Search

Background— It is unknown whether the appropriate use of percutaneous coronary intervention (PCI) has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the use of PCI. Methods and Results— We applied appropriate use criteria to determine the appropriateness of all 51 872 PCI performed in Washington State from 2010 through 2013. We evaluated the number of PCIs performed from 2006 through 2013 to provide a comparator period that preceded statewide appropriateness assessment beginning in 2010. Between 2010 and 2013, the overall number of PCI decreased by 6.8% (13 267 PCIs in 2010 to 12 193 in 2013) with a 43% decline in the number of PCIs for elective indications (3818 PCIs in 2010 to 2193 PCIs in 2013). The decline in the use of elective PCI was significantly larger after the onset of statewide PCI appropriateness assessment in 2010 ( P =0.03). The proportion of elective PCIs classified as appropriate increased from 26% in 2010 to 38% in 2013, whereas the proportion of inappropriate PCIs decreased from 16% to 13% ( P P =0.03). Conclusions— In Washington State, the use of PCI for elective indications has decreased over time with concurrent improvements in PCI appropriateness. However, improvements in PCI appropriateness were limited to a minority of hospitals. Understanding processes at these high-performing hospitals may inform efforts to improve PCI appropriateness.

Background Alcohol use is associated with angina incidence, but associations between alcohol use and experience of angina among patients with coronary artery disease (CAD) have not been described. Methods Outpatients with CAD from 7 clinics in the Veterans Health Administration were surveyed; alcohol use was measured using the validated Alcohol Use Disorders Identification Test-Consumption scores categorized into 6 groups: nondrinking, low-risk drinking, and mild, moderate, severe, and very severe unhealthy alcohol use. Three domains of self-reported angina symptoms (frequency, stability, and physical function) were measured with the Seattle Angina Questionnaire. Linear regression models evaluated associations between alcohol use groups and angina symptoms. Models were adjusted first for age and then additionally for smoking, comorbidities, and depression. Results Patients (n = 8303) had a mean age of 66 years. In age-adjusted analyses, a U-shaped association was observed between alcohol use groups and all angina outcomes, with patients in nondrinking and severe unhealthy alcohol groups reporting the greatest angina symptoms and lowest functioning. After full adjustment, no clinically important and few statistically important differences were observed across alcohol use in angina stability or frequency. Patients in the nondrinking group had statistically greater functional limitation from angina than those in all groups of unhealthy alcohol use, though differences were small. Patients in all groups of unhealthy alcohol use did not differ significantly from those with low-risk drinking. Conclusions Alcohol use was associated with some small statistically but no clinically important differences in angina symptoms among patients with CAD. This cross-sectional study does not support a protective effect of low-level drinking on self-reported angina.

Background/Purpose Compared with trans-femoral percutaneous coronary intervention (TFI), trans-radial PCI (TRI) has a lower risk of bleeding, access site complications and hospital costs, and is preferred by patients. However, TRI accounts for a minority of PCIs in the US, and there is currently little research that explores why. Methods/Material We conducted a national survey in February 2013 to assess perceptions of TRI vs. TFI, and barriers to TRI adoption and implementation among interventional cardiologists employed by the US Veterans Health Administration (VHA), and linked these data to site-level TRI annual rates for 2013. Results We received 78 completed surveys (32% response rate). Respondents at sites that perform few or no TRIs identified increased radiation exposure as the greatest barrier while at sites that perform a high percentage of TRIs respondents identified the steep learning curve as the greatest barrier. Majorities of survey respondents at all sites rated TRI as superior on 5 of 7 criteria, including patient comfort and bleeding complications, but rated TFI as superior on procedure time and procedure success. Conclusions Even interventional cardiologists at sites that perform few or any TRIs recognized the superiority of TRI for patient comfort and safety, but rated it inferior to TFI on procedure time and technical results. Interventional cardiologists at high-TRI labs rated TRI as equivalent on procedure time and technical results. Efforts to increase TRI adoption and implementation may be more successful if they emphasize that procedure times and technical results depend on achieving proficiency.

Expert guidelines for treatment of cardiac arrest recommend administration of adrenaline (epinephrine) every three to five minutes. However, the effects of different dosing periods of epinephrine remain unclear. We sought to evaluate the association between epinephrine average dosing period and survival to hospital discharge in adults with an in-hospital cardiac arrest (IHCA).We performed a retrospective review of prospectively collected data on 20,909 IHCA events from 505 hospitals participating in the Get With The Guidelines-Resuscitation (GWTG-R) quality improvement registry. Epinephrine average dosing period was defined as the time between the first epinephrine dose and the resuscitation endpoint, divided by the total number of epinephrine doses received subsequent to the first epinephrine dose. Associations with survival to hospital discharge were assessed by using generalized estimating equations to construct multivariable logistic regression models.Compared to a referent epinephrine average dosing period of 4 to5 min per dose, survival to hospital discharge was significantly higher in patients with the following epinephrine average dosing periods: for 6 to7 min/dose, adjusted odds ratio [OR], 1.41 (95%CI: 1.12, 1.78); for 7 to8 min/dose, adjusted OR, 1.30 (95%CI: 1.02, 1.65); for 8 to9 min/dose, adjusted OR, 1.79 (95%CI: 1.38, 2.32); for 9 to10 min/dose, adjusted OR, 2.17 (95%CI: 1.62, 2.92). This pattern was consistent for both shockable and non-shockable cardiac arrest rhythms.Less frequent average epinephrine dosing than recommended by consensus guidelines was associated with improved survival of in-hospital cardiac arrest.

Improving the quality of alcohol-related care requires practical approaches to assessing alcohol consumption to guide management and monitor outcomes. Given the increasing use of alcohol screening questionnaires to identify alcohol misuse it would be ideal if scores on screening questionnaires were also indicators of average alcohol consumption. However, the questionnaires were not designed for this purpose and include dimensions of drinking that may not reflect average consumption (e.g. heavy episodic drinking, alcohol-related problems). In a general population sample, scores on the AUDIT-C screen correlated with reports of alcohol consumption in detailed interviews, but the relationship is unknown for clinical populations and other questionnaires. Serum high-density lipoprotein cholesterol (HDL) is a biomarker routinely obtained in clinical care and is known to rise with average alcohol consumption. This cross-sectional study of 11,175 male U.S. Veterans Affairs patients enrolled in a primary care study used HDL as an objective biomarker to evaluate whether average alcohol consumption increased as scores increased on 3 brief alcohol screens – the AUDIT-C, AUDIT Question #3 (a single-item screen), and the CAGE questionnaire. Mean HDL progressively increased as screening scores increased for the AUDIT-C and AUDIT Question #3: about 12 mg/dL from the lowest to the highest scores. The association was much weaker for the CAGE questionnaire. Results were minimally affected by adjustment for covariates (e.g. age, race, medical comorbidity, smoking, medication count, and depression) but the association was modified ( p = 0.008) and mildly attenuated by adherent use of lipid-lowering medications. This study using HDL as a biomarker of average alcohol consumption adds to evidence that some alcohol screening scores may also serve as scaled markers of average alcohol consumption.

Transradial percutaneous coronary intervention (tPCI) as opposed to the femoral approach (fPCI) is associated with lower rates of bleeding. The purposes of this study were to describe the use of tPCI in the Washington State Clinical Outcomes Assessment Program, identify the predictors of bleeding, and determine whether tPCI was associated with less bleeding in women vs men, age75 years vs ≥75 years, and baseline creatinine2.0 mg/dL vs ≥2.0 mg/dL.This study included 23,599 individuals who had a first tPCI or fPCI performed in 30 centers in Washington State in 2010 and 2011. Data were collected according to specifications from the American College of Cardiology National Cardiovascular Data Registry Cath-PCI version 4.3. The American College of Cardiology National Cardiovascular Data Registry bleeding model was used to calculate adjusted rates.Transradial percutaneous coronary intervention was used in only 5% of procedures, and in just 3 centers, tPCI was used in10% of cases. Patient demographics and medical histories were similar in tPCI and fPCI, although the percent of acute cases was higher in fPCI (68% vs 45%, P.0001). The overall bleeding rate was 2.2%, and the 3 most important predictors of bleeding were acute procedure, women, and age ≥75 years. For women, unadjusted rates of bleeding were 1.4% for tPCI and 4.0% for fPCI (P = .013). Among women, adjusted rates were almost 20% lower for tPCI (3.3% vs 4.1%).In Washington State, tPCI was used infrequently, although it was associated with lower bleeding rates in high-risk groups including women.

While there has been extensive research into patient-specific predictors of medication adherence and patient-specific interventions to improve adherence, there has been little examination of variation in clinic-level medication adherence.We examined the clinic-level variation of oral hypoglycemic agent (OHA) medication adherence among patients with diabetes treated in the Department of Veterans Affairs (VA) primary care clinics. We hypothesized that there would be systematic variation in clinic-level adherence measures, and that adherence within organizationally-affiliated clinics, such as those sharing local management and support, would be more highly correlated than adherence between unaffiliated clinics.Retrospective cohort study.VA hospital and VA community-based primary care clinics in the contiguous 48 states.444,418 patients with diabetes treated with OHAs and seen in 158 hospital-based clinics and 401 affiliated community primary care clinics during fiscal years 2006 and 2007.Refill-based medication adherence to OHA.Adjusting for patient characteristics, the proportion of patients adherent to OHAs ranged from 57 % to 81 % across clinics. Adherence between organizationally affiliated clinics was high (Pearson Correlation = 0.82), and adherence between unaffiliated clinics was low (Pearson Correlation = 0.04).The proportion of patients adherent to OHAs varied widely across VA primary care clinics. Clinic-level adherence was highly correlated to other clinics in the same organizational unit. Further research should identify which factors common to affiliated clinics influence medication adherence.

Background— In anticipation of applying Appropriate Use Criteria for percutaneous coronary intervention (PCI) quality improvement, we determined the prevalence of appropriate, uncertain, and inappropriate PCIs stratified by indication for all PCIs performed in the state of Washington. Methods and Results— Within the Clinical Outcomes Assessment Program, we assigned appropriateness ratings to all PCIs performed in 2010 in accordance with published Appropriate Use Criteria. Of 13 291 PCIs, we successfully mapped the clinical scenario to the Appropriate Use Criteria in 9924 (75%) cases. Of the 3367 PCIs not classified, common failures to map to the criteria included nonacute PCI without prior noninvasive stress results (n = 1906; 57%) and unstable angina without high-risk features (n = 902; 27%). Of mapped PCIs, 8010 (71%) were for acute indications, with 7887 (98%) rated as appropriate, 39 (th to 75 th percentiles = 9% to 24%) and nonacute indications with missing data precluding appropriateness classification (median = 54%; 25 th to 75 th percentiles = 35% to 66%). Conclusions— In a complete cohort of PCIs performed in Washington state, 1% of PCIs for acute indications and 17% of PCIs for nonacute indications were classified as inappropriate. Missing data on noninvasive stress tests present a challenge in the application of the criteria for quality improvement.

Background— Adherence to cardioprotective medications in the year after acute coronary syndrome hospitalization is generally poor and is associated with increased risk of rehospitalization and mortality. Few interventions have specifically targeted this high-risk patient population to improve medication adherence. We hypothesize that a multifaceted patient-centered intervention could improve adherence to cardioprotective medications. Methods and Results— To evaluate this intervention, we propose enrolling 280 patients with a recent acute coronary syndrome event into a multicenter randomized, controlled trial. The intervention comprises4 main components: (1) pharmacist-led medication reconciliation and tailoring; (2) patient education; (3) collaborative care between pharmacist and primary care provider/cardiologist; and (4) 2 types of voice messaging (educational and medication refill reminder calls). Patients in the intervention arm will visit with the study pharmacist ≈1 week post-hospital discharge. The pharmacist will work with the patient and collaborate with providers to reconcile medication issues. Voice messages will augment the educational process and remind patients to refill their cardioprotective medications. The study will compare the intervention versus usual care for 12 months. The primary outcome of interest is adherence using the ReComp method. Secondary and tertiary outcomes include achievement of targets for blood pressure and low-density lipoprotein, and reduction in the combined cardiovascular end points of myocardial infarction hospitalization, coronary revascularization, and all-cause mortality. Finally, we will also evaluate the cost-effectiveness of the intervention compared with usual care. Conclusions— If the intervention is effective in improving medication adherence and demonstrating a lower cost, the intervention has the potential to improve cardiovascular outcomes in this high-risk patient population.

To examine longitudinal changes in Medicare-eligible veterans' reliance on the Department of Veterans Affairs (VA) healthcare system for primary and specialty care over 4 years.We merged VA administrative and Medicare claims data to examine outpatient use during fiscal years (FY) 2001 to 2004 by 15,520 Medicare-eligible veterans who used VA primary care in FY2000. Reliance on VA outpatient care was defined as the proportion of total (VA/Medicare) visits received in VA for primary or specialty care.Of 869,000 primary and specialty care visits in the study period, 39% occurred within VA and 77% were specialty care. Reliance on VA primary care was substantially higher than specialty care (66% vs. 50% in FY2001; P0.001). Reliance on VA primary and specialty care decreased over time (57% vs. 31% in FY2004; P0.001). Significant shifts occurred at both extremes of VA reliance. From FY2001 to FY2004, the proportion of patients in the top decile of reliance on VA primary care decreased from 39% to 31%, whereas the proportion in the bottom decile doubled from 8% to 18%. Similarly, the proportion of patients in the top decile of reliance on VA specialty care decreased from 24% to 13%, whereas the proportion in the bottom decile doubled from 22% to 47%.Reliance on VA primary and specialty care among VA primary care patients decreased substantially over time, particularly for specialty care. Increasing use of non-VA services may complicate VA's implementation of patient-centered medical home models and performance measurement.

There is little data about the combined effects of COPD and obesity. We compared dyspnea, health-related quality of life (HRQoL), exacerbations, and inhaled medication use among patients who are overweight and obese to those of normal weight with COPD.We performed secondary data analysis on 364 Veterans with COPD. We categorized subjects by body mass index (BMI). We assessed dyspnea using the Medical Research Council (MRC) dyspnea scale and HRQoL using the St. George's Respiratory Questionnaire. We identified treatment for an exacerbation and inhaled medication use in the past year. We used multiple logistic and linear regression models as appropriate, with adjustment for age, COPD severity, smoking status, and co-morbidities.The majority of our population was male (n = 355, 98%) and either overweight (n = 115, 32%) or obese (n = 138, 38%). Obese and overweight subjects had better lung function (obese: mean FEV(1) 55.4% ±19.9% predicted, overweight: mean FEV(1) 50.0% ±20.4% predicted) than normal weight subjects (mean FEV(1) 44.2% ±19.4% predicted), yet obese subjects reported increased dyspnea [adjusted OR of MRC score ≥2 = 4.91 (95% CI 1.80, 13.39], poorer HRQoL, and were prescribed more inhaled medications than normal weight subjects. There was no difference in any outcome between overweight and normal weight patients.Despite having less severe lung disease, obese patients reported increased dyspnea and poorer HRQoL than normal weight patients. The greater number of inhaled medications prescribed for obese patients may represent overuse. Obese patients with COPD likely need alternative strategies for symptom control in addition to those currently recommended.

Measuring health services provided to patients can be difficult when patients see providers across multiple health systems and all visits are rarely captured in a single data source covering all systems where patients receive care. Studies that account for only one system will omit the out-of-system health-care use at the patient level. Combining data across systems and comparing utilization patterns across health systems creates complications for both aggregation and accuracy because data-generating processes (DGPs) tend to vary across systems. We develop a hybrid methodology for aggregation across systems, drawing on the strengths of the DGP in each system, and demonstrate its validity for answering research questions requiring cross-system assessments of health-care utilization. Positive and negative predictive probabilities can be useful to assess the impact of the hybrid methodology. We illustrate these issues comparing public sector (administrative records from the US Department of Veterans Affairs system) and private sector (billing records from the US Medicare system) patient level data to identify primary-care utilization. Understanding the context of a particular health system and its effect on the DGP is important in conducting effective valid evaluations. Published in 2010 by John Wiley & Sons, Ltd.

Objective To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients.

Background High quality patient-clinician communication is widely advocated, but little is known about which health outcomes are associated with communication for patients with COPD. Methods Using a cross-sectional study of 342 veterans enrolled in a randomized controlled trial, we evaluated the association of communication, measured with the quality of communication (QOC) instrument, with subject-reported quality of clinician care, breathing problem confidence, and general self-rated health. We measured these associations using general estimating equations and adjusted odds ratios (OR) of patient-reported outcomes associated with one-point changes in QOC scores. Results Nearly one-half of the subjects reported receiving the best imaginable care (47%), whereas fewer reported being confident with their breathing problems all the time (29%) or in very good or excellent health (15%). General communication was associated with best-imagined quality of care (OR, 4.29; 95% CI, 2.84–6.48; P P P = .19). Specific clinician behaviors with larger associations with higher quality care included listening, caring, and attentiveness. The associations between general communication and quality care increased over time ( P for interaction .03). Conclusions Communication between patients and clinicians is associated with quality of care and confidence in dealing with breathing problems, and this association may change over time. Attention to specific communication strategies may lead to improvements in the care of patients with COPD.

Alcohol use is associated with self-reported health status. However, little is known about the concurrent association between alcohol screening scores and patient perception of health. We evaluated this association in a sample of primarily older male veterans.: This secondary, cross-sectional analysis included male general medicine outpatients from 7 VA medical centers who returned mailed questionnaires. Screening scores from the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questionnaire were divided into 6 categories (0, 1-3, 4-5, 6-7, 8-9, and 10-12). Outcomes included scores on the 8 subscales and 2 component scores of the 36-item Short Form Health Survey (SF-36). Unadjusted and adjusted linear regression models were fit to characterize the association between AUDIT-C categories and SF-36 scores. Models were adjusted for demographic characteristics, smoking, and site-both alone and in combination with 14 self-reported comorbid conditions.: Male respondents (n = 24,531; mean age = 63.6 years) represented 69% of those surveyed with the SF-36. After adjustment, a quadratic (inverted U-shaped) relationship was demonstrated between AUDIT-C categories and all SF-36 scores such that patients with AUDIT-C scores 4-5 or 6-7 reported the highest health status, and patients with AUDIT-C scores 0, 8-9, and ≥10 reported the lowest health status.: Across all measures of health status, patients with the most severe alcohol misuse had significantly poorer health status than those who screened positive for alcohol misuse at mild or moderate levels of severity. The relatively good health status reported by patients with mild-moderate alcohol misuse might interfere with clinicians' acceptance and adoption of guidelines recommending that they counsel these patients about their drinking.

Medication adherence usually refers to whether patients take their medications as prescribed (eg, twice daily), as well as whether they continue to take a prescribed medication. Medication nonadherence is a growing concern to clinicians, healthcare systems, and other stakeholders (eg, payers) because of mounting evidence that it is prevalent and associated with adverse outcomes and higher costs of care. To date, measurement of patient medication adherence and use of interventions to improve adherence are rare in routine clinical practice. The goals of the present report are to address (1) different methods of measuring adherence, (2) the prevalence of medication nonadherence, (3) the association between nonadherence and outcomes, (4) the reasons for nonadherence, and finally, (5) interventions to improve medication adherence.

Extensive research demonstrates a J- or U-shaped association between in-depth interview measures of alcohol consumption and mortality. Little is known about the relationship between alcohol screening questionnaires and mortality. This study examined the association between scores (ranging from 0 to 12) on the three-item Alcohol Use Disorder Identification Test-Consumption Questionnaire (AUDIT-C) and mortality.This cohort study included male outpatients from seven Veterans Affairs (VA) medical centers who completed the AUDIT-C on mailed surveys (1997-2000; n=34,292) and who were followed for a mean of 2.5 years. Death was ascertained from VA databases.In analyses adjusted for demographics, a U-shaped relationship was observed between AUDIT-C scores and all-cause mortality. Nondrinkers (AUDIT-C 0) and heavy drinkers (AUDIT-C 8-9 and 10-12) had increased risk of death compared with drinkers who screened negative for alcohol misuse (AUDIT-C 1-3): hazard ratios (HR)=1.41 (95% confidence interval [CI]: 1.29-1.54), 1.32 (1.03-1.69), and 1.47 (1.14-1.91), respectively. This association differed across age groups (p=.003). For men younger than 50 years, AUDIT-C scores 10-12 were associated with increased mortality (HR=2.21, 95% CI: 1.29-3.77), whereas for men age 50 or older, self-reported abstinence (AUDIT-C 0) was associated with increased mortality, compared with drinkers with AUDIT-C scores 1-3: HR formen 50-64=1.45 (1.19-1.77); HR for men 65 or older=1.42 (1.28-1.58).A U-shaped association between the AUDIT-C and mortality was observed, with important differences by age group. This is the first study to demonstrate that a clinical scaled screening measure of alcohol use has a similar association with mortality to that observed in epidemiological research with lengthier measures.

Background: Alcohol has been associated with COPD-related mortality but has not yet been demonstrated to be an independent risk factor for COPD exacerbation. Our objective was to evaluate the association between alcohol consumption and the subsequent risk of COPD exacerbation. Methods: A prospective cohort study of general medicine outpatients seen at one of seven Veterans Affairs (VA) medical centers who returned health screening questionnaires. Three screening questionnaires, AUDIT-C (0 to 12 points), CAGE (0 to 4 points), and a single item about the frequency of drinking six or more drinks on an occasion (binge drinking), were used to classify alcohol consumption. The main outcome, COPD exacerbation, was based on primary VA discharge diagnosis (International Classification of Diseases, Ninth Revision) or outpatient diagnosis of COPD accompanied by prescriptions for either antibiotics or prednisone within 2 days. Results: Among the 30,503 patients followed up for a median of 3.35 years, those patients with AUDIT-C scores > 6, CAGE scores > 2, or who reported binge drinking at least weekly were at an increased risk of COPD exacerbation in age-adjusted analysis. Adjusted hazard ratios were 1.4 (95% confidence interval [CI], 1.1 to 1.7) for AUDIT-C score > 6, 1.4 (95% CI, 1.3 to 1.5) for CAGE score > 2, and 1.6 (95% CI, 1.2 to 2.2) for those who reported binge drinking daily or almost daily. However, with adjustment for measures of tobacco use, the association between alcohol consumption and increased risk of COPD exacerbation was no longer evident. Conclusions: Alcohol consumption, whether quantified by AUDIT-C, CAGE score, or binge drinking, was not associated with an increased risk of COPD exacerbation independent of tobacco use. (CHEST 2008; 134:761–767)

Background: Alcohol misuse is a common cause of liver disease, upper gastrointestinal (GI) bleeding, and pancreatitis, but it is not known whether alcohol screening questionnaires can identify patients at increased risk for hospitalizations due to these conditions. Objective: To evaluate the association of alcohol screening scores with the risk of subsequent hospitalization for alcohol-related GI conditions. Design: Retrospective cohort study. Participants: Male general medicine outpatients from 7 Veterans Affairs (VA) medical centers who returned mailed questionnaires. Measurements: The CAGE questionnaire (0–4 points) and the Alcohol Use Disorders Identification Test-Consumption questions (AUDIT-C; 0–12 points) were included on mailed surveys. The main outcome, “GI hospitalization,” was a primary VA or Medicare discharge diagnosis indicating liver disease, upper GI bleeding, or pancreatitis. Results: Among 31,311 patients followed, a median of 3.75 years, patients with CAGE scores ≥2 points or AUDIT-C scores ≥6 points were at a significantly increased risk for GI hospitalizations. Adjusted hazard ratios (HRadj) ranged from 1.6 (95% CI 1.2–2.0) for CAGE score 2, to 1.7 (1.4–2.2) for CAGE 4, and from 1.4 (1.01–2.0) for AUDIT-C scores from 6 to 7, to 2.7 (1.9–3.8) for AUDIT-C scores from 10 to 12. Secondary analyses demonstrated that the association was the strongest among patients less than 50 years of age who reported drinking in the past year. Conclusions: Brief alcohol screening questionnaires predict subsequent hospitalizations for alcohol-related GI conditions.

Lucas N Marzec,1 Evan P Carey,1 Anne C Lambert-Kerzner,1 Eric J Del Giacco,2 Stephanie D Melnyk,3 Chris L Bryson,4 Ibrahim E Fahdi,2 Hayden B Bosworth,3 Fran Fiocchi,5 P Michael Ho11Division of Cardiology, Denver VA Medical Center, Denver, CO, USA; 2Department of Medicine, Little Rock VA Medical Center, Little Rock, AR, USA; 3Department of Medicine, Durham VA Medical Center, Durham, NC, USA; 4Department of Medicine, Puget Sound VA Medical Center, Seattle, WA, USA; 5American College of Cardiology, Washington, DC, USABackground: Patient nonadherence to cardiac medications following acute coronary syndrome (ACS) is associated with increased risk of recurrent events. However, the prevalence of cognitive dysfunction and poor health literacy among ACS patients and their association with medication nonadherence are poorly understood.Methods: We assessed rates of cognitive dysfunction and poor health literacy among participants of a clinical trial that tested the effectiveness of an intervention to improve medication adherence in patients hospitalized with ACS. Of 254 patients, 249 completed the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) survey, an assessment of risk for poor literacy, and the St Louis University Mental Status (SLUMS) exam, a tool assessing for neurocognitive deficits, during ACS hospitalization. We assessed if SLUMS or REALM-R scores were associated with medication adherence.Results: Based on SLUMS score, 14% of patients were categorized as having dementia, and 52% with mild neurocognitive disorder (MNCD). Based on REALM-R score of ≤6, 34% of patients were categorized as at risk for poor health literacy. There was no association between poor health literacy and medication nonadherence. Of those with MNCD, 35.5% were nonadherent, compared to 17.5% with normal cognitive function and 6.7% with dementia. In multivariable analysis, cognitive dysfunction was associated with medication nonadherence (P=0.007), mainly due to an association between MNCD and nonadherence (odds ratio =12.2, 95% confidence interval =1.9 to 243; P=0.007). Cognitive status was not associated with adherence in patients randomized to the intervention.Conclusion: Cognitive dysfunction and risk for poor health literacy are common in patients hospitalized with ACS. We found an association between MNCD and medication nonadherence in the usual care group but not in the intervention group. These findings suggest efforts to screen for MNCD are needed during ACS hospitalization to identify patients at risk for nonadherence and who may benefit from an adherence intervention.Keyword: medication adherence

Background: It is unknown if the appropriate use of percutaneous coronary intervention (PCI) has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the rate of PCI use. Methods: We applied 2012 Appropriate Use Criteria to determine the appropriateness of all 51,872 PCI performed in Washington State from 2010 through 2013. PCI procedural rates were studied from 2006 through 2013 to provide a comparator period that preceded statewide appropriateness assessment beginning in 2010. Procedural appropriateness and rates of use were determined separately for acute (ST segment elevation myocardial infarction, non-ST segment myocardial infarction, unstable angina) and elective (stable angina) indications. Results: Between 2010 and 2013, the overall rate of PCI decreased by 6.8% (13,267 PCI in 2010 to 12,193 in 2013) with a 43% decline in the rate of PCI for elective indications (3,818 PCI in 2010 to 2,193 PCI in 2013) (Figure). The rate of decline in elective PCI procedures was significantly larger following the onset of statewide PCI appropriateness assessment in 2010 (P = 0.03). The proportion of PCI for acute indications classified as appropriate remained >92% throughout the study period. The proportion of elective PCI classified as appropriate increased from 26% in 2010 to 38% in 2013 while the proportion of inappropriate PCI decreased from 16% to 13% (P Conclusions: In Washington State, the use of PCI for non-acute indications has decreased over time with concurrent improvements in PCI appropriateness. However, improvements in PCI appropriateness were limited to a minority of hospitals. Understanding processes at these high-performing hospitals may inform efforts to improve PCI appropriateness.

Background. Use of complementary and alterna- tive medicine (CAM) is increasing in the United States. This study investigates whether the use of alternative medicine is associated with a delay of treatment in head and neck cancer. Methods. This study used the records obtained from a large trial involving ambulatory care US veterans. Subjects completed a CAM utilization questionnaire. The primary outcome variable was the time duration from cancer diagnosis to the time of can- cer treatment. Results. Of veterans with head and neck cancer, 51% reported using some form of CAM, whereas 23% reported using a therapy classified as alternative medicine. Patients who used alternative medicine significantly delayed cancer treatment by 22 days compared with those who did not use alternative medi- cine (p ¼ .05, 95% confidence interval (CI) ¼ 0-44 days). Conclusions. CAM use is common in veterans with head and neck cancer. Use of alternative medicine was associated with a significant delay in cancer treatment. V C 2006 Wiley Periodi

Purpose To assess the association between the type of antihypertensive medication and all-cause mortality among patients with chronic obstructive pulmonary disease (COPD). Methods The cohort comprised 1966 patients (mean [± SD] age, 65.8 ± 10.7 years) enrolled in general internal medicine clinics at seven Veterans Affairs medical centers between December 1996 and October 1999. Patients had a diagnosis of both COPD and hypertension and were receiving single-agent antihypertensive therapy. Results Compared with calcium channel blockers, beta-blockers were associated with a decrease in mortality from any cause after adjusting for propensity for having been prescribed a beta-blocker (hazard ratio=0.57; 95% confidence interval: 0.33 to 0.89). The association was similar when beta-blockers were compared with all other antihypertensive medications, and the decreased risk of mortality was apparent among patients with pre-existing cardiac disease. Restriction of analyses to long-acting calcium channel blockers or to patients who used beta-agonists did not affect the point estimates. Exposure to the remaining classes of antihypertensive agents was not associated with mortality. Conclusion Beta-blockers may have beneficial effects in patients who have COPD, pre-existing cardiac disease, and hypertension. Beta-blockers may not be contraindicated among patients with COPD.

Objectives: To compare the risk of congestive heart failure (CHF) in elderly individuals treated with any peripheral alpha-1 antagonist for hypertension with any thiazide, test whether the risk persists in subjects without cardiovascular disease (CVD) at baseline, and examine CHF risk in normotensive men with prostatism treated with alpha antagonists. Design: Prospective cohort study. Setting: Four U.S. sites: Washington County, Maryland; Allegheny County, Pennsylvania; Sacramento County, California; and Forsyth County, North Carolina. Participants: A total of 5,888 community-dwelling subjects aged 65 and older. Measurements: Adjudicated incident CHF. Results: The 3,105 participants with treated hypertension were at risk for CHF; 22% of men and 8% of women took alpha antagonists during follow-up. The age-adjusted risk of CHF in those receiving monotherapy treated with alpha antagonists was 1.90 (95% confidence interval=1.03–3.50) compared with thiazides. In subjects without CVD at baseline receiving monotherapy, women taking an alpha antagonist had a 3.6 times greater age-adjusted risk of CHF, whereas men had no difference in risk. Adjustment for systolic blood pressure attenuated statistical differences in risk. There were 930 men without hypertension at risk for CHF; 5% used alpha antagonists during follow-up, with no observed increase in CHF risk. Conclusion: Subjects receiving alpha antagonist monotherapy for hypertension had a two to three times greater risk of incident CHF, also seen in lower-risk subjects, but differences in blood pressure control partly explained this.

Objectives: To evaluate the association between alcohol screening results and health status or mortality in elderly patients. Design: Cross-sectional and longitudinal cohort studies. Setting: Primary care clinics at seven Veterans Affairs medical centers. Participants: A total of 16,958 male patients aged 65 and older. Measurements: Alcohol screening questionnaires were used to divide patients into four mutually exclusive groups: drinkers who screened negative or positive for problem drinking and nondrinkers (in the previous year) who screened negative or positive for problem drinking. A subset of patients (n=12,491) completed a measure of health status, the Medical Outcomes Study Short Form (SF-36). All-cause mortality was ascertained using Veterans Affairs data over a mean follow-up of 2.8 years. Results: Forty-eight percent of participants reported drinking in the previous year. Half of the drinkers and nondrinkers screened positive for problem drinking. The SF-36 item scores were consistently higher for drinkers than for nondrinkers and for patients who screened negative for problems than for those who screened positive. Similarly, survival was consistently better in drinkers than nondrinkers (mortality hazard ratio (HR)=0.74, 95% confidence interval (CI)=0.68–0.82) and in patients who screened negative for problem drinking than in those who screened positive (mortality HR=0.87, 95% CI=0.80–0.95). Nondrinkers who screened positive for problem drinking had the poorest health status and survival, whereas drinkers who screened negative for problem drinking had the best health status and survival. Conclusion: Elderly patients who reported drinking alcohol and those who screened negative for problem drinking had consistently better health status and survival than those who did not drink and those who screened positive.

Observational studies of inhaled corticosteroids in chronic obstructive pulmonary disease (COPD) have shown improved survival whereas randomized trials have not. It has been suggested that this difference may be due to immortal time bias. To investigate this further, we performed a prospective cohort study of patients with COPD, using time-dependent methods to determine whether use of inhaled corticosteroids more than 80% of the time reduced the risk of all-cause mortality and COPD exacerbations. Of 8,033 patients, 2,686 (33%) received inhaled corticosteroids. We did not find a significant reduction in mortality for average inhaled steroid use at either low (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.69-1.33) or medium/high dose (HR, 0.86; 95% CI, 0.67-1.10). Similarly, recent inhaled corticosteroid use was not associated with a reduction in mortality at low (HR, 0.80; 95% CI, 0.60-1.07) or medium/high doses (HR, 0.88; 95% CI, 0.71-1.09). There was no association between inhaled corticosteroid use and hospitalizations or exacerbations due to COPD. Patients using medium/high-dose inhaled corticosteroids did not have a significantly lower risk of COPD hospitalizations (HR, 0.85; 95% CI, 0.64-1.13) or COPD exacerbations (HR, 1.13; 95% CI, 0.94-1.36). In a time-dependent study of outpatients with COPD, adherence to inhaled corticosteroid use was not associated with a decreased risk of mortality or exacerbations.

Age, race, education, and diabetes have been associated with differences in anginal symptoms, treatments, and outcomes among outpatients with coronary artery disease (CAD), but there is little data on whether such characteristics affect relationships between anginal symptoms and mortality.Using a prospective cohort design, we examined associations of anginal symptoms, as assessed by the Seattle Angina Questionnaire, with total mortality among 8908 outpatients with CAD to investigate whether this relationship is influenced by patient demographic or clinical characteristics. Potential effect modification was primarily assessed for age, race, education, and diabetes, and secondarily assessed for smoking, prevalent congestive heart failure (CHF), myocardial infarction, and coronary revascularization.Over 2 years mean follow-up, there were 896 deaths. After adjustment for potential confounders, persons reporting greater physical limitation due to angina had higher mortality: 27% higher with mild limitation (hazard ratio [HR] 1.27, 95% CI 0.98-1.64), 61% higher with moderate limitation (HR 1.61, 95% CI 1.27-2.05), and 2.5-fold higher with the greatest limitation (HR 2.55, 95% CI 1.97-3.30), compared with little or no limitation (P for trend.001). Anginal instability was also independently predictive of mortality. There was little evidence that these relationships varied by age, race, education, diabetes, smoking, or presence of CHF, prior myocardial infarction, or prior coronary revascularization (P for each interaction.28). Anginal symptoms predicted higher mortality risk comparable to a decade of age difference, presence of diabetes, or presence of CHF.Among outpatients with CAD, self-reported anginal symptoms consistently predict mortality irrespective of differences in age, race, education, or clinical comorbidities.

Background: Prior studies have shown that depression may be associated with longitudinal medication non-adherence for patients with chronic cardiovascular disease. However, little is known about depression and medication adherence following acute coronary syndrome (ACS) hospitalization. Our objective was to assess whether depression was associated with longitudinal medication adherence following ACS among Veterans enrolled in a clinical trial designed to improve medication adherence. Methods: Patients included in the current analysis were enrolled in the MEDICATION study, which tested a multifaceted intervention versus usual care to improve medication adherence in the year following ACS hospitalization at 4 VA Medical Centers. Depression was assessed using the Patient Health Questionnaire (PHQ-9) prior to hospital discharge based on a score of ≥10. Medication adherence was assessed for 4 classes of cardioprotective medications (Statins, ACEI/ARBs, Clopidogrel, and Beta Blockers) in the 12-months following hospital discharge using pharmacy refill data. A proportion of days covered (PDC) was calculated based on the 4 classes of medications, and adherent patients were categorized based on a PDC ≥0.80. Then, we assessed the association between depression and medication adherence in the year after ACS hospitalization. Results: Of the 241 patients, the average age was 63.9 years, mean BMI was 30.9 kg/m 2 , and they had a number of comorbidities: 45.2% had diabetes and 65.6% had a history of coronary artery disease. The mean PHQ-9 score was 8.2 and 35.4% had depression (PHQ≥10) prior to discharge, with no difference in the prevalence of depression between treatment groups. In the year after ACS hospitalization, the mean PDC was 0.90 for all patients and there was no difference between depressed (PDC=0.91) and non-depressed patients (PDC=0.90). Among patients in the usual care group, there was also no difference in adherence between depressed (PDC=0.88) and non-depressed (PDC=0.86) patients. Conclusions: In this cohort of patients enrolled in a clinical trial, depression was present in 1 out of 3 patients during ACS hospitalization but not associated with medication adherence in the year after hospital discharge. A potential explanation for the lack of association between depression and adherence may be related to the overall high adherence rates found in the MEDICATION study. It will be important to assess whether depression is a marker of medication non-adherence in other ACS cohorts.

Background Alcohol use is associated with health behaviors that impact cardiovascular outcomes in patients with hypertension, including avoiding salt, exercising, weight management, and not smoking. This study examined associations between varying levels of alcohol use and self-reported cardiovascular health behaviors among hypertensive Veterans Affairs (VA) outpatients. Methods Male outpatients with self-reported hypertension from 7 VA sites who returned mailed questionnaires ( N = 11,927) were divided into 5 levels of alcohol use: nondrinking, low-level use, and mild, moderate, and severe alcohol misuse based on AUDIT-C (Alcohol Use Disorders Identification Test—Consumption) scores (0, 1–3, 4–5, 6–7, and 8–12, respectively). For each category, adjusted logistic regression models estimated the prevalence of patients who self-reported avoiding salt, exercising, controlling weight, or not smoking, and the composite of all four. Results Increasing level of alcohol use was associated with decreasing prevalence of avoiding salt, controlling weight, not smoking, and the combination of all 4 behaviors ( P values all Conclusions Alcohol consumption is inversely associated with adherence to cardiovascular self-care behaviors among hypertensive VA outpatients. Clinicians should be especially aware of alcohol use level among hypertensive patients.

Background. Despite evidence demonstrating clinical benefits of oral hypoglycemic agents (OHAs), adherence to OHAs is generally poor. The economic benefit of OHA adherence among patients in the Veterans Affairs Health System (VA) is unknown. Objective. This study assessed the impact of OHA adherence on medical costs and hospitalization probability in a VA population. Methods. This retrospective cohort study included 26 051 VA patients with diabetes who completed the 2006 Survey of Health Care Experiences of Patients. We calculated total costs in fiscal year (FY) 2007 from the VA perspective as the sum of costs for all inpatient and outpatient services provided by VA. We measured adherence using the medication possession ratio (MPR), which reflected the proportion of days covered in FY2007. Patients were classified as adherent if MPR ≥80%. Analyses using instrumental variables (IVs) addressed potential biases from unobserved confounding. Results. On average, adherent patients incurred lower total medical costs ($4051 vs $5133, P < 0.001) and were less likely to be hospitalized (4.6% vs 7.2%, P < 0.001) compared with nonadherent patients. After covariate adjustment, adherence was associated with a $170 reduction in total costs ( P < 0.011) and a 1.5 percentage point decrease ( P < 0.001) in hospitalization probability. IV estimates indicated that the impacts of OHA adherence were larger in magnitude. Conclusion. On average, OHA adherence was associated with lower medical costs of at least $170 per patient over a 1-year period. Results from this study are important for informing policy decisions to broadly disseminate programs to promote diabetes medication adherence, particularly in a VA setting.

Importance Adherence to cardioprotective medication regimens in the year after hospitalization for acute coronary syndrome (ACS) is poor. Objective To test a multifaceted intervention to improve adherence to cardiac medications. Design, Setting, and Participants In this randomized clinical trial, 253 patients from 4 Department of Veterans Affairs medical centers located in Denver (Colorado), Seattle (Washington); Durham (North Carolina), and Little Rock (Arkansas) admitted with ACS were randomized to the multifaceted intervention (INT) or usual care (UC) prior to discharge. Interventions The INT lasted for 1 year following discharge and comprised (1) pharmacist-led medication reconciliation and tailoring; (2) patient education; (3) collaborative care between pharmacist and a patient’s primary care clinician and/or cardiologist; and (4) 2 types of voice messaging (educational and medication refill reminder calls). Main Outcomes and Measures The primary outcome of interest was proportion of patients adherent to medication regimens based on a mean proportion of days covered (PDC) greater than 0.80 in the year after hospital discharge using pharmacy refill data for 4 cardioprotective medications (clopidogrel, β-blockers, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors [statins], and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers [ACEI/ARB]). Secondary outcomes included achievement of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) level targets. Results Of 253 patients, 241 (95.3%) completed the study (122 in INT and 119 in UC). In the INT group, 89.3% of patients were adherent compared with 73.9% in the UC group ( P = .003). Mean PDC was higher in the INT group (0.94 vs 0.87; P P = .03), statins (93.2% vs 71.3%; P P = .03) but not β-blockers (88.1% vs 84.8%; P = .59). There were no statistically significant differences in the proportion of patients who achieved BP and LDL-C level goals. Conclusions and Relevance A multifaceted intervention comprising pharmacist-led medication reconciliation and tailoring, patient education, collaborative care between pharmacist and patients’ primary care clinician and/or cardiologist, and voice messaging increased adherence to medication regimens in the year after ACS hospital discharge without improving BP and LDL-C levels. Understanding the impact of such improvement in adherence on clinical outcomes is needed prior to broader dissemination of the program. Trial Registration clinicaltrials.gov Identifier:NCT00903032

Literature indicates favorable selection among Medicare Advantage (MA) enrollees compared with fee-for-service (FFS) enrollees. This study examined whether favorable selection into MA affected readmission rates among Medicare-eligible veterans following hospitalization for congestive heart failure in the Veterans Affairs Health System (VA). We measured total (VA + Medicare FFS) 30-day all-cause readmission rates across hospitals and all of VA. We used Heckman’s correction to adjust readmission rates to be representative of all Medicare-eligible veterans, not just FFS-enrolled veterans. The adjusted all-cause readmission rate among FFS veterans was 27.1% (95% confidence interval [CI] = 26.5% to 27.7%), while the adjusted readmission rate among Medicare-eligible veterans was 25.3% (95% CI = 23.6% to 27.1%) after correcting for favorable selection. Readmission rate estimates among FFS veterans generalize to all Medicare-eligible veterans only after accounting for favorable selection into MA. Estimation of quality metrics should carefully consider sample selection to produce valid policy inferences.

Patients who have access to different health care systems, such as Medicare-eligible veterans, may obtain services in either or both health systems. We examined whether quality of diabetes care was associated with care continuity or veterans’ usual source of primary care in a retrospective cohort study of 1,867 Medicare-eligible veterans with diabetes in 2001 to 2004. Underprovision of quality of diabetes care was more common than overprovision. In adjusted analyses, veterans who relied only on Medicare fee-for-service (FFS) for primary care were more likely to be underprovided HbA1c testing than veterans who relied only on Veteran Affairs (VA) for primary care. Dual users of VA and Medicare FFS primary care were significantly more likely to be overprovided HbA1c and microalbumin testing than VA-only users. VA and Medicare providers may need to coordinate more effectively to ensure appropriate diabetes care to Medicare-eligible veterans, because VA reliance was a stronger predictor than care continuity.

Background. It is unknown if patient selection for diagnostic coronary angiography is associated with PCI quality as assessed by the Appropriate Use Criteria (AUC). We sought to determine if hospitals that frequently perform coronary angiography in asymptomatic patients, a clinical scenario where the benefit of angiography is less clear, are more likely to perform inappropriate PCI. Methods. We restricted our analyses to patients without known heart disease undergoing elective (non-acute) angiography or PCI at NCDR hospitals reporting at least 50 PCI procedures annually. As not all NCDR participating hospitals report diagnostic angiograms, we excluded hospitals reporting fewer diagnostic coronary angiograms than PCI. We identified 521,125 patients who underwent elective coronary angiography and 155,220 patients who underwent elective PCI at 553 hospitals reporting to the NCDR CathPCI Registry between July 2009 and June 2012. The association between hospital quartiles of the proportion of asymptomatic patients at angiography and the proportion of inappropriate PCI, per the 2012 AUC, was evaluated by Mantel-Haenszel trend test. Results. Overall, 132,613 patients (25.5%) who underwent coronary angiography were asymptomatic. The hospital proportion of asymptomatic patients at angiography ranged from 0.2% to 87.7%. Categorized as hospital quartiles, the median proportion of asymptomatic patients was 7.9% in hospitals of the lowest-quartile, 15.6% in the second lowest-quartile, 23.7% in the second highest-quartile and 35.5% in the highest-quartile. By hospital quartiles, the proportion of asymptomatic patients at angiography was significantly associated with the proportion of inappropriate PCI (median hospital proportion of inappropriate PCI; 17.7% vs. 22.6% vs. 26.5% vs. 28.9% from lowest to highest quartile, p Conclusions. In a national sample of hospitals performing invasive coronary procedures, the proportion of coronary angiograms performed in asymptomatic patients was associated with the proportion of inappropriate PCI. Further study to clarify factors related to practice variability in processes of patient selection prior to the cardiac catheterization laboratory may optimize the use of both diagnostic angiography and PCI.

Studies have shown that increased medication cost sharing is associated with reductions in medication adherence among prevalent users (Goldman, Joyce, and Zheng 2007), yet the magnitude of adherence reductions has varied across studies. Prevalent users of a medication are patients with a history of filling a medication of interest within a defined lookback period (e.g., 12 months) prior to the copayment change (Ray 2003). Researchers interested in examining medication adherence of prevalent users typically utilize pharmacy administrative data both as a source from which to apply inclusion criteria as well as the substrate data from which adherence measurements are calculated. Prevalent use is typically specified within a defined duration of a lookback period, a number of intervals within the lookback period (e.g., two 6-month periods), and a minimum number of medication fills per interval. Such specifications may vary from inclusive (e.g., one medication fill in the prior 12 months) to restrictive (e.g., two fills within the prior 6 months). The impact of different durations of the lookback periods have been examined in risk adjustment studies (Zhang, Iwashyna, and Christakis 1999; Preen et al. 2006) and in studies identifying incident, or new, medication users (Gardarsdottir, Heerdink, and Egberts 2006). However, the impact of applying different inclusion criteria for identifying prevalent medication users has not been examined previously and is a potential source of between-study difference in estimated adherence changes. This has been demonstrated in two prior evaluations of a $5 VA copayment increase on statin adherence. Both studies defined prevalent users as patients who filled one or more medications in the quarter prior to the copayment change (Doshi et al. 2009; Maciejewski et al. 2010a). One study also required 1+ fills within the 24 months prior to the copayment increase (Doshi et al. 2009) for inclusion, whereas the second study also required 1+ fills in the 4–12 months prior to the copayment increase. The first study with the longer (24-month) medication fill criteria found a significant reduction in statin adherence (Doshi et al. 2009). Another study (Maciejewski et al. 2010a) found no significant reduction, suggesting that the chosen lookback period and criteria may unduly influence findings or inferences. Studies of medication adherence have applied different lookback and historic fill criteria to define prevalent users (Table 1), which may have contributed to the variability in the estimated adherence response across studies. Table 1 Summary of Prior Literature on Medication Inclusion Criteria for Identifying Prevalent User Cohorts in Copay Change Evaluations Alternative inclusion criteria are likely to retain differing proportions of poorly adherent, episodic, and highly adherent patients, as well as differing proportions of current and noncurrent medication users. In the absence of gold standard inclusion criteria for identifying prevalent medication users, we conducted two analyses to examine whether the choice of medication use inclusion criteria causes variation in estimated adherence changes associated with a copayment increase. In the first analysis, we applied different medication use inclusion criteria to a sampling frame for a fixed index date (February 2002) when the VA medication copayment increase was implemented. This first approach allowed us to examine whether different inclusion criteria generated similar or different adherence trends when the index date was held constant. This is analogous to four research teams independently evaluating the same policy change, each using a different set of inclusion criteria to identify prevalent users. In the second analysis, we applied the same medication use inclusion criteria to the same sampling frame but at four different time periods. The time periods included the date of the actual copayment change (February 2002) when we expected an adherence response, and three alternative time periods when we did not expect an adherence response because no cost-sharing changes occurred. These alternative time periods were established 6 months before the copayment increase (August 2001), 6 months after (August 2002), and 12 months after the copayment increase (February 2003). We retained similar proportions of poorly adherent, episodic, and highly adherent patients using a common inclusion criterion. This allowed us to examine whether adherence trends associated with the copayment change differed from adherence trends observed in time periods when no medication copayment changes occurred. This second evaluation is analogous to testing the stability in adherence trends in the absence of copayment changes. We would have greater confidence that the adherence changes around the actual copayment increase were valid if no adherence changes were observed at these alternative three time points. On the other hand, the validity of our results would be called into question if similar adherence trends were observed at all four time periods because the similar trends would suggest that we induced an artifact by our particular choice of inclusion criteria. These two analyses are informative for researchers and policy makers identifying prevalent medication user cohorts from secondary data to evaluate the effects of policy changes on medication use. To ensure that comparative effectiveness research (CER) for medication use based on observational studies generates unbiased results, it is important to understand the possible influence of inclusion criteria for identifying prevalent users on adherence results.

Background COPD and hypertension both increase the risk of congestive heart failure (CHF). Current clinical trials do not inform the selection of combination antihypertensive therapy among patients with COPD. We performed a comparative effectiveness study to investigate whether choice of dual agent antihypertensive therapy is associated with risk of hospitalization for CHF among patients with these two conditions. Methods We identified a cohort of 7,104 patients with COPD and hypertension receiving care within Veterans Administration hospitals between January 2001 and December 2006, with follow-up through April 2009. We included only patients prescribed two antihypertensive medications. We used Cox proportional hazard models for statistical analysis. Results Compared with β-blockers plus an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, patients prescribed a thiazide diuretic plus a β-blocker (adjusted hazard ratio [HR], 0.49; 95% CI, 0.32-0.75), a thiazide plus an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (adjusted HR, 0.50; 95% CI, 0.35-0.71), and a thiazide plus a calcium channel blocker (adjusted HR, 0.55; 95% CI, 0.35-0.88) had a significantly lower risk of hospitalization for CHF. After stratification by history of CHF, we found that this association was isolated to patients without a history of CHF. Adjustment for patient characteristics and comorbidities had a small effect on risk of hospitalization. Choice of antihypertensive medication combination had no significant association with risk of COPD exacerbation. Conclusions Among patients with comorbid hypertension and COPD requiring two antihypertensive agents, combination therapy that includes a thiazide diuretic was associated with a significantly lower risk of hospitalization for CHF among patients without a history of CHF.

Alcohol misuse is associated with poor adherence to recommended self-care behaviors, which are critical for diabetes management. This study investigated whether scores on a validated brief alcohol misuse screen are associated with diabetes self-care.Male outpatients (n=3,930) from seven Veterans Affairs sites returned the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) alcohol screen on mailed surveys and indicated they had diabetes. Patients were divided into five alcohol screening groups: no past year alcohol use (AUDIT-C 0), low-level alcohol use (AUDIT-C 1-3); and mild (AUDIT-C 4-5), moderate (AUDIT-C 6-7), and severe (AUDIT-C 8-12) misuse. Outcomes included self-report of monitoring blood glucose, maintaining normal blood glucose levels, inspecting feet, following a meal plan, not smoking, and laboratory data indicating that glycosylated hemoglobin A1c (HbA1c) had been tested in the past year. For each group, the proportion of patients adherent to each behavior were estimated from logistic regression models adjusted for demographics, comorbidity, and depressive symptoms.Patients who did not drink were most likely to report adherence to self-care behaviors, except for past-year HbA1c testing. Compared to patients who did not drink, patients with AUDIT-C scores ?6 were significantly less likely to report maintaining normal blood glucose levels (eg, AUDIT-C 6-7 44% versus AUDIT-C 0 59%) or following a meal plan (48% versus 58%), and were more likely to smoke (71% abstained versus 85%) in adjusted analyses.Results of this study indicate that higher alcohol screening scores are associated with poorer diabetes self-care.

Contributions of informal caregivers to adherence among chronic obstructive pulmonary disease (COPD) patients remain understudied.This study aims to evaluate the association between caregiver presence and adherence to medical recommendations among COPD patients.Three hundred and seventy-four COPD patients were asked whether they had a caregiver. Medication adherence was assessed using pharmacy refill data. Smoking status was based on patient self-report. One-way ANOVAs and chi-square analyses were performed controlling for age and number of illnesses.Compared with the "no caregiver" group, antihypertensive medications adherence was higher in the "spousal caregiver" (0.68 vs. 0.81; 95% CI=0.04 and 0.22) and "non-spousal caregiver" (0.68 vs. 0.80; 95% CI=0.03 and 0.22) groups; long-acting beta agonist adherence was higher in the "spousal caregiver" group (0.60 vs.0.80; 95% CI=0.05 and 0.43). Patients in the "spousal caregiver" group had fewer current smokers compared with the "no caregiver" (χ(2)=16.08; p0.001) and "non-spousal caregiver" (χ(2)=5.07; p0.05) groups; those in the "non-spousal caregiver" group reported fewer smokers than the "no caregiver" group (χ(2)=4.54; p0.05).Caregivers, especially spouses, may improve adherence in COPD. Future interventions may target patients without caregivers to optimize COPD management.

Background More than half of veterans who use Veterans Health Administration (VA) care are also eligible for Medicare via disability or age, but no prior studies have examined variation in use of outpatient services by Medicare-eligible veterans across health system, type of care or time. Objectives To examine differences in use of VA and Medicare outpatient services by disability-eligible or age-eligible veterans among veterans who used VA primary care services and were also eligible for Medicare. Methods A retrospective cohort study of 4,704 disability- and 10,816 age-eligible veterans who used VA primary care services in fiscal year (FY) 2000. We tracked their outpatient utilization from FY2001 to FY2004 using VA administrative and Medicare claims data. We examined utilization differences for primary care, specialty care, and mental health outpatient visits using generalized estimating equations. Results Among Medicare-eligible veterans who used VA primary care, disability-eligible veterans had more VA primary care visits (p < 0.001) and more VA specialty care visits (p < 0.001) than age-eligible veterans. They were more likely to have mental health visits in VA (p < 0.01) and Medicare-reimbursed visits (p < 0.01). Disability-eligible veterans also had more total (VA+Medicare) visits for primary care (p < 0.01) and specialty care (p < 0.01), controlling for patient characteristics. Conclusions Greater use of primary care and specialty care visits by disability-eligible veterans is most likely related to greater health needs not captured by the patient characteristics we employed and eligibility for VA care at no cost. Outpatient care patterns of disability-eligible veterans may foreshadow care patterns of veterans returning from Afghanistan and Iraq wars, who are entering the system in growing numbers. This study provides an important baseline for future research assessing utilizations among returning veterans who use both VA and Medicare systems. Establishing effective care coordination protocols between VA and Medicare providers can help ensure efficient use of taxpayer resources and high quality care for disabled veterans.

Prior research found that in the Veterans Affairs health care system (VA), the proportion of patients adherent to oral hypoglycemic agents varies from 50% to 80% across primary care clinics. This study examined whether variation in patient and facility characteristics determined those differences.Retrospective cohort study of 444,418 VA primary care patients with diabetes treated in 559 clinics in fiscal year (FY) 2006-2007. Patients' adherence to each oral hypoglycemic agent was computed for the first 3 months of FY2007, and averaged across agents to produce an adherence score for the patient's overall regimen. Patients with an adherence score over 0.8 were defined as adherent. Risk adjustment used hierarchical logistic regression accounting for patient factors and facility effects by clustering patients within clinics and clinics within parent VA medical centers. We then assessed the influence of risk adjustment using observed-to-expected (O/E) ratios computed for each clinic.The mean unadjusted proportion of adherent patients in clinics was 0.715 (interdecile range 0.559-0.826). The percent variation in patient's likelihood of being adherent explained at the patient, clinic, and parent VA medical center levels was 2.94%, 0.27%, and 0.76%, respectively. The mean clinic-level observed-to-expected ratio was 1.001 (interdecile range 0.975-1.027).The variation in the proportion of patients adherent across clinics remained large after risk adjustment. As patient and facility effects explained only 4% of the variance in adherence, comparing clinics based on unadjusted scores is a reasonable starting point unless more predictive patient, provider, and facility factors are identified.

Background. The use of percutaneous coronary intervention (PCI) has increased dramatically in the past decade despite uncertainty regarding the appropriateness of these procedures. Methods. Within the Clinical Outcomes Assessment Program (COAP), a quality-improvement initiative that captures all revascularization procedures performed in Washington State, we assessed the appropriateness of PCI performed between June 2009 and September 2010 in accordance with published Appropriate Use Criteria. We report the appropriateness of PCI stratified by acute (acute myocardial infarction or unstable angina with high-risk features) or non-acute (stable angina) coronary presentation. Results. Of 12,528 PCI performed during the study period, we successfully mapped the PCI indication to the Appropriate Use Criteria in 9,025 (72%) of cases. Of the 3,521 PCI not classified, common failures to map to the criteria included acute PCI of multiple lesions without evidence of shock (n=517, 14.7%), unstable angina without high-risk features (n=918, 26.1%), or non-acute PCI without preprocedural non-invasive stress results (n=2,049, 58.2%). Of mapped PCI, 7,031 (77.9%) were for acute indications with 6,921 (98.4%) rated as “appropriate”, 40 (0.6%) as “uncertain”, and 70 (1.0%) as “inappropriate”. Of 1,987 non-acute coronary presentations, 788 (39.7%) were rated as appropriate, 812 (40.9%) as uncertain, and 387 (19.5%) as inappropriate (Table). Assuming non-acute PCI with missing data on non-invasive stress test were performed in the setting of high-risk non-invasive stress testing, 387 (9.8%) PCI were inappropriate. Conclusion. In a complete cohort of PCI performed in Washington State, 1.0% of PCI for acute indications and 9.8% of PCI for non-acute indications were classified as inappropriate after assumptions to maximize appropriateness. These findings suggest an opportunity to improve the selection of patients undergoing PCI to maximize anticipated benefit. TABLE 1 Appropriateness of PCI in Washington State PCI Indication Total Cases Appropriateness Rating by Indication, n (%) Appropriate Uncertain Inappropriate All PCI 9018 7708 (85.4) 853 (9.5) 464 (4.7) Acute presentation 7031 6921 (98.4) 40 (0.6) 70 (1.0) Non-acute presentation 1987 788 (39.7) 812 (40.9) 387 (19.5) Acute presentation includes STEMI, NSTEMI, and unstable angina with high risk features. Non-acute presentation is limited to stable angina.

Patients who screen positive for alcohol misuse on the Alcohol Use Disorder Identification Test Consumption Questionnaire (AUDIT-C ≥5 points) have significantly increased postoperative complications. Severe alcohol misuse (AUDIT-C ≥9 points) is associated with increased postoperative health care use; however, little is known about the prevalence of alcohol misuse in demographic and clinical subgroups of surgical patients.The prevalence of alcohol misuse was evaluated among 10,284 patients (9,771 men and 513 women) who underwent major noncardiac surgery in Veterans Affairs (VA) hospitals during the fiscal years 2004 to 2006 and completed the AUDIT-C. Sex-stratified analyses evaluated prevalence rates of alcohol misuse (AUDIT-C ≥5) and severe misuse (AUDIT-C ≥9) across demographic and clinical subgroups.Overall, 1,607 (16%) men and 24 (5%) women screened positive for alcohol misuse (AUDIT-C ≥5) in the year before operation, with 4% and 2% screening positive for severe misuse (AUDIT-C ≥9), respectively. Alcohol misuse was more common among men who were60 years of age, divorced or separated, current smokers, or American Stoke Association class 1 or 2, and those with cirrhosis/hepatitis or substance use disorders. Among patients with alcohol misuse, 36% of men and 58% of women were American Society of Anesthesiologists class 1 or 2, and most did not have diagnoses that were commonly associated with alcohol misuse.Alcohol misuse is relatively common in male surgical patients. Moreover, surgical patients undergoing operation who screen positive for alcohol misuse are often relatively healthy, without health problems that might alert providers to their alcohol misuse in the absence of screening.

Alcohol consumption is a risk factor for traumatic injury, but it is unknown whether responses to alcohol screening questionnaires administered routinely in primary care are associated with subsequent hospitalization for traumatic injury.We evaluated the association between alcohol screening scores and the risk for subsequent hospitalizations for trauma among Veterans Affairs (VA) general medicine patients.This study included VA outpatients (n = 32,623) at seven sites who returned mailed surveys (1997-1999). Alcohol Use Disorders Identification Test Consumption (AUDIT-C) scores grouped patients into six drinking categories representing nondrinkers, screen-negative drinkers, and drinkers who screened positive for mild, moderate, severe, and very severe alcohol misuse (scores 0, 1-3, 4-5, 6-7, 8-9, 10-12, respectively). VA administrative and Medicare data identified primary discharge diagnoses for trauma. Cox proportional hazard models were used to estimate the risk of trauma-related hospitalization for each drinking group adjusted for demographics, smoking, and comorbidity.Compared with screen-negative drinkers, patients with severe and very severe alcohol misuse (AUDIT-C 8-9 and ≥10) were at significantly increased risk for trauma-related hospitalization over the follow-up period (adjusted hazard ratios AUDIT-C: 8-9 2.06, 95% confidence interval (CI) 1.31- 3.24 and AUDIT-C≥10 2.13, 95% CI 1.32-3.42).Patients with severe and very severe alcohol misuse had a twofold increased risk of hospital admission for trauma compared to drinkers without alcohol misuse.Alcohol screening scores could be used to provide feedback to patients regarding risk of trauma-related hospitalization. Findings could be used by providers during brief alcohol-related interventions with patients with alcohol misuse.

Background High-quality systems have adopted a comprehensive approach to preventive care instead of diagnosis or procedure driven care. The current emphasis on prescribing medications to prevent complications of coronary artery disease (CAD) at discharge following an acute coronary syndrome (ACS) may exclude high-risk patients who are hospitalized with conditions other than ACS. Methods Among a sample of patients with CAD treated at Veterans Affairs medical centers between January, 2005 and November, 2006, we investigated whether recent non-ACS hospitalization was associated with prescriptions of preventive medications as compared with patients recently hospitalized with ACS. Results Of 13,211 patients with CAD, 58% received aspirin, 70% β-blocker, 60% angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB), and 65% lipid-lowering therapy. Twenty-five percent of eligible patients were receiving all four medications. Having been hospitalized for a non-ACS event in the prior 6 months did not substantially affect the adjusted proportion on preventive medications. In contrast, among patients hospitalized for ACS in the prior 6 months, the adjusted proportion prescribed aspirin was 21% higher (p < 0.001), β-blocker was 14% higher (p < 0.001), ACE-I or ARB was 9% higher (p < 0.001), lipid therapy was 12% higher (p < 0.001), and prescribed all four medications was 18% higher (p < 0.001) than among patients hospitalized for ACS more than 2 years earlier. Conclusions Being hospitalized for a non-ACS condition did not appear to influence preventive medication use among patients with CAD and represents a missed opportunity to improve patient care. The same protocols employed to improve use of preventive medications in patients discharged for ACS might be extended to CAD patients discharged for other conditions as well.

Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed. To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire—up to a year before surgery—were associated with the risk of postoperative complications. This is a cohort study. Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA’s Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery. One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews. Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8–6.6%) in patients with AUDIT-C scores 1–4, to 7.9% (6.3–9.7%) in patients with AUDIT-Cs 5–8, 9.7% (6.6–14.1%) in patients with AUDIT-Cs 9–10 and 14.0% (8.9–21.3%) in patients with AUDIT-Cs 11–12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1–5.7%) in patients with AUDIT-C scores 1–4, to 6.9% (5.5–8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0–11.3%) among those with AUDIT-Cs 9–10. AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.

Hospitalizations for ambulatory care sensitive conditions (ACSCs) are used to assess quality of care, but studies rarely adjust for health behaviors. This study evaluated whether results of smoking or alcohol screening were associated with hospitalizations for ACSCs. Participants included 33,273 male Veterans Affairs general medicine outpatients who returned mailed surveys. The main outcome was hospitalization with a primary discharge diagnosis for an ACSC in the year following screening. Analyses were adjusted for demographics, comorbidity, and other health behaviors. Current and previous smoking and abstaining from alcohol were associated with significantly increased risk of hospitalization for ACSCs, but alcohol misuse was not. However, severe alcohol misuse was associated with increased risk of hospitalizations with a primary or secondary ACSC discharge diagnosis. When ACSCs are used to evaluate the quality of care, health systems caring for populations with higher rates of smoking or nondrinking could falsely appear to have poorer quality care if alcohol and tobacco use are not considered.