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2024 DEC 7 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- New research on veterans health is the subject of a new report. [...]

2024 MAR 30 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- Researchers detail new data in veterans health. According to news reporting from [...]

2023 JUL 1 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- Investigators discuss new findings in veterans health. According to news reporting out [...]

Objective: To examine the relationship between care fragmentation and patient ratings of care quality and identify potentially actionable mediators. Data Sources/Study Setting: 2015 telephone survey of 1395 women Veterans with three or more visits in primary care and/or women's health care in the prior year at 12 Veterans Affairs (VA) medical centers. Study Design: Cross-sectional analysis. Data Collection/Extraction Methods: We operationalized lower care fragmentation as receiving VA-only care versus dual use of VA/non-VA care. Participants rated VA care quality (overall care, women's health care (WH), and primary care (PC)) and three aspects of their patient experience (ease of access to services, provider communication, and gender sensitivity of VA environments). We examined associations between care fragmentation and care ratings and applied the Karlson-Holm-Breen decomposition method to test for mediation by aspects of patients' experience. Principal Findings: Lower care fragmentation was associated with higher ratings of care quality (odds ratios [95% CI] for overall care: 1.57 [1.14;2.17]; WH: 1.65 [1.20;2.27]; PC: 1.41 [1.10;1.82]). Relationships were mediated by patient-rated provider communication and gender sensitivity (26-54 percent and 14-15 percent of total effects, respectively). Ease of access was associated with higher care ratings (odds ratios [95% CI] for overall care: 2.93 [2.25;3.81]; WH: 2.81 [2.15;3.68]; PC: 2.33 [1.63;3.33], in models with the three types of patient care experiences included), but did not mediate the association of care fragmentation and care ratings. Conclusions: Potential negative effects of care fragmentation on care quality ratings could be mitigated by attention to quality of patient-provider communication and gender sensitivity of VA environments. KEYWORDS access to care, gender, patient experience, patient-provider communication, Veterans, 1 | INTRODUCTION In the face of widely publicized access delays, the 2014 Veterans Access, Choice and Accountability Act created new provisions for Veteran access to care by increasing Veterans [...]

Objective: To develop and test predictive models of housing instability and homelessness based on responses to a brief screening instrument administered throughout the Veterans Health Administration (VHA).Data Sources/Study Setting: Electronic medical record data from 5.8 million Veterans who responded to the VHA's Homelessness Screening Clinical Reminder (HSCR) between October 2012 and September 2015.Study Design: We randomly selected 80% of Veterans in our sample to develop predictive models. We evaluated the performance of both logistic regression and random forests--a machine learning algorithm--using the remaining 20% of cases.Data Collection/Extraction Methods: Data were extracted from two sources: VHA's Corporate Data Warehouse and National Homeless Registry.Principal Findings: Performance for all models was acceptable or better. Random forests models were more sensitive in predicting housing instability and homelessness than logistic regression, but less specific in predicting housing instability. Rates of positive screens for both outcomes were highest among Veterans in the top strata of model-predicted risk.Conclusions: Predictive models based on medical record data can identify Veterans likely to report housing instability and homelessness, making the HSCR screening process more efficient and informing new engagement strategies. Our findings have implications for similar instruments in other health care systems.KEYWORDShomelessness, veterans, 1 | INTRODUCTIONHousing instability and especially homelessness, which is an acute form of housing instability, are associated with a range of adverse health outcomes (1,2) and increased costs for health [...]

At the height of debates over the Affordable Care Act, Reed Tuckson (then a VP at United Healthcare) implored the audience of health service researchers, "You wanted to be relevant--well, [...]

Objective. To examine factors associated with 0- to 7-day admission after outpatient surgery in high-volume specialties: general surgery, orthopedics, urology, ear/nose/throat, and podiatry. Study Design. We calculated rates and assessed diagnosis codes for 0- to 7-day admission after outpatient surgery for Centers for Medicare and Medicaid Services (CMS) and Veterans Health Administration (VA) dually enrolled patients age 65 and older. We also estimated separate multilevel logistic regression models to compare patient, procedure, and facility characteristics associated with postoperative admission. Data Collection. 2011-2013 surgical encounter data from the VA Corporate Data Warehouse; geographic data from the Area Health Resources File; CMS enrollment and hospital admission data. Principal Findings. Among 63,585 outpatient surgeries in 124 facilities, 0- to 7-day admission rates ranged from 5 percent (podiatry) to 28 percent (urology); nearly 66 percent of the admissions occurred on the day of surgery. Only 97 admissions were detected in the CMS data (1 percent). Surgical complications were diagnosed in 4 percent of admissions. Procedure complexity, measured by relative value units or anesthesia risk score, was associated with admission across all specialties. Conclusion. As many as 20 percent of VA outpatient surgeries result in an admission. Complex procedures are more likely to be followed by admission, but more evidence is required to determine how many of these reflect potential safety or quality problems. Key Words. Ambulatory surgery, adverse event detection, readmissions, health services research, Veterans Health Administration, Hospital admission following outpatient surgery may be associated with a patient safety problem. Similar to readmissions following inpatient surgery, some outpatient surgical admissions may be preventable with improvements in surgical [...]

Objective. To test the effectiveness of a collaborative depression care model in improving depression and hepatitis C virus (HCV) care. Data Sources/Study Setting. Hepatitis C virus clinic patients who screened positive for depression at four Veterans Affairs Hospitals. Study Design. We compared off-site depression collaborative care (delivered by depression care manager, pharmacist, and psychiatrist) with usual care in a randomized trial. Primary depression outcomes were treatment response (>50 percent decrease in 20-item Hopkins Symptoms Checklist [SCL-20] score), remission (mean SCL-20 score, Data Collection. Patient data were collected by self-report telephone surveys at baseline and 12 months, and from electronic medical records. Principal Findings. Baseline screening identified 292 HCV-infected patients with depression, and 242 patients completed 12-month follow-up (82.9 percent). Intervention participants were more likely to report depression treatment response, remission, and more DFDs than usual care participants. Intervention participants were more likely to receive antiviral treatment; however, the difference was not statistically significant. Conclusion. Off-site depression collaborative care improved depression outcomes in HCV patients and may serve as a model for collaboration between mental health and specialty physical health providers in other high co-occurring conditions. Key Words. Physical health, depression, hepatitis C, Depression is one of the most common mental health disorders affecting persons with chronic hepatitis C virus (HCV) infection (El-Serag et al. 2002; Lehman and Cheung 2002; Bini et al. [...]

Objective. To examine associations between clinics' extent of patient-centered medical home (PCMH) implementation and improvements in chronic illness care quality. Data Source. Data from 808 Veterans Health Administration (VHA) primary care clinics nationwide implementing the Patient Aligned Care Teams (PACT) PCMH initiative, begun in 2010. Design. Clinic-level longitudinal observational study of clinics that received training and resources to implement PACT. Clinics varied in the extent they had PACT components in place by 2012. Data Collection. Clinical care quality measures reflecting intermediate outcomes and care processes related to coronary artery disease (CAD), diabetes, and hypertension care were collected by manual chart review at each VHA facility from 2009 to 2013. Findings. In adjusted models containing 808 clinics, the 77 clinics with the most PACT components in place had significantly larger improvements in five of seven chronic disease intermediate outcome measures (e.g., BP < 160/100 in diabetes), ranging from 1.3 percent to 5.2 percent of the patient population meeting measures, and two of eight process measures (HbA1c measurement, LDL measurement in CAD) than the 69 clinics with the least PACT components. Clinics with moderate levels of PACT components showed few significandy larger improvements than the lowest PACT clinics. Conclusions. Veterans Health Administration primary care clinics with the most PCMH components in place in 2012 had greater improvements in several chronic disease quality measures in 2009-2013 than the lowest PCMH clinics. Key Words. Patient-centered medical home, primary care, chronic disease, quality of care, The patient-centered medical home (PCMH) model of primary care practice (Kellerman and Kirk 2007; American Academy of Family Physicians 2008) is being implemented in multiple health care settings nationwide (Edwards [...]

Objective. To examine whether changes in resident-centered care (RCC) over time were associated with changes in quality. Data Sources/Study Setting. Data sources were the Minimum Dataset quality indicators (which consist of measures of both prevalence and incidence of adverse events) and the Artifacts of Culture Change Tool (which measures RCC; FYs 2009-2012) from 130 Veterans Health Administration community living centers. Study Design. A retrospective longitudinal study. Data Collection/Extraction Methods. Data were from VA secondary data sources. Principal Findings. The overall relationship between RCC and quality was not statistically significant (p = .22), although there was a weakly significant negative relationship (i.e., increased RCC was associated with poorer quality) in the seven quarters after implementation of an automated version of the Artifacts Tool (p = .08). In facility-specific analyses, there were 15 facilities with a weakly significant (p < .10) positive relationship between RCC and quality and 21 with a weakly significant negative relationship. Adjusted cost per patient day was over 50 percent higher in the 21 facilities with a negative relationship than in the 15 facilities with a positive relationship (p < .05). Conclusions. The Artifacts score is a formal performance metric in the VA, and thus, facilities were explicitly incentivized to increase RCC. Using qualitative methods to identify characteristics that distinguished those facilities able to increase both RCC and quality from those that suffered declines in quality as RCC was improved is an important follow-up to this study. Key Words. Nursing homes, resident-centered care, quality, Veterans Health Administration, Following the passage of the Omnibus Budget Reconciliation Act of 1987, skilled nursing facilities (SNFs) became focused on a medical model of care, with an emphasis on standardization, safety, and [...]

Objective. To design and test the validity of a method to identify homelessness among Medicaid enrollees using mailing address data. Data Sources/Study Setting. Enrollment and claims data on Medicaid expansion enrollees in Hennepin and Ramsey counties who also provided self-reported information on their current housing situation in a psychosocial needs assessment. Study Design. Construction of address-based indicators and comparison with self-report data. Principal Findings. Among 1,677 enrollees, 427 (25 percent) self-reported homelessness, of whom 328 (77 percent) had at least one positive address indicator. Depending on the type of addresses included in the indicator, sensitivity to detect self-reported homelessness ranged from 30 to 76 percent and specificity from 79 to 97 percent. Conclusions. An address-based indicator can identify a large proportion of Medicaid enrollees who are experiencing homelessness. This approach may be of interest to researchers, states, and health systems attempting to identify homeless populations. Key Words. Medicaid expansion, homelessness, determinants of health/population health/socioeconomic causes of health, Homelessness is a serious social problem affecting over half a million Americans on any given night (Henry et al. 2015). People who are homeless experience substantial morbidity and premature mortality [...]

Objectives. To examine how dual coverage for nonelderly, low-income veterans by Veterans Affairs (VA) and Medicaid affects their demand for care. Data Sources. Veterans Affairs utilization data and Medicaid Analytic Extract Files. Study Design. A retrospective, longitudinal study of VA users prior to and following enrollment in Medicaid 2006-2010. Data Collection/Extraction Methods. Veterans Affairs reliance, or proportion of care provided by VA, was estimated with beta-binomial models, adjusting for patient and state Medicaid program factors. Principal Findings. In a cohort of 19,890 nonelderly veterans, VA utilization levels were similar before and after enrolling in Medicaid. VA outpatient reliance was 0.65, and VA inpatient reliance was 0.53 after Medicaid enrollment. Factors significantly associated with greater VA reliance included sociodemographic factors, having a service-connected disability, comorbidity, and higher state Medicaid reimbursement. Factors significantly associated with less VA reliance included months enrolled in Medicaid, managed care enrollment, Medicaid eligibility type, longer drive time to VA care, greater Medicaid eligibility generosity, and better Medicaid quality. Conclusion. Veterans Affairs utilization following new Medicaid enrollment remained relatively unchanged, and the VA continued to provide the large majority of care for dually enrolled veterans. There was variation among patients as Medicaid eligibility and other program factors influenced their use of Medicaid services. Key Words. Veterans, Medicaid, utilization, The Veterans Affairs (VA) health care system has historically cared for many low-income veterans without employer-based coverage. While most elderly veterans are dually covered by Medicare and VA, many nonelderly [...]

Objective. To assess the influence of relational climate on quality of diabetes care. Data Sources/Study Setting. The study was conducted at the Department of Veterans Affairs (VA). The VA AH Employee Survey (AES) was used to measure relational climate. Patient and facility characteristics were gathered from VA administrative datasets. Study Design. Multilevel panel data (2008-2012) with patients nested into clinics. Data Collection/Extraction Methods. Diabetic patients were identified using ICD-9 codes and assigned to the clinic with the highest frequency of primary care visits. Multiple quality indicators were used, including an all-or-none process measure capturing guideline compliance, the actual number of tests and procedures, and three intermediate continuous outcomes (cholesterol, glycated hemoglobin, and blood pressure). Principal Findings. The study sample included 327,805 patients, 212 primary care clinics, and 101 parent facilities in 2010. Across all study years, there were 1,568,180 observations. Clinics with the highest relational climate were 25 percent more likely to provide guideline-compliant care than those with the lowest relational climate (OR for a 1-unit increase: 1.02, p-value Conclusions. Relational climate is positively associated with tests and procedures provision, but not with intermediate outcomes of diabetes care. Key Words. Diabetes, primary care, quality of care, relational climate, Successful diabetes quality improvement strategies often involve enhancing team functioning. Expanding roles, building multidisciplinary teams, and collaboratively providing care are a common quality improvement formula (Wagner 2000; Shojania et al. [...]

2021 JUL 24 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- Data detailed on Enterobacteriaceae have been presented. According to news reporting out [...]

Objective. To compare the effects of two sequential policy changes--the addition of a high-potency statin to the Department of Veterans Affairs (VA) formulary and the release of the American College of Cardiology/American Heart Association (ACC/AHA) cholesterol guidelines--on VA provider prescribing. Data Sources/Study Setting. Retrospective analysis of 1,100,682 VA patients, 2011-2016. Study Design. Interrupted time-series analysis of changes in prescribing of moderate-to-high-intensity statins among high-risk patients and across high-risk subgroups. We also assessed changes in prescribing of atorvastatin and other statin drugs. We estimated marginal effects (ME) of formulary and guideline changes by comparing predicted and observed statin use. Data Collection/Extraction Methods. Data from VA Corporate Data Warehouse. Principal Findings. The use of moderate-to-high-intensity statins increased by 2 percentage points following the formulary change (ME, 2.4, 95% confidence interval [CI], 2.2 to 2.6) and less than 1 percentage point following the guideline change (ME, 0.8, 95% CI, 0.6 to 0.9). The formulary change led to approximately a 12 percentage-point increase in the use of moderate-to-high-intensity atorvastatin (ME, 11.5, 95% CI, 11.3 to 11.6). The relatively greater provider response to the formulary change occurred across all patient subgroups. Conclusions. Addition of a high-potency statin to formulary affected provider prescribing more than the ACC/AHA guidelines. Key Words. Veterans Affairs, quality of care, cardiovascular disease, provider interventions, pharmaceuticals, Cholesterol-lowering statin drugs are among the most important tools in medicine for lowering the rates of cardiovascular disease. In spite of this, the quality and effectiveness of statin prescribing are [...]

Objective. To test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient-centered medical homes (PCMH). Data Sources/Study Setting. Primary data were collected as part of the American Academy of Family Physicians' National Demonstration Project of the PCMH. Study Design. We conducted a cross-sectional survey of clinicians and staff from 36 family medicine practices across the United States. Surveys measured seven characteristics of practice relationships (trust, diversity, mindfulness, heedful interrelation, respectful interaction, social/task relatedness, and rich and lean communication) and three organizational attributes (reflection, sensemaking, and learning) of practices. Data Collection/Extraction Methods. We surveyed 396 clinicians and practice staff. We performed a multigroup path analysis of the data. Parameter estimates were calculated using a Bayesian estimation method. Principal Findings. Trust and reflection were important in explaining the characteristics of practice relationships and their associations with sensemaking and learning. The strongest associations between relationships, sensemaking, and learning were found under conditions of high trust and reflection. The weakest associations were found under conditions of low trust and reflection. Conclusions. Trust and reflection appear to play a key role in moderating relationships, sensemaking, and learning in practices undergoing practice redesign. Key Words. Practice redesign, relationships, reflection, sensemaking, learning, There is increasing recognition that improving the current U.S. health care system will require achieving the triple aim of improving patient experiences, improving the health of populations, and lowering per [...]

Objectives. To demonstrate how falsification tests can be used to evaluate instrumental variables methods applicable to a wide variety of comparative effectiveness research questions. Study Design. Brief conceptual review of instrumental variables and falsification testing principles and techniques accompanied by an empirical application. Sample STATA code related to the empirical application is provided in the Appendix. Empirical Application. Comparative long-term risks of sulfonylureas and thiazolidinediones for management of type 2 diabetes. Outcomes include mortality and hospitalization for an ambulatory care-sensitive condition. Prescribing pattern variations are used as instrumental variables. Conclusions. Falsification testing is an easily computed and powerful way to evaluate the validity of the key assumption underlying instrumental variables analysis. If falsification tests are used, instrumental variables techniques can help answer a multitude of important clinical questions. Key Words. Comparative effectiveness research, instrumental variables, falsification testing, big data, causal inference, Falsification testing is an old idea that has great potential as a method for evaluating the internal validity of comparative effectiveness research (CER) studies. Though rarely identified as such, falsification [...]

2019 OCT 26 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- Investigators publish new report on Opioids. According to news reporting out of [...]

Objective. To determine the effects of including diagnostic and utilization data from a secondary payer on readmission rates and hospital profiles. Data Sources/Study Setting. Veterans Health Administration (VA) and Medicare inpatient and outpatient administrative data for veterans discharged from 153 VA hospitals during FY 2008-2010 with a principal diagnosis of acute myocardial infarction, heart failure, or pneumonia. Study Design. We estimated hospital-level risk-standardized readmission rates derived using VA data only. We then used data from both VA and Medicare to re-estimate readmission rates and compared hospital profiles using two methods: Hospital Compare and the CMS implementation of the Hospital Readmissions Reduction Program (HRRP). Data Collection/Extraction Methods. Retrospective data analysis using VA hospital discharge and outpatient data matched with Medicare fee-for-service claims by scrambled Social Security numbers. Principal Findings. Less than 2 percent of hospitals in any cohort were classified discordantly by the Hospital Compare method when using VA-only compared with VA/ Medicare data. In contrast, using the HRRP method, 13 percent of hospitals had differences in whether they were flagged as having excessive readmission rates in at least one cohort. Conclusions. Inclusion of secondary payer data may cause changes in hospital profiles, depending on the methodology used. An assessment of readmission rates should include, to the extent possible, all available information about patients' utilization of care. Key Words. Readmissions, Veterans Affairs (U.S.), quality assessment, public reporting, Medicare, Hospital readmission has received increased attention from policy makers and researchers since the finding that unplanned readmissions cost Medicare $17.4 billion in 2004 (Jencks, Williams, and Coleman 2009). Rates of [...]