Reducing Barriers to Mental Health and Social Services for Iraq and Afghanistan Veterans: Outcomes of an Integrated Primary Care Clinic

BACKGROUND  

Despite high rates of post-deployment psychosocial problems in Iraq and Afghanistan veterans, mental health and social services are under-utilized.     

Does Mental Health Care Integration Affect Primary Care Clinician Burnout? Results from a Longitudinal Veterans Affairs Survey

BackgroundBurnout among primary care clinicians (PCPs) is associated with negative health and productivity consequences. The Veterans Health Administration (VA) embedded mental health specialists and care managers in primary care to manage common psychiatric diseases. While challenging to implement, mental health integration is a team-based care model thought to improve clinician well-being.ObjectiveTo examine the relationships between PCP-reported burnout (and secondarily, job satisfaction) and mental health integration at provider and clinic levelsDesignAnalysis of 286 cross-sectional surveys in 2012 (n = 171) and 2013 (n = 115)Participants210 PCPs in one VA regionMain MeasuresOutcomes were PCP-reported burnout (Maslach Burnout Inventory emotional exhaustion subscale), and secondarily, job satisfaction. Two independent variables represented mental health integration: (1) PCP-specialty communication rating and (2) proportion of clinic patients who saw integrated specialists. Using multilevel regression models, we examined PCP-reported burnout (and job satisfaction) and mental health integration, adjusting for PCP characteristics (e.g., gender), PCP ratings of team functioning (communication, knowledge/skills, satisfaction), and organizational factors.Key ResultsOn average, PCPs reported high burnout (29, range = 9–54) across all VA healthcare systems. In total, 46% of PCPs reported “very easy” communication with mental health; 9% of primary clinic patients had seen integrated specialists. Burnout was not significantly associated with mental health communication ratings (β coefficient = − 0.96, standard error [SE] = 1.29, p = 0.46), nor with proportion of clinic patients who saw integrated specialists (β = 0.02, SE = 0.11, p = 0.88). No associations were observed with job satisfaction either. Among study participants, PCPs with poor team functioning, as exhibited by low team communication ratings, reported high burnout (β = − 1.28, SE = 0.22, p < 0.001) and low job satisfaction (β = 0.12, SE = 0.02, p < 0.001).ConclusionsAs currently implemented, primary care and mental health integration did not appear to impact PCP-reported burnout, nor job satisfaction. More research is needed to explore care model variation among clinics in order to optimize implementation to enhance PCP well-being.KEY WORDS: burnout, primary care, mental health, communication, veterans     

Association Between Lipid Testing and Statin Adherence in the Veterans Affairs Health System

BackgroundMeasurement with a lipid panel after statin initiation and in long-term follow-up is recommended in both 2013 and 2018 cholesterol guidelines to assess statin efficacy and adherence. We assessed whether routine laboratory evaluation with lipid panels is associated with greater statin adherence.MethodsWe identified patients with atherosclerotic cardiovascular disease within the entire Veterans Affairs (VA) health care system with at least one primary care visit between October 2013 and September 2014, who were on statin therapy (n = 813,887; n = 52,583 for new statin users). Statin adherence was determined using medication refill data and assessed by proportion of days covered (PDC). Association between number of lipid panels completed and PDC was assessed with adjusted regression models.ResultsWithin the study period, the mean number of lipid panels that were completed per patient was 1.5 ± 1.0. In the overall cohort, percentage of statin users with PDC ≥ 80% was 66.0% for patients with ≥ 1 lipid panel and 61.2% for patients with 0 lipid panels (P < .0001). Among new statin users, PDC ≥ 80% was 68.0% for patients with lipid panels completed within 4-12 weeks of therapy initiation and 59.3% for those without lipid panels completed within the timeframe (P < .0001). In adjusted analysis, number of lipid panels completed was associated with a modest but significant increase in PDC, when PDC was evaluated as a continuous (beta-coefficient 0.0054, P < .001) or categorical (PDC ≥ 80% [odds ratio (OR) 1.01; 95% confidence interval (CI), 1.00-1.01]) measure of statin adherence. The significant association was also observed in new users (beta-coefficient 0.0058, P < .001; OR 1.02; 95% CI, 1.00-1.03).ConclusionRoutine, guideline-directed completion of lipid panels in atherosclerotic cardiovascular disease patients on statins overall and among new statin users is associated with a modes6t but significant increase in statin adherence.     

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.     

Survival of colorectal cancer patients hospitalized in the Veterans Affairs Health Care System

OBJECTIVES: A recent analysis based on data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute indicates that no survival benefit occurred, for white or for black individuals, in colorectal cancer diagnosed during 1986-1997, and that blacks fared worse than whites. The objective of this research was to evaluate recent temporal trends in the survival of patients with colorectal cancer admitted to hospitals in the Veterans Affairs (VA) system, which offers equal access to care and facilitates systemwide implementation of prevention and treatment services. METHODS: This research was a cohort study of patients admitted to all VA hospitals with a new diagnosis of colorectal cancer between October, 1987, and September, 1998, and followed through September, 2001. Temporal changes in observed 5-yr survival were evaluated for the periods 1987-1989, 1990-1992, 1993-1995, and 1996-1998. Cumulative survival was obtained from Kaplan-Meier estimates, whereas adjusted risk of death was calculated using a Cox proportional hazards model. Adjustment was made for differences in patient characteristics, including comorbidity. RESULTS: We identified 46,044 individuals with colorectal cancer in VA hospitals during 1987-1998, 98.5% of whom were men. The mean age was 67.7 yr, and the two largest racial/ethnic groups were whites (76.5%) and blacks (17.1%). Significant differences in survival were seen over time (p < 0.001, log rank test) with longer survival in patients diagnosed in the more recent time periods. In the multivariable Cox model, survival showed an 18% increase over time (1987-1998) after adjusting for differences in age, race, comorbidity, cancer site, and extent of disease. There was a small but statistically significant decrease in chance of survival in blacks compared with whites (adjusted relative survival 0.96, 95% CI = 0.92-0.99). CONCLUSIONS: Recent non-VA studies have shown stable survival for colorectal cancer patients over time, coupled with significantly decreased survival for blacks compared with whites. In contrast, in the VA system, survival has improved for both white and black patients; in addition, the racial discrepancy in survival is markedly attenuated. These results suggest that the benefits of prevention and treatment advances may be more readily achieved in the VA's equal access, integrated health care system.     

Technology for Diabetes Care and Evaluation in the Veterans Health Administration: Veterans Affairs Research on Health Information Technologies for Diabetes Self-Management Support

Background

Like many patients with diabetes, Department of Veterans Affairs (VA) patients frequently fall short of self-management goals and experience multiple barriers to self-care. Health information technologies (HITs) may provide the tools that patients need to manage their illness under the direction of their primary care team.

Methods

We describe several ongoing projects focused on HIT resources for self-management in VA. VA researchers are developing HITs that seek to bolster a variety of potential avenues for self-management support, including patients′ relationships with other patients, connections with their informal care networks, and communication with their health care teams.

Results

Veterans Affairs HIT research projects are developing services that can address the needs of patients with multiple challenges to disease self-care, including multimorbidity, health literacy deficits, and limited treatment access. These services include patient-to-patient interactive voice response (IVR) calling systems, IVR assessments with feedback to informal caregivers, novel information supports for clinical pharmacists based on medication refill data, and enhanced pedometers.

Conclusion

Large health care systems such as the VA can play a critical role in developing HITs for diabetes self-care. To be truly effective, these efforts should include a continuum of studies: observational research to identify barriers to self-management, developmental studies (e.g., usability testing), efficacy trials, and implementation studies to evaluate utility in real-world settings. VA HIT researchers partner with operations to promote the dissemination of efficacious services, and such relationships will be critical to move HIT innovations into practice.     

Utilization of Primary Care by Veterans with Psychiatric Illness in the National Department of Veterans Affairs Health Care System

BACKGROUND

Psychiatric illness is associated with increased medical morbidity and mortality. Studies of primary care utilization by patients with psychiatric disorders have been limited by nonrepresentative samples and confounding by medical co-morbidity.

OBJECTIVE

To determine whether patients with psychiatric disorders use primary care services differently than patients without these disorders, after controlling for medical co-morbidity.

DESIGN

Data from the 1999 Large Health Survey of Veterans (LHS) ( = 559,985) were linked to VA administrative data in order to identify veterans who received primary care. After adjusting for sociodemographic and clinical characteristics, medical co-morbidity, and facility characteristics, multivariate logistic regression was used to evaluate whether seven psychiatric diagnoses were associated with an increased or decreased likelihood of any primary care visit over 12 months.

RESULTS

Veterans with either schizophrenia, bipolar disorder or a drug use disorder were less likely to have had any primary care visit during the study period: [OR 0.61, 95% CI 0.59 to 0.63], [OR 0.63, 95% CI 0.60 to 0.67] and [OR 0.88, 95% CI 0.83 to 0.92], respectively, than veterans without these diagnoses, even after controlling for medical co-morbidity. Among patients with any primary care utilization, those with six of the seven psychiatric diagnoses had fewer visits in the study period.

CONCLUSIONS

Patients with schizophrenia, bipolar disorder or drug use disorders use less primary care than patients without these disorders. Interventions are needed to increase engagement in primary care by these vulnerable groups.Key Words: primary care, psychiatric illness, Axis I psychiatric disorders, Veterans Affairs Health Care System     

Social Work Mental Health Services and the Long-Term Care Continuum

Mental health services are provided to the elderly by social workers in senior centers, Veterans Administration programs, family service agencies, home health care agencies, and in the private sector. The psychosocial approach is emphasized and the growing need to provide sufficient and appropriate mental health services to older adults is addressed.     

Patient Satisfaction of Female and Male Users of Veterans Health Administration Services

OBJECTIVE: To compare patient satisfaction of male and female users of Veterans Health Administration (VHA) services.
DESIGN: Cross-sectional study based on secondary analysis of data from VHA's Survey of Healthcare Experiences of Patients (SHEP).
PATIENTS: National random sample of 107,995 outpatients and 112,817 inpatients in FY2004.
MEASURES: Patient's ratings of overall quality (OQ) and unique dimensions of satisfaction. Sociodemographic and health-related patient attributes.
ANALYSIS: Bivariate unadjusted analyses of the association between gender and other patient attributes and the outcomes of OQ and dimensions of satisfaction were conducted followed by multivariate analyses for each outcome, adjusting for demographic and health variables.
RESULTS: Significant differences between female and male reporting of satisfaction were found in the unadjusted analyses with males showing greater levels of satisfaction than females ( P <.05). These differences disappeared or became smaller for both outpatient and inpatient services, after adjusting for covariates. For 6 of the inpatient dimensions (Transitions, Physical Comfort, Involvement Family and Friends, Courtesy, Coordination, and Access) males had higher satisfaction than females after statistical adjustment.
CONCLUSIONS: After adjustment for patient attributes, female VHA outpatients report similar OQ with VHA services as male patients. The fact that some inpatient dimensions of satisfaction continued to show effects favoring males even after adjustment suggests areas for continued focus in improving health care quality. Covariate adjustment is essential for evaluating satisfaction with health care services. Breaking down overall satisfaction into independent aspects of services is useful. The SHEP survey has provided a useful tool for evaluating and improving satisfaction among its VHA veteran users.     

Comparison of Medicine Resident Diabetes Care Between Veterans Affairs and Academic Health Care Systems

BACKGROUND  Although others have reported national disparities in the quality of diabetes care between the Veterans Affairs (VA) and private health care delivery systems, it is not known whether these differences persist among internal medicine resident providers in academic settings. OBJECTIVE  We compared the quality of diabetes primary care delivered by resident physicians in either a private academic health care system (AHS) or its affiliated VA health care system. DESIGN  Cross-sectional observational study PARTICIPANTS  We included patients who: had a diagnosis of diabetes, had >2 primary care visits with the same resident provider during 2005, and were not separately managed by an attending physician or endocrinologist. A total of 640 patients met our criteria and were included in the analysis. MEASUREMENTS AND RESULTS  Compared to the VA, patients in the AHS were more likely to be younger, female, have fewer medications, and be treated with insulin, but had less comorbidity. Patients in the VA were more likely to be referred for an annual eye exam (94% vs. 78%), receive lipid screening (88% vs. 74%), receive proteinuria screening (63% vs. 34%), and receive a complete foot exam (85% vs. 32%) in analyses adjusted for patient demographics and comorbidities (p-value <0.001 for all comparisons). In adjusted analyses, there were no significant differences in HbA1_c, blood pressure, or LDL cholesterol control. CONCLUSIONS  In spite of similar resident providers and practice models, there were substantial differences in the diabetes quality of care delivered in the VA and AHS. Understanding how these factors influence subsequent practice patterns is an important area for study. This research was supported by the The Joseph C. Greenfield, Jr. Scholars Endowment. The first author (BJP) was supported by a KL2 career development award through Duke University and the NIH (KL2 RR024127). This research has been presented as a poster at the VA HSR&D 2009 National Meeting in Baltimore, MD, on February 11, 2009.     

Outcomes of Veterans Undergoing TAVR Within Veterans Affairs Medical Centers: Insights From the Veterans Affairs Clinical Assessment,Reporting, and Tracking Program

ObjectivesThis study sought to describe clinical and procedural characteristics of veterans undergoing transcatheter aortic valve replacement (TAVR) within U.S. Department of Veterans Affairs (VA) centers and to examine their association with short- and long-term mortality, length of stay (LOS), and rehospitalization within 30 days.BackgroundVeterans with severe aortic stenosis frequently undergo TAVR at VA medical centers.MethodsConsecutive veterans undergoing TAVR between 2012 and 2017 were included. Patient and procedural characteristics were obtained from the VA Clinical Assessment, Reporting, and Tracking system. The primary outcomes were 30-day and 1-year survival, LOS >6 days, and rehospitalization within 30 days. Logistic regression and Cox proportional hazards analyses were performed to evaluate the associations between pre-procedural characteristics and LOS and rehospitalization.ResultsNine hundred fifty-nine veterans underwent TAVR at 8 VA centers during the study period, 860 (90%) by transfemoral access, 50 (5%) transapical, 36 (3.8%) transaxillary, and 3 (0.3%) transaortic. Men predominated (939 of 959 [98%]), with an average age of 78.1 years. There were 28 deaths within 30 days (2.9%) and 134 at 1 year (14.0%). Median LOS was 5 days, and 141 veterans were rehospitalized within 30 days (14.7%). Nonfemoral access (odds ratio: 1.74; 95% confidence interval [CI]: 1.10 to 2.74), heart failure (odds ratio: 2.51; 95% CI: 1.83 to 3.44), and atrial fibrillation (odds ratio: 1.40; 95% CI: 1.01 to 1.95) were associated with increased LOS. Atrial fibrillation was associated with 30-day rehospitalization (hazard ratio: 1.79; 95% CI: 1.22 to 2.63).ConclusionsVeterans undergoing TAVR at VA centers are predominantly elderly men with significant comorbidities. Clinical outcomes of mortality and rehospitalization at 30 days and 1-year mortality compare favorably with benchmark outcome data outside the VA.     

Comparing Quality of Care in Veterans Affairs and Non-Veterans Affairs Settings

Background

Congress, veterans’ groups, and the press have expressed concerns that access to care and quality of care in Department of Veterans Affairs (VA) settings are inferior to access and quality in non-VA settings.

Objective

To assess quality of outpatient and inpatient care in VA at the national level and facility level and to compare performance between VA and non-VA settings using recent performance measure data.

Main Measures

We assessed Patient Safety Indicators (PSIs), 30-day risk-standardized mortality and readmission measures, and ORYX measures for inpatient safety and effectiveness; Healthcare Effectiveness Data and Information Set (HEDIS®) measures for outpatient effectiveness; and Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS) and Survey of Healthcare Experiences of Patients (SHEP) survey measures for inpatient patient-centeredness. For inpatient care, we used propensity score matching to identify a subset of non-VA hospitals that were comparable to VA hospitals.

Key Results

VA hospitals performed on average the same as or significantly better than non-VA hospitals on all six measures of inpatient safety, all three inpatient mortality measures, and 12 inpatient effectiveness measures, but significantly worse than non-VA hospitals on three readmission measures and two effectiveness measures. The performance of VA facilities was significantly better than commercial HMOs and Medicaid HMOs for all 16 outpatient effectiveness measures and for Medicare HMOs, it was significantly better for 14 measures and did not differ for two measures. High variation across VA facilities in the performance of some quality measures was observed, although variation was even greater among non-VA facilities.

Conclusions

The VA system performed similarly or better than the non-VA system on most of the nationally recognized measures of inpatient and outpatient care quality, but high variation across VA facilities indicates a need for targeted quality improvement.

     

The prevalence and outcomes of in-hospital acute myocardial infarction in the Department of Veterans Affairs Health System

BACKGROUND: Most studies of the epidemiology and treatment of acute myocardial infarction (AMI) have focused on patients who experienced onset of their symptoms in the community and then presented to the hospital. There are, however, patients whose symptoms of AMI begin after hospitalization for other medical conditions. The purposes of this study were to determine the prevalence of in-hospital AMI in the Veterans Health Administration (VHA) and to compare baseline characteristics, treatments, and outcomes according to whether individuals presented with AMI or had an in-hospital AMI. METHODS: This was a retrospective cohort study of 7054 veterans who were hospitalized for AMI in 127 VHA medical centers between July 2003 and August 2004. The main outcome measure was 30-day mortality. Key covariates included age, body mass index, admission systolic blood pressure, heart rate, previous use of lipid-lowering drugs, elevated admission troponin value, prolonged and/or atypical chest pain on admission, and ST-segment elevation on the initial electrocardiogram. RESULTS: There were 792 patients (11.2%) who had AMI while hospitalized for other medical conditions. These patients differed substantially from those who presented to the hospital with AMI. The odds of 30-day mortality were greater in the in-hospital group (odds ratio, 3.6; 95% confidence interval, 3.1-4.3; P<.001) and remained higher after statistical adjustment (odds ratio, 2.0; 95% confidence interval, 1.7-2.4; P<.001). CONCLUSION: Although most attention has been paid to patients with AMI admitted via the community emergency medical system or through the emergency department, AMI occurring during hospitalization for other medical problems is an important clinical problem.     

Racial,Ethnic, and Gender Equity in Veteran Satisfaction with Health Care in the Veterans Affairs Health Care System

Background

Patient satisfaction is an important dimension of health care quality. The Veterans Health Administration (VA) is committed to providing high-quality care to an increasingly diverse patient population.

Objective

To assess Veteran satisfaction with VA health care by race/ethnicity and gender.

Design and Participants

We conducted semi-structured telephone interviews with gender-specific stratified samples of black, white, and Hispanic Veterans from 25 predominantly minority-serving VA Medical Centers from June 2013 to January 2015.

Main Measures

Satisfaction with health care was assessed in 16 domains using five-point Likert scales. We compared the proportions of Veterans who were very satisfied, somewhat satisfied, and less than satisfied (i.e., neither satisfied nor dissatisfied, somewhat dissatisfied, or very dissatisfied) in each domain, and used random-effects multinomial regression to estimate racial/ethnic differences by gender and gender differences by race/ethnicity.

Key Results

Interviews were completed for 1222 of the 1929 Veterans known to be eligible for the interview (63.3%), including 421 white, 389 black, and 396 Hispanic Veterans, 616 of whom were female. Veterans were less likely to be somewhat satisfied or less than satisfied versus very satisfied with care in each of the 16 domains. The highest satisfaction ratings were reported for costs, outpatient facilities, and pharmacy (74–76% very satisfied); the lowest ratings were reported for access, pain management, and mental health care (21–24% less than satisfied). None of the joint tests of racial/ethnic or gender differences in satisfaction (simultaneously comparing all three satisfaction levels) was statistically significant (p > 0.05). Pairwise comparisons of specific levels of satisfaction revealed racial/ethnic differences by gender in three domains and gender differences by race/ethnicity in five domains, with no consistent directionality across demographic subgroups.

Conclusions

Our multisite interviews of a diverse sample of Veterans at primarily minority-serving sites showed generally high levels of health care satisfaction across 16 domains, with few quantitative differences by race/ethnicity or gender.