The antibiotic treatment trial of Gulf War Veterans' Illnesses: issues,design, screening,and baseline characteristics

Many veterans who were deployed to the Persian Gulf during the 1990-1991 Gulf War developed multiple unexplained symptoms such as pain, fatigue, and neurocognitive problems. This constellation of symptoms has been termed Gulf War Veterans' Illnesses (GWVI). Although there is no proven explanation for the cause of GWVI, one fairly widespread explanation is systemic Mycoplasma fermentans infection. The Antibiotic Treatment Trial of GWVI is a randomized placebo-controlled trial to determine whether a 1-year course of doxycycline treatment in deployed Gulf War veterans with GWVI and testing as Mycoplasma species positive will improve their overall functional status as measured by the Physical Component Summary of the SF-36V questionnaire. The study of a multisymptom illness such as GWVI is complicated by the nonspecific nature of the illness, the unknown etiology, and the lack of a widely accepted outcome measure. The presumption of mycoplasma infection raises concerns regarding the methodology for determination of mycoplasma infection, the choice of treatment, and the duration of treatment. However, such a presumption allows the formulation of a clear testable hypothesis that can be tested with treatments with known rates of adverse events and known activity against Mycoplasma species. This paper describes the major issues faced by the investigators during planning, the study design, the patient screening results, and the baseline characteristics of the study patients. There were 2712 patients screened for study entry at 26 Department of Veterans Affairs and two Department of Defense medical centers. Of these, 491 met all study entry criteria and were randomized to either 1 year of doxycycline (200 mg/day) or 1 year of placebo. All patients were seen monthly during treatment and at 6 months after the end of treatment. Study patients had a mean age of 41 years and were mostly male (86%), white (64%), married (68%), and employed full-time (71%).     

Older veterans' future use of VA health care services

This study is a secondary analysis of the Harris Survey of Aging Veterans (SAV) and is designed to identify variables that may be associated with older veterans' future use of the Veterans Administration (VA) health care system. Using regression and discriminant analysis techniques, the study identifies variables that may predispose older veterans to use the VA health care system in the next 10 years. The results indicate that older veterans may elect to use their health care benefits on objective criteria consistent with their health and financial resources, e.g., past use of veterans benefits, expected health status, and private insurance coverage. These variables suggest that the VA's recently enacted means test and the removal of automatic age eligibility will disenfranchise few older veterans.     

COPD in VA hospitals

The Department of Veterans Affairs (VA) Health Care System is the largest integrated single-payer system in the United States. Its primary mission is to provide primary care, specialized care, and related medical and social support services to veterans. Much time and resources are expended on chronic obstructive pulmonary disease, known as COPD, at VA hospitals and clinics, thereby justifying the development of multifaceted strategies to address this problem. This article discusses the special problems of COPD in veterans who use VA facilities. The article also highlights the contributions of the VA to the research, training, and development of clinical practice guidelines for the management of this pervasive disease and presents the challenges that threaten its role in this area.     

Identifying veterans with acute strokes with high-specificity ICD-9 algorithm with VA automated records and Medicare claims data: a more complete picture

Medicare claims data are available to Department of Veterans Affairs (VA) researchers to identify veterans with acute stroke. Our study sought to (1) ascertain whether additional acute stroke cases are identified with Medicare data and (2) assess the use of VA and Medicare inpatient automated data for assigning the stroke date. The study population was veterans living in Veterans Integrated Service Network 8 with an acute stroke diagnosis during fiscal year 2001. High-sensitivity and high-specificity algorithms were applied to VA data sets and matched with Medicare files. We confirmed acute stroke cases and index dates using the VA Computerized Patient Record System (CPRS). VA data identified 582 veterans with acute stroke, but Medicare claims data identified 201 more such veterans. CPRS confirmed 94% of the VA and 77% of the Medicare cases. The median difference between CPRS and automated index dates was 11 days for VA and 4 days for Medicare data. Use of both VA and Medicare data provides a more complete sample of veterans with acute stroke.     

Creating a sampling frame for population-based veteran research: representativeness and overlap of VA and Department of Defense databases

Most veteran research is conducted in Department of Veterans Affairs (VA) healthcare settings, although most veterans obtain healthcare outside the VA. Our objective was to determine the adequacy and relative contributions of Veterans Health Administration (VHA), Veterans Benefits Administration (VBA), and Department of Defense (DOD) administrative databases for representing the U.S. veteran population, using as an example the creation of a sampling frame for the National Survey of Women Veterans. In 2008, we merged the VHA, VBA, and DOD databases. We identified the number of unique records both overall and from each database. The combined databases yielded 925,946 unique records, representing 51% of the 1,802,000 U.S. women veteran population. The DOD database included 30% of the population (with 8% overlap with other databases). The VHA enrollment database contributed an additional 20% unique women veterans (with 6% overlap with VBA databases). VBA databases contributed an additional 2% unique women veterans (beyond 10% overlap with other databases). Use of VBA and DOD databases substantially expands access to the population of veterans beyond those in VHA databases, regardless of VA use. Adoption of these additional databases would enhance the value and generalizability of a wide range of studies of both male and female veterans.     

Testing a self-directed lifestyle intervention among veterans: The D-ELITE pragmatic clinical trial

Nearly half of Veterans have obesity, fueling chronic diseases. The Department of Veterans Affairs (VA) offers an evidence-based behavioral weight management intervention called MOVE!, mostly delivered through in-person group sessions. Few eligible Veterans participate due to factors like distance and preferences, mirroring barriers in the general population. Practical alternatives to standard in-person programs are needed to improve access and engagement. A self-directed lifestyle intervention called D-ELITE—delivered through pre-recorded videos by DVD or online streaming—previously efficacious in a general primary care population, may provide such an alternative. This pragmatic clinical trial will evaluate whether D-ELITE improves weight and general health status among Veterans with obesity, relative to VA usual care. The yearlong intervention includes one orientation by phone, supplemental lifestyle coaching primarily via technology-based messages, 12 DVD or online streaming sessions over 3 months, and continued self-directed weight management for months 4–12. Participants use MyFitnessPal.com or paper booklets for self-monitoring weight, diet, and physical activity. Follow-up assessments at 12 and 24 months are administered by mail or phone. The study hypothesis is that compared with usual care, D-ELITE will lead to greater improvements in 12-month weight loss, per VA electronic health records, and general physical health status, assessed using the self-reported SF-12 physical composite score. We will also explore D-ELITE's effects on secondary biometric (e.g., HbA1c) and intermediate (e.g., diet) outcomes, reach, and budget impact. If effective, D-ELITE will offer a potentially scalable, low-cost alternative to VA's existing weight loss interventions by mitigating barriers presented by distance and technology.     

You won't know if you're improving unless you measure: recommendations for evaluating Hospice-Veteran Partnerships

Growing evidence indicates that there are abundant opportunities to improve the care that patients receive near the end of life. Hospice care has been associated with improvements in these and other outcomes, but hospice is underused by most patient populations. Therefore, the Department of Veterans Affairs (VA) has made hospice access a priority in its plan to improve end-of-life care for all veterans. In addition to committing funding for hospice care, the VA has also established a national network of Hospice-Veteran Partnerships (HVPs) whose goal is to improve access to hospice for veterans. This article describes the results of a nationwide consensus project to develop measures of the success of HVPs and recommends key measures that should be used to track improvements and to identify opportunities for highly successful collaborative strategies.     

What can Medicaid data add to research on VA patients?

This article is the first to describe Department of Veterans Affairs (VA) patients' use of Medicaid at a national level. We obtained 1999 national VA enrollment and utilization data, Centers for Medicare and Medicaid Services enrollment and claims, and Medicare information from the VA Information Resource Center. The research team created files for program characteristics and described the VA-Medicaid dually enrolled population, healthcare utilization, and costs. In 1999, VA-Medicaid dual enrollees comprised 10.2% of VA's annual patient load (350,000/3,450,000); 304,000 were veterans. These veterans differed marginally from VA's veteran patients, being on average half a year younger and having 1% fewer males. Dual enrollees with mental health diagnoses and care were almost three times as numerous as long-term care patients; these two groups accounted for ~60% of dual enrollees. Dual enrollees disproportionately included housebound veterans and veterans needing aid and assistance. Half the dual enrollees had 12 months of Medicaid eligibility, and total Federal expenditures per patient not in managed care programs averaged >$18,000 (median >$6,000). Dually enrolled women veterans cost ~55% less than men. Medicaid benefits complement VA and are more accessible in many states. VA researchers need to consider including Medicaid utilization and costs in their studies if they target populations or programs related to long-term care or mental disorders.     

Design of Department of Veterans Affairs Cooperative Study no. 420: group treatment of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a significant problem for a large number of veterans who receive treatment from the Department of Veterans Affairs (VA) health-care system. VA Cooperative Study 420 is a randomized clinical trial of group psychotherapy for treating PTSD among veterans who sought VA care. Participants at ten sites were randomly assigned to receive one of the two treatments: active treatment that embedded exposure therapy in a group context or comparison treatment that avoided trauma focus and instead addressed current interpersonal problems. Treatment was delivered weekly to groups of six participants for 30 weeks, followed by five monthly booster sessions. Follow-up assessments were conducted at the end of treatment (7 months) and the end of boosters (12 months) for all participants. Long-term follow-up data were collected for a subset of participants at 18 and 24 months. The primary outcome is PTSD severity; other symptoms, functional status, quality of life, physical health, and service utilization also were assessed. Data analysis will account for the clustering introduced by the group nature of the intervention. The pivotal comparison was at the end of treatment. Analyses of subsequent outcomes will concentrate on the question of the durability of effects. The study provides an example of how to address the unique challenges posed by multisite trials of group psychotherapy through attention to methodological and statistical issues. This article discusses these challenges and describes the design and methods of the study. Control Clin Trials 2001;22:74-88     

Differences in cause of death of Washington State veterans who did and did not use Department of Veterans Affairs healthcare services

Relatively little is known about the cause of death in the veteran population, although more is known about the cause of death in Vietnam veterans or veterans receiving mental health services. This article compares characteristics and causes of death in Washington State veterans who did and did not use Department of Veterans Affairs (VA) healthcare services in the 5 years prior to death. This study included 62,080 veterans who died between 1998 and 2002, of whom 21% were users of VA healthcare services. The veterans who used VA healthcare services were younger, more often men, less educated, more often divorced, and more often smokers than the veterans who did not use VA healthcare services. Both female and male veterans who used VA healthcare services were more likely to die from drug- and/or alcohol-related causes. These findings suggest that the VA patient population is socially disadvantaged and more severely affected by substance-use disorders compared with veterans who do not use VA healthcare services.     

"To care for him who shall have borne the battle and for his widow and his orphan" (Abraham Lincoln): the Department of Veterans Affairs polytrauma system of care

Sigford BJ. “To care for him who shall have borne the battle and for his widow and his orphan” (Abraham Lincoln): the Department of Veterans Affairs Polytrauma System of Care.The initiation of combat in Iraq and Afghanistan has resulted in a new cohort of active-duty service members and veterans seeking rehabilitation care through the U.S. Department of Veterans Affairs (VA). Service members injured in combat most often sustain multiple injuries (polytrauma) and require a unique service delivery model to meet their needs. The VA recognized this need and responded with the development of the Polytrauma System of Care (PSC). This national system of care balances access and expertise to provide specialized life-long care to the combat injured. The PSC is comprised of: 4 specialized regional rehabilitation centers that are accredited in brain injury by the Commission on Accreditation of Rehabilitation Facilities; 21 specialized outpatient and subacute rehabilitation programs; designated polytrauma teams at smaller, more remote VA facilities; and a point of contact at all other VA facilities. In addition, the PSC has developed a proactive case-management model, a specialized telehealth network, guidelines for long-term follow-up, and services for those individuals who are unable to return home. The following commentary and articles provide additional detail on this new and unique system of care.     

Military and VA telemedicine systems for patients with traumatic brain injury

Telemedicine plays a critical role within the Department of Veterans Affairs (VA) Veterans Health Administration by allowing the surveillance and care of patients who are isolated by geography, poverty, and disability. In military settings, telemedicine is being widely used to identify injury and illness and aid in the treatment, rehabilitation, and recovery of combat-wounded soldiers in theater. Rapid advances in both domains are transforming the way clinicians provide care, education, and support to patients with traumatic brain injury (TBI) and their families. This article discusses the military and VA telemedicine capabilities that are supporting the care of service members and veterans with TBI. These capabilities include new technologies that enhance the identification of TBI, management of symptoms in theater, and application of proven technologies (interactive video, Internet, and World Wide Web) to improve overall care coordination throughout military and VA systems. The impact of distance learning, teleconsultation, telerehabilitation, and home telehealth programs is also described within this context.     

Decision‐making preference and opportunity in VA ambulatory care patients: Association with patient satisfaction

Using data from the Veterans Health Study, associations were examined for decision‐making preference, decision‐making opportunity, and satisfaction with medical care among a sample of 266 men who use Department of Veterans Affairs (VA) ambulatory health care services. Results indicated that veterans with a high preference for involvement in decision‐making and low provider‐offered decision‐making opportunities had significantly lower satisfaction with medical care compared to veterans with either low preference for decision‐making involvement with high or low opportunity, or those with a high decision‐making preference and high decision‐making opportunity. The findings suggest that health care providers may increase patient satisfaction with medical care by providing opportunities for decision‐making to patients who prefer involvement in their health care decision‐making. Provider strategies for increasing patient decision‐making involvement are discussed. © 1999 John Wiley & Sons, Inc. Res Nurs Health 22: 39–48, 1999.     

Brief report: Comparison of methods to identify Iraq and Afghanistan war veterans using Department of Veterans Affairs administrative data

The Department of Veterans Affairs (VA) has made treatment and care of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans a priority. Researchers face challenges identifying the OIF/OEF population because until fiscal year 2008, no indicator of OIF/OEF service was present in the Veterans Health Administration (VHA) administrative databases typically used for research. In this article, we compare an algorithm we developed to identify OIF/OEF veterans using the Austin Information Technology Center administrative data with the VHA Support Service Center OIF/OEF Roster and veterans' self-report of military service. We drew data from two different institutional review board-approved funded studies. The positive predictive value of our algorithm compared with the VHA Support Service Center OIF/OEF Roster and self-report was 92% and 98%, respectively. However, this method of identifying OIF/OEF veterans failed to identify a large proportion of OIF/OEF veterans listed in the VHA Support Service Center OIF/OEF Roster. Demographic, diagnostic, and VA service use differences were found between veterans identified using our method and those we failed to identify but who were in the VHA Support Service Center OIF/OEF Roster. Therefore, depending on the research objective, this method may not be a viable alternative to the VHA Support Service Center OIF/OEF Roster for identifying OIF/OEF veterans.     

Deployment-Related Traumatic Brain Injury and Risk of New Episodes of Care for Back Pain in Veterans

Traumatic brain injury (TBI) may be a predisposing factor to pain syndromes other than headache. We conducted a longitudinal cohort study among veterans evaluated for TBI in the US Department of Veterans Affairs (VA). Among 36,880 veterans at baseline, 55% reported back pain. TBI history was classified by trained clinicians according to VA-US Department of Defense criteria. 14,223 Veterans without back pain were followed for up to 6 years for new (incident) episodes of VA care for back pain. We estimated adjusted odds ratios (aORs), adjusted hazard ratios (aHRs), and 95% confidence intervals (CI), accounting for covariates. Deployment-related mild TBI was significantly associated with self-reported back pain in cross-sectional analyses (aOR?=?1.27, 95% CI?=?1.21–1.35), but not with incident episodes of VA care for back pain in longitudinal analysis (aHR?=?1.07, 95% CI?=?0.99–1.17). Deployment-related moderate to severe TBI was significantly associated with self-reported back pain in cross-sectional (aOR?=?1.74, 95% CI?=?1.58–1.91), and longitudinal analyses (aHR?=?1.20, 95% CI?=?1.05–1.38; P?=?.01). These findings indicate that deployment-related moderate to severe TBI confers increased back pain risk, but do not support a causal effect of deployment-related mild TBI on back pain.

Determinants of VA utilization. The 1983 survey of aging veterans

By the end of the decade, fully one half of American males aged 65 years and over will be veterans. In anticipation of the increased demand for medical services, the Veterans Administration recently commissioned a survey of the needs of aging veterans. From a national probability sample, approximately 34,500 households were screened to yield interviews with 3,013 veterans aged 55 years and over. Using multivariate regression analyses, the present study employed this data set for two purposes: 1) to identify covariates of past and present service utilization in the VA system, and 2) to identify the conditions under which veterans will declare an intention to use VA services in the future. Independent variables included medical diagnoses, ADLs, demographic and background characteristics, convenience and proximity to VA facilities, alternative forms of insurance coverage, VA eligibility, and attitudes about the quality of VA care. The results suggest markedly different predictors for current use versus likelihood of future use; however, income was related to both current and intended future utilization. The implications of these findings for policy development and utilization projections are discussed.     

VA community-based outpatient clinics: performance measures based on patient perceptions of care

BACKGROUND: The Department of Veterans Affairs (VA) recently initiated a system of Community- Based Outpatient Clinics (CBOCs) to enhance delivery of primary care to veterans. OBJECTIVE: The objective of this study was to determine the effect of CBOCs on patients' perceptions of care. RESEARCH DESIGN: The study design is a cross-sectional survey. SUBJECTS: This study compares 4,980 patients from 44 geographically diverse CBOCs to 4,159 patients from 36 parent VA Medical Center primary care clinics administratively and geographically associated with the CBOCs studied. MEASURES: Survey data were obtained from the 1998 VA National Outpatient Customer Satisfaction Survey which assesses eight multiitem scales addressing access and timeliness of care, education/information, patient preferences, emotional support, coordination of care, courtesy, and specialty care access. Each scale was evaluated based upon item responses that indicate a problem with care. The survey also contained SF-12 health status measures used for case-mix adjustment. RESULTS: Multivariate logistic regression controlling for patient health status measures revealed that CBOC patients reported fewer problems with care than VA-based patients on 7 of 8 scales though the absolute differences were small for most of the scales. The largest difference was observed for the access/timeliness scale. Significant differences between VA-staff and contract CBOCs were not observed. CONCLUSIONS: These results suggest that veterans participating in VA's initiative to provide primary care in community-based settings report no more than, and in some dimensions fewer problems with care compared with veterans who receive care in VAMC clinics.     

Using Telehealth Technology to Support Family Caregivers: Description of a Pilot Intervention and Preliminary Results

ABSTRACT

This project was funded by the Department of Veterans Affairs (VA) as a part of a national pilot program to design interventions that would support caregivers of older veterans. The specific project described here employed in-home messaging units, which are already widely used by the VA in disease-management programs, as a device to educate and support family caregivers (CGs) of older, functionally impaired veterans. The primary goal of the pilot program was to improve the well-being of both family CGs and their veteran care recipients (CRs) by (a) engaging CGs more actively and effectively in their veterans’ care, and (b) directly addressing the emotional needs of caregivers themselves. A three-group quasi-experimental design (instrumental support, instrumental+emotional support, wait-list control) was employed. Outcomes from the perspective of the caregiver, care recipient, and the health system were evaluated. In this paper, we further describe the experimental design of the program, the role of the technology employed in the program, a brief summary of common opinions of the intervention as voiced by caregivers and care recipients in the program, and a preliminary look at interim quantitative results 3 months prior to the planned final 6-month outcomes analysis.