure use for older patients with myocardial infarction. However, it is unknown whether SMI is associated with increased long term mortality risk among patients presenting with acute coronary syndromes (ACS). We tested the hypothesis that SMI is associated with higher one-year mortality following ACS hospitalization.

METHODS

All ACS patients (n = 14,194) presenting to Veterans Health Administration (VHA) hospitals between October 2003 and September 2005 were included. Survival analysis evaluated the association between SMI and one-year all-cause mortality, adjusting for demographics, co-morbidities, in-hospital treatment, and discharge medications.

RESULTS

Overall, 18.4 % of ACS patients had SMI. Patients with SMI were more likely female, younger, Caucasian race, have a history of alcohol abuse, liver disease, dementia, hypertension and more likely to be a current smoker; however, prior cardiac history was similar between the 2 groups. There were no significant differences in cardiac procedure use, including coronary angiogram (38.7% vs. 40.3%, p = 0.14) or coronary revascularization (31.0% vs. 32.3%, p = 0.19), and discharge medications between those with and without SMI. One-year mortality was lower for patients with SMI (15.8% vs. 19.1%, p < 0.001). However, in multivariable analysis, there were no significant differences in mortality (HR 0.91; 95% CI 0.81-1.02) between patients with and without SMI.

CONCLUSION

Among ACS patients in the VHA, SMI is prevalent, affecting almost 1 in 5 patients. However, patients with SMI were as likely to undergo coronary revascularization and be prescribed evidence-based medications at hospital discharge, and were not at elevated risk of adverse 1-year outcomes compared to patients without SMI.

Colorectal cancer screening among men and women in the United States

BACKGROUND

A few previous studies have shown that men were more likely than women to be screened for colorectal cancer (CRC).

METHODS

The 2000 National Health Interview Survey (NHIS) was administered to 32,374 adults > or = 18 years of age. Participants were asked if they ever had a sigmoidoscopy or colonoscopy and if they ever had a home fecal occult blood test (FOBT). Men and women > or = 50 years were eligible for analysis. Participants were considered to be current in testing if they reported sigmoidoscopy in the last 5 years, colonoscopy in the last 10 years, or home FOBT in the last 1 year.

RESULTS

Overall, 62.9% of adults had ever had CRC testing, and 37.1% were current for testing. Compared to older men, a greater proportion of older women were not current for testing (62.6% for women vs. 56.7% for men > 75 years). In multivariate analysis, women were not less likely than men to be current in CRC testing (OR 0.98, 95% CI 0.88-1.08). When compared with white women, black women were less likely to be current for CRC screening (OR 0.79, 95% CI 0.65-0.95).

CONCLUSIONS

CRC screening is underused. Targeting interventions to improve CRC screening for all appropriate patients will be important.

Gender and racial disparities in the management of diabetes mellitus among Medicare patients

BACKGROUND

Racial/ethnic disparities in diabetes care have been demonstrated in several settings, but few studies have evaluated whether racial/ethnic differences vary by gender. The objective of this study is to understand gender and racial effects on diabetes care for Medicare managed care beneficiaries.

METHODS

Using data from: (1) Healthcare Effectiveness Data and Information Set (HEDIS); (2) Medicare Enrollment Files; and (3) U.S. Census, hierarchical generalized linear analyses were conducted to model the six HEDIS comprehensive diabetes care quality indicators, including processes of care and intermediate outcome measures, as a function of gender and race/ethnicity.

RESULTS

Women were more likely to have received HbA(1c) screening or eye examination, but less likely to have LDL control at <100 mg/dL, compared to men. Racial disparities favored whites in five measures, where African Americans were less likely to have received HbA(1c) screening, eye examination, cholesterol screening, or achieve adequate HbA(1c) control or LDL control at <100 mg/dL. Enrollees in managed care plans where African Americans constituted more than 20% of their insured population tended to have lower likelihood of meeting the HbA(1c) screening, HbA(1c) control, and eye examination measures.

CONCLUSIONS AND DISCUSSION

Gender and racial disparities in performance indicators were present among persons enrolled in Medicare managed care. White women were more likely to have met the performance measures related to process of care, but African Americans fared worse in both process of care and intermediate health outcome measures, compared to their white counterparts. Poor performance in cholesterol control observed in women of both races suggests the possibility of less intensive cholesterol treatment in women. The differences in the pattern of care demonstrate the need for interventions tailored to address gender and race/ethnicity.

Gender differences in aspirin use among adults with coronary heart disease in the United States

BACKGROUND

Aspirin reduces mortality for men and women with coronary heart disease (CHD). Previous research suggests women with acute coronary syndromes receive less aggressive care, including less frequent early administration of aspirin. The presence of gender differences in aspirin use for secondary prevention is less clear.

OBJECTIVE

To determine if a gender difference exists in the use of aspirin for secondary prevention among individuals with CHD.

DESIGN

We analyzed data from the nationally representative 2000-2002 Medical Expenditure Panel Surveys to determine the prevalence of regular aspirin use among men and women with CHD.

PARTICIPANTS

Participants, 1,869, 40 years and older who reported CHD or prior myocardial infarction.

RESULTS

Women were less likely than men to use aspirin regularly (62.4% vs 75.6%, p < .001) even after adjusting for demographic, socioeconomic and clinical characteristics (adjusted OR = 0.62, 95% CI, 0.48-0.79). This difference narrowed but remained significant when the analysis was limited to those without self-reported contraindications to aspirin (79.8% vs 86.4%, P = .002, adjusted OR = 0.68, 95% CI, 0.48-0.97). Women were more likely than men to report contraindications (20.5% vs 12.5%, P < .001). Differences in aspirin use were greater between women and men with private health insurance (61.8% vs 79.0%, P < .001, adjusted OR = 0.48, 95% CI, 0.35-0.67) than among those with public coverage (62.5% vs 70.7%, P = .04, adjusted OR = 0.74, 95% CI, 0.50-1.11) (P < .001 for gender-insurance interaction).

CONCLUSION

We found a gender difference in aspirin use among patients with CHD not fully explained by differences in patient characteristics or reported contraindications. These findings suggest a need for improved secondary prevention of cardiovascular events for women with CHD.

Racial/ethnic differences in influenza vaccination in the Veterans Affairs Healthcare System

BACKGROUND

Racial/ethnic differences in influenza vaccination exist among elderly adults despite nearly universal Medicare health insurance coverage. Overall influenza vaccination prevalence in the Veterans Affairs (VA) Healthcare System is higher than in the general population; however, it is not known whether racial/ethnic differences exist among older adults receiving VA healthcare. Racial/ethnic differences in influenza vaccination in VA were assessed, and barriers to and facilitators of influenza vaccination were examined among veteran outpatients aged 50 years and older.

METHODS

A random sample of 121,738 veterans receiving care at VA outpatient clinics during the 2003-2004 influenza season completed the mailed Survey of Health Experiences of Patients (77% response rate). Multivariate logistic regression was used to examine associations among race/ethnicity and influenza vaccination prevalence, barriers, and facilitators. Analyses were conducted during 2005 and 2006.

RESULTS

Based on unadjusted prevalences, non-Hispanic blacks, Hispanics, and American Indian/Alaskan Natives were significantly less likely to be vaccinated for influenza compared to non-Hispanic whites (71%, 79%, and 74%, respectively, vs 82%). After adjustment for age, gender, marital status, education level, employment, having a primary care provider, confidence and/trust in provider, and health status, only non-Hispanic blacks remained significantly less likely to be vaccinated compared to non-Hispanic whites (75% vs 81%). Influenza vaccination barriers and facilitators varied by race/ethnic group.

CONCLUSIONS

Compared to non-Hispanic whites, non-Hispanic blacks were less likely to receive influenza vaccination in the VA healthcare system during the 2003-2004 influenza season. Although these differences were small, results suggest the need for further study and culturally informed interventions.

Brief report: lack of a race effect in primary care ratings among women veterans

OBJECTIVE

To explore the effect of race on primary care quality and satisfaction among women in the Department of Veterans Affairs (VA).

METHODS

We used a mail survey to measure primary care quality and satisfaction. We focused on 4 primary care domains: patient preference for provider, interpersonal communication, accumulated knowledge, and coordination. We performed univariate analyses to compare variables by race and multiple logistic regression analysis to examine the effect of race on the probability of reporting a perfect score on each domain, while adjusting for patient characteristics and site.

RESULTS

Black women were younger, unmarried, educated, of higher income, and reported female providers and gynecological care in VA more often. In regression analysis, race was not significantly associated with any primary care domain or satisfaction. Gynecological care from VA provider was associated with perfect ratings on patient preference for provider (odds ratio [OR] 2.0, 95% confidence intervals [CI] 1.3, 3.1), and satisfaction (OR 1.6, 95% CI 1.2, 2.3), while female provider was associated with interpersonal communication (OR 1.9, 95% CI 1.4, 2.6).

CONCLUSIONS

While demographics and health experiences vary by race among veterans, race had no effect on primary care ratings. Future studies need to determine whether this racial equity persists in health outcomes among women veterans.

Pay-for-performance programs in family practices in the United Kingdom

BACKGROUND

In 2004, after a series of national initiatives associated with marked improvements in the quality of care, the National Health Service of the United Kingdom introduced a pay-for-performance contract for family practitioners. This contract increases existing income according to performance with respect to 146 quality indicators covering clinical care for 10 chronic diseases, organization of care, and patient experience.

METHODS

We analyzed data extracted automatically from clinical computing systems for 8105 family practices in England in the first year of the pay-for-performance program (April 2004 through March 2005), data from the U.K. Census, and data on characteristics of individual family practices. We examined the proportion of patients deemed eligible for a clinical quality indicator for whom the indicator was met (reported achievement) and the proportion of the total number of patients with a medical condition for whom a quality indicator was met (population achievement), and we used multiple regression analysis to determine the extent to which practices achieved high scores by classifying patients as ineligible for quality indicators (exception reporting).

RESULTS

The median reported achievement in the first year of the new contract was 83.4 percent (interquartile range, 78.2 to 87.0 percent). Sociodemographic characteristics of the patients (age and socioeconomic features) and practices (size of practice, number of patients per practitioner, age of practitioner, and whether the practitioner was medically educated in the United Kingdom) had moderate but significant effects on performance. Exception reporting by practices was not extensive (median rate, 6 percent), but it was the strongest predictor of achievement: a 1 percent increase in the rate of exception reporting was associated with a 0.31 percent increase in reported achievement. Exception reporting was high in a small number of practices: 1 percent of practices excluded more than 15 percent of patients.

CONCLUSIONS

English family practices attained high levels of achievement in the first year of the new pay-for-performance contract. A small number of practices appear to have achieved high scores by excluding large numbers of patients by exception reporting. More research is needed to determine whether these practices are excluding patients for sound clinical reasons or in order to increase income.

Patient satisfaction of female and male users of Veterans Health Administration services

OBJECTIVE

To compare patient satisfaction of male and female users of Veterans Health Administration (VHA) services.

DESIGN

Cross-sectional study based on secondary analysis of data from VHA's Survey of Healthcare Experiences of Patients (SHEP).

PATIENTS

National random sample of 107,995 outpatients and 112,817 inpatients in FY2004.

MEASURES

Patient's ratings of overall quality (OQ) and unique dimensions of satisfaction. Sociodemographic and health-related patient attributes.

ANALYSIS

Bivariate unadjusted analyses of the association between gender and other patient attributes and the outcomes of OQ and dimensions of satisfaction were conducted followed by multivariate analyses for each outcome, adjusting for demographic and health variables.

RESULTS

Significant differences between female and male reporting of satisfaction were found in the unadjusted analyses with males showing greater levels of satisfaction than females (P<.05). These differences disappeared or became smaller for both outpatient and inpatient services, after adjusting for covariates. For 6 of the inpatient dimensions (Transitions, Physical Comfort, Involvement Family and Friends, Courtesy, Coordination, and Access) males had higher satisfaction than females after statistical adjustment.

CONCLUSIONS

After adjustment for patient attributes, female VHA outpatients report similar OQ with VHA services as male patients. The fact that some inpatient dimensions of satisfaction continued to show effects favoring males even after adjustment suggests areas for continued focus in improving health care quality. Covariate adjustment is essential for evaluating satisfaction with health care services. Breaking down overall satisfaction into independent aspects of services is useful. The SHEP survey has provided a useful tool for evaluating and improving satisfaction among its VHA veteran users.