1
|
Hynes DM, Edwards S, Hickok A, Niederhausen M, Weaver FM, Tarlov E, Gordon H, Jacob RL, Bartle B, O’Neill A, Young R, Laliberte A. Veterans' Use of Veterans Health Administration Primary Care in an Era of Expanding Choice. Med Care 2021; 59:S292-S300. [PMID: 33976079 PMCID: PMC8132904 DOI: 10.1097/mlr.0000000000001554] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The Veterans Choice Program (VCP), aimed at improving access to care, included expanded options for Veterans to receive primary care through community providers. OBJECTIVES The objective of this study was to characterize and compare Veterans use of Veterans Health Administration (VA) primary care services at VA facilities and through a VA community care network (VA-CCN) provider. RESEARCH DESIGN This was a retrospective, observational over fiscal years (FY) 2015-2018. SUBJECTS Veterans receiving primary care services paid for by the VA. MEASURES Veteran demographic, socioeconomic and clinical factors and use of VA primary care services under the VCP each year. RESULTS There were 6.3 million Veterans with >54 million VA primary care visits, predominantly (98.5% of visits) at VA facility. The proportion of VA-CCN visits increased in absolute terms from 0.7% in 2015 to 2.6% in 2018. Among Veterans with any VA-CCN primary care, the proportion of VA-CCN visits increased from 22.6% to 55.3%. Logistic regression indicated that Veterans who were female, lived in rural areas, had a driving distance >40 miles, had health insurance or had a psychiatric/depression condition were more likely to receive VA-CCN primary care. Veterans who were older, identified as Black race, required to pay VA copayments, or had a higher Nosos score, were less likely to receive VA-CCN primary care. CONCLUSION As the VA transitions from the VCP to MISSION and VA facilities gain experience under the new contracts, attention to factors that impact Veterans' use of primary care services in different settings are important to monitor to identify access barriers and to ensure Veterans' health care needs are met.
Collapse
Affiliation(s)
- Denise M. Hynes
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
- College of Public Health and Human Sciences, Oregon State University, Corvallis
- School of Nursing
| | - Samuel Edwards
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
- School of Medicine, Oregon Health and Science University
| | - Alex Hickok
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
| | - Meike Niederhausen
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
- Oregon Health and Science University, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR
| | - Frances M. Weaver
- US Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines
- Parkinson School of Health Sciences and Public Health, Loyola University, Maywood
| | - Elizabeth Tarlov
- US Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines
- University of Illinois at Chicago, College of Nursing
| | - Howard Gordon
- US Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines
- US Department of Veterans Affairs, Jesse Brown VA Medical Center and University of Illinois at Chicago, College of Medicine, Chicago, IL
| | - Reside L. Jacob
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
| | - Brian Bartle
- US Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines
| | - Allison O’Neill
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
| | - Rebecca Young
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
| | - Avery Laliberte
- US Department of Veterans Affairs (VA), VA Portland Healthcare System, Center to Improve Veteran Involvement in Care (CIVIC), Portland
| |
Collapse
|
2
|
Neelon B. Bayesian Zero-Inflated Negative Binomial Regression Based on Pólya-Gamma Mixtures. BAYESIAN ANALYSIS 2019; 14:829-855. [PMID: 33584949 PMCID: PMC7880198 DOI: 10.1214/18-ba1132] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Motivated by a study examining spatiotemporal patterns in inpatient hospitalizations, we propose an efficient Bayesian approach for fitting zero-inflated negative binomial models. To facilitate posterior sampling, we introduce a set of latent variables that are represented as scale mixtures of normals, where the precision terms follow independent Pólya-Gamma distributions. Conditional on the latent variables, inference proceeds via straightforward Gibbs sampling. For fixed-effects models, our approach is comparable to existing methods. However, our model can accommodate more complex data structures, including multivariate and spatiotemporal data, settings in which current approaches often fail due to computational challenges. Using simulation studies, we highlight key features of the method and compare its performance to other estimation procedures. We apply the approach to a spatiotemporal analysis examining the number of annual inpatient admissions among United States veterans with type 2 diabetes.
Collapse
Affiliation(s)
- Brian Neelon
- Medical University of South Carolina, Charleston, SC
| |
Collapse
|
3
|
Variations in VA and Medicare Use Among Veterans With Diabetes: Impacts on Ambulatory Care Sensitive Conditions Hospitalizations for 2008, 2009, and 2010. Med Care 2019; 57:425-436. [PMID: 31045693 DOI: 10.1097/mlr.0000000000001119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION VA and Medicare use among older Veterans has been considered fragmented care, however, it may represent access to needed care. METHODS The population studied were Veterans with diabetes, age 66 years and older, dually enrolled in VA and Medicare. DATA SOURCE/STUDY SETTING We conducted a dynamic retrospective cohort study with 2008, 2009, and 2010 as the outcome years (Ambulatory Care Sensitive Conditions Hospitalization (ACSC-H) or not). We analyzed administrative data to identify comorbidities; ambulatory care utilization to identify variations in use before hospitalization. We linked 2007 primary care (PC) survey data to assess if organizational factors were associated with ACSC-H. MEASURES AND ANALYSIS We identified ACSC-Hs using a validated definition. We categorized VA/Medicare use as: single system; dual system: supplemental specialty care use; or primary care use. Using hierarchical logistic regression models, we tested for associations between VA/Medicare use, organizational characteristics, and ACSC-H controlling for patient-level, organizational-level, and area-level characteristics. RESULTS Our analytic population was comprised of 210,726 Medicare-eligible Veterans; more than one quarter had an ACSC-H. We found that single system users had higher odds of ACSC-H compared with dual system specialty supplemental care use (odds ratio, 1.14; 95% confidence interval, 1.09-1.20), and no significant difference between dual-system users. Veterans obtaining care at sites where PC leaders reported greater autonomy (eg, authority over personnel issues) had lower odds of ACSC-H (odds ratio, 0.74; 95% confidence interval, 0.59-0.92). DISCUSSION Our findings suggest that earlier assumptions about VA/Medicare use should be weighed against the possibility that neither VA nor Medicare may address complex Veterans' health needs. Greater PC leader autonomy may allow for tailoring of care to match local clinical contexts.
Collapse
|
4
|
Liu C, Batten A, Wong ES, Fihn SD, Hebert PL. Fee-for-Service Medicare-Enrolled Elderly Veterans Are Increasingly Voting with Their Feet to Use More VA and Less Medicare, 2003-2014. Health Serv Res 2018; 53 Suppl 3:5140-5158. [PMID: 30151827 PMCID: PMC6235817 DOI: 10.1111/1475-6773.13029] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE To examine the long-term reliance on outpatient care at the population (i.e., system) level among fee-for-service Medicare-enrolled elderly veterans in the Department of Veterans Affairs (VA) health care system and Medicare from 2003 to 2014. DATA SOURCES/STUDY SETTING We analyzed a 5 percent random sample, stratified by facility, age, gender, and race, of Medicare-enrolled veterans enrolled in a VA primary care panel using VA administrative data and Medicare claims. STUDY DESIGN We performed a repeated cross-sectional analysis over 48 quarters. VA reliance was defined at the system level as the proportion of total visits (VA + Medicare) that occurred in VA. We examined four visit types and seven high-volume medical subspecialties. We applied direct standardization adjusting for age, gender, and race using the 2010 population distribution of Medicare-enrolled veterans. PRINCIPAL FINDINGS Over the 12-year period, VA provided the vast majority of mental health care. Conversely, veterans received slightly more than half of their primary care and most of their specialty care, surgical care, and seven high-volume medical subspecialties through Medicare. However, reliance on VA outpatient care steadily increased over time for all categories of care. CONCLUSIONS Despite the controversies about VA access to care, Medicare-enrolled veterans, who have a choice of using VA or Medicare providers, appear to increase their use of VA care prior to the Choice Act.
Collapse
Affiliation(s)
- Chuan‐Fen Liu
- Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWA
- Department of Health ServicesUniversity of WashingtonSeattleWA
| | - Adam Batten
- Office of Clinical System Development and EvaluationVeterans Health AdministrationSeattleWA
| | - Edwin S. Wong
- Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWA
- Department of Health ServicesUniversity of WashingtonSeattleWA
| | - Stephan D. Fihn
- Department of Health ServicesUniversity of WashingtonSeattleWA
- Department of MedicineUniversity of WashingtonSeattleWA
| | - Paul L. Hebert
- Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWA
- Department of Health ServicesUniversity of WashingtonSeattleWA
| |
Collapse
|
5
|
Nelson RE, Jones M, Liu CF, Samore MH, Evans ME, Stevens VW, Reese T, Rubin MA. The Impact of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Infections on Postdischarge Health Care Costs and Utilization across Multiple Health Care Systems. Health Serv Res 2018; 53 Suppl 3:5419-5437. [PMID: 30298924 DOI: 10.1111/1475-6773.13063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To measure how much of the postdischarge cost and utilization attributable to methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) occur within the US Department of Veterans Affairs (VA) system and how much occurs outside. DATA SOURCES/STUDY SETTING Health care encounters from 3 different settings and payment models: (1) within the VA; (2) outside the VA but paid for by the VA (purchased care); and (3) outside the VA and paid for by Medicare. STUDY DESIGN Historical cohort study using data from admissions to VA hospitals between 2007 and 2012. METHODS We assessed the impact of a positive MRSA test result on costs and utilization during the 365 days following discharge using inverse probability of treatment weights to balance covariates. PRINCIPAL FINDINGS Among a cohort of 152,687 hospitalized Veterans, a positive MRSA test result was associated with an overall increase of 6.6 (95 percent CI: 5.7-7.5) inpatient days and $9,237 (95 percent CI: $8,211-$10,262) during the postdischarge period. VA inpatient admissions, Medicare reimbursements, and purchased care payments accounted for 60.6 percent, 22.5 percent, and 16.9 percent of these inpatient costs. CONCLUSIONS While most of the excess postdischarge health care costs associated with MRSA HAIs occurred in the VA, non-VA costs make up an important subset of the overall burden.
Collapse
Affiliation(s)
- Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Makoto Jones
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Chuan-Fen Liu
- Veterans Affairs Puget Sound Health Care System, Seattle, WA.,Department of Health Services, University of Washington, Seattle, WA
| | - Matthew H Samore
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Martin E Evans
- Lexington Veterans Affairs Medical Center, Lexington, KY.,MRSA/MDRO Program, National Infectious Diseases Service, Veterans Health Administration, Lexington, KY.,Department of Internal Medicine, University of Kentucky, Lexington, KY
| | - Vanessa W Stevens
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Thomas Reese
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT
| | - Michael A Rubin
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| |
Collapse
|
6
|
Schleiden LJ, Thorpe CT, Cashy JP, Gellad WF, Good CB, Hanlon JT, Mor MK, Niznik JD, Pleis JR, Van Houtven CH, Thorpe JM. Characteristics of dual drug benefit use among veterans with dementia enrolled in the Veterans Health Administration and Medicare Part D. Res Social Adm Pharm 2018; 15:701-709. [PMID: 30236896 DOI: 10.1016/j.sapharm.2018.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/29/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Obtaining prescription medications from multiple health systems may complicate coordination of care. Older Veterans who obtain medications concurrently through Veterans Affairs (VA) benefits and Medicare Part D benefits (dual users) are at higher risk of unintended negative outcomes. OBJECTIVE To explore characteristics predicting dual drug benefit use from both VA and Medicare Part D in a national sample of older Veterans with dementia. METHODS Administrative data were obtained from the VA and Medicare for a national sample of 110,828 Veterans with dementia ages 68 and older in 2010. Veterans were classified into three drug benefit user groups based on the source of all prescription medications they obtained in 2010: VA-only, Part D-only, and Dual Use. Multinomial logistic regression was used to examine predictors of drug benefit user group. The source of prescriptions was described for each of the ten most frequently used drug classes and opioids. RESULTS Fifty-six percent of Veterans received all of their prescription medications from VA-only, 28% from Part D-only, and 16% from both VA and Part D. Veterans who were eligible for Medicaid or who had a priority group score conferring less generous drug benefits within the VA were more likely to be Part D-only or dual users. Nearly one fourth of Veterans taking opioids concurrently received opioid prescriptions from dual sources (24.7%). CONCLUSIONS Medicaid eligibility and Veteran priority group status, which largely decrease copayments for drugs obtained outside versus within the VA, respectively, were the main factors predicting drug user benefit group. Policies to encourage single-system prescribing and enhance communication across health systems are crucial to preventing negative health outcomes related to care fragmentation.
Collapse
Affiliation(s)
- Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, United States.
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, United States
| | - John P Cashy
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of General Internal Medicine, School of Medicine, University of Pittsburgh, University of Pittsburgh Medical Center Montefiore Hospital, Suite W933, Pittsburgh, PA, 5213, United States
| | - Chester B Good
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, United States; Division of General Internal Medicine, School of Medicine, University of Pittsburgh, University of Pittsburgh Medical Center Montefiore Hospital, Suite W933, Pittsburgh, PA, 5213, United States; Center for Value Based Pharmacy Initiatives, University of Pittsburgh Medical Center, 600 Grant St, Pittsburgh, PA, 15219, United States
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, 3471 Fifth Ave, Kaufmann Medical Building, Suite 500, Pittsburgh, PA, 15213, United States
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, 130 De Soto St, Pittsburgh, PA, 15261, United States
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace St, Pittsburgh, PA, 15213, United States; Division of Geriatric Medicine, School of Medicine, University of Pittsburgh, 3471 Fifth Ave, Kaufmann Medical Building, Suite 500, Pittsburgh, PA, 15213, United States
| | - John R Pleis
- National Center for Health Statistics, Centers for Disease Control and Prevention, Division of Research and Methodology, 3311 Toledo Road, Hyattsville, MD, 20782, United States
| | - Courtney H Van Houtven
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, VA Medical Center (152), 508 Fulton St., Durham, NC, 27705, United States; Department of Population Health Sciences, School of Medicine, Duke University Medical Center, Imperial Center, Durham, NC, 27713, United States
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, United States; Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, United States; Veterans Experience Center, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Annex Suite 202, Philadelphia, PA, 19104, United States
| |
Collapse
|
7
|
Aiken AB, Mahar AL, Kurdyak P, Whitehead M, Groome PA. A descriptive analysis of medical health services utilization of Veterans living in Ontario: a retrospective cohort study using administrative healthcare data. BMC Health Serv Res 2016; 16:351. [PMID: 27488736 PMCID: PMC4973105 DOI: 10.1186/s12913-016-1596-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 07/28/2016] [Indexed: 11/21/2022] Open
Abstract
Background Health services utilization by Veterans following release may be different than the general population as the result of occupational conditions, requirements and injuries. This study provides the first longitudinal overview of Canadian Veteran healthcare utilization in the Ontario public health system. Methods This is a retrospective cohort study designed to use Ontario’s provincial healthcare data to study the demographics and healthcare utilization of Canadian Armed Forces (CAF) & RCMP Veterans living in Ontario. Veterans were eligible for the study if they released between January 1, 1990 and March 31, 2013. Databases at the Institute for Clinical Evaluative Sciences were linked by a unique identifier to study non-mental health related hospitalizations, emergency department visits, and physician visits. Overall and age-stratified descriptive statistics were calculated in five-year intervals following the date of release. Results The cohort is comprised of 23, 818 CAF or RCMP Veterans. Following entry into the provincial healthcare system, 82.6 % (95 % CI 82.1–83.1) of Veterans saw their family physician at least once over the first five years following release, 60.7 % (95 % CI 60.0–61.3) saw a non-mental health specialist, 40.8 % (95 % CI 40.2–41.5) went to the emergency department in that same time period and 9.9 % (9.5–10.3) were hospitalized for non-mental health related complaints. Patterns of non-mental health services utilization appeared to be time and service dependant. Stratifying health services utilization by age of the Veteran at entry into the provincial healthcare system revealed significant differences in service use and intensity. Conclusion This study provides the first description of health services utilization by Veterans, following release from the CAF or RCMP. This work will inform the planning and delivery of support to Veterans in Ontario. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1596-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Alice B Aiken
- School of Rehabilitation Therapy, Queen's University, Kingston, ON, Canada.
| | - Alyson L Mahar
- Department of Public Health, Queen's University, Kingston, ON, Canada
| | - Paul Kurdyak
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Marlo Whitehead
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Patti A Groome
- Department of Public Health, Queen's University, Kingston, ON, Canada
| |
Collapse
|
8
|
Mahar AL, Aiken AB, Kurdyak P, Whitehead M, Groome PA. Description of a longitudinal cohort to study the health of Canadian Veterans living in Ontario. JOURNAL OF MILITARY, VETERAN AND FAMILY HEALTH 2016. [DOI: 10.3138/jmvfh.3721] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction: Social determinants of health are associated with the risk of disease and health services utilization. Understanding the distributions of sex, age, income, and other demographic variables in Canadian Veterans and how they change over time is necessary to optimize service delivery and enhance research validity. This study describes the demographic patterns over time and by age at release in an Ontario cohort of Canadian Armed Forces (CAF) and Royal Canadian Mounted Police (RCMP) Veterans following release. Methods: This is a retrospective cohort study using administrative healthcare data in Ontario from the Institute for Clinical Evaluative Sciences. Veterans were identified using codes housed at the Ministry of Health and Long-Term Care. A descriptive analysis of key demographic variables was presented and stratified by five-year time intervals following release (0–5 years, 5–10 years, 10–15 years, and 15–20 years) and age at release. Results: This cohort includes 23, 818 CAF and RCMP Veterans. At baseline, the average age of the cohort was 41, and 14% were female. Age-specific patterns of median community income and geographic location of residence were noted. In the first five years following release, younger Veterans had a lower income than older Veterans. The majority of older Veterans lived in the Ottawa and Kingston areas following release. Overall, the demographic profile of the cohort was stable over time. Discussion: We have identified a valuable resource to inform the development of relevant provincial public health policy and resource allocation for Veterans. The use of routinely collected healthcare data in Ontario will augment our current understanding of Veteran health in Canada.
Collapse
Affiliation(s)
- Alyson L. Mahar
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
- Canadian Institute for Military and Veteran Health Research, Kingston, Ontario, Canada
| | - Alice B. Aiken
- Canadian Institute for Military and Veteran Health Research, Kingston, Ontario, Canada
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
| | - Paul Kurdyak
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Marlo Whitehead
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Patti A. Groome
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| |
Collapse
|
9
|
Lee PW, Lee RE, Markle P, Shirley EA, Welch P. Dissemination of a Care Collaboration Project. Fed Pract 2015; 32:38-42. [PMID: 30766027 PMCID: PMC6364816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
A core project team was able to identify essential implementation components for a successful dual-care program aimed at improving communication and collaboration with non-VA health care providers.
Collapse
Affiliation(s)
- Pamela W Lee
- is a research health scientist and is a program analyst, both at the White River Junction VAMC in Vermont. is associate director and is an administrative officer, both at the VA Maine Healthcare System in Lewiston. is the director of the VISN 1 Primary Care Service Line. All except Dr. Shirley are with the Veterans Rural Health Resource Center-Eastern Region
| | - Richard E Lee
- is a research health scientist and is a program analyst, both at the White River Junction VAMC in Vermont. is associate director and is an administrative officer, both at the VA Maine Healthcare System in Lewiston. is the director of the VISN 1 Primary Care Service Line. All except Dr. Shirley are with the Veterans Rural Health Resource Center-Eastern Region
| | - Penelope Markle
- is a research health scientist and is a program analyst, both at the White River Junction VAMC in Vermont. is associate director and is an administrative officer, both at the VA Maine Healthcare System in Lewiston. is the director of the VISN 1 Primary Care Service Line. All except Dr. Shirley are with the Veterans Rural Health Resource Center-Eastern Region
| | - Eric A Shirley
- is a research health scientist and is a program analyst, both at the White River Junction VAMC in Vermont. is associate director and is an administrative officer, both at the VA Maine Healthcare System in Lewiston. is the director of the VISN 1 Primary Care Service Line. All except Dr. Shirley are with the Veterans Rural Health Resource Center-Eastern Region
| | - Phillip Welch
- is a research health scientist and is a program analyst, both at the White River Junction VAMC in Vermont. is associate director and is an administrative officer, both at the VA Maine Healthcare System in Lewiston. is the director of the VISN 1 Primary Care Service Line. All except Dr. Shirley are with the Veterans Rural Health Resource Center-Eastern Region
| |
Collapse
|
10
|
Ono SS, Dziak KM, Wittrock SM, Buzza CD, Stewart KR, Charlton ME, Kaboli PJ, Reisinger HS. Treating Dual-Use Patients Across Two Health Care Systems: A Qualitative Study. Fed Pract 2015; 32:32-37. [PMID: 30766081 PMCID: PMC6363321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Improved communication and increased education may enhance the experience and outcomes for veterans using multiple health care systems, according to this qualitative assessment of health care provider views.
Collapse
Affiliation(s)
- Sarah S Ono
- is a core investigator at the Center to Improve Veteran Involvement in Care (CIVIC) at the VA Portland Health Care System in Portland, Oregon. is a sociology PhD candidate at the University of Iowa Graduate College in Iowa City. is a qualitative analyst, is associate director, and is an investigator, all at the Comprehensive Access and Delivery Research and Evaluation Center, at the VHA Office of Rural Health, Veterans Rural Health Resource Center-Central Region and at the Iowa City VA Health Care System. is a resident physician at the University of California San Francisco School of Medicine. Dr. Ono is an assistant professor at Oregon Health & Science University in Portland. Dr. Reisinger is an assistant professor and Dr. Kaboli is a professor, both at the University of Iowa Carver College of Medicine in Iowa City. is an assistant professor at University of Iowa College of Public Health in Iowa City. is a program analyst at the VHA Blind Rehabilitation Service in Washington, DC
| | - Kathleen M Dziak
- is a core investigator at the Center to Improve Veteran Involvement in Care (CIVIC) at the VA Portland Health Care System in Portland, Oregon. is a sociology PhD candidate at the University of Iowa Graduate College in Iowa City. is a qualitative analyst, is associate director, and is an investigator, all at the Comprehensive Access and Delivery Research and Evaluation Center, at the VHA Office of Rural Health, Veterans Rural Health Resource Center-Central Region and at the Iowa City VA Health Care System. is a resident physician at the University of California San Francisco School of Medicine. Dr. Ono is an assistant professor at Oregon Health & Science University in Portland. Dr. Reisinger is an assistant professor and Dr. Kaboli is a professor, both at the University of Iowa Carver College of Medicine in Iowa City. is an assistant professor at University of Iowa College of Public Health in Iowa City. is a program analyst at the VHA Blind Rehabilitation Service in Washington, DC
| | - Stacy M Wittrock
- is a core investigator at the Center to Improve Veteran Involvement in Care (CIVIC) at the VA Portland Health Care System in Portland, Oregon. is a sociology PhD candidate at the University of Iowa Graduate College in Iowa City. is a qualitative analyst, is associate director, and is an investigator, all at the Comprehensive Access and Delivery Research and Evaluation Center, at the VHA Office of Rural Health, Veterans Rural Health Resource Center-Central Region and at the Iowa City VA Health Care System. is a resident physician at the University of California San Francisco School of Medicine. Dr. Ono is an assistant professor at Oregon Health & Science University in Portland. Dr. Reisinger is an assistant professor and Dr. Kaboli is a professor, both at the University of Iowa Carver College of Medicine in Iowa City. is an assistant professor at University of Iowa College of Public Health in Iowa City. is a program analyst at the VHA Blind Rehabilitation Service in Washington, DC
| | - Colin D Buzza
- is a core investigator at the Center to Improve Veteran Involvement in Care (CIVIC) at the VA Portland Health Care System in Portland, Oregon. is a sociology PhD candidate at the University of Iowa Graduate College in Iowa City. is a qualitative analyst, is associate director, and is an investigator, all at the Comprehensive Access and Delivery Research and Evaluation Center, at the VHA Office of Rural Health, Veterans Rural Health Resource Center-Central Region and at the Iowa City VA Health Care System. is a resident physician at the University of California San Francisco School of Medicine. Dr. Ono is an assistant professor at Oregon Health & Science University in Portland. Dr. Reisinger is an assistant professor and Dr. Kaboli is a professor, both at the University of Iowa Carver College of Medicine in Iowa City. is an assistant professor at University of Iowa College of Public Health in Iowa City. is a program analyst at the VHA Blind Rehabilitation Service in Washington, DC
| | - Kenda R Stewart
- is a core investigator at the Center to Improve Veteran Involvement in Care (CIVIC) at the VA Portland Health Care System in Portland, Oregon. is a sociology PhD candidate at the University of Iowa Graduate College in Iowa City. is a qualitative analyst, is associate director, and is an investigator, all at the Comprehensive Access and Delivery Research and Evaluation Center, at the VHA Office of Rural Health, Veterans Rural Health Resource Center-Central Region and at the Iowa City VA Health Care System. is a resident physician at the University of California San Francisco School of Medicine. Dr. Ono is an assistant professor at Oregon Health & Science University in Portland. Dr. Reisinger is an assistant professor and Dr. Kaboli is a professor, both at the University of Iowa Carver College of Medicine in Iowa City. is an assistant professor at University of Iowa College of Public Health in Iowa City. is a program analyst at the VHA Blind Rehabilitation Service in Washington, DC
| | - Mary E Charlton
- is a core investigator at the Center to Improve Veteran Involvement in Care (CIVIC) at the VA Portland Health Care System in Portland, Oregon. is a sociology PhD candidate at the University of Iowa Graduate College in Iowa City. is a qualitative analyst, is associate director, and is an investigator, all at the Comprehensive Access and Delivery Research and Evaluation Center, at the VHA Office of Rural Health, Veterans Rural Health Resource Center-Central Region and at the Iowa City VA Health Care System. is a resident physician at the University of California San Francisco School of Medicine. Dr. Ono is an assistant professor at Oregon Health & Science University in Portland. Dr. Reisinger is an assistant professor and Dr. Kaboli is a professor, both at the University of Iowa Carver College of Medicine in Iowa City. is an assistant professor at University of Iowa College of Public Health in Iowa City. is a program analyst at the VHA Blind Rehabilitation Service in Washington, DC
| | - Peter J Kaboli
- is a core investigator at the Center to Improve Veteran Involvement in Care (CIVIC) at the VA Portland Health Care System in Portland, Oregon. is a sociology PhD candidate at the University of Iowa Graduate College in Iowa City. is a qualitative analyst, is associate director, and is an investigator, all at the Comprehensive Access and Delivery Research and Evaluation Center, at the VHA Office of Rural Health, Veterans Rural Health Resource Center-Central Region and at the Iowa City VA Health Care System. is a resident physician at the University of California San Francisco School of Medicine. Dr. Ono is an assistant professor at Oregon Health & Science University in Portland. Dr. Reisinger is an assistant professor and Dr. Kaboli is a professor, both at the University of Iowa Carver College of Medicine in Iowa City. is an assistant professor at University of Iowa College of Public Health in Iowa City. is a program analyst at the VHA Blind Rehabilitation Service in Washington, DC
| | - Heather Schacht Reisinger
- is a core investigator at the Center to Improve Veteran Involvement in Care (CIVIC) at the VA Portland Health Care System in Portland, Oregon. is a sociology PhD candidate at the University of Iowa Graduate College in Iowa City. is a qualitative analyst, is associate director, and is an investigator, all at the Comprehensive Access and Delivery Research and Evaluation Center, at the VHA Office of Rural Health, Veterans Rural Health Resource Center-Central Region and at the Iowa City VA Health Care System. is a resident physician at the University of California San Francisco School of Medicine. Dr. Ono is an assistant professor at Oregon Health & Science University in Portland. Dr. Reisinger is an assistant professor and Dr. Kaboli is a professor, both at the University of Iowa Carver College of Medicine in Iowa City. is an assistant professor at University of Iowa College of Public Health in Iowa City. is a program analyst at the VHA Blind Rehabilitation Service in Washington, DC
| |
Collapse
|
11
|
Damschroder LJ, Moin T, Datta SK, Reardon CM, Steinle N, Weinreb J, Billington CJ, Maciejewski ML, Yancy WS, Hughes M, Makki F, Richardson CR. Implementation and evaluation of the VA DPP clinical demonstration: protocol for a multi-site non-randomized hybrid effectiveness-implementation type III trial. Implement Sci 2015; 10:68. [PMID: 25962598 PMCID: PMC4429938 DOI: 10.1186/s13012-015-0250-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/18/2015] [Indexed: 01/07/2023] Open
Abstract
Background The Diabetes Prevention Program (DPP) study showed that lifestyle intervention resulted in a 58% reduction in incidence of type 2 diabetes among individuals with prediabetes. Additional large randomized controlled trials have confirmed these results, and long-term follow-up has shown sustained benefit 10–20 years after the interventions ended. Diabetes is a common and costly disease, especially among Veterans, and despite strong evidence supporting the feasibility of type 2 diabetes prevention, the DPP has not been widely implemented. The first aim of this study will evaluate implementation of the Veterans Affairs (VA) DPP in three VA medical centers. The second aim will assess weight and hemoglobin A1c (A1c) outcomes, and the third aim will determine the cost-effectiveness and budget impact of implementation of the VA DPP from a health system perspective. Methods/Design This partnered multi-site non-randomized systematic assignment study will use a highly pragmatic hybrid effectiveness-implementation type III mixed methods study design. The implementation and administration of the VA DPP will be funded by clinical operations while the evaluation of the VA DPP will be funded by research grants. Seven hundred twenty eligible Veterans will be systematically assigned to the VA DPP clinical demonstration or the usual care VA MOVE!® weight management program. A multi-phase formative evaluation of the VA DPP implementation will be conducted. A theoretical program change model will be used to guide the implementation process and assess applicability and feasibility of the DPP for VA. The Consolidated Framework for Implementation Research (CFIR) will be used to guide qualitative data collection, analysis, and interpretation of barriers and facilitators to implementation. The RE-AIM framework will be used to assess Reach, Effectiveness, Adoption, Implementation, and Maintenance of the VA DPP. Twelve-month weight and A1c change will be evaluated for the VA DPP compared to the VA MOVE! program. Mediation analyses will be conducted to identify whether program design differences impact outcomes. Discussion Findings from this pragmatic evaluation will be highly applicable to practitioners who are tasked with implementing the DPP in clinical settings. In addition, findings will determine the effectiveness and cost-effectiveness of the VA DPP in the Veteran population. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0250-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Laura J Damschroder
- Ann Arbor VA Center for Clinical Management Research, P.O. Box 130170, Ann Arbor, MI, 48113-0170, USA. .,VA Diabetes QUERI, Ann Arbor, MI, USA.
| | - Tannaz Moin
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,David Geffen School of Medicine, University of California, Los Angeles, CA, USA. .,Greater Los Angeles VA Health Services Research and Development (HSR & D) Center for Healthcare Innovation, Implementation and Policy, Los Angeles, CA, USA.
| | - Santanu K Datta
- Durham VA Medical Center, Durham, NC, USA. .,Duke University School of Medicine, Durham, NC, USA.
| | - Caitlin M Reardon
- Ann Arbor VA Center for Clinical Management Research, P.O. Box 130170, Ann Arbor, MI, 48113-0170, USA.
| | - Nanette Steinle
- Baltimore VA Medical Center, Baltimore, MD, USA. .,University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Jane Weinreb
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
| | - Charles J Billington
- Minneapolis VA Healthcare System, Minneapolis, MN, USA. .,University of Minnesota Medical Center, Minneapolis, MN, USA.
| | - Matt L Maciejewski
- Durham VA Medical Center, Durham, NC, USA. .,Duke University School of Medicine, Durham, NC, USA.
| | - William S Yancy
- Durham VA Medical Center, Durham, NC, USA. .,Duke University School of Medicine, Durham, NC, USA.
| | - Maria Hughes
- Ann Arbor VA Center for Clinical Management Research, P.O. Box 130170, Ann Arbor, MI, 48113-0170, USA.
| | - Fatima Makki
- Ann Arbor VA Center for Clinical Management Research, P.O. Box 130170, Ann Arbor, MI, 48113-0170, USA.
| | - Caroline R Richardson
- Ann Arbor VA Center for Clinical Management Research, P.O. Box 130170, Ann Arbor, MI, 48113-0170, USA. .,VA Diabetes QUERI, Ann Arbor, MI, USA. .,Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
12
|
Hormone therapy use in women veterans accessing veterans health administration care: a national cross-sectional study. J Gen Intern Med 2015; 30:169-75. [PMID: 25373833 PMCID: PMC4314474 DOI: 10.1007/s11606-014-3073-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 09/19/2014] [Accepted: 10/15/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED The majority of women Veterans using VA (Veterans Administration) care fall in the 45-65 year-old age range. Understanding how menopause is managed in this group is of importance to optimizing their health. OBJECTIVE National population estimates showed a prevalence of hormone therapy (HT) use by women over 45 years of 4.7 % (2009-2010). Our study described the frequency of HT use among women Veterans in VA, and examined whether mental health (MH) was predictive of HT use. DESIGN This was a cross-sectional analysis of national VA administrative data for fiscal year 2009. PARTICIPANTS Women Veterans over the age of 45 (N = 157,195) accessing VA outpatient care were included in the analysis. MAIN MEASURES Logistic regression analyses using HT use as the dependent variable. KEY RESULTS Mean age was 59.4 years (SD =12.2, range =46-110), and 16,227 (10.3 %) of all women used HT. Hysterectomy (OR 3.99 [3.53, 4.49]) and osteoporosis (1.34 [1.27, 1.42]) were the strongest medical indicators of HT use. A total of 49,557 (31.5 %) women in the sample received at least one primary diagnosis of a MH disorder and were more likely to use HT than women with no MH diagnoses (unadjusted OR 1.56, 95 % CI [1.50, 1.61]). Women Veterans with a mood disorder (depression/bipolar) or anxiety disorder [post-traumatic stress disorder (PTSD), other anxiety diagnoses] were more likely to use HT after controlling for demographics and medical comorbidity. CONCLUSION The prevalence of HT use among women Veterans using VA is more than twice that of the general population. Prior work suggested that women Veterans were discontinuing HT at comparable rates, but these data demonstrate that decline in VA HT use has not kept pace with that of civilian medical care. The association of MH diagnosis with HT use suggests that MH plays an important role in VA rates. Further study is needed to understand contributing patient and provider factors.
Collapse
|
13
|
Wong ES, Hebert PL, Maciejewski ML, Perkins M, Bryson CL, Au DH, Liu CF. Does Favorable Selection Among Medicare Advantage Enrollees Affect Measurement of Hospital Readmission Rates? Med Care Res Rev 2014; 71:367-83. [PMID: 24811933 DOI: 10.1177/1077558714533823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Accepted: 03/13/2014] [Indexed: 11/16/2022]
Abstract
Literature indicates favorable selection among Medicare Advantage (MA) enrollees compared with fee-for-service (FFS) enrollees. This study examined whether favorable selection into MA affected readmission rates among Medicare-eligible veterans following hospitalization for congestive heart failure in the Veterans Affairs Health System (VA). We measured total (VA + Medicare FFS) 30-day all-cause readmission rates across hospitals and all of VA. We used Heckman's correction to adjust readmission rates to be representative of all Medicare-eligible veterans, not just FFS-enrolled veterans. The adjusted all-cause readmission rate among FFS veterans was 27.1% (95% confidence interval [CI] = 26.5% to 27.7%), while the adjusted readmission rate among Medicare-eligible veterans was 25.3% (95% CI = 23.6% to 27.1%) after correcting for favorable selection. Readmission rate estimates among FFS veterans generalize to all Medicare-eligible veterans only after accounting for favorable selection into MA. Estimation of quality metrics should carefully consider sample selection to produce valid policy inferences.
Collapse
Affiliation(s)
- Edwin S Wong
- VA Puget Sound Health Care System, Seattle, WA, USA University of Washington, Seattle, WA, USA
| | - Paul L Hebert
- VA Puget Sound Health Care System, Seattle, WA, USA University of Washington, Seattle, WA, USA
| | | | - Mark Perkins
- VA Puget Sound Health Care System, Seattle, WA, USA
| | - Chris L Bryson
- VA Puget Sound Health Care System, Seattle, WA, USA University of Washington, Seattle, WA, USA
| | - David H Au
- VA Puget Sound Health Care System, Seattle, WA, USA University of Washington, Seattle, WA, USA
| | - Chuan-Fen Liu
- VA Puget Sound Health Care System, Seattle, WA, USA University of Washington, Seattle, WA, USA
| |
Collapse
|
14
|
Wu A, Good C, Downs JR, Fine MJ, Pugh MJV, Anzueto A, Mortensen EM. The association of cardioprotective medications with pneumonia-related outcomes. PLoS One 2014; 9:e85797. [PMID: 24489672 PMCID: PMC3904855 DOI: 10.1371/journal.pone.0085797] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 12/02/2013] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Little research has examined whether cardiovascular medications, other than statins, are associated with improved outcomes after pneumonia. Our aim was to examine the association between the use of beta-blockers, statins, angiotensin converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs) with pneumonia-related outcomes. MATERIALS AND METHODS We conducted a retrospective population-based study on male patients ≥ 65 years of age hospitalized with pneumonia and who did not have pre-existing cardiac disease. Our primary analyses were multilevel regression models that examined the association between cardiovascular medication classes and either mortality or cardiovascular events. RESULTS Our cohort included 21,985 patients: 22% died within 90 days of admission, and 22% had a cardiac event within 90 days. The cardiovascular medications studied that were associated with decreased 90-day mortality included: statins (OR 0.70, 95% CI 0.63-0.77), ACE inhibitors (OR 0.82, 95% CI 0.74-0.91), and ARBs (OR 0.58, 95% CI 0.44-0.77). However, none of the medications were significantly associated with decreased cardiovascular events. DISCUSSION While statins, ACE inhibitors, and ARBs, were associated with decreased mortality, there was no significant association with decreased CV events. These results indicate that this decreased mortality is unlikely due to their potential cardioprotective effects.
Collapse
Affiliation(s)
- Albert Wu
- Medical Service, South Texas Veterans Health Care System, San Antonio, Texas, United States of America
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
| | - Chester Good
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - John R. Downs
- Medical Service, South Texas Veterans Health Care System, San Antonio, Texas, United States of America
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
| | - Michael J. Fine
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Mary Jo V. Pugh
- Medical Service, South Texas Veterans Health Care System, San Antonio, Texas, United States of America
- Departments of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
| | - Antonio Anzueto
- Medical Service, South Texas Veterans Health Care System, San Antonio, Texas, United States of America
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
| | - Eric M. Mortensen
- Medical Service, VA North Texas Health Care System, Dallas, Texas, United States of America
- Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| |
Collapse
|
15
|
Tarlov E, Lee TA, Weichle TW, Durazo-Arvizu R, Zhang Q, Perrin R, Bentrem D, Hynes DM. Reduced overall and event-free survival among colon cancer patients using dual system care. Cancer Epidemiol Biomarkers Prev 2012; 21:2231-41. [PMID: 23064003 DOI: 10.1158/1055-9965.epi-12-0548] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Many veterans have dual Veterans Administration (VA) and Medicare healthcare coverage. We compared 3-year overall and cancer event-free survival (EFS) among patients with nonmetastatic colon cancer who obtained substantial portions of their care in both systems and those whose care was obtained predominantly in the VA or in the Medicare fee-for-service system. METHODS We conducted a retrospective observational cohort study of patients older than 65 years with stages I to III colon cancer diagnosed from 1999 to 2001 in VA and non-VA facilities. Dual use of VA and non-VA colon cancer care was categorized as predominantly VA use, dual use, or predominantly non-VA use. Extended Cox regression models evaluated associations between survival and dual use. RESULTS VA and non-VA users (all stages) had reduced hazard of dying compared with dual users [e.g., for stage I, VA HR 0.40, 95% confidence interval (CI): 0.28-0.56; non-VA HR 0.54, 95% CI: 0.38-0.78). For EFS, stage I findings were similar (VA HR 0.47, 95% CI: 0.35-0.62; non-VA HR 0.64, 95% CI: 0.47-0.86). Stage II and III VA users, but not non-VA users, had improved EFS (stage II: VA HR 0.74, 95% CI: 0.56-0.97; non-VA HR 0.92, 95% CI: 0.69-1.22; stage III: VA HR 0.73, 95% CI: 0.56-0.94; non-VA HR 0.81, 95% CI: 0.62-1.06). CONCLUSIONS Improved survival among VA and non-VA compared with dual users raises questions about coordination of care and unmet needs. IMPACT Additional study is needed to understand why these differences exist, why patients use both systems, and how systems may be improved to yield better outcomes in this population.
Collapse
Affiliation(s)
- Elizabeth Tarlov
- Center for Management of Complex Chronic Care, Edward Hines, Jr. VA Hospital, 5000 South 5th Ave., 151H, Hines, IL 60141, USA.
| | | | | | | | | | | | | | | |
Collapse
|