Same-Day Discharge After Outpatient PCI in a VA Hospital: Shared Decision Making and the VA MISSION Act

IntroductionThe VA Mission Act of 2018 sought to increase access to local care facilities for Veterans meeting certain eligibility criteria including a drive time of >60 min from a VA facility. As part of an ongoing review of our VA program's same day discharge (SDD) program following elective percutaneous coronary intervention (PCI), we investigated whether the distance criteria of the VA Mission Act had any impact on overall safety outcomes.MethodsWe performed a single center, retrospective study in patients who underwent outpatient PCI between 2013 and 2019. We stratified patients into an overnight observation (ON) and SDD group. We used Google Maps in order to calculate patient home distance to the Jesse Brown Veterans Affairs Hospital (JBVA).Primary endpoints included all-cause death andmajor adverse cardiac events (MACE; cardiovascular death, myocardial infarction, stroke, and/or target vessel revascularization). Secondary outcomes included total unplanned interactions with the healthcare system. Outcomes were analyzed at 30 days after PCI.ResultsThere were 76 patients in the SDD group. The SDD group had a median drive time of 80 min from the JBVA.Regarding primary outcomes, there were no cases of MACE in either group and there was no statistically significant difference in terms of all-cause mortality (ON: 1.3%, SDD: 0%, p = .5) 30 days following PCI. All secondary outcomes at 30 days did not demonstrate a statistically significant difference between either group.ConclusionSame day discharge following successful PCI procedures appears safe. In response to the VA Mission Act, drive time and distance travelled did not appear to impact outcomes.SummarySame day discharge in select patients at our VA hospital was both safe and feasible. Neither drive time nor distance travelled affected overall outcomes in response to the 2018 VA MISSION Act. As such, shared decision making between patients and physicians remains essential to ensure Veterans continue to receive high quality care that is in their best medical interest.     

Treatment of patients with acute myocardial infarction at a veterans affairs (VA) hospital and a non-VA hospital

Comparisons of care in Veterans Affairs (VA) hospitals with care in non-VA hospitals are needed to define the future role of the VA health care system. Therefore, the authors conducted a retrospective cohort study of 385 patients who had acute myocardial infarctions and were admitted to a private nonprofit teaching hospital and to a university-affiliated VA hospital, which were staffed by attending and resident physicians from a single medicine department. Data were obtained from hospital databases and from patient records. The authors found that the 206 VA patients, compared with the 179 non-VA patients, were younger and more likely to be men. The VA patients also had higher comorbidity but lower admission severity of illness, according to previously validated measures. Although the VA patients were less likely than the non-VA patients to receive thrombolytic therapy (6% vs 20%, respectively; p<0.05), they were more likely to undergo coronary angiography (67% vs 57%; p<0.05) and echocardiography or gated blood pool scanning (54% vs 44%; p<0.05) during hospitalization. Finally, the VA and the non-VA patients had similar rates of in-hospital mortality in univariate analysis (9% vs 11%, respectively; p=0.4) and in multivariate analysis, adjusting for covariates. These results suggest that the VA and the non-VA patients who had acute myocardial infarction had similar outcomes and generally received care of similar qualities. Future studies are needed to explore the generalizability of these findings and to provide the data needed to adequately define the VA’s future role in American health care. Received from the Section of Clinical Epidemiology, Division of General Internal Medicine, Department of Medicine, Cleveland Veterans Affairs Medical Center and University Hospitals of Cleveland; and Case Western Reserve University School of Medicine, Cleveland, Ohio. Presented in part at the Department of Veterans Affairs 11th Annual HSR&D Service Meeting, Washington, DC, April 27, 1993. Supported by a grant (LIP 41-063) from the Department of Veterans Affairs Great Lakes Regional HSR&D Field Program.     

Association of Integrated Mental Health Services with Physical Health Quality Among VA Primary Care Patients

BackgroundIntegrated care for comorbid depression and chronic medical disease improved physical and mental health outcomes in randomized controlled trials. The Veterans Health Administration (VA) implemented Primary Care–Mental Health Integration (PC-MHI) across all primary care clinics nationally to increase access to mental/behavioral health treatment, alongside physical health management.ObjectiveTo examine whether widespread, pragmatic PC-MHI implementation was associated with improved care quality for chronic medical diseases.Design, Setting, and ParticipantsThis retrospective cohort study included 828,050 primary care patients with at least one quality metric among 396 VA clinics providing PC-MHI services between October 2013 and September 2016.Main Measure(s)For outcome measures, chart abstractors rated whether diabetes and cardiovascular quality metrics were met for patients at each clinic as part of VA’s established quality reporting program. The explanatory variable was the proportion of primary care patients seen by integrated mental health specialists in each clinic annually. Multilevel logistic regression models examined associations between clinic PC-MHI proportion and patient-level quality metrics, adjusting for regional, patient, and time-level effects and clinic and patient characteristics.Key ResultsMedian proportion of patients seen in PC-MHI per clinic was 6.4% (IQR=4.7–8.7%). Nineteen percent of patients with diabetes had poor glycemic control (hemoglobin A1c >9%). Five percent had severely elevated blood pressure (>160/100 mmHg). Each two-fold increase in clinic PC-MHI proportion was associated with 2% lower adjusted odds of poor glycemic control (95% CI=0.96–0.99; p=0.046) in diabetes. While there was no association with quality for patients diagnosed with hypertension, patients without diagnosed hypertension had 5% (CI=0.92–0.99; p=0.046) lower adjusted odds of having elevated blood pressures.Conclusions and RelevancePrimary care clinics where integrated mental health care reached a greater proportion of patients achieved modest albeit statistically significant gains in key chronic care quality metrics, providing optimism about the expected effects of large-scale PC-MHI implementation on physical health.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07287-2.KEY WORDS: Health services, Mental health, Diabetes, Hypertension, Veterans     

Effect of Health-Related Quality of Life on Women and Men’s Veterans Affairs (VA) Health Care Utilization and Mortality

Introduction Although women will account for almost 11% of veterans by 2040, we know little about their health and functioning, particularly compared to men. Objective To compare women and men veterans’ health-related quality of life (HRQOL) and VA health care utilization and to see if previously described associations between HRQOL, subsequent VA health care utilization, and mortality in male veterans would generalize to women veterans. Methods Prospective cohort study of all veterans who received medical care from an Upper Midwest Veterans Affairs facility between 10/1/96 and 3/31/98 and returned a mailed questionnaire. Results Women’s effective survey response rate was 52% (n = 1,500); men’s, 58% (n = 35,000). In the following year, 9% of women and 12% of men had at least one hospitalization. One percent of women and 3% of men died in the post-survey year. After adjustment, women’s HRQOL was higher than men’s; for every 10-point decrement in overall physical or mental functioning, women and men had similarly increased risk/odds of subsequently dying, being hospitalized at a VA facility, or making a VA outpatient stop. Among younger women and women who received VA care outside of the Twin City metro area, poorer overall mental or physical health functioning was associated with fewer primary care stops; among their male counterparts, it was associated with more primary care stops. Conclusion Compared to men, women veterans receiving VA health care in the upper Midwest catchment area had better HRQOL and used fewer health services. Although VA health care utilization was similar across gender after adjusting for HRQOL, poorer mental or physical health was associated with fewer primary care stops for selected subgroups of women. CCDOR is a VA Health Services and Research service Center of Excellence.     

Providing all-inclusive care for frail elderly veterans: evaluation of three models of care

Frail elderly veterans aged 55 and older who met state nursing home admission criteria were enrolled in one of three models of all-inclusive long-term care (AIC) at three Veterans Affairs (VA) medical centers (n=386). The models included: VA as sole care provider, VA-community partnership with a Program of All-inclusive Care for the Elderly (PACE), and VA as care manager with care provided by PACE. Healthcare use was monitored for 6 months before and 6 to 36 months after enrollment using VA, DataPACE, and Medicare files. Hospital and outpatient care did not differ before and after AIC enrollment. Only 53% of VA sole-provider patients used adult day health care (ADHC), whereas all other patients used ADHC. Nursing home days increased, but permanent institutionalization was low. Thirty percent of participants died; of those still enrolled in AIC, 92% remained in the community. VA successfully implemented three variations of AIC and was able to keep frail elderly veterans in the community. Further research on providing variations of AIC in general is warranted.     

Early Impact of VA MISSION Act Implementation on Primary Care Appointment Wait Time

BackgroundThrough Community Care Networks (CCNs) implemented with the VA MISSION Act, VA expanded provider contracting and instituted network adequacy standards for Veterans’ community care.ObjectiveTo determine whether early CCN implementation impacted community primary care (PC) appointment wait times overall, and by rural/urban and PC shortage area (HPSA) status.DesignUsing VA administrative data from February 2019 through February 2020 and a difference-in-differences approach, we compared wait times before and after CCN implementation for appointments scheduled by VA facilities that did (CCN appointments) and did not (comparison appointments) implement CCNs. We ran regression models with all appointments, and stratified by rural/urban and PC HPSA status. All models adjusted for Veteran characteristics and VA facility–level clustering.Appointments13,720 CCN and 40,638 comparison appointments.Main MeasuresWait time, measured as number of days from authorization to use community PC to a Veteran’s first corresponding appointment.Key ResultsOverall, unadjusted wait times increased by 35.7 days ([34.4, 37.1] 95% CI) after CCN implementation. In adjusted analysis, comparison wait times increased on average 33.7 days ([26.3, 41.2] 95% CI, p < 0.001) after CCN implementation; there was no significant difference for CCN wait times (across-group mean difference: 5.4 days, [−3.8, 14.6] 95% CI, p = 0.25). In stratified analyses, comparison wait time increases ranged from 29.6 days ([20.8, 38.4] 95% CI, p < 0.001) to 42.1 days ([32.9, 51.3] 95% CI, p > 0.001) after CCN implementation, while additional differences for CCN appointments ranged from 13.4 days ([3.5, 23.4] 95% CI, p = 0.008) to −15.1 days ([−30.1, −0.1] 95% CI, p = 0.05) for urban and PC HPSA appointments, respectively.ConclusionsAfter early CCN implementation, community PC wait times increased sharply at VA facilities that did and did not implement CCNs, regardless of rural/urban or PC HPSA status, suggesting community care demand likely overwhelmed VA resources such that CCNs had limited impact.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-07800-1.KEY WORDS: Veterans, primary, care, health, outcomes     

VA and Medicare Utilization Among Dually Enrolled Veterans with Type 2 Diabetes: A Latent Class Analysis

BACKGROUND

Many Veterans treated within the VA Healthcare System (VA) are also enrolled in fee-for-service (FFS) Medicare and receive treatment outside the VA. Prior research has not accounted for the multiple ways that Veterans receive services across healthcare systems.

OBJECTIVE

We aimed to establish a typology of VA and Medicare utilization among dually enrolled Veterans with type 2 diabetes.

DESIGN

This was a retrospective cohort.

PARTICIPANTS

316,775 community-dwelling Veterans age ≥ 65 years with type 2 diabetes who were dually enrolled in the VA and FFS Medicare in 2008–2009.

METHODS

Using latent class analysis, we identified classes of Veterans based upon their probability of using VA and Medicare diabetes care services, including patient visits, laboratory tests, glucose test strips, and medications. We compared the amount of healthcare use between classes and identified factors associated with class membership using multinomial regression.

KEY RESULTS

We identified four distinct latent classes: class 1 (53.9 %) had high probabilities of VA use and low probabilities of Medicare use; classes 2 (17.2 %), 3 (21.8 %), and 4 (7.0 %) had high probabilities of VA and Medicare use, but differed in their Medicare services used. For example, Veterans in class 3 received test strips exclusively through Medicare, while Veterans in class 4 were reliant on Medicare for medications. Living ≥ 40 miles from a VA predicted membership in classes 3 (OR 1.1, CI 1.06–1.15) and 4 (OR 1.11, CI 1.04–1.18), while Medicaid eligibility predicted membership in class 4 (OR 4.30, CI 4.10–4.51).

CONCLUSIONS

Veterans with diabetes can be grouped into four distinct classes of dual health system use, representing a novel way to characterize how patients use multiple services across healthcare systems. This classification has applications for identifying patients facing differential risk from care fragmentation.

     

Better Access,Quality, and Cost for Clinically Complex Veterans with Home‐Based Primary Care

In successfully reducing healthcare expenditures, patient goals must be met and savings differentiated from cost shifting. Although the Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) program for chronically ill individuals has resulted in cost reduction for the VA, it is unknown whether cost reduction results from restricting services or shifting costs to Medicare and whether HBPC meets patient goals. Cost projection using a hierarchical condition category (HCC) model adapted to the VA was used to determine VA plus Medicare projected costs for 9,425 newly enrolled HBPC recipients. Projected annual costs were compared with observed annualized costs before and during HBPC. To assess patient perspectives of care, 31 veterans and caregivers were interviewed from three representative programs. During HBPC, Medicare costs were 10.8% lower than projected, VA plus Medicare costs were 11.7% lower than projected, and combined hospitalizations were 25.5% lower than during the period without HBPC. Patients reported high satisfaction with HBPC team access, education, and continuity of care, which they felt contributed to fewer exacerbations, emergency visits, and hospitalizations. HBPC improves access while reducing hospitalizations and total cost. Medicare is currently testing the HBPC approach through the Independence at Home demonstration.     

Risk-Adjusting Mortality in the Nationwide Veterans Affairs Healthcare System

BackgroundThe US Veterans Affairs (VA) healthcare system began reporting risk-adjusted mortality for intensive care (ICU) admissions in 2005. However, while the VA’s mortality model has been updated and adapted for risk-adjustment of all inpatient hospitalizations, recent model performance has not been published. We sought to assess the current performance of VA’s 4 standardized mortality models: acute care 30-day mortality (acute care SMR-30); ICU 30-day mortality (ICU SMR-30); acute care in-hospital mortality (acute care SMR); and ICU in-hospital mortality (ICU SMR).MethodsRetrospective cohort study with split derivation and validation samples. Standardized mortality models were fit using derivation data, with coefficients applied to the validation sample. Nationwide VA hospitalizations that met model inclusion criteria during fiscal years 2017–2018(derivation) and 2019 (validation) were included. Model performance was evaluated using c-statistics to assess discrimination and comparison of observed versus predicted deaths to assess calibration.ResultsAmong 1,143,351 hospitalizations eligible for the acute care SMR-30 during 2017–2019, in-hospital mortality was 1.8%, and 30-day mortality was 4.3%. C-statistics for the SMR models in validation data were 0.870 (acute care SMR-30); 0.864 (ICU SMR-30); 0.914 (acute care SMR); and 0.887 (ICU SMR). There were 16,036 deaths (4.29% mortality) in the SMR-30 validation cohort versus 17,458 predicted deaths (4.67%), reflecting 0.38% over-prediction. Across deciles of predicted risk, the absolute difference in observed versus predicted percent mortality was a mean of 0.38%, with a maximum error of 1.81% seen in the highest-risk decile.Conclusions and RelevanceThe VA’s SMR models, which incorporate patient physiology on presentation, are highly predictive and demonstrate good calibration both overall and across risk deciles. The current SMR models perform similarly to the initial ICU SMR model, indicating appropriate adaption and re-calibration.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07377-1.KEY WORDS: hospital mortality, risk adjustment, logistic models     

Access to Medications for Opioid Use Disorder in Rural Versus Urban Veterans Health Administration Facilities

BackgroundFor patients with opioid use disorder (OUD), medications for OUD (MOUD) reduce morbidity, mortality, and return to use. Nevertheless, a minority of patients receive MOUD, and underutilization is pronounced among rural patients.ObjectiveWhile Veterans Health Administration (VHA) initiatives have improved MOUD access overall, it is unknown whether access has improved in rural VA health systems specifically. How “Community Care,” healthcare paid for by VHA but received from non-VA providers, has affected rural access is also unknown.DesignData for this observational study were drawn from the VHA Corporate Data Warehouse. Facility rurality was defined by rural-urban commuting area code of the primary medical center. International Classification of Diseases codes identified patients with OUD within each year, 2015–2020. We included MOUD (buprenorphine, methadone, extended-release naltrexone) received from VHA or paid for by VHA but received at non-VA facilities through Community Care. We calculated average yearly MOUD receipt; linear regression of outcomes on study years identified trends; an interaction between year and rural status evaluated trend differences over time.ParticipantsAll 129 VHA Health Systems, a designation that encompasses one or more medical centers and their affiliated community-based outpatient clinicsMain MeasuresThe average proportion of patients diagnosed with OUD that receive MOUD within rural versus urban VHA health care systems.Key ResultsFrom 2015 to 2020, MOUD access increased substantially: the average proportion of patients receiving MOUD increased from 34.6 to 48.9%, with a similar proportion of patients treated with MOUD in rural and urban systems in all years. Overall, a small proportion (1.8%) of MOUD was provided via Community Care, and Community Care did not disproportionately benefit rural health systems.ConclusionsStrategies utilized by VHA could inform other health care systems seeking to ensure that, regardless of geographic location, all patients are able to access MOUD.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-023-08027-4.KEY WORDS: rural, veterans, access, opioid agonist, opioid use disorder

For patients diagnosed with opioid use disorder (OUD), receipt of medications for OUD (MOUD) is associated with substantial improvements in morbidity and mortality, as well as reduced rates of return to use.^1–4 However, in the USA, a minority of patients receive MOUD.² While access is suboptimal among all patients, it is more pronounced among rural patients.^5–7 In 2018, 57% of rural US counties had no clinician approved to prescribe buprenorphine, while this was true of just 12% of large, metropolitan counties.⁸ Rural federally qualified health centers (FQHCs) are also less likely to offer buprenorphine, relative to urban FQHCs.⁹ Rural patients face even greater barriers to accessing methadone, which requires frequent attendance at an opioid treatment program (OTP).^10,11 Although federal policy changes responsive to the COVID pandemic have temporarily increased rural patients’ access to methadone via OTPs, methadone remains difficult to access for rural patients, who experience median drive times of 45+ min one way to access treatment.¹²VHA has undertaken multiple initiatives to expand access to MOUD for patients generally and rural patients specifically. Such initiatives are justified given that approximately one-third of VHA patients are rural residents.⁷ Recent national efforts have included the Stepped Care for Opioid Use Disorder Train the Trainer Initiative, increased buprenorphine prescribing through telemedicine, external facilitation provided to low-performing sites, and an initiative to hire clinical pharmacists to address substance use disorders in rural settings.^13–19Access to MOUD in rural settings may also have been impacted by a national policy change enacted by Congress under the Veterans Access, Choice and Accountability Act (2014) and finalized under the VA MISSION Act (2019). Under this legislation, VA patients who meet certain criteria (for instance, those who live >40 miles from a Veterans Health Administration facility) can be treated in a non-VA health care setting and have this care reimbursed by VHA. An explicit goal of this legislation was to enhance health care access for rural VA patients.²⁰In this study, we (1) describe trends in the proportion of VHA patients receiving MOUD from 2015 to 2020, (2) compare urban and rural VA health care systems across this outcome, and (3) measure the relative contribution of MOUD received from community providers in rural versus urban systems. We hypothesized that urban health systems would show improved patient access to MOUD relative to rural health systems, and that a larger proportion of MOUD would be provided by Community Care in rural relative to urban systems.     

Comparison between remifentanil and other opioids in adult critically ill patients: A systematic review and meta-analysis

Background and aims:To identify the efficacy and safety of remifentanil when compared with other opioids in adult critically ill patients.Methods:We searched for studies in the Cochrane Library, MEDLINE, and EMBASE that had been published up to May 31st, 2019. Randomized clinical trials using remifentanil comparing with other opioids for analgesia were included. Two reviewers independently applied eligibility criteria, assessed quality, and extracted data. Duration of mechanical ventilation was the primary outcome, and secondary outcomes included weaning time, intensive care unit (ICU), length of stay (LOS), hospital LOS, mortality, side effects, and costs.Results:Fifteen studies with 1233 patients were included. Remifentanil was associated with a significant reduction in the duration of mechanical ventilation in the adult ICU patients when compared with other opioids (P = .01). Remifentanil also reduced the weaning time (P = .02) and the ICU LOS when compared with other opioids (P = .01). There was no difference in the hospital LOS (P = .15), side effects (P = .39), and mortality (P = .79) between remifentanil and other opioids, what''s more, remifentanil increased the costs of anesthesia (P < .001) but did not increase cost of hospitalization (P = .30) when comparing with other opioids.Conclusions:Remifentanil reduced the duration of mechanical ventilation, weaning time, and ICU LOS when compared with other opioids in adult critically ill patients. Higher quality RCTs are necessary to prove our findings.PROSPERO registration number:CRD42016041438.     

Improving Death Certificate Completion: A Trial of Two Training Interventions

BACKGROUND AND OBJECTIVE: Effects of advances in Department of Veterans Affairs (VA) women’s health care on women veterans’ health care decision making are unknown. Our objective was to determine why women veterans use or do not use VA health care. DESIGN AND PARTICIPANTS: Cross-sectional survey of 2,174 women veteran VA users and VA-eligible nonusers throughout southern California and southern Nevada. MEASUREMENTS: VA utilization, attitudes toward care, and socio-demographics. RESULTS: Reasons cited for VA use included affordability (67.9%); women’s health clinic (WHC) availability (58.8%); quality of care (54.8%); and convenience (47.9%). Reasons for choosing health care in non-VA settings included having insurance (71.0%); greater convenience of non-VA care (66.9%); lack of knowledge of VA eligibility and services (48.5%); and perceived better non-VA quality (34.5%). After adjustment for sociodemographics, health characteristics, and VA priority group, knowledge deficits about VA eligibility and services and perceived worse VA care quality predicted outside health care use. VA users were less likely than non-VA users to have after-hours access to nonemergency care, but more likely to receive both general and gender-related care from the same clinic or provider, to use a WHC for gender-related care, and to consider WHC availability very important. CONCLUSIONS: Lack of information about VA, perceptions of VA quality, and inconvenience of VA care, are deterrents to VA use for many women veterans. VA WHCs may foster VA use. Educational campaigns are needed to fill the knowledge gap regarding women veterans’ VA eligibility and advances in VA quality of care, while VA managers consider solutions to after-hours access barriers. The author have no conflict of interest to declare. This study was funded by the Department of Veterans Affairs, Health Services Research and Development Service (#GEN-00-082). Dr. Washington is supported by an Advanced Research Career Development Award from the Veterans Affairs Health Services Research and Development Service (#RCD-00-017). The authors gratefully acknowledge Mark Canning for overall project management, Barbara Sasso for assistance with survey development, Martin Lee, PhD, for statistical assistance, and the site principal investigators Leslie Satz, MSN, ANP, Stuart Gilman, MD, MPH, Nancy McNulty, MSN, ANP, and Denise Bartlett-Chekal, MSN, FNP. We also thank James Strike and Rick Paulson of the VA Austin Automation Center and Patricia Murphy of the VA Information Resource Center (VIReC) for assistance with sample development, and California Survey Research Services Inc. for survey fieldwork. The views expressed within are solely those of the authors, and do not necessarily represent the views of the Department of Veterans Affairs.     

Hypertension,cholesterol and diabetes medication adherence,health care utilization and expenditure in a Medicare Supplemental sample

Limited evidence exists regarding the relationships between adherence, as defined in Pharmacy Quality Alliance (PQA) medication adherence measures, health care utilization, and economic outcomes. PQA adherence measures for hypertension, cholesterol, and diabetes are of particular interest given their use in Medicare Star Ratings to evaluate health plan performance.The objective of this study was to assess the relationship between adherence and utilization and cost among Medicare Supplemental beneficiaries included in the aforementioned PQA measures over a 1-year period.Retrospective cohort study.Three cohorts (hypertension, cholesterol, and diabetes) of eligible individuals from the Truven Health MarketScan Commercial Claims and Encounters Research Databases (2009–2015) were used to assess associations between adherence and health care expenditure and utilization for Medicare Supplemental beneficiaries.Generalized linear models with log link and negative binomial (utilization) or gamma (expenditure) distributions assessed relationships between adherence (≥80% proportion of days covered) and health care utilization and expenditure (in 2015 US dollars) while adjusting for confounding variables. Beta coefficients were used to compute cost ratios and rate ratios.Adherence for all 3 disease cohorts was associated with lower outpatient and inpatient visits. During the 1-year study period, adherence was associated with lower outpatient, inpatient, and total expenditures across the cohorts, ranging from 9% lower outpatient costs (diabetes cohort) to 41.9% lower inpatient costs (hypertension cohort). Savings of up to $324.53 per member per month in total expenditure were observed for the hypertension cohort.Our findings indicate adherence is associated with lower health care utilization and expenditures within 1 year.     

Risk factors for death in patients with sepsis admitted to an obstetric intensive care unit: A cohort study

Improving understanding of the prognostic factors associated with death resulting from sepsis in obstetric patients is essential to allow management to be optimized. This retrospective cohort study aimed to determine the risk factors for death in patients with sepsis admitted to the obstetric intensive care unit of a tertiary teaching hospital in northeastern Brazil between April 2012 and April 2016.The clinical, obstetric, and laboratory data of the sepsis patients, as well as data on their final outcome, were collected. A significance level of 5% was adopted. Risk factors for death in patients with sepsis were evaluated in a multivariate analysis.During the period analyzed, 155 patients with sepsis were identified and included in the study, representing 5.2% of all obstetric intensive care unit (ICU) admissions. Of these, 14.2% (n = 22) died. The risk factors for death were septic shock at the time of hospitalization (relative risk [RR] = 3.45; 95% confidence interval [CI]: 1.64–7.25), need for vasopressors during hospitalization (RR = 17.32; 95% CI: 4.20–71.36), lactate levels >2 mmol/L at the time of diagnosis (RR = 4.60; 95% CI: 1.05–20.07), and sequential organ failure assessment score >2 at the time of diagnosis (RR = 5.97; 95% CI: 1.82–19.94). Following multiple logistic regression analysis, only the need for vasopressors during hospitalization remained as a risk factor associated with death (odds ratio [OR] = 26.38; 95% CI: 5.87–118.51).The need for vasopressors during hospitalization is associated with death in obstetric patients with sepsis.     

Prevalence of and Predictors for Frequent Utilization of Emergency Department: A Population-Based Study

Frequent emergency department (ED) users contribute to a disproportionate number of ED visits that consume a substantial amount of medical resources. Additionally, people with frequent ED visits may be at greater risks of illnesses and injury and are vulnerable to even more severe health events. We conducted, based on a nationally representative sample, a population-based study to estimate the prevalence of frequent ED users among all ED users, and to explore factors associated with frequent ED visits.This is a population-based cross-sectional study. Data of 1 million people randomly selected from all beneficiaries of Taiwan''s National Health Insurance claim database in 2010 were analyzed to estimate the distribution of ED visit among ED users. Multivariate logistic regression was employed to calculate the independent associations of factors with prevalence of frequent (4-12 ED visits per year) and highly frequent (>12 ED visits per year) ED visits.Of the 1 million beneficiaries 170,475 subjects used ED service in 2010 and 103,111 (60.5%), 37,964 (22.3%), 14,881 (8.7%), 14,041 (8.2%), and 460 (0.3%) subjects had 1, 2, 3, 4 to 12, and more than 12 ED visits, respectively. ED users with 4 to 12 visits and those with >12 visits disproportionally accounted for 24.1% and 3.0%, respectively, of all ED visits in 2010. We noted significant associations of frequent ED visit with a number of factors including socio-demographics, health care utilization, and comorbidity. Among them, the most increased adjusted odds ratio (AOR) was noted for hospitalization during the past year (AOR = 1.85) and younger ages (1–6 years) (AOR = 1.84). On the contrary, the significant predictors for highly frequent ED visit with greater AOR included hospitalization during the past year (AOR = 3.95), >12 outpatient visits during the past year (AOR = 2.66), and a history of congestive heart failure (AOR = 2.64) and psychiatric disorders (AOR = 2.35).People admitted and with frequent outpatient visits were at greater risk of frequent ED visit. Because people with a history of various comorbidities were also vulnerable to become frequent ED users, careful management of those comorbidities by clinicians may help further reduce the likelihood of frequent ED visit.     

Prompt Oseltamivir Therapy Reduces Medical Care and Mortality for Patients With Influenza Infection: An Asian Population Cohort Study

There are limited population-based studies on the progress of oseltamivir therapy for influenza infection.Using insurance claims data of 2005, 2009, and 2010, the authors established an “in-time” cohort and a “lag-time” cohort representing influenza patients taking the medicine within and not within 1 week to examine the treatment progress. Incident outpatient visit, emergency care and hospitalization, and fatality were compared between the 2 cohorts in the first week and the second week of follow-up periods, after the oseltamivir therapy.A total of 112,492 subjects diagnosed with influenza on oseltamivir therapy in 2005, 2009, and 2010 were identified. The multivariate logistic regression analysis showed that the in-time treatment was superior to the lag-time treatment with less repeat outpatient visits, hospitalizations, and fatality. The overall corresponding in-time treatment to lag-time treatment odds ratios (OR) were 0.50, 0.54, and 0.71 (all P value < 0.05), respectively. The in-time to lag-time ORs of all events were 0.50 in 2009 and 0.54 in 2010.Our study demonstrates that the in-time oseltamivir therapy leads to significantly better treatment outcomes. Oseltamivir should be administered as early as the onset of influenza symptoms appears.     

A cross-sectional study of latent tuberculosis infection,insurance coverage,and usual sources of health care among non-US-born persons in the United States

More than 70% of tuberculosis (TB) cases diagnosed in the United States (US) occur in non-US-born persons, and this population has experienced less than half the recent incidence rate declines of US-born persons (1.5% vs 4.2%, respectively). The great majority of TB cases in non-US-born persons are attributable to reactivation of latent tuberculosis infection (LTBI). Strategies to expand LTBI-focused TB prevention may depend on LTBI positive non-US-born persons’ access to, and ability to pay for, health care.To examine patterns of health insurance coverage and usual sources of health care among non-US-born persons with LTBI, and to estimate LTBI prevalence by insurance status and usual sources of health care.Self-reported health insurance and usual sources of care for non-US-born persons were analyzed in combination with markers for LTBI using 2011–2012 National Health and Nutrition Examination Survey (NHANES) data for 1793 sampled persons. A positive result on an interferon gamma release assay (IGRA), a blood test which measures immunological reactivity to Mycobacterium tuberculosis infection, was used as a proxy for LTBI. We calculated demographic category percentages by IGRA status, IGRA percentages by demographic category, and 95% confidence intervals for each percentage.Overall, 15.9% [95% confidence interval (CI) = 13.5, 18.7] of non-US-born persons were IGRA-positive. Of IGRA-positive non-US-born persons, 63.0% (95% CI = 55.4, 69.9) had insurance and 74.1% (95% CI = 69.2, 78.5) had a usual source of care. IGRA positivity was highest in persons with Medicare (29.1%; 95% CI: 20.9, 38.9).Our results suggest that targeted LTBI testing and treatment within the US private healthcare sector could reach a large majority of non-US-born individuals with LTBI. With non-US-born Medicare beneficiaries’ high prevalence of LTBI and the high proportion of LTBI-positive non-US-born persons with private insurance, future TB prevention initiatives focused on these payer types are warranted.     

To Use or Not to Use

BACKGROUND AND OBJECTIVE: Effects of advances in Department of Veterans Affairs (VA) women's health care on women veterans' health care decision making are unknown. Our objective was to determine why women veterans use or do not use VA health care.
DESIGN AND PARTICIPANTS: Cross-sectional survey of 2,174 women veteran VA users and VA-eligible nonusers throughout southern California and southern Nevada.
MEASUREMENTS: VA utilization, attitudes toward care, and socio-demographics.
RESULTS: Reasons cited for VA use included affordability (67.9%); women's health clinic (WHC) availability (58.8%); quality of care (54.8%); and convenience (47.9%). Reasons for choosing health care in non-VA settings included having insurance (71.0%); greater convenience of non-VA care (66.9%); lack of knowledge of VA eligibility and services (48.5%); and perceived better non-VA quality (34.5%). After adjustment for socio-demographics, health characteristics, and VA priority group, knowledge deficits about VA eligibility and services and perceived worse VA care quality predicted outside health care use. VA users were less likely than non-VA users to have after-hours access to nonemergency care, but more likely to receive both general and gender-related care from the same clinic or provider, to use a WHC for gender-related care, and to consider WHC availability very important.
CONCLUSIONS: Lack of information about VA, perceptions of VA quality, and inconvenience of VA care, are deterrents to VA use for many women veterans. VA WHCs may foster VA use. Educational campaigns are needed to fill the knowledge gap regarding women veterans' VA eligibility and advances in VA quality of care, while VA managers consider solutions to after-hours access barriers.