Physical Function Does Not Predict Care Assessment Need Score in Older Veterans

Implementation of a Pilot PharmD Medication Optimization Telehealth Clinic Within a Veterans Affairs System

Background Patients older than 65 years of age with an anticipated life-expectancy of 12 months or less may have complex medication regimens and an increased risk of adverse drug reactions, and drug-drug interactions. Within the Department of Veterans Affairs, a commonly used medication optimization model is known as the VIONE methodology. Objective This project aimed to pilot implementation of board-certified clinical pharmacist practitioners utilizing the VIONE model within a patient-aligned care team targeting patients 65 years of age and older. Methods The population was identified through the VIONE dashboards. Veteran inclusion criteria included five or more medications, a VIONE risk score of 5 or greater, and CAN scores of greater than 90. The project team reached out via telephone to the patients for a medication regimen review and a 14-day follow-up call. Primary outcomes were quantity of medications discontinued per patient, classes of medications that were discontinued, number and encounter time spent, and cost avoidance over 1 year. Secondary outcomes were VIONE classification of medications, VIONE discontinuation reason, number of recommendations given and accepted by primary provider, and safety analysis. Results There were 53 patients who were successfully contacted via telephone. The top four most discontinued medication classes included 1) vitamins/supplements, 2) ophthalmology medications, 3) gastrointestinal medications, and 4) non-controlled analgesic medications. During the project period the potential cost avoidance over 1 year was $17,716. CONCLUSION: This project demonstrated that usage of VIONE methodology ensures medication optimization with minimal harm and provides significant cost savings in the ambulatory care setting.

Reliability of Virtual Physical Performance Assessments in Veterans During the COVID-19 Pandemic

Objective

To determine the reliability of 3 physical performance tests performed via a telehealth visit (30-s arm curls test, 30-s chair stand test, 2-min step test) among community-dwelling older veterans.

Design

Cross sectional study.

Setting

Virtual.

Participants

Veterans (N=55; mean age 75y) who enrolled in Gerofit, a virtual group exercise program.

Interventions

Not applicable.

Main Outcome Measures

Participants were tested by 2 different assessors at 1 time point. The intraclass correlation coefficient (ICC) with 95% confidence intervals and Bland-Altman plots were used as measures of reliability. To assess generalizability, ICCs were further evaluated by health conditions (type 2 diabetes, arthritis, obesity, depression).

Results

Assessments were conducted among 55 participants. The ICC was above 0.98 for all 3 tests across health conditions and Bland-Altman plots indicated that there were no significant systematic errors in the measurement.

Conclusions

The virtual physical performance measures appear to have high reliability and the findings are generalizable across health conditions among veterans. Thus, they are reliable for evaluating physical performance in older veterans in virtual settings.

Data Object Exchange (DOEx) as a Method to Facilitate Intraorganizational Collaboration by Managed Data Sharing: Viewpoint

Background

To help reduce expenses, shorten timelines, and improve the quality of final deliverables, the Veterans Health Administration (VA) and other health care systems promote sharing of expertise among informatics user groups. Traditional barriers to time-efficient sharing of expertise include difficulties in finding potential collaborators and availability of a mechanism to share expertise.

Objective

We aim to describe how the VA shares expertise among its informatics groups by describing a custom-built tool, the Data Object Exchange (DOEx), along with statistics on its usage.

Methods

A centrally managed web application was developed in the VA to share informatics expertise using database objects. Visitors to the site can view a catalog of objects published by other informatics user groups. Requests for subscription and publication made through the site are routed to database administrators, who then actualize the resource requests through modifications of database object permissions.

Results

As of April 2019, the DOEx enabled the publication of 707 database objects to 1202 VA subscribers from 758 workgroups. Overall, over 10,000 requests are made each year regarding permissions on these shared database objects, involving diverse information. Common “flavors” of shared data include disease-specific study populations (eg, patients with asthma), common data definitions (eg, hemoglobin laboratory results), and results of complex analyses (eg, models of anticipated resource utilization). Shared database objects also enable construction of community-built data pipelines.

Conclusions

To increase the efficiency of informatics user groups, a method was developed to facilitate intraorganizational collaboration by managed data sharing. The advantages of this system include (1) reduced duplication of work (thereby reducing expenses and shortening timelines) and (2) higher quality of work based on simplifying the adoption of specialized knowledge among groups.

Subjective and Objective Mental and Physical Functions Affect Subjective Cognitive Decline in Community-Dwelling Elderly Japanese People

Subjective cognitive decline (SCD) is complex and not well understood, especially among Japanese people. In the present study, we aimed to elucidate the relationships of subjective and objective mental and physical function with SCD among older community-dwelling Japanese adults. SCD was evaluated using the Kihon Checklist: Cognitive Function. Other parameters were evaluated using the Mini-Mental State Examination (MMSE) and the five-item version of the Geriatric Depression Scale (GDS-5), for an objective mental function other than SCD. A timed up-and-go test (TUG) and knee extension strength were used to test objective physical function, and the Mental Component Summary (MCS) and Physical Component Summary (PCS) in the Health-Related Quality of Life survey eight-item short form (SF-8) were used for subjective mental and physical functions. The results of the MMSE, GDS-5, TUG, knee extension strength, and MCS were significantly worse in the SCD group. In addition, logistic regression analysis showed that GDS-5 and MCS were associated with SCD onset. Depressive symptoms and decreased subjective mental function contribute to SCD among community-dwelling Japanese adults. These findings will be useful for planning dementia prevention and intervention programs for older Japanese adults.

Patient Electronic Health Records Score for Preoperative Risk Assessment Before Total Knee Arthroplasty

Background:

Current preoperative risk assessment tools are often cumbersome, have limited accuracy, and are poorly adopted. The Care Assessment Need (CAN) score, an existing tool developed for primary care providers in the U.S. Veterans Administration health-care system (VA), is automatically calculated for individual patients using electronic health record data. Therefore, it could present an efficient preoperative risk assessment tool. The aim of this project was to determine if the CAN score can be repurposed as a preoperative risk assessment tool for patients undergoing total knee arthroplasty (TKA).

Methods:

A multicenter retrospective observational study was conducted using national VA data from 2013 to 2016. The cohort included veterans who underwent TKA identified through ICD-9 (International Classification of Diseases, Ninth Revision), ICD-10, and CPT (Current Procedural Terminology) codes. The focus of the study was the preoperative patient CAN score, a single numerical value ranging from 0 to 99 (with a higher score representing greater risk) that is automatically calculated each week using multiple data points in the VA electronic health record. Study outcomes of interest were 90-day readmission, prolonged hospital stay (>5 days), 1-year mortality, and non-routine patient discharge.

Results:

The study included 17,210 veterans. Their median preoperative CAN score was 75, although there was substantial variability in patient CAN scores among different facilities. A preoperative CAN score of >75 was significantly associated with mortality (odds ratio [OR] = 3.54), prolonged length of stay (OR = 1.97), 90-day readmission (OR = 1.65), and non-routine discharge (OR = 1.57). The CAN score had good accuracy with a receiver operating characteristic (ROC) curve value of >0.7 for all outcomes except 90-day readmission.

Conclusions:

The CAN score can be leveraged as an extremely efficient way to risk-stratify patients before TKA, with results that surpass other commonly available and labor-intensive alternatives. As a result, this simple and efficient solution is well positioned for broad adoption as a standardized decision support tool.

Level of Evidence:

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Medical foster home is less costly than traditional nursing home care

OBJECTIVE

To compare the costs of Community Nursing Homes (CNHs) to Medical Foster Homes (MFHs) at Veteran Health Administration (VHA) Medical Centers that established MFH programs.

DATA SOURCES

Episode and costs data were derived from VA and Medicare files (inpatient, outpatient, emergency room, skilled nursing facility, dialysis, and hospice).

STUDY DESIGN

Propensity scores matched 354 MFH to 1693 CNH Veterans on demographics, clinical characteristics, health care utilization, and costs.

DATA EXTRACTION METHODS

Data were retrieved for years 2010-2011 from the VA Corporate Data Warehouse, VA Health Data Repository, and the VA MFH Program through the VA Informatics and Computing Infrastructure (VINCI).

PRINCIPAL FINDINGS

After matching on unique characteristics of MFH Veterans, costs were $71.28 less per day alive compared to CNH care. Home-based and mental health care costs increased with savings largely attributable to avoiding CNH residential care. When average out-of-pocket payments by Veterans of $74/day are considered, MFH is at least cost neutral. Mortality was 12 percent higher among matched Veterans in CNHs.

CONCLUSIONS

MFHs may serve as alternatives to traditional CNH care that do not increase total costs with mortality benefits. Future work should examine the differences for functional disability subgroups.