Mental health services research issues in the Veterans Administration

In 1975 the Veterans Administration treated 351,000 veterans in psychiatric inpatient services and had 2.7 million psychiatric outpatient visits and 10% of all psychiatric beds in the United States. The VA has led the nation in a shift toward outpatient treatment of psychiatric disorders. The VA patient population differs from the rest of the country in that VA psychiatric patients have a higher incidence of psychoses and organic brain syndrome as well as being older, being predominantly male, and having a higher rate of chronic disorders. Mental health services research directed toward the VA medical care system falls into two major categories: utilization and patterns of care, and quality and effectiveness of care. Several possible avenues of research are offered in each of these two major areas.     

Evolution of a computerized support system for health care capacity planning

This paper describes the evolution of a computerized support system for health care capacity planning within the Veterans Administration (VA) health care system. The VA's early attempts at computerization are described, along with the subsequent refinements made necessary by the deficiencies in those early attempts. The evolution of both the planning logic and the software configurations is set forth, along with some plans for future development.     

Planning and decision making for ambulatory surgery

There has been rapid growth in the number of ambulatory surgical centers in the United States over the past few years. Yet little research has been done to assist community health planners and surgeons in decision making and planning for ambulatory surgery. In this paper, an analytical framework is developed to assist surgeons in deciding whether to perform a procedure on an ambulatory or an inpatient basis. The Hospital Discharge Survey data collected by the National Center for Health Statistics are also analyzed to investigate their applicability in this analytical framework as well as to aid planners in developing community-wide ambulatory surgery projections. In spite of the limitations on the available data, the models developed here suggest possible future avenues for planning ambulatory surgeries.     

Experience using the CQI model in health care management

This article describes practical applications of the Continuous Quality Improvement (CQI) concept applied to management of the Information Services Departments of a health care institution. The article is valuable for two reasons: (1) it is valuable as a successful application of CQI in an award-winning information services division of an award-winning health care institution, and (2) since the work of the information services function is so complex, has major interdependencies with many other functions throughout the entire organization, and is driven by fast-paced change, successful use in that function can be a model for other major functions of the hospital.     

Health services research in alcoholism

Alcoholism has become an important health care problem for the United States and the VA medical care system. The percentage of inpatients in Veterans Administration hospitals with a diagnosis of alcoholism rose from 13.0% in 1970 to a high of 15.6% in 1977. Health services research work in alcoholism has generally fallen into four major areas: community diagnosis; utilization of services by alcoholics; the effectiveness, efficiency, and quality of services; and the organization of information systems and their applicability to alcoholism. Obstacles to research include a poor understanding of the prevalence of the disease among the veteran's population, but the system offers many more opportunities than obstacles. A new information system. SATAR (Substance Abuse Treatment Automated Records), offers a chance for large-scale investigation of the problem of alcoholism among VA patients when combined with other information systems and allows for special comparisons through its large, integrated network of hospitals and clinics.     

A PC-based free text DSS for health care

A free text decision support system (DSS) has been constructed for health care professionals that allows the analysis of complex medical cases and the creation of a diagnostic list of potential diseases for clinical evaluation. The system uses a PC-based text management system specifically designed for desktop operation. The texts employed in the decision support package include The Merck Manual (published by Merck Sharpe & Dohme) and Control of Communicable Diseases in Man (published by the American Public Health Association). The background and design of the database are discussed, along with a structured analysis procedure for handling free text DSS systems. A case study is presented to show the application of this technology and conclusions are drawn in the summary that point to expanded areas of professional interaction and new frontiers yet to be explored in this rapidly progressing field.     

Legal constraints and alternatives in the Veterans Administration

The Veterans Administration is a federal system that has functioned, so far, independently of state and local laws and rules. The system has proven flexible, however, as it has adjusted to meet needs perceived within its organization where legal justification has been found. The impact of the overall health care system in the United States is beginning to be felt within the Veterans Administration as the possibility of national health insurance implementation may greatly affect the number and kinds of patients seen in the hospitals. The response of the Veterans Administration system will have to be within its legal framework and an understanding of the relationship between the actual operation of the system and the law will be necessary. More and better understanding of the practical impact of external programs such as comprehensive health planning, manpower training and licensing laws will be necessary for the Veterans Administration to successfully adjust within the United States' health care framework.     

The organization of health services research in the Veterans Administration

The VA health services research, development, and education efforts are organized in four main programs: (1) the Intramural Research Program, (2) the VA-University Health Services Research Affiliation Program, (3) the Health Services Research Training Program, and (4) the Contract Research Program. This report first describes the administrative location and structure of the Health Services Research and Development Service within the VA Department of Medicine and Surgery. Then the goals, organizational structure, and major activities of each program are presented.     

Productivity and selected indicators of care in Maternity and Infant Care and Children and Youth Projects according to sponsorship

Bureau Common Reporting Requirements (BCRR) data tapes for Fiscal Year 1980 were analyzed to determine whether the type of sponsoring agency influenced the productivity or indicators of care of Maternity and Infant Care and Children and Youth Projects. Sponsors were classified as either health department or non-health department, health department or major medical center, or public or private in three separate sets of analyses. Some of these analyses indicated that special projects that were either health department or public agency sponsored were more likely to have more non-medical patient encounters and more health education and social work staff for a given level of expenditures. Although publicly sponsored projects employed fewer physician equivalents than did the non-public projects, those physicians were more productive. Despite these differences in encounters, staffing, and utilization of physicians, there were no differences in available measures of the process of care between categories of projects in any of the analyses.     

Opportunities for health services research in the VA with regard to care of the aged

The VA has recognized that it must respond vigorously to the problems of the aging veteran: the ways in which it responds can be significantly shaped by, and in turn will shape, health services research conducted in the VA medical care system. The VA has the resources necessary to conduct comprehensive, valuable research within its system—a large, aging patient population; the new Geriatric Research, Education and Clinical Centers; and the Gerontology fellows program. Despite some barriers to research on all modalities of care for the aging veteran, there are four promising areas in which enterprising health services research can be conducted: prognostic studies, community care, geriatric manpower, and clinical epidemiology.     

Monitoring Changes in Home Health Care: A Comparison of Two National Surveys

Home health care is the fastest growing component of medical care in the United States. To understand better the nature and scope of changes taking place in home health, two current national surveys are described and compared. The two federally sponsored surveys are the National Home and Hospice Care Survey (NHHCS) conducted by the National Center for Health Statistics and the Medical Expenditure Panel Survey (MEPS) of the Agency for Health Care Policy and Research. Computer data files from both surveys are publicly available.     

The health care resource allocation debate. Defining our terms

The problem of health care distribution in the United States demands immediate action. Many different solutions have been proposed to slow rising health care costs and to improve access to care for the poor and uninsured. Debate among proponents of these various proposals might be advanced if a common language were adopted with regard to certain key terms instead of the various meanings currently assigned to these terms. For this reason, we propose and defend the following three definitions: (1) rationing is the societal toleration of inequitable access to health services acknowledged to be necessary by reference to necessary-care guidelines; (2) health care needs are desires for services that have been reasonably well demonstrated to provide significant net benefit for patients with specified clinical conditions; and (3) basic benefit plans are insurance packages that provide for all and only acknowledged health care needs, again by reference to appropriate clinical guidelines.     

Using mathematical programming to assess the relative performance of the health care industry

Unlike conventional methods for evaluating program efficiency, a recently developed mathematical programming technique, Data Envelopment Analysis (DEA), is able to handle multiple inputs and outputs simultaneously without assigning arbitrary weights and does not require the use of homogeneous measurement units nor a prespecified functional relationship between inputs and outputs. Despite of its unfamiliarity to health care researchers and administrators, this technique is becoming increasingly popular as a means of evaluating relative performance in not-for-profit emities.     

Physicians' opinions of a health information exchange

Background

Arizona Medicaid developed a Health Information Exchange (HIE) system called the Arizona Medical Information Exchange (AMIE).

Objective

To evaluate physicians'' perceptions regarding AMIE''s impact on health outcomes and healthcare costs.

Measurements

A focus-group guide was developed and included five domains: perceived impact of AMIE on (1) quality of care; (2) workflow and efficiency; (3) healthcare costs; (4) system usability; and (5) AMIE data content. Qualitative data were analyzed using analytical coding.

Results

A total of 29 clinicians participated in the study. The attendance rate was 66% (N=19) for the first and last month of focus-group meetings and 52% (N=15) for the focus group meetings conducted during the second month. The benefits most frequently mentioned during the focus groups included: (1) identification of “doctor shopping”; (2) averting duplicative testing; and (3) increased efficiency of clinical information gathering. The most frequent disadvantage mentioned was the limited availability of data in the AMIE system.

Conclusion

Respondents reported that AMIE had the potential to improve care, but they felt that AMIE impact was limited due to the data available.     

Patients' satisfaction with reproductive health services at Gogo Chatinkha Maternity Unit, Queen Elizabeth Central Hospital, Blantyre, Malawi

Patient satisfaction is an individual''s state of being content with the care provided in the health system. It is important for reproductive health care providers to get feedback from women regarding satisfaction with reproductive health services. There is a dearth of knowledge about patient satisfaction in Malawi.

Aim

The specific objective of the study was to determine the extent to which women are satisfied with the care they receive when they come to deliver at the Queen Elizabeth Central Hospital maternity unit.

Methods

A cross sectional study of postpartum women using interviewer administered semi-structured questionnaires was conducted between November 2008 and May 2009. The questionnaires captured mainly quantitative data.

Results

1562 women were interviewed. Most women were housewives (79%) who were referred from Health Centres within the city. Ninety five percent delivered a live baby. The majority of women (97.3%) were satisfied with the care they received from admission through labour and delivery and the immediate postpartum period. Most women cited doctors'' and nurses'' reviews (65%) as what they liked most about the care they received during their stay in the unit.Most women expected to receive efficient and definitive care. The women''s knowledge on patient''s rights was extremely low (16%) and equally very few women were offered an opportunity to give an opinion regarding their care by the doctors and nurses in the maternity unit.

Conclusion

Most women who deliver at the hospital are satisfied with the care offered. This satisfaction is mainly due to the frequent reviews of patients by nurses and doctors in the unit. There is a great need to educate both the population of women served and the health workers that serve them on patient''s rights.     

Consumer-driven health care: lessons from Switzerland

Regina E. Herzlinger, DBA; Ramin Parsa-Parsi, MD, MPH

JAMA. 2004;292:1213-1220.

Switzerland's consumer-driven health care system achieves universal insurance and high quality of care at significantly lower costs than the employer-based US system and without the constrained resources that can characterize government-controlled systems. Unlike other systems in which the choice and most of the funding for health insurance is provided by third parties, such as employers and governments, in the Swiss system, individuals are required to purchase their own health insurance. The positive results achieved by the Swiss system may be attributed to its consumer control, price transparency of the insurance plans, risk adjustment of insurers, and solidarity. However, the constraints the Swiss system places on hospitals and physicians and the paucity of provider quality information may unduly limit its impact. The Swiss health care system holds important lessons, including evidence about its feasibility and equity, for the United States, which is now embarking on its own consumer-driven health care system.

     

Query Health: standards-based,cross-platform population health surveillance

Objective

Understanding population-level health trends is essential to effectively monitor and improve public health. The Office of the National Coordinator for Health Information Technology (ONC) Query Health initiative is a collaboration to develop a national architecture for distributed, population-level health queries across diverse clinical systems with disparate data models. Here we review Query Health activities, including a standards-based methodology, an open-source reference implementation, and three pilot projects.

Materials and methods

Query Health defined a standards-based approach for distributed population health queries, using an ontology based on the Quality Data Model and Consolidated Clinical Document Architecture, Health Quality Measures Format (HQMF) as the query language, the Query Envelope as the secure transport layer, and the Quality Reporting Document Architecture as the result language.

Results

We implemented this approach using Informatics for Integrating Biology and the Bedside (i2b2) and hQuery for data analytics and PopMedNet for access control, secure query distribution, and response. We deployed the reference implementation at three pilot sites: two public health departments (New York City and Massachusetts) and one pilot designed to support Food and Drug Administration post-market safety surveillance activities. The pilots were successful, although improved cross-platform data normalization is needed.

Discussions

This initiative resulted in a standards-based methodology for population health queries, a reference implementation, and revision of the HQMF standard. It also informed future directions regarding interoperability and data access for ONC''s Data Access Framework initiative.

Conclusions

Query Health was a test of the learning health system that supplied a functional methodology and reference implementation for distributed population health queries that has been validated at three sites.