Medication Use among Veterans across Health Care Systems

Identification of Hypertension in Electronic Health Records Through Computable Phenotype Development and Validation for Use in Public Health Surveillance: Retrospective Study

BACKGROUND

Electronic health record (EHR) systems are widely used in the United States to document care delivery and outcomes. Health information exchange (HIE) networks, which integrate EHR data from the various health care providers treating patients, are increasingly used to analyze population-level data. Existing methods for population health surveillance of essential hypertension by public health authorities may be complemented using EHR data from HIE networks to characterize disease burden at the community level.

OBJECTIVE

We aimed to derive and validate computable phenotypes (CPs) to estimate hypertension prevalence for population-based surveillance using an HIE network.

METHODS

Using existing data available from an HIE network, we developed 6 candidate CPs for essential (primary) hypertension in an adult population from a medium-sized Midwestern metropolitan area in the United States. A total of 2 independent clinician reviewers validated the phenotypes through a manual chart review of 150 randomly selected patient records. We assessed the precision of CPs by calculating sensitivity, specificity, positive predictive value (PPV), F1-score, and validity of chart reviews using prevalence-adjusted bias-adjusted κ. We further used the most balanced CP to estimate the prevalence of hypertension in the population.

RESULTS

Among a cohort of 548,232 adults, 6 CPs produced PPVs ranging from 71% (95% CI 64.3%-76.9%) to 95.7% (95% CI 84.9%-98.9%). The F1-score ranged from 0.40 to 0.91. The prevalence-adjusted bias-adjusted κ revealed a high percentage agreement of 0.88 for hypertension. Similarly, interrater agreement for individual phenotype determination demonstrated substantial agreement (range 0.70-0.88) for all 6 phenotypes examined. A phenotype based solely on diagnostic codes possessed reasonable performance (F1-score=0.63; PPV=95.1%) but was imbalanced with low sensitivity (47.6%). The most balanced phenotype (F1-score=0.91; PPV=83.5%) included diagnosis, blood pressure measurements, and medications and identified 210,764 (38.4%) individuals with hypertension during the study period (2014-2015).

CONCLUSIONS

We identified several high-performing phenotypes to identify essential hypertension prevalence for local public health surveillance using EHR data. Given the increasing availability of EHR systems in the United States and other nations, leveraging EHR data has the potential to enhance surveillance of chronic disease in health systems and communities. Yet given variability in performance, public health authorities will need to decide whether to seek optimal balance or declare a preference for algorithms that lean toward sensitivity or specificity to estimate population prevalence of disease.

Treatment and Control of Hypertension Among Adults With Chronic Kidney Disease, 2011 to 2019

BACKGROUND

Hypertension frequently accompanies chronic kidney disease (CKD) as etiology and sequela. We examined contemporary trends in hypertension treatment and control in a national sample of adults with CKD.

METHODS

We evaluated 5% cross-sectional samples of adults with CKD between 2011 and 2019 in the Veterans Health Administration. We defined CKD as a sustained estimated glomerular filtration rate value <60 mL/min per 1.73 m2 or a urine albumin-to-creatinine ratio ≥30 mg/g. The main outcomes were blood pressure (BP) control, defined as a systolic BP <140 mm Hg and a diastolic BP <90 mm Hg based on the mean of monthly BP measurements, and prescriptions for antihypertensive medications.

RESULTS

The annual samples ranged between n=22 110 and n=33 039 individuals, with a mean age of 72 years, 96% of whom were men. Between 2011 and 2014, the age-adjusted proportion of adults with controlled BP declined from 78.0% to 72.2% (P value for linear trend, <0.001), reached a nadir of 71.0% in 2015, and then increased to 72.9% by 2019 (P value for linear trend, <0.001). Among adults with BP above goal, the age-adjusted proportion who did not receive antihypertensive treatment increased throughout the decade from 18.8% to 21.6%, and the age-adjusted proportion who received ≥3 antihypertensive medications decreased from 41.8% to 36.3%. Prescriptions for first-line antihypertensive agents also decreased.

CONCLUSIONS

Among adults with CKD treated in the Veterans Health Administration, the proportion with controlled BP declined between 2011 and 2015 followed by a modest increase, coinciding with fewer prescriptions for antihypertensive medications.

A process to deduplicate individuals for regional chronic disease prevalence estimates using a distributed data network of electronic health records

Introduction

Learning health systems can help estimate chronic disease prevalence through distributed data networks (DDNs). Concerns remain about bias introduced to DDN prevalence estimates when individuals seeking care across systems are counted multiple times. This paper describes a process to deduplicate individuals for DDN prevalence estimates.

Methods

We operationalized a two‐step deduplication process, leveraging health information exchange (HIE)‐assigned network identifiers, within the Colorado Health Observation Regional Data Service (CHORDS) DDN. We generated prevalence estimates for type 1 and type 2 diabetes among pediatric patients (0‐17 years) with at least one 2017 encounter in one of two geographically‐proximate DDN partners. We assessed the extent of cross‐system duplication and its effect on prevalence estimates.

Results

We identified 218 437 unique pediatric patients seen across systems during 2017, including 7628 (3.5%) seen in both. We found no measurable difference in prevalence after deduplication. The number of cases we identified differed slightly by data reconciliation strategy. Concordance of linked patients' demographic attributes varied by attribute.

Conclusions

We implemented an HIE‐dependent, extensible process that deduplicates individuals for less biased prevalence estimates in a DDN. Our null pilot findings have limited generalizability. Overlap was small and likely insufficient to influence prevalence estimates. Other factors, including the number and size of partners, the matching algorithm, and the electronic phenotype may influence the degree of deduplication bias. Additional use cases may help improve understanding of duplication bias and reveal other principles and insights. This study informed how DDNs could support learning health systems' response to public health challenges and improve regional health.

Leadership Perspectives on Implementing Health Information Exchange: Qualitative Study in a Tertiary Veterans Affairs Medical Center

Background

The US Department of Veterans Affairs (VA) seeks to achieve interoperability with other organizations, including non-VA community and regional health information exchanges (HIEs).

Objective

This study aims to understand the perspectives of leaders involved in implementing information exchange between VA and non-VA providers via a community HIE.

Methods

We interviewed operational, clinical, and information technology leaders at one VA facility and its community HIE partner. Respondents discussed their experiences with VA-HIE, including barriers and facilitators to implementation, and the associated impact on health care providers. Transcribed interviews were coded and analyzed using immersion-crystallization methods.

Results

VA and community HIE leaders found training to be a key factor when implementing VA-HIE and worked cooperatively to provide several styles and locations of training. During recruitment, a high-touch approach was successfully used to enroll patients and overcome their resistance to opting in. Discussion with leaders revealed the high levels of complexity navigated by VA providers and staff to send and retrieve information. Part of the complexity stemmed from the interconnected web of information systems and human teams necessary to implement VA-HIE information sharing. These interrelationships must be effectively managed to guide organizational decision making.

Conclusions

Organizational leaders perceived information sharing to be of essential value in delivering high-quality, coordinated health care. The VA continues to increase access to outside care through the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act. Along with this increase in non-VA medical care, there is a need for greater information sharing between VA and non-VA health care organizations. Insights by leaders into barriers and facilitators to VA-HIE can be applied by other national and regional networks that seek to achieve interoperability across health care delivery systems.

Association of Continuity of Care With Outcomes in US Veterans With Inflammatory Bowel Disease

IMPORTANCE

Health care fragmentation is associated with inefficiency and worse outcomes. Continuity of care (COC) models were developed to address fragmentation.

OBJECTIVE

To examine COC and selected outcomes in US veterans with inflammatory bowel disease (IBD).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used the Veterans Health Administration (VHA) Corporate Data Warehouse to identify veterans with IBD who received care in the VHA health care system between January 1, 2002, and December 31, 2014. Included patients were veterans with IBD who had a primary care physician and at least 4 outpatient visits with key physicians (gastroenterologist, primary care physician, and surgeon) within the first year after an index IBD encounter. Data were analyzed from November 2018 to May 2020.

EXPOSURES

Care continuity was measured with the Bice-Boxerman COC index to define care density and dispersion within year 1 after the initial presentation.

MAIN OUTCOMES AND MEASURES

A Cox proportional hazards regression model was used to quantify the association between a low level of COC in year 1 (defined as ≤0.25 on a 0 to 1 scale) and subsequent IBD-related outcomes in years 2 and 3 (outpatient flare, hospitalization, and surgical intervention).

RESULTS

Among the 20 079 veterans with IBD who met the inclusion criteria, 18 632 were men (92.8%) and the median (interquartile range [IQR]) age was 59 (48-66) years. In the first year of follow-up, substantial variation in the dispersion of care was observed (median [IQR] COC, 0.24 [0.13-0.46]). In a Cox proportional hazards regression model, a low level of COC was associated with a higher likelihood of outpatient flares that required corticosteroids (adjusted hazard ratio [aHR], 1.11; 95% CI, 1.01-1.22), hospitalizations (aHR, 1.25; 95% CI, 1.06-1.47), and surgical interventions (aHR, 1.72; 95% CI, 1.43-2.07).

CONCLUSIONS AND RELEVANCE

Results of this cohort study showed a wide variation in dispersion of IBD care and an association between a lower level of COC and active IBD and worse outcomes. The findings suggest that investigating the barriers to COC in integrated systems that have invested in care coordination is key to not only better understanding COC but also identifying opportunities to improve care fragmentation.

VA Care Coordination Program Increased Primary Care Visits and Improved Transitional Care for Veterans Post Non-VA Hospital Discharge

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.

Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non-VA Hospitals to Primary Care in a Single VA Healthcare System

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.

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

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.

Automated Text Messaging With Patients in Department of Veterans Affairs Specialty Clinics: Cluster Randomized Trial

Background

Acceptability of mobile phone text messaging as a means of asynchronous communication between health care systems and patients is growing. The US Department of Veterans Affairs (VA) has adopted an automated texting system (aTS) for national rollout. The aTS allows providers to develop clinical texting protocols to promote patient self-management and allows clinical teams to monitor patient progress between in-person visits. Texting-supported hepatitis C virus (HCV) treatment has not been previously tested.

Objective

Guided by the Practical, Robust Implementation and Sustainability Model (PRISM), we developed an aTS HCV protocol and conducted a mixed methods, hybrid type 2 effectiveness implementation study comparing two programs supporting implementation of the aTS HCV protocol for medication adherence in patients with HCV.

Methods

Seven VA HCV specialty clinics were randomized to usual aTS implementation versus an augmented implementation facilitation program. Implementation process measures included facilitation metrics, usability, and usefulness. Implementation outcomes included provider and patient use of the aTS HCV protocol, and effectiveness outcomes included medication adherence, health perceptions and behaviors, and sustained virologic response (SVR).

Results

Across the seven randomized clinics, there were 293 facilitation events using a core set of nine implementation strategies (157 events in augmented implementation facilitation, 136 events in usual implementation). Providers found the aTS appropriate with high potential for scale-up but not without difficulties in startup, patient selection and recruitment, and clinic workflow integration. Patients largely found the aTS easy to use and helpful; however, low perceived need for self-management support contributed to high declination. Reach and use was modest with 197 patients approached, 71 (36%) enrolled, 50 (25%) authenticated, and 32 (16%) using the aTS. In augmented implementation facilitation clinics, more patients actively used the aTS HCV protocol compared with usual clinic patients (20% vs 12%). Patients who texted reported lower distress about failing HCV treatment (13/15, 87%, vs 8/15, 53%; P=.05) and better adherence to HCV medication (11/15, 73%, reporting excellent adherence vs 6/15, 40%; P=.06), although SVR did not differ by group.

Conclusions

The aTS is a promising intervention for improving patient self-management; however, augmented approaches to implementation may be needed to support clinician buy-in and patient engagement. Considering the behavioral, social, organizational, and technical scale-up challenges that we documented, successful and sustained implementation of the aTS may require implementation strategies that operate at the clinic, provider, and patient levels.

Trial Registration

Retrospectively registered at ClinicalTrials.gov NCT03898349; https://clinicaltrials.gov/ct2/show/NCT03898349

Recommendations for the Evaluation of Cross-System Care Coordination from the VA State-of-the-art Working Group on VA/Non-VA Care

In response to widespread concerns regarding Veterans' access to VA care, Congress enacted the Veterans Access, Choice and Accountability Act of 2014, which required VA to establish the Veterans Choice Program (VCP). Since the inception of VCP, more than two million Veterans have received care from community providers, representing approximately 25% of Veterans enrolled in VA care. However, expanded access to non-VA care has created challenges in care coordination between VA and community health systems. In March 2018, the VA Health Services Research & Development Service hosted a VA State of the Art conference (SOTA) focused on care coordination. The SOTA convened VA researchers, program directors, clinicians, and policy makers to identify knowledge gaps regarding care coordination within the VA and between VA and community systems of care. This article provides a summary and synthesis of relevant literature and provides recommendations generated from the SOTA about how to evaluate cross-system care coordination. Care coordination is typically evaluated using health outcomes including hospital readmissions and death; however, in cross-system evaluations of care coordination, measures such as access, cost, Veteran/patient and provider satisfaction (including with cross-system communication), comparable quality metrics, context (urban vs. rural), and patient complexity (medical and mental health conditions) need to be included to fully evaluate care coordination effectiveness. Future research should examine the role of multiple individuals coordinating VA and non-VA care, and how these coordinators work together to optimize coordination.

Veterans Health Information Exchange: Successes and Challenges of Nationwide Interoperability

Health Information Exchange (HIE) between organizations is necessary to have more complete information and coordinate care. Given its nationwide footprint, the Department of Veterans Affairs (VA) connects and exchanges health information with a large number of organizations and consequently has a unique opportunity to experience most issues affecting clinical interoperability. The Veterans HIE Program manages these exchanges by focusing on patient engagement, provider adoption, partner relationship, technology platform, and performance. This paper analyzes the success and challenges of this program over the last five years, and offers valuable metrics and insights. Although significant progress has been made, nationwide interoperability remains fragmented and laborious, requiring multiple agreements and exchange methods. A future nationwide interoperability would embrace a single "on-ramp" to connect to everyone.

Effect of Dual Use of Veterans Affairs and Medicare Part D Drug Benefits on Antihypertensive Medication Supply in a National Cohort of Veterans with Dementia

OBJECTIVE

To evaluate the effect of dual use of VA/Medicare Part D drug benefits on antihypertensive medication supply in older Veterans with dementia.

DATA SOURCES/STUDY SETTING

National, linked 2007-2010 Veterans Affairs (VA) and Medicare utilization and prescription records for 50,763 dementia patients with hypertension.

STUDY DESIGN

We used inverse probability of treatment (IPT)-weighted multinomial logistic regression to examine the association of dual prescription use with undersupply and oversupply of antihypertensives.

DATA COLLECTION/EXTRACTION METHODS

Veterans Affairs and Part D prescription records were used to classify patients as VA-only, Part D-only, or dual VA/Part D users of antihypertensives and summarize their antihypertensive medication supply in 2010: (1) appropriate supply of all prescribed antihypertensive classes, (2) undersupply of ≥1 class with no oversupply of another class, (3) oversupply of ≥1 class with no undersupply, or (4) both undersupply and oversupply.

PRINCIPAL FINDINGS

Dual prescription users were more likely than VA-only users to have undersupply only (aOR = 1.28; 95 percent CI = 1.18-1.39), oversupply only (aOR = 2.38; 95 percent CI = 2.15-2.64), and concurrent under- and oversupply (aOR = 2.89; 95 percent CI = 2.53-3.29), versus appropriate supply of all classes.

CONCLUSIONS

Obtaining antihypertensives through both VA and Part D was associated with increased antihypertensive under- and oversupply. Efforts to understand how best to coordinate dual-system prescription use are critically needed.