Extreme makeover: Transformation of the veterans health care system

Differences in use of Veterans Health Administration and non-Veterans Health Administration hospitals by rural and urban Veterans after access expansions

PURPOSE

To examine changes in rural and urban Veterans' utilization of acute inpatient care in Veterans Health Administration (VHA) and non-VHA hospitals following access expansion from the Veterans Choice Act, which expanded eligibility for VHA-paid community hospitalization.

METHODS

Using repeated cross-sectional data of VHA enrollees' hospitalizations in 9 states (AZ, CA, CT, FL, LA, MA, NY, PA, and SC) between 2012 and 2017, we compared rural and urban Veterans' probability of admission in VHA and non-VHA hospitals by payer over time for elective and nonelective hospitalizations using multinomial logistic regression to adjust for patient-level sociodemographic features. We also used generalized linear models to compare rural and urban Veterans' travel distances to hospitals.

FINDINGS

Over time, the probability of VHA-paid community hospitalization increased more for rural Veterans than urban Veterans. For elective inpatient care, rural Veterans' probability of VHA-paid admission increased from 2.9% (95% CI 2.6%-3.2%) in 2012 to 6.5% (95% CI 5.8%-7.1%) in 2017. These changes were associated with a temporal trend that preceded and continued after the implementation of the Veterans Choice Act. Overall travel distances to hospitalizations were similar over time; however, the mean distance traveled decreased from 39.2 miles (95% CI 35.1-43.3) in 2012 to 32.3 miles (95% CI 30.2-34.4) in 2017 for rural Veterans receiving elective inpatient care in VHA-paid hospitals.

CONCLUSIONS

Despite limited access to rural hospitals, these data demonstrate an increase in rural Veterans' use of non-VHA hospitals for acute inpatient care and a small reduction in distance traveled to elective inpatient services.

Software is Policy: Electronic Health Record Governance and the Implications of Clinical Standardization

BACKGROUND

Electronic health record (EHR) implementations, whether replacing paper or electronic systems, are major social and organizational transformations. Yet studies of EHR-to-EHR transitions have largely neglected to elucidate accompanying social and organizational changes. One such underexplored change is the standardization of clinical practice in the context of EHR transitions. The Department of Veterans Affairs (VA) has begun a decade-long process of replacing the approximately 130 separate versions of its homegrown EHR with a single commercial EHR system. This provides an opportunity to explore the standardization of clinical practice amidst an EHR transition.

OBJECTIVE

To identify, in the context of a large-scale EHR transition, (1) the scope and content of clinical standardization and (2) the anticipated implications of such standardization.

DESIGN

Qualitative study.

PARTICIPANTS

Twenty-nine members of VA councils established for the EHR transition.

APPROACH

We conducted semi-structured interviews, which were professionally transcribed, and analyzed first using rapid analysis methods, followed by coding and content analysis.

KEY RESULTS

Clinical standardization across facilities was a central goal of the EHR transition, encompassing computerized recommendations, order sets, professional roles/permissions, and clinical documentation. The anticipated implications of this standardization include (i) potential efficiency gains, with less duplicated effort across facilities; (ii) expanded bureaucracy; and (iii) increased uniformity, reducing both wanted and unwanted variation in care.

CONCLUSIONS

EHR systems shape a wide range of clinical processes, particularly in a large organization like VA with a long history of EHR use. This makes standardization of EHR content a powerful mechanism for standardizing clinical practice itself, which can bring dramatic collateral consequences. Organizations undergoing EHR transitions need to recognize the important role that clinical standardization plays by treating EHR transitions as major organizational transformations in the governance of clinical practice.

Comparing Quality of Surgical Care Between the US Department of Veterans Affairs and Non-Veterans Affairs Settings: A Systematic Review

In response to concerns about healthcare access and long wait times within the Veterans Health Administration (VA), Congress passed the Choice Act of 2014 and the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 to create a program for patients to receive care in non-VA sites of care, paid by VA. Questions remain about the quality of surgical care between these sites in specific and between VA and non-VA care in general. This review synthesizes recent evidence comparing surgical care between VA and non-VA delivered care across the domains of quality and safety, access, patient experience, and comparative cost/efficiency (2015 to 2021). Eighteen studies met the inclusion criteria. Of 13 studies reporting quality and safety outcomes, 11 reported that quality and safety of VA surgical care were as good as or better than non-VA sites of care. Six studies of access did not have a preponderance of evidence favoring care in either setting. One study of patient experience reported VA care as about equal to non-VA care. All 4 studies of cost/efficiency outcomes favored non-VA care. Based on limited data, these findings suggest that expanding eligibility for veterans to get care in the community may not provide benefits in terms of increasing access to surgical procedures, will not result in better quality, and may result in worse quality of care, but may reduce inpatient length of stay and perhaps cost less.

Uptake and Equity in Influenza Vaccination Among Veterans with VA Coverage, Veterans Without VA Coverage, and Non-Veterans in the USA, 2019-2020

BACKGROUND

Vaccination is a primary method of reducing the burden of influenza, yet uptake is neither optimal nor equitable. Single-tier, primary care-oriented health systems may have an advantage in the efficiency and equity of vaccination.

OBJECTIVE

To assess the association of Veterans' Health Administration (VA) coverage with influenza vaccine uptake and disparities.

DESIGN

Cross-sectional.

PARTICIPANTS

Adult respondents to the 2019-2020 National Health Interview Survey.

MAIN MEASURES

We examined influenza vaccination rates, and racial/ethnic and income-based vaccination disparities, among veterans with VA coverage, veterans without VA coverage, and adult non-veterans. We performed multivariable logistic regressions adjusted for demographics and self-reported health, with interaction terms to examine differential effects by race/ethnicity and income.

KEY RESULTS

Our sample included n=2,277 veterans with VA coverage, n=2,821 veterans without VA coverage, and n=46,456 non-veterans. Veterans were more often White and male; among veterans, those with VA coverage had worse health and lower incomes. Veterans with VA coverage had a higher unadjusted vaccination rate (63.0%) than veterans without VA coverage (59.1%) and non-veterans (46.5%) (p<0.05 for each comparison). In our adjusted model, non-veterans were 11.4 percentage points (95% CI -14.3, -8.5) less likely than veterans with VA coverage to be vaccinated, and veterans without VA coverage were 6.7 percentage points (95% CI -10.3, -3.0) less likely to be vaccinated than those with VA coverage. VA coverage, compared with non-veteran status, was also associated with reduced racial/ethnic and income disparities in vaccination.

CONCLUSIONS

VA coverage is associated with higher and more equitable influenza vaccination rates. A single-tier health system that emphasizes primary care may improve the uptake and equity of vaccination for influenza, and possibly other pathogens, like SARS-CoV2.

Robotic Foregut Surgery in the Veterans Health Administration: Increasing Prevalence, Decreasing Operative Time, and Improving Outcomes

BACKGROUND

Historically, robotic surgery incurs longer operative times, higher costs, and nonsuperior outcomes compared with laparoscopic surgery. However, in areas of limited visibility and decreased accessibility such as the gastroesophageal junction, robotic platforms may improve visualization and facilitate dissection. This study compares 30-day outcomes between robotic-assisted foregut surgery (RAF) and laparoscopic-assisted foregut surgery in the Veterans Health Administration.

STUDY DESIGN

This is a retrospective review of the Veterans Affairs Quality Improvement Program database. Patients undergoing laparoscopic-assisted foregut surgery and RAF were identified using CPT codes 43280, 43281, 43282, and robotic modifier S2900. Multivariable logistic regression and multivariable generalized linear models were used to analyze the independent association between surgical approach and outcomes of interest.

RESULTS

A total of 9,355 veterans underwent minimally invasive fundoplication from 2008 to 2019. RAF was used in 5,392 cases (57.6%): 1.63% of cases in 2008 to 83.41% of cases in 2019. After adjusting for confounding covariates, relative to laparoscopic-assisted foregut surgery, RAF was significantly associated with decreased adjusted odds of pulmonary complications (adjusted odds ratio [aOR] 0.44, p < 0.001), acute renal failure (aOR 0.14, p = 0.046), venous thromboembolism (aOR 0.44, p = 0.009) and increased odds of infectious complications (aOR 1.60, p = 0.017). RAF was associated with an adjusted mean ± SD of 29 ± 2-minute shorter operative time (332 minutes vs 361 minutes; p < 0.001).

CONCLUSIONS

Veterans undergoing RAF ascertained shorter operative times and reduced complications vs laparoscopy. As surgeons use the robotic platform, clinical outcomes and operative times continue to improve, particularly in operations where extra articulation in confined spaces is required.

The Perils of a "My Work Here is Done" perspective: a mixed methods evaluation of sustainment of an evidence-based intervention for transient ischemic attack

BACKGROUND

To evaluate quality improvement sustainment for Transient Ischemic Attack (TIA) and identify factors influencing sustainment, which is a challenge for Learning Healthcare Systems.

METHODS

Mixed methods were used to assess changes in care quality across periods (baseline, implementation, sustainment) and identify factors promoting or hindering sustainment of care quality. PREVENT was a stepped-wedge trial at six US Department of Veterans Affairs implementation sites and 36 control sites (August 2015-September 2019). Quality of care was measured by the without-fail rate: proportion of TIA patients who received all of the care for which they were eligible among brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, and high/moderate potency statins. Key informant interviews were used to identify factors associated with sustainment.

RESULTS

The without-fail rate at PREVENT sites improved from 36.7% (baseline, 58/158) to 54.0% (implementation, 95/176) and settled at 48.3% (sustainment, 56/116). At control sites, the without-fail rate improved from 38.6% (baseline, 345/893) to 41.8% (implementation, 363/869) and remained at 43.0% (sustainment, 293/681). After adjustment, no statistically significant difference in sustainment quality between intervention and control sites was identified. Among PREVENT facilities, the without-fail rate improved ≥2% at 3 sites, declined ≥2% at two sites, and remained unchanged at one site during sustainment. Factors promoting sustainment were planning, motivation to sustain, integration of processes into routine practice, leadership engagement, and establishing systems for reflecting and evaluating on performance data. The only factor that was sufficient for improving quality of care during sustainment was the presence of a champion with plans for sustainment. Challenges during sustainment included competing demands, low volume, and potential problems with medical coding impairing use of performance data. Four factors were sufficient for declining quality of care during sustainment: low motivation, champion inactivity, no reflecting and evaluating on performance data, and absence of leadership engagement.

CONCLUSIONS

Although the intervention improved care quality during implementation; performance during sustainment was heterogeneous across intervention sites and not different from control sites. Learning Healthcare Systems seeking to sustain evidence-based practices should embed processes within routine care and establish systems for reviewing and reflecting upon performance.

TRIAL REGISTRATION

Clinicaltrials.gov ( NCT02769338 ).

Obesity treatment initiation, retention, and outcomes in the Veterans Affairs MOVE! Program among rural and urban veterans

Objective

Rural veterans have high obesity rates. Yet, little is known about this population's engagement with the Veterans Affairs (VA) weight management program (MOVE!). The study objective is to determine whether MOVE! enrollment, anti-obesity medication use, bariatric surgery use, retention, and outcomes differ by rurality for veterans with severe obesity.

Methods

This is a retrospective cohort study using Veterans Health Administration patient databases, including VA patients with severe obesity during 2015-2017. Patients were categorized using Rural-Urban Commuting Area codes. Primary outcomes included proportion of patients and risk-adjusted likelihood of initiating VA MOVE!, anti-obesity medication, or bariatric surgery and risk-adjusted highly rural|Hazard Ratio (HR) of any obesity treatment. Secondary outcomes included treatment retention (≥12 weeks) and successful weight loss (5%) among patients initiating MOVE!, and risk-adjusted odds of retention and successful weight loss.

Results

Among 640,555 eligible veterans, risk-adjusted relative likelihood of MOVE! treatment was significantly lower for rural and HR veterans (HR = 0.83, HR = 0.67, respectively). Initiation rates of anti-obesity medication use were significantly lower as well, whereas bariatric surgery rates, retention, and successful weight loss did not differ.

Conclusions

Overall treatment rates with MOVE!, bariatric surgery, and anti-obesity medications remain low. Rural veterans are less likely to enroll in MOVE! and less likely to receive anti-obesity medications than urban veterans.

Relationships between work-environment characteristics and behavioral health provider burnout in the Veterans Health Administration

Objective

To identify work–environment characteristics associated with Veterans Health Administration (VHA) behavioral health provider (BHP) burnout among psychiatrists, psychologists, and social workers.

Data Sources

The 2015–2018 data from Annual All Employee Survey (AES); Mental Health Provider Survey (MHPS); N = 57,397 respondents; facility‐level Mental Health Onboard Clinical (MHOC) staffing and productivity data, N = 140 facilities.

Study Design

For AES and MHPS separately, we used mixed‐effects logistic regression to predict BHP burnout using surveys from year pairs (2015–2016, 2016–2017, 2017–2018; six models). Within each year‐pair, we used the earlier year of data to train models and tested the model in the later year, with burnout (emotional exhaustion and/or depersonalization) as the outcome for each survey. We used potentially modifiable work–environment characteristics as predictors, controlling for employee demographic characteristics as covariates, and employment facility as random intercepts.

Data Collection/Extraction Methods

We included work–environment predictors that appeared in all 4 years (11 in AES; 17 in MHPS).

Principal Findings

In 2015–2018, 31.0%–38.0% of BHPs reported burnout in AES or MHPS. Work characteristics consistently associated with significantly lower burnout were included for AES: reasonable workload; having appropriate resources to perform a job well; supervisors address concerns; given an opportunity to improve skills. For MHPS, characteristics included: reasonable workload; work improves veterans' lives; mental health care provided is well‐coordinated; and three reverse‐coded items: staffing vacancies; daily work that clerical/support staff could complete; and collateral duties reduce availability for patient care. Facility‐level staffing ratios and productivity did not significantly predict individual‐level burnout. Workload represented the strongest predictor of burnout in both surveys.

Conclusions

This study demonstrated substantial, ongoing impacts that having appropriate resources including staff, workload, and supervisor support had on VHA BHP burnout. VHA may consider investing in approaches to mitigate the impact of BHP burnout on employees and their patients through providing staff supports, managing workload, and goal setting.

Trends in Incident Varenicline Prescribing Among Veterans Following the US Food and Drug Administration Drug Safety Warnings

Objective: To evaluate national trends in incident varenicline and nicotine replacement therapy (NRT) prescribing among Department of Veterans Affairs (VA) beneficiaries before and after US Food and Drug Administration (FDA) warnings regarding neuropsychiatric side effects with varenicline use. Methods: All adult VA patients identified as smokers from 2007 to 2019 (N = 3,600,947) were determined and monthly counts of new varenicline and NRT users were calculated. An interrupted time-series analysis estimated the effect of the FDA warnings on varenicline and NRT prescribing overall and among Veterans with and without mental health disorders. Results: The incident use rate of varenicline decreased from a peak of 6.2 per 1,000 veteran smokers in October 2007 to 1.0 by July 2009 following the first FDA warning (pre-warning monthly slope = -0.27; P = .03). New NRT use increased from 10.7 per 1,000 veteran smokers in October 2007 to a peak of 12.6 per 1,000 in July 2009 (slope change = 0.71; P = .01), suggesting potential substitution. Following removal of the FDA boxed warning in December 2016, varenicline prescribing increased but did not return to pre-warning levels by December 2019. Among veterans with and without mental health disorders, varenicline use decreased 90% and 88%, respectively, following the first FDA warning, and both groups had comparable rates of new NRT use. Conclusions: Following the first FDA warning, incident use of varenicline declined significantly among veterans both with and without mental health disorders. Despite removal of the FDA boxed warning in December 2016, new use of varenicline had not returned to pre-warning levels 3 years following the removal.

Racial/Ethnic Differences in 30-Day Mortality for Heart Failure and Pneumonia in the Veterans Health Administration Using Claims-based, Clinical, and Social Risk-adjustment Variables

BACKGROUND

Prior studies have identified lower mortality in Black Veterans compared with White Veterans after hospitalization for common medical conditions, but these studies adjusted for comorbid conditions identified in administrative claims.

OBJECTIVES

The objectives of this study were to compare mortality for non-Hispanic White (hereafter, "White"), non-Hispanic Black (hereafter, "Black"), and Hispanic Veterans hospitalized for heart failure (HF) and pneumonia and determine whether observed mortality differences varied according to whether claims-based comorbid conditions and/or clinical variables were included in risk-adjustment models.

RESEARCH DESIGN

This was an observational study.

SUBJECTS

The study cohort included 143,520 admissions for HF and 127,782 admissions for pneumonia for Veterans hospitalized in 132 Veterans Health Administration (VA) Medical Centers between January 2009 and September 2015.

MEASURES

The primary independent variable was racial/ethnic group (ie, Black, Hispanic, and non-Hispanic White), and the outcome was all-cause mortality 30 days following admission. To compare mortality by race/ethnicity, we used logistic regression models that included different combinations of claims-based, clinical, and sociodemographic variables. For each model, we estimated the average marginal effect (AME) for Black and Hispanic Veterans relative to White Veterans.

RESULTS

Among the 143,520 (127,782) hospitalizations for HF (pneumonia), the average patient age was 71.6 (70.9) years and 98.4% (97.1%) were male. The unadjusted 30-day mortality rates for HF (pneumonia) were 7.2% (11.0%) for White, 4.1% (10.4%) for Black and 8.4% (16.9%) for Hispanic Veterans. Relative to White Veterans, when only claims-based variables were used for risk adjustment, the AME (95% confidence interval) for the HF [pneumonia] cohort was -2.17 (-2.45, -1.89) [0.08 (-0.41, 0.58)] for Black Veterans and 1.32 (0.49, 2.15) [4.51 (3.65, 5.38)] for Hispanic Veterans. When clinical variables were incorporated in addition to claims-based ones, the AME, relative to White Veterans, for the HF [pneumonia] cohort was -1.57 (-1.88, -1.27) [-0.83 (-1.31, -0.36)] for Black Veterans and 1.50 (0.71, 2.30) [3.30 (2.49, 4.11)] for Hispanic Veterans.

CONCLUSIONS

Compared with White Veterans, Black Veterans had lower mortality, and Hispanic Veterans had higher mortality for HF and pneumonia. The inclusion of clinical variables into risk-adjustment models impacted the magnitude of racial/ethnic differences in mortality following hospitalization. Future studies examining racial/ethnic disparities should consider including clinical variables for risk adjustment.

Understanding and Addressing the Unique Challenges and Conditions of the Veteran: Improving Sleep and Well-Being

Veterans are those who have served our country in one of the branches of armed forces or military reserves. The Veterans Health Administration is the largest integrated health system in the nation, providing health care services and latest research for veterans. Non-Veteran Health Administration primary care clinicians, who also take care of veterans, deserve to have an understanding of the unique challenges and conditions these individuals face and the resources that are available to improve sleep health and well-being of all veterans. This article guides these clinicians to manage sleep disorders, mental health disorders, and substance use among veterans.

Acceptability of a complex team-based quality improvement intervention for transient ischemic attack: a mixed-methods study

BACKGROUND

The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was a complex quality improvement (QI) intervention targeting transient ischemic attack (TIA) evidence-based care. The aim of this study was to evaluate program acceptability among the QI teams and factors associated with degrees of acceptability.

METHODS

QI teams from six Veterans Administration facilities participated in active implementation for a one-year period. We employed a mixed methods study to evaluate program acceptability. Multiple data sources were collected over implementation phases and triangulated for this evaluation. First, we conducted 30 onsite, semi-structured interviews during active implementation with 35 participants at 6 months; 27 interviews with 28 participants at 12 months; and 19 participants during program sustainment. Second, we conducted debriefing meetings after onsite visits and monthly virtual collaborative calls. All interviews and debriefings were audiotaped, transcribed, and de-identified. De-identified files were qualitatively coded and analyzed for common themes and acceptability patterns. We conducted mixed-methods matrix analyses comparing acceptability by satisfaction ratings and by the Theoretical Framework of Acceptability (TFA).

RESULTS

Overall, the QI teams reported the PREVENT program was acceptable. The clinical champions reported high acceptability of the PREVENT program. At pre-implementation phase, reviewing quality data, team brainstorming solutions and development of action plans were rated as most useful during the team kickoff meetings. Program acceptability perceptions varied over time across active implementation and after teams accomplished actions plans and moved into sustainment. We observed team acceptability growth over a year of active implementation in concert with the QI team's self-efficacy to improve quality of care. Guided by the TFA, the QI teams' acceptability was represented by the respective seven components of the multifaceted acceptability construct.

CONCLUSIONS

Program acceptability varied by time, by champion role on QI team, by team self-efficacy, and by perceived effectiveness to improve quality of care aligned with the TFA. A complex quality improvement program that fostered flexibility in local adaptation and supported users with access to data, resources, and implementation strategies was deemed acceptable and appropriate by front-line clinicians implementing practice changes in a large, national healthcare organization.

TRIAL REGISTRATION

clinicaltrials.gov : NCT02769338 .

Possible Effects on VA Outpatient Care of Expanding Medicaid: Implications of Having Access to Overlapping Publicly Funded Health Care Services

BACKGROUND

Because veterans who use Veterans Health Administration (VA) health care retain VA eligibility while enrolling in Medicaid, increasing Medicaid eligibility may create improved health system access but also create unique challenges for the quality and coordination of health care for veterans. We analyze how pre-Affordable Care Act (ACA) state Medicaid expansions influence VA and Medicaid-funded outpatient care utilization.

MATERIALS AND METHODS

This study uses Difference-in-difference analysis to evaluate association between pre-ACA 2001 Medicaid expansions and VA utilization in a natural experiment. Veterans aged 18-64 years living in a study state during the study period were the participants. Dependent variables included participants' proportion of outpatient care received at the VA, whether a participant recorded care with both Medicaid and the VA, and total outpatient utilization. We analyzed changes between two states that expanded Medicaid in 2001 against three similar states that did not from 1999 to 2006. We adjusted for age, non-White race, gender, disease burden, and distance to VA facilities. This study was approved by the Baylor College of Medicine Institutional Review Board (IRB), protocol number H-40441.

RESULTS

In total, 346,364 VA-enrolled veterans lived in the five study states during the time of our study, 70,987 of whom were enrolled in Medicaid for at least 1 month. For low-income veterans, Medicaid expansion was associated with a 2.88 percentage-point decline in the VA proportion of outpatient services (99% CI -3.26 to -2.49), and a 2.07-point increase (1.80 to 2.35) in the percentage of patients using both VA and Medicaid services. Results also showed small increases in total (VA plus Medicaid) annual per-capita outpatient visits among low-income veterans. We estimate that this corresponds to an annual reduction of 80,338 VA visits across study states (66,155-94,521).

CONCLUSIONS

This study shows usage shifts when Medicaid expansion allows veterans to gain access to non-VA care. It highlights increased potential for care-coordination challenges among VA patients as states implement ACA Medicaid expansion and policymakers consider additional public health insurance options, as well as programs like CHOICE and the MISSION Act that increase veteran choices of traditional VA and community care providers.

Implementation Evaluation of a Complex Intervention to Improve Timeliness of Care for Veterans with Transient Ischemic Attack

BACKGROUND

The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA).

OBJECTIVE

We evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019).

DESIGN

A stepped-wedge implementation trial with six geographically diverse sites.

PARTICIPANTS

The six facility QI teams were multi-disciplinary, clinical staff.

INTERVENTIONS

PREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback.

MAIN MEASURES

Using a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year.

KEY RESULTS

Facility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation.

CONCLUSIONS

The CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system.

TRIAL REGISTRATION

clinicaltrials.gov: NCT02769338.

Assessment of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Program for Improving Quality of Care for Transient Ischemic Attack: A Nonrandomized Cluster Trial

IMPORTANCE

Patients with transient ischemic attack (TIA) are at high risk of recurrent vascular events. Timely management can reduce that risk by 70%; however, gaps in TIA quality of care exist.

OBJECTIVE

To assess the performance of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention to improve TIA quality of care.

DESIGN, SETTING, AND PARTICIPANTS

This nonrandomized cluster trial with matched controls evaluated a multicomponent intervention to improve TIA quality of care at 6 diverse medical centers in 6 geographically diverse states in the US and assessed change over time in quality of care among 36 matched control sites (6 control sites matched to each PREVENT site on TIA patient volume, facility complexity, and quality of care). The study period (defined as the data period) started on August 21, 2015, and extended to May 12, 2019, including 1-year baseline and active implementation periods for each site. The intervention targeted clinical teams caring for patients with TIA.

INTERVENTION

The quality improvement (QI) intervention included the following 5 components: clinical programs, data feedback, professional education, electronic health record tools, and QI support.

MAIN OUTCOMES AND MEASURES

The primary outcome was the without-fail rate, which was calculated as the proportion of veterans with TIA at a specific facility who received all 7 guideline-recommended processes of care for which they were eligible (ie, anticoagulation for atrial fibrillation, antithrombotic use, brain imaging, carotid artery imaging, high- or moderate-potency statin therapy, hypertension control, and neurological consultation). Generalized mixed-effects models with multilevel hierarchical random effects were constructed to evaluate the intervention associations with the change in the mean without-fail rate from the 1-year baseline period to the 1-year intervention period.

RESULTS

Six facilities implemented the PREVENT QI intervention, and 36 facilities were identified as matched control sites. The mean (SD) age of patients at baseline was 69.85 (11.19) years at PREVENT sites and 71.66 (11.29) years at matched control sites. Most patients were male (95.1% [154 of 162] at PREVENT sites and 94.6% [920 of 973] at matched control sites at baseline). Among the PREVENT sites, the mean without-fail rate improved substantially from 36.7% (58 of 158 patients) at baseline to 54.0% (95 of 176 patients) during a 1-year implementation period (adjusted odds ratio, 2.10; 95% CI, 1.27-3.48; P = .004). Comparing the change in quality at the PREVENT sites with the matched control sites, the improvement in the mean without-fail rate was greater at the PREVENT sites than at the matched control sites (36.7% [58 of 158 patients] to 54.0% [95 of 176 patients] [17.3% absolute improvement] vs 38.6% [345 of 893 patients] to 41.8% [363 of 869 patients] [3.2% absolute improvement], respectively; absolute difference, 14%; P = .008).

CONCLUSIONS AND RELEVANCE

The implementation of this multifaceted program was associated with improved TIA quality of care across the participating sites. The PREVENT QI program is an example of a health care system using QI strategies to improve performance, and may serve as a model for other health systems seeking to provide better care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02769338.

The Impact of Co-occurring Anxiety and Alcohol Use Disorders on Video Telehealth Utilization Among Rural Veterans

Co-occurring anxiety and alcohol use disorders lead to poorer treatment outcomes for both disorders. Compounding risk for poor outcomes related to these disorders, individuals living in rural areas face barriers receiving evidence-based mental health treatment. Video to home telehealth (VTH) has been implemented broadly within the Veterans Health Administration to improve access to care for rural veterans. However, VTH may not be utilized equally across disorders and comorbidities, including co-occurring anxiety and alcohol use disorders, potentially contributing to gaps in care that are not available in person. A cohort of veterans who received at least one VTH mental health visit between fiscal years 2016–2019 was compiled from VA administrative data. Multilevel linear growth curve models were used to examine growth in VTH use over time among veterans with anxiety only, alcohol use disorder only, and co-occurring disorders. Fixed effects were significant for both time and diagnosis group and a significant interaction between time and group. For each subsequent fiscal year, the percentage of total MH visits that were VTH increased for all groups but less so for those with co-occurring anxiety and alcohol use diagnoses. Despite VTH being an important tool to reach underserved rural veterans, rural veterans with AUD and co-occurring anxiety and AUD are at risk for not receiving care using this modality. Findings suggest that veterans with co-occurring anxiety and AUD are especially at risk for being underserved, given that a major goal of VTH is to increase access to mental health services.

Quality information disclosure and health insurance demand: evidence from VA hospital report cards

This study examines the effect of public reporting of quality information on the demand for public insurance. In particular, we examine the effect of the introduction of Veterans Affairs (VA) hospital quality report cards in 2008. Using data from the Current Population Survey in 2005-2015, we find that new information about the quality of a VA hospital had a significant effect on VA coverage among veterans living in the same Metropolitan Statistical Area (MSA). Despite the significant effect on VA coverage, the quality report did not have a spillover effect on veterans' labor supply. Moreover, updated quality information released in later years, which was presented in a less straightforward form, led to no additional changes in VA coverage. These findings suggest that quality reports for public insurance programs can be used as a policy lever to facilitate take up decision among potential beneficiaries.

Mortality Trends for Veterans Hospitalized With Heart Failure and Pneumonia Using Claims-Based vs Clinical Risk-Adjustment Variables

IMPORTANCE

Prior studies have reported declines in mortality for patients admitted to Veterans Health Administration (VA) and non-VA hospitals using claims-based risk adjustment. These apparent mortality reductions may be influenced by changes in coding practices.

OBJECTIVE

To compare trends in the VA for 30-day mortality following hospitalization for heart failure (HF) and pneumonia using claims-based and clinical risk-adjustment models.

DESIGN, SETTING, AND PARTICIPANTS

This observational time-trend study analyzed admissions to a VA Medical Center with a principal diagnosis of HF, pneumonia, or sepsis/respiratory failure (RF) with a secondary diagnosis of pneumonia. Exclusion criteria included having less than 12 months of VA enrollment, being discharged alive within 24 hours, leaving against medical advice, and hospice utilization.

EXPOSURES

Admission to a VA hospital from January 2009 through September 2015.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day, all-cause mortality. All models included age and sex. Claims-based covariates included 22 (30) comorbidities for HF (pneumonia). Clinical covariates included vital signs, laboratory values, and ejection fraction.

RESULTS

Among the 146 924 HF admissions, the mean (SD) age was 71.6 (11.4) years and 144 502 (98.4%) were men; among the 131 325 admissions for pneumonia, the mean (SD) age was 70.8 (12.3) years and 127 491 (97.1%) were men. Unadjusted 30-day mortality rates were 6.45% (HF) and 11.22% (pneumonia). Claims-based models showed an increased predicted risk of 30-day mortality over time (0.019 percentage points per quarter for HF [95% CI, 0.015 to 0.023]; 0.053 percentage points per quarter for pneumonia [95% CI, 0.043 to 0.063]). Clinical models showed declines or no change in predicted risk (-0.014 percentage points per quarter for HF [95% CI, -0.020 to -0.008]; -0.004 percentage points per quarter for pneumonia [95% CI, -0.017 to 0.008]). Claims-based risk adjustment yielded declines in 30-day mortality of 0.051 percentage points per quarter for HF (95% CI, -0.074 to -0.027) and 0.084 percentage points per quarter for pneumonia (95% CI, -0.111 to -0.056). Models adjusting for clinical covariates attenuated or eliminated these changes for HF (-0.017 percentage points per quarter; 95% CI, -0.039 to 0.006) and for pneumonia (-0.026 percentage points per quarter; 95% CI, -0.052 to 0.001). Compared with the claims-based models, the clinical models for HF and pneumonia more accurately differentiated between patients who died after 30 days and those who did not.

CONCLUSIONS AND RELEVANCE

Among HF and pneumonia hospitalizations, adjusting for clinical covariates attenuated declines in mortality rates identified using claims-based models. Assessments of temporal trends in 30-day mortality using claims-based risk adjustment should be interpreted with caution.

The protocol-guided rapid evaluation of veterans experiencing new transient neurological symptoms (PREVENT) quality improvement program: rationale and methods

BACKGROUND

Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) developed, implemented, and evaluated a TIA quality improvement (QI) intervention aligned with Learning Healthcare System principles.

METHODS

This stepped-wedge trial developed, implemented and evaluated a provider-facing, multi-component intervention to improve TIA care at six facilities. The unit of analysis was the medical center. The intervention was developed based on benchmarking data, staff interviews, literature, and electronic quality measures and included: performance data, clinical protocols, professional education, electronic health record tools, and QI support. The effectiveness outcome was the without-fail rate: the proportion of patients who receive all processes of care for which they are eligible among seven processes. The implementation outcomes were the number of implementation activities completed and final team organization level. The intervention effects on the without-fail rate were analyzed using generalized mixed-effects models with multilevel hierarchical random effects. Mixed methods were used to assess implementation, user satisfaction, and sustainability.

DISCUSSION

PREVENT advanced three aspects of a Learning Healthcare System. Learning from Data: teams examined and interacted with their performance data to explore hypotheses, plan QI activities, and evaluate change over time. Learning from Each Other: Teams participated in monthly virtual collaborative calls. Sharing Best Practices: Teams shared tools and best practices. The approach used to design and implement PREVENT may be generalizable to other clinical conditions where time-sensitive care spans clinical settings and medical disciplines.

TRIAL REGISTRATION

clinicaltrials.gov: NCT02769338 [May 11, 2016].

Financial Implications of 12-Month Dispensing of Oral Contraceptive Pills in the Veterans Affairs Health Care System

IMPORTANCE

The Veterans Affairs (VA) health care system is the largest integrated health care system in the United States. Like most US health plans, the VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). However, 12-month OCP dispensing has been shown to improve continuation of use, decrease coverage gaps, and reduce unintended pregnancy in other practice settings.

OBJECTIVE

To estimate the financial and reproductive health implications for the VA of implementing a 12-month OCP dispensing option, with the goal of informing policy change.

DESIGN, SETTING, AND PARTICIPANTS

A decision model from the VA payer perspective was developed to estimate incremental costs to the health care system of allowing the option to receive a 12-month supply of OCPs up front, compared with the standard 3-month maximum, during a 1-year time horizon. A model cohort of 24 309 reproductive-aged, heterosexually active, female VA enrollees who wish to avoid pregnancy for at least 1 year was assumed. Probabilities of continuation of OCP use, coverage gaps, pregnancy, and pregnancy outcomes were drawn from published data. Costs of OCP provision and pregnancy-related care and the number of women using OCPs were drawn from VA administrative data. One-way and probabilistic sensitivity analyses were performed to assess model robustness.

MAIN OUTCOMES AND MEASURES

Incremental per-woman and total costs to the VA of allowing for 12-month dispensing of OCPs compared with standard 3-month dispensing.

RESULTS

The 12-month OCP dispensing option, modeled from the VA health system perspective using a cohort of 24 309 women, resulted in anticipated VA annual cost savings of $87.12 per woman compared with the cost of 3-month dispensing, or an estimated total savings of $2 117 800 annually. Cost savings resulted from an absolute reduction of 24 unintended pregnancies per 1000 women per year with 12-month dispensing, or 583 unintended pregnancies averted annually. Expected cost savings with 12-month dispensing were sensitive to changes in the probability of OCP coverage gaps with 3-month dispensing, the probability of pregnancy during coverage gaps, and the proportion of pregnancies paid for by the VA. When simultaneously varying all variables across plausible ranges, the 12-month strategy was cost saving in 95.4% of model iterations.

CONCLUSIONS AND RELEVANCE

Adoption of a 12-month OCP dispensing option is expected to produce substantial cost savings for the VA while better supporting reproductive autonomy and reducing unintended pregnancy among women veterans.

A Quality Strategy to Advance the Triple Aim in California's Medicaid Program

The California Department of Health Care Services (DHCS) administers the nation's largest Medicaid program. In 2012, DHCS developed a Quality Strategy modeled after the National Quality Strategy to guide the Department's activities aimed at advancing the Triple Aim. The Triple Aim seeks to improve the patient experience of care and the health of populations as well as reduce the per capita cost of health care. An academic team was contracted to assist DHCS in developing the strategy, which also was informed by extensive stakeholder input, an advisory committee, and a comprehensive inventory of DHCS quality improvement (QI) activities. From 2012 to 2018, the strategy included 129 unique QI activities. Most activities were intended to deliver more effective, efficient, affordable care or to advance disease prevention. This qualitative assessment of the DHCS Quality Strategy provides insights that may inform other Medicaid programs or large health systems as they develop quality strategies.

Outcomes of Ambulatory Upper Extremity Surgery Patients Discharged Home with Perineural Catheters from a Veterans Health Administration Medical Center

Objective

The feasibility and safety of managing ambulatory continuous peripheral nerve blocks (CPNB) in Veterans Health Administration (VHA) patients are currently unknown. We aimed to characterize the outcomes of a large VHA cohort of ambulatory upper extremity surgery patients discharged with CPNB and identify differences, if any, between catheter types.

Methods

With institutional review board approval, we reviewed data for consecutive patients from a single VHA hospital who had received ambulatory CPNB for upper extremity surgery from March 2011 to May 2017. The composite primary outcome was the occurrence of any catheter-related issue or additional all-cause health care intervention after discharge. Our secondary outcome was the ability to achieve regular daily telephone contact.

Results

Five hundred one patients formed the final sample. The incidence of any issue or health care intervention was 104/274 (38%) for infraclavicular, 58/185 (31%) for interscalene, and 14/42 (33%) for supraclavicular; these rates did not differ between groups. Higher ASA status was associated with greater odds of having any issue, whereas increasing age was slightly protective. Distance was associated with an increase in catheter-related issues (P < 0.01) but not additional health care interventions (P = 0.51). Only interscalene catheter patients (3%) reported breathing difficulty. Infraclavicular catheter patients had the most emergency room visits but rarely for CPNB issues. Consistent daily telephone contact was not achieved.

Conclusions

For VHA ambulatory CPNB patients, the combined incidence of a catheter-related issue or additional health care intervention was approximately one in three patients and did not differ by brachial plexus catheter type. Serious adverse events were generally uncommon.

Clinical dashboard development and use for academic detailing in the U.S. Department of Veterans Affairs

OBJECTIVE

To describe the U.S. Department of Veterans Affairs (VA) Academic Detailing Service's (ADS) experience with the development and use of clinical dashboards across the VA's national clinical campaigns. We focused only on dashboards developed by the VA ADS national clinical program managers.

SETTING

U.S. Department of Veterans Affairs Pharmacy Benefits Management National Academic Detailing Service.

PRACTICE DESCRIPTION

Academic detailing is a multifaceted, educational outreach intervention that services providers through interactions with academic detailers (at the VA, these are specially trained clinical pharmacy specialists) using evidence-based research, educational brochures, and clinical dashboards to align prescribing behavior with best practices. The VA ADS developed clinical dashboards to benchmark and monitor academic detailing activities and performance and to identify opportunities for redistributing resources. We used the opioid crisis as an example to highlight key steps in the development of a clinical dashboard.

EVALUATION

Testing is an important part of clinical dashboard development. Evaluations of the users perceptions contributed to lessons learned.

RESULTS

Data validation, missing data, data availability, standardization, user engagement, and technical limitations were among several challenges the VA ADS encountered during dashboard development. Stakeholder engagement, communication, and flexibility with development time allowed us to develop efficient dashboards.

CONCLUSIONS

Health care data and health analytics have transformed the type of clinical care that can be practiced by creating the ability to implement system-wide processes for both population management and quality improvement processes. End users of these VA ADS clinical dashboards can generate priority panel reports and data visualization of key performance indicators to identify areas for improvement or action.

How Views of the Organization of Primary Care Among Patients with Hypertension Vary by Race or Ethnicity

INTRODUCTION

We assessed potential racial or ethnic differences in the degree to which veterans with pharmaceutically treated hypertension report experiences with their primary care system that are consistent with optimal chronic illness care as suggested by Wagner's Chronic Care Model (CCM).

MATERIALS AND METHODS

A cross-sectional analysis of the results of the Patient Assessment of Chronic Illness Care (PACIC), which measured components of the care system suggested by the CCM and was completed at baseline by participants in a hypertension disease management clinical trial. Participants had a recent history of uncontrolled systolic blood pressure.

RESULTS

Among 377 patients, non-Hispanic African American veterans had almost twice the odds of indicating that their primary care experience is consistent with CCM features when compared with non-Hispanic White patients (odds ratio (OR) = 1.86; 95% confidence interval (CI) = 1.16-2.98). Similar statistically significant associations were observed for follow-up care (OR = 2.59; 95% CI = 1.49-4.50), patient activation (OR = 1.80; 95% CI = 1.13-2.87), goal setting (OR = 1.65; 95% CI = 1.03-2.64), and help with problem solving (OR = 1.62; 95% CI = 1.00-2.60).

CONCLUSIONS

Non-Hispanic African Americans with pharmaceutically treated hypertension report that the primary care system more closely approximates the Wagner CCM than non-Hispanic White patients.

Linkage of VA and State Prescription Drug Monitoring Program Data to Examine Concurrent Opioid and Sedative-Hypnotic Prescriptions among Veterans

OBJECTIVE

To examine the prevalence of concurrent Veterans Health Administration (VA) and non-VA prescriptions for opioids and sedative-hypnotic medications among post-9/11 veterans in Oregon.

DATA SOURCES

VA health care and prescription data were probabilistically linked with Oregon Prescription Drug Monitoring Program (PDMP) data.

STUDY DESIGN

This retrospective cohort study examined concurrent prescriptions among n = 19,959 post-9/11 veterans, by year (2014-2016) and by patient demographic and clinical characteristics. Veterans were included in the cohort for years in which they received VA outpatient care; those receiving hospice or palliative care were excluded. Concurrent prescriptions were defined as ≥1 days of overlap between outpatient prescriptions for opioids and/or sedative-hypnotics (categorized as benzodiazepines vs. non-benzodiazepines).

PRINCIPAL FINDINGS

Among 5,882 veterans who filled opioid or sedative-hypnotic prescriptions at VA pharmacies, 1,036 (17.6 percent) filled concurrent prescriptions from non-VA pharmacies. Within drug class, 15.1, 8.8, and 4.6 percent received concurrent VA and non-VA opioids, benzodiazepines, and non-benzodiazepines, respectively. Veteran demographics and clinical diagnoses were associated with the likelihood of concurrent prescriptions, as was enrollment in the Veterans Choice Program.

CONCLUSIONS

A considerable proportion of post-9/11 veterans receiving VA care in Oregon filled concurrent prescriptions for opioids and sedative-hypnotics. Fragmentation of care may contribute to prescription drug overdose risk among veterans.

The physical and mental health burden of obesity in U.S. veterans: Results from the National Health and Resilience in Veterans Study

In this study, we provide an updated estimate of the prevalence of obesity in U.S. military veterans, and evaluate a broad range of sociodemographic, military, physical and mental health, and lifestyle characteristics associated with obesity in this population. Data were analyzed from a nationally representative sample of 3122 U.S. veterans who participated in the National Health and Resilience in Veterans Study (NHRVS). Associations between obesity status, and physical and mental health, and lifestyle variables were evaluated using multivariate logistic regression and linear regression analyses. Results revealed that 32.7% of U.S. veterans are obese, which is higher than the previously reported estimates for U.S. military veterans nationally, and was particularly high among younger and non-white veterans and those using the Veterans Heath Administration (VHA) healthcare system. Obesity was associated with greater trauma burden; elevated rates of a broad range of health conditions such as diabetes, arthritis, and heart disease, PTSD, nicotine dependence; poor physical and mental functioning and quality of life, and decreased engagement in an active lifestyle. Taken together, these results suggest that the prevalence of obesity is high in U.S. veterans and associated with substantial health burden. Results have implications for informing obesity prevention and treatment programs in veterans, and underscore the importance of assessing, monitoring, and treating obesity in this population.

The Relationship between Costs and Quality in Veterans Health Administration Community Living Centers: An Analysis Using Longitudinal Data

OBJECTIVE

To examine the relationship between cost and quality in Veterans Health Administration (VA) nursing homes (called Community Living Centers, CLCs) using longitudinal data.

DATA SOURCES/STUDY SETTING

One hundred and thirty CLCs over 13 quarters (from FY2009 to FY2012) were studied. Costs, resident days, and resident severity (RUGs score) were obtained from the VA Managerial Cost Accounting System. Clinical quality measures were obtained from the Minimum Data Set, and resident-centered care (RCC) was measured using the Artifacts of Culture Change Tool.

STUDY DESIGN

We used a generalized estimating equation model with facilities included as fixed effects to examine the relationship between total cost and quality after controlling for resident days and severity. The model included linear and squared terms for all independent variables and interactions with resident days.

PRINCIPAL FINDINGS

With the exception of RCC, all other variables had a statistically significant relationship with total costs. For most poorer performing smaller facilities (lower size quartile), improvements in quality were associated with higher costs. For most larger facilities, improvements in quality were associated with lower costs.

CONCLUSIONS

The relationship between cost and quality depends on facility size and current level of performance.

Delivering a "New Deal" of Kidney Health Opportunities to Improve Outcomes Within the Veterans Health Administration

Just as the "New Deal" aimed to elevate the "forgotten man" of the Great Depression through governmental relief and reform, so does the Department of Veterans Affairs (VA) health care system aim to improve the health of veterans with the invisible illness of chronic kidney disease through a concerted series of health care delivery reforms. Augmenting its primary care platform with advances in informatics and health service delivery initiatives targeting kidney disease, the VA is changing how nephrology care is provided to veterans with the goal of optimized population kidney health. As the largest provider of kidney health services in the country, the VA offers an instructive case study of the value of comprehensive health care coverage for people with chronic kidney disease. Recent reports of kidney health outcomes among veterans support the benefit of the VA's integrated health care delivery system. Suggestions to optimize veterans' kidney health further may be equally applicable to other health systems caring for people afflicted with kidney disease.

Assessing Responsiveness of Health Systems to Drug Safety Warnings

OBJECTIVE

In 2011-2012 the U.S. Food and Drug Administration (FDA) issued safety announcements cautioning providers against prescribing high doses of citalopram given concerns for QT prolongation. The authors evaluated Veterans Affairs (VA) national trends in citalopram use and dose compared with alternative antidepressants after the FDA warnings.

METHODS

Time series analyses estimated the effect of the FDA warnings on citalopram and other antidepressant across three periods: before the first FDA warning in August 2011, after the 2011 FDA warning until the second warning in March 2012, and after the 2012 FDA warning. In a National VA health system, adult VA outpatients prescribed citalopram or alternative antidepressants from February 2010 to September 2013 were studied. Outpatient use of high-dose citalopram (>40 or >20 mg daily in adults aged > 60 years) including the proportion of patients prescribed citalopram and difference between study periods.

RESULTS

Between the first and second FDA warnings, among patients aged 18-60, high-dose citalopram use decreased by 2.0% per month (p < 0.001) and by 1.9% per month (p < 0.001) for older adults. After the second FDA warning in 2012, 30.7% of older patients remained on doses higher than the newly recommended dose of 20 mg. Reductions in overall use of citalopram were accompanied by significant increases in prescriptions of alternative antidepressants, with sertraline most widely prescribed.

CONCLUSION

Although trends in high-dose citalopram use declined after the 2011-2012 FDA warnings, roughly one-third of older adults still remained on higher than recommended doses. Concomitant increases in sertraline and other antidepressant prescriptions suggest potential substitution of these medications for citalopram.

Trends in Health Insurance and Type Among Military Veterans: United States, 2000-2016

OBJECTIVES

To describe long-term national trends in health insurance coverage among US veterans from 2000 to 2016 in the context of recent health care reform.

METHODS

We used 2000 to 2016 National Health Interview Survey data on veterans aged 18 to 64 years to examine trends in insurance coverage and uninsurance by year, income, and state Medicaid expansion status. We also explored the current proportions of veterans with each type of insurance by age group.

RESULTS

The percentage of veterans with private insurance decreased from 70.8% in 2000 to 56.9% in 2011, whereas between 2000 and 2016 Department of Veterans Affairs (VA) health care coverage (only) almost tripled, Medicaid (without concurrent TRICARE or private coverage) doubled, and TRICARE coverage of any type tripled. After 2011, the percentage of veterans who were uninsured decreased. In 2016, low-income veterans in Medicaid expansion states had double the Medicaid coverage (41.1%) of low-income veterans in nonexpansion states (20.1%).

CONCLUSIONS

Our estimates, which are nationally representative of noninstitutionalized veterans, show marked increases in military-related coverage through TRICARE and VA health care. In 2016, only 7.2% of veterans aged 18 to 64 years and 3.7% of all veterans (aged 18 years or older) remained uninsured.

Development of Veteran-Centric Competency Domains for Psychiatric-Mental Health Nurse Practitioner Residents

The mental health needs of military service members, Veterans, and their families are a designated national priority; however, there has been little emphasis on the inclusion of Veteran-centric domains in competency-based nursing education for psychiatric-mental health nurse practitioners (PMHNPs). The current article describes the identification and application of Veteran-centric domains in an innovative pilot residency program for PMHNPs, funded by the Veterans Health Administration Office of Academic Affiliations. Fourteen Veteran-centric competency domains were developed from literature review, including knowledge, attitudes, and skill behaviors. Adoption and application of these domains in curricular components included the resident competency evaluation, baseline assessment of military experience, and evidence-based practice seminars and training. Methods of competency domain evaluation are presented, along with gaps related to the evaluation of competency skills. The delivery of mental health services reflecting these domains is consistent with the VA core values and goal of developing a positive service culture. [Journal of Psychosocial Nursing and Mental Health Services, 54(11), 31-36.].

Revisiting Organisational Learning in Integrated Care

Progress in health care integration is largely linked to changes in processes and ways of doing. These changes have knowledge management and learning implications. For this reason, the use of the concept of organisational learning is explored in the field of integrated care.

There are very limited contributions that have connected the fields of organisational learning and care integration in a systematic way, both at the theoretical and empirical level. For this reason, hybridization of both perspectives still provides opportunities for understanding care integration initiatives from a research perspective as well as potential applications in health care management and planning.

Linkage between theory-based measurement of organizational readiness for change and lessons learned conducting quality improvement-focused research

Organizations have different levels of readiness to implement change in the patient care process. The Hypertension Telemedicine Nurse Implementation Project for Veterans (HTN-IMPROVE) is an example of an innovation that seeks to enhance delivery of care for patients with hypertension. We describe the link between organizational readiness for change (ORC), assessed as the project began, and barriers and facilitators occurring during the process of implementing a primary care innovation. Each of 3 Veterans Affairs medical centers provided a half-time nurse and implemented a nurse-delivered, telephone-based self-management support program for patients with uncontrolled hypertension. As the program was starting, we assessed the ORC and factors associated with ORC. On the basis of consensus of medical center and research partners, we enumerated implementation process barriers and facilitators. The primary ORC barrier was unclear long-term commitment of nursing to provide continued resources to the program. Three related barriers included the need to address: (1) competing organizational demands, (2) differing mechanisms to integrate new interventions into existing workload, and (3) methods for referring patients to disease and self-management support programs. Prior to full implementation, however, stakeholders identified a high level of commitment to conduct nurse-delivered interventions fully using their skills. There was also a significant commitment from the core implementation team and a desire to improve patient outcomes. These facilitators were observed during the implementation of HTN-IMPROVE. As demonstrated by the link between barriers to and facilitators of implementation anticipated though the evaluation of ORC and what was actually observed during the process of implementation, this project demonstrates the practical utility of assessing ORC prior to embarking on the implementation of significant new clinical innovations.

Moving From Discovery to System-Wide Change: The Role of Research in a Learning Health Care System: Experience from Three Decades of Health Systems Research in the Veterans Health Administration

The Veterans Health Administration is unique, functioning as an integrated health care system that provides care to more than six million veterans annually and as a home to an established scientific enterprise that conducts more than $1 billion of research each year. The presence of research, spanning the continuum from basic health services to translational research, has helped the Department of Veterans Affairs (VA) realize the potential of a learning health care system and has contributed to significant improvements in clinical quality over the past two decades. It has also illustrated distinct pathways by which research influences clinical care and policy and has provided lessons on challenges in translating research into practice on a national scale. These lessons are increasingly relevant to other health care systems, as the issues confronting the VA—the need to provide timely access, coordination of care, and consistent high quality across a diverse system—mirror those of the larger US health care system.

The musculoskeletal diagnosis cohort: examining pain and pain care among veterans

Musculoskeletal disorders (MSDs) are highly prevalent, painful, and costly disorders. The MSD Cohort was created to characterize variation in pain, comorbidities, treatment, and outcomes among patients with MSD receiving Veterans Health Administration care across demographic groups, geographic regions, and facilities. We searched electronic health records to identify patients treated in Veterans Health Administration who had ICD-9-CM codes for diagnoses including, but not limited to, joint, back, and neck disorders, and osteoarthritis. Cohort inclusion criteria were 2 or more outpatient visits occurring within 18 months of one another or one inpatient visit with an MSD diagnosis between 2000 and 2011. The first diagnosis is the index date. Pain intensity numeric rating scale (NRS) scores, comorbid medical and mental health diagnoses, pain-related treatments, and other characteristics were collected retrospectively and prospectively. The cohort included 5,237,763 patients; their mean age was 59, 6% were women, 15% identified as black, and 18% reported severe pain (NRS ≥ 7) on the index date. Nontraumatic joint disorder (27%), back disorder (25%), and osteoarthritis (21%) were the most common MSD diagnoses. Patients entering the cohort in recent years had more concurrent MSD diagnoses and higher NRS scores. The MSD Cohort is a rich resource for collaborative pain-relevant health service research.

Patient-Centered Medical Home Implementation in the Veterans Health Administration and Primary Care Use: Differences by Patient Comorbidity Burden

BACKGROUND

The patient-centered medical home (PCMH) model has several components to improve care for patients with high comorbidity, including greater access to face-to-face primary care.

OBJECTIVE

We examined whether high-comorbidity patients had larger increases in primary care provider (PCP) visits attributable to PCMH implementation in a large integrated health system relative to other patients enrolled in primary care.

DESIGN, SUBJECTS AND MAIN MEASURES

This longitudinal study examined a 1 % random sample of 9.3 million patients enrolled in the Veterans Health Administration (VHA) at any time between 2003 and 2013. Face-to-face visits with PCPs per quarter were identified through VHA administrative data. Comorbidity was measured using the Gagne index and patients with a weighted score of ≥ 2 were defined as high comorbidity. We applied interrupted time-series models to estimate marginal changes in PCP visits attributable to PCMH implementation. Differences in marginal changes were calculated across comorbidity groups (high vs. low). Analyses were stratified by age group to account for Medicare eligibility.

KEY RESULTS

Among age 65+ patients, PCMH was associated with greater PCP visits starting four and ten quarters following implementation for high- and low-comorbidity patients, respectively. Changes were larger for high-comorbidity patients (eight to 11 greater visits per 1000 patients per quarter). Among patients age < 65, PCMH was associated with greater visits for high-comorbidity patients starting eight quarters following implementation, but fewer visits for low-comorbidity patients in all quarters. The difference in visit changes across groups ranged from 18 to 67 visits per 1000 patients per quarter.

CONCLUSIONS

Increases in PCP visits attributable to PCMH were greater among patients with higher comorbidity. Health systems implementing PCMH should account for population-level comorbidity burden when planning for PCMH-related changes in PCP utilization.

Through Their Eyes: Lessons Learned Using Participatory Methods in Health Care Quality Improvement Projects

In this methodological article, we examine participatory methods in depth to demonstrate how these methods can be adopted for quality improvement (QI) projects in health care. We draw on existing literature and our QI initiatives in the Department of Veterans Affairs to discuss the application of photovoice and guided tours in QI efforts. We highlight lessons learned and several benefits of using participatory methods in this area. Using participatory methods, evaluators can engage patients, providers, and other stakeholders as partners to enhance care. Participant involvement helps yield actionable data that can be translated into improved care practices. Use of these methods also helps generate key insights to inform improvements that truly resonate with stakeholders. Using participatory methods is a valuable strategy to harness participant engagement and drive improvements that address individual needs. In applying these innovative methodologies, evaluators can transcend traditional approaches to uniquely support evaluations and improvements in health care.

Patterns of Care for Colorectal Liver Metastasis Within an Integrated Health System: Secular Trends and Outcomes

BACKGROUND

Utilization of evidence-based treatments for patients with colorectal liver metastasis (CRC-LM) outside high-volume centers is not well-characterized. We sought to describe trends in treatment and outcomes, and identify predictors of therapy within a nationwide integrated health system.

METHODS

Observational cohort study of patients with CRC-LM treated within the Veterans Affairs (VA) health system (1998-2012). Secular trends and outcomes were compared on the basis of treatment type. Multivariate regression was used to identify predictors of no treatment (chemotherapy or surgery).

RESULTS

Among 3270 patients, 57.3 % received treatment (chemotherapy and/or surgery) during the study period. The proportion receiving treatment doubled (38 % in 1998 vs. 68 % in 2012; trend test, p < 0.001), primarily driven by increased use of chemotherapy (26 vs. 57 %; trend test, p < 0.001). Among patients having surgery (16 %), the proportion having ablation (10 vs. 61.9 %; trend test, p < 0.001) and multimodality therapy (15 vs. 67 %; trend test, p < 0.001) increased significantly over time. Older patients [65-75 years: odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.39-1.97; >75 years: OR 3.84, 95 % CI 3.13-4.69] and those with high comorbidity index (Charlson ≥3: OR 1.47, 95 % CI 1.16-1.85) were more likely to be untreated. Overall survival was significantly different based on treatment strategy (log-rank p < 0.001).

CONCLUSIONS

The proportion of CRC-LM patients receiving treatment within the largest integrated health system in the US (VA health system) has increased substantially over time; however, one in three patients still does not receive any treatment. Future initiatives should focus on increasing treatment among older patients as well as on evaluating reasons leading to the no-treatment approach and increased use of ablation procedures.

Variations in payment patterns for surgical care in the centers for Medicare and Medicaid Services

BACKGROUND

We investigated provider and regional variation in payments made to surgeons by the Centers for Medicare & Medicaid Services (CMS) by indexing payments to unique beneficiaries treated and examined the proportion of charges that resulted in payments. Understanding variation in care within CMS may prove actionable by identifying modifiable, and potentially unwarranted, variations.

METHODS

We analyzed the Medicare Part B Provider Utilization and Payment Data released by CMS for 2012. We included Medicare B participants in the fee-for-service program. We calculated for each provider the ratio of number of services provided to individual beneficiaries, and the ratio of total submitted charges to total Medicare payments. We also categorized each provider into deciles of total Medicare payments, and calculated the means per decile of total Medicare payment for surgeons and urologists. To determine any associations with ratio of services to beneficiaries, we conducted multivariate linear regressions.

RESULTS

The 20th, 40th, 60th, and 80th percentiles for the services-per-beneficiary ratios are 1.6, 2.2, 3.1, and 5.0, respectively (n = 83,376). Greater-earning surgeons offered more services per beneficiary, with a precipitous increase from the lowest decile to the highest. Charges were consistently greater than payments by a factor of 3. In our multivariate analysis of services per beneficiary ratio, female providers had lower ratios (P < .01), and we noted significant regional variation in the ratio of services per unique beneficiary (P < .001 for each of the 10 Standard Federal Regions).

CONCLUSION

We found significant variation in patterns of payments for surgical care in CMS.

Racial Differences in Processes of Care at End of Life in VA Medical Centers: Planned Secondary Analysis of Data from the BEACON Trial

BACKGROUND

Racial differences exist for a number of health conditions, services, and outcomes, including end-of-life (EOL) care.

OBJECTIVE

The aim of the study was to examine differences in processes of care in the last 7 days of life between African American and white inpatients.

METHODS

Secondary analysis was conducted of data collected in the Best Practices for End-of-Life Care for Our Nation's Veterans (BEACON) trial (conducted 2005-2011). Subjects were 4891 inpatient decedents in six Veterans Administration Medical Centers. Data were abstracted from decedents' medical records. Multi-variable analyses were conducted to examine the relationship between race and each of 18 EOL processes of care controlling for patient characteristics, study site, year of death, and whether the observation was pre- or post-intervention.

RESULTS

The sample consisted of 1690 African American patients (34.6%) and 3201 white patients (65.4%). African Americans were less likely to have: do not resuscitate (DNR) orders (odds ratio [OR]: 0.67; p = 0.004), advance directives (OR: 0.71; p = 0.023), active opioid orders (OR: 0.64, p = 0.0008), opioid medications administered (OR: 0.61, p = 0.004), benzodiazepine orders (OR: 0.68, p < 0.0001), benzodiazepines administered (OR: 0.61, p < 0.0001), antipsychotics administered (OR: 0.73, p = 0.004), and steroids administered (OR: 0.76, p = 0.020). Racial differences were not found for other processes of care, including palliative care consultation, pastoral care, antipsychotic and steroid orders, and location of death.

CONCLUSIONS

Racial differences exist in some but not all aspects of EOL care. Further study is needed to understand the extent to which racial differences reflect different patient needs and preferences and whether interventions are needed to reduce disparities in patient/family education or access to quality EOL care.

Quality of HIV Care and Mortality Rates in HIV-Infected Patients

BACKGROUND

The Patient Protection and Affordable Care Act encourages healthcare systems to track quality-of-care measures; little is known about their impact on mortality rates. The objective of this study was to assess associations between HIV quality of care and mortality rates.

METHODS

A longitudinal survival analysis of the Veterans Aging Cohort Study included 3038 human immunodeficiency virus (HIV)-infected patients enrolled between June 2002 and July 2008. The independent variable was receipt of ≥80% of 9 HIV quality indicators (QIs) abstracted from medical records in the 12 months after enrollment. Overall mortality rates through 2014 were assessed from the Veterans Health Administration, Medicare, and Social Security National Death Index records. We assessed associations between receiving ≥80% of HIV QIs and mortality rates using Kaplan-Meier survival analysis and adjusted Cox proportional hazards models. Results were stratified by unhealthy alcohol and illicit drug use.

RESULTS

The majority of participants were male (97.5%) and black (66.8%), with a mean (standard deviation) age of 49.0 (8.8) years. Overall, 25.9% reported past-year unhealthy alcohol use and 28.4% reported past-year illicit drug use. During 24 805 person-years of follow-up (mean [standard deviation], 8.2 [3.3] years), those who received ≥80% of QIs experienced lower age-adjusted mortality rates (adjusted hazard ratio, 0.75; 95% confidence interval, .65-.86). Adjustment for disease severity attenuated the association.

CONCLUSIONS

Receipt of ≥80% of select HIV QIs is associated with improved survival in a sample of predominantly male, black, HIV-infected patients but was insufficient to overcome adjustment for disease severity. Interventions to ensure high-quality care and address underlying chronic illness may improve survival in HIV-infected patients.

Transformational change in healthcare: an examination of four case studies

Objectives Healthcare leaders around the world are calling for radical, transformational change of our health and care systems. This will be a difficult and complex task. In this article, we examine case studies in which transformational change has been achieved, and seek to learn from these experiences. Methods We used the case study method to investigate examples of transformational change in healthcare. The case studies were identified from preliminary doctoral research into the transition towards future sustainable health and social care systems. Evidence was collected from multiple sources, key features of each case study were displayed in a matrix and thematic analysis was conducted. The results are presented in narrative form. Results Four case studies were selected: two from the US, one from Australia and one from the UK. The notable features are discussed for each case study. There were many common factors: a well communicated vision, innovative redesign, extensive consultation and engagement with staff and patients, performance management, automated information management and high-quality leadership. Conclusions Although there were some notable differences between the case studies, overall the characteristics of success were similar and collectively provide a blueprint for transformational change in healthcare. What is known about the topic? Healthcare leaders around the world are calling for radical redesign of our systems in order to meet the challenges of modern society. What does this paper add? There are some remarkable examples of transformational change in healthcare. The key factors in success are similar across the case studies. What are the implications for practitioners? Collectively, these key factors can guide future attempts at transformational change in healthcare.

Unhealthy alcohol use in older adults: Association with readmissions and emergency department use in the 30 days after hospital discharge

BACKGROUND

Unhealthy alcohol use could impair recovery of older patients after medical or surgical hospitalizations. However, no prior research has evaluated whether older patients who screen positive for unhealthy alcohol use are at increased risk of readmissions or emergency department (ED) visits within 30 days after discharge. This study examined the association between AUDIT-C alcohol screening results and 30-day readmissions or ED visits.

METHODS

Veterans Affairs (VA) patients age 65 years or older, were eligible if they were hospitalized for a medical or surgical condition (2/1/2009-10/1/2011) and had an AUDIT-C score documented in their VA electronic medical record in the year before they were hospitalized. VA and Medicare data identified VA or non-VA index hospitalizations, readmissions, and ED visits. Primary analyses adjusted for demographics, comorbid conditions, and past-year health care utilization.

RESULTS

Among 579,330 hospitalized patients, 13.7% were readmitted and 12.0% visited an ED within 30 days of discharge. In primary analyses, high-risk drinking (n=7,167) and nondrinking (n=357,086) were associated with increased probability of readmission (13.8%, 95% CI 13.0-14.6%; and 14.2%, 95% CI 14.1-14.3%, respectively), relative to low-risk drinking (12.9%; 95% CI 12.7-13.0%). Only nondrinkers had increased risk for ED visits.

CONCLUSIONS

Alcohol screening results indicating high-risk drinking that were available in medical records were modestly associated with risk for 30-day readmissions and were not associated with risk for ED visits.