Program at Home: A Veterans Affairs Healthcare Program to Deliver Hospital Care in the Home

The Portland Veterans Affairs Medical Center (PVAMC) participated in a research‐based National Demonstration and Evaluation Study of Hospital at Home Care for Elderly Patients. PVAMC continued hospital at home care in a modified form based on the results of that research phase and feedback from patients, families, and staff. The modified clinical program (referred to as Program @ Home) provided care for the same diagnoses (exacerbation of congestive heart failure, exacerbation of chronic obstructive pulmonary disease, community‐acquired pneumonia, cellulitis) but differed from the research‐based demonstration project in that it accepted patients of all ages, accepted early‐discharge patients from the hospital, and provided a less‐intensive physician and nursing model. In the first 42 months, 290 patients were admitted; 23% came from the emergency room, 54% were early hospital discharge, and the remainder came from an outpatient clinic or home care. Average length of stay was 3.2 days, and 37% were younger than 65. The results describe how a home hospital program has been integrated into the clinical care offerings of a managed care health system and how it supports inpatient, primary, emergency, and home care programs.     

Wanderers with cognitive impairment in Department of Veterans Affairs nursing home care units

OBJECTIVES: To explore the extent of and factors associated with male nursing home residents who wander. DESIGN: Cross-sectional design with secondary data analyses. SETTING: One hundred thirty-four nursing home facilities operated by the Department of Veterans Affairs. PARTICIPANTS: Fifteen thousand ninety-two nursing home residents with moderate or severe cognitive impairment admitted over a 4-year period. MEASUREMENTS: Selected variables from the Minimum Data Set included ratings recorded at residents' admission to the nursing home (cognitive impairment, mood, behavior problems, activities of daily living, and wandering). RESULTS: In this sample of residents with moderate or severe cognitive impairment, the proportion of wanderers was found to be 21%. Wanderers were more likely to exhibit severe (vs moderate) cognitive impairment, socially inappropriate behavior, resistance to care, use of antipsychotic medication, independence in locomotion or ambulation, and dependence in activities of daily living related to basic hygiene. A sizable proportion of wanderers were found to be wheelchair users (25%) or were wanderers with dual dementia and psychiatric diagnoses (23%), characteristics that are not well documented in the literature. CONCLUSION: These results support previous clinical understanding of wanderers to be those who are more likely to exhibit more-severe cognitive impairment. Based on a statistical model with variables generated from prior research findings, classification as a wanderer was found to be associated with other disruptive activity such as socially inappropriate behavior and resisting care. Two understudied populations of wanderers were documented: wheelchair wanderers and those with comorbid dementia and psychiatric diagnoses. Future longitudinal studies should examine predictors of wandering behavior, and further research should explore the understudied subpopulations of wheelchair and dual-diagnosis wanderers who emerged in this study.     

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs

Background and objectives

The secular trend toward dialysis initiation at progressively higher levels of eGFR is not well understood. This study compared temporal trends in eGFR at dialysis initiation within versus outside the Department of Veterans Affairs (VA)—the largest non–fee-for-service health system in the United States.

Design, setting, participants, & measurements

The study used linked data from the US Renal Data System, VA, and Medicare to compare temporal trends in eGFR at dialysis initiation between 2000 and 2009 (n=971,543). Veterans who initiated dialysis within the VA were compared with three groups who initiated dialysis outside the VA: (1) veterans whose dialysis was paid for by the VA, (2) veterans whose dialysis was not paid for by the VA, and (3) nonveterans. Logistic regression was used to estimate average predicted probabilities of dialysis initiation at an eGFR≥10 ml/min per 1.73 m².

Results

The adjusted probability of starting dialysis at an eGFR≥10 ml/min per 1.73 m² increased over time for all groups but was lower for veterans who started dialysis within the VA (0.31; 95% confidence interval [95% CI], 0.30 to 0.32) than for those starting outside the VA, including veterans whose dialysis was (0.36; 95% CI, 0.35 to 0.38) and was not (0.40; 95% CI, 0.40 to 0.40) paid for by the VA and nonveterans (0.39; 95% CI, 0.39 to 0.39). Differences in eGFR at initiation within versus outside the VA were most pronounced among older patients (P for interaction <0.001) and those with a higher risk of 1-year mortality (P for interaction <0.001).

Conclusions

Temporal trends in eGFR at dialysis initiation within the VA mirrored those in the wider United States dialysis population, but eGFR at initiation was consistently lowest among those who initiated within the VA. Differences in eGFR at initiation within versus outside the VA were especially pronounced in older patients and those with higher 1-year mortality risk.     

Risk factors for hepatitis C virus infection among patients receiving health care in a Department of Veterans Affairs hospital

A cross-sectional, seroepidemiological study was conducted to determine the prevalence and risk factors for hepatitis C virus (HCV) infection among veterans receiving health care from the VA. Among 274 evaluated outpatients, anti-HCV was found in 27 (9.9%). The prevalence of anti-HCV was 3.7% among 190 individuals who reported no illicit drug use compared to 24.7% among 81 subjects who had used drugs (P < 0.001). The prevalence of anti-HCV was 4.8% among 208 veterans who had never been incarcerated compared to 27.9% among 61 veterans who had been incarcerated (P < 0.001). A multivariate model found the following factors to be independently associated with anti-HCV: having used illicit drugs [odds ratio (OR) = 3.7, 95% CI 1.3–11.8; P = 0.001), having been incarcerated ( OR = 4.4, 95% CI 1.7–10.9; P = 0.001), and a yearly income less than US $10,000 ( OR = 3.5, 95% CI 1.3–9.4; P = 0.002). Because HCV infection was most strongly associated with illicit drug use, incarceration, and low income, these risk factors should be utilized to develop screening strategies among VA patients.     

Use of Medicare and Department of Veterans Affairs Health Care by Veterans with Dementia: A Longitudinal Analysis

The objectives of this study were to examine longitudinal patterns of Department of Veterans Affairs (VA)–only use, dual VA and Medicare use, and Medicare-only use by veterans with dementia. Data on VA and Medicare use were obtained from VA administrative datasets and Medicare claims (1998–2001) for 2,137 male veterans who, in 1997, used some VA services, had a formal diagnosis of Alzheimer's disease or vascular dementia in the VA, and were aged 65 and older. Generalized ordered logit models were used to estimate the effects of patient characteristics on use group over time. In 1998, 41.7% of the sample were VA-only users, 55.4% were dual users, and 2.9% were Medicare-only users. By 2001, 30.4% were VA-only users, 51.5% were dual users, and 18.1% were Medicare-only users. Multivariate results show that greater likelihood of Medicare use was associated with older age, being white, being married, having higher education, having private insurance or Medicaid, having low VA priority level, and living in a nursing home or dying during the year. Higher comorbidities were associated with greater likelihood of dual use as opposed to any single system use. Alternatively, number of functional limitations was associated with greater likelihood of Medicare-only use and less likelihood of VA-only use. These results imply that different aspects of veterans' needs have differential effects on where they seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure that patients receive high-quality care, especially patients with multiple comorbidities.     

Technology for Diabetes Care and Evaluation in the Veterans Health Administration: Teleretinal Imaging to Screen for Diabetic Retinopathy in the Veterans Health Administration

Diabetes is the leading cause of adult vision loss in the United States and other industrialized countries. While the goal of preserving vision in patients with diabetes appears to be attainable, the process of achieving this goal poses a formidable challenge to health care systems. The large increase in the prevalence of diabetes presents practical and logistical challenges to providing quality care to all patients with diabetes. Given this challenge, the Veterans Health Administration (VHA) is increasingly using information technology as a means of improving the efficiency of its clinicians. The VHA has taken advantage of a mature computerized patient medical record system by integrating a program of digital retinal imaging with remote image interpretation (teleretinal imaging) to assist in providing eye care to the nearly 20% of VHA patients with diabetes. We describe this clinical pathway for accessing patients with diabetes in ambulatory care settings, evaluating their retinas for level of diabetic retinopathy with a teleretinal imaging system, and prioritizing their access into an eye and health care program in a timely and appropriate manner.     

Gender Differences in Health Care Utilization Among Veterans with Chronic Pain

Background Previous research reports that 48% of veterans regularly experience and express concern over pain. Outpatient service use is higher for veterans with pain than for veterans without pain. Our study objective was to identify differences in outpatient utilization between men and women veterans with chronic pain. Methods We identified all men and women veterans at the Durham Veterans Affairs Medical Center in fiscal year (FY) 2002 between the ages of 21 and 60 that had two visits for the same pain location at least 6 weeks apart as determined by ICD-9 coding. Men and women were age-matched at a 2:1 ratio. We then compared the number of outpatient visits between genders in FY 2003. Results We identified 406 female and 812 male veterans. The mean number of clinic visits for women was 25.2 (SD 30.2) and for men 17.6 (SD 24.1). After adjusting for multiple pain sites, psychiatric diagnoses, age, and comorbidities, women veterans had a 27% higher rate of outpatient visits than men (incidence rate ratio [RR] 1.27, 95% confidence [CI] 1.15 to 1.41). Specifically, women had higher rates of visits to primary care (RR 1.36, 95% CI 1.24 to 1.50), physical therapy (RR 1.67, 95% CI 1.20 to 2.33), and other clinics (RR 1.28, 95% CI 1.14 to 1.44), and had a higher rate of visits to address pain (RR 1.15, 95% CI 1.02 to 1.30) than men. Conclusions This is the first study to examine gender differences in chronic pain and utilization in the veteran population. Women veterans with chronic pain may need more resources to adequately manage chronic pain conditions as well as associated comorbidities and psychiatric disease. Portions of this research were presented at the annual Society of General Internal Medicine conference, May, 2005, as well as the Women’s Health Congress, June, 2005.     

The Impact of Managed Care on Health Care Utilization Among Adults with Asthma

Study Objectives. To compare kinds and amounts of health care used by adults with asthma in managed care and fee-for-service settings. Design. Cross-sectional structured telephone survey of Northern California adults with asthma from random samples of pulmonologists, allergist-immunologists, family practitioners, and from a random sample of the non-institutionalized population. Measurements. Validated measures of kind of health insurance plans, kinds and amounts of services used for asthma and other reasons, demographic characteristics, severity of asthma, comorbidity, and overall health and functional status. Results. Eighty one percent of the 416 adults with asthma studied were in some form of managed care (75% in HMOs and 6% in PPOs). Those in managed care (MC) and fee-for-service (FFS) did not differ substantively in the proportion with a regular source or principal provider of asthma care, with a peak flow meter or action plan, having received instructions in the use of an inhaler, reporting current use of inhaled beta-agonists, home nebulized beta-agonists, or inhaled steroids, or reporting ER visits or flu shots in the year prior to interview. Persons with asthma in MC reported significantly fewer total physician visits (after adjustment, 4.3 MC, 7.1 FFS, difference = 2.8, 95% CI - 5.4, - 0.1), principally because those in MC had many fewer visits to allergist-immunologists (after adjustment 4.9 MC, 21.4 FFS, difference = - 16.5, 95% CI - 27.8-5.3). The two groups did not differ significantly in the proportion with asthma-related or non asthma hospital admissions. Conclusions. Persons with asthma in fee-for-service settings reported a greater number of certain kinds of ambulatory visits, particularly visits to allergist-immunologists, for their asthma than those in managed care, but did not differ in the use of the hospital for their asthma and in non asthma care.     

Telemedicine Specialty Support Promotes Hepatitis C Treatment by Primary Care Providers in the Department of Veterans Affairs

Background

The Department of Veterans Affairs is the largest US provider of hepatitis C treatment. Although antiviral regimens are becoming simpler, hepatitis C antivirals are not typically prescribed by primary care providers. The Veterans Affairs Extension for Community Health Outcomes (VA-ECHO) program was launched to promote primary care–based hepatitis C treatment using videoconferencing-based specialist support. We aimed to assess whether primary care provider participation in VA-ECHO was associated with hepatitis C treatment and sustained virologic response.

Ethnicity and Quality of Diabetes Care in a Health System with Universal Coverage: Population-Based Cross-sectional Survey in Primary Care

BACKGROUND The UK has a universal health care system that is free at the point of access. Over the past decade, the UK government has implemented an ambitious agenda of quality improvement initiatives in chronic disease management. OBJECTIVE To assess the quality of diabetes care and intermediate clinical outcomes within a multiethnic population after a sustained period of investment in quality improvement. DESIGN Population based cross-sectional survey, using electronic general practice records, carried out between November 2005 and January 2006. PATIENTS Seven thousand six hundred five adults (≥18 years) with diabetes registered with 32 primary care practices. MEASUREMENTS Percentage achievement by ethnic group (black, south Asian, or white) of the quality indicators for diabetes in a new pay-for performance contract. RESULTS There were only modest variations in recording of process measures of care between ethnic groups, with no significant differences in recent measurement of blood pressure, HbA1c, cholesterol, micro-albuminuria, creatinine, or retinopathy screening attendance. Blacks and south Asians were significantly less likely to meet all three national treatment targets for diabetes (HbA1c ≤ 7.4%, blood pressure ≤ 145/85 mmHg, total cholesterol ≤ 5 mmol/L [193 mg/dL]) than whites (25.3%, 24.8% , and 32.0%, respectively). CONCLUSIONS Our findings suggest that substantial investment in quality improvement initiatives in the UK may have led to more systematic and equitable processes of care for diabetes but have not addressed ethnic disparities in intermediate clinical outcomes.