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1
Callegari, Lisa, Stephanie Edmonds, Sonya Borrero, Ginny Ryan, Caitlin Cusack, and Laurie Zephyrin. "Preconception Care in the Veterans Health Administration." Seminars in Reproductive Medicine 36, no. 06 (November 2018): 327–39. http://dx.doi.org/10.1055/s-0039-1678753.
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AbstractPreconception care (PCC), defined as a set of interventions to help women optimize their health and well-being prior to pregnancy, can improve pregnancy outcomes and is recommended by national organizations including the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists. Women Veterans who use the Department of Veterans Affairs (VA) health care system may face elevated risks of adverse pregnancy and birth outcomes due to a high prevalence of chronic medical and mental health conditions as well as psychosocial stressors including sexual trauma history and intimate partner violence. Many women Veterans of childbearing age experience poverty and homelessness, which are key social determinants of poor reproductive health outcomes. Furthermore, racial/ethnic disparities in maternal and neonatal outcomes are well documented, and nearly half of women Veterans of reproductive age are minority race/ethnicity. High-quality, equitable, patient-centered PCC services to address modifiable risks in this population are therefore a priority for VA. In this article, we provide a brief background of PCC, discuss the health risks of Veterans associated with adverse pregnancy outcomes, and highlight VA initiatives related to PCC. Lastly, we discuss implications and future directions for PCC research and policy within VA and across other health systems.
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Nichols, Linda. "Reader's Comments on "Practicing Medical Anthropology at a Veterans Administration Medical Center"." Practicing Anthropology 36, no. 1 (January 1, 2014): 48. http://dx.doi.org/10.17730/praa.36.1.x585785825154526.
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As an anthropologist in the Department of Veterans Affairs (VA) for the past 30 years, I read with some concern the article in the latest issue of Practicing Anthropology, "Practicing Medical Anthropology at a Veterans Administration Medical Center: An Investigation of the Health Care Experiences of WWII-Era Veterans" by Dr. Denver Lewellen (Practicing Anthropology 35[3]:44-48).
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Miller, Edward Alan, Stefanie Gidmark, Emily Gadbois, James L. Rudolph, and Orna Intrator. "Nursing Home Referral Within the Veterans Health Administration: Practice Variation by Payment Source and Facility Type." Research on Aging 40, no. 7 (September 13, 2017): 687–711. http://dx.doi.org/10.1177/0164027517730383.
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Veterans enrolled within the Veterans Health Administration (VHA) of the U.S. Department of Veterans Affairs (VA) may receive nursing home (NH) care in VHA-operated Community Living Centers (CLCs), State Veterans Homes (SVHs), or community NHs, which may or may not be under contract with the VHA. This study examined VHA staff perceptions of how Veterans’ eligibility for VA and other payment impacts NH referrals within VA Medical Centers (VAMCs). Thirty-five semistructured interviews were performed with discharge planning and contracting staff from 12 VAMCs from around the country. VA staff highlights the preeminent role that VA priority status played in determining placement in VA-paid NH care. VHA staff reported that Veterans’ placement in a CLC, community NH, or SVH was contingent, in part, on potential payment source (VA, Medicare, Medicaid, and other) and anticipated length of stay. They also reported that variation in Veteran referral to VA-paid NH care across VAMCs derived, in part, from differences in local and regional policies and markets. Implications for NH referral within the VHA are drawn.
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Matsumoto, Rachel A., Bryant R. England, Ginnifer Mastarone, J. Steuart Richards, Elizabeth Chang, Patrick R. Wood, and Jennifer L. Barton. "Rheumatology Clinicians’ Perceptions of Telerheumatology Within the Veterans Health Administration: A National Survey Study." Military Medicine 185, no. 11-12 (November 1, 2020): e2082-e2087. http://dx.doi.org/10.1093/milmed/usaa203.
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Abstract Introduction The Department of Veterans Affairs Veterans Health Administration (VA) Strategic Plan (Fiscal Year 2018–2024) identified four priorities for care including easy access, timely and integrated care, accountability, and modernization, all of which can be directly or indirectly impacted by telemedicine technologies. These strategic goals, coupled with an anticipated rheumatology workforce shortage, has created a need for additional care delivery methods such as clinical video telehealth application to rheumatology (ie, telerheumatology). Rheumatology clinician perceptions of clinical usefulness telerheumatology have received limited attention in the past. The present study aimed to evaluate rheumatologists’ perceptions of and experiences with telemedicine, generally, and telerheumatology, specifically, within the VA. Materials and Methods A 38-item survey based on an existing telehealth providers’ satisfaction survey was developed by two VA rheumatologists with experience in telemedicine as well as a social scientist experienced in survey development and user experience through an iterative process. Questions probed VA rheumatology clinician satisfaction with training and information technology (IT) supports, as well as barriers to using telemedicine. Additionally, clinician perceptions of the impact and usefulness of and appropriate clinical contexts for telerheumatology were evaluated. The survey was disseminated online via VA REDCap to members of the VA Rheumatology Consortium (VARC) through a LISTSERV. The study protocol was approved by the host institution IRB through expedited review. Survey responses were analyzed using descriptive statistics. Results Forty-five anonymous responses (20% response rate) were collected. Of those who responded, 47% were female, 98% were between 35 and 64 years old, 71% reported working at an academic center, and the majority was physician-level practitioners (98%). Respondents generally considered themselves to be tech savvy (58%). Thirty-six percent of the sample reported past experience with telemedicine, and, of those, 29% reported experience with telerheumatology specifically. Clinicians identified the greatest barrier to effective telerheumatology as the inability to perform a physical exam (71%) but agreed that telerheumatology is vital to increasing access to care (59%) and quality of care (40%) in the VA. Overall, regardless of experience with telemedicine, respondents reported that telerheumatology was more helpful for management of rheumatologic conditions rather than initial diagnosis. Conclusions While the majority of rheumatology clinicians did not report past experience with telerheumatology, they agreed that it has potential to further the VA mission of improved access and quality of care. Rheumatology clinicians felt the suitability of telerheumatology is dependent on the phase of care. As remote care technologies continue to be rapidly adopted into clinic, clinician perceptions of and experiences with telemedicine will need to be addressed in order to maintain high-quality and clinician- and patient-centric care within VA rheumatology.
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Mäkinen, K. K., D. Pemberton, J. Cole, P. L. Mäkinen, C. Y. Chen, and P. Lambert. "Saliva Stimulants and the Oral Health of Geriatric Patients." Advances in Dental Research 9, no. 2 (July 1995): 125–26. http://dx.doi.org/10.1177/08959374950090020901.
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Root-surface caries (RSC) has been recognized as a specific and important dental disease. Significant advances have been made in the pathology and microbiology of RSC, and the need to standardize the guidelines for recording RSC data has been recognized. Researchers have emphasized the increasing impact RSC will have on the geriatric population, especially since the methods to treat and prevent this disease are limited. The purpose of this study was to investigate the possibility of limiting RSC in a Veterans Administration (VA) patient population, using polyol-containing saliva stimulants that were voluntarily consumed by residents of a VA Medical Center (VAMC) over a period of from six to 30 months. Another aim was to study the effect of this program on the gingival health of periodontal patients.
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Cashion, Winn, Walid F. Gellad, Florentina E. Sileanu, Maria K. Mor, Michael J. Fine, Jennifer Hale, Daniel E. Hall, et al. "Source of Post-Transplant Care and Mortality among Kidney Transplant Recipients Dually Enrolled in VA and Medicare." Clinical Journal of the American Society of Nephrology 16, no. 3 (February 18, 2021): 437–45. http://dx.doi.org/10.2215/cjn.10020620.
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Background and objectivesMany kidney transplant recipients enrolled in the Veterans Health Administration are also enrolled in Medicare and eligible to receive both Veterans Health Administration and private sector care. Where these patients receive transplant care and its association with mortality are unknown.Design, setting, participants, & measurementsWe conducted a retrospective cohort study of veterans who underwent kidney transplantation between 2008 and 2016 and were dually enrolled in Veterans Health Administration and Medicare at the time of surgery. We categorized patients on the basis of the source of transplant-related care (i.e., outpatient transplant visits, immunosuppressive medication prescriptions, calcineurin inhibitor measurements) delivered during the first year after transplantation defined as Veterans Health Administration only, Medicare only (i.e., outside Veterans Health Administration using Medicare), or dual care (mixed use of Veterans Health Administration and Medicare). Using multivariable Cox regression, we examined the independent association of post-transplant care source with mortality at 5 years after kidney transplantation.ResultsAmong 6206 dually enrolled veterans, 975 (16%) underwent transplantation at a Veterans Health Administration hospital and 5231 (84%) at a non–Veterans Health Administration hospital using Medicare. Post-transplant care was received by 752 patients (12%) through Veterans Health Administration only, 2092 (34%) through Medicare only, and 3362 (54%) through dual care. Compared with patients who were Veterans Health Administration only, 5-year mortality was significantly higher among patients who were Medicare only (adjusted hazard ratio, 2.2; 95% confidence interval, 1.5 to 3.1) and patients who were dual care (adjusted hazard ratio, 1.5; 95% confidence interval, 1.1 to 2.1).ConclusionsMost dually enrolled veterans underwent transplantation at a non–Veterans Health Administration transplant center using Medicare, yet many relied on Veterans Health Administration for some or all of their post-transplant care. Veterans who received Veterans Health Administration–only post-transplant care had the lowest 5-year mortality.
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Day, T. Eugene, Ajit N. Babu, Steven M. Kymes, and Nathan Ravi. "Discrete Event Simulation and Real Time Locating Systems." International Journal of E-Adoption 4, no. 4 (October 2012): 16–28. http://dx.doi.org/10.4018/jea.2012100102.
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The Veteran’s Health Administration (VHA) is the largest integrated health care system in the United States, forming the arm of the Department of Veterans Affairs (VA) that delivers medical services. From a troubled past, the VHA today is regarded as a model for healthcare transformation. The VA has evaluated and adopted a variety of cutting-edge approaches to foster greater efficiency and effectiveness in healthcare delivery as part of their systems redesign initiative. This paper discusses the integration of two health care analysis platforms: Discrete Event Simulation (DES), and Real Time Locating systems (RTLS) presenting examples of work done at the St. Louis VA Medical Center. Use of RTLS data for generation and validation of DES models is detailed, with prescriptive discussion of methodologies. The authors recommend the careful consideration of these relatively new approaches which show promise in assisting systems redesign initiatives across the health care spectrum.
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Poorani, Ali A., and Vincent Kane. "Veteran Patient Experience Academy: Putting Veterans First." Journal of Patient Experience 8 (January 1, 2021): 237437352110346. http://dx.doi.org/10.1177/23743735211034619.
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With a national priority to make the Veteran Health Administration (VA) a leading customer service organization and provide patient-centric services to veterans and their families, the Wilmington VA Medical Center (W VAMC) partnered with the University of Delaware’s Department of Hospitality and Sport Business Management at the Lerner College of Business & Economics to develop the VA Patient Experience Academy. The program focused on employee training and provided tools to enhance the veterans’ experience, operationalized the VA Way (VA Core Values, Service Behaviors, Service Recovery), and Own the Moment. Phase 1 of the VA Patient Experience Academy launched with 25 managers in February 2019 and were followed by 5 cohorts including physicians, nurse practitioners, registered nurses, licensed practical nurses, medical staff assistants, and staff. The participants were selected from the W VAMC and 5 Community-Based Outpatient Clinics. The results were measured on 3 levels: Learning outcomes, application of training to practice, and the veterans’ satisfaction scores. Scores in all 3 areas showed significant improvements.
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Etingen, Bella, Jamie Patrianakos, Marissa Wirth, Timothy P. Hogan, Bridget M. Smith, Elizabeth Tarlov, Kevin T. Stroupe, Rebecca Kartje, and Frances M. Weaver. "TeleWound Practice Within the Veterans Health Administration: Protocol for a Mixed Methods Program Evaluation." JMIR Research Protocols 9, no. 7 (July 20, 2020): e20139. http://dx.doi.org/10.2196/20139.
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Background Chronic wounds, such as pressure injuries and diabetic foot ulcers, are a significant predictor of mortality. Veterans who reside in rural areas often have difficulty accessing care for their wounds. TeleWound Practice (TWP), a coordinated effort to incorporate telehealth into the provision of specialty care for patients with skin wounds, has the potential to increase access to wound care by allowing veterans to receive this care at nearby outpatient clinics or in their homes. The Veterans Health Administration (VA) is championing the rollout of the TWP, starting with regional implementation. Objective This paper aims to describe the protocol for a mixed-methods program evaluation to assess the implementation and outcomes of TWP in VA. Methods We are conducting a mixed-methods evaluation of 4 VA medical centers and their community-based outpatient clinics that are participating in the initial implementation of the TWP. Data will be collected from veterans, VA health care team members, and other key stakeholders (eg, clinical leadership). We will use qualitative methods (ie, semistructured interviews), site visits, and quantitative methods (ie, surveys, national VA administrative databases) to assess the process and reach of TWP implementation and its impact on veterans’ clinical outcomes and travel burdens and costs. Results This program evaluation was funded in October 2019 as a Partnered Evaluation Initiative by the US Department of Veterans Affairs, Diffusion of Excellence Office, and Office of Research and Development, Health Services Research and Development Service, Quality Enhancement Research Initiative Program (PEC 19-310). Conclusions Evaluation of the TWP will identify barriers and solutions to TeleWound implementation in a small number of sites that can be used to inform successful rollout of the TWP nationally. Our evaluation work will inform future efforts to scale up the TWP across VA and optimize reach of the program to veterans across the nation. International Registered Report Identifier (IRRID) DERR1-10.2196/20139
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Dixon, Brian E., Susan Ofner, Susan M. Perkins, Laura J. Myers, Marc B. Rosenman, Alan J. Zillich, Dustin D. French, Michael Weiner, and David A. Haggstrom. "Which veterans enroll in a VA health information exchange program?" Journal of the American Medical Informatics Association 24, no. 1 (June 6, 2016): 96–105. http://dx.doi.org/10.1093/jamia/ocw058.
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Objective: To characterize patients who voluntarily enrolled in an electronic health information exchange (HIE) program designed to share data between Veterans Health Administration (VHA) and non-VHA institutions. Materials and Methods: Patients who agreed to participate in the HIE program were compared to those who did not. Patient characteristics associated with HIE enrollment were examined using a multivariable logistic regression model. Variables selected for inclusion were guided by a health care utilization model adapted to explain HIE enrollment. Data about patients’ sociodemographics (age, gender), comorbidity (Charlson index score), utilization (primary and specialty care visits), and access (distance to VHA medical center, insurance, VHA benefits) were obtained from VHA and HIE electronic health records. Results: Among 57 072 patients, 6627 (12%) enrolled in the HIE program during its first year. The likelihood of HIE enrollment increased among patients ages 50–64, of female gender, with higher comorbidity, and with increasing utilization. Living in a rural area and being unmarried were associated with decreased likelihood of enrollment. Discussion and Conclusion: Enrollment in HIE is complex, with several factors involved in a patient’s decision to enroll. To broaden HIE participation, populations less likely to enroll should be targeted with tailored recruitment and educational strategies. Moreover, inclusion of special populations, such as patients with higher comorbidity or high utilizers, may help refine the definition of success with respect to HIE implementation.
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Sullivan, Jennifer L., Dana Beth Weinburg, Stefanie Gidmark, Ryann L. Engle, Victoria A. Parker, and Denise A. Tyler. "Collaborative capacity and patient-centered care in the Veterans’ Health Administration Community Living Centers." International Journal of Care Coordination 22, no. 2 (June 2019): 90–99. http://dx.doi.org/10.1177/2053434519858028.
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Introduction Previous research in acute care settings has shown that collaborative capacity, defined as the way providers collaborate as equal team members, can be improved by the ways in which an organization supports its staff and teams. This observational cross-sectional study examines the association between collaborative capacity and supportive organizational context, supervisory support, and person-centered care in nursing homes to determine if similar relationships exist. Methods We adapted the Care Coordination Survey for nursing homes and administered it to clinical staff in 20 VA Community Living Centers. We used random effects models to examine the associations between supportive organizational context, supervisory support, and person-centered care with collaborative capacity outcomes including quality of staff interactions, task independence, and collaborative influence. Results A total of 723 Community Living Center clinical staff participated in the Care Coordination Survey resulting in a response rate of 29%. We found that teamwork and collaboration—measured as task interdependence, quality of interactions and collaborative influence—did not differ significantly between Community Living Centers but did differ significantly across occupational groups. Moreover, staff members’ experiences of teamwork and collaboration were positively associated with supportive organizational context and person-centered care. Discussion Our findings suggest that elements of organizational context are important to facilitating collaborative capacity. Additionally, investing in staffing, rewards, and person-centered care may improve teamwork.
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Simons, Kelsey, Katherine Luci, Lauren Hagemann, Lindsey Jacobs, Emily Bower, Morgan Eichorst, and Michelle Hilgeman. "SAVE-CLC: An Intervention to Reduce Suicide Risk in Veterans Who Discharge From VA Nursing Homes." Innovation in Aging 4, Supplement_1 (December 1, 2020): 91–92. http://dx.doi.org/10.1093/geroni/igaa057.302.
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Abstract Prior research has established transitions into and out of nursing homes as periods of suicide risk for older adults. Deaths by suicide were found to be 2.4 times as likely among Veterans within six months of discharge from US Veterans Health Administration (VA) nursing homes when compared with gender and age-matched Veterans from the general VA patient population (McCarthy, Szymanski, Karlin, & Katz, 2013). Despite these trends, suicide prevention interventions implemented during nursing home and post-acute care transitions, including those taking place from Centers for Medicare and Medicaid Services regulated nursing homes, are lacking. Suicide Awareness for Veterans Exiting the Community Living Center (SAVE-CLC) was piloted as a quality improvement intervention to reduce suicide risk for older Veterans discharging from VA nursing homes. VA clinicians from three sites provided a friendly contact by phone after discharge (n = 66) to screen for depression, facilitate a strengths-based discussion about service needs, and provide service referrals. Compared to a group of patients discharged prior to the start of the intervention (matched on location, age range, and Care Assessment Need scores), SAVE-CLC patients received more depression screening within 30 days after discharge (chi square = 38.7, p < .001) and were seen more quickly for mental health care (t = 3.1, p = .005) when indicated. Implications for suicide prevention with older Veterans and for the general population of older adults receiving short stay services in US nursing homes will be addressed.
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Ysea-Hill, Otoniel, Tesil Nedumkallel Sani, Lubna A. Nasr, Christian J. Gomez, Nagapratap Ganta, Sehrish Sikandar, Olga Theou, and Jorge G. Ruiz. "Concurrent Validity of Pictorial Fit-Frail Scale (PFFS) in Older Adult Male Veterans with Different Levels of Health Literacy." Gerontology and Geriatric Medicine 7 (January 2021): 233372142110038. http://dx.doi.org/10.1177/23337214211003804.
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Introduction: Frailty is a state of vulnerability characterized by multisystemic physiological decline. The Pictorial Fit Frail Scale (PFFS) is a practical, image-based assessment that may facilitate the assessment of frailty in individuals with inadequate health literacy (HL). Objective: Determine the concurrent validity and feasibility of the PFFS in older Veterans with different levels of HL and cognition. Methods: Cross-sectional study in a geriatric clinic at a Veteran Health Administration (VHA) medical center. Veterans ≥65 years old completed a HL evaluation, PFFS, FRAIL scale and cognitive screening. We assessed the associations between PFFS, FRAIL scale, and VA-Frailty Index (VA-FI), and compared PFFS and FRAIL scale accuracy with a Receiver Operating Characteristic curve, Area Under the Curve (AUC) analysis, using the VA-FI as reference. Results: Eighty-three Veterans, mean age 76.20 ( SD = 6.02) years, 65.1% Caucasian, 69.9% had inadequate HL, 57.8% were frail and 20.5% had cognitive impairment. All participants completed the 43 PFFS items. There were positive correlations between PFFS and VA-FI, r = .55 (95% CI: 0.365–0.735, p < .001), and FRAIL scale, r = .673 (95% CI: 0.509–0.836, p < .001). Compared to the VA-FI, the PFFS (AUC = 0.737; 95% CI: 0.629–0.844) and FRAIL scale (AUC = 0.724;95% CI: 0.615–0.824; p < .001) showed satisfactory diagnostic accuracy. Conclusions: The PFFS is valid and feasible in evaluating frailty in older Veterans with different levels of HL and cognition.
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Ayele, Roman A., Emily Lawrence, Marina McCreight, Kelty Fehling, Russell E. Glasgow, Borsika A. Rabin, Robert E. Burke, and Catherine Battaglia. "Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non-VA Hospitals to Primary Care in a Single VA Healthcare System." Journal of Hospital Medicine, Volume 15, Issue 03 (October 23, 2019): 133–39. http://dx.doi.org/10.12788/jhm.3320.
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BACKGROUND: Veterans with healthcare needs utilize both Veterans Health Administration (VA) and non-VA hospitals. These dual-use veterans are at high risk of adverse outcomes due to the lack of coordination for safe transitions. OBJECTIVES: The aim of this study was to understand the barriers and facilitators to providing high-quality continuum of care for veterans transitioning from non-VA hospitals to the VA primary care setting. DESIGN: Guided by the practical robust implementation and sustainability model (PRISM) and the ideal transitions of care, we conducted a qualitative assessment using semi-structured interviews with clinicians, staff, and patients. SETTING: This study was conducted at a single urban VA medical center and two non-VA hospitals. PARTICIPANTS: A total of 70 participants, including 52 clinicians and staff (23 VA and 29 non-VA) involved in patient transition and 18 veterans recently discharged from non-VA hospitals, were included in this study. APPROACH: Data were analyzed using a conventional content analysis and managed in Atlas.ti (Berlin, Germany). RESULTS: Four major themes emerged where participants consistently discussed that transitions were delayed when they were not able to (1) identify patients as veterans and notify VA primary care of discharge, (2) transfer non-VA hospital medical records to VA primary care, (3) obtain follow-up care appointments with VA primary care, and (4) write VA formulary medications for veterans that they could fill at VA pharmacies. Participants also discussed factors involved in smooth transition and recommendations to improve care coordination. CONCLUSIONS: All participants perceived the current transition-of-care process across healthcare systems to be inefficient. Efforts to improve quality and safety in transitional care should address the challenges clinicians and patients experience when transitioning from non-VA hospitals to VA primary care.
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Kunthur, Anuradha, Eric R. Siegel, and Rangaswamy Govindarajan. "Cisplatin and gemcitabine versus carboplatin and gemcitabine in metastatic bladder cancer: Survival analysis of veterans' health care data." Journal of Clinical Oncology 35, no. 15_suppl (May 20, 2017): e16023-e16023. http://dx.doi.org/10.1200/jco.2017.35.15_suppl.e16023.
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e16023 Background: Background: Cisplatin and gemcitabine combination chemotherapy is the standard regimen used for the treatment of metastatic bladder cancer. Most Veterans Administration (VA) patients with metastatic bladder cancer are elderly or with poor renal function, and are considered not good candidates for cisplatin administration. It is a common practice to substitute carboplatin for cisplatin in this population. Methods: Methods: We identified stage IV bladder cancer patients treated initially with cisplatin plus gemcitabine (Ci+G) or carboplatin plus gemcitabine (Ca+G) at VA medical centers from 2000 to 2010. The data was obtained via the VA central cancer registry from all VA medical centers across the country. Overall survival (OS) was summarized as Kaplan-Meier medians and compared for difference between platinum groups via Cox regression. Results: Results: 196 subjects () with stage IV bladder cancer were identified. There were 194 males , 78 received Ca+G, 118 received Ci+G. 149 deaths occurred during 197.49 person-years of follow up, for a median OS of 10.35 months. Median OS was 11.14 months with Ca+G versus 10.35 months with Ci+G. Cox regression revealed nearly equal group mortality rates, with Ca+G having a hazard ratio (90% confidence limits) of 1.02 (0.77–1.34) compared to Ci+G ( P= 0.93). Conclusions: Conclusion: Patients treated with Ca+G and Ci+G regimens had similar median OS, supporting the substitution of carboplatin for cisplatin with gemcitabine in this patient population.
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Bidassie, Balmatee, William Gunnar, Leigh Starr, George Van Buskirk, Lisa Warner, Clifford Anckaitis, and Angela Howard. "Data-driven process to improve VA surgical flow." International Journal of Health Care Quality Assurance 31, no. 4 (May 14, 2018): 283–94. http://dx.doi.org/10.1108/ijhcqa-03-2017-0053.
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PurposeDuring years 2014-2016, Veterans Health Administration National Surgery Office conducted a surgical flow improvement initiative (SFII) to assist low-performing surgery programs to improve their operating room efficiency (ORE). The initiative was co-sponsored by VHA National Surgery Office and VHA Office of Systems Redesign and Improvement. The paper aims to discuss this issue.Design/methodology/approachAn SFII algorithm, based on first-time-start (FTS), cancellation rate (CR), lag time (LT) and OR utilization, assigned an ORE performance Level (1-low to 4-high) to each VA Medical Center (VAMC). In total, 15 VAMCs with low-performance surgery programs participated in SFII to assess the current state of their surgical flow processes and used redesign methods to focus on improvement objectives.FindingsAt the end of the project, 14 VSAs, 40 RPIWs, 45 “90-day projects” and 73 Just-Do-It’s were completed with 65 percent (158/243) improvement actions and 86 percent sites improving/sustaining all four ORE metrics. There was a statistically significant difference in improvement across the three stages (baseline, improvement, sustain) for FTS (45.6-68.7 percent;F=44.74;p<0.000); CR (16.1-9.5 percent;F=34.46;p<0.000); LT (63.1-36.3 percent;F=92.00;p<0.000); OR utilization (43.4-57.7 percent;F=6.92;p<0.001) and VAMC level (1.7-3.65;F=80.11;p<0.000). The majority developed “fair to excellent” sustainment (91 percent) and spread (82 percent) plans. The projected annual estimated return-on-investment was $27,949,966.Originality/valueThe SFII successfully leveraged a small number of faculty, coaches, and industrial engineers to produce significant improvement in ORE across a large national integrated health care network. This strategy can serve healthcare leaders in managing complex healthcare issues in their facilities.
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Ewers, Tola, Babak Aryanfar, Marvin J. Bittner, Erin C. Balkenende, Suzanne F. Bradley, Madisen Brown, Matthew B. Goetz, et al. "885. Feasibility of Observing Traffic Patterns (FOOT Patter) in Veterans Health Administration Operating Rooms." Open Forum Infectious Diseases 7, Supplement_1 (October 1, 2020): S478. http://dx.doi.org/10.1093/ofid/ofaa439.1073.
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Abstract Background Surgical site infections (SSIs) complicate nearly 6% of surgeries performed in Veterans Health Administration (VA) hospitals and occur despite adoption of practices known to reduce them. SSIs are associated with prolonged hospitalization and an increased risk of readmission, reoperation and mortality. Operating room (OR) door openings may increase SSI through disruption of desired OR air flow patterns and increased wound microbe counts. Our study objectives were to: 1) develop a methodological approach for collecting data on entry/exit traffic patterns in VA ORs and 2) characterize patterns across different surgery types. Methods Trained researchers from 10 VA-Centers for Disease Control and Prevention (CDC) Practice-based Research Network sites observed staff entering and exiting VA ORs. Staff were categorized and identified by role. Exits/entries were recorded on a standardized tracking sheet. Surgery type and observation duration from incision to closure were noted. Mean hourly door openings across procedure and role types were compared via a one-way ANOVA using Stata ver. 15.0. Results We observed 56 surgeries on 55 patients (Fig. 1). During 9,801 observation minutes, 766 staff opened doors 3,882 times. Door openings by role differed significantly (p < 0.001) with nurses, perfusionists, anesthesia and vendors having the highest mean door-opening rate. Coronary artery bypass grafts (CABGs) accounted for most door openings and significantly greater surgical duration than other procedures (p=0.012). Time-adjusted OR door opening rate was similar across procedure types at ~22-26 hourly openings (p=0.186). Figure 1. FOOT Patter results Conclusion The hourly rate of door openings varied notably by staff role. Our data show that measurement of OR movements is feasible although gaining access and approval to observe, achieving ideal observer positioning in complex floor plans, and potential misidentification of entering/exiting staff are challenges of direct methods. Scaling this study up may require automated processes. Studies exploring influences of traffic patterns on OR air quality metrics and impact on risk of SSI, identifying rationale and necessity for door openings and effective strategies for reducing unneeded door openings are needed. Disclosures All Authors: No reported disclosures
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Dobalian, Aram, Judith A. Stein, Kevin C. Heslin, Deborah Riopelle, Brinda Venkatesh, Andrew B. Lanto, Barbara Simon, Elizabeth M. Yano, and Lisa V. Rubenstein. "Impact of the Northridge Earthquake on the Mental Health of Veterans: Results From a Panel Study." Disaster Medicine and Public Health Preparedness 5, S2 (September 2011): S220—S226. http://dx.doi.org/10.1001/dmp.2011.60.
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ABSTRACTObjective: The 1994 earthquake that struck Northridge, California, led to the closure of the Veterans Health Administration Medical Center at Sepulveda. This article examines the earthquake's impact on the mental health of an existing cohort of veterans who had previously used the Sepulveda Veterans Health Administration Medical Center.Methods: From 1 to 3 months after the disaster, trained interviewers made repeated attempts to contact participants by telephone to administer a repeated measures follow-up design survey based on a survey that had been done preearthquake. Postearthquake data were obtained on 1144 of 1800 (64%) male veterans for whom there were previous data. We tested a predictive latent variable path model of the relations between sociodemographic characteristics, predisaster physical and emotional health measures, and postdisaster emotional health and perceived earthquake impact.Results: Perceived earthquake impact was predicted by predisaster emotional distress, functional limitations, and number of health conditions. Postdisaster emotional distress was predicted by preexisting emotional distress and earthquake impact. The regression coefficient from earthquake impact to postearthquake emotional distress was larger than that of the stability coefficient from preearthquake emotional distress. Postearthquake emotional distress also was affected indirectly by preearthquake emotional distress, health conditions, younger age, and lower socioeconomic status.Conclusions: The postdisaster emotional health of veterans who experienced greater earthquake impact would have likely benefited from postdisaster intervention, regardless of their predisaster emotional health. Younger veterans and veterans with generally poor physical and emotional health were more vulnerable to greater postearthquake emotional distress. Veterans of lower socioeconomic status were disproportionately likely to experience more effects of the disaster because they had more predisaster emotional distress, more functional limitations, and a greater number of health conditions. Because many veterans use non–Department of Veterans Affairs (VA) health care providers for at least some of their health needs, future disaster planning for both VA and non-VA providers should incorporate interventions targeted at these groups.(Disaster Med Public Health Preparedness. 2011;5:S220-S226)
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Naville-Cook, Chad, Leroy Rhea, Mark Triboletti, and Christina White. "Analyzing the Clinical Outcomes of a Rapid Mass Conversion From Rosuvastatin to Atorvastatin in a VA Medical Center Outpatient Setting." Journal of Pharmacy Technology 33, no. 5 (July 10, 2017): 189–94. http://dx.doi.org/10.1177/8755122517719545.
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Background: Medication conversions occur frequently within the Veterans Health Administration. This manual process involves several pharmacists over an extended period of time. Macros can automate the process of converting a list of patients from one medication to a therapeutic alternative. Objectives: To develop a macro that would convert active rosuvastatin prescriptions to atorvastatin and to create an electronic dashboard to evaluate clinical outcomes. Methods: A conversion protocol was approved by the Pharmacy & Therapeutics Committee. A macro was developed using Microsoft Visual Basic. Outpatients with active prescriptions for rosuvastatin were reviewed and excluded if they had a documented allergy to atorvastatin or a significant drug-drug interaction. An electronic dashboard was created to compare safety and efficacy endpoints pre- and postconversion. Primary endpoints included low-density lipoprotein (LDL), creatine phosphokinase (CPK), aspartate transaminase (AST), alanine transaminase (ALT), and alkaline phosphatase. Secondary endpoints evaluated cardiovascular events, including the incidences of myocardial infarction, stroke, and stent placement. Results: The macro was used to convert 1520 patients from rosuvastatin to atorvastatin over a period of 20 hours saving $5760 in pharmacist labor. There were no significant changes in LDL, AST, ALT, or secondary endpoints ( P > .05). There was a significant increase in alkaline phosphatase ( P = .0035). Conclusions: A rapid mass medication conversion from rosuvastatin to atorvastatin saved time and money and resulted in no clinically significant changes in safety or efficacy endpoints. Macros and clinical dashboards can be applied to any Veterans Health Administration facility.
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Naples, Jennifer G., Tracie Rothrock-Christian, and Jamie N. Brown. "Characteristics of Postgraduate Year 1 Pharmacy Residency Programs at Veterans Affairs Medical Centers." Journal of Pharmacy Practice 28, no. 4 (February 9, 2015): 425–29. http://dx.doi.org/10.1177/0897190014568386.
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Purpose: Although the characteristics of pharmacy postgraduate year 1 (PGY1) residency programs have been examined among large academic medical centers, there are no identified studies comparing the attributes of individual programs in the Veterans Affairs (VA) Health Administration System. The primary objective of this study was to describe and contrast characteristics of VA PGY1 residency programs. Methods: This was a cross-sectional survey of VA pharmacy residency programs. An online survey was distributed electronically to residency program directors of VA PGY1 residencies. Results: Responses from 33 (33%) PGY1 programs were available for the analysis. Programs reported growth over the previous 2 years and expected continued expansion. There was a wide variety of learning opportunities, although experiences were customizable based on residents’ interests. Notably, many programs allowed residents to seek rotations at other locations if specific experiences were not available on-site. Additionally, most programs had a mandatory staffing component and required residents to present the results of residency research projects. Conclusion: There is a high degree of variability among individual VA facilities with regard to the requirements and opportunities available to PGY1 pharmacy residents. This assessment is able to characterize the currently established residency programs and allows for an active comparison of programs in a nationally integrated health care system.
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Mastarone, Ginnifer L., Jessica J. Wyse, Eileen R. Wilbur, Benjamin J. Morasco, Somnath Saha, and Kathleen F. Carlson. "Barriers to Utilization of Prescription Drug Monitoring Programs Among Prescribing Physicians and Advanced Practice Registered Nurses at Veterans Health Administration Facilities in Oregon." Pain Medicine 21, no. 4 (November 13, 2019): 695–703. http://dx.doi.org/10.1093/pm/pnz289.
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Abstract Objective To identify barriers to using state prescription drug monitoring programs (PDMPs) among prescribing physicians and advanced practice registered nurses across a variety of Veterans Health Administration (VA) settings in Oregon. Design In-person and telephone-based qualitative interviews and user experience assessments conducted with 25 VA prescribers in 2018 probed barriers to use of state PDMPs. Setting VA health care facilities in Oregon. Subjects Physicians (N = 11) and advanced practice registered nurses (N = 14) who prescribed scheduled medications, provided care to patients receiving opioids, and used PDMPs in their clinical practice. Prescribers were stationed at VA medical centers (N = 10) and community-based outpatient clinics (N = 15); medical specialties included primary care (N = 10), mental health (N = 9), and emergency medicine (N = 6). Methods User experience was analyzed using descriptive statistics. Qualitative interviews were analyzed using conventional content analysis methodology. Results The majority of physicians (64%) and advanced practice registered nurses (79%) rated PDMPs as “useful.” However, participants identified both organizational and software design issues as barriers to their efficient use of PDMPs. Organizational barriers included time constraints, clinical team members without access, and lack of clarity regarding the priority of querying PDMPs relative to other pressing clinical tasks. Design barriers included difficulties entering or remembering passwords, unreadable data formats, time-consuming program navigation, and inability to access patient information across state lines. Conclusions Physicians and advanced practice registered nurses across diverse VA settings reported that PDMPs are an important tool and contribute to patient safety. However, issues regarding organizational processes and software design impede optimal use of these resources.
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Sutton, Scott, Joseph Magagnoli, Tammy Cummings, James Hardin, and Babatunde Edun. "Inpatient, Outpatient, and Pharmacy Costs in Patients With and Without HIV in the US Veteran’s Affairs Administration System." Journal of the International Association of Providers of AIDS Care (JIAPAC) 18 (January 1, 2019): 232595821985537. http://dx.doi.org/10.1177/2325958219855377.
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Objectives: To evaluate the association between human immunodeficiency virus (HIV) patients and medical costs (inpatient, outpatient, pharmacy, total) using a national cohort of HIV-infected Veterans and non-HIV matched controls within the Veteran’s Affairs (VA) Administration system. Design: This study used claims (January 2000 to December 2016) extracted from the VA Informatics and Computing Infrastructure and VA Health Economics Resource Center. Cases included Veterans with an International Classification of Diseases, Ninth Revision/International Classification of Diseases, Tenth Revision for HIV with at least 1 prescription for a complete antiretroviral therapy regimen (January 2000 to September 2016). Two non-HIV controls were exact matched on race, sex, month, and year of birth. All patients were followed until the earliest of the following: last date of VA activity, death, or December 31, 2016. Results: A total of 79 578 patients (26 526 HIV and 53 052 non-HIV) met all study criteria. The average age was 49.3 years, 38% were black, 32% were white, and 97% were male for both the HIV and control cohorts. Adjusted multivariable logistic regression models demonstrated that HIV was associated with higher odds of incurring a pharmacy cost (odds ratio = 2286.45, 95% confidence interval: 322.79-16 195.82), 4-fold, and 2-fold higher odds of incurring both outpatient and inpatient costs compared to the matched controls, respectively. In adjusted multivariable gamma generalized linear models, HIV-positive patients had an almost 4-fold, 17-fold, and almost 2-fold higher cost than matched controls in total, pharmacy, and outpatient costs, respectively. Conclusions: This study found an association between HIV-positive patients having higher odds of incurring a medical cost as well as higher medical costs compared to non-HIV controls.
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Resnik, Linda J., and Matthew L. Borgia. "Factors Associated With Utilization of Preoperative and Postoperative Rehabilitation Services by Patients With Amputation in the VA System: An Observational Study." Physical Therapy 93, no. 9 (September 1, 2013): 1197–210. http://dx.doi.org/10.2522/ptj.20120415.
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Background The Department of Veterans Affairs (VA) and the Department of Defense published evidence-based guidelines to standardize and improve rehabilitation of veterans with lower limb amputations; however, no studies have examined the guidelines' impact. Objectives The purposes of this study were: (1) to describe the utilization of rehabilitative services in the acute care setting by people who underwent major lower limb amputation in the VA from 2005 to 2010, (2) to identify factors associated with receipt of rehabilitation services, and (3) to examine the impact of the guidelines on service receipt. Design A cross-sectional study of 12,599 patients, who underwent major surgical amputation of the lower limb at a VA medical center from January 1, 2005, to December 31, 2010, was conducted. Data were obtained from main and surgical inpatient datasets and the inpatient encounters files of the Veterans Health Administration databases. Methods Rehabilitation services were categorized as physical therapy, occupational therapy, and either (any therapy), before or after amputation. Separate multivariate logistic regressions examined the impact of guideline implementation and identified factors associated with service receipt. Results Patients were 1.45 and 1.73 times more likely to receive preoperative physical therapy and occupational therapy and 1.68 and 1.79 times more likely to receive postoperative physical therapy and occupational therapy after guideline implementation. Patients in the Northeast had the lowest likelihood of receiving preoperative and postoperative rehabilitation services, whereas patients in the West had the highest likelihood. Other patient characteristics associated with service receipt were identified. Limitations The sample included only veterans who had surgeries at VA Medical Centers and cannot be generalized to veterans with surgeries outside the VA or to nonveteran patients and settings. Conclusions Further quality improvement efforts are needed to standardize delivery of rehabilitation services for veterans with amputations in the acute care setting.
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Karel, Michele J., Karen M. Benson, Youliana Piscopo, Susan Maataoui, and Kimberly Curyto. "CHALLENGES AND STRATEGIES FOR SUSTAINING A NEW DEMENTIA BEHAVIORAL CARE APPROACH IN NURSING HOMES." Innovation in Aging 3, Supplement_1 (November 2019): S380. http://dx.doi.org/10.1093/geroni/igz038.1393.
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Abstract The STAR-VA training program in Veterans Health Administration Community Living Centers (CLCs) has been helping interdisciplinary care teams understand and manage dementia-related behaviors in the nursing home setting, with promising clinical outcomes. However, sustaining a new care approach in a health care system poses multiple challenges. This presentation will discuss facilitators and barriers to STAR-VA sustainability based on CLC team and nurse leader feedback. Findings are informing development of a new site coaching program and a sustainability toolkit. Feedback to date suggests that critical STAR-VA implementation and sustainability strategies include: regularly scheduled team meetings to discuss behavioral assessment and care plans; ongoing staff training (e.g., new staff orientation); communicating care plans across shifts and in the health record; multiple nurse/shift champions; impromptu huddles; acknowledging staff successes; leadership engagement. The coaching program engages teams in setting and tracking site sustainability goals. Lessons learned will be discussed.
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Curyto, Kim, and Kimberly Van Haitsma. "SUSTAINING STAR-VA: EVALUATING SYSTEMIC OUTCOMES AND TEAM STRATEGIES FOR MANAGING BEHAVIOR SYMPTOMS OF DEMENTIA." Innovation in Aging 3, Supplement_1 (November 2019): S630—S631. http://dx.doi.org/10.1093/geroni/igz038.2350.
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Abstract The Veterans Health Administration (VHA) has invested in the implementation and evaluation of STAR-VA, a Veteran-centered, interprofessional intervention for managing behavioral symptoms of dementia (BSD), with 86 Community Living Center (CLC nursing home) teams between 2013 and 2018. Results of a VHA Quality Enhancement Research Initiative (QUERI) partnered evaluation project are presented, including a multi-site interprofessional network created to collaborate on evaluation of the longitudinal impact of STAR-VA on CLC Veteran- and site-level outcomes, and to determine factors associated with sustained implementation and positive outcomes. The development and validation of a Minimum Data Set quality indicator of behavior symptoms of dementia (BSD) is presented. Characteristics of STAR-VA trained and untrained CLCs are presented, along with facilitators and barriers to sustained program implementation. Findings support the effectiveness of implementation of STAR-VA on decreased use of psychotropic medication. Qualitative outcomes demonstrate importance of having the appropriate staff, positive team relationships, supportive usual routines, and culture as critical for STAR-VA sustainability efforts. Results emphasize the importance of using a valid, routine measure of BSD to provide feedback to CLC teams, and to develop a sustainability intervention focused on addressing reported barriers to program sustainability through interprofessional networks. Both qualitative and quantitative outcomes will inform development and recommendations for an implementation and evaluation strategy for an outcome-driven, tailored intervention to support CLC teams in sustaining STAR-VA and to improve poor-performer and maintain high-performer outcomes. The potential benefit of our findings for other interprofessional behavioral nursing home interventions will be discussed.
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Parikh, Divya Ahuja, Meera Vimala Ragavan, Sana Khateeb, and Manali I. Patel. "Financial toxicity among veterans with cancer." Journal of Clinical Oncology 37, no. 27_suppl (September 20, 2019): 103. http://dx.doi.org/10.1200/jco.2019.37.27_suppl.103.
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103 Background: Financial toxicity of cancer care has not previously been studied within the Veterans Health Administration (VHA). The VHA provides health care for veterans in VA hospitals across the United States (US). It is a single-payer system and the largest integrated health system in the US and in this study we sought to assess financial toxicity experienced by veterans at a VA hospital. Methods: We asked veterans with oncology clinic visits at the VA Palo Alto to complete a survey that included an 11-item validated questionnaire called the COST tool. The COST tool calculates a score 0-44 with higher scores suggestive of higher financial toxicity. We also assessed demographic factors including gender, education, race, income, and insurance status as well as monthly out of pocket costs (OOPC) and suggested resources to reduce burden. We coded responses and calculated descriptive statistics with proportions. Results: A total of 84 veterans completed the survey and demographic factors are depicted in Table. Veterans were predominantly male (96%), high school or less educated (46%), white (61%), with annual income less than $50,000 (81%), and VA insurance (95%). The mean COST score was 21. The majority of veterans (63%) reported less than $100 of monthly OOPC and many (56%) reported transportation as a major expense and requested transportation resources. Conclusions: Financial toxicity is an unmet concern among veterans. Despite low monthly OOPC in the VHA single-payer system, financial toxicity as measured by the COST score at a VA hospital was as high as a nearby academic center. Transportation was the most significant expense and future studies should evaluate interventions to reduce the financial burden of transportation for veterans. [Table: see text]
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Bedoya, Armando, Roy A. Pleasants, Joel C. Boggan, Danielle Seaman, Anne Reihman, Lauren Howard, Robert Kundich, Karen Welty-Wolf, and Robert M. Tighe. "Interstitial lung disease in a veterans affairs regional network; a retrospective cohort study." PLOS ONE 16, no. 3 (March 18, 2021): e0247316. http://dx.doi.org/10.1371/journal.pone.0247316.
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Background The epidemiology of Interstitial Lung Diseases (ILD) in the Veterans Health Administration (VHA) is presently unknown. Research question Describe the incidence/prevalence, clinical characteristics, and outcomes of ILD patients within the Veteran’s Administration Mid-Atlantic Health Care Network (VISN6). Study design and methods A multi-center retrospective cohort study was performed of veterans receiving hospital or outpatient ILD care from January 1, 2008 to December 31st, 2015 in six VISN6 facilities. Patients were identified by at least one visit encounter with a 515, 516, or other ILD ICD-9 code. Demographic and clinical characteristics were summarized using median, 25th and 75th percentile for continuous variables and count/percentage for categorical variables. Characteristics and incidence/prevalence rates were summarized, and stratified by ILD ICD-9 code. Kaplan Meier curves were generated to define overall survival. Results 3293 subjects met the inclusion criteria. 879 subjects (26%) had no evidence of ILD following manual medical record review. Overall estimated prevalence in verified ILD subjects was 256 per 100,000 people with a mean incidence across the years of 70 per 100,000 person-years (0.07%). The prevalence and mean incidence when focusing on people with an ILD diagnostic code who had a HRCT scan or a bronchoscopic or surgical lung biopsy was 237 per 100,000 people (0.237%) and 63 per 100,000 person-years respectively (0.063%). The median survival was 76.9 months for 515 codes, 103.4 months for 516 codes, and 83.6 months for 516.31. Interpretation This retrospective cohort study defines high ILD incidence/prevalence within the VA. Therefore, ILD is an important VA health concern.
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Arthur, Karen J., Deanna S. Kania, and Christina A. White. "Utilization of Lean Techniques in Pharmacy Residency Training: Modifying the PGY1 Management and Leadership Experience." Hospital Pharmacy 53, no. 4 (November 16, 2017): 247–55. http://dx.doi.org/10.1177/0018578717741568.
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Purpose: The purpose of this study was to utilize lean process improvement principles to enhance the health-system pharmacy administration learning experience within a postgraduate year 1 (PGY1) residency program. Summary: The Richard L. Roudebush VA Medical Center adopted the use of lean to improve customer service and workplace efficiency. The Residency Advisory Council, overseeing the 6 pharmacy residency programs, felt that training residents in a proven process improvement technique would benefit the service and assist in developing problem-solving skills. Yellow Belt training was incorporated into the residency programs in 2012, and the Yellow Belt project for the 2014-2015 residency class was the modification of the PGY1 Health-System Pharmacy Administration learning experience. Residents focused on a few key areas as part of their completion plan: educating residents and preceptors on the importance of leadership activities, establishing a list of consistent topic discussions to be held during the administration learning experience, confirming a topic list for the pharmacy practice management and leadership seminars, piloting collaborative precepting for the administration experience, revising the staff development program, and increasing resident involvement in the PGY1 interview process. Two portions of the project lacked effective and timely communication, and as a result, those areas were not fully implemented. The remainder of the items achieved 100% completion. Conclusion: Lean techniques were effectively utilized within a residency program to enhance the health-system pharmacy administration learning experience. Successful implementation of lean requires engagement of stakeholders within the health-system, timely communication, frequent reassessments, and accountability.
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Mayer, Patricia A., Bryn Esplin, Christopher J. Burant, Brigid M. Wilson, MaryAnn Lamont Krall, Barbara J. Daly, and Jason Gatliff. "In My Best Interest." American Journal of Hospice and Palliative Medicine® 34, no. 2 (July 11, 2016): 160–65. http://dx.doi.org/10.1177/1049909115609576.
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Background: Advance directives (ADs) have traditionally been viewed as clear instructions for implementing patient wishes at times of compromised decision-making capacity (DMC). However, whether individuals prefer ADs to be strictly followed or to serve as general guidelines has not been studied. The Veterans Administration’s Advance Directive Durable Power of Attorney for Health Care and Living Will (VA AD) provides patients the opportunity to indicate specific treatment preferences and to indicate how strictly the directive is to be followed. Objective: To describe preferences for life-sustaining treatments (LSTs) in various illness conditions as well as instructions for the use of VA ADs. Design/Setting: A descriptive study was performed collecting data from all ADs entered into the medical record at 1 VA Medical Center between January and June 2014. Measurements: Responses to VA AD with emphasis on health care agents (HCAs) and LW responses. Results: Veterans were more likely to reject LST when death was imminent (74.6%), when in a coma (71.1%), if they had brain damage (70.6%), or were ventilator dependent (70.4%). A majority (67.4%) of veterans preferred the document to be followed generally rather than strictly. Veterans were more likely to want VA ADs to serve as a general guide when a spouse was named HCA. Conclusion: Most of the sampled veterans rejected LST except under conditions of permanent disability. A majority intend VA ADs to serve as general guidelines rather than strict, binding instructions. These findings have significant implications for surrogate decision making and the use of ADs more generally.
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Evans, Martin E., Loretta A. Simbartl, Stephen M. Kralovic, Rajiv Jain, and Gary A. Roselle. "Clostridium difficile Infections in Veterans Health Administration Acute Care Facilities." Infection Control & Hospital Epidemiology 35, no. 8 (August 2014): 1037–42. http://dx.doi.org/10.1086/677151.
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ObjectiveAn initiative was implemented in July 2012 to decrease Clostridium difficile infections (CDIs) in Veterans Affairs (VA) acute care medical centers nationwide. This is a report of national baseline CDI data collected from the 21 months before implementation of the initiative.MethodsPersonnel at each of 132 data-reporting sites entered monthly retrospective CDI case data from October 2010 through June 2012 into a central database using case definitions similar to those of the National Healthcare Safety Network multidrug-resistant organism/CDI module.ResultsThere were 958,387 hospital admissions, 5,286,841 patient-days, and 9,642 CDI cases reported during the 21-month analysis period. The pooled CDI admission prevalence rate (including recurrent cases) was 0.66 cases per 100 admissions. The nonduplicate/nonrecurrent community-onset not-healthcare-facility-associated (CO-notHCFA) case rate was 0.35 cases per 100 admissions, and the community-onset healthcare facility–associated (CO-HCFA) case rate was 0.14 cases per 100 admissions. Hospital-onset healthcare facility–associated (HO-HCFA), clinically confirmed HO-HCFA (CC-HO-HCFA), and CO-HCFA rates were 9.32, 8.40, and 2.56 cases per 10,000 patient-days, respectively. There were significant decreases in admission prevalence (P = .0006, Poisson regression), HO-HCFA (P = .003), and CC-HO-HCFA (P = .004) rates after adjusting for type of diagnostic test. CO-HCFA and CO-notHCFA rates per 100 admissions also trended downward (P = .07 and .10, respectively).ConclusionsVA acute care medical facility CDI rates were higher than those reported in other healthcare systems, but unlike rates in other venues, they were decreasing or trending downward. Despite these downward trends, there is still a substantial burden of CDI in the system supporting the need for efforts to decrease rates further.
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Johnson, Brett, David P. Tuck, Spyridon Ganas, Nicholas Bayless, Nikesh Kotecha, and Nhan Do. "Endocrinopathies associated with immune checkpoint inhibitors: Standard of care at veterans administration medical centers." Journal of Clinical Oncology 37, no. 15_suppl (May 20, 2019): e14148-e14148. http://dx.doi.org/10.1200/jco.2019.37.15_suppl.e14148.
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e14148 Background: Multiple different immune checkpoint inhibitors (ICI) have now received FDA approval for nearly 70 separate indications covering 14 different tumor types. Patients treated with these agents in clinical trials have an observed incidence of immune related adverse events (irAEs), including endocrinopathies, which may increase morbidity and mortality. Limited information describes the incidence and impact of these events outside of clinical trials. Methods: Retrospective data from the Veterans Health Administration (VA) of patients treated with ICI has been aggregated to understand the impact of these events in a standard of care setting, with a goal of improving patient care through predictive models and contributing to the understanding of the mechanisms and response to treatment. Results: Between October 2015 and December 2018, 10,280 patients were prescribed ICI at VA medical centers, with an average age of 70 years (range 20-99). A total of 11098 ICI orders, allowing for combinations or sequential treatments. Overall, nivolumab was prescribed 6024 times (54.3%), pembrolizumab 3976 (35.8%), ipilimumab 565 (5.1%) and atezolizumab 519 (4.6%). Avelumab (13) and durvalumab (1) had limited use. A candidate set of potential endocrine adverse events was estimated based on selected ICD10 codes recorded for the first time after treatment with ICI (Table). Conclusions: The frequency of endocrine immune related adverse events has been reported to be 5-10%. Here we have identified a cohort of ICI treated patients who may have developed endocrine adverse events. This cohort will be used to evaluate phenotyping, potential biomarkers and models of predictive risk.[Table: see text]
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Nearing, Kathryn, Sumathi Misra, and Katharina Echt. "Expanding Workforce Capacity to Care for Older Veterans: The VA GRECC Interprofessional Training Experience." Innovation in Aging 4, Supplement_1 (December 1, 2020): 3–4. http://dx.doi.org/10.1093/geroni/igaa057.010.
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Abstract The Veterans Health Administration (VHA) contributes more to training healthcare professionals in geriatrics/gerontology than any other entity nationally, with the Geriatric Research Education and Clinical Center (GRECC) network serving as a leader in geriatric-/gerontology-specific interprofessional education. The Associated Health Training (AHT) Program is supported by all GRECCs, training ~427 trainees annually (FY17). Each AHT program brings together a diverse array of trainees – the specific constellation of disciplines unique to each GRECC based on local capacity/expertise. Common to all programs is intentional interprofessional training, aligned with Interprofessional Education Collaborative (IPEC) competencies. In 2016, the VA Office of Academic Affiliations (OAA) administered a 22-item survey to characterize the depth and breadth of geriatric-/gerontologic-specific interprofessional education across GRECCs. Questions explored how AHT programs addressed each of the four IPEC competency domains. Responses were de-identified; at least 2 coders independently applied directed coding to responses. Across GRECCs (n=18), 323 interprofessional training activities were coded, of which 9% were didactic; 27%, clinical; and, 63%, combination. Interprofessional education activities were integrated with profession-specific curricula (65.3%) or featured as part of GRECC-specific core curricula (5.4%). GRECC AHT interprofessional programs involved an average of 11 disciplines. GRECC AHT programs provide a vital infrastructure for building workforce capacity through robust, interprofessional training that engages diverse disciplines across a variety of care settings representing the continuum of care for older Veterans. GRECC and OAA efforts are critical to enhancing the quality, and expanding the capacity, of this workforce to meet increasing needs for patient-directed, team-based care for older adults.
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Chien, Hsu-Chih, Vikas Patil, Kelli M. Rasmussen, Christina Yong, Juliana M. L. Biondo, Mary Halloran, Sheila Shapouri, et al. "Discontinuation Patterns in Patients Receiving Novel Oral Agents for Chronic Lymphocytic Leukemia in the Veterans Health Administration." Blood 134, Supplement_1 (November 13, 2019): 4309. http://dx.doi.org/10.1182/blood-2019-128645.
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Introduction Chronic lymphocytic leukemia (CLL) is the most common leukemia in adults, accounting for 25-30% of all leukemias in the United States. During the past decade, there has been a paradigm shift in CLL treatment, with increasing adoption of novel oral agents (NOAs) such as acalabrutinib (ACALA), duvelisib (DUV), ibrutinib (IBR), idelalisib (IDELA), and venetoclax (VEN) instead of traditional chemoimmunotherapy (CIT). Unlike CIT, most NOAs are given daily for an indefinite period of time and are self-administered at home, raising concerns about adherence and discontinuation. The discontinuation patterns of NOAs in a real-world population of CLL patients is currently unknown. Methods Using the Veterans Administration (VA) Cancer Registry System and electronic healthcare records, we identified patients treated for CLL with NOAs in the VA from November 1, 2013 to November 30, 2018. Patients were followed from the first NOA dispensation until death or the end of the study observation (May 31, 2019). NOAs were selected in accordance with the National Comprehensive Cancer Network (NCCN) guidelinesfor CLL and were extracted using pharmacy dispensation records. Discontinuation was defined as the absence of NOA dispensation within 60 days of estimated exhaustion of patient's NOA supply from the last recorded dispensation. A discontinuation event for each NOA treatment episode in each patient was classified as either 1) a drug holiday, if there was evidence of resumption of the same treatment without any other treatment interventions after the first discontinuation; or 2) permanent discontinuation, in which the treatment ceased without evidence of resumption for 60 days or there was evidence of new treatment initiation after the discontinuation of previous treatment. We report the proportion of discontinuation and exposure-adjusted discontinuation rates (e-AR), which were calculated using the length of NOA duration in person-time. Results We identified 1,196 CLL patients treated with NOAs from November 1, 2013 to November 30, 2018. The mean age at NOA initiation was 70.7 years; 96.7% of patients were male. The median time from diagnosis to NOA initiation was 56.5 months (0-189.5 months). Of the 1,196 patients treated with NOAs, 1,172 received IBR, 53 received IDELA, and 106 received VEN. There were few patients (<10)treated with ACALA and DUV, therefore these patientswere omitted from the final analyses. During a median follow-up of 18.9 months (0-65.3 months), 48.2% NOA treatment courses were followed by a discontinuation event. The proportions of patients who discontinued for IBR, IDELA, and VEN were 47.5%, 77.4%, and 41.5%. The e-AR of IBR, IDELA, and VEN are reported in Table 2. At the end of the study observation (May 2019), 52.6% of IBR, 22.6% of IDELA, and 58.3% of VEN treatment courses were still being administered. In first-line (L1) IBR, the median NOA treatment duration until the first discontinuation was 10.7 months (0.8-55.8 months), 12.6 months (0.5-62.0 months) in second-line (L2) IBR, and 12.2 months (0.78-57.8 months) in third-line or subsequent lines (L3+) IBR. In IDELA treatment courses, the median treatment duration until the first discontinuation was 17.8 months (1.9-41.6 months) in L2 and 4.3 months (1.7-26.2 months) in L3+. In VEN, the median treatment duration until the first discontinuation was 8.4 months (3.1-26.0 months) in L2 and 7.4 months (1.7-18.5 months) in L3+. Of 532 L1 IBR treatment courses with >1 dispensation, 96 (18%) were associated with a drug holiday and 97 (18%) with permanent discontinuation. These numbers were 64 (27%) and 50 (21%) for L2 IBR courses, and 90 (28%) and 76 (24%) for L3+ IBR courses. Similarly, 24 (67%) of L3 IDELA treatment courses with >1 dispensation were associated with permanent discontinuation. Among 63 L3+ VEN courses with >1 dispensation, 6 (10%) were associated with a drug holiday and 14 (22%) with permanent discontinuation. Conclusions To our knowledge, this study is the first to report on the NOA discontinuation in a nationwide VA cohort of CLL patients treated in a real-world setting. Our results suggest there is a substantial proportion of drug holidays and permanent discontinuation among commonly used NOAs. Further efforts will focus on understanding factors leading to discontinuation and the impact of discontinuation/drug holidays on clinical outcomes. Disclosures Biondo: Genentech, Inc.: Employment; F. Hoffmann-La Roche Ltd: Equity Ownership. Halloran:Roche: Equity Ownership; Genentech, Inc.: Employment. Shapouri:Roche: Equity Ownership; Genentech, Inc.: Employment. Wu:Genentech, Inc.: Employment. Sauer:University of Utah and SLC VA Medical Center: Employment. Halwani:Miragen: Research Funding; Kyowa Hakko Kirin: Research Funding; Pharmacyclics: Research Funding; Amgen: Research Funding; Seattle Genetics: Research Funding; Genentech, Inc.: Research Funding; AbbVie: Research Funding; Takeda: Research Funding; Bristol-Myers Squibb: Research Funding; Immune Design: Research Funding.
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Jedele, Jenefer M., Kim Curyto, Brian M. Ludwin, and Michele J. Karel. "Addressing Behavioral Symptoms of Dementia Through STAR-VA Implementation: Do Outcomes Vary by Behavior Type?" American Journal of Alzheimer's Disease & Other Dementiasr 35 (January 1, 2020): 153331752091157. http://dx.doi.org/10.1177/1533317520911577.
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Objectives: The STAR-VA program in Veterans Health Administration Community Living Centers (CLCs, nursing home settings) trains teams to implement a psychosocial intervention with residents with behavioral symptoms of dementia (BSD). Methods: Across 71 CLCs, 302 residents selected as training cases had target behaviors categorized into one of 5 types: physically aggressive (PA), physically nonaggressive, verbally aggressive, verbally nonaggressive, and behavior deficit (BD). Results: Across all groups, there were significant declines in team-rated behavior frequency (36%) and severity (44%), agitation (10%), distress behaviors (42%), depression (17%), and anxiety (20%). The magnitude of changes varied across behavior category. For example, those with a PA target behavior experienced a greater percentage decline in agitation and distress behavior scores, and those with a BD target behavior experienced a greater percentage decline in depressive and anxiety symptoms. Conclusions: STAR-VA, a multicomponent intervention, is generally effective across various types of behavioral symptoms associated with dementia.
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Bidassie, Balmatee, William Gunnar, Leigh Starr, George Van Buskirk, Lisa J. Warner, and Clifford Anckaitis. "A modified collaborative model to improve surgical flow health care processes in Veterans Affairs Medical Centers." International Journal of Healthcare 3, no. 2 (July 28, 2017): 47. http://dx.doi.org/10.5430/ijh.v3n2p47.
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The Veterans Health Administration (VHA) Office of Systems Redesign and Improvement, in collaboration with the VHA National Surgery Office and Veterans Affairs Center for Applied Systems Engineering (VA-CASE) - Veterans Engineering Resource Center (VERC), conducted a national process improvement initiative in Fiscal Year 2012 to promote more effective and efficient use of surgical unit resources. This improvement effort adopted a modified collaborative model with the incorporation of symposia and Rapid Process Improvement Workshops (RPIWs) to address concerns from collaborative teams for a more efficient surgical flow. Throughout the seven-month duration of the initiative, 20 teams participated and completed a total of 468 Plan-Do-Study-Act (PDSA) cycles to implement changes and improve performance levels in defined measures. At the conclusion, on average, teams were able to improve performance on the first case on-time start rate by 24%, mean turnover time by 14%, cancellation rate by 5%, and Operating Room (OR) utilization by 8%. The projected annual Cost Savings was estimated to be nearly $25 million. This modified improvement model overcame some of the challenges experienced in a traditional improvement collaborative model such as lack of clarity of clear roles and responsibilities of team members and clear and consistent aims. The operations in surgical flow were improved in multiple ways to achieve overall better performance. Future improvement initiatives have the potential to further enhance performance outcomes by focusing even more efforts on the preparation phase, increasing team participation and leadership buy-in, utilizing on-going reports that track team progress and focusing on sustain and spread.
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Dryden, Eileen M., Rendelle E. Bolton, Barbara G. Bokhour, Juliet Wu, Kelly Dvorin, Lauri Phillips, and Justeen K. Hyde. "Leaning Into Whole Health: Sustaining System Transformation While Supporting Patients and Employees During COVID-19." Global Advances in Health and Medicine 10 (January 2021): 216495612110210. http://dx.doi.org/10.1177/21649561211021047.
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Background The US Veterans Health Administration (VA) is transforming its healthcare system to create a Whole Health System (WHS) of care. Akin to such reorganization efforts as creating patient-centered medical homes and primary care behavioral health integration, the WHS goes beyond by transforming the entire system to one that takes a proactive approach to support patient and employee health and wellness. The SARS-CoV-2 pandemic disrupted the VA’s healthcare system and added stress for staff and patients, creating an exogenous shock for this transformation towards a WHS. Objective We examined the relationship between VA’s WHS transformation and the pandemic to understand if transformation was sustained during crisis and contributed to VA’s response. Methods Qualitative interviews were conducted as part of a multi-year study of WHS transformation. A single multi-person interview was conducted with 61 WHS leaders at 18 VA Medical Centers, examining WH transformation and use during the pandemic. Data were analyzed using rapid directed content analysis. Results While the pandemic initially slowed transformation efforts, sites intentionally embraced a WH approach to support patients and employees during this crisis. Efforts included conducting patient wellness calls, and, for patients and employees, promoting complementary and integrative health therapies, self-care, and WH concepts to combat stress and support wellbeing. A surge in virtual technology use facilitated innovative delivery of complementary and integrative therapies and promoted continued use of WH activities. Conclusion The pandemic called attention to the need for healthcare systems to address the wellbeing of both patients and providers to sustain high quality care delivery. At a time of crisis, VA sites sustained WH transformation efforts, recognizing WH as one strategy to support patients and employees. This response indicates cultural transformation is taking hold, with WH serving as a promising approach for promoting wellbeing among patients and employees alike.
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Sokolova, Alexandra, Heather H. Cheng, Bradley J. Hintze, Michael J. Kelley, Neil L. Spector, Jill Duffy, Julie Ann Lynch, Matthew Rettig, and Robert B. Montgomery. "The Veterans Health Administration Precision Oncology Program for Advanced Prostate Cancer Patients: Expanding tumor NGS opportunities to a broader patient population." Journal of Clinical Oncology 37, no. 7_suppl (March 1, 2019): 193. http://dx.doi.org/10.1200/jco.2019.37.7_suppl.193.
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193 Background: Progress in understanding molecular changes in advanced prostate cancer has led to promising precision oncology opportunities; to date, most have been concentrated at tertiary research centers and urban centers and unequally available to patients. The VHA is the largest integrated healthcare system in the U.S. and provides medical care to >6 million veterans (~40% living in rural areas). The VHA has implemented a system-wide National Precision Oncology Program (NPOP) to offer tumor NGS testing to veterans with cancer. Methods: VHA patients with advanced stage cancers were offered targeted NGS gene panels (Personalis ACE Extended Cancer Panel; PGDx CancerSELECT/PlasmaSELECT) as part of clinical care. Annotated sequence data is collected by NPOP. We report preliminary findings of the participating veterans with prostate cancer. Results: 372 veterans from 81 sites underwent NGS sequencing of their prostate tumors (n=311) or cfDNA (n=61). Tumors from 165 (44%) were found to have mutations (allelic ratio ≥5%) in 47 genes. Of 372, 62 harbored mutations in TP53 (17%), 9 in NOTCH1 (2%), 16 in PTEN (4%), 16 in AR (4%), 13 in ATM (4%), 11 in BRCA2 (3%), 2 in MSH2 (0.5%), 1 in NBN (0.3%), and 1 in PALB2 (0.3%). 7 men (1.8%) had adequate tumor, but no identifiable somatic mutations. NPOP findings were compared to the existing databases SU2C/PCF (of metastatic biopsies in metastatic castration resistant disease) and TCGA (of primary tumors in localized disease), see table. Findings will be updated at presentation. Conclusions: The VA NPOP has been successfully implemented, and prostate tumors from veterans were found to carry potentially actionable mutations, including BRCA2 and ATM, for which there are precision treatment trials. The program will be expanded and will facilitate more diverse and equitable distribution of access to precision oncology diagnostics and therapeutic opportunities, in alignment with the Cancer Moonshot Initiative. (e.g. VA-ABCD clinicaltrials.gov; NCT02985021). [Table: see text]
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Herout, Jennifer, Jolie Dobre, William Plew, and Jason J. Saleem. "Gathering Information in Healthcare Settings: A Tool to Facilitate On-Site Work." Proceedings of the Human Factors and Ergonomics Society Annual Meeting 62, no. 1 (September 2018): 600–604. http://dx.doi.org/10.1177/1541931218621137.
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The coordination of site visits to execute human factors methods, such as onsite usability tests, interviews, or observations, in clinical settings requires a high level of management to attain successful data collection outcomes. Members of the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Human Factors Engineering (HFE) team occasionally visit VHA medical centers or outpatient clinics to complete our work. We have developed a site visit checklist as a practice innovation to facilitate logistical coordination when gathering data onsite. This Practice-Oriented paper includes the full checklist, as well as discussion of its use to enable other groups to benefit from lessons we have learned in conducting onsite work in health care settings.
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Schoen, Martin W., Suhong Luo, Kenneth R. Carson, and Kristen M. Sanfilippo. "Outcomes of Black Patients with Multiple Myeloma in the Veterans Health Administration." Blood 132, Supplement 1 (November 29, 2018): 840. http://dx.doi.org/10.1182/blood-2018-99-119845.
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Abstract Background: Multiple myeloma (MM) is the most common hematologic malignancy in blacks with more than twice the incidence of non-black populations in national registry data. Prior studies have shown that blacks present with MM at an earlier age and have improved survival compared to non-blacks, contrary to the pattern in most malignancies. These findings have been theorized due to the effects of obesity, treatment variation, and disparities in care, in addition to alternate disease biology in black patients. In order to understand possible effects of race on outcomes while adjusting for confounders not available in other national datasets such as treatment, comorbidities, and baseline laboratory characteristics, we studied outcomes in a nationwide population of United States veterans with MM in the Veterans Health Administration (VHA). Methods: Patients with MM were identified by the VHA Central Cancer Registry between September 1, 1999 and December 31, 2013 and followed through December 31, 2014. Age, sex, race, body mass index (BMI), Charlson (Romano) comorbidity index, treatment (including transplant), hemoglobin (hgb), albumin, renal function (eGFR), and statin use were included. Cox proportional hazards regression modeling was used to assess the association between black race and overall survival at five years while controlling for known prognostic factors. The study was approved the Saint Louis VA Medical Center institutional review board. Results: 4805 patients were identified with MM, of which 1418 (29.5%) were black. Black patients were younger (66.2 years vs. 69.2, p<0.001) with increased mean comorbidity scores (3.7 vs. 3.0 p<0.001) compared to non-black patients. Black patients had lower mean BMI (27.0 years vs. 27.8, p<0.001) and higher rates of hgb <10 g/dL, 49.1% vs. 35.3%, p<0.001) and albumin below 3 g/dL (35.3% vs. 28.3% p<0.001) with similar rates of decreased renal function of eGFR <30 (22.1% vs. 21.2%, p=0.69) compared to non-black patients. Black patients underwent stem cell transplantation at similar rates (12.3% vs. 14.2%, p=0.09) and there no differences based on race in treatment with lenalidomide (35.1% vs. 36.0%, p=0.52), thalidomide (36.7% vs. 38.7%, p=0.20), or melphalan (32.7% vs. 34.8%, p=0.16). More black patients were treated with bortezomib compared to non-blacks (50.1% vs 44.4%, p<0.001). In unadjusted analyses, black race was associated with reduced risk of death at five years (Hazard Ratio [HR] 0.89, 95% CI 0.83-0.97). After controlling for age, comorbidity score, hgb, albumin, transplant, and treatment; black patients also had improved survival (HR 0.82, 95% CI 0.76-0.89). After adding BMI, year of diagnosis, and statin use to the final Cox model, black patients continued to have improved survival (HR 0.80, 95% CI 0.73-0.86). Conclusions: Survival of black patients with MM was improved compared to non-blacks in the VHA, a national comprehensive care delivery system. Black patients also received similar therapies compared to non-blacks, while presenting at a younger age with more comorbidities. These results are strengthened after adjusting for treatments and patient characteristics not available in other large data studies. Despite increased incidence of MM in the black population, outcomes are improved, similar to other large studies of patients in the United States. Alternate disease biology may be responsible for improved survival and further studies of MM based on race are appropriate. Disclosures Carson: Flatiron Health: Employment; Washington University in St. Louis: Employment; Roche: Consultancy. Sanfilippo:BMS/Pfizer: Speakers Bureau.
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Hale, Anne, Leah Haverhals, Chelsea Manheim, and Cari Levy. "Vet Connect: A Quality Improvement Program to Provide Telehealth Subspecialty Care for Veterans Residing in VA-Contracted Community Nursing Homes." Geriatrics 3, no. 3 (September 5, 2018): 57. http://dx.doi.org/10.3390/geriatrics3030057.
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Veterans residing in Veterans Health Administration (VA) contracted Community Nursing Homes (CNHs) receive primary care from the CNH they reside in, but often travel to Veterans Affairs Medical Centers (VAMCs) for specialty care services. The Vet Connect project is a quality improvement project aiming to implement video technology to support access to specialty care. Methods: Eight Denver VAMC specialty care providers and three project nurses underwent telehealth training and obtained appropriate equipment. To identify in-person visits eligible for substitution of video visits, project nurses review charts of CNH Veterans, consult directly with Veterans, and obtain recommendations from staff. Project nurses serve as tele-presenters within the CNHs, while VA specialists provide care from the VAMC. After each visit, team nurses coordinate care with and deliver specialty care recommendations to CNH staff. Results: We assessed clinical, business, and technical domains of the Vet Connect project, and utilized process mapping to identify barriers and facilitators to implementation. Clinically, starting on 26 June 2017 through 1 June 2018, N = 203 video visits have been conducted with 11 different CNHs in three subspecialties: geriatrics, palliative care, and mental health. These visits generated 49 referrals for 37 Veterans. Fiscally, cost analyses indicate that per visit, the health care system saves an estimated $310. Technologically, the success rate was 83%. Process mapping helped identify facilitators and barriers to implementation of the telehealth program, including cultivating buy-in from key stakeholders (i.e., medical and mental health providers, telehealth staff, and CNH staff), communication allowing for ongoing program adaptation, and building relationships. Conclusion: Subspecialty care delivery to nursing homes using video visit technology in the Vet Connect program is feasible using centralized organization to coordinate complex clinical, business and technical processes. Vet Connect has proved sustainable and has potential to expand within and outside of the VA.
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File, Danielle M., Carlos Eduardo Arce-Lara, Jeffrey C. Whittle, Elizabeth Gore, and Rafael Santana-Davila. "Impact of the distance from a radiation oncology treatment facilty on initiation of therapy and its influence on survival in patients with stage III and IV NSCLC." Journal of Clinical Oncology 31, no. 15_suppl (May 20, 2013): e17594-e17594. http://dx.doi.org/10.1200/jco.2013.31.15_suppl.e17594.
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e17594 Background: Patients with stage III and IV lung cancer require multidisciplinary care. The Milwaukee VA is the only center within the Veterans Health Administration in the state that has a radiation oncology facility. Patients frequently travel from across the state to receive treatment here. We conducted a retrospective review of cases seen in our institution to determine if the distance from the patients’ home to our center influenced their outcome. Methods: Patients with NSCLC treated between 2000 and 2012 were identified from our internal registry. Type of treatment was identified from the registry and confirmed in a chart review.. SAS 9.2 was used for statistical analysis and to measure distance between the patients’ home address and our center. Results: We included 230 patients with stage III disease treated with radiation therapy and 139 patients with stage IV treated with chemotherapy. Of those with Stage III (53% with IIIA and 47% IIIB) 41.3% (n=95) received concurrent radiation therapy and chemotherapy, 14% received sequential therapy, 40% received radiation therapy alone and 5% were treated with chemotherapy followed by palliative radiation. In those with metastatic disease 61% received palliative radiation at some point during their treatment. Median distance between the patients’ home and the Milwaukee VA was 57miles (IQR 10-109) in patients with stage III disease and 22 (IQR 5-84) in those with metastatic disease. There was no correlation between the distance travelled and the time to first treatment in either stage (r=0.008 in stage III and r=0.05 in stage IV). In a univariate analysis living further than 50 miles did not appear to influence survival in stage III (median OS 14.6 vs. 16.4 months p=0.25) nor stage IV disease(9.7 vs 8 p=0.55). In a multivariate analysis when controlling for age, time to first treatment and distance as a continuous variable was not associated with survival in patients with stage III(HR 1.01, 95% CI 0.99-1.02 p=0.15) or stage IV disease (HR 1.01, 95%CI 0.98-1.04 p=0.35). Conclusions: Distance traveled to a radiation oncology treatment facility in this cohort did not influence survival in patients with stage III and IV NSCLC.
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Chang, Michael G., Kristine DeSotto, Paul Taibi, and Sandra Troeschel. "Development of a PSA tracking system for patients wtih prostate cancer following definitive radiotherapy to enhance rural health." Journal of Clinical Oncology 34, no. 2_suppl (January 10, 2016): 39. http://dx.doi.org/10.1200/jco.2016.34.2_suppl.39.
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39 Background: Patients with prostate cancer (PC) may benefit from early intervention when they experience relapse/recur. About 50% of our PC patients are rural and experience barriers to care due to distance, cost, and convenience. We sought to create a PSA tracking system with the Veterans Administration’s (VA) Electronic Medical Record (EMR) that would provide a remote way to monitor disease progression after definitive radiotherapy (XRT) by annual PSA testing alone. Methods: Using VA’s EMR, we developed a query tool to identify all patients ever treated at our center with XRT for prostate cancer who were alive, had not been seen in our clinic in more than a year, did not have metastatic disease, and had a rising PSA of at least 0.5 ng/ml above nadir, or who had no PSA drawn within 15 months. Results: Among roughly 50,000 unique patients in the McGuire VAMC EMR, we found 1,858 patients treated with XRT for PC more than 5 years ago between 1997 and 2015. Of these 1,190 were still alive and 455 had not been seen by our clinic in 400 days or more. Of these 455 patients, 159 patients had not had a PSA drawn within 15 months and/or their most recent PSA was more than 0.5 ng/ml above nadir, triggering a chart review followed by either a phone call, repeat testing, in person follow up visit, or removal from follow up monitoring if clinically indicated. 296 patients were receiving appropriate care outside of our clinic and had no sign of significant rise in PSA. An analysis by the VA showed annual savings of $60,360 per year in fuel costs by avoiding unnecessary visits. Conclusions: The VA’s robust EMR and a new query tool can identify patients with prostate cancer who are lost to follow up or who needed intervention from among thousands of patients in the EMR, improving quality while reducing cost and unnecessary time and travel for rural and all patients. More importantly, our tool could be modified to improve survival for all VA patients with prostate cancer by creating a VA-wide PSA failure detection system. The system would alert providers to any patient who may benefit from early salvage radiotherapy or hormonal therapy before their disease progresses beyond the therapeutic window of benefit.
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Silva, M. A., E. M. Brennan, E. Noyes, A. Royer, and R. Nakase-Richardson. "0729 Sleep Apnea Diagnosis And Severity And Their Impact On Cognition After TBI: A VA TBI Model Systems Study." Sleep 43, Supplement_1 (April 2020): A277—A278. http://dx.doi.org/10.1093/sleep/zsaa056.725.
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Abstract Introduction For persons with moderate-to-severe traumatic brain injury (TBI), chronic cognitive impairment contributes to long term disability. Health comorbidities may contribute to the neurologic burden in TBI. Indeed, obstructive sleep apnea (OSA) is associated with neuropathological and cognitive changes. The objective of this study was to examine the relationship between OSA and cognition after TBI. Methods Participants were prior inpatient rehabilitation patients drawn from the Tampa VA TBI Model Systems longitudinal study. Post-discharge interviews occurred 2 to 6 years post-TBI. Participants reported whether they were diagnosed with OSA and completed the Brief Test of Adult Cognition by Telephone (BTACT) which measures recall, working memory, processing speed, fluency, and reasoning. Participants with polysomnography (PSG) were separately analyzed to examine the impact of sleep apnea severity (i.e., Apnea-Hypopnea Index [AHI]) on cognition. Results Participants (N=104) were mostly male (95.2%), age M=37.7 (SD=12.5), Education M=13.6 years (SD=2.1), and 45.2% were diagnosed with OSA. Participants with and without OSA did not differ by age, education, gender, or time since injury at time of BTACT (ps > .05). ANCOVAs were conducted examining OSA diagnosis on BTACT subscale scores, covarying TBI severity level, but results did not reach statistical significance (ps > .05). A subset of participants with OSA had PSG (n=27), AHI score quartiles = 6.7/10.4/21.6. Higher AHI was associated with poorer reasoning (Spearman ρ = -0.45, p = .019). Nonsignificant results were found for word recall (Spearman ρ = -0.35, p = .074) and processing speed (Spearman ρ = -0.36, p = .069). Conclusion Severity of sleep apnea may influence aspects of cognition among persons with TBI, although these results are preliminary and need replication with a larger and more representative sample. Support This work was supported by the Veterans Health Administration Central Office VA TBI Model Systems Program of Research and subcontract from General Dynamics Information Technology [W91YTZ-13-C-0015, HT0014-19-C-0004] from the Defense and Veterans Brain Injury Center (DVBIC); and from the United States Department of Veterans Affairs [W81XWH-13-2-0095]; and from the United States Department of Defense Congressionally Directed Medical Research Programs; and from the Patient Centered Outcomes Research Institute (PCORI) [CER-1511-33005].
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Nayar, Preethy, Diptee Ojha, Ann Fetrick, and Anh T. Nguyen. "Applying Lean Six Sigma to improve medication management." International Journal of Health Care Quality Assurance 29, no. 1 (February 8, 2016): 16–23. http://dx.doi.org/10.1108/ijhcqa-02-2015-0020.
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Purpose – A significant proportion of veterans use dual care or health care services within and outside the Veterans Health Administration (VHA). In this study conducted at a VHA medical center in the USA, the authors used Lean Six Sigma principles to develop recommendations to eliminate wasteful processes and implement a more efficient and effective process to manage medications for dual care veteran patients. The purpose of this study is to: assess compliance with the VHA’s dual care policy; collect data and describe the current process for co-management of dual care veterans’ medications; and draft recommendations to improve the current process for dual care medications co-management. Design/methodology/approach – Input was obtained from the VHA patient care team members to draw a process map to describe the current process for filling a non-VHA prescription at a VHA facility. Data were collected through surveys and direct observation to measure the current process and to develop recommendations to redesign and improve the process. Findings – A key bottleneck in the process that was identified was the receipt of the non-VHA medical record which resulted in delays in filling prescriptions. The recommendations of this project focus on the four domains of: documentation of dual care; veteran education; process redesign; and outreach to community providers. Research limitations/implications – This case study describes the application of Lean Six Sigma principles in one urban Veterans Affairs Medical Center (VAMC) in the Mid-Western USA to solve a specific organizational quality problem. Therefore, the findings may not be generalizable to other organizations. Practical implications – The Lean Six Sigma general principles applied in this project to develop recommendations to improve medication management for dual care veterans are applicable to any process improvement or redesign project and has valuable lessons for other VAMCs seeking to improve care for their dual care veteran patients. Originality/value – The findings of this project will be of value to VA providers and policy makers and health care managers who plan to apply Lean Six Sigma techniques in their organizations to improve the quality of care for their patients.
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Mardian, Aram S., Eric R. Hanson, Lisa Villarroel, Anita D. Karnik, John G. Sollenberger, Heather A. Okvat, Amrita Dhanjal-Reddy, and Shakaib Rehman. "Flipping the Pain Care Model: A Sociopsychobiological Approach to High-Value Chronic Pain Care." Pain Medicine 21, no. 6 (January 7, 2020): 1168–80. http://dx.doi.org/10.1093/pm/pnz336.
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Abstract Objective Much of the pain care in the United States is costly and associated with limited benefits and significant harms, representing a crisis of value. We explore the current factors that lead to low-value pain care within the United States and provide an alternate model for pain care, as well as an implementation example for this model that is expected to produce high-value pain care. Methods From the perspective of aiming for high-value care (defined as care that maximizes clinical benefit while minimizing harm and cost), we describe the current evidence practice gap (EPG) for pain care in the United States, which has developed as current clinical care diverges from existing evidence. A discussion of the biomedical, biopsychosocial, and sociopsychobiological (SPB) models of pain care is used to elucidate the origins of the current EPG and the unconscious factors that perpetuate pain care systems despite poor results. Results An interprofessional pain team within the Veterans Health Administration is described as an example of a pain care system that has been designed to deliver high-value pain care and close the EPG by implementing the SPB model. Conclusions Adopting and implementing a sociopsychobiological model may be an effective approach to address the current evidence practice gap and deliver high-value pain care in the United States. The Phoenix VA Health Care System’s Chronic Pain Wellness Center may serve as a template for providing high-value, evidence-based pain care for patients with high-impact chronic pain who also have medical, mental health, and opioid use disorder comorbidities.
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Possis, Elizabeth, Beret Skroch, Samuel Hintz, Carrie Bronars, Michael Mallen, Haley Crowl, Kelly Moore, Heather Bemmels, and Douglas Olson. "Examining and Improving Provider Adherence to the Primary Care Mental Health Integration Model." Military Medicine 185, no. 9-10 (July 3, 2020): e1411-e1416. http://dx.doi.org/10.1093/milmed/usaa140.
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Abstract Introduction The Veterans Health Administration (VHA) is a national leader in integrated care, known in the VHA as the Primary Care Mental Health Integration (PCMHI) model. This model is associated with improved quality of services and same-day access for veterans. There has been some recent development of PCMHI/integrated care competencies within VHA and across the nation. To fully implement these competencies, however, PCMHI providers must not only be trained, but their adherence to the PCMHI model must also be assessed. While there have been recent advances, there has been little research that has examined the adherence of PCMHI providers to the model or methods to improve adherence. Materials and Methods The present study sought to examine and improve the clinical practice of a team of eight PCMHI providers to make practice more adherent to the PCMHI model. This study was conducted at a large Midwestern VA Medical Center using interventions based in assessment, feedback, and training—measured at three points in time. The Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ; Beehler GP, Funderburk JS, Possemato K, et al.: Psychometric assessment of the primary care behavioral health provider adherence questionnaire (PPAQ). Transl Behav Med 2013; 3: 379–91.) was used to assess provider adherence and the PPAQ toolkit was used to provide tailored recommendations for improving provider practice. In addition, the VHA “Foundations Manual” and Functional Tool outlined essential behavioral targets that are consistent with the PCMHI model and the “essential provider behaviors” from the PPAQ. A combination of individual and group interventions was presented and adherence, pre and post, was assessed with the PPAQ and with evaluation of clinical practice data. Results Results indicated that the behavior of PCMHI providers changed over time, with providers exhibiting more PCMHI consistent behaviors and fewer inconsistent behaviors. Adherence to the PCMHI model increased. Conclusion Providing assessment, feedback, and training in the PCMHI model changed the clinical practice of PCMHI providers and resulted in improved adherence. Clinical and research implications are discussed.
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Baser, Onur, Elyse Fritschel, Lu Li, J. Zhang, and Li Wang. "An overview of clinical and economic outcomes of U.S. veteran colorectal cancer patients." Journal of Clinical Oncology 31, no. 15_suppl (May 20, 2013): e14689-e14689. http://dx.doi.org/10.1200/jco.2013.31.15_suppl.e14689.
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e14689 Background: Colorectal cancer is the second leading cause of cancer-related death in the United States. While studies have shown that conditions such as diabetes are associated with shorter disease-free survival in colon cancer patients, fewer U.S. Department of Veterans Affairs (VA)-specific studies have been conducted focusing on colorectal cancer outcomes (Centers for Disease Control and Prevention. Colorectal (colon) cancer. www.cdc.gov/cancer/colorectal. Extermann M. Interaction between comorbidity and cancer. Cancer Control. 2007; 14(1): 13-22). This study aimed to describe the comorbidity profile and economic outcomes of colorectal cancer patients in the VA population. Methods: A retrospective study of patients diagnosed with colorectal cancer during the study period of October 1, 2005 to September 30, 2010 was conducted using the Veterans Health Administration datasets. All colorectal cancer patients were identified using International Classification of Disease 9thRevision Clinical Modification (ICD-9-CM) diagnosis codes 153.xx and 154.xx. Descriptive statistics were calculated as means ± standard deviation (SD) and percentages using SAS version 9.3 software. Results: In diagnosed colorectal cancer patients (n=62,200), common comorbidities included hypertension (n=18,309, 29.44%) and diabetes (n=10,891, 17.51%). Other minor comorbidities included hyperlipidemia and benign neoplasm of the colon. The average Fecal Occult Blood Test result (found in 12.21% of colorectal cancer veterans) was 96.37. Outpatient services were utilized by 99.71% of colorectal cancer patients, followed by pharmacy (91.94%) and inpatient visits (31.15%). Costs for outpatient ($10,637, SD=$17,125), pharmacy ($2,704, SD=$9,773), and inpatient services ($16,032, SD=$53,078) contributed to follow-up health care expenditures. Conclusions: Despite frequent outpatient utilization, inpatient costs have the greatest impact on the considerable health care cost incurred by lung cancer veterans. The presence of comorbid conditions may further complicate colorectal cancer treatment, though further characterization requires further research.
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Razjouyan, J., S. Nowakowski, A. D. Naik, A. Sharafkhaneh, and M. E. Kunik. "1157 Comparison Of Polysomnography Total Sleep Time In Veterans With A Dementia Diagnosis, Incipient Dementia, And No Dementia." Sleep 43, Supplement_1 (April 2020): A441. http://dx.doi.org/10.1093/sleep/zsaa056.1151.
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Abstract Introduction Neuroprotection, early diagnosis, and behavioral intervention are national priorities for dementia research. Sleep duration is emerging as an important potential remediable risk factor. In this study, we examined the total sleep time derived from overnight polysomnography (PSG) studies in veterans with a current dementia diagnosis at the time of PSG study (dementia), future diagnosis of dementia following the PSG study (incipient dementia), and no diagnosis of dementia at any time point (no dementia) over a 19-year period. Methods We identified 69,847 PSG sleep studies using CPT code 95810 and all-cause dementia diagnosis using ICD 9/10 codes (e.g., F03.90) from 2000-19 in the US Department of Veteran Affairs (VA) national database. To be included patients must have ≥ 1 VA visits in 12 months leading up to PSG. Dementia diagnosis must be documented on two separate visits between 12 months prior to 6 months following PSG for current dementia group and anytime after the PSG for incipient dementia. We used natural language processing to extract TST values from the patient free-text notes. Analysis of variance was used to compare PSG TST of the three groups. Results Patients had a mean age of 55.4±13.8 at the time of PSG study, 91.5% were male, and 64% were Caucasian. TST of dementia patients (N=1,031) was m=257±110m (d=0.33, p<.05), incipient dementia (N=1,875) was m=253±116m (d=0.35, p<.05) versus no dementia (61,871) m=292±104mins. Conclusion Patients with a diagnosis of dementia at the time of PSG study and patients that went on to receive a diagnosis following their PSG study had a significantly lower total sleep time compared to patients that have never received a dementia diagnosis. This is an important study that compares sleep duration during overnight PSG studies and dementia diagnosis across 19 years in the largest integrated healthcare system in the US. Support This material is based upon work supported in part by the Department of Veteran Affairs, Veterans Health Administration, Office of Research and Development, and the Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413). Dr. Nowakowski is also supported by a National Institutes of Health (NIH) Grant (R01NR018342).
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Sandulache, Vlad, Anita Sabichi, George Chen, and Scott Charnitsky. "QIM19-142: Development of a Low Resource Tool for Improving Head and Neck Cancer Treatment Delivery Within an Integrated Health Care Delivery System." Journal of the National Comprehensive Cancer Network 17, no. 3.5 (March 8, 2019): QIM19–142. http://dx.doi.org/10.6004/jnccn.2018.7128.
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Background: The Veterans Health Administration (VHA) is the only nationally integrated healthcare delivery system in the United States. The vertical and horizontal integration of the VHA make it an ideal environment for development of tools designed to streamline cancer diagnosis and treatment. Head and neck cancer (HNC) remains a difficult disease to diagnose and treat. Delivery of multimodality treatment for advanced HNC is challenging at both academic centers and in the community setting. This problem is magnified by the increased incidence of HNC, powered by an epidemic increase in the incidence of human papilloma virus (HPV)–associated oropharyngeal cancer (OPC). Objective: To develop a non–resource-intensive approach to improving: (1) time to treatment initiation and (2) compliance with optimal treatment package time for HNC patients. Methods: Retrospective analysis of 300 patients with a diagnosis of HNC from the Michael E. DeBakey VA Medical Center (MEDVAMC) was used to generate baseline data (2000–2010) for: (1) time to treatment (surgery, 24 days; radiation, 48 days) and (2) treatment package time <100 days compliance (68%). We developed a tool available to providers and clinic staff to prospectively track patients from initial referral, through diagnosis and treatment, along with completion of ancillary studies (modified barium swallow) and completion of the survivorship care plan. Between June 2016 and October 2018, 350 patients were tracked using this tool; 275 patients were new HNC diagnoses. Results: Implementation of the tracking tool reduced diagnosis to treatment start (mean, 44 days; median, 26 days). Compliance with treatment package time <100 days was increased to 95%; compliance with initiation of adjuvant radiation within 6 weeks of surgery was increased to 75%. Utilization of the tool allowed for streamlined surgical care, particularly through integration of dental extractions into the oncologic resection, and facilitated timely initiation of adjuvant radiation for advanced HNC. Conclusions: It is possible to improve: (1) time to diagnosis, (2) time to treatment initiation, and (3) treatment completion rates for complex HNC requiring multimodality treatment without additional resource utilization. However, appropriate implementation requires a robust multidisciplinary treatment team, with appropriate “buy in” from all participants and is facilitated by the presence of a fully integrated health care delivery system.
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Shorr, Ronald I., Sherry Ahrentzen, Stephen L. Luther, Chad Radwan, Bridget Hahm, Mahshad Kazemzadeh, Slande Alliance, Gail Powell-Cope, and Gary M. Fischer. "Examining the Relationship Between Environmental Factors and Inpatient Hospital Falls: Protocol for a Mixed Methods Study." JMIR Research Protocols 10, no. 7 (July 13, 2021): e24974. http://dx.doi.org/10.2196/24974.
Full textAbstract:
Background Patient falls are the most common adverse events reported in hospitals. Although it is well understood that the physical hospital environment contributes to nearly 40% of severe or fatal hospital falls, there are significant gaps in the knowledge about the relationship between inpatient unit design and fall rates. The few studies that have examined unit design have been conducted in a single hospital (non-Veterans Health Administration [VHA]) or a small number of inpatient units, limiting generalizability. The goal of this study is to identify unit design factors contributing to inpatient falls in the VHA. Objective The first aim of the study is to investigate frontline and management perceptions of and experiences with veteran falls as they pertain to inpatient environmental factors. An iterative rapid assessment process will be used to analyze the data. Interview findings will directly inform the development of an environmental assessment survey to be conducted as part of aim 2 and to contribute to interpretation of aim 2. The second aim of this study is to quantify unit design factors and compare spatial and environmental factors of units with higher- versus lower-than-expected fall rates. Methods We will first conduct walk-through interviews with facility personnel in 10 medical/surgical units at 3 VHA medical centers to identify environmental fall risk factors. Data will be used to finalize an environmental assessment survey for nurse managers and facilities managers. We will then use fall data from the VA Inpatient Evaluation Center and patient data from additional sources to identify 50 medical/surgical nursing units with higher- and lower-than-expected fall rates. We will measure spatial factors by analyzing computer-aided design files of unit floorplans and environmental factors from the environmental assessment survey. Statistical tests will be performed to identify design factors that distinguish high and low outliers. Results The VA Health Services Research and Development Service approved funding for the study. The research protocol was approved by institutional review boards and VA research committees at both sites. Data collection started in February 2018. Results of the data analysis are expected by February 2022. Data collection and analysis was completed for aim 1 with a manuscript of results in progress. For aim 2, the medical/surgical units were categorized into higher- and lower-than-expected fall categories, the environmental assessment surveys were distributed to facility managers and nurse managers. Data to measure spatial characteristics are being compiled. Conclusions To our knowledge, this study is the first to objectively identify spatial risks for falls in hospitals within in a large multihospital system. Findings can contribute to evidence-based design guidelines for hospitals such as those of the Facility Guidelines Institute and the Department of Veterans Affairs. The metrics for characterizing spatial features are quantitative indices that could be incorporated in larger scale contextual studies examining contributors to falls, which to date often exclude physical environmental factors at the unit level. Space syntax measures could be used as physical environmental factors in future research examining a range of contextual factors—social, personal, organizational, and environmental—that contribute to patient falls. International Registered Report Identifier (IRRID) DERR1-10.2196/24974