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Slightam C, SooHoo S, Greene L, Zulman DM, Kimerling R. Development and Validation of a Measure to Assess Patient Experiences With Video Care Encounters. JAMA Netw Open 2024; 7:e245277. [PMID: 38578639 PMCID: PMC10998154 DOI: 10.1001/jamanetworkopen.2024.5277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/08/2024] [Indexed: 04/06/2024] Open
Abstract
Importance As video-based care expands in many clinical settings, assessing patient experiences with this care modality will help optimize health care quality, safety, and communication. Objective To develop and assess the psychometric properties of the video visit user experience (VVUE) measure, a patient-reported measure of experiences with video-based technology. Design, Setting, and Participants In this survey study, veterans completed a web-based, mail, or telephone survey about their use of Veterans Healthcare Administration (VHA) virtual care between September 2021 and January 2022. The survey was completed by patients who reported having a VHA video visit on their own device or a VHA-issued device and linked to VHA utilization data for the 6 months following the survey. Data analysis was performed from March 2022 to February 2023. Main Outcomes and Measures The survey included 19 items about experiences with video visits that were rated using a 4-point Likert-type scale (strongly disagree to strongly agree). First, an exploratory factor analysis was conducted to determine the factor structure and parsimonious set of items, using the McDonald Omega test to assess internal consistency reliability. Then, a confirmatory factor analysis was conducted to test structural validity, and bivariate correlations between VVUE and VHA health care engagement were calculated to test concurrent validity. Finally, predictive validity was assessed using logistic regression to determine whether VVUE was associated with future VHA video visit use. Results Among 1887 respondents included in the analyses, 83.2% (95% CI, 81.5%-84.8%) were male, 41.0% (95% CI, 38.8%-43.1%) were aged 65 years or older, and the majority had multiple chronic medical and mental health conditions. The exploratory factor analysis identified a 10-item single-factor VVUE measure (including questions about satisfaction, user-centeredness, technical quality, usefulness, and appropriateness), explaining 96% of the total variance, with acceptable internal consistency reliability (ω = 0.95). The confirmatory factor analysis results confirmed a single-factor solution (standardized root mean squared residual = 0.04). VVUE was positively associated with VHA health care engagement (ρ = 0.47; P < .001). Predictive validity models demonstrated that higher VVUE measure scores were associated with future use of video visits, where each 1-point increase on VVUE was associated with greater likelihood of having a video visit in subsequent 6 months (adjusted odds ratio, 1.04; 95% CI, 1.02-1.06). Conclusions and Relevance The findings of this study of veterans using video visits suggest that a brief measure is valid to capture veterans' experiences receiving VHA virtual care.
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Affiliation(s)
- Cindie Slightam
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
| | - Sonya SooHoo
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
| | - Liberty Greene
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Donna M. Zulman
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Rachel Kimerling
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- National Center for PTSD, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
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Alfaro AJ, Greene L, Van Campen J, Zulman DM, Gould CE, Blonigen DM. Patterns and predictors of mental health service use among older veterans with alcohol use disorder who received a video-enabled tablet. Aging Ment Health 2024; 28:604-610. [PMID: 37723897 DOI: 10.1080/13607863.2023.2253448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 08/25/2023] [Indexed: 09/20/2023]
Abstract
Objectives: Video-based telehealth may expand access to mental health services among older veterans with alcohol use disorder (AUD). We examined the modalities through which mental health services were rendered, and predictors of video visits before and after video-enabled tablet receipt from the Veterans Health Administration. Method: 11,210 veterans aged 60 or older with a diagnosis of AUD who received a tablet between 1 April 2020 and 25 October 2021 were identified. The electronic health record was used to characterized encounters by modality of mental health care delivery in the six months pre/post tablet receipt. Logistic regression examined predictors of a video visit for mental health. Results: Phone was the most common modality; however, the proportion of video encounters increased from 8.7% to 26.2% after tablet receipt. Individuals who were older, male, and had more physical health conditions, were less likely to have a video visit. Individuals who were married, resided in urban areas, had a history of housing instability, and had more mental health conditions, were more likely to have a video visit. Conclusion: Video-enabled tablets may help older adults with AUD overcome access barriers to mental health services, although targeted support for certain groups may be necessary.
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Affiliation(s)
- Ana J Alfaro
- VA Palo Alto Health Care System, Geriatric Research, Education and Clinical Center (GRECC), Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Services, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Liberty Greene
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - James Van Campen
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Christine E Gould
- VA Palo Alto Health Care System, Geriatric Research, Education and Clinical Center (GRECC), Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Services, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Daniel M Blonigen
- Department of Psychiatry and Behavioral Services, Stanford University School of Medicine, Palo Alto, CA, USA
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
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Wray CM, Ferguson JM, Greene L, Griffin A, Van Campen J, O'Shea AM, Slightam C, Zulman DM. Overcoming Obstacles: Barriers to Virtual Care Use Among Video-Enabled Tablet Recipients in the Veterans Health Administration. J Gen Intern Med 2024; 39:549-556. [PMID: 37914909 PMCID: PMC10973323 DOI: 10.1007/s11606-023-08468-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/06/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION The Veterans Health Administration (VHA) distributes video-enabled tablets to individuals with barriers to accessing care. Data suggests that many tablets are under-used. We surveyed Veterans who received a tablet to identify barriers that are associated with lower use, and evaluated the impact of a telephone-based orientation call on reported barriers and future video use. METHODS We used a national survey to assess for the presence of 13 barriers to accessing video-based care, and then calculated the prevalence of the barriers stratified by video care utilization in the 6 months after survey administration. We used multivariable modeling to examine the association between each barrier and video-based care use and evaluated whether a telephone-based orientation modified this association. RESULTS The most prevalent patient-reported barriers to video-based care were not knowing how to schedule a visit, prior video care being rescheduled/canceled, and past problems using video care. Following adjustment, individuals who reported vision or hearing difficulties and those who reported that video care does not provide high-quality care had a 19% and 12% lower probability of future video care use, respectively. Individuals who reported no interest in video care, or did not know how to schedule a video care visit, had an 11% and 10% lower probability of being a video care user, respectively. A telephone-based orientation following device receipt did not improve the probability of being a video care user. DISCUSSION Barriers to engaging in virtual care persist despite access to video-enabled devices. Targeted interventions beyond telephone-based orientation are needed to facilitate adoption and engagement in video visits.
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Affiliation(s)
- Charlie M Wray
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Section of Hospital Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | | | - Liberty Greene
- VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | - Ashley Griffin
- VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | - James Van Campen
- VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | - Amy Mj O'Shea
- The Center for Access and Delivery Research and Evaluation (CADRE, Iowa City VA Healthcare System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Cindie Slightam
- VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | - Donna M Zulman
- VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Maciejewski ML, Greene L, Grubber JM, Blalock DV, Jacobs J, Rao M, Zulman DM, Smith VA. Association between patient-reported social and behavioral risks and health care costs in high-risk Veterans health administration patients. Health Serv Res 2024; 59:e14243. [PMID: 37767603 PMCID: PMC10771909 DOI: 10.1111/1475-6773.14243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVE Social risks complicate patients' ability to manage their conditions and access healthcare, but their association with health expenditures is not well established. To identify patient-reported social risk, behavioral, and health factors associated with health expenditures in Veterans Affairs (VA) patients at high risk for hospitalization or death. DATA SOURCES, STUDY SETTING, AND STUDY DESIGN Prospective cohort study among high-risk Veterans obtaining VA care. Patient-reported social risk, function, and other measures derived from a 2018 survey sent to 10,000 VA patients were linked to clinical and demographic characteristics extracted from VA data. Response-weighted generalized linear and marginalized two-part models were used to examine VA expenditures (total, outpatient, medication, inpatient) 1 year after survey completion in adjusted models. PRINCIPAL FINDINGS Among 4680 survey respondents, the average age was 70.9 years, 6.3% were female, 16.7% were African American, 20% had body mass index ≥35, 42.4% had difficulty with two or more basic or instrumental activities of daily living, 19.3% reported transportation barriers, 12.5% reported medication insecurity and 21.8% reported food insecurity. Medication insecurity was associated with lower outpatient expenditures (-$1859.51 per patient per year, 95% confidence interval [CI]: -3200.77 to -518.25) and lower total expenditures (-$4304.99 per patient per year, 95% CI: -7564.87 to -1045.10). Transportation barriers were negatively associated with medication expenditures (-$558.42, 95% CI: -1087.93 to -31.91). Patients with one functional impairment had higher outpatient expenditures ($2997.59 per patient year, 95% CI: 1185.81-4809.36) than patients without functional impairments. No social risks were associated with inpatient expenditures. CONCLUSIONS In this study of VA patients at high risk for hospitalization and mortality, few social and functional measures were independently associated with the costs of VA care. Individuals with functional limitations and those with barriers to accessing medications and transportation may benefit from targeted interventions to ensure that they are receiving the services that they need.
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Affiliation(s)
- Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Liberty Greene
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Janet M. Grubber
- Cooperative Studies Program Coordinating CenterBoston Veterans Affairs Health Care SystemBostonMassachusettsUSA
| | - Dan V. Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Josephine Jacobs
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Health Economics Resource CenterVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
| | - Mayuree Rao
- Seattle‐Denver Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWashingtonUSA
| | - Donna M. Zulman
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
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Rao M, Greene L, Nelson K, Maciejewski ML, Zulman DM. Associations Between Social Risks and Primary Care Utilization Among Medically Complex Veterans. J Gen Intern Med 2023; 38:3339-3347. [PMID: 37369890 PMCID: PMC10682359 DOI: 10.1007/s11606-023-08269-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Social risks contribute to poor health outcomes, especially for patients with complex medical needs. These same risks may impact access to primary care services. OBJECTIVE To study associations between social risks and primary care utilization among patients with medical complexity. DESIGN Prospective cohort study of respondents to a 2018 mailed survey, followed up to 2 years after survey completion. PARTICIPANTS Nationally representative sample of 10,000 primary care patients in the Veterans Affairs (VA) health care system, with high (≥ 75th percentile) 1-year risk of hospitalization or death. MAIN MEASURES Survey-based exposures were low social support, no family member/friend involved in health care, unemployment, transportation problem, food insecurity, medication insecurity, financial strain, low medical literacy, and less than high school graduate. Electronic health record-based outcomes were number of primary care provider (PCP) encounters, number of primary care team encounters (PCP, nurse, clinical pharmacist, and social worker), and having ≥ 1 social work encounter. KEY RESULTS Among 4680 respondents, mean age was 70.3, 93.7% were male, 71.8% White non-Hispanic, and 15.8% Black non-Hispanic. Unemployment was associated with fewer PCP and primary care team encounters (incident rate ratio 0.77, 95% CI 0.65-0.91; p = 0.002 and 0.75, 0.59-0.95; p = 0.02, respectively), and low medical literacy was associated with more primary care team encounters (1.17, 1.05-1.32; p = 0.006). Among those with one or more social risks, 18.4% had ≥ 1 social work encounter. Low medical literacy (OR 1.95, 95% CI 1.45-2.61; p < 0.001), transportation problem (1.42, 1.10-1.83; p = 0.007), and low social support (1.31, 1.06-1.63; p = 0.01) were associated with higher odds of ≥ 1 social work encounter. CONCLUSIONS We found few differences in PCP and primary care team utilization among medically complex VA patients by social risk. However, social work use was low, despite its central role in addressing social risks. More work is needed to understand barriers to social work utilization.
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Affiliation(s)
- Mayuree Rao
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.
- General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Karin Nelson
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Ferguson JM, Wray CM, Jacobs J, Greene L, Wagner TH, Odden MC, Freese J, Van Campen J, Asch SM, Heyworth L, Zulman DM. Variation in initial and continued use of primary, mental health, and specialty video care among Veterans. Health Serv Res 2023; 58:402-414. [PMID: 36345235 PMCID: PMC10012228 DOI: 10.1111/1475-6773.14098] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To identify which Veteran populations are routinely accessing video-based care. DATA SOURCES AND STUDY SETTING National, secondary administrative data from electronic health records at the Veterans Health Administration (VHA), 2019-2021. STUDY DESIGN This retrospective cohort analysis identified patient characteristics associated with the odds of using any video care; and then, among those with a previous video visit, the annual rate of video care utilization. Video care use was reported overall and stratified into care type (e.g., primary, mental health, and specialty video care) between March 10, 2020 and February 28, 2021. DATA COLLECTION Veterans active in VA health care (>1 outpatient visit between March 11, 2019 and March 10, 2020) were included in this study. PRINCIPAL FINDINGS Among 5,389,129 Veterans in this evaluation, approximately 27.4% of Veterans had at least one video visit. We found differences in video care utilization by type of video care: 14.7% of Veterans had at least one primary care video visit, 10.6% a mental health video visit, and 5.9% a specialty care video visit. Veterans with a history of housing instability had a higher overall rate of video care driven by their higher usage of video for mental health care compared with Veterans in stable housing. American Indian/Alaska Native Veterans had reduced odds of video visits, yet similar rates of video care when compared to White Veterans. Low-income Veterans had lower odds of using primary video care yet slightly elevated rates of primary video care among those with at least one video visit when compared to Veterans enrolled at VA without special considerations. CONCLUSIONS Variation in video care utilization patterns by type of care identified Veteran populations that might require greater resources and support to initiate and sustain video care use. Our data support service specific outreach to homeless and American Indian/Alaska Native Veterans.
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Affiliation(s)
- Jacqueline M. Ferguson
- Center for Innovation to ImplementationVeterans Affairs Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Charlie M. Wray
- Department of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
- Section of Hospital MedicineVeterans Affairs San Francisco Health Care SystemSan FranciscoCaliforniaUSA
| | - Josephine Jacobs
- Health Economics Resource CenterVeterans Affairs Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
| | - Liberty Greene
- Center for Innovation to ImplementationVeterans Affairs Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Todd H. Wagner
- Center for Innovation to ImplementationVeterans Affairs Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Health Economics Resource CenterVeterans Affairs Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
| | - Michelle C. Odden
- Geriatric Research, Education, and Clinical CenterVeterans Affairs Palo Alto Health Care SystemPalo AltoCaliforniaUSA
- Department of Epidemiology and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Jeremy Freese
- Department of SociologyStanford UniversityStanfordCaliforniaUSA
| | - James Van Campen
- Center for Innovation to ImplementationVeterans Affairs Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
| | - Steven M. Asch
- Center for Innovation to ImplementationVeterans Affairs Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Leonie Heyworth
- Office of Connected Care/TelehealthDepartment of Veterans Affairs Central OfficeWashingtonDCUSA
- Department of MedicineUniversity of California, San Diego School of MedicineSan DiegoCaliforniaUSA
| | - Donna M. Zulman
- Center for Innovation to ImplementationVeterans Affairs Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
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Greene L, Maciejewski ML, Grubber J, Smith VA, Blalock DV, Zulman DM. Association between patient-reported social, behavioral, and health factors and emergency department visits in high-risk VA patients. Health Serv Res 2023; 58:383-391. [PMID: 36310448 PMCID: PMC10012238 DOI: 10.1111/1475-6773.14094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
RESEARCH OBJECTIVE To identify patient-reported social risk, behavioral, and health factors associated with emergency department (ED) utilization in high-risk Veterans Affairs (VA) patients. DATA SOURCES Patient survey, VA, Medicare data. STUDY DESIGN Prospective cohort study using multivariable logistic regression to identify patient-reported factors associated with all-cause and ambulatory care sensitive condition (ACSC)-related ED visits among VA patients at high risk for hospitalization or death. DATA EXTRACTION METHODS Patient-reported measures derived from a 2018 survey sent to 10,000 VA patients; clinical and demographic characteristics derived from VA data; ED visits derived from VA and Medicare claims. PRINCIPAL FINDINGS Among 4680 survey respondents, 52.5% and 16.3% experienced an all-cause or ACSC-related ED visit in the following year, respectively. An ED visit was more likely among individuals with functional status limitations (6.0% points (Confidence Interval [CI] 0.017-0.103)) and transportation barriers (5.2% points [CI 0.005-0.099]). An ACSC-related ED visit was more likely among individuals with functional status limitations (3.2% points [CI 0.003-0.062]) and self-rated poorer health (7.4% points (CI 0.030-0.119) poor; 6.2% points (CI 0.029-0.096) fair; 4.1% points (CI 0.009-0.073) good; compared with excellent/very good). CONCLUSIONS Patient-reported factors not present in most electronic health records were significantly associated with future ED visits in high-risk VA patients.
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Affiliation(s)
- Liberty Greene
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
| | - Matthew L. Maciejewski
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Janet Grubber
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Valerie A. Smith
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
- Durham VA Medical CenterDurhamNorth CarolinaUSA
| | - Dan V. Blalock
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham Veterans Affairs Health Care SystemDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
- Durham VA Medical CenterDurhamNorth CarolinaUSA
| | - Donna M. Zulman
- Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCaliforniaUSA
- Division of Primary Care and Population HealthStanford University School of MedicineStanfordCaliforniaUSA
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Cohen-Mekelburg S, Greene L, Berinstein J, Waljee AK, Hofer TP, Saini SD, Zulman DM. Distinct health care use patterns of patients with chronic gastrointestinal diseases. Am J Manag Care 2023; 29:e71-e78. [PMID: 36947019 DOI: 10.37765/ajmc.2023.89332] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
OBJECTIVES Patients with complex chronic conditions have varying multidisciplinary care needs and utilization patterns, which limit the effectiveness of initiatives designed to improve continuity of care (COC) and reduce utilization. Our objective was to categorize patients with complex chronic conditions into distinct groups by pattern of outpatient care use and COC to tailor interventions. STUDY DESIGN Observational cohort study from 2014 to 2015. METHODS We identified patients whose 1-year hospitalization risk was in at least the 90th percentile in 2014 who had a chronic gastrointestinal disease (cirrhosis, inflammatory bowel disease, chronic pancreatitis) as case examples of complex chronic disease. We described frequency of office visits, number of outpatient providers, and 2 COC measures (usual provider of care, Bice-Boxerman COC indices) over 12 months. We used latent profile analysis, a statistical method for identifying distinct subgroups, to categorize patients based on overall, primary care, gastroenterology, and mental health continuity patterns. RESULTS The 26,751 veterans in the cohort had a mean (SD) of 13.3 (8.6) office visits and 7.2 (3.8) providers in 2014. Patients were classified into 5 subgroups: (1) high gastroenterology-specific COC with mental health use; (2) high gastroenterology-specific COC without mental health use; (3) high overall utilization with mental health use; (4) low overall COC with mental health use; and (5) low overall COC without mental health use. These groups varied in their sociodemographic characteristics and risk for hospitalization, emergency department use, and mortality. CONCLUSIONS Patients at high risk for health care utilization with specialty care needs can be grouped by varying propensity for health care continuity patterns.
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Trivedi RB, Rossi FS, Javier SJ, Greene L, Singer SJ, Vanneman ME, Goldstein M, Zulman DM. Association Between Mental Health Conditions and Outpatient Care Fragmentation: a National Study of Older High-Risk Veterans. J Gen Intern Med 2022; 37:4071-4079. [PMID: 35869316 PMCID: PMC9708986 DOI: 10.1007/s11606-022-07705-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 06/16/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Healthcare fragmentation may lead to adverse consequences and may be amplified among older, sicker patients with mental health (MH) conditions. OBJECTIVE To determine whether older Veterans with MH conditions have more fragmented outpatient non-MH care, compared with older Veterans with no MH conditions. DESIGN Retrospective cohort study using FY2014 Veterans Health Administration (VHA) administrative data linked to Medicare data. PARTICIPANTS 125,481 VHA patients ≥ 65 years old who were continuously enrolled in Medicare Fee-for-Service Parts A and B and were at high risk for hospitalization. MAIN OUTCOME AND MEASURES The main outcome was non-MH care fragmentation as measured by (1) non-MH provider count and (2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen non-MH provider. We tested the association between no vs. any MH conditions and outcomes using Poisson regression and fractional regression with logit link, respectively. We also compared Veterans with no MH condition with each MH condition and combinations of MH conditions, adjusting for sociodemographics, comorbidities, and drive-time to VHA specialty care. KEY RESULTS In total, 47.3% had at least one MH condition. Compared to those without MH conditions, Veterans with MH conditions had less fragmented care, with fewer non-MH providers (IRR = 0.96; 95% CI: 0.96-0.96) and more concentrated care with their usual provider (OR = 1.08 for a higher UPC; 95% CI: 1.07, 1.09) in adjusted models. Secondary analyses showed that those with individual MH conditions (e.g., depression) had fewer non-MH providers (IRR range: 0.86-0.98) and more concentrated care (OR range: 1.04-1.20). A similar pattern was observed when examining combinations of MH conditions (IRR range: 0.80-0.90; OR range: 1.16-1.30). CONCLUSIONS Contrary to expectations, having a MH condition was associated with less fragmented non-MH care among older, high-risk Veterans. Further research will determine if this is due to different needs, underuse, or appropriate use of healthcare.
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Affiliation(s)
- Ranak B Trivedi
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA.
- Division of Public Mental Health and Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA.
| | - Fernanda S Rossi
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah J Javier
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
| | - Liberty Greene
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sara J Singer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mary Goldstein
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
- Office of Geriatrics and Extended Care, Department of Veterans Affairs, Washington, DC, USA
| | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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10
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Tisdale RL, Ferguson J, Van Campen J, Greene L, Sandhu AT, Heidenreich PA, Zulman DM. Disparities in virtual cardiology visits among Veterans Health Administration patients during the COVID-19 pandemic. JAMIA Open 2022; 5:ooac103. [PMID: 36531138 PMCID: PMC9754629 DOI: 10.1093/jamiaopen/ooac103] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 10/06/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
Objective In response to the coronavirus disease 2019 (COVID-19) pandemic, the Veterans Health Administration (VA) rapidly expanded virtual care (defined as care delivered by video and phone), raising concerns about technology access disparities (ie, the digital divide). Virtual care was somewhat established in primary care and mental health care prepandemic, but video telehealth implementation was new for most subspecialties, including cardiology. We sought to identify patient characteristics of virtual and video-based care users in VA cardiology clinics nationally during the first year of the COVID-19 pandemic. Materials and Methods Cohort study of Veteran patients across all VA facilities with a cardiology visit January 1, 2019-March 10, 2020, with follow-up January 1, 2019-March 10, 2021. Main measures included cardiology visits by visit type and likelihood of receiving cardiology-related virtual care, calculated with a repeated event survival model. Results 416 587 Veterans with 1 689 595 total cardiology visits were analyzed; average patient age was 69.6 years and 4.3% were female. Virtual cardiology care expanded dramatically early in the COVID-19 pandemic from 5% to 70% of encounters. Older, lower-income, and rural-dwelling Veterans and those experiencing homelessness were less likely to use video care (adjusted hazard ratio for ages 75 and older 0.80, 95% confidence interval (CI) 0.75-0.86; for highly rural residents 0.77, 95% CI 0.68-0.87; for low-income status 0.94, 95% CI 0.89-0.98; for homeless Veterans 0.85, 95% CI 0.80-0.92). Conclusion The pandemic worsened the digital divide for cardiology care for many vulnerable patients to the extent that video visits represent added value over phone visits. Targeted interventions may be necessary for equity in COVID-19-era access to virtual cardiology care.
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Affiliation(s)
- Rebecca L Tisdale
- Health Services Research and Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Department of Health Policy, Stanford University School of Medicine, Stanford, CA, USA
| | - Jacqueline Ferguson
- Health Services Research and Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - James Van Campen
- Health Services Research and Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Liberty Greene
- Health Services Research and Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Department of Medicine, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Donna M Zulman
- Health Services Research and Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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11
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Greene L, Barker LA, Reidy J, Morton N, Atherton A. Emotion recognition and eye tracking of static and dynamic facial affect: Acomparison of individuals with and without traumatic brain injury. J Clin Exp Neuropsychol 2022; 44:461-477. [PMID: 36205649 DOI: 10.1080/13803395.2022.2128066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2022]
Abstract
Diminished social functioning is often seen after traumatic brain injury (TBI). Mechanisms contributing to these deficits are poorly understood but thought to relate to impaired ability to recognize facial expressions. Static stimuli are often used to investigate ability post-TBI, and there is less evidence using more real-life dynamic stimuli. In addition, most studies rely on behavioral responses alone. The present study investigated the performance of a TBI group and matched non-TBI group on static and dynamic tasks using eye-tracking technology alongside behavioral measures. This is the first study to use eye tracking methodology alongside behavioral measures in emotion recognition tasks in people with brain injury. Eighteen individuals with heterogeneous TBI and 18 matched non-TBI participants were recruited. Stimuli representing six core emotions (Anger, Disgust, Fear, Happy, Sad, and Surprise faces) were selected from the Amsterdam Dynamic Facial Expression Set (ADFES). Participants were instructed to identify the emotion displayed correctly whilst eye movement metrics were recorded. RESULTS Results of analyses showed that TBI patients had First Fixation to nose for all emotion stimuli, shorter Fixation Duration and lower Fixation Count to eyes, were generally slower to classify stimuli, and less accurate than non-TBI group for the static task. Those with TBI were also less accurate at identifying Angry, Disgust, and Fear stimulus faces compared to the non-TBI group during the dynamic unfolding of an emotion. CONCLUSION In the present study, those with TBI had atypical eye scan patterns during emotion identification in the static emotion recognition task compared to the non-TBI group and were associated with lower identification accuracy on behavioral measures in both static and dynamic tasks. Findings suggest potential disruption to oculomotor systems vital for first stage perceptual processing. Arguably, these impairments may contribute to diminished social functioning.
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Affiliation(s)
- L Greene
- Centre for Behavioural Science and Applied Psychology, Department of Psychology,Sociology & Politics, Sheffield Hallam University, Sheffield, UK
| | - L A Barker
- Centre for Behavioural Science and Applied Psychology, Department of Psychology,Sociology & Politics, Sheffield Hallam University, Sheffield, UK
| | - J Reidy
- Centre for Behavioural Science and Applied Psychology, Department of Psychology,Sociology & Politics, Sheffield Hallam University, Sheffield, UK
| | - N Morton
- Neuro Rehabilitation Outreach Team, Rotherham, Doncaster and South Humber NHS Trust, Doncaster, UK
| | - A Atherton
- Atherton Neuropsychological Consultancy Ltd, Yorkshire, UK
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12
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Edwards ST, Greene L, Chaudhary C, Boothroyd D, Kinosian B, Zulman DM. Outpatient Care Fragmentation and Acute Care Utilization in Veterans Affairs Home-Based Primary Care. JAMA Netw Open 2022; 5:e2230036. [PMID: 36066895 PMCID: PMC9449785 DOI: 10.1001/jamanetworkopen.2022.30036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/19/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Veterans Affairs (VA) Home-Based Primary Care (HBPC) provides comprehensive, interdisciplinary primary care at home to patients with complex, chronic, disabling disease, but little is known about care fragmentation patterns and consequences among these patients. Objective To examine outpatient care fragmentation patterns and subsequent acute care among HBPC-engaged patients at high risk of hospitalization or death. Design, Setting, and Participants This retrospective cohort study included VA patients aged at least 65 years who were enrolled in the VA and Medicare, whose risk of hospitalization or death was in the top 10%, and who had at least 4 outpatient visits between October 1, 2013, and September 30, 2014. HBPC engagement was defined as having at least 2 HBPC encounters between July 1, 2014, and September 30, 2014. Data were analyzed from March 2020 to March 2022. Exposures Two indices of outpatient care fragmentation: practitioner count and the Usual Provider Continuity Index (UPC), based on VA and non-VA health care use from October 1, 2013, to September 30, 2014. All care delivered by HBPC clinicians was analyzed as coming from a single practitioner. Main Outcomes and Measures Emergency department (ED) visits and hospitalizations for ambulatory care sensitive conditions (ACSC) from VA records and Medicare claims from October 1, 2014, to September 30, 2015. Results Among 8908 identified HBPC patients, 8606 (96.6%) were male, 1562 (17.5%) were Black, 249 (2.8%) were Hispanic, 6499 (73.0%) were White, 157 (1.8%) were other race or ethnicity, and 441 (5.0%) had unknown race or ethnicity; the mean (SD) age was 80.0 (9.02) years; patients had a mean (SD) of 11.25 (3.87) chronic conditions, and commonly had disabling conditions such as dementia (38.8% [n = 3457]). In adjusted models, a greater number of practitioners was associated with increased odds of an ED visit (adjusted odds ratio [aOR], 1.05 [95% CI, 1.03-1.07]) and hospitalization for an ACSC (aOR, 1.04 [95% CI, 1.02-1.06]), whereas more concentrated care with a higher UPC was associated with reduced odds of these outcomes (highest vs lowest tertile of UPC: aOR for ED visit, 0.77 [95% CI, 0.67-0.88], aOR for ACSC hospitalization, 0.78 [95% CI, 0.68-0.88]). Conclusions and Relevance Among patients in HBPC, fragmented care was associated with more ED visits and ACSC hospitalizations. These findings suggest that consolidating or coordinating fragmented care may be a target for reducing preventable acute care.
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Affiliation(s)
- Samuel T. Edwards
- Section of General Internal Medicine, VA Portland Health Care System, Portland, Oregon
- General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Camila Chaudhary
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Derek Boothroyd
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Bruce Kinosian
- Geriatrics Extended Care Data Analysis Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Perelman School of Medicine, Division of Geriatrics, University of Pennsylvania, Philadelphia
| | - Donna M. Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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13
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Vanneman ME, Yoon J, Singer SJ, Wagner TH, Goldstein MK, Hu J, Boothroyd D, Greene L, Zulman DM. Anticipating VA/non-VA care coordination demand for Veterans at high risk for hospitalization. Medicine (Baltimore) 2022; 101:e28864. [PMID: 35363189 PMCID: PMC9281999 DOI: 10.1097/md.0000000000028864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/31/2022] [Indexed: 01/09/2023] Open
Abstract
U.S. Veterans Affairs (VA) patients' multi-system use can create challenges for VA clinicians who are responsible for coordinating Veterans' use of non-VA care, including VA-purchased care ("Community Care") and Medicare.To examine the relationship between drive distance and time-key eligibility criteria for Community Care-and VA reliance (proportion of care received in VA versus Medicare and Community Care) among Veterans at high risk for hospitalization. We used prepolicy data to anticipate the impact of the 2014 Choice Act and 2018 Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act), which expanded access to Community Care.Cross-sectional analysis using fractional logistic regressions to examine the relationship between a Veteran's reliance on VA for outpatient primary, mental health, and other specialty care and their drive distance/time to a VA facility.Thirteen thousand seven hundred three Veterans over the age of 65 years enrolled in VA and fee-for-service Medicare in federal fiscal year 2014 who were in the top 10th percentile for hospitalization risk.Key explanatory variables were patients' drive distance to VA > 40 miles (Choice Act criteria) and drive time to VA ≥ 30 minutes for primary and mental health care and ≥60 minutes for specialty care (MISSION Act criteria).Veterans at high risk for hospitalization with drive distance eligibility had increased odds of an outpatient specialty care visit taking place in VA when compared to Veterans who did not meet Choice Act eligibility criteria (odds ratio = 1.10, 95% confidence interval 1.05-1.15). However, drive time eligibility (MISSION Act criteria) was associated with significantly lower odds of an outpatient specialty care visit taking place in VA (odds ratio = 0.69, 95% confidence interval 0.67, 0.71). Neither drive distance nor drive time were associated with reliance for outpatient primary care or mental health care.VA patients who are at high risk for hospitalization may continue to rely on VA for outpatient primary care and mental health care despite access to outside services, but may increase use of outpatient specialty care in the community in the MISSION era, increasing demand for multi-system care coordination.
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Affiliation(s)
- Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
| | - Jean Yoon
- Health Economics Resource Center, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA
- Department of General Internal Medicine, UCSF School of Medicine, 4150 Clement St., 111A, San Francisco, CA
| | - Sara J. Singer
- VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA
- Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, Medical School Office Building, Room 328, Stanford, CA
- Stanford Graduate School of Business, 655 Knight Way, Stanford, CA
| | - Todd H. Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA
- Department of Surgery, Stanford University School of Medicine, 1070 Arastradero Road, Stanford, CA
| | - Mary K. Goldstein
- Data Analytics, Quality Improvement, and Research, Office of Geriatrics and Extended Care, Veterans Health Administration, Department of Veterans Affairs, VA Palo Alto Health Care System, 3801 Miranda Avenue (GRECC 182B), Palo Alto, CA
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, 117 Encina Commons, Stanford, CA
| | - Jiaqi Hu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD
| | - Derek Boothroyd
- Quantitative Sciences Unit, Stanford University School of Medicine, 1701 Page Mill Road, Palo Alto, CA
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA
| | - Donna M. Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA
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14
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Zulman DM, Greene L, Slightam C, Singer SJ, Maciejewski ML, Goldstein MK, Vanneman ME, Yoon J, Trivedi RB, Wagner T, Asch SM, Boothroyd D. Outpatient care fragmentation in Veterans Affairs patients at high-risk for hospitalization. Health Serv Res 2022; 57:764-774. [PMID: 35178702 PMCID: PMC9264453 DOI: 10.1111/1475-6773.13956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine outpatient care fragmentation and its association with future hospitalization among patients at high risk for hospitalization. DATA SOURCES Veterans Affairs (VA) and Medicare data. STUDY DESIGN We conducted a longitudinal study, using logistic regression to examine how outpatient care fragmentation in FY14 (as measured by number of unique providers, Breslau's Usual Provider of Care (UPC), Bice-Boxerman's Continuity of Care Index (COCI), and Modified Modified Continuity Index (MMCI)) was associated with all-cause hospitalizations and hospitalizations related to ambulatory care sensitive conditions (ACSC) in FY15. We also examined how fragmentation varied by patient's age, gender, race, ethnicity, marital status, rural status, history of homelessness, number of chronic conditions, Medicare utilization, and mental healthcare utilization. DATA EXTRACTION METHODS We extracted data for 130,704 VA patients ≥65 years old with a hospitalization risk ≥90th percentile and ≥ four outpatient visits in the baseline year. PRINCIPAL FINDINGS Mean (standard deviation) of FY14 outpatient visits was 13.2 (8.6). Fragmented care (more providers, less care with a usual provider, more dispersed care based on COCI) was more common among patients with more chronic conditions and those receiving mental health care. In adjusted models, most fragmentation measures were not associated with all-cause hospitalization, and patients with low levels of fragmentation (more concentrated care based on UPC, COCI, and MMCI) had a higher likelihood of an ACSC-related hospitalization (AOR, 95% CI = 1.21 (1.09-1.35), 1.27 (1.14-1.42), and 1.28 (1.18-1.40), respectively). CONCLUSIONS Contrary to expectations, outpatient care fragmentation was not associated with elevated all-cause hospitalization rates among VA patients in the top 10th percentile for risk of admission; in fact, fragmented care was linked to lower rates of hospitalization for ACSCs. In integrated settings such as the VA, multiple providers and dispersed care might offer access to timely or specialized care that offsets risks of fragmentation, particularly for conditions that are sensitive to ambulatory care.
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Affiliation(s)
- Donna M Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Cindie Slightam
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States
| | - Sara J Singer
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, North Carolina, United States.,Department of Population Health Sciences, Duke University, Durham, North Carolina, United States
| | - Mary K Goldstein
- Office of Geriatrics and Extended Care, Veterans Health Administration.,Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California, United States
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, United States.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States.,Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Jean Yoon
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of General Internal Medicine, UCSF School of Medicine, San Francisco, California, United States
| | - Ranak B Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Division of Public Mental Health and Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, United States
| | - Todd Wagner
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of Surgery, Stanford University School of Medicine, Palo Alto, California, United States
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Derek Boothroyd
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, United States.,Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, California, United States
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15
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Jacobs JC, Maciejeweski ML, Wagner TH, Van Houtven CH, Lo J, Greene L, Zulman DM. Improving Prediction of Long-Term Care Utilization Through Patient-Reported Measures: Cross-Sectional Analysis of High-Need U.S. Veterans Affairs Patients. Med Care Res Rev 2021; 79:676-686. [PMID: 34906010 DOI: 10.1177/10775587211062403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article examines the relative merit of augmenting an electronic health record (EHR)-derived predictive model of institutional long-term care (LTC) use with patient-reported measures not commonly found in EHRs. We used survey and administrative data from 3,478 high-risk Veterans aged ≥65 in the U.S. Department of Veterans Affairs, comparing a model based on a Veterans Health Administration (VA) geriatrics dashboard, a model with additional EHR-derived variables, and a model that added survey-based measures (i.e., activities of daily living [ADL] limitations, social support, and finances). Model performance was assessed via Akaike information criteria, C-statistics, sensitivity, and specificity. Age, a dementia diagnosis, Nosos risk score, social support, and ADL limitations were consistent predictors of institutional LTC use. Survey-based variables significantly improved model performance. Although demographic and clinical characteristics found in many EHRs are predictive of institutional LTC, patient-reported function and partnership status improve identification of patients who may benefit from home- and community-based services.
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Affiliation(s)
- Josephine C Jacobs
- VA Palo Alto Health Care System, Menlo Park, CA, USA.,Stanford University School of Medicine, Stanford, CA, USA
| | | | - Todd H Wagner
- VA Palo Alto Health Care System, Menlo Park, CA, USA.,Stanford University School of Medicine, Stanford, CA, USA
| | | | - Jeanie Lo
- VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Liberty Greene
- VA Palo Alto Health Care System, Menlo Park, CA, USA.,Stanford University School of Medicine, Stanford, CA, USA
| | - Donna M Zulman
- VA Palo Alto Health Care System, Menlo Park, CA, USA.,Stanford University School of Medicine, Stanford, CA, USA
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16
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Rosenfeld M, Ong T, Carlin K, McNamara S, Gorry S, Kanter A, Gibson R, Cassidy J, Greene L, Choi M, Reonal R, Culley L, Thompson J. 68: Improving timeliness of CF diagnosis following a positive CF newborn screen in Washington State. J Cyst Fibros 2021. [DOI: 10.1016/s1569-1993(21)01493-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Cassidy J, McNamara S, Gorry S, Hughes R, Vajda J, Hill L, Akers M, Greene L, Ong T. 144: Quality improvement process to improve home spirometer use in a pediatric CF care center. J Cyst Fibros 2021. [DOI: 10.1016/s1569-1993(21)01569-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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18
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Blalock DV, Grubber J, Smith VA, Zulman DM, Weidenbacher HJ, Greene L, Dedert EA, Maciejewski ML. The association of alcohol use with all-cause and cardiovascular disease-related hospitalizations or death in older, high-risk Veterans. Alcohol Clin Exp Res 2021; 45:1215-1224. [PMID: 33844300 DOI: 10.1111/acer.14610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The prevalence of alcohol misuse among older adults has grown dramatically in the past decade, yet little is known about the association of alcohol misuse with hospitalization and death in this patient population. METHODS We examined the association between alcohol use (measured by a screening instrument in primary care) and rates of all-cause and cardiovascular disease (CVD)-related 6-month hospitalization or death via electronic health records (EHRs) in a nationally representative sample of older, high-risk Veterans. Models were adjusted for sociodemographic and clinical characteristics, including frailty and comorbid conditions. RESULTS The all-cause hospitalization or death rate at 6 months was 14.9%, and the CVD-related hospitalization or death rate was 1.8%. In adjusted analyses, all-cause hospitalization or death was higher in older Veterans who were nondrinkers or harmful use drinkers compared to moderate use drinkers, but CVD-related hospitalization or death was similar in all categories of drinking. CONCLUSIONS These findings suggest that the complex association between alcohol and all-cause acute healthcare utilization found in the broader population is similar in older, high-risk Veteran patients. These findings do not support an association between alcohol consumption and CVD-specific hospitalizations.
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Affiliation(s)
- Dan V Blalock
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Janet Grubber
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Valerie A Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Hollis J Weidenbacher
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Eric A Dedert
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA.,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Population Health Sciences, Duke University, Durham, NC, USA.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
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19
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Blalock DV, Maciejewski ML, Zulman DM, Smith VA, Grubber J, Rosland AM, Weidenbacher HJ, Greene L, Zullig LL, Whitson HE, Hastings SN, Hung A. Subgroups of High-Risk Veterans Affairs Patients Based on Social Determinants of Health Predict Risk of Future Hospitalization. Med Care 2021; 59:410-417. [PMID: 33821830 PMCID: PMC8034377 DOI: 10.1097/mlr.0000000000001526] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Population segmentation has been recognized as a foundational step to help tailor interventions. Prior studies have predominantly identified subgroups based on diagnoses. In this study, we identify clinically coherent subgroups using social determinants of health (SDH) measures collected from Veterans at high risk of hospitalization or death. STUDY DESIGN AND SETTING SDH measures were obtained for 4684 Veterans at high risk of hospitalization through mail survey. Eleven self-report measures known to impact hospitalization and amenable to intervention were chosen a priori by the study team to identify subgroups through latent class analysis. Associations between subgroups and demographic and comorbidity characteristics were calculated through multinomial logistic regression. Odds of 180-day hospitalization were compared across subgroups through logistic regression. RESULTS Five subgroups of high-risk patients emerged-those with: minimal SDH vulnerabilities (8% hospitalized), poor/fair health with few SDH vulnerabilities (12% hospitalized), social isolation (10% hospitalized), multiple SDH vulnerabilities (12% hospitalized), and multiple SDH vulnerabilities without food or medication insecurity (10% hospitalized). In logistic regression, the "multiple SDH vulnerabilities" subgroup had greater odds of 180-day hospitalization than did the "minimal SDH vulnerabilities" reference subgroup (odds ratio: 1.53, 95% confidence interval: 1.09-2.14). CONCLUSION Self-reported SDH measures can identify meaningful subgroups that may be used to offer tailored interventions to reduce their risk of hospitalization and other adverse events.
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Affiliation(s)
- Dan V. Blalock
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC
| | - Matthew L. Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Donna M. Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford CA
| | - Valerie A. Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Janet Grubber
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | - Ann-Marie Rosland
- VA Pittsburgh Center for Health Equity Research and Promotion, Pittsburgh PA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Hollis J. Weidenbacher
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford CA
| | - Leah L. Zullig
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
| | - Heather E. Whitson
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC
- Center for the Study of Human Aging and Development, Duke University, Durham, NC
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Susan N. Hastings
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC
- Center for the Study of Human Aging and Development, Duke University, Durham, NC
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Anna Hung
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham NC
- Duke Clinical Research Institute, Duke University, Durham, NC
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20
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Jacobs J, Ferguson JM, Van Campen J, Yefimova M, Greene L, Heyworth L, Zulman DM. Organizational and External Factors Associated with Video Telehealth Use in the Veterans Health Administration Before and During the COVID-19 Pandemic. Telemed J E Health 2021; 28:199-211. [PMID: 33887166 DOI: 10.1089/tmj.2020.0530] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives: To identify organizational and external factors associated with medical center video telehealth uptake (i.e., the proportion of patients using telemedicine) before and early in the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: We conducted a retrospective, observational study using cross-sectional data for all 139 U.S. Veterans Affairs Medical Centers (VAMCs). We used logistic regression analyses to identify factors that predicted whether a VAMC was in the top quartile of VA Video Connect (VVC) telehealth uptake for primary care and mental health care. Results: All 139 VAMCs increased their VVC uptake at least 2-fold early in the pandemic, with most increasing uptake between 5- and 10-fold. Pre-COVID-19, higher VVC uptake in primary care was weakly and positively associated with having more high-risk patients, negatively associated with having more long-distance patients, and positively associated with the prior fiscal year's VVC uptake. During COVID-19, the positive association with high-risk patients and the negative association with long-distance patients strengthened, while weaker broadband coverage was negatively associated with VVC uptake. For mental health care, having more long-distance patients was positively associated with higher VVC uptake pre-COVID-19, but this relationship reversed during COVID-19. Discussion: Despite the marked increase in VVC uptake early in the COVID-19 pandemic, significant VAMC-level variation indicates that VVC adoption was more difficult for some medical centers, particularly those with poorer broadband coverage and less prior VVC experience. Conclusions and Relevance: These findings highlight opportunities for medical centers, VA Central Office, and other federal entities to ensure equitable access to video telehealth.
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Affiliation(s)
- Josephine Jacobs
- Health Economics Resource Center, and Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Divisions of Primary Care and Outcomes Research and Stanford University School of Medicine, Stanford, California, USA
| | - Jacqueline M Ferguson
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Divisions of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - James Van Campen
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Divisions of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Maria Yefimova
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Divisions of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.,Office of Research Patient Care Services, Stanford Health Care, Stanford, California, USA
| | - Liberty Greene
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Divisions of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Leonie Heyworth
- Office of Connected Care/Telehealth, Department of Veterans Affairs Central Office, Washington, District of Columbia, USA.,Department of Medicine, University of California, San Diego School of Medicine, San Diego, California, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Divisions of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
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21
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Ferguson JM, Jacobs J, Yefimova M, Greene L, Heyworth L, Zulman DM. Virtual care expansion in the Veterans Health Administration during the COVID-19 pandemic: clinical services and patient characteristics associated with utilization. J Am Med Inform Assoc 2021; 28:453-462. [PMID: 33125032 PMCID: PMC7665538 DOI: 10.1093/jamia/ocaa284] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/16/2020] [Accepted: 10/26/2020] [Indexed: 11/14/2022] Open
Abstract
Objectives To describe the shift from in-person to virtual care within Veterans Affairs (VA) during the early phase of the COVID-19 pandemic and to identify at-risk patient populations who require greater resources to overcome access barriers to virtual care. Materials and Methods Outpatient encounters (N = 42 916 349) were categorized by care type (eg, primary, mental health, etc) and delivery method (eg, in-person, video). For 5 400 878 Veterans, we used generalized linear models to identify patient sociodemographic and clinical characteristics associated with: 1) use of virtual (phone or video) care versus no virtual care and 2) use of video care versus no video care between March 11, 2020 and June 6, 2020. Results By June, 58% of VA care was provided virtually compared to only 14% prior. Patients with lower income, higher disability, and more chronic conditions were more likely to receive virtual care during the pandemic. Yet, Veterans aged 45–64 and 65+ were less likely to use video care compared to those aged 18–44 (aRR 0.80 [95% confidence interval (CI) 0.79, 0.82] and 0.50 [95% CI 0.48, 0.52], respectively). Rural and homeless Veterans were 12% and 11% less likely to use video care compared to urban (0.88 [95% CI 0.86, 0.90]) and nonhomeless Veterans (0.89 [95% CI 0.86, 0.92]). Discussion Veterans with high clinical or social need had higher likelihood of virtual service use early in the COVID-19 pandemic; however, older, homeless, and rural Veterans were less likely to have video visits, raising concerns for access barriers. Conclusions and Relevance While virtual care may expand access, access barriers must be addressed to avoid exacerbating disparities.
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Affiliation(s)
- Jacqueline M Ferguson
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Josephine Jacobs
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA
| | - Maria Yefimova
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.,Office of Research Patient Care Services, Stanford Health Care, Stanford, California, USA
| | - Liberty Greene
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Leonie Heyworth
- Department of Veterans Affairs Central Office, Office of Connected Care/Telehealth, Washington, DC, USA.,Department of Medicine, UC San Diego School of Medicine, San Diego, California, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA.,Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
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22
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Trivedi R, Rossi F, Javier S, Greene L, Singer S, Vanneman M, Goldstein M, Zulman D. Association Between Mental Health Conditions and Care Fragmentation: A National Study of High-Risk Older Veterans. Innov Aging 2020. [PMCID: PMC7740954 DOI: 10.1093/geroni/igaa057.1202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Fragmented healthcare causes information loss, duplicative tests, and unwieldy self-care regimens. These challenges may be amplified among older, high-risk patients with co-occurring mental health conditions (MHC). We compared healthcare fragmentation for chronic physical conditions among Veterans with and without MHC (depression, PTSD, schizophrenia, bipolar disorder, anxiety, personality disorder, or psychosis based on ICD-9 codes). Sample included Veterans who were □65y, at high risk for 1-year hospitalization, and had □4 non-MHC visits during FY14. Visits were covered by Veterans Affairs (VA), VA-purchased care (both from VA Corporate Data Warehouse), or Medicare Parts A/B (claims data from VA Information Resource Center). Outcomes were two fragmentation measures calculated in FY15: 1) non-mental health provider count, where a higher number indicates more fragmentation, and 2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen provider, where a higher number indicates less fragmentation. We used Poisson regression and GLM with binomial distribution and logit link to test the association between MHC status and fragmentation, controlling for sociodemographic characteristics (e.g., age), medical comorbidity, and driving distance to VA. Of the 125,481 Veterans included, 47.3% had 1+ MHC. Compared to older, high-risk Veterans without MHC, those with MHC saw fewer providers (pseudo R2 = 0.02) and had a higher UPC (more concentrated care; OR = 1.07). Within the VA, older, high-risk Veterans with MHC do not experience greater healthcare fragmentation. Further research is needed to determine if this is due to different needs, underuse, or appropriate use of healthcare across the groups.
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Affiliation(s)
- Ranak Trivedi
- VA Palo Alto/Stanford University, Menlo Park, California, United States
| | - Fernanda Rossi
- VA Palo Alto Health Care System, Menlo Park, California, United States
| | - Sarah Javier
- VA Palo Alto Health Care System, Menlo Park, California, United States
| | - Liberty Greene
- VA Palo Alto Healthcare System, Menlo Park, California, United States
| | - Sara Singer
- Stanford University, Stanford, California, United States
| | - Megan Vanneman
- University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Mary Goldstein
- Stanford University, Palo Alto, California, United States
| | - Donna Zulman
- VA Palo Alto Healthcare System, Menlo Park, California, United States
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23
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Yefimova M, Hu J, Slightam C, Greene L, Chaudhary C, Hayworth L, Zulman D. Use of Video-Enabled Tablet for Virtual Care Among Older Veterans. Innov Aging 2020. [PMCID: PMC7740424 DOI: 10.1093/geroni/igaa057.637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
With the proliferation of virtual care, healthcare systems are exploring ways to bridge the digital divide among vulnerable patients. Department of Veterans Affairs (VA) is distributing devices for qualifying Veterans to enable video visits with medical providers at home, yet their use among older patients is unknown. This retrospective cohort study used administrative data to characterize the use of VA-loaned iPads among older Veterans compared to younger Veterans and identify demographic predictors of utilization. Among 16,385 patients who were shipped a VA-loaned iPad in 2014-2019, 33.66% (n=5,516) were over 65 years old, and 3.1% (n=503) were over the age of 85. Two thirds (n=6799) of younger patients had a video visit (mean=3 visits) with provider using iPad in the 6 months since shipment, compared to 50% (n=253) of 85+ year-olds (mean=1.8 visits). Most common types of virtual visits for the oldest old patients were for geriatrics or home-based primary care, compared to mental health visits among younger patients. Logistic regression identified characteristics of older patients who were more likely to use iPads, such a marital status, urban location, and lower disease burden, which is similar to their younger counterparts. While older age groups used VA-loaned tablets less frequently, those who engaged with the devices were similar in demographics as their younger counterparts. Older patients used iPads differently, with higher engagement in geriatric and primary care services. Providing devices for virtual care may allow health systems to more easily reach older patients in the comfort of their home.
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Affiliation(s)
- Maria Yefimova
- VA Palo Alto Healthcare System, Redwood City, California, United States
| | - Jiaqi Hu
- VA Palo Alto Healthcare System, Palo Alto, California, United States
| | - Cindie Slightam
- VA Palo Alto Healthcare System, Palo Alto, California, United States
| | - Liberty Greene
- VA Palo Alto Healthcare System, Menlo Park, California, United States
| | - Camila Chaudhary
- VA Palo Alto Healthcare System, Menlo Park, California, United States
| | - Leonie Hayworth
- Veterans Health Administration, Palo Alto, California, United States
| | - Donna Zulman
- VA Palo Alto Healthcare System, Menlo Park, California, United States
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24
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Zulman DM, Maciejewski ML, Grubber JM, Weidenbacher HJ, Blalock DV, Zullig LL, Greene L, Whitson HE, Hastings SN, Smith VA. Patient-Reported Social and Behavioral Determinants of Health and Estimated Risk of Hospitalization in High-Risk Veterans Affairs Patients. JAMA Netw Open 2020; 3:e2021457. [PMID: 33079198 PMCID: PMC7576406 DOI: 10.1001/jamanetworkopen.2020.21457] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE Despite recognition of the association between individual social and behavioral determinants of health (SDH) and patient outcomes, little is known regarding the value of SDH in explaining variation in outcomes for high-risk patients. OBJECTIVE To describe SDH factors among veterans who are at high risk for hospitalization, and to determine whether adding patient-reported SDH measures to electronic health record (EHR) measures improves estimation of 90-day and 180-day all-cause hospital admission. DESIGN, SETTING, AND PARTICIPANTS A survey was mailed between April 16 and June 29, 2018, to a nationally representative sample of 10 000 Veterans Affairs (VA) patients whose 1-year risk of hospitalization or death was in the 75th percentile or higher based on a VA EHR-derived risk score. The survey included multiple SDH measures, such as resilience, social support, health literacy, smoking status, transportation barriers, and recent life stressors. MAIN OUTCOMES AND MEASURES The EHR-based characteristics of survey respondents and nonrespondents were compared using standardized differences. Estimation of 90-day and 180-day hospital admission risk was assessed for 3 logistic regression models: (1) a base model of all prespecified EHR-based covariates, (2) a restricted model of EHR-based covariates chosen via forward selection based on minimizing Akaike information criterion (AIC), and (3) a model of EHR- and survey-based covariates chosen via forward selection based on AIC minimization. RESULTS In total, 4685 individuals (response rate 46.9%) responded to the survey. Respondents were comparable to nonrespondents in most characteristics, but survey respondents were older (eg, >80 years old, 881 [18.8%] vs 800 [15.1%]), comprised a higher percentage of men (4391 [93.7%] vs 4794 [90.2%]), and were composed of more White non-Hispanic individuals (3366 [71.8%] vs 3259 [61.3%]). Based on AIC, the regression model with survey-based covariates and EHR-based covariates better estimated hospital admission at 90 days (AIC, 1947.7) and 180 days (AIC, 2951.9) than restricted models with only EHR-based covariates (AIC, 1980.2 at 90 days; AIC, 2981.9 at 180 days). This result was due to inclusion of self-reported measures such as marital or partner status, health-related locus of control, resilience, smoking status, health literacy, and medication insecurity. CONCLUSIONS AND RELEVANCE Augmenting EHR data with patient-reported social information improved estimation of 90-day and 180-day hospitalization risk, highlighting specific SDH factors that might identify individuals who are at high risk for hospitalization.
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Affiliation(s)
- Donna M. Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Matthew L. Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
| | - Janet M. Grubber
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Hollis J. Weidenbacher
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Dan V. Blalock
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Leah L. Zullig
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Heather E. Whitson
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Center for the Study of Human Aging and Development, Duke University, Durham, North Carolina
| | - Susan N. Hastings
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Center for the Study of Human Aging and Development, Duke University, Durham, North Carolina
| | - Valerie A. Smith
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
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25
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Vashi AA, Urech T, Carr B, Greene L, Warsavage T, Hsia R, Asch SM. Identification of Emergency Care-Sensitive Conditions and Characteristics of Emergency Department Utilization. JAMA Netw Open 2019; 2:e198642. [PMID: 31390036 PMCID: PMC6686774 DOI: 10.1001/jamanetworkopen.2019.8642] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
IMPORTANCE Monitoring emergency care quality requires understanding which conditions benefit most from timely, quality emergency care. OBJECTIVES To identify a set of emergency care-sensitive conditions (ECSCs) that are treated in most emergency departments (EDs), are associated with a spectrum of adult age groups, and represent common reasons for seeking emergency care and to provide benchmark national estimates of ECSC acute care utilization. DESIGN, SETTING, AND PARTICIPANTS A modified Delphi method was used to identify ECSCs. In a cross-sectional analysis, ECSC-associated visits by adults (aged ≥18 years) were identified based on International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes and analyzed with nationally representative data from the 2016 US Nationwide Emergency Department Sample. Data analysis was conducted from January 2018 to December 2018. MAIN OUTCOMES AND MEASURES Identification of ECSCs and ECSC-associated ED utilization patterns, length of stay, and charges. RESULTS An expert panel rated 51 condition groups as emergency care sensitive. Emergency care-sensitive conditions represented 16 033 359 of 114 323 044 ED visits (14.0%) in 2016. On average, 8 535 261 of 17 886 220 ED admissions (47.7%) were attributed to ECSCs. The most common ECSC ED visits were for sepsis (1 716 004 [10.7%]), chronic obstructive pulmonary disease (1 273 319 [7.9%]), pneumonia (1 263 971 [7.9%]), asthma (970 829 [6.1%]), and heart failure (911 602 [5.7%]) but varied by age group. Median (interquartile range) length of stay for ECSC ED admissions was longer than non-ECSC ED admissions (3.2 [1.7-5.8] days vs 2.7 [1.4-4.9] days; P < .001). In 2016, median (interquartile range) ED charges per visit for ECSCs were $2736 ($1684-$4605) compared with $2179 ($1118-$4359) per visit for non-ECSC ED visits (P < .001). CONCLUSIONS AND RELEVANCE This comprehensive list of ECSCs can be used to guide indicator development for pre-ED, intra-ED, and post-ED care and overall assessment of the adult, non-mental health, acute care system. Health care utilization and costs among patients with ECSCs are substantial and warrant future study of validation, variations in care, and outcomes associated with ECSCs.
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Affiliation(s)
- Anita A. Vashi
- Department of Emergency Medicine, Stanford University, Stanford, California
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Tracy Urech
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Brendan Carr
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Liberty Greene
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
- Division of Primary Care and Population Health, Stanford University, Stanford, California
| | - Theodore Warsavage
- Denver Center of Innovation for Veteran Centered and Value Driven Care, Rocky Mountain Regional VA Medical Center, Denver, Colorado
| | - Renee Hsia
- Philip R. Lee Institute for Health Policy Studies, Department of Emergency Medicine, University of California, San Francisco
| | - Steven M. Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
- Division of Primary Care and Population Health, Stanford University, Stanford, California
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Greene L, Carmack H. Development of Cultural Desire in Dietetics and Nutrition Students during Service-learning Opportunities. J Acad Nutr Diet 2018. [DOI: 10.1016/j.jand.2018.08.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
BACKGROUND Patient-centered access to mental health describes the fit between patient needs and resources of the system. To date, little data are available to guide implementation of services to women veterans, an underrepresented minority within Department of Veteran Affairs (VA) health care. The current study examines access to mental health care among women veterans, and identifies gender-related indicators of perceived access to mental health care. METHODS A population-based sample of 6287 women veterans using VA primary care services participated in a survey of past year perceived need for mental health care, mental health utilization, and gender-related mental health care experiences. Subjective rating of how well mental health care met their needs was used as an indicator of perceived access. RESULTS Half of all women reported perceived mental health need; 84.3% of those women received care. Nearly all mental health users (90.9%) used VA services, although only about half (48.8%) reported that their mental health care met their needs completely or very well. Gender related experiences (availability of female providers, women-only treatment settings, women-only treatment groups, and gender-related comfort) were each associated with 2-fold increased odds of perceived access, and associations remained after adjusting for ease of getting care. CONCLUSIONS Women VA users demonstrate very good objective access to mental health services. Desire for, and access to specialized mental health services for women varies across the population and are important aspects of shared decision making in referral and treatment planning for women using VA primary care.
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Affiliation(s)
- Rachel Kimerling
- National Center for PTSD
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park
| | | | | | | | - Allison Rodriguez
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park
| | | | - Donna L. Washington
- VA Greater Los Angeles Health Services Research and Development Centerzfor the Study of Healthcare Innovation, Implementation & Policy, Sepulveda
- Department of Medicine, Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
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Magill SS, Klompas M, Balk R, Burns SM, Deutschman CS, Diekema D, Fridkin S, Greene L, Guh A, Gutterman D, Hammer B, Henderson D, Hess DR, Hill NS, Horan T, Kollef M, Levy M, Septimus E, VanAntwerpen C, Wright D, Lipsett P. Developing a New, National Approach to Surveillance for Ventilator-Associated Events: Executive Summary. Respir Care 2013. [DOI: 10.4187/respcare.02759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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29
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Finucane C, O'Connell MDL, Fan CW, Soraghan C, Cronin H, Kenny RA, Shields L, McMurray M, Nolan H, Cronin H, Dunne L, Greene L, Walsh P, Kearney PM, Kenny RA, Finucane C, Romero-Ortuno R, Fouweather T, Jagger C. Epidemiology. Age Ageing 2013. [DOI: 10.1093/ageing/aft100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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30
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Greene L. Institutional Profile: USF Health: the power of creativity, the passion to improve health. Per Med 2011; 8:17-21. [PMID: 29768780 DOI: 10.2217/pme.10.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
USF Health (FL, USA) is home to a broad spectrum of health experts - from doctors to public health scientists to nurses to pharmacists - working together to envision a new kind of healthcare. USF Health encompasses the University of South Florida's Colleges of Medicine, Nursing, Public Health and Pharmacy. One of the only campuses in the nation with such a broad vision of health, USF Health is designed to reflect a future in which patient care, education and research benefit from a cooperative approach. USF Health focuses on leading changes in healthcare with bold, energetic and creative programs. Innovative initiatives include a new partnership with The Jackson Laboratory; a new medical degree program that emphasizes leadership, undertaken with the Lehigh Valley Health System in Pennsylvania; and 'Bringing Science Home', a new program to help patients who suffer from chronic disease live more optimistic and fulfilling lives.
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Abstract
The aim of this study was to determine how widespread the use is of dual nucleic acid amplification tests (NAATs) for the diagnosis of both Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) in England and Wales. A structured telephone questionnaire was used to collect information on the method of dual testing used by laboratories, the patient groups tested, the types of specimens obtained and the use of GC culture. Of the 108 laboratories participating, 29% performed dual CT and GC NAAT assays. The platforms used included: (i) BD Probetec (19/31), (ii) Aptima Combo 2 (9/31) and (iii) COBAS AMPLICOR (2/31). GC-positive specimens were either repeated using the same test (21) or an alternative target (9). Most laboratories confirmed positive GC NAATs by performing culture (26/31). Laboratories performed dual NAAT testing on specimens sourced from both community and genitourinary medicine clinic settings, and on a wide variety of different specimen types. This survey highlights a lack of consistency in the current use of dual NAAT platforms in the UK and the need for national guidelines.
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Affiliation(s)
- A Benzie
- Department of Genitourinary Medicine, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK
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32
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Lee H, Angelastro J, Kenney A, Mason C, Greene L. [P1.16]: Regulation of ATF5 during cerebellar granule neuron progenitor proliferation and differentiation. Int J Dev Neurosci 2008. [DOI: 10.1016/j.ijdevneu.2008.09.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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33
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Campbell D, Wood G, Greene L. Transmucosal fixation. Br J Oral Maxillofac Surg 2008. [DOI: 10.1016/j.bjoms.2008.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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34
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Greene L, Zavod M, Krusinski P, Roseman D, Hausrath S, Bosenberg M, Cook D. Pustular Drug Eruption to Voriconazole. J Cutan Pathol 2008. [DOI: 10.1111/j.0303-6987.2005.320ci.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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35
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Connor SEJ, Arscott T, Berry J, Greene L, O'Gorman R. Precision and accuracy of low-dose CT protocols in the evaluation of skull landmarks. Dentomaxillofac Radiol 2007; 36:270-6. [PMID: 17586853 DOI: 10.1259/dmfr/90016954] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES It was proposed to design a series of low-dose three-dimensional (3D) CT protocols with an effective dose similar to that of the conventional radiographic series (0.011-0.032 mSv) used to assess craniofacial asymmetry. It was then aimed to assess the precision and accuracy for skull landmarks recorded ex vivo using these CT protocols. METHODS Four ultra low-dose CT protocols (5 mAs, pitch 1.375/1.75; 10 mAs, pitch 1.375/1.75) were constructed on the basis of published data, dose calculations and measurements. A high-dose CT protocol was used as a reference standard examination. The protocols were used to scan a skull immersed in water. For each protocol, two observers evaluated 17 skull landmarks on two separate occasions. 3D and two-dimensional (2D) accuracy relative to the reference standard examination and inter- and intraobserver precision was calculated. RESULTS The 2D accuracy was superior for the 10 mAs protocols and the 10 mAs/1.375 pitch protocol allowed one observer to achieve an accuracy of less than 2 mm for all landmarks. The 2D interrater precision for the 10 mAs/1.375 pitch protocol was superior to the other low-dose protocols and also the high-dose protocol, achieving precision less than 2 mm for 15/17 points. The 10 mAs protocols enabled greater 2D intrarater precision than the 5 mAs protocols for both observers. CONCLUSIONS Using the 10 mAs/1.375 pitch CT protocol, it was possible to achieve 2D accuracy of less than 2 mm for almost all skull landmarks with an interrater precision similar to a high-dose CT protocol. Although the estimated effective dose of 0.035 mSv was slightly greater than that of the conventional radiographic series (0.011-0.032 mSv), there was the additional benefit of a 3D data set. The 10 mAs protocols allowed accuracy and precision superior to that of the 5 mAs protocols and hence they are more likely to be clinically applicable.
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Affiliation(s)
- S E J Connor
- Neuroradiology Department, King's College Hospital, Denmark Hill, London SES 9RS, UK.
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36
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Willett R, Greene L. [P162]: The role of GATA‐2 in neurite outgrowth and neuronal migration. Int J Dev Neurosci 2006. [DOI: 10.1016/j.ijdevneu.2006.09.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Sethi G, Holden BM, Gaffney J, Greene L, Ghani AC, Ward H. HIV, sexually transmitted infections, and risk behaviours in male sex workers in London over a 10 year period. Sex Transm Infect 2006; 82:359-63. [PMID: 16916883 PMCID: PMC2563850 DOI: 10.1136/sti.2005.019257] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To describe changing characteristics of men who sold sex in London between 1994 and 2003. METHODS A baseline survey of 823 male sex workers attending a specialist clinic, plus follow up of 628 men for 1379 person years. RESULTS Men recruited earlier (1994 to 1996) were more likely than those recruited later (2000 to 2003) to be UK born and to self define as homosexual. Later recruits included more men from South/Central America and eastern Europe and a higher proportion reported regular female partners. Baseline prevalence of HIV was 9% (59/636), and multivariate analysis showed an associated with injecting drug use and unprotected sex with a casual partner. During follow up there were 49 incident cases of HIV. Survival analysis showed earlier recruitment (1994-6) to be associated with a higher incidence of HIV. The prevalence of gonorrhoea increased over time. CONCLUSIONS Men who sell sex are at risk of HIV and other STIs, but these risks do not appear to be directly linked to sex work. The changing demographics of these men is associated with different patterns of infection and poses challenges for service delivery.
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Affiliation(s)
- G Sethi
- Department of Genitourinary Medicine, St Mary's NHS Trust, Lambeth Palace Road London SE1, UK.
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38
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Farnsworth D, Greene L, Dumyati G. If First You Don't Succeed: Re-Analyze the Data or: Drilling down Dialysis Data. Am J Infect Control 2006. [DOI: 10.1016/j.ajic.2006.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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39
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Abstract
BACKGROUND Male sex workers are at risk of blood borne viruses but may have limited access to sexual health services, including vaccination. We explore factors associated with hepatitis B vaccination uptake among male sex workers in London METHODS Follow up study of men attending the Working Men's Project, a specialist health project for men who sell sex, between 1994 and 2003. RESULTS At baseline 797 men were screened for hepatitis B; 308 were not eligible for vaccination because of past or current infection (155, 19.4%) or previous vaccination 153 (19.2%). Of the 489 men eligible for a full course of vaccination 292 (59.8%) completed the course. Completion rates fell over time: men recruited up to 1999 were more likely to complete the course than those recruited more recently (177/259, 68.3% compared with 115/229, 50.2%, OR 2.14, 95% CI 1.48 to 3.09). CONCLUSION This specialist service achieved a high rate of vaccine completion in the early years, but the decline is a concern. It may reflect wider availability of vaccination elsewhere and a more mobile population of sex workers. Shorter courses may achieve a higher completion.
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Affiliation(s)
- G Sethi
- Department of Genitourinary Medicine, St Mary's Hospital, London, UK.
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40
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Greene L, Brundage W, Cooper K. Large cell neuroendocrine carcinoma of the larynx: a case report and a review of the classification of this neoplasm. J Clin Pathol 2005; 58:658-61. [PMID: 15917422 PMCID: PMC1770703 DOI: 10.1136/jcp.2004.019927] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2004] [Indexed: 11/04/2022]
Abstract
This report describes a case of large cell neuroendocrine carcinoma (LCNEC) of the larynx. A 74 year old man who presented with otalgia underwent direct laryngoscopy with biopsy, which revealed an invasive poorly differentiated carcinoma. Laryngectomy with bilateral neck dissections revealed invasion of the pre-epiglottic space by the tumour, with metastases to bilateral lymph nodes (AJCC T3N2c). The tumour was characterised by large cells with vesicular chromatin and prominent nucleoli. The cells were arranged in organoid and trabecular patterns with a background of extensive necrosis and numerous mitotic figures. Immunohistochemical and ultrastructural analyses confirmed the neuroendocrine nature of the tumour. Metastatic disease was present in the liver, and the patient died within weeks of surgery. LCNEC carcinoma is a rare tumour of the larynx. Recognition at this site is essential so that proper patient management can be initiated.
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Affiliation(s)
- L Greene
- Department of Pathology, University of Vermont and Fletcher Allen Health Care, Smith 2, Pathology, 111 Colchester Avenue, Burlington, VT 05401, USA.
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41
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Greene L, Farnsworth D, Sposato K, Lovejoy G, Dumyati G. An organization-wide approach to decreasing central venous catheter bloodstream infections: Applying lessons learned from intensive care surveillance to general patient care units. Am J Infect Control 2005. [DOI: 10.1016/j.ajic.2005.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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42
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Abstract
BACKGROUND United States National Health Objectives include increasing the proportion of trips made by walking to and from school for children who live within 1.6 km to 50%. The purpose of this objective is to increase the level of physical activity among children. However, the impact of walking, bicycling or skating (active commuting) to and from school on the prevalence of overweight is unknown. METHODS Body mass index (BMI) was measured for 320 children (age 10.2+/-0.7 years) in September. Over 5 months, an active commuting index (SI) and daily physical activity were estimated via questionnaire. In April, BMI and body fat were measured. RESULTS A significant positive association was found between April BMI and SI adjusting for September BMI (partial r=0.03, P<0.05). Positive associations were found between SI and physical activity before school (r=0.17, P<0.05) and daily moderate intensity physical activity (r=0.13, P<0.05). There were no significant association between SI and BF (P>0.05). CONCLUSIONS This preliminary data suggests that active commuting does not appear to provide sufficient amounts of physical activity to attenuate BMI; however, it may contribute to the attainment of physical activity recommendations. Future research is needed to objectively measure the impact of active commuting on the prevalence of overweight.
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Affiliation(s)
- K A Heelan
- Department of Health, Physical Education, Recreation and Leisure Studies, University of Nebraska at Kearney, Kearney, NE 68849, USA.
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Crawford MJ, Lowe PC, Greene L, Brookings C. The prevalence of excessive alcohol consumption and the acceptability of brief advice in a sexual health clinic: cross sectional survey. Sex Transm Infect 2004; 80:416-7. [PMID: 15459416 PMCID: PMC1744891 DOI: 10.1136/sti.2003.008938] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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44
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Affiliation(s)
- C Valavanis
- Department of Biology, Morrill Science Center, University of Massachusetts, Amherst, Massachusetts 01003, USA
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45
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Abstract
The Conners' Parent Rating Scales (CPRS) have undergone a considerable amount of scrutiny--and subsequent refining, reshaping, and revising--since their development in 1970. While such longitudinal scrutiny has ultimately led to a more reliable, valid assessment tool, it has left behind a wake of literature filled with misinformation and ambiguity. Multiple versions of the Conners' Rating Scales (CRS), their misuse, and inaccurate reporting by researchers have created a body of literature that is difficult to interpret and misleading to both researchers and clinicians. This review is aimed at clarifying issues regarding the proper use of the CPRS as both a diagnostic instrument and a research tool.
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Affiliation(s)
- W J Gianarris
- Center for Psychological Studies, Nova Southeastern University, 3301 College Ave., Fort Landerdale, FL 33314, USA
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46
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Ison C, Martin I, Ivens D, Philip S, Greene L. Ciprofloxacin resistance in gonococci. Lancet 2001; 357:803. [PMID: 11253997 DOI: 10.1016/s0140-6736(05)71229-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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47
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Levy MF, Greene L, Ramsay MA, Jennings LW, Ramsay KJ, Meng J, Hein HA, Goldstein RM, Husberg BS, Gonwa TA, Klintmalm GB. Readmission to the intensive care unit after liver transplantation. Crit Care Med 2001; 29:18-24. [PMID: 11176152 DOI: 10.1097/00003246-200101000-00004] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We undertook this study to understand the factors at our transplant center that contribute to patients' return to the ICU after their liver transplant and their initial discharge from that unit. Patients who, after liver transplantation, fail discharge from the Intensive Care Unit (ICU) and must be readmitted to that unit may well utilize many more resources than those patients who are well enough to stay out of the ICU. DESIGN A retrospective review of a prospectively maintained liver transplant research database followed by a retrospective review of (a subgroup) patient charts and contemporaneous controls. SETTING A large metropolitan tertiary care center and adult liver transplant center. PATIENTS A total of 1,197 consecutive adult patients who underwent their initial liver transplantation from 1984 to 1996. INTERVENTION Readmission to the intensive care unit after adult liver transplantation and discharge from that unit. MAIN RESULTS Only recipient age, pretransplant synthetic function labs (protime and albumin), bilirubin levels, and intraoperative blood product requirements could be statistically linked to the group requiring ICU readmission. The primary etiology for ICU readmission was cardiopulmonary deterioration. Readmission was associated with significantly lower patient and graft survivals. A detailed review of 23 patients transplanted from October 1994 to June 1996 was made, with special emphasis on cardiopulmonary status (hemodynamics, respiratory variables, and chest radiograph findings). This subgroup was compared with 30 temporally matched controls who were not readmitted to the ICU. Intravascular fluid overload and lower inspiratory capacity were significant factors related to ICU readmission. Readmitted patients had a longer hospitalization with higher hospital charges than the control group. CONCLUSIONS We conclude that the most important means of preventing ICU readmission in liver transplantation patients is to optimize cardiopulmonary function and status. Close monitoring of fluid balance to avoid hypervolemia is essential. Readmitted patients have a greater resource utilization and have lower survival rates.
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Affiliation(s)
- M F Levy
- Department of Transplant Services, Baylor University Medical Center, Dallas, TX 75246-2096, USA.
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48
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Greene L, Espe-Pfeifer P, Selden J, Mahrou M, Mleko A, Escalona A, Golden A. Correlation of the Geriatric Depression Scale with cognitive abilities. Arch Clin Neuropsychol 2000. [DOI: 10.1093/arclin/15.8.737a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Marsh J, Espe-Pfeifer P, Mahrou M, Devaraju-Backhaus S, Greene L, Escalona A, Mleko A, Golden C. Parent--teacher rating reliability of the CBCL and Conners in neuropsychology. Arch Clin Neuropsychol 2000. [DOI: 10.1093/arclin/15.8.803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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50
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Mleko A, Mahrou M, Espe-Pfeifer P, Escalona A, Greene L, Devearju-Backhaus S, Marsh J, Golden C. Relationship between PIC constructs and the TOVA. Arch Clin Neuropsychol 2000. [DOI: 10.1093/arclin/15.8.786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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