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Torgersen J, Mezochow AK, Newcomb CW, Carbonari DM, Hennessy S, Rentsch CT, Park LS, Tate JP, Bräu N, Bhattacharya D, Lim JK, Mezzacappa C, Njei B, Roy JA, Taddei TH, Justice AC, Lo Re V. Severe Acute Liver Injury After Hepatotoxic Medication Initiation in Real-World Data. JAMA Intern Med 2024; 184:943-952. [PMID: 38913369 PMCID: PMC11197444 DOI: 10.1001/jamainternmed.2024.1836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/30/2024] [Indexed: 06/25/2024]
Abstract
Importance Current approaches to classify the hepatotoxic potential of medications are based on cumulative case reports of acute liver injury (ALI), which do not consider the size of the exposed population. There is little evidence from real-world data (data relating to patient health status and/or the delivery of health care routinely collected from sources outside of a research setting) on incidence rates of severe ALI after initiation of medications, accounting for duration of exposure. Objective To identify the most potentially hepatotoxic medications based on real-world incidence rates of severe ALI and to examine how these rates compare with categorization based on case reports. Design, Setting, and Participants This series of cohort studies obtained data from the US Department of Veterans Affairs on persons without preexisting liver or biliary disease who initiated a suspected hepatotoxic medication in the outpatient setting between October 1, 2000, and September 30, 2021. Data were analyzed from June 2020 to November 2023. Exposures Outpatient initiation of any one of 194 medications with 4 or more published reports of hepatotoxicity. Main Outcomes and Measures Hospitalization for severe ALI, defined by either inpatient: (1) alanine aminotransferase level greater than 120 U/L plus total bilirubin level greater than 2.0 mg/dL or (2) international normalized ratio of 1.5 or higher plus total bilirubin level greater than 2.0 mg/dL recorded within the first 2 days of admission. Acute or chronic liver or biliary disease diagnosis recorded during follow-up or as a discharge diagnosis of a hospitalization for severe ALI resulted in censoring. This study calculated age- and sex-adjusted incidence rates of severe ALI and compared observed rates with hepatotoxicity categories based on cumulative published case reports. Results The study included 7 899 888 patients across 194 medication cohorts (mean [SD] age, 64.4 [16.4] years, 7 305 558 males [92.5%], 4 354 136 individuals [55.1%] had polypharmacy). Incidence rates of severe ALI ranged from 0 events per 10 000 person-years (candesartan, minocycline) to 86.4 events per 10 000 person-years (stavudine). Seven medications (stavudine, erlotinib, lenalidomide or thalidomide, chlorpromazine, metronidazole, prochlorperazine, and isoniazid) exhibited rates of 10.0 or more events per 10 000 person-years, and 10 (moxifloxacin, azathioprine, levofloxacin, clarithromycin, ketoconazole, fluconazole, captopril, amoxicillin-clavulanate, sulfamethoxazole-trimethoprim, and ciprofloxacin) had rates between 5.0 and 9.9 events per 10 000 person-years. Of these 17 medications with the highest observed rates of severe ALI, 11 (64%) were not included in the highest hepatotoxicity category when based on case reports. Conclusions and Relevance In this study, incidence rates of severe ALI using real-world data identified the most potentially hepatotoxic medications and can serve as a tool to investigate hepatotoxicity safety signals obtained from case reports. Case report counts did not accurately reflect the observed rates of severe ALI after medication initiation.
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Affiliation(s)
- Jessie Torgersen
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology and Informatics, Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alyssa K. Mezochow
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Craig W. Newcomb
- Department of Biostatistics, Epidemiology and Informatics, Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Dena M. Carbonari
- Department of Biostatistics, Epidemiology and Informatics, Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sean Hennessy
- Department of Biostatistics, Epidemiology and Informatics, Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Christopher T. Rentsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lesley S. Park
- Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California
| | - Janet P. Tate
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Norbert Bräu
- Division of Infectious Diseases, Department of Medicine, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Debika Bhattacharya
- Division of Infectious Diseases, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph K. Lim
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Catherine Mezzacappa
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Basile Njei
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jason A. Roy
- Department of Biostatistics, Rutgers University School of Public Health, New Brunswick, New Jersey
| | - Tamar H. Taddei
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Amy C. Justice
- VA Connecticut Healthcare System, US Department of Veterans Affairs, West Haven
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Division of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology and Informatics, Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Williams EC, Frost MC, Bounthavong M, Edmonds AT, Lau MK, Edelman EJ, Harvey MA, Christopher MLD. Implementation of Opioid Safety Efforts: Influence of Academic Detailing on Adverse Outcomes Among Patients in the Veterans Health Administration. SUBSTANCE USE & ADDICTION JOURNAL 2024:29767342241243309. [PMID: 38634339 DOI: 10.1177/29767342241243309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND The Veterans Health Administration (VA) implemented academic detailing (AD) to support safer opioid prescribing and overdose prevention initiatives. METHODS Patient-level data were extracted monthly from VA's electronic health record to evaluate whether AD implementation was associated with changes in all-cause mortality, opioid poisoning inpatient admissions, and opioid poisoning emergency department (ED) visits in an observational cohort of patients with long-term opioid prescriptions (≥45-day supply of opioids 6 months prior to a given month with ≤15 days between prescriptions). A single-group interrupted time series analysis using segmented logistic regression for mortality and Poisson regression for counts of inpatient admissions and ED visits was used to identify whether the level and slope of these outcomes changed in response to AD implementation. RESULTS Among 955 376 unique patients (19 431 241 person-months), there were 53 369 deaths (29 025 pre-AD; 24 344 post-AD), 1927 opioid poisoning inpatient admissions (610 pre-AD; 1317 post-AD), and 408 opioid poisoning ED visits (207 pre-AD; 201 post-AD). Immediately after AD implementation, there was a 5.8% reduction in the odds of all-cause mortality (95% confidence interval [CI]: 0.897, 0.990). However, patients had a significantly increased incidence rate of inpatient admissions for opioid poisoning immediately after AD implementation (incidence rate ratio = 1.523; 95% CI: 1.118, 2.077). No significant differences in ED visits for opioid poisoning were observed. CONCLUSIONS AD was associated with decreased all-cause mortality but increased inpatient hospitalization for opioid poisoning among patients prescribed long-term opioids. Mechanisms via which AD's efforts influenced opioid-related outcomes should be explored.
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Affiliation(s)
- Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Mark Bounthavong
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
- VA Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA
- UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
| | - Amy T Edmonds
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Mathematica, Seattle, WA, USA
| | - Marcos K Lau
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
| | | | - Michael A Harvey
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
| | - Melissa L D Christopher
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
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Butt AA, Yan P, Shaikh OS, Omer SB, Mayr FB, Talisa VB. Molnupiravir Use and 30-Day Hospitalizations or Death in a Previously Uninfected Nonhospitalized High-risk Population With COVID-19. J Infect Dis 2023; 228:1033-1041. [PMID: 37260359 PMCID: PMC10582917 DOI: 10.1093/infdis/jiad195] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/24/2023] [Accepted: 05/31/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Clinical benefit of molnupiravir (MPV) in coronavirus disease 2019 (COVID-19)-infected subpopulations is unclear. METHODS We used a matched cohort study design to determine the rate of hospitalization or death within 30 days of COVID-19 diagnosis among MPV treated and untreated controls. Participants were nonhospitalized, previously uninfected Veterans with a first confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection between 1 January and 31 August 2022, who were prescribed MPV within 3 days of COVID-19 diagnosis, and matched individuals who were not prescribed MPV. RESULTS Among 1459 matched pairs, the incidence of hospitalization/death was not different among MPV treated versus untreated controls (48 vs 44 cases; absolute risk difference [ARD], 0.27; 95% confidence interval [CI], -.94 to 1.49). No benefit was observed among those >60 or ≤60 years old (ARD, 0.27; 95% CI, -1.25 to 1.79 vs ARD, -0.29; 95% CI, -1.22 to 1.80), those with specific comorbidities, or by vaccination status. A significant benefit was observed in asymptomatic but not in symptomatic persons (ARD, -2.80; 95% CI, -4.74 to -.87 vs ARD, 1.12; 95% CI -.31 to 2.55). Kaplan-Meier curves did not show a difference in proportion of persons who were hospitalized or died among MPV treated compared with untreated controls (logrank P = .7). CONCLUSIONS MPV was not associated with a reduction in hospitalization or death within 30 days of COVID-19 diagnosis. A subgroup of patients presenting without symptoms experienced a benefit.
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Affiliation(s)
- Adeel A Butt
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
- Department of Population Health Sciences, Weill Cornell Medicine, Doha, Qatar
- Hamad Medical Corporation, Doha, Qatar
| | - Peng Yan
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Obaid S Shaikh
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Medicine, Division of Gastroenterology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Saad B Omer
- Institute for Global Health, Yale University, New Haven, Connecticut, USA
| | - Florian B Mayr
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Victor B Talisa
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Aboumrad M, Peritz D, Friedman S, Zwain G, Watts BV, Taub C. Rural-urban trends in health care utilization, treatment, and mortality among US veterans with congestive heart failure: A retrospective cohort study. J Rural Health 2023; 39:844-852. [PMID: 37005093 DOI: 10.1111/jrh.12756] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
PURPOSE To compare longitudinal rates of health care utilization, evidence-based treatment, and mortality between rural and urban-dwelling patients with congestive heart failure (CHF). METHODS We used electronic medical record data from the Veterans Health Administration (VHA) to identify adult patients with CHF from 2012 through 2017. We stratified our cohort using left ventricular ejection fraction percentage at diagnosis (<40% = reduced ejection fraction [HFrEF]; 40%-50% = midrange ejection fraction [HFmrEF]; >50% = preserved ejection fraction [HFpEF]). Within each ejection fraction cohort, we stratified patients into rural or urban groups. We used Poisson regression to estimate annual rates of health care utilization and CHF treatment. We used Fine and Gray regression to estimate annual hazards of CHF and non-CHF mortality. FINDINGS One-third of patients with HFrEF (N = 37,928/109,110), HFmrEF (N = 24,447/68,398), and HFpEF (N = 39,298/109,283) resided in a rural area. Rural compared to urban patients used VHA facilities at similar or lower annual rates for outpatient specialty care across all ejection fraction cohorts. Rural patients used VHA facilities at similar or higher rates for primary care and telemedicine-delivered specialty care. They also had lower and declining rates of VHA inpatient and urgent care use over time. There were no meaningful rural-urban differences in treatment receipt among patients with HFrEF. On multivariable analysis, the rate of CHF and non-CHF mortality was similar between rural and urban patients in each ejection fraction cohort. CONCLUSIONS Our findings suggest the VHA may have mitigated access and health outcome disparities typically observed for rural patients with CHF.
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Affiliation(s)
- Maya Aboumrad
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
| | - David Peritz
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Scott Friedman
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
| | - Gabrielle Zwain
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
| | - Bradley V Watts
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Cynthia Taub
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Ysea-Hill O, Gomez CJ, Mansour N, Wahab K, Hoang M, Labrada M, Ruiz JG. The association of a frailty index from laboratory tests and vital signs with clinical outcomes in hospitalized older adults. J Am Geriatr Soc 2022; 70:3163-3175. [PMID: 35932256 DOI: 10.1111/jgs.17977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 06/19/2022] [Accepted: 06/26/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Frailty, a state of vulnerability to stressors resulting from loss of physiological reserve due to multisystemic dysfunction, is common among hospitalized older adults. Hospital clinicians need objective and practical instruments that identify older adults with frailty. The FI-LAB is based on laboratory values and vital signs and may capture biological changes of frailty that predispose hospitalized older adults to complications. The study's aim was to assess the association of the FI-LAB versus VA-FI with hospital and post-hospital clinical outcomes in older adults. METHODS Retrospective cohort study was conducted on Veterans aged ≥60 admitted to a VA hospital. We identified acute hospitalizations January 2011-December-2014 with 1-year follow-up. A 31-item FI-LAB was created from blood laboratory tests and vital signs collected within the first 48 h of admission and scores were categorized as low (<0.25), moderate (0.25-0.40), and high (>0.40). For each FI-LAB group, we obtained odds ratio (OR) and confidence intervals (CI) for hospital and post-hospital outcomes using multivariate binomial logistic regression. Additionally, we calculated hazard ratios (HR) and CI for all-cause in-hospital mortality comparing the high and moderate FI-LAB group with the low group. RESULTS Patients were 1407 Veterans, mean age 72.7 (SD = 9.0), 67.8% Caucasian, 96.1% males, 47.0% (n = 661), 41.0% (n = 577), and 12.0% (n = 169) were in the low, moderate, and high FI-LAB groups, respectively. Moderate and high scores were associated with prolonged LOS, OR:1.62 (95% CI:1.29-2.03); and 3.36 (95% CI:2.27-4.99), ICU admission, OR:1.40 (95% CI:1.03-1.90); and OR:2.00 (95% CI:1.33-3.02), nursing home placement OR:2.36 (95% CI:1.26-4.44); and 5.99 (95% CI:2.83-12.70), 30-day readmissions OR:1.74 (95% CI:1.20-2.52); and 2.20 (95% CI:1.30-3.74), 30-day mortality OR: 2.51 (95% CI:1.01-6.23); and 8.97 (95% CI:3.42-23.53), 6-month mortality OR:3.00 (95% CI:1.90-4.74); and 6.16 (95% CI:3.55-10.71), and 1-year mortality OR: 2.66 (95% CI:1.87-3.79); and 4.76 (95% CI:3.00-7.54) respectively. The high FI-LAB group showed higher risk of in-hospital mortality, HR:18.17 (95% CI:4.01-80.52) with an area-under-the-curve of 0.843 (95% CI:0.75-0.93). CONCLUSIONS High and moderate FI-LAB scores were associated with worse in-hospital and post-hospital outcomes. The FI-LAB may identify hospitalized older patients with frailty at higher risk and assist clinicians in implementing strategies to improve outcomes.
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Affiliation(s)
- Otoniel Ysea-Hill
- Geriatric Research, Education and Clinical Center (GRECC), Miami VA Healthcare System, Miami, Florida, USA
| | - Christian J Gomez
- Geriatric Research, Education and Clinical Center (GRECC), Miami VA Healthcare System, Miami, Florida, USA
| | - Natalie Mansour
- Geriatric Research, Education and Clinical Center (GRECC), Miami VA Healthcare System, Miami, Florida, USA
| | - Kamal Wahab
- Department of Medicine, University of Miami, Jackson Health System, Miami, Florida, USA
| | - Mihn Hoang
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA.,Medical Service, Bruce W. Carter Miami VAMC, Miami, Florida, USA
| | - Mabel Labrada
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA.,Medical Service, Bruce W. Carter Miami VAMC, Miami, Florida, USA
| | - Jorge G Ruiz
- Geriatric Research, Education and Clinical Center (GRECC), Miami VA Healthcare System, Miami, Florida, USA.,Department of Medicine, University of Miami, Jackson Health System, Miami, Florida, USA.,Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
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Baik SH, Fung KW, McDonald CJ. The Mortality Risk of Proton Pump Inhibitors in 1.9 Million US Seniors: An Extended Cox Survival Analysis. Clin Gastroenterol Hepatol 2022; 20:e671-e681. [PMID: 33453399 DOI: 10.1016/j.cgh.2021.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/05/2021] [Accepted: 01/10/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Observational studies have linked proton pump inhibitors (PPIs) with increased risk of mortality and other safety outcomes, in contradiction with a recent PPI randomized controlled trial (RCT). Observational studies may be prone to reverse causality, where deaths are attributed to the treatment rather than the conditions that are treated (protopathic bias). METHODS We analyzed an incident drug user cohort of 1,930,728 elderly Medicare fee-for-service beneficiaries to evaluate the PPI-associated risk of death with a Cox regression analysis with time-varying covariates and propensity score adjustments. To correct for protopathic bias which occurs when a given drug is associated with prodromal signs of death, we implemented a lag-time approach by which any study drug taken during a 90-day look-back window before each death was disregarded. RESULTS Among 1,930,728 study individuals, 80,972 (4.2%) died during a median 3.8 years of follow-up, yielding an overall unadjusted death rate/1000 person-years of 9.85; 14.31 for PPI users and 7.93 for non- users. With no lag-time, PPI use (vs no use) was associated with 10% increased mortality risk (adjusted HR=1.10; 95% CI 1.08-1.12). However, with a lag-time of 90 days, mortality risk associated with PPI use was near zero (adjusted HR=1.01; 95% CI 0.99-1.02). CONCLUSION Given the usage patterns of PPIs in patients with conditions that may presage death, protopathic bias may explain the association of PPIs with increased risk of death reported in observational studies.
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Affiliation(s)
- Seo H Baik
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, US National Institutes of Health, Bethesda, Maryland
| | - Kin-Wah Fung
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, US National Institutes of Health, Bethesda, Maryland
| | - Clement J McDonald
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, US National Institutes of Health, Bethesda, Maryland.
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Cai S, Bakerjian D, Bang H, Mahajan SM, Ota D, Kiratli J. Data acquisition process for VA and non-VA emergency department and hospital utilization by veterans with spinal cord injury and disorders in California using VA and state data. J Spinal Cord Med 2022; 45:254-261. [PMID: 32543354 PMCID: PMC8986188 DOI: 10.1080/10790268.2020.1773028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Context: To identify VA and non-VA Emergency Department (ED) and hospital utilization by veterans with spinal cord injury and disorders (SCI/D) in California.Design: Retrospective cohort study.Setting: VA and Office of Statewide Health Planning and Development (OSHPD) in California.Participants: Total 300 veterans admitted to the study VA SCI/D Center for initial rehabilitations from 01/01/1999 through 08/17/2014.Interventions: N/A.Outcome Measures: Individual-level ED visits and hospitalizations during the first-year post-rehabilitation.Results: Among 145 veterans for whom ED visit data available, 168 ED visits were identified: 94 (55.2%) at non-VA EDs and 74 (44.8%) at the VA ED, with a mean of 1.16 (±2.21) ED visit/person. Seventy-seven (53.1%) veterans did not visit any ED. Of 68 (46.9%) veterans with ≥ one ED visit, 20 (29.4%) visited the VA ED only, 34 (50.0%) visited non-VA EDs only, and 14 (20.6%) visited both VA and non-VA EDs. Among 212 Veterans for whom hospitalization data were available, 247 hospitalizations were identified: 82 (33.2%) non-VA hospitalizations and 165 (66.8%) VA hospitalization with a mean of 1.17 (±1.62) hospitalizations/person. One hundred-seven (50.5%) veterans had no hospitalizations. Of 105 veterans with ≥ one hospitalization, 58 (55.2%) were hospitalized at the study VA hospital, 15 (14.3%) at a non-VA hospital, and 32 (30.5%) at both VA and non-VA hospitals.Conclusion: Non-VA ED and hospital usage among veterans with SCI/D occurred frequently. The acquisition of non-VA healthcare data managed by state agencies is vital to accurately and comprehensively evaluate needs and utilization rates among veteran populations.
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Affiliation(s)
- Sujuan Cai
- Department of the Veterans Affairs, Palo Alto Health Care System, Palo Alto, California, USA,The Betty Irene Moore School of Nursing, University of California at Davis, Sacramento, California, USA,Correspondence to: Sujuan Cai, 3801 Miranda Ave. Building 7, VA Palo Alto Health Care System, Spinal Cord Injury/Disorder, Palo Alto, California94304, USA; Ph: 408-832-4205.
| | - Debra Bakerjian
- The Betty Irene Moore School of Nursing, University of California at Davis, Sacramento, California, USA
| | - Heejung Bang
- Division of Biostatistics, Department of Public Health Sciences, University of California at Davis, Davis, California, USA
| | - Satish M. Mahajan
- Department of the Veterans Affairs, Palo Alto Health Care System, Palo Alto, California, USA
| | - Doug Ota
- Department of the Veterans Affairs, Palo Alto Health Care System, Palo Alto, California, USA
| | - Jenny Kiratli
- Department of the Veterans Affairs, Palo Alto Health Care System, Palo Alto, California, USA
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Koufacos NS, May J, Judon KM, Franzosa E, Dixon BE, Schubert CC, Schwartzkopf AL, Guerrero VM, Traylor M, Boockvar KS. Improving Patient Activation among Older Veterans: Results from a Social Worker-Led Care Transitions Intervention. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2022; 65:63-77. [PMID: 34053407 PMCID: PMC8982469 DOI: 10.1080/01634372.2021.1932003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/14/2021] [Accepted: 05/16/2021] [Indexed: 06/12/2023]
Abstract
Older veterans enrolled in the Veterans Health Administration (VHA) often use both VHA and non-VHA providers for their care. This dual use, especially around an inpatient visit, can lead to fragmented care during the time of transition post-discharge. Interventions that target patient activation may be valuable ways to help veterans manage complex medication regimens and care plans from multiple providers. The Care Transitions Intervention (CTI) is an evidence-based model that helps older adults gain confidence and skills to achieve their health goals post-discharge. Our study examined the impact of CTI upon patient activation for veterans discharged from non-VHA hospitals. In total, 158 interventions were conducted for 87 veterans. From baseline to follow-up there was a significant 1.7-point increase in patient activation scores, from 5.4 to 7.1. This association was only found among those who completed the intervention. The most common barriers to completion were difficulty reaching the veteran by phone, patient declining the intervention, and rehospitalization during the 30 days post-discharge. Care transitions guided by social workers may be a promising way to improve patient activation. However, future research and practice should address barriers to completion and examine the impact of increased patient activation on health outcomes.
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Affiliation(s)
- Nicholas S Koufacos
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Justine May
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Kimberly M Judon
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Emily Franzosa
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian E Dixon
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
- Department of Epidemiology, Indiana University, Fairbanks School of Public Health, Indianapolis, Indiana, USA
- Center for Biomedical Informatics, Regenstrief Institute, Center for Biomedical Informatics, Indianapolis, Indiana, USA
| | - Cathy C Schubert
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
- Department of Medicine, Indiana University, School of Medicine, Indianapolis, Indiana, USA
| | - Ashley L Schwartzkopf
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Vivian M Guerrero
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
| | - Morgan Traylor
- Center for Health Information and Communication, Health Services Research & Development Service, Richard L. Roudebush VA, Indianapolis, Indiana, USA
| | - Kenneth S Boockvar
- Geriatric Research Education and Clinical Center, James J. Peters VA, Bronx, New York, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Garvin LA, Pugatch M, Gurewich D, Pendergast JN, Miller CJ. Interorganizational Care Coordination of Rural Veterans by Veterans Affairs and Community Care Programs: A Systematic Review. Med Care 2021; 59:S259-S269. [PMID: 33976075 PMCID: PMC8132902 DOI: 10.1097/mlr.0000000000001542] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the unique context of rural Veterans' health care needs, expansion of US Department of Veterans Affairs and Community Care programs under the MISSION Act, and the uncertainties of coronavirus disease 2019 (COVID-19), it is critical to understand what may support effective interorganizational care coordination for increased access to high-quality care. OBJECTIVES We conducted a systematic review to examine the interorganizational care coordination initiatives that Veterans Affairs (VA) and community partners have pursued in caring for rural Veterans, including challenges and opportunities, organizational domains shaping care coordination, and among these, initiatives that improve or impede health care outcomes. RESEARCH DESIGN We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search 2 electronic databases (PubMed and Embase) for peer-reviewed articles published between January 2009 and May 2020. Building on prior research, we conducted a systematic review. RESULTS Sixteen articles met our criteria. Each captured a unique health care focus while examining common challenges. Four organizational domains emerged: policy and administration, culture, mechanisms, and relational practices. Exemplars highlight how initiatives improve or impede rural health care delivery. CONCLUSIONS This is the first systematic review, to our knowledge, examining interorganizational care coordination of rural Veterans by VA and Community Care programs. Results provide exemplars of interorganizational care coordination domains and program effectiveness. It suggests that partners' efforts to align their coordination domains can improve health care, with rurality serving as a critical contextual factor. Findings are important for policies, practices, and research of VA and Community Care partners committed to improving access and health care for rural Veterans.
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Affiliation(s)
- Lynn A. Garvin
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
| | - Marianne Pugatch
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Deborah Gurewich
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Medicine, Boston University School of Medicine
| | - Jacquelyn N. Pendergast
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
| | - Christopher J. Miller
- United States Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System
- Department of Psychiatry, Harvard Medical School, Boston, MA
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10
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Howren MB, Kazmerzak D, Pruin S, Barbaris W, Abrams TE. Behavioral Health Screening and Care Coordination for Rural Veterans in a Federally Qualified Health Center. J Behav Health Serv Res 2021; 49:50-60. [PMID: 34036516 PMCID: PMC8148401 DOI: 10.1007/s11414-021-09758-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/27/2022]
Abstract
Many rural veterans receive care in community settings but could benefit from VA services for certain needs, presenting an opportunity for coordination across systems. This article details the Collaborative Systems of Care (CSC) program, a novel, nurse-led care coordination program identifying and connecting veterans presenting for care in a Federally Qualified Health Center to VA behavioral health and other services based upon the veteran’s preferences and eligibility. The CSC program systematically identifies veteran patients, screens for common behavioral health issues, explores VA eligibility for interested veterans, and facilitates coordination with VA to improve healthcare access. While the present program focuses on behavioral health, there is a unique emphasis on assisting veterans with the eligibility and enrollment process and coordinating additional care tailored to the patient. As VA expands its presence in community care, opportunities for VA-community care coordination will increase, making the development and implementation of such interventions important.
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Affiliation(s)
- M Bryant Howren
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Health Care System, Iowa City, IA, USA.
- Department of Behavioral Sciences & Social Medicine, College of Medicine, Florida State University, 1115 W. Call Street, Tallahassee, FL, 32306, USA.
- Florida Blue Center for Rural Health Research & Policy, College of Medicine, Florida State University, Tallahassee, FL, USA.
- Center for Access Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.
| | | | - Sheryl Pruin
- Community Health Centers of Southeastern Iowa, West Burlington, IA, USA
| | - Wendy Barbaris
- Community Health Centers of Southeastern Iowa, West Burlington, IA, USA
| | - Thad E Abrams
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City, Iowa City VA Health Care System, Iowa City, IA, USA
- Center for Access Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- Carver College of Medicine, The University of Iowa, Iowa City, IA, USA
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11
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Franzosa E, Traylor M, Judon KM, Guerrero Aquino V, Schwartzkopf AL, Boockvar KS, Dixon BE. Perceptions of event notification following discharge to improve geriatric care: qualitative interviews of care team members from a 2-site cluster randomized trial. J Am Med Inform Assoc 2021; 28:1728-1735. [PMID: 33997903 DOI: 10.1093/jamia/ocab074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/02/2021] [Accepted: 04/09/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess primary care teams' perceptions of a health information exchange (HIE) event notification intervention for geriatric patients in 2 Veterans Health Administration (VHA) medical centers. MATERIALS AND METHODS We conducted a qualitative evaluation of an event notification alerting primary care teams to non-VHA hospital admissions and emergency department visits. Data were collected through semistructured interviews (n = 23) of primary care team physicians, nurses and medical assistants. Study design and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). RESULTS Team members found the alerts necessary, helpful for filling information gaps, and effective in supporting timely follow-up care, although some expressed concern over scheduling capacity and distinguishing alerts from other VHA notices. Participants also suggested improvements including additional data on patients' diagnosis and discharge instructions, timing alerts to patients' discharge (including clear next steps), including additional team members to ensure alerts were acted upon, and implementing a single sign-on. DISCUSSION Primary care team members perceived timely event notification of non-VHA emergency department visits and hospital admissions as potentially improving post-discharge follow-up and patient outcomes. However, they were sometimes unsure of next steps and suggested the alerts and platform could be streamlined for easier use. CONCLUSIONS Event notifications may be a valuable tool in coordinating care for high-risk older patients. Future intervention research should explore the optimal amount and types of information and delivery method across sites and test the integration of alerts into broader care coordination efforts.
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Affiliation(s)
- Emily Franzosa
- Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA.,Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Morgan Traylor
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA
| | - Kimberly M Judon
- Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Vivian Guerrero Aquino
- Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Ashley L Schwartzkopf
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA
| | - Kenneth S Boockvar
- Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA.,Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian E Dixon
- Department of Veterans Affairs, Health Services Research & Development Service, Center for Health Information and Communication, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA.,Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
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12
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O'Mahen PN, Petersen LA. Possible Effects on VA Outpatient Care of Expanding Medicaid: Implications of Having Access to Overlapping Publicly Funded Health Care Services. Mil Med 2021; 187:e735-e741. [PMID: 33857298 DOI: 10.1093/milmed/usab094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/12/2021] [Accepted: 02/23/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Patrick N O'Mahen
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, U.S. Veterans' Health Administration, Houston, TX 77030, USA.,Section for Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Laura A Petersen
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, U.S. Veterans' Health Administration, Houston, TX 77030, USA.,Section for Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
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13
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Ayele RA, Liu W, Rohs C, McCreight M, Mayberry A, Sjoberg H, Kelley L, Glasgow RE, Rabin BA, Battaglia C. VA Care Coordination Program Increased Primary Care Visits and Improved Transitional Care for Veterans Post Non-VA Hospital Discharge. Am J Med Qual 2020; 36:221-228. [PMID: 32772849 DOI: 10.1177/1062860620946362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Veterans are increasingly eligible for non-VA care through the Veteran Health Administration (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks Act while maintaining care in the VA. Continuity of care is challenging when delivered across multiple systems resulting in avoidable complications. The Community Hospital Transitions Program (CHTP) intervention was developed to address challenges veterans face post non-VA hospitalization. Propensity score-matched analysis was used to compare outcomes between 334 intervention and matched control patients who were discharged from non-VA hospitals. Veterans in CHTP were more likely than matched controls to receive a follow-up appointment within 14 days (mean: 0.43 vs 0.34, P < .05) and 30 days (mean: 0.62 vs 0.50, P < .05). There were no significant differences in 30-day readmissions or 30-day emergency department visits. CHTP veterans received timely follow-up care post discharge in VA facilities. Providing quality care to dual-use veterans is dependent on coordinated transitional care.
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Affiliation(s)
- Roman A Ayele
- Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, CO University of Colorado, Anschutz Medical Campus, Aurora, CO University of California San Diego, San Diego, CA
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14
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Effects of State-level Medicaid Expansion on Veterans Health Administration Dual Enrollment and Utilization: Potential Implications for Future Coverage Expansions. Med Care 2020; 58:526-533. [PMID: 32205790 DOI: 10.1097/mlr.0000000000001327] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to examine how pre-Affordable Care Act (ACA) state-level Medicaid expansions affect dual enrollment and utilization of Veterans Health Administration (VA) and Medicaid-funded care. RESEARCH DESIGN We employed difference-in-difference analysis to determine the association between pre-ACA Medicaid expansions in New York and Arizona in 2001 and VA utilization. Participants' dual enrollment in Medicaid and VA, the distribution of their annual hospital admissions and emergency department (ED) visits between VA and Medicaid were dependent variables. We controlled for age, race, sex, disease burden, distance to VA facilities and income-based eligibility for VA services. MEASURES Secondary data collected from 1999 to 2006 in 2 states expanding Medicaid and 3 demographically similar nonexpansion states. We obtained residency, enrollment and utilization data from VA's Corporate Data Warehouse and Medicaid Analytic Extract files. RESULTS For low-income Veterans, Medicaid expansion was associated with increased dual enrollment of 4.87 percentage points (99% confidence interval: 4.48-5.25), a 4.63-point decline in VA proportion of admissions (-5.87 to -3.38), and a 11.70-point decrease in the VA proportion of ED visits (-13.06 to -10.34). Results also showed increases in the number of total (VA plus Medicaid) annual per-capita hospitalizations and ED visits among the group of VA enrollees most likely to be eligible for expansion. CONCLUSIONS This study shows slight usage shifts when Veterans gain access to non-VA care. It highlights the need to overcome care-coordination challenges among VA patients as states implement ACA Medicaid expansion and policymakers consider additional expansions of public health insurance programs such as Medicare-for-All.
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15
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Makaroun LK, Brignone E, Rosland AM, Dichter ME. Association of Health Conditions and Health Service Utilization With Intimate Partner Violence Identified via Routine Screening Among Middle-Aged and Older Women. JAMA Netw Open 2020; 3:e203138. [PMID: 32315066 PMCID: PMC7175082 DOI: 10.1001/jamanetworkopen.2020.3138] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The US Preventive Services Task Force recently determined that there is insufficient evidence to recommend routine screening for intimate partner violence (IPV) in women who are middle-aged and older. Certain Veterans Health Administration (VHA) clinics have been routinely screening women of all ages for IPV since 2014. OBJECTIVES To examine the proportion of women older than childbearing age (ie, ≥45 years) who have positive results when routinely screened for past-year IPV at VHA clinics and to evaluate the associations of a positive screening result with health conditions and health service utilization. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 4481 women aged 45 years and older who were screened for past-year IPV in 13 VHA outpatient clinics in 11 states between April 2014 and April 2016. Data analysis was conducted from March 2019 to August 2019. EXPOSURE Positive screening result for past-year IPV. MAIN OUTCOMES AND MEASURES Mental and physical health conditions (identified using International Classification of Diseases, Ninth Edition [ICD-9] and ICD-10 codes from VHA medical record data) and VHA health services utilization (identified using inpatient and outpatient VHA encounter data) in the 20 months after screening. RESULTS In this study, 2937 of 4481 women (65.5%) were middle-aged (ie, aged 45 to 59 years), and 1544 (34.5%) were older (ie, aged ≥60 years), with 1955 (43.6%) black participants. A total of 255 middle-aged women (8.7%; mean [SD] age, 51 [4] years) and 79 older women (5.1%; mean [SD] age, 64 [5] years) screened positive for past-year IPV. In adjusted logistic regression models among middle-aged women, screening positive for IPV was associated with subsequent diagnoses of anxiety (adjusted odds ratio [aOR], 2.00; 95% CI, 1.50-2.70; P < .001), depression (aOR, 2.30; 95% CI, 1.80-3.00; P < .001), posttraumatic stress disorder (aOR, 2.30; 95% CI, 1.80-3.00; P < .001), suicidal ideation and/or behavior (aOR, 3.80; 95% CI, 2.10-6.90; P < .001), and substance use disorder (aOR, 2.50; 95% CI, 1.80-3.50; P < .001). Similar but attenuated associations were seen for older women (eg, substance use disorder: aOR, 2.20; 95% CI, 1.10-4.40; P = .04). In adjusted negative binomial regression models among middle-aged women, screening positive for IPV was associated with a higher rate of subsequent psychosocial (eg, mental health) visits (adjusted rate ratio [aRR], 2.40; 95% CI, 2.00-2.90; P < .001), primary care visits (aRR, 1.20; 95% CI, 1.10-1.30; P < .001), and emergency department visits (aRR, 1.50; 95% CI 1.20-1.80; P < .001). Older women screening positive for IPV had a higher rate of psychosocial visits (aRR, 1.90; 95% CI, 1.30-2.70; P < .001) but not of other visit types. CONCLUSIONS AND RELEVANCE To our knowledge, this study was the largest to evaluate routine screening for IPV among women aged 45 years and older, and it found that IPV remained prevalent and was associated with morbidity for these women. Screening for IPV in women older than 44 years may improve detection and provision of evidence-based services to this growing population.
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Affiliation(s)
- Lena K. Makaroun
- VA Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emily Brignone
- VA Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa E. Dichter
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Temple University School of Social Work, Philadelphia, Pennsylvania
- VA Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania
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16
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Ayele RA, Lawrence E, McCreight M, Fehling K, Glasgow RE, Rabin BA, Burke RE, Battaglia C. Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non-VA Hospitals to Primary Care in a Single VA Healthcare System. J Hosp Med 2020; 15:133-139. [PMID: 31634102 PMCID: PMC7064299 DOI: 10.12788/jhm.3320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/13/2019] [Accepted: 08/27/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Veterans with healthcare needs utilize both Veterans Health Administration (VA) and non-VA hospitals. These dual-use veterans are at high risk of adverse outcomes due to the lack of coordination for safe transitions. OBJECTIVES The aim of this study was to understand the barriers and facilitators to providing high-quality continuum of care for veterans transitioning from non-VA hospitals to the VA primary care setting. DESIGN Guided by the practical robust implementation and sustainability model (PRISM) and the ideal transitions of care, we conducted a qualitative assessment using semi-structured interviews with clinicians, staff, and patients. SETTING This study was conducted at a single urban VA medical center and two non-VA hospitals. PARTICIPANTS A total of 70 participants, including 52 clinicians and staff (23 VA and 29 non-VA) involved in patient transition and 18 veterans recently discharged from non-VA hospitals, were included in this study. APPROACH Data were analyzed using a conventional content analysis and managed in Atlas.ti (Berlin, Germany). RESULTS Four major themes emerged where participants consistently discussed that transitions were delayed when they were not able to (1) identify patients as veterans and notify VA primary care of discharge, (2) transfer non-VA hospital medical records to VA primary care, (3) obtain follow-up care appointments with VA primary care, and (4) write VA formulary medications for veterans that they could fill at VA pharmacies. Participants also discussed factors involved in smooth transition and recommendations to improve care coordination. CONCLUSIONS All participants perceived the current transition-of-care process across healthcare systems to be inefficient. Efforts to improve quality and safety in transitional care should address the challenges clinicians and patients experience when transitioning from non-VA hospitals to VA primary care.
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Affiliation(s)
- Roman A Ayele
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
- Corresponding Author: Roman A. Ayele; E-mail: ; Telephone: (720) 857-5907
| | - Emily Lawrence
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
| | - Marina McCreight
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
| | - Kelty Fehling
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
| | - Russell E Glasgow
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Borsika A Rabin
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
- University of California San Diego, San Diego, California
| | - Robert E Burke
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
- VA Center for Health Equity Research and Promotion (CHERP), Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Catherine Battaglia
- Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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17
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Wong ES, Schuttner L, Reddy A. Does machine learning improve prediction of VA primary care reliance? THE AMERICAN JOURNAL OF MANAGED CARE 2020; 26:40-44. [PMID: 31951358 PMCID: PMC11305163 DOI: 10.37765/ajmc.2020.42144] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The Veterans Affairs (VA) Health Care System is among the largest integrated health systems in the United States. Many VA enrollees are dual users of Medicare, and little research has examined methods to most accurately predict which veterans will be mostly reliant on VA services in the future. This study examined whether machine learning methods can better predict future reliance on VA primary care compared with traditional statistical methods. STUDY DESIGN Observational study of 83,143 VA patients dually enrolled in fee-for-service Medicare using VA and Medicare administrative databases and the 2012 Survey of Healthcare Experiences of Patients. METHODS The primary outcome was a dichotomous measure denoting whether patients obtained more than 50% of all primary care visits (VA + Medicare) from VA. We compared the performance of 6 candidate models-logistic regression, elastic net regression, decision trees, random forest, gradient boosting machine, and neural network-in predicting 2013 reliance as a function of 61 patient characteristics observed in 2012. We measured performance using the cross-validated area under the receiver operating characteristic (AUROC) metric. RESULTS Overall, 72.9% and 74.5% of veterans were mostly VA reliant in 2012 and 2013, respectively. All models had similar average AUROCs, ranging from 0.873 to 0.892. The best-performing model used gradient boosting machine, which exhibited modestly higher AUROC and similar variance compared with standard logistic regression. CONCLUSIONS The modest gains in performance from the best-performing model, gradient boosting machine, are unlikely to outweigh inherent drawbacks, including computational complexity and limited interpretability compared with traditional logistic regression.
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Affiliation(s)
- Edwin S Wong
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S Columbian Way, HSR&D MS-152, Seattle, WA 98108.
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18
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Miller LB, Sjoberg H, Mayberry A, McCreight MS, Ayele RA, Battaglia C. The advanced care coordination program: a protocol for improving transitions of care for dual-use veterans from community emergency departments back to the Veterans Health Administration (VA) primary care. BMC Health Serv Res 2019; 19:734. [PMID: 31640673 PMCID: PMC6805730 DOI: 10.1186/s12913-019-4582-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Veterans who access both the Veterans Health Administration (VA) and non-VA health care systems require effective care coordination to avoid adverse health care outcomes. These dual-use Veterans have diverse and complex needs. Gaps in transitions of care between VA and non-VA systems are common. The Advanced Care Coordination (ACC) quality improvement program aims to address these gaps by implementing a comprehensive longitudinal care coordination intervention with a focus on Veterans' social determinants of health (SDOH) to facilitate Veterans' transitions of care back to the Eastern Colorado Health Care System (ECHCS) for follow-up care. METHODS The ACC program is an ongoing quality improvement study that will enroll dual-use Veterans after discharge from non-VA emergency department (EDs), and will provide Veterans with social worker-led longitudinal care coordination addressing SDOH and providing linkage to resources. The ACC social worker will complete biopsychosocial assessments to identify Veteran needs, conduct regular in-person and phone visits, and connect Veterans back to their VA care teams. We will identify non-VA EDs in the Denver, Colorado metro area that will provide the most effective partnership based on location and Veteran need. Veterans will be enrolled into the ACC program when they visit one of our selected non-VA EDs without being hospitalized. We will develop a program database to allow for continuous evaluation. Continuing education and outreach including the development of a resource guide, Veteran Care Cards, and program newsletters will generate program buy-in and bridge communication. We will evaluate our program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, supported by the Practical, Robust Implementation and Sustainability Model, Theoretical Domains Framework, and process mapping. DISCUSSION The ACC program will improve care coordination for dual-use Veterans by implementing social-work led longitudinal care coordination addressing Veterans' SDOH. This intervention will provide an essential service for effective care coordination.
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Affiliation(s)
- Lindsay B Miller
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Heidi Sjoberg
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.
| | - Ashlea Mayberry
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Marina S McCreight
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Roman A Ayele
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.,University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, 13001 E. 17th Pl, Aurora, CO, 80045, USA
| | - Catherine Battaglia
- Department of Veterans Affairs, Eastern Colorado Health Care System, 1700 N. Wheeling St, Aurora, CO, 80045, USA.,University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, 13001 E. 17th Pl, Aurora, CO, 80045, USA
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van Aalst R, Russo EM, Neupane N, Mahmud SM, Mor V, Wilschut J, Chit A, Postma M, Young-Xu Y. Economic assessment of a high-dose versus a standard-dose influenza vaccine in the US Veteran population: Estimating the impact on hospitalization cost for cardio-respiratory disease. Vaccine 2019; 37:4499-4503. [DOI: 10.1016/j.vaccine.2019.06.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 11/25/2022]
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Moyo P, Zhao X, Thorpe CT, Thorpe JM, Sileanu FE, Cashy JP, Hale JA, Mor MK, Radomski TR, Donohue JM, Hausmann LRM, Hanlon JT, Good CB, Fine MJ, Gellad WF. Dual Receipt of Prescription Opioids From the Department of Veterans Affairs and Medicare Part D and Prescription Opioid Overdose Death Among Veterans: A Nested Case-Control Study. Ann Intern Med 2019; 170:433-442. [PMID: 30856660 PMCID: PMC6736692 DOI: 10.7326/m18-2574] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND More than half of enrollees in the U.S. Department of Veterans Affairs (VA) are also covered by Medicare and can choose to receive their prescriptions from VA or from Medicare-participating providers. Such dual-system care may lead to unsafe opioid use if providers in these 2 systems do not coordinate care or if prescription use is not tracked between systems. OBJECTIVE To evaluate the association between dual-system opioid prescribing and death from prescription opioid overdose. DESIGN Nested case-control study. SETTING VA and Medicare Part D. PARTICIPANTS Case and control patients were identified from all veterans enrolled in both VA and Part D who filled at least 1 opioid prescription from either system. The 215 case patients who died of a prescription opioid overdose in 2012 or 2013 were matched (up to 1:4) with 833 living control patients on the basis of date of death (that is, index date), using age, sex, race/ethnicity, disability, enrollment in Medicaid or low-income subsidies, managed care enrollment, region and rurality of residence, and a medication-based measure of comorbid conditions. MEASUREMENTS The exposure was the source of opioid prescriptions within 6 months of the index date, categorized as VA only, Part D only, or VA and Part D (that is, dual use). The outcome was unintentional or undetermined-intent death from prescription opioid overdose, identified from the National Death Index. The association between this outcome and source of opioid prescriptions was estimated using conditional logistic regression with adjustment for age, marital status, prescription drug monitoring programs, and use of other medications. RESULTS Among case patients, the mean age was 57.3 years (SD, 9.1), 194 (90%) were male, and 181 (84%) were non-Hispanic white. Overall, 60 case patients (28%) and 117 control patients (14%) received dual opioid prescriptions. Dual users had significantly higher odds of death from prescription opioid overdose than those who received opioids from VA only (odds ratio [OR], 3.53 [95% CI, 2.17 to 5.75]; P < 0.001) or Part D only (OR, 1.83 [CI, 1.20 to 2.77]; P = 0.005). LIMITATION Data are from 2012 to 2013 and cannot capture prescriptions obtained outside the VA or Medicare Part D systems. CONCLUSION Among veterans enrolled in VA and Part D, dual use of opioid prescriptions was independently associated with death from prescription opioid overdose. This risk factor for fatal overdose among veterans underscores the importance of care coordination across health care systems to improve opioid prescribing safety. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.
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Affiliation(s)
- Patience Moyo
- Brown University School of Public Health, Providence, Rhode Island (P.M.)
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - Carolyn T Thorpe
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina (C.T.T., J.M.T.)
| | - Joshua M Thorpe
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina (C.T.T., J.M.T.)
| | - Florentina E Sileanu
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - John P Cashy
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - Jennifer A Hale
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (X.Z., F.E.S., J.P.C., J.A.H.)
| | - Maria K Mor
- VA Pittsburgh Healthcare System and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (M.K.M., J.M.D.)
| | - Thomas R Radomski
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F.)
| | - Julie M Donohue
- VA Pittsburgh Healthcare System and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania (M.K.M., J.M.D.)
| | - Leslie R M Hausmann
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F.)
| | - Joseph T Hanlon
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania; VA Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, Pennsylvania (J.T.H.)
| | - Chester B Good
- VA Pittsburgh Healthcare System, University of Pittsburgh School of Medicine, and UPMC Health Plan, Pittsburgh, Pennsylvania (C.B.G.)
| | - Michael J Fine
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (T.R.R., L.R.H., M.J.F.)
| | - Walid F Gellad
- VA Pittsburgh Healthcare System, and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (W.F.G.)
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Taber DJ, Ward R, Axon RN, Walker RJ, Egede LE, Gebregziabher M. The Impact of Dual Health Care System Use for Obtaining Prescription Medications on Nonadherence in Veterans With Type 2 Diabetes. Ann Pharmacother 2019; 53:675-682. [PMID: 30724092 DOI: 10.1177/1060028019828681] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Dual health system use may provide increased access to physicians, medications, and other health care resources but may also increase the complexity and coordination of medication regimens. Thus, it is important to elucidate the impact of dual use on medication adherence. OBJECTIVE The objective of this study was to evaluate the impact on medication adherence for veterans with dual health care system use (VA and Medicare) when obtaining prescription antihyperglycemic medications to treat diabetes. METHODS This was a longitudinal cohort study using VA and Medicare data from 2006 to 2010. Medication adherence was estimated by calculating annualized drug class-level proportion of days covered (PDC), where PDC >80% was considered adherent. Generalized linear models were used for estimations, accounting for correlation over time. RESULTS In total, 254 267 veterans with diabetes were included, with 71 057 (27.9%) defined as pharmacy system dual users. Mean age was 77.5 years, and nearly all had multiple comorbidities (mean count 10.2). During follow-up, 75% of VA-only users were deemed adherent to diabetes prescriptions, compared with 63% of dual users. In adjusted models, dual prescription benefit use from VA/Medicare was associated with 39% lower odds of medication adherence (odds ratio [OR] = 0.61; 95% CI = 0.60-0.61). Medication adherence significantly worsened with each additional diabetes medication (OR = 0.65; 95% CI = 0.64-0.65) and significantly decreased over time (OR = 0.95 per year; 95% CI = 0.95-0.96). Conclusion and Relevance: These data suggest that veterans utilizing VA and Medicare to obtain diabetes prescriptions are significantly less likely to be adherent.
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Affiliation(s)
- David J Taber
- 1 Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA.,2 Medical University of South Carolina, Charleston, SC, USA
| | - Ralph Ward
- 1 Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA
| | - R Neal Axon
- 1 Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA
| | | | | | - Mulugeta Gebregziabher
- 1 Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA.,2 Medical University of South Carolina, Charleston, SC, USA
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Pope CA, Davis BH, Wine L, Nemeth LS, Haddock KS, Hartney T, Axon RN. Perceptions of U.S. Veterans Affairs and community healthcare providers regarding cross-system care for heart failure. Chronic Illn 2018; 14:283-296. [PMID: 28906129 DOI: 10.1177/1742395317729887] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study explores perceptions of US Veterans Affairs (VA) and non-VA healthcare providers caring for Veterans with heart failure (HF) regarding Veteran knowledge and motivations for dual use, provider roles in recommending and coordinating dual use, systems barriers and facilitators, and suggestions for improving cross-system care. METHODS Twenty VA and 11 non-VA providers participated in semi-structured interviews, which were analyzed using parallel qualitative content and discourse analysis. RESULTS VA and non-VA providers described variable HF knowledge and self-management among Veterans, and both groups described the need for improved education addressing medication adherence, self-care, and management of acute symptoms. Both groups described highly limited roles for providers in shaping choices surrounding dual use. VA and non-VA providers had significantly different perceptions regarding the availability, quality, and effectiveness of VA HF services. Multiple non-VA providers expressed frustration with and difficulty in contacting VA providers, accessing records, and making referrals into the VA system. Suggestions for improved care focused on patient education and care coordination. DISCUSSION Dual healthcare system use for Veterans is increasingly common. Similarities and contrasts in perceptions of VA and non-VA providers are instructive and should be incorporated into future policy and program initiatives.
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Affiliation(s)
- Charlene A Pope
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA.,2 Division General Pediatrics, Department of Pediatrics, College of Medicine, Medical University of South Carolina (MUSC), Charleston, USA
| | - Boyd H Davis
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA.,3 University of North Carolina-Charlotte, Charlotte, NC, USA
| | - Leticia Wine
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA
| | - Lynne S Nemeth
- 4 College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - K Sue Haddock
- 5 William J.B. Dorn VA Medical Center, Columbia, SC, USA
| | - Tom Hartney
- 6 Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - R Neal Axon
- 1 Health Equity & Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, SC, USA.,7 Department of Internal Medicine, College of Medicine, Medical University of South Carolina (MUSC), Charleston, SC, USA
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Axon RN, Gebregziabher M, Everett CJ, Heidenreich P, Hunt KJ. Dual Healthcare System Use During Episodes of Acute Care Heart Failure Associated With Higher Healthcare Utilization and Mortality Risk. J Am Heart Assoc 2018; 7:e009054. [PMID: 30371248 PMCID: PMC6201461 DOI: 10.1161/jaha.118.009054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/11/2018] [Indexed: 01/04/2023]
Abstract
Background Individuals receiving cross-system care (dual users) have higher rates of healthcare utilization and worse outcomes for heart failure ( HF ) and other conditions. Individuals can be dual users or single-system users at different times, though, and little is known about utilization and mortality within discrete episodes of care. Methods and Results A retrospective cohort of 3439 patients with 5231 discrete episodes of HF exacerbation were identified between 2007 and 2011. Episodes encompassed the period from 2 weeks before an initial HF emergency department ( ED ) visit or hospitalization, included any acute care visits within 30 days after initial visit, and ended 30 days after the last acute care visit in the episode chain. All-cause and HF -specific ED visits and hospitalization within 30 days of index visit were analyzed using generalized estimating equations with robust variance. Hazard for death within episodes of acute illness was analyzed using Cox proportional hazards models. In adjusted analyses, dual use acute HF episodes were associated with higher odds of all-cause ED visits (odds ratio 1.61, 95% confidence interval [ CI ], 1.33, 1.95), HF -specific ED visits, (odds ratio 1.54, 95% CI , 1.12, 2.13), all-cause hospitalization (odds ratio 1.89, 95% CI , 1.50, 2.38), and HF -specific hospitalization (odds ratio 1.62, 95% CI , 1.15-2.30) as compared with Veterans Health Administration-only episodes of acute HF care. Dual use episodes of care were associated with higher hazard for mortality (hazard ratio=1.52, 95% CI 1.07, 2.16) as compared with all-Veterans Health Administration episodes of care. Conclusions Episodes of acute HF care spanning across healthcare systems appear to be associated with higher risk of subsequent ED visits, hospitalization, and mortality.
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Affiliation(s)
- R. Neal Axon
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
- Division of General Internal MedicineDepartment of MedicineThe Medical University of South CarolinaCharlestonSC
| | - Mulugeta Gebregziabher
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
- Department of Public Health SciencesThe Medical University of South CarolinaCharlestonSC
| | - Charles J. Everett
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
| | - Paul Heidenreich
- Division of CardiologyVA Palo Alto Healthcare SystemStanford University Medical CenterPalo AltoCA
| | - Kelly J. Hunt
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC)Ralph H. Johnson VA Medical CenterCharlestonSC
- Department of Public Health SciencesThe Medical University of South CarolinaCharlestonSC
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Chang ET, Zulman DM, Asch SM, Stockdale SE, Yoon J, Ong MK, Lee M, Simon A, Atkins D, Schectman G, Kirsh SR, Rubenstein LV. An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): Study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation. Contemp Clin Trials 2018; 69:65-75. [PMID: 29698772 DOI: 10.1016/j.cct.2018.04.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/09/2018] [Accepted: 04/18/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patient-centered medical homes have made great strides providing comprehensive care for patients with chronic conditions, but may not provide sufficient support for patients at highest risk for acute care use. To address this, the Veterans Health Administration (VHA) initiated a five-site demonstration project to evaluate the effectiveness of augmenting the VA's Patient Aligned Care Team (PACT) medical home with PACT Intensive Management (PIM) teams for Veterans at highest risk for hospitalization. METHODS/DESIGN Researchers partnered with VHA leadership to design a mixed-methods prospective multi-site evaluation that met leadership's desire for a rigorous evaluation conducted as quality improvement rather than research. We conducted a randomized QI evaluation and assigned high-risk patients to participate in PIM and compared them with high-risk Veterans receiving usual care through PACT. The summative evaluation examines whether PIM: 1) decreases VHA emergency department and hospital use; 2) increases satisfaction with VHA care; 3) decreases provider burnout; and 4) generates positive returns on investment. The formative evaluation aims to support improved care for high-risk patients at demonstration sites and to inform future initiatives for high-risk patients. The evaluation was reviewed by representatives from the VHA Office of Research and Development and the Office of Research Oversight and met criteria for quality improvement. DISCUSSION VHA aims to function as a learning organization by rapidly implementing and rigorously testing QI innovations prior to final program or policy development. We observed challenges and opportunities in designing an evaluation consistent with QI standards and operations priorities, while also maintaining scientific rigor. TRIAL REGISTRATION This trial was retrospectively registered at ClinicalTrials.gov on April 3, 2017: NCT03100526. Protocol v1, FY14-17.
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Affiliation(s)
- Evelyn T Chang
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States; Department of Medicine, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States.
| | - Donna M Zulman
- VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, United States; Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, United States.
| | - Steven M Asch
- VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, United States; Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, United States.
| | - Susan E Stockdale
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, United States.
| | - Jean Yoon
- VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, United States; VA Health Economics Resource Center, Menlo Park, CA, United States.
| | - Michael K Ong
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States; Department of Medicine, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States.
| | - Martin Lee
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, United States.
| | - Alissa Simon
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States.
| | - David Atkins
- VA Office of Health Services Research and Development, Washington, DC, United States.
| | | | - Susan R Kirsh
- VA Office of Primary Care, Washington, DC, United States; Case Western Reserve University School of Medicine, Cleveland, OH, United States.
| | - Lisa V Rubenstein
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Medicine, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States; Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, United States; RAND, Santa Monica, CA, United States.
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25
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Yoon J, Vanneman ME, Dally SK, Trivedi AN, Phibbs CS. Use of Veterans Affairs and Medicaid Services for Dually Enrolled Veterans. Health Serv Res 2018; 53:1539-1561. [PMID: 28608413 PMCID: PMC5980176 DOI: 10.1111/1475-6773.12727] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To examine how dual coverage for nonelderly, low-income veterans by Veterans Affairs (VA) and Medicaid affects their demand for care. DATA SOURCES Veterans Affairs utilization data and Medicaid Analytic Extract Files. STUDY DESIGN A retrospective, longitudinal study of VA users prior to and following enrollment in Medicaid 2006-2010. DATA COLLECTION/EXTRACTION METHODS Veterans Affairs reliance, or proportion of care provided by VA, was estimated with beta-binomial models, adjusting for patient and state Medicaid program factors. PRINCIPAL FINDINGS In a cohort of 19,890 nonelderly veterans, VA utilization levels were similar before and after enrolling in Medicaid. VA outpatient reliance was 0.65, and VA inpatient reliance was 0.53 after Medicaid enrollment. Factors significantly associated with greater VA reliance included sociodemographic factors, having a service-connected disability, comorbidity, and higher state Medicaid reimbursement. Factors significantly associated with less VA reliance included months enrolled in Medicaid, managed care enrollment, Medicaid eligibility type, longer drive time to VA care, greater Medicaid eligibility generosity, and better Medicaid quality. CONCLUSION Veterans Affairs utilization following new Medicaid enrollment remained relatively unchanged, and the VA continued to provide the large majority of care for dually enrolled veterans. There was variation among patients as Medicaid eligibility and other program factors influenced their use of Medicaid services.
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Affiliation(s)
- Jean Yoon
- Health Economics Resource CenterVA Palo Alto Health Care SystemMenlo ParkCA
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCA
- Department of General Internal MedicineUCSF School of MedicineSan FranciscoCA
| | - Megan E. Vanneman
- Informatics, Decision‐Enhancement and Analytic Sciences CenterVA Salt Lake City Health Care SystemSalt Lake CityUT
- Department of Internal MedicineDivision of EpidemiologyUniversity of Utah School of MedicineSalt Lake CityUT
- Department of Population Health SciencesDivision of Health System Innovation and ResearchUniversity of Utah School of MedicineSalt Lake CityUT
| | - Sharon K. Dally
- Health Economics Resource CenterVA Palo Alto Health Care SystemMenlo ParkCA
| | - Amal N. Trivedi
- Providence VA Medical CenterProvidenceRI
- Department of Health Services, Policy and PracticeBrown UniversityProvidenceRI
| | - Ciaran S. Phibbs
- Health Economics Resource CenterVA Palo Alto Health Care SystemMenlo ParkCA
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCA
- Department of PediatricsStanford University School of MedicineStanfordCA
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Hatch MN, Raad J, Suda K, Stroupe KT, Hon AJ, Smith BM. Evaluating the Use of Medicare Part D in the Veteran Population With Spinal Cord Injury/Disorder. Arch Phys Med Rehabil 2018; 99:1099-1107. [PMID: 29425699 DOI: 10.1016/j.apmr.2017.12.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 12/05/2017] [Accepted: 12/22/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine the different sources of medications, the most common drug classes filled, and the characteristics associated with Medicare Part D pharmacy use in veterans with spinal cord injury/disorder (SCI/D). DESIGN Retrospective, cross-sectional, observational study. SETTING Outpatient clinics and pharmacies. PARTICIPANTS Veterans (N=13,442) with SCI/D using Medicare or Veteran Affairs pharmacy benefits. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Characteristics and top 10 most common drug classes were examined in veterans who (1) used VA pharmacies only; (2) used both VA and Medicare Part D pharmacies; or (3) used Part D pharmacies only. Chi-square tests and multinomial logistic regression analyses were used to determine associations between various patient variables and source of medications. Patient level frequencies were used to determine the most common drug classes. RESULTS A total of 13,442 veterans with SCI/D were analyzed in this study: 11,788 (87.7%) used VA pharmacies only, 1281 (9.5%) used both VA and Part D pharmacies, and 373 (2.8%) used Part D pharmacies only. Veterans older than 50 years were more likely to use Part D pharmacies, whereas those with traumatic injury, or secondary conditions, were less associated with the use of Part D pharmacies. Opioids were the most frequently filled drug class across all groups. Other frequently used drug classes included skeletal muscle relaxants, gastric medications, antidepressants (other category), anticonvulsants, and antilipemics. CONCLUSIONS Approximately 12% of veterans with SCI/D are receiving medication outside the VA system. Polypharmacy in this population of veterans is relatively high, emphasizing the importance of health information exchange between systems for improved care for this medically complex population.
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Affiliation(s)
- Maya N Hatch
- Spinal Cord Injury and Disorders Center, Long Beach Veterans Affairs Medical Center, Long Beach, CA
| | - Jason Raad
- Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Chicago, IL
| | - Katie Suda
- Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Chicago, IL
| | - Kevin T Stroupe
- Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Chicago, IL
| | - Alice J Hon
- Spinal Cord Injury and Disorders Center, Long Beach Veterans Affairs Medical Center, Long Beach, CA
| | - Bridget M Smith
- Center for Management of Complex Chronic Care, Edward Hines Jr. VA Hospital, Chicago, IL; Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL.
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Young-Xu Y, van Aalst R, Russo E, Lee JKH, Chit A. The Annual Burden of Seasonal Influenza in the US Veterans Affairs Population. PLoS One 2017; 12:e0169344. [PMID: 28046080 PMCID: PMC5207669 DOI: 10.1371/journal.pone.0169344] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 12/15/2016] [Indexed: 11/26/2022] Open
Abstract
Seasonal influenza epidemics have a substantial public health and economic burden in the United States (US). On average, over 200,000 people are hospitalized and an estimated 23,000 people die from respiratory and circulatory complications associated with seasonal influenza virus infections each year. Annual direct medical costs and indirect productivity costs across the US have been found to average respectively at $10.4 billion and $16.3 billion. The objective of this study was to estimate the economic impact of severe influenza-induced illness on the US Veterans Affairs population. The five-year study period included 2010 through 2014. Influenza-attributed outcomes were estimated with a statistical regression model using observed emergency department (ED) visits, hospitalizations, and deaths from the Veterans Health Administration of the Department of Veterans Affairs (VA) electronic medical records and respiratory viral surveillance data from the Centers for Disease Control and Prevention (CDC). Data from VA’s Managerial Cost Accounting system were used to estimate the costs of the emergency department and hospital visits. Data from the Bureau of Labor Statistics were used to estimate the costs of lost productivity; data on age at death, life expectancy and economic valuations for a statistical life year were used to estimate the costs of a premature death. An estimated 10,674 (95% CI 8,661–12,687) VA ED visits, 2,538 (95% CI 2,112–2,964) VA hospitalizations, 5,522 (95% CI 4,834–6,210) all-cause deaths, and 3,793 (95% CI 3,375–4,211) underlying respiratory or circulatory deaths (inside and outside VA) among adult Veterans were attributable to influenza each year from 2010 through 2014. The annual value of lost productivity amounted to $27 (95% CI $24–31) million and the annual costs for ED visits were $6.2 (95% CI $5.1–7.4) million. Ninety-six percent of VA hospitalizations resulted in either death or a discharge to home, with annual costs totaling $36 (95% CI $30–43) million. The remaining 4% of hospitalizations were followed by extended care at rehabilitation and skilled nursing facilities with annual costs totaling $5.5 (95% CI $4.4–6.8) million. The annual monetary value of quality-adjusted life years (QALYs) lost amounted to $1.1 (95% CI $1.0–1.2) billion. In total, the estimated annual economic burden was $1.2 (95% CI $1.0–1.3) billion, indicating the substantial burden of seasonal influenza epidemics on the US Veterans Affairs population. Premature death was found to be the largest driver of these costs, followed by hospitalization.
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Affiliation(s)
- Yinong Young-Xu
- Clinical Epidemiology Program, Veterans Affairs Medical Center, White River Junction, Vermont, United States of America
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States of America
| | - Robertus van Aalst
- Clinical Epidemiology Program, Veterans Affairs Medical Center, White River Junction, Vermont, United States of America
- * E-mail:
| | - Ellyn Russo
- Clinical Epidemiology Program, Veterans Affairs Medical Center, White River Junction, Vermont, United States of America
| | - Jason K. H. Lee
- Health Outcomes and Economics, Sanofi Pasteur, Swiftwater, Pennsylvania, United States of America
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Ayman Chit
- Health Outcomes and Economics, Sanofi Pasteur, Swiftwater, Pennsylvania, United States of America
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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West AN, Charlton ME. Insured Veterans' Use of VA and Non-VA Health Care in a Rural State. J Rural Health 2016; 32:387-396. [PMID: 27481190 DOI: 10.1111/jrh.12196] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 06/06/2016] [Accepted: 06/24/2016] [Indexed: 01/05/2023]
Abstract
PURPOSE To understand how working-age VA-enrolled veterans with commercial insurance use both VA and non-VA outpatient care, and how rural residence affects dual use, for common diagnoses and procedures. METHODS We analyzed VA and non-VA outpatient treatment records for any months during 2005-2010 that New Hampshire veterans ages <65 were simultaneously enrolled in VA health care and commercial insurance (per NH's mandatory claims database). Controlling for covariates, we used analysis of variance to compare urban and rural VA users, non-VA users, and dual users on travel burden, diagnosis counts, duration in outpatient care, and visit frequencies, and logistic regressions to assess whether rural veterans were as likely to be seen for common conditions and procedures. FINDINGS More than half of patients were non-VA users and another third were dual users; rural residents were slightly more likely than urban residents to be dual users. For nearly any common diagnosis or procedure, dual users were more likely to have it at some time during treatment than other patients in either VA or non-VA care, but they seldom had it listed in both care systems. Dual users also were seen most often overall, although within either care system they were seen less often than other patients, particularly if they were rural residents living far from care. Rural residence reduced chances of treatment for a wide variety of conditions, though it also was associated with more musculoskeletal and connective tissue diagnoses. It also reduced chances that patients had some diagnostic and treatment procedures but increased the odds of others that may require fewer visits. CONCLUSIONS Dual users living in rural areas may have less continuity in their health care. Ensuring that rural dual users are identified in primary care should improve access and care coordination.
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Affiliation(s)
- Alan N West
- Research Service, VA Medical Center, White River Junction, Vermont. .,Office of Rural Health, Veterans Health Administration, Washington, DC.
| | - Mary E Charlton
- Iowa City VA Health Care System, Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City, Iowa.,Department of Epidemiology, The University of Iowa College of Public Health, Iowa City, Iowa
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Charlton ME, Mengeling MA, Schlichting JA, Jiang L, Turvey C, Trivedi AN, Kizer KW, West AN. Veteran Use of Health Care Systems in Rural States: Comparing VA and Non-VA Health Care Use Among Privately Insured Veterans Under Age 65. J Rural Health 2016; 32:407-417. [DOI: 10.1111/jrh.12206] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 06/01/2016] [Accepted: 07/11/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Mary E. Charlton
- Department of Epidemiology; University of Iowa College of Public Health; Iowa City Iowa
| | - Michelle A. Mengeling
- VA Office of Rural Health, Rural Health Resource Center-Central Region, and the Comprehensive Access and Delivery Research and Evaluation (CADRE); Center at the Iowa City VA Healthcare System; Iowa City Iowa
| | | | - Lan Jiang
- VA Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans; Providence VA Healthcare System; Providence Rhode Island
| | - Carolyn Turvey
- Department of Epidemiology; University of Iowa College of Public Health; Iowa City Iowa
- VA Office of Rural Health, Rural Health Resource Center-Central Region, and the Comprehensive Access and Delivery Research and Evaluation (CADRE); Center at the Iowa City VA Healthcare System; Iowa City Iowa
- Department of Psychiatry, Carver College of Medicine; University of Iowa; Iowa City Iowa
| | - Amal N. Trivedi
- VA Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans; Providence VA Healthcare System; Providence Rhode Island
- Department of Health Services, Policy and Practice and Department of Medicine; Brown University; Providence Rhode Island
| | - Kenneth W. Kizer
- UC Davis School of Medicine, and Betty Irene Moore School of Nursing, Institute for Population Health Improvement; University of California (UC)-Davis Health System; Sacramento California
| | - Alan N. West
- Research Service, VA Medical Center; White River Junction; Vermont
- Office of Rural Health; Veterans Health Administration; Washington DC
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