Teleconsultation and Training of VHA Providers on Transgender Care: Implementation of a Multisite Hub System.

PubMed

Kauth, Michael R; Shipherd, Jillian C; Lindsay, Jan A; Kirsh, Susan; Knapp, Herschel; Matza, Lexi

2015-12-01

The Veterans Health Administration (VHA) is piloting a national program providing teleconsultation and training to clinicians to increase knowledge and comfort with treating transgender veterans and to expand clinical capacity. This program is based on Project ECHO and uses specialist expertise to train and educate front-line clinicians. Over time, the front-line clinicians increase knowledge and skills, enabling them to provide care locally and obviate need for patient travel. This program is innovative in its national scope, interdisciplinary team model, and multihub structure. This article describes development of the program and initial results for the first cohort of learners. Five interdisciplinary clinical teams participated in the 14-session, 7-month program. Most teams had some experience treating transgender veterans prior to participation. The teams completed at least 12 of 14 sessions. Thirteen of 33 participants completed an evaluation. In general, respondents found the teleconsultation program very helpful and credited the experience with improving their team functioning. Furthermore, respondents reported a significant increase in confidence to treat transgender veterans by the end of the program (59% versus 83%). We explored whether it is possible to recruit VHA clinical teams to participate in lengthy training on a low prevalence but complex condition. Early results support the feasibility and effectiveness of this national VHA teleconsultation and training program for transgender care. Lessons learned from the first group of learners have been applied to two concurrent groups with positive results.

Molecular characterization, light-dependent expression, and cellular localization of a host vacuolar-type H+-ATPase (VHA) subunit A in the giant clam, Tridacna squamosa, indicate the involvement of the host VHA in the uptake of inorganic carbon and its supply to the symbiotic zooxanthellae.

PubMed

Ip, Yuen K; Hiong, Kum C; Lim, Leon J Y; Choo, Celine Y L; Boo, Mel V; Wong, Wai P; Neo, Mei L; Chew, Shit F

2018-06-15

The giant clam, Tridacna squamosa, represents a clam-zooxanthellae association. In light, the host clam and the symbiotic zooxanthellae conduct light-enhanced calcification and photosynthesis, respectively. We had cloned the cDNA coding sequence of a Vacuolar-type Proton ATPase (VHA) subunit A, ATP6V1A, from T. squamosa, whereby the VHA is an electrogenic transporter that actively 'pumps' H + out of the cell. The ATP6V1A of T. squamosa comprised 1866 bp, encoding a protein of 622 amino acids and 69.9 kDa, and had a host-origin. Its gene expression was strong in the ctenidium and the colorful outer mantle, but weak in the whitish inner mantle, corroborating a previous proposition that VHA might have a trivial role in light-enhanced calcification. Light exposure led to significant increases in the gene and protein expression levels of ATP6V1A/ATP6V1A in the ctenidium and the outer mantle. In the ctenidium, the ATP6V1A was localized in the apical epithelia of the filaments and tertiary water channels, indicating that the VHA could participate in the increased excretion of H + produced during light-enhanced calcification. Additionally, the excreted H + would augment HCO 3 - dehydration in the external medium and facilitate the uptake of CO 2 by the ctenidium during insolation. In the outer mantle, the ATP6V1A was detected in intracellular vesicles in a type of cells, presumably iridocytes, surrounding the zooxanthellal tubules, and in the apical epithelium of zooxanthellal tubules. Hence, the host VHA could participate in the transfer of inorganic carbon from the hemolymph to the luminal fluid of the tubules by increasing the supply of H + for the dehydration of HCO 3 - to CO 2 during insolation to benefit the photosynthesizing zooxanthellae. Copyright © 2018 Elsevier B.V. All rights reserved.

A social marketing approach to implementing evidence-based practice in VHA QUERI: the TIDES depression collaborative care model.

PubMed

Luck, Jeff; Hagigi, Fred; Parker, Louise E; Yano, Elizabeth M; Rubenstein, Lisa V; Kirchner, JoAnn E

2009-09-28

Collaborative care models for depression in primary care are effective and cost-effective, but difficult to spread to new sites. Translating Initiatives for Depression into Effective Solutions (TIDES) is an initiative to promote evidence-based collaborative care in the U.S. Veterans Health Administration (VHA). Social marketing applies marketing techniques to promote positive behavior change. Described in this paper, TIDES used a social marketing approach to foster national spread of collaborative care models. The approach relied on a sequential model of behavior change and explicit attention to audience segmentation. Segments included VHA national leadership, Veterans Integrated Service Network (VISN) regional leadership, facility managers, frontline providers, and veterans. TIDES communications, materials and messages targeted each segment, guided by an overall marketing plan. Depression collaborative care based on the TIDES model was adopted by VHA as part of the new Primary Care Mental Health Initiative and associated policies. It is currently in use in more than 50 primary care practices across the United States, and continues to spread, suggesting success for its social marketing-based dissemination strategy. Development, execution and evaluation of the TIDES marketing effort shows that social marketing is a promising approach for promoting implementation of evidence-based interventions in integrated healthcare systems.

A social marketing approach to implementing evidence-based practice in VHA QUERI: the TIDES depression collaborative care model

PubMed Central

2009-01-01

Abstract Collaborative care models for depression in primary care are effective and cost-effective, but difficult to spread to new sites. Translating Initiatives for Depression into Effective Solutions (TIDES) is an initiative to promote evidence-based collaborative care in the U.S. Veterans Health Administration (VHA). Social marketing applies marketing techniques to promote positive behavior change. Described in this paper, TIDES used a social marketing approach to foster national spread of collaborative care models. TIDES social marketing approach The approach relied on a sequential model of behavior change and explicit attention to audience segmentation. Segments included VHA national leadership, Veterans Integrated Service Network (VISN) regional leadership, facility managers, frontline providers, and veterans. TIDES communications, materials and messages targeted each segment, guided by an overall marketing plan. Results Depression collaborative care based on the TIDES model was adopted by VHA as part of the new Primary Care Mental Health Initiative and associated policies. It is currently in use in more than 50 primary care practices across the United States, and continues to spread, suggesting success for its social marketing-based dissemination strategy. Discussion and conclusion Development, execution and evaluation of the TIDES marketing effort shows that social marketing is a promising approach for promoting implementation of evidence-based interventions in integrated healthcare systems. PMID:19785754

PAs in orthopedics in the VHA's community-based outpatient clinics.

PubMed

Reed, Daniel O; Hooker, Roderick S

2017-04-01

In the Veterans Health Administration (VHA) system, most orthopedic care takes place in the VA medical centers (VAMCs). Because most patients receiving orthopedic care were referred by adult medicine providers, more widely deploying physician assistants (PAs) in orthopedic medicine might help offset this workload. An orthopedic medicine demonstration project recruited, trained, and positioned PAs in community-based outpatient clinics (CBOCs) to improve access to care. The project involved surgeons at the Houston VAMC instructing five newly employed PAs in a wide range of orthopedic evaluation and management strategies before their assignment to a CBOC. An administrative assessment compared encounter data pre- and postproject (2012 and 2014) to determine if this strategy modified orthopedic workload and improved patient access to care. By 2014, orthopedic patient visit volume had increased 31%-10% at the VAMC and 21% at the five CBOCs. Overall, the five deployed PAs managed 28% of all orthopedic encounters spread over 1 year and only 3.2% of visits required VAMC referral for further evaluation or treatment. During the project, the total volume of patient visits increased throughout the Houston VAMC region but access to care for this specialty service also increased, with more veteran musculoskeletal care being met at the five CBOCs, off-loading visit demand centrally. The adaptability and flexibility of new roles has been identified as one of the defining characteristics of PAs. That the VHA can take advantage of this role malleability suggests that employing PAs is useful in meeting medical service needs of veterans.

An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): Study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation.

PubMed

Chang, Evelyn T; Zulman, Donna M; Asch, Steven M; Stockdale, Susan E; Yoon, Jean; Ong, Michael K; Lee, Martin; Simon, Alissa; Atkins, David; Schectman, Gordon; Kirsh, Susan R; Rubenstein, Lisa V

2018-06-01

Patient-centered medical homes have made great strides providing comprehensive care for patients with chronic conditions, but may not provide sufficient support for patients at highest risk for acute care use. To address this, the Veterans Health Administration (VHA) initiated a five-site demonstration project to evaluate the effectiveness of augmenting the VA's Patient Aligned Care Team (PACT) medical home with PACT Intensive Management (PIM) teams for Veterans at highest risk for hospitalization. Researchers partnered with VHA leadership to design a mixed-methods prospective multi-site evaluation that met leadership's desire for a rigorous evaluation conducted as quality improvement rather than research. We conducted a randomized QI evaluation and assigned high-risk patients to participate in PIM and compared them with high-risk Veterans receiving usual care through PACT. The summative evaluation examines whether PIM: 1) decreases VHA emergency department and hospital use; 2) increases satisfaction with VHA care; 3) decreases provider burnout; and 4) generates positive returns on investment. The formative evaluation aims to support improved care for high-risk patients at demonstration sites and to inform future initiatives for high-risk patients. The evaluation was reviewed by representatives from the VHA Office of Research and Development and the Office of Research Oversight and met criteria for quality improvement. VHA aims to function as a learning organization by rapidly implementing and rigorously testing QI innovations prior to final program or policy development. We observed challenges and opportunities in designing an evaluation consistent with QI standards and operations priorities, while also maintaining scientific rigor. This trial was retrospectively registered at ClinicalTrials.gov on April 3, 2017: NCT03100526. Protocol v1, FY14-17. Copyright © 2018 Elsevier Inc. All rights reserved.

Microstructures and mechanical properties of powder injection molded Ti-6Al-4V/HA powder.

PubMed

Thian, E S; Loh, N H; Khor, K A; Tor, S B

2002-07-01

Taguchi method with an L9 orthogonal array was employed to investigate the sintered properties of Ti-6Al-4V/HA tensile bars produced by powder injection molding. The effects of sintering factors at the 90% significance level: sintering temperature (1050 degrees C, 1100 degrees C and 1150 degrees C), heating rate (5 degrees C/min, 7.5 degrees C/min and 10 degrees C/min), holding time (30, 45 and 60 min) and cooling rate (5 degrees C/min, 20 degrees C/min and 40 degrees C/min) were investigated. Results showed that sintering temperature, heating rate and cooling rate have significant effects on sintered properties, whereas the influence of holding time was insignificant. It was found that a sintering temperature of 1100 degrees C, a heating rate of 7.5 degrees C/min and a cooling rate of 5 degrees C/min increased the relative density, Vicker's microhardness, flexural strength and flexural modulus. However, a further increment of sintering temperature to 1150 degrees C did not show any discernable improvement in the relative density and Vicker's microhardness, but there was a slight increase of 0.6% and 0.9% in the flexural strength and flexural modulus, respectively. Mechanically strong Ti-6Al-4V/HA parts with an open porosity of around 50% were developed.

Demographic characteristics associated with homelessness and risk among female and male veterans accessing VHA outpatient care.

PubMed

Montgomery, Ann Elizabeth; Dichter, Melissa E; Thomasson, Arwin M; Fu, Xiaoying; Roberts, Christopher B

2015-01-01

This study explored demographic influences on veterans' reports of homelessness or imminent risk of homelessness with a particular focus on gender. We analyzed data for a cohort of veterans who responded to the U.S. Department of Veterans Affairs (VA), Veterans Health Administration (VHA) universal screener for homelessness and risk during a 3-month period. Multinomial mixed effects models-stratified by gender-predicted veterans' reports of homelessness or risk based on age, race, marital status, and receipt of VA compensation. The proportion of positive screens-homelessness or risk-was 2.7% for females and 1.7% for males. Women more likely to report being at risk of homelessness were aged 35 to 54 years, Black, and unmarried; those more likely to experience homelessness were Black and unmarried. Among male veterans, the greatest predictors of both homelessness and risk were Black race and unmarried status. Among both genders, receiving VA disability compensation was associated with lesser odds of being homeless or at risk. The findings describe the current population of veterans using VHA health care services who may benefit from homelessness prevention or intervention services, identify racial differences in housing stability, and distinguish subpopulations who may be in particular need of intervention. Interventions to address these needs are described. Published by Elsevier Inc.

The Comparative Effectiveness of Cognitive Processing Therapy for Male Veterans Treated in a VHA Posttraumatic Stress Disorder Residential Rehabilitation Program

ERIC Educational Resources Information Center

Alvarez, Jennifer; McLean, Caitlin; Harris, Alex H. S.; Rosen, Craig S.; Ruzek, Josef I.; Kimerling, Rachel

2011-01-01

Objective: To examine the effectiveness of group cognitive processing therapy (CPT) relative to trauma-focused group treatment as usual (TAU) in the context of a Veterans Health Administration (VHA) posttraumatic stress disorder (PTSD) residential rehabilitation program. Method: Participants were 2 cohorts of male patients in the same program…

Measurement-based management of mental health quality and access in VHA: SAIL mental health domain.

PubMed

Lemke, Sonne; Boden, Matthew Tyler; Kearney, Lisa K; Krahn, Dean D; Neuman, Matthew J; Schmidt, Eric M; Trafton, Jodie A

2017-02-01

We outline the development of a Mental Health Domain to track accessibility and quality of mental health care in the United States Veterans Health Administration (VHA) as part of a broad-based performance measurement system. This domain adds an important element to national performance improvement efforts by targeting regional and facility leadership and providing them a concise yet comprehensive measure to identify facilities facing challenges in their mental health programs. We present the conceptual framework and rationale behind measure selection and development. The Mental Health Domain covers three important aspects of mental health treatment: Population Coverage, Continuity of Care, and Experience of Care. Each component is a composite of existing and newly adapted measures with moderate to high internal consistency; components are statistically independent or moderately related. Development and dissemination of the Mental Health Domain involved a variety of approaches and benefited from close collaboration between local, regional, and national leadership and from coordination with existing quality-improvement initiatives. During the first year of use, facilities varied in the direction and extent of change. These patterns of change were generally consistent with qualitative information, providing support for the validity of the domain and its component measures. Measure maintenance remains an iterative process as the VHA mental health system and potential data resources continue to evolve. Lessons learned may be helpful to the broader mental health-provider community as mental health care consolidates and becomes increasingly integrated within healthcare systems. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Charitable intentions. CHA, VHA unveil community-benefit guidelines developed to help not-for-profit hospitals justify their tax exemptions.

PubMed

Becker, Cinda

2006-06-05

With new guidelines from the CHA and VHA on reporting community benefits, not-for-profit hospitals are being advised to drop bad debt and Medicare shortfalls from their accounting of how they fulfill their mission. While the AHA doesn't agree, some experts do. MedPAC member Nancy Kane, right, says bad debt "is a tough one, but I don't think a lot of bad debt is a community benefit.

A multivariate fall risk assessment model for VHA nursing homes using the minimum data set.

PubMed

French, Dustin D; Werner, Dennis C; Campbell, Robert R; Powell-Cope, Gail M; Nelson, Audrey L; Rubenstein, Laurence Z; Bulat, Tatjana; Spehar, Andrea M

2007-02-01

The purpose of this study was to develop a multivariate fall risk assessment model beyond the current fall Resident Assessment Protocol (RAP) triggers for nursing home residents using the Minimum Data Set (MDS). Retrospective, clustered secondary data analysis. National Veterans Health Administration (VHA) long-term care nursing homes (N = 136). The study population consisted of 6577 national VHA nursing home residents who had an annual assessment during FY 2005, identified from the MDS, as well as an earlier annual or admission assessment within a 1-year look-back period. A dichotomous multivariate model of nursing home residents coded with a fall on selected fall risk characteristics from the MDS, estimated with general estimation equations (GEE). There were 17 170 assessments corresponding to 6577 long-term care nursing home residents. The increased odds ratio (OR) of being classified as a faller relative to the omitted "dependent" category of activities of daily living (ADL) ranged from OR = 1.35 for "limited" ADL category up to OR = 1.57 for "extensive-2" ADL (P < .0001). Unsteady gait more than doubles the odds of being a faller (OR = 2.63, P < .0001). The use of assistive devices such as canes, walkers, or crutches, or the use of wheelchairs increases the odds of being a faller (OR = 1.17, P < .0005) or (OR = 1.19, P < .0002), respectively. Foot problems may also increase the odds of being a faller (OR = 1.26, P < .0016). Alzheimer's or other dementias also increase the odds of being classified as a faller (OR = 1.18, P < .0219) or (OR=1.22, P < .0001), respectively. In addition, anger (OR = 1.19, P < .0065); wandering (OR = 1.53, P < .0001); or use of antipsychotic medications (OR = 1.15, P < .0039), antianxiety medications (OR = 1.13, P < .0323), or antidepressant medications (OR = 1.39, P < .0001) was also associated with the odds of being a faller. This national study in one of the largest managed healthcare systems in the United States has empirically

Zika virus infection in the Veterans Health Administration (VHA), 2015-2016.

PubMed

Schirmer, Patricia L; Wendelboe, Aaron; Lucero-Obusan, Cynthia A; Ryono, Russell A; Winters, Mark A; Oda, Gina; Martinez, Mirsonia; Saavedra, Sonia; Holodniy, Mark

2018-05-01

Zika virus (ZIKV) is an important flavivirus infection. Although ZIKV infection is rarely fatal, risk for severe disease in adults is not well described. Our objective was to describe the spectrum of illness in U.S. Veterans with ZIKV infection. Case series study including patients with laboratory-confirmed or presumed positive ZIKV infection in all Veterans Health Administration (VHA) medical centers. Adjusted odds ratios of clinical variables associated with hospitalization and neurologic complications was performed. Of 1,538 patients tested between 12/2015-10/2016 and observed through 3/2017, 736 (48%) were RT-PCR or confirmed IgM positive; 655 (89%) were male, and 683 (93%) from VA Caribbean Healthcare System (VACHCS). Ninety-four (13%) were hospitalized, 91 (12%) in the VACHCS. Nineteen (3%) died after ZIKV infection. Hospitalization was associated with increased Charlson co-morbidity index (adjusted odds ratio [OR] 1.2; 95% confidence interval [CI], 1.1-1.3), underlying connective tissue disease (OR, 29.5; CI, 3.6-244.7), congestive heart failure (OR, 6; CI, 2-18.5), dementia (OR, 3.6; CI, 1.1-11.2), neurologic symptom presentation (OR, 3.9; CI, 1.7-9.2), leukocytosis (OR, 11.8; CI, 4.5-31), thrombocytopenia (OR, 7.8; CI, 3.3-18.6), acute kidney injury (OR, 28.9; CI, 5.8-145.1), or using glucocorticoids within 30 days of testing (OR, 13.3; CI 1.3-133). Patients presenting with rash were less likely to be hospitalized (OR, 0.29; CI, 0.13-0.66). Risk for neurologic complications increased with hospitalization (OR, 5.9; CI 2.9-12.2), cerebrovascular disease (OR 4.9; CI 1.7-14.4), and dementia (OR 2.8; CI 1.2-6.6). Older Veterans with multiple comorbidities or presenting with neurologic symptoms were at increased risk for hospitalization and neurological complications after ZIKV infection.

Environmental Validation of Legionella Control in a VHA Facility Water System.

PubMed

Jinadatha, Chetan; Stock, Eileen M; Miller, Steve E; McCoy, William F

2018-03-01

OBJECTIVES We conducted this study to determine what sample volume, concentration, and limit of detection (LOD) are adequate for environmental validation of Legionella control. We also sought to determine whether time required to obtain culture results can be reduced compared to spread-plate culture method. We also assessed whether polymerase chain reaction (PCR) and in-field total heterotrophic aerobic bacteria (THAB) counts are reliable indicators of Legionella in water samples from buildings. DESIGN Comparative Legionella screening and diagnostics study for environmental validation of a healthcare building water system. SETTING Veterans Health Administration (VHA) facility water system in central Texas. METHODS We analyzed 50 water samples (26 hot, 24 cold) from 40 sinks and 10 showers using spread-plate cultures (International Standards Organization [ISO] 11731) on samples shipped overnight to the analytical lab. In-field, on-site cultures were obtained using the PVT (Phigenics Validation Test) culture dipslide-format sampler. A PCR assay for genus-level Legionella was performed on every sample. RESULTS No practical differences regardless of sample volume filtered were observed. Larger sample volumes yielded more detections of Legionella. No statistically significant differences at the 1 colony-forming unit (CFU)/mL or 10 CFU/mL LOD were observed. Approximately 75% less time was required when cultures were started in the field. The PCR results provided an early warning, which was confirmed by spread-plate cultures. The THAB results did not correlate with Legionella status. CONCLUSIONS For environmental validation at this facility, we confirmed that (1) 100 mL sample volumes were adequate, (2) 10× concentrations were adequate, (3) 10 CFU/mL LOD was adequate, (4) in-field cultures reliably reduced time to get results by 75%, (5) PCR provided a reliable early warning, and (6) THAB was not predictive of Legionella results. Infect Control Hosp Epidemiol 2018;39:259-266.

Preferrential rearrangement in normal rabbits of the 3' VHa allotype gene that is deleted in Alicia mutants; somatic hypermutation/conversion may play a major role in generating the heterogeneity of rabbit heavy chain variable region sequences.

PubMed

Allegrucci, M; Young-Cooper, G O; Alexander, C B; Newman, B A; Mage, R G

1991-02-01

The rabbit is unique in having well-defined allotypes in the variable region of the heavy chain. Products of the VHa locus, (with alleles a1, a2, and a3), account for the majority of the serum immunoglobulins. A small percentage of the serum immunoglobulins are a-negative. In 1986, Kelus and Weiss described a mutation that depressed the expression of the Ig VH a2 genes in an a1/a2 rabbit. From this animal the Alicia rabbit strain was developed and the mutation was termed ali. We previously showed, using Southern analysis and the transverse alternating field electrophoresis technique, that the difference between the ali rabbit and normal is a relatively small deletion including some of the most 3' VH genes. The most JH proximal 3' VH1 genes in DNA from normal rabbits of a1, a2 and a3 haplotypes encode a1, a2 and a3 molecules respectively, and it has been suggested that these genes are responsible for allelic inheritance of VHa allotypes. The present study suggests that the 3' end of the VH locus probably plays a key role in regulation of VH gene expression in rabbits because VH gene(s) in this region are the target(s) of preferential VDJ rearrangements. This raises the possibility that mechanisms such as somatic gene conversion and hypermutation are at work to generate the antibody repertoire in this species. Our data support the view that the 3' VH1 gene may be the preferred target for rearrangement in normal rabbits, and for the normal chromosome in heterozygous ali animals. However, homozygous ali rabbits with a deletion that removed the a2-encoding VH1 on both chromosomes do survive, rearrange other VH genes and produce normal levels of immunoglobulins as well as a significant percentage of B cells which bear the a2 allotype. This challenges the view that one VH gene, VH1, is solely responsible for the inheritance pattern of VHa allotypes.

Location of cancer surgery for older veterans with cancer.

PubMed

Kouri, Elena M; Landrum, Mary Beth; Lamont, Elizabeth B; Bozeman, Sam; McNeil, Barbara J; Keating, Nancy L

2012-04-01

Many veterans undergo cancer surgery outside of the Veterans Health Administration (VHA). We assessed to what extent these patients obtained care in the VHA before surgery. VHA-Medicare data, VHA administrative data, and Veterans Affairs Central Cancer Registry data. We identified patients aged ≥65 years in the VHA-Medicare cohort who underwent lung or colon cancer resection outside the VHA and assessed VHA visits in the year before surgery. Over 60% of patients in the VHA-Medicare cohort who received lung or colon cancer surgeries outside the VHA did not receive any care in VHA before surgery. Veterans' receipt of major cancer surgery outside the VHA probably reflects usual private sector care among veterans who are infrequent VHA users. © Health Research and Educational Trust.

Five-year trends in women veterans' use of VA maternity benefits, 2008-2012.

PubMed

Mattocks, Kristin M; Frayne, Susan; Phibbs, Ciaran S; Yano, Elizabeth M; Zephyrin, Laurie; Shryock, Holly; Haskell, Sally; Katon, Jodie; Sullivan, J Cherry; Weinreb, Linda; Ulbricht, Christine; Bastian, Lori A

2014-01-01

An increasing number of young women veterans are returning from war and military service and are seeking reproductive health care from the Veterans Health Administration (VHA). Many of these women seek maternity benefits from the VHA, and yet little is known regarding the number of women veterans utilizing VHA maternity benefits nor the characteristics of pregnant veterans using these benefits. In May 2010, VHA maternity benefits were expanded to include 7 days of infant care, which may serve to entice more women to use VHA maternity benefits. Understanding the changing trends in women veterans seeking maternity benefits will help the VHA to improve the quality of reproductive care over time. The goal of this study was to examine the trends in delivery claims among women veterans receiving VHA maternity benefits over a 5-year period and the characteristics of pregnant veterans utilizing VHA benefits. We undertook a retrospective, national cohort study of pregnant veterans enrolled in VHA care with inpatient deliveries between fiscal years (FY) 2008 and 2012. We included pregnant veterans using VHA maternity benefits for delivery. Measures included annualized numbers and rates of inpatient deliveries and delivery-related costs, as well as cesarean section rates as a quality indicator. During the 5-year study period, there was a significant increase in the number of deliveries to women veterans using VHA maternity benefits. The overall delivery rate increased by 44% over the study period from 12.4 to 17.8 deliveries per 1,000 women veterans. A majority of women using VHA maternity benefits were age 30 or older and had a service-connected disability. From FY 2008 to 2012, the VHA paid more than $46 million in delivery claims to community providers for deliveries to women veterans ($4,993/veteran). Over a 5-year period, the volume of women veterans using VHA maternity benefits increased by 44%. Given this sizeable increase, the VHA must increase its capacity to care

Decisionmaker Forums

DTIC Science & Technology

2005-03-01

Committee professional staff, Brian Hurley of Edward Martin & Associates, Michael Kussman of the VA, Steve Lillie of DoD, Steve Mirick ofAMSUSBob...Michael Kussman of VHA; Bruce Levine of VHA; Miklos Losonczy of VHA; Susan Mather of VHA; Theodore Nam of DoD; Harold Wain of DoD; Terry Washam of

Treatment experiences among LGBT veterans with discrimination-based trauma exposure: A pilot study.

PubMed

Shipherd, Jillian C; Ruben, Mollie A; Livingston, Nicholas A; Curreri, Andrew; Skolnik, Avy A

2018-01-01

Past research suggests that rates of trauma exposure and Posttraumatic Stress Disorder (PTSD) are elevated among lesbian, gay, bisexual, and transgender (LGBT) veterans compared to heterosexual and cisgender veterans. Given higher rates of trauma exposure and PTSD, and the culture associated with the Department of Defense's history of policies excluding LGBT people, it is important to understand if LGBT veterans are seeking PTSD treatment following discrimination-based traumatic events, where they seek care, and if they are satisfied with treatment. This study aimed to describe the experiences of discrimination-based trauma-exposed LGBT veterans' (n = 47) experiences with PTSD treatment, including location of treatment (Veterans Health Administration [VHA] versus non-VHA) and satisfaction with care. The majority of veterans had received a PTSD diagnosis from a health-care provider in their lifetimes (78.72%, n = 37), and over half reported currently experiencing PTSD symptoms. Approximately 47% of LGBT veterans with discrimination-based trauma histories preferred to seek PTSD treatment exclusively at VHA (46.81%) or with a combination of VHA and non-VHA services (38.30%). Veterans who received PTSD treatment exclusively from VHA reported higher satisfaction ratings (7.44 on 0-9 scale) than veterans who received PTSD treatment exclusively from outside VHA (5.25 on 0-9 scale). For veterans who sought PTSD treatment at both VHA and non-VHA facilities, there were no significant differences regarding satisfaction ratings for their PTSD treatment in the two settings. Results are discussed in terms of VHA's continued efforts to establish equitable, patient-centered health care for all veterans and the importance of non-VHA facilities to recognize veteran identities.

Prevalence of gender identity disorder and suicide risk among transgender veterans utilizing veterans health administration care.

PubMed

Blosnich, John R; Brown, George R; Shipherd Phd, Jillian C; Kauth, Michael; Piegari, Rebecca I; Bossarte, Robert M

2013-10-01

We estimated the prevalence and incidence of gender identity disorder (GID) diagnoses among veterans in the Veterans Health Administration (VHA) health care system and examined suicide risk among veterans with a GID diagnosis. We examined VHA electronic medical records from 2000 through 2011 for 2 official ICD-9 diagnosis codes that indicate transgender status. We generated annual period prevalence estimates and calculated incidence using the prevalence of GID at 2000 as the baseline year. We cross-referenced GID cases with available data (2009-2011) of suicide-related events among all VHA users to examine suicide risk. GID prevalence in the VHA is higher (22.9/100 000 persons) than are previous estimates of GID in the general US population (4.3/100 000 persons). The rate of suicide-related events among GID-diagnosed VHA veterans was more than 20 times higher than were rates for the general VHA population. The prevalence of GID diagnosis nearly doubled over 10 years among VHA veterans. Research is needed to examine suicide risk among transgender veterans and how their VHA utilization may be enhanced by new VA initiatives on transgender care.

Prevalence of Gender Identity Disorder and Suicide Risk Among Transgender Veterans Utilizing Veterans Health Administration Care

PubMed Central

Brown, George R.; Shipherd, PhD, Jillian C.; Kauth, Michael; Piegari, Rebecca I.; Bossarte, Robert M.

2013-01-01

Objectives. We estimated the prevalence and incidence of gender identity disorder (GID) diagnoses among veterans in the Veterans Health Administration (VHA) health care system and examined suicide risk among veterans with a GID diagnosis. Methods. We examined VHA electronic medical records from 2000 through 2011 for 2 official ICD-9 diagnosis codes that indicate transgender status. We generated annual period prevalence estimates and calculated incidence using the prevalence of GID at 2000 as the baseline year. We cross-referenced GID cases with available data (2009–2011) of suicide-related events among all VHA users to examine suicide risk. Results. GID prevalence in the VHA is higher (22.9/100 000 persons) than are previous estimates of GID in the general US population (4.3/100 000 persons). The rate of suicide-related events among GID-diagnosed VHA veterans was more than 20 times higher than were rates for the general VHA population. Conclusions. The prevalence of GID diagnosis nearly doubled over 10 years among VHA veterans. Research is needed to examine suicide risk among transgender veterans and how their VHA utilization may be enhanced by new VA initiatives on transgender care. PMID:23947310

Army Active Duty Members’ Linkage to Veterans Health Administration Services After Deployments to Iraq or Afghanistan and Following Separation

PubMed Central

Vanneman, Megan E.; Harris, Alex H. S.; Chen, Cheng; Mohr, Beth A.; Adams, Rachel Sayko; Williams, Thomas V.; Larson, Mary Jo

2015-01-01

This study described the rate and predictors of Operation Enduring Freedom/Operation Iraqi Freedom active duty Army members’ enrollment in and use of Veterans Health Administration (VHA) services (linkage), as well as variation in linkage rates by VHA facility. We used a multivariate mixed effect regression model to predict linkage to VHA, and also calculated linkage rates in the catchment areas of each facility (n = 158). The sample included 151,122 active duty members who deployed to Iraq or Afghanistan and then separated from the Army between fiscal years 2008 and 2012. Approximately 48% of the active duty members separating utilized VHA as an enrollee within one year. There was significant variation in linkage rates by VHA facilities (31–72%). The most notable variables associated with greater linkage included probable serious injury during index deployment (odds ratio = 1.81), separation because of disability (odds ratio = 2.86), and various measures of receipt of VHA care before and after separation. Information about the individual characteristics that predict greater or lesser linkage to VHA services can be used to improve delivery of health care services at VHA as well as outreach efforts to active duty Army members. PMID:26444467

Accuracy of external cause-of-injury coding in VA polytrauma patient discharge records.

PubMed

Carlson, Kathleen F; Nugent, Sean M; Grill, Joseph; Sayer, Nina A

2010-01-01

Valid and efficient methods of identifying the etiology of treated injuries are critical for characterizing patient populations and developing prevention and rehabilitation strategies. We examined the accuracy of external cause-of-injury codes (E-codes) in Veterans Health Administration (VHA) administrative data for a population of injured patients. Chart notes and E-codes were extracted for 566 patients treated at any one of four VHA Polytrauma Rehabilitation Center sites between 2001 and 2006. Two expert coders, blinded to VHA E-codes, used chart notes to assign "gold standard" E-codes to injured patients. The accuracy of VHA E-coding was examined based on these gold standard E-codes. Only 382 of 517 (74%) injured patients were assigned E-codes in VHA records. Sensitivity of VHA E-codes varied significantly by site (range: 59%-91%, p < 0.001). Sensitivity was highest for combat-related injuries (81%) and lowest for fall-related injuries (60%). Overall specificity of E-codes was high (92%). E-coding accuracy was markedly higher when we restricted analyses to records that had been assigned VHA E-codes. E-codes may not be valid for ascertaining source-of-injury data for all injuries among VHA rehabilitation inpatients at this time. Enhanced training and policies may ensure more widespread, standardized use and accuracy of E-codes for injured veterans treated in the VHA.

Predictors of Army National Guard and Reserve members' use of Veteran Health Administration health care after demobilizing from OEF/OIF deployment.

PubMed

Harris, Alex H S; Chen, Cheng; Mohr, Beth A; Adams, Rachel Sayko; Williams, Thomas V; Larson, Mary Jo

2014-10-01

This study described rates and predictors of Army National Guard and Army Reserve members' enrollment in and utilization of Veteran Health Administration (VHA) services in the 365 days following demobilization from an index deployment. We also explored regional and VHA facility variation in serving eligible members in their catchment areas. The sample included 125,434 Army National Guard and 48,423 Army Reserve members who demobilized after a deployment ending between FY 2008 and FY 2011. Demographic, geographic, deployment, and Military Health System eligibility were derived from Defense Enrollment Eligibility Reporting System and "Contingency Tracking System" data. The VHA National Patient Care Databases were used to ascertain VHA utilization and status (e.g., enrollee, TRICARE). Logistic regression models were used to evaluate predictors of VHA utilization as an enrollee in the year following demobilization. Of the study members demobilizing during the observation period, 56.9% of Army National Guard members and 45.7% of Army Reserve members utilized VHA as an enrollee within 12 months. Demographic, regional, health coverage, and deployment-related factors were associated with VHA enrollment and utilization, and significant variation by VHA facility was found. These findings can be useful in the design of specific outreach efforts to improve linkage from the Military Health System to the VHA. Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.

Gender differences in substance abuse, PTSD and intentional self-harm among veterans health administration patients.

PubMed

Gradus, Jaimie L; Leatherman, Sarah; Curreri, Andrew; Myers, Lisa G; Ferguson, Ryan; Miller, Matthew

2017-02-01

Epidemiologic studies have reported substance abuse and posttraumatic stress disorder (PTSD) diagnoses as risk factors for suicide among Veterans Health Administration (VHA) patients. Research on risk factors for suicide may not generalize to our understanding of non-fatal intentional self-harm (ISH), given the evidence that these outcomes have unique risk factors. The aims of this study were to examine (1) gender-stratified rates of non-fatal ISH in VHA patients with alcohol abuse/dependence, drug abuse/dependence, and PTSD and (2) gender-stratified interaction between alcohol abuse and dependence and drug abuse and dependence and PTSD in predicting non-fatal ISH. Participants include all VHA care users who received a PTSD diagnosis in Massachusetts from 2000 to 2008 (n=16,004) and an age- and gender-matched comparison group (n=52,502). Data were obtained from the VHA administrative registries. We found evidence of stronger interactions between substance abuse diagnoses and PTSD in predicting non-fatal ISH for females than for males. The interaction contrast (IC) for alcohol abuse and dependence and PTSD in predicting non-fatal ISH among female VHA patients was 62.35/100,000 person-years; for male VHA patients the comparable IC was 21.49/100,000 person-years. For female VHA patients the IC for drug abuse and dependence and PTSD predicting ISH was 256.33/100,000 person-years; no interaction was observed for male VHA patients. This study contributes to the scant literature on gender differences in substance abuse and PTSD among VHA patients. The findings highlight comorbid diagnoses as particularly important risk factors for non-fatal ISH among female VHA patients. Published by Elsevier B.V.

Veterans Health Administration and Indian Health Service: healthcare utilization by Indian Health Service enrollees.

PubMed

Kramer, B Josea; Wang, Mingming; Jouldjian, Stella; Lee, Martin L; Finke, Bruce; Saliba, Debra

2009-06-01

The Veterans Health Administration (VHA) and Indian Health Service (IHS) have executed an agreement to share resources to improve access and health outcomes for American Indian and Alaska Native (AIAN) veterans. To describe the extent of dual use, health needs, and utilization patterns for IHS-enrollees served by VHA and IHS. Our objective is to fill those gaps in knowledge to inform strategic planning between these federal agencies. Secondary data analysis of linked and merged VHA and IHS centralized administrative data from FY02 and FY03. Of 64,746 IHS enrollees who used VHA and/or IHS, 25% accessed care at both healthcare organizations, whereas most used either the VHA (28%) or the IHS (46%). The proportion of dual users varied markedly by state. Like all other VHA users, these AIAN veterans have the same 3 most frequent diagnoses associated with healthcare encounters: posttraumatic stress disorder, hypertension, and diabetes. VHA-IHS dual users were more likely to receive primary care from IHS and to receive diagnostic and behavioral healthcare from VHA. Many dual users who had been diagnosed with diabetes, hypertension, and/or cardiovascular disease received overlapping attention in VHA and IHS. Strategies to improve outcomes for AIAN veterans should target those receiving care in both systems and include information sharing or coordination of clinical care to reduce the potential for duplication and for treatment conflicts. Strategies to improve access may differ regionally.

The Development of a Veterans Health Administration Emergency Management Research Agenda

PubMed Central

Dobalian, Aram; Claver, Maria; Riopelle, Deborah; Wyte-Lake, Tamar; Canelo, Ismelda

2017-01-01

Introduction: The Veterans Health Administration (VHA), the largest integrated healthcare delivery system in the United States, is charged with ensuring timely access to high-quality care for veterans during disasters, and supporting national, state, local, and tribal emergency management and homeland security efforts. In 2008, the VHA Office of Public Health (OPH) sponsored the first VHA Emergency Management Research Agenda-setting conference to develop research priorities that address the needs of veterans and to position VHA as a national leader in emergency management by having VHA serve as a “laboratory” for the development of evidence-based emergency management practices. Methods: We focused on four steps: #1: Appraising the emergency management research portfolio of VHA-based researchers; #2: Obtaining systematic information on VHA’s role in emergency management and the healthcare needs of veterans during disasters; #3: Based upon gaps between the current research portfolio and the existing evidence base, identifying strategic priorities using a research agenda-setting conference; and #4: Laying the groundwork to foster the conduct of emergency management research within VHA. Results: Identified research priorities included how to prevent and treat behavioral health problems related to a disaster, the efficacy of training programs, crisis communication strategies, workforce resilience, and evacuating veterans from health care facilities. Conclusion: VHA is uniquely situated to answer research questions that cannot be readily addressed in other settings. VHA should partner with other governmental and private entities to build on existing work and establish shared research priorities. PMID:28439447

Perceived Stigma, Discrimination, and Disclosure of Sexual Orientation Among a Sample of Lesbian Veterans Receiving Care in the Department of Veterans Affairs.

PubMed

Mattocks, Kristin M; Sullivan, J Cherry; Bertrand, Christina; Kinney, Rebecca L; Sherman, Michelle D; Gustason, Carolyn

2015-06-01

Many lesbian women experience stigma and discrimination from their healthcare providers as a result of their sexual orientation. Additionally, others avoid disclosure of their sexual orientation to their providers for fear of mistreatment. With the increasing number of lesbian, gay, bisexual, and transgender (LGBT) veterans seeking care from the Veterans Health Administration (VHA), it is important to understand lesbian veterans' experiences with stigma, discrimination, and disclosure of sexual orientation. This article examines lesbian veterans' experiences with perceived stigma and discrimination in VHA healthcare, their perspectives on disclosure of sexual orientation to VHA providers, and their recommendations for improvements in VHA healthcare to create a welcoming environment for lesbian veterans. This is a mixed methods study of twenty lesbian veterans at four VHA facilities. The women veterans participated in a one-hour interview and then completed an anonymous survey. Ten percent of lesbian veterans had experienced mistreatment from VHA staff or providers, but nearly 50% feared that their Veterans Affairs (VA) providers would mistreat them if they knew about their sexual orientation. A majority of lesbian veterans (70%) believed that VHA providers should never ask about sexual orientation or should only ask if the veteran wanted to discuss it. A majority (80%) believed the VHA had taken steps to create a welcoming environment for LBGT veterans. Though many lesbian veterans have fears of stigma and discrimination in the context of VHA care, few have experienced this. Most lesbian veterans believed the VHA was trying to create a welcoming environment for its LGBT veterans. Future research should focus on expanding this study to include a larger and more diverse sample of lesbian, gay, bisexual, and transgender veterans receiving care at VA facilities across the country.

Postdeployment Behavioral Health Screens and Linkage to the Veterans Health Administration for Army Reserve Component Members.

PubMed

Vanneman, Megan E; Harris, Alex H S; Chen, Cheng; Adams, Rachel Sayko; Williams, Thomas V; Larson, Mary Jo

2017-08-01

Approximately three to six months after returning from deployment, military service members complete the Post-Deployment Health Reassessment (PDHRA), which includes screens for alcohol misuse, depression, and posttraumatic stress disorder (PTSD). To determine whether Army Reserve Component (RC) members (Army National Guard and Army Reserve) with positive screening scores on the PDHRA receive needed care, the investigators examined the association between positive scores and enrollment and utilization of care ("linkage") in the Veterans Health Administration (VHA), as well as rescreening scores, diagnosis, and behavioral treatment in VHA. Mixed-effects regression models were used to predict linkage to VHA within six months after RC members (N=73,164) completed the PDHRA, with alcohol misuse, depression, and PTSD screen scores as key independent variables. Regression models were stratified by gender and National Guard versus Reserve status. Among those who linked to VHA (N=25,168), screening scores and subsequent diagnosis and treatment in VHA were also examined. Army RC members with positive PTSD and depression screening scores were more likely than those with negative screens to link to VHA, and most (54%-84%) received VHA treatment once diagnosed. Positive screens for alcohol misuse were associated with linkage to VHA for men but not for women, and treatment rates for alcohol use disorders were relatively low (0%-25%) for both men and women diagnosed as having an alcohol use disorder. The finding that Army RC members with greater indications of behavioral health problems linked to VHA is encouraging. However, more outreach and treatment engagement strategies could be directed to those with alcohol use disorder, particularly women.

Limited number of immunoglobulin VH regions expressed in the mutant rabbit "Alicia".

PubMed

DiPietro, L A; Short, J A; Zhai, S K; Kelus, A S; Meier, D; Knight, K L

1990-06-01

A unique feature of rabbit Ig is the presence of VH region allotypic specificities. In normal rabbits, more than 80% of circulating immunoglobulin molecules bear the VHa allotypic specificities, al, a2 or a3; the remaining 10% to 20% of immunoglobulin molecules lack VHa allotypic specificities and are designated VHa-. A mutant rabbit designated Alicia, in contrast, has predominantly serum immunoglobulin molecules that lack the VHa allotypic specificities (Kelus and Weiss, Proc. Natl. Acad. Sci. USA 1986. 83: 4883). To study the nature and molecular complexity of VHa- molecules, we cloned and determined the nucleotide sequence of seven cDNA prepared from splenic RNA of an Alicia rabbit. Six of the clones appeared to encode VHa- molecules; the framework regions encoded by these clones were remarkably similar to each other, each having an unusual insertion of four amino acids at position 10. This insertion of four amino acids has been seen in only 2 of 54 sequenced rabbit VH genes. The similarity of the sequences of the six VHa- clones to each other and their dissimilarity to most other VH genes leads us to suggest that the VHa- molecules in Alicia rabbits are derived predominantly from one or a small number of very similar VH genes. Such preferential utilization of a small number of VH genes may explain the allelic inheritance of VH allotypes.

Understanding variation in primary prostate cancer treatment within the Veterans Health Administration.

PubMed

Nambudiri, Vinod E; Landrum, Mary Beth; Lamont, Elizabeth B; McNeil, Barbara J; Bozeman, Samuel R; Freedland, Stephen J; Keating, Nancy L

2012-03-01

To examine the variation in prostate cancer treatment in the Veterans Health Administration (VHA)--a national, integrated delivery system. We also compared the care for older men in the VHA with that in fee-for-service Medicare. We used data from the Veterans Affairs Central Cancer Registry linked with administrative data and Surveillance, Epidemiology, and End Results-Medicare data to identify men with local or regional prostate cancer diagnosed during 2001 to 2004. We used multinomial logistic and hierarchical regression models to examine the patient, tumor, and facility characteristics associated with treatment in the VHA and, among older patients, used propensity score methods to compare primary therapy between the VHA and fee-for-service Medicare. The rates of radical prostatectomy and radiotherapy varied substantially across VHA facilities. Among the VHA patients, older age, black race/ethnicity, and greater comorbidity were associated with receiving neither radical prostatectomy nor radiotherapy. Facilities with more black patients with prostate cancer had lower rates of radical prostatectomy, and those with less availability of external beam radiotherapy had lower radiotherapy rates. The adjusted rates of radiotherapy (39.7% vs 52.0%) and radical prostatectomy (12.1% vs 15.8%) were lower and the rates of receiving neither treatment greater (48.2% vs 32.2%) in the VHA versus fee-for-service Medicare (P < .001). In the VHA, the treatment rates varied substantially across facilities, and black men received less aggressive prostate cancer treatment than white men, suggesting factors other than patient preferences influence the treatment decisions. Also, primary prostate cancer therapy for older men is less aggressive in the VHA than in fee-for-service Medicare. Copyright © 2012 Elsevier Inc. All rights reserved.

Emergency medicine in the Veterans Health Administration-results from a nationwide survey.

PubMed

Ward, Michael J; Collins, Sean P; Pines, Jesse M; Dill, Curt; Tyndall, Gary; Kessler, Chad S

2015-07-01

We describe emergency physician staffing, capabilities, and academic practices in US Veterans Health Administration (VHA) emergency departments (EDs). As part of an ongoing process improvement effort for the VHA emergency care system, VHA-wide surveys are conducted among ED medical directors every 3 years. Web-based surveys of VHA ED directors were conducted in 2013 on clinical operations and academic program development. We describe the results from the 2013 survey. When available, we compare responses with the previously administered survey from 2010. A total of 118 of 118 ED directors filled out the survey in 2013 (100% response rate). Respondents reported that 45.5% of VHA emergency physicians are board certified in emergency medicine, and 95% spend most their time in direct patient care. Clinical care is also provided by part-time (<0.5 full-time employee equivalent) emergency physicians in 59.3% of EDs. More than half of EDs (57%) provide on-site tissue plasminogen activator for acute ischemic stroke patients, and only 39% can administer tissue plasminogen activator 24 hours per day, 7 days per week. Less than half (48.3%) of EDs have emergency Obstetrics and Gynecology consultation availability. Most VHA EDs (78.8%) have a university affiliation, but only 21.5% participated in the respective academic emergency medicine program. Veterans Health Administration emergency physicians have primarily clinical responsibilities, and less than half have formal emergency medicine board certification. Despite most VHA EDs having university affiliations, traditional academic activities (eg, teaching and research) are performed in only 1 in 3 VHA EDs. Less than half of VHA EDs have availability of consulting services, including advanced stroke care and women's health. Published by Elsevier Inc.

Postdeployment Behavioral Health Screens and Linkage to the Veterans Health Administration for Army Reserve Component Members

PubMed Central

Vanneman, Megan E.; Harris, Alex H. S.; Chen, Cheng; Adams, Rachel Sayko; Williams, Thomas V.; Larson, Mary Jo

2017-01-01

Objective Approximately three to six months after returning from deployment, military service members complete the Post-Deployment Health Reassessment (PDHRA), which includes screens for alcohol misuse, depression, and post-traumatic stress disorder (PTSD). To determine whether Army Reserve Component (RC) members (Army National Guard and Army Reserve) with positive screening scores on the PDHRA receive needed care, the investigators examined the association between positive scores and enrollment and utilization of care (“linkage”) in the Veterans Health Administration (VHA), as well as rescreening scores, diagnosis, and behavioral treatment in VHA. Methods Mixed-effects regression models were used to predict linkage to VHA within six months after RC members (N=73,164) completed the PDHRA, with alcohol misuse, depression, and PTSD screen scores as key independent variables. Regression models were stratified by gender and National Guard versus Reserve status. Among those who linked to VHA (N=25,168), screening scores and subsequent diagnosis and treatment in VHA were also examined. Results Army RC members with positive PTSD and depression screening scores were more likely than those with negative screens to link to VHA, and most (54%–84%) received VHA treatment once diagnosed. Positive screens for alcohol misuse were associated with linkage to VHA for men but not for women, and treatment rates for alcohol use disorders were relatively low (0%–25%) for both men and women diagnosed as having an alcohol use disorder. Conclusions The finding that Army RC members with greater indications of behavioral health problems linked to VHA is encouraging. However, more outreach and treatment engagement strategies could be directed to those with alcohol use disorder, particularly women. PMID:28412888

Declining mortality following acute myocardial infarction in the Department of Veterans Affairs Health Care System.

PubMed

Fihn, Stephan D; Vaughan-Sarrazin, Mary; Lowy, Elliott; Popescu, Ioana; Maynard, Charles; Rosenthal, Gary E; Sales, Anne E; Rumsfeld, John; Piñeros, Sandy; McDonell, Mary B; Helfrich, Christian D; Rusch, Roxane; Jesse, Robert; Almenoff, Peter; Fleming, Barbara; Kussman, Michael

2009-08-31

Mortality from acute myocardial infarction (AMI) is declining worldwide. We sought to determine if mortality in the Veterans Health Administration (VHA) has also been declining. We calculated 30-day mortality rates between 2004 and 2006 using data from the VHA External Peer Review Program (EPRP), which entails detailed abstraction of records of all patients with AMI. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files. Using EPRP data on 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p = .011). Similar declines were found for in-hospital and 90-day mortality.Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08). Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals.

Declining mortality following acute myocardial infarction in the Department of Veterans Affairs Health Care System

PubMed Central

Fihn, Stephan D; Vaughan-Sarrazin, Mary; Lowy, Elliott; Popescu, Ioana; Maynard, Charles; Rosenthal, Gary E; Sales, Anne E; Rumsfeld, John; Piñeros, Sandy; McDonell, Mary B; Helfrich, Christian D; Rusch, Roxane; Jesse, Robert; Almenoff, Peter; Fleming, Barbara; Kussman, Michael

2009-01-01

Background Mortality from acute myocardial infarction (AMI) is declining worldwide. We sought to determine if mortality in the Veterans Health Administration (VHA) has also been declining. Methods We calculated 30-day mortality rates between 2004 and 2006 using data from the VHA External Peer Review Program (EPRP), which entails detailed abstraction of records of all patients with AMI. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files. Results Using EPRP data on 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p = .011). Similar declines were found for in-hospital and 90-day mortality. Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08). Conclusion Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals. PMID:19719849

Multiple Sources of Prescription Payment and Risky Opioid Therapy Among Veterans.

PubMed

Becker, William C; Fenton, Brenda T; Brandt, Cynthia A; Doyle, Erin L; Francis, Joseph; Goulet, Joseph L; Moore, Brent A; Torrise, Virginia; Kerns, Robert D; Kreiner, Peter W

2017-07-01

Opioid overdose and other related harms are a major source of morbidity and mortality among US Veterans, in part due to high-risk opioid prescribing. We sought to determine whether having multiple sources of payment for opioids-as a marker for out-of-system access-is associated with risky opioid therapy among veterans. Cross-sectional study examining the association between multiple sources of payment and risky opioid therapy among all individuals with Veterans Health Administration (VHA) payment for opioid analgesic prescriptions in Kentucky during fiscal year 2014-2015. Source of payment categories: (1) VHA only source of payment (sole source); (2) sources of payment were VHA and at least 1 cash payment [VHA+cash payment(s)] whether or not there was a third source of payment; and (3) at least one other noncash source: Medicare, Medicaid, or private insurance [VHA+noncash source(s)]. Our outcomes were 2 risky opioid therapies: combination opioid/benzodiazepine therapy and high-dose opioid therapy, defined as morphine equivalent daily dose ≥90 mg. Of the 14,795 individuals in the analytic sample, there were 81.9% in the sole source category, 6.6% in the VHA+cash payment(s) category, and 11.5% in the VHA+noncash source(s) category. In logistic regression, controlling for age and sex, persons with multiple payment sources had significantly higher odds of each risky opioid therapy, with those in the VHA+cash having significantly higher odds than those in the VHA+noncash source(s) group. Prescribers should examine the prescription monitoring program as multiple payment sources increase the odds of risky opioid therapy.

MdMYB1 Regulates Anthocyanin and Malate Accumulation by Directly Facilitating Their Transport into Vacuoles in Apples1[OPEN

PubMed Central

Hu, Da-Gang; Sun, Cui-Hui; Ma, Qi-Jun; You, Chun-Xiang; Hao, Yu-Jin

2016-01-01

Tonoplast transporters, including proton pumps and secondary transporters, are essential for plant cell function and for quality formation of fleshy fruits and ornamentals. Vacuolar transport of anthocyanins, malate, and other metabolites is directly or indirectly dependent on the H+-pumping activities of vacuolar H+-ATPase (VHA) and/or vacuolar H+-pyrophosphatase, but how these proton pumps are regulated in modulating vacuolar transport is largely unknown. Here, we report a transcription factor, MdMYB1, in apples that binds to the promoters of two genes encoding the B subunits of VHA, MdVHA-B1 and MdVHA-B2, to transcriptionally activate its expression, thereby enhancing VHA activity. A series of transgenic analyses in apples demonstrates that MdMYB1/10 controls cell pH and anthocyanin accumulation partially by regulating MdVHA-B1 and MdVHA-B2. Furthermore, several other direct target genes of MdMYB10 are identified, including MdVHA-E2, MdVHP1, MdMATE-LIKE1, and MdtDT, which are involved in H+-pumping or in the transport of anthocyanins and malates into vacuoles. Finally, we show that the mechanism by which MYB controls malate and anthocyanin accumulation in apples also operates in Arabidopsis (Arabidopsis thaliana). These findings provide novel insights into how MYB transcription factors directly modulate the vacuolar transport system in addition to anthocyanin biosynthesis, consequently controlling organ coloration and cell pH in plants. PMID:26637549

MdMYB1 Regulates Anthocyanin and Malate Accumulation by Directly Facilitating Their Transport into Vacuoles in Apples.

PubMed

Hu, Da-Gang; Sun, Cui-Hui; Ma, Qi-Jun; You, Chun-Xiang; Cheng, Lailiang; Hao, Yu-Jin

2016-03-01

Tonoplast transporters, including proton pumps and secondary transporters, are essential for plant cell function and for quality formation of fleshy fruits and ornamentals. Vacuolar transport of anthocyanins, malate, and other metabolites is directly or indirectly dependent on the H(+)-pumping activities of vacuolar H(+)-ATPase (VHA) and/or vacuolar H(+)-pyrophosphatase, but how these proton pumps are regulated in modulating vacuolar transport is largely unknown. Here, we report a transcription factor, MdMYB1, in apples that binds to the promoters of two genes encoding the B subunits of VHA, MdVHA-B1 and MdVHA-B2, to transcriptionally activate its expression, thereby enhancing VHA activity. A series of transgenic analyses in apples demonstrates that MdMYB1/10 controls cell pH and anthocyanin accumulation partially by regulating MdVHA-B1 and MdVHA-B2. Furthermore, several other direct target genes of MdMYB10 are identified, including MdVHA-E2, MdVHP1, MdMATE-LIKE1, and MdtDT, which are involved in H(+)-pumping or in the transport of anthocyanins and malates into vacuoles. Finally, we show that the mechanism by which MYB controls malate and anthocyanin accumulation in apples also operates in Arabidopsis (Arabidopsis thaliana). These findings provide novel insights into how MYB transcription factors directly modulate the vacuolar transport system in addition to anthocyanin biosynthesis, consequently controlling organ coloration and cell pH in plants. © 2016 American Society of Plant Biologists. All Rights Reserved.

The Obesity Epidemic in the Veterans Health Administration: Prevalence Among Key Populations of Women and Men Veterans.

PubMed

Breland, Jessica Y; Phibbs, Ciaran S; Hoggatt, Katherine J; Washington, Donna L; Lee, Jimmy; Haskell, Sally; Uchendu, Uchenna S; Saechao, Fay S; Zephyrin, Laurie C; Frayne, Susan M

2017-04-01

Most US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services. To inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA patients. Cross-sectional descriptive analyses of fiscal year 2014 (FY2014) national VHA administrative and clinical data, stratified by gender. Differences ≥5% higher than the population mean were considered clinically significant. Veteran VHA primary care patients with a valid weight within ±365 days of their first FY2014 primary care visit, and a valid height (98% of primary care patients). We used VHA vital signs data to ascertain height and weight and calculate body mass index, and VHA outpatient, inpatient, and fee basis data to identify sociodemographic- and comorbidity-based subpopulations. Among nearly five million primary care patients (347,112 women, 4,567,096 men), obesity prevalence was 41% (women 44%, men 41%), and overweight prevalence was 37% (women 31%, men 38%). Across the VHA's 140 facilities, obesity prevalence ranged from 28% to 49%. Among gender-stratified subpopulations, obesity prevalence was high among veterans under age 65 (age 18-44: women 40%, men 46%; age 45-64: women 49%, men 48%). Obesity prevalence varied across racial/ethnic and comorbidity subpopulations, with high obesity prevalence among black women (51%), women with schizophrenia (56%), and women and men with diabetes (68%, 56%). Overweight and obesity are common among veterans served by the VHA. VHA's weight management initiatives have the potential to avert long-term morbidity arising from obesity-related conditions. High-risk groups-such as black women veterans, women veterans with schizophrenia, younger veterans, and Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans-may require particular attention to ensure that

Unsheltered Homelessness Among Veterans: Correlates and Profiles.

PubMed

Byrne, Thomas; Montgomery, Ann Elizabeth; Fargo, Jamison D

2016-02-01

We identified correlates of unsheltered status among Veterans experiencing homelessness and described distinct subgroups within the unsheltered homeless Veteran population using data from a screening instrument for homelessness that is administered to all Veterans accessing outpatient care at a Veterans Health Administration (VHA) facility. Correlates of unsheltered homelessness included male gender, white race, older age, lower levels of VHA eligibility, substance use disorders, frequent use of VHA inpatient and infrequent use of VHA outpatient services, and residing in the West. We identified six distinct subgroups of unsheltered Veterans; the tri-morbid frequent users represented the highest need group, but the largest group was comprised of Veterans who made highly infrequent use of VHA healthcare services. Differences between sheltered and unsheltered Veterans and heterogeneity within the unsheltered Veteran population should be considered in targeting housing and other interventions.

The Veterans Health Administration: An American Success Story?

PubMed Central

Oliver, Adam

2007-01-01

The Veterans Health Administration (VHA) provides health care for U.S. military veterans. By the early 1990s, the VHA had a reputation for delivering limited, poor-quality care, which led to health care reforms. By 2000, the VHA had substantially improved in terms of numerous indicators of process quality, and some evidence shows that its overall performance now exceeds that of the rest of U.S. health care. Recently, however, the VHA has started to become a victim of its own success, with increased demands on the system raising concerns from some that access is becoming overly restricted and from others that its annual budget appropriations are becoming excessive. Nonetheless, the apparent turnaround in the VHA's performance offers encouragement that health care that is both financed and provided by the public sector can be an effective organizational form. PMID:17319805

The measurement of quality of care in the Veterans Health Administration.

PubMed

Halpern, J

1996-03-01

The Veterans Health Administration (VHA) is committed to continual refinement of its system of quality measurement. The VHA organizational structure for quality measurement has three levels. At the national level, the Associate Chief Medical Director for Quality Management provides leadership, sets policy, furnishes measurement tools, develops and distributes measures of quality, and delivers educational programs. At the intermediate level, VHA has four regional offices with staff responsible for reviewing risk management data, investigating quality problems, and ensuring compliance with accreditation requirements. At the hospital level, staff reporting directly to the chief of staff or the hospital director are responsible for implementing VHA quality management policy. The Veterans Health Administration's philosophy of quality measurement recognizes the agency's moral imperative to provide America's veterans with care that meets accepted standards. Because the repair of faulty systems is more efficient than the identification of poor performers, VHA has integrated the techniques of total quality into a multifaceted improvement program that also includes the accreditation program and traditional quality assurance activities. VHA monitors its performance by maintaining adverse incident databases, conducting patient satisfaction surveys, contracting for external peer review of 50,000 records per year, and comparing process and outcome rates internally and when possible with external benchmarks. The near-term objectives of VHA include providing medical centers with a quality matrix that will permit local development of quality indicators, construction of a report card for VHA's customers, and implementing the Malcolm W. Baldrige system for quality improvement as the road map for systemwide continuous improvement. Other goals include providing greater access to data, creating a patient-centered database, providing real-time clinical decision support, and expanding the

Trends in the Purchase of Surgical Care in the Community by the Veterans Health Administration.

PubMed

Rosen, Amy K; O'Brien, William; Chen, Qi; Shwartz, Michael; Itani, Kamal F M; Gunnar, William

2017-07-01

The 2014 implementation of the Veterans Choice Program increased opportunities for Veterans to receive care in the community. Although surgical care is a Veterans Health Administration (VHA) priority, little is known about the types of surgeries provided in the VHA versus those referred to community care (CC), and whether Veterans are increasing their use of surgical care through CC with these additional opportunities. To examine national trends across VHA facilities in the frequencies and types of surgeries provided in the VHA and through CC, and explore the association between facilities' purchase of care with rurality and surgical complexity designation. Retrospective study using Veterans Administration (VA) outpatient and CC data from the VA's Corporate Data Warehouse (October 1, 2013-September 30, 2016). Veterans' demographics, outpatient surgeries, facility rurality, and surgical complexity. Our sample included 525,283 outpatient surgeries; 79% occurred in the VHA over the study timeframe. The proportion of CC surgeries increased from 16% in October 2013 to 29% in December 2014, and then subsequently declined, leveling off at 21% in June 2016 (trend, P<0.05). These trends varied by surgery type. Increases in CC surgeries were evident for 4 surgery types: cardiovascular, digestive, eye and ocular, and male genital surgeries (all trends, P<0.05). Rural and low-complexity facilities were more likely to purchase surgical CC than their urban and high-complexity counterparts (P<0.0001). Although the VHA remains the primary provider of surgical care for Veterans, Veterans Choice Program implementation increased Veterans' use of CC relative to the VHA for certain types of surgeries, potentially bringing challenges to the VHA in delivering and coordinating surgical care across settings.

The Veterans Health Administration’s Treatment of PTSD and Traumatic Brain Injury Among Recent Combat Veterans

DTIC Science & Technology

2012-02-01

make it more difficult for veterans with PTSD to seek or maintain treatment. VHA provides treatment for PTSD at VHA hospitals , outpatient clinics ...measured in days of inpatient hospital care and outpatient clinic visits. A veteran may have had several outpatient visits on a sin- gle day, each...reproduce the same results precisely. The DSS system takes clinical and financial information from other VHA databases and uses algorithms that merge

Risk and Resiliency for Dementia: Comparison of Male and Female Veterans

DTIC Science & Technology

2017-09-01

from the Veterans Health Administration (VHA) National Patient Care Database (NPCD) 2. Obtain data from the Veterans Health Administration (VHA...National Patient Care Database (NPCD): Months 6-12  In the second quarter, we submitted and received approval to receive data from the VHA NPCD  In...injury. We plan to capitalize on our prior experience working with the Veterans Health Administration National Patient Care Database . We will use data

Care Coordination/Home Telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions.

PubMed

Darkins, Adam; Ryan, Patricia; Kobb, Rita; Foster, Linda; Edmonson, Ellen; Wakefield, Bonnie; Lancaster, Anne E

2008-12-01

Between July 2003 and December 2007, the Veterans Health Administration (VHA) introduced a national home telehealth program, Care Coordination/Home Telehealth (CCHT). Its purpose was to coordinate the care of veteran patients with chronic conditions and avoid their unnecessary admission to long-term institutional care. Demographic changes in the veteran population necessitate VHA increase its noninstitutional care (NIC) services 100% above its 2007 level to provide care for 110,000 NIC patients by 2011. By 2011, CCHT will meet 50% of VHA's anticipated NIC provision. CCHT involves the systematic implementation of health informatics, home telehealth, and disease management technologies. It helps patients live independently at home. Between 2003 and 2007, the census figure (point prevalence) for VHA CCHT patients increased from 2,000 to 31,570 (1,500% growth). CCHT is now a routine NIC service provided by VHA to support veteran patients with chronic conditions as they age. CCHT patients are predominantly male (95%) and aged 65 years or older. Strict criteria determine patient eligibility for enrollment into the program and VHA internally assesses how well its CCHT programs meet standardized clinical, technology, and managerial requirements. VHA has trained 5,000 staff to provide CCHT. Routine analysis of data obtained for quality and performance purposes from a cohort of 17,025 CCHT patients shows the benefits of a 25% reduction in numbers of bed days of care, 19% reduction in numbers of hospital admissions, and mean satisfaction score rating of 86% after enrolment into the program. The cost of CCHT is $1,600 per patient per annum, substantially less than other NIC programs and nursing home care. VHA's experience is that an enterprise-wide home telehealth implementation is an appropriate and cost-effective way of managing chronic care patients in both urban and rural settings.

Informatics Resources to Support Health Care Quality Improvement in the Veterans Health Administration

PubMed Central

Hynes, Denise M.; Perrin, Ruth A.; Rappaport, Steven; Stevens, Joanne M.; Demakis, John G.

2004-01-01

Information systems are increasingly important for measuring and improving health care quality. A number of integrated health care delivery systems use advanced information systems and integrated decision support to carry out quality assurance activities, but none as large as the Veterans Health Administration (VHA). The VHA's Quality Enhancement Research Initiative (QUERI) is a large-scale, multidisciplinary quality improvement initiative designed to ensure excellence in all areas where VHA provides health care services, including inpatient, outpatient, and long-term care settings. In this paper, we describe the role of information systems in the VHA QUERI process, highlight the major information systems critical to this quality improvement process, and discuss issues associated with the use of these systems. PMID:15187063

Positive selection of the peripheral B cell repertoire in gut-associated lymphoid tissues

PubMed Central

Rhee, Ki-Jong; Jasper, Paul J.; Sethupathi, Periannan; Shanmugam, Malathy; Lanning, Dennis; Knight, Katherine L.

2005-01-01

Gut-associated lymphoid tissues (GALTs) interact with intestinal microflora to drive GALT development and diversify the primary antibody repertoire; however, the molecular mechanisms that link these events remain elusive. Alicia rabbits provide an excellent model to investigate the relationship between GALT, intestinal microflora, and modulation of the antibody repertoire. Most B cells in neonatal Alicia rabbits express VHn allotype immunoglobulin (Ig)M. Within weeks, the number of VHn B cells decreases, whereas VHa allotype B cells increase in number and become predominant. We hypothesized that the repertoire shift from VHn to VHa B cells results from interactions between GALT and intestinal microflora. To test this hypothesis, we surgically removed organized GALT from newborn Alicia pups and ligated the appendix to sequester it from intestinal microflora. Flow cytometry and nucleotide sequence analyses revealed that the VHn to VHa repertoire shift did not occur, demonstrating the requirement for interactions between GALT and intestinal microflora in the selective expansion of VHa B cells. By comparing amino acid sequences of VHn and VHa Ig, we identified a putative VH ligand binding site for a bacterial or endogenous B cell superantigen. We propose that interaction of such a superantigen with VHa B cells results in their selective expansion. PMID:15623575

Paths to partnership: Veterans Health Administration's Journey in pilot testing breast cancer care quality measures.

PubMed

Hogg, Lori Hoffman

2014-01-01

Prioritizing personalized, proactive, patient-driven health care is among the Veterans Health Administration's (VHA's) transformational initiatives. As one of the largest integrated healthcare systems, the VHA sets standards for performance measures and outcomes achieved in quality of care. Evidence-based practice (EBP) is a hallmark in oncology nursing care. EBP can be linked to positive outcomes and improving quality that can be influenced directly by nursing interventions. VHA oncology nurses had the opportunity to partner with the Oncology Nursing Society (ONS), ONS Foundation, and the Joint Commission in the multiyear development of a comprehensive approach to quality cancer care. Building on a platform of existing measures and refining measurement sets culminated in testing evidence-based, nursing-sensitive quality measures for reliability through the ONS Foundation-supported Breast Cancer Care (BCC) Quality Measures Set. The BCC Measures afforded the VHA to have its many sites collectively assess documentation of the symptoms of patients with breast cancer, the use of colony-stimulating factors, and education about neutropenia precautions provided. Parallel paths of the groups, seeking evidence-based measures, led to the perfect partnership in the VHA's journey in pilot testing the BCC Measures in veterans with breast cancer. This generated further quality assessments and continuous improvement projects for spread and sustainability throughout the VHA.

VA Suicide Prevention Applications Network: A National Health Care System-Based Suicide Event Tracking System.

PubMed

Hoffmire, Claire; Stephens, Brady; Morley, Sybil; Thompson, Caitlin; Kemp, Janet; Bossarte, Robert M

2016-11-01

The US Department of Veterans Affairs' Suicide Prevention Applications Network (SPAN) is a national system for suicide event tracking and case management. The objective of this study was to assess data on suicide attempts among people using Veterans Health Administration (VHA) services. We assessed the degree of data overlap on suicide attempters reported in SPAN and the VHA's medical records from October 1, 2010, to September 30, 2014-overall, by year, and by region. Data on suicide attempters in the VHA's medical records consisted of diagnoses documented with E95 codes from the International Classification of Diseases, Ninth Revision . Of 50 518 VHA patients who attempted suicide during the 4-year study period, data on fewer than half (41%) were reported in both SPAN and the medical records; nearly 65% of patients whose suicide attempt was recorded in SPAN had no data on attempted suicide in the VHA's medical records. Evaluation of administrative data suggests that use of SPAN substantially increases the collection of data on suicide attempters as compared with the use of medical records alone, but neither SPAN nor the VHA's medical records identify all suicide attempters. Further research is needed to better understand the strengths and limitations of both systems and how to best combine information across systems.

A Report of the Efforts of the Veterans Health Administration National Antimicrobial Stewardship Initiative.

PubMed

Kelly, Allison A; Jones, Makoto M; Echevarria, Kelly L; Kralovic, Stephen M; Samore, Matthew H; Goetz, Matthew B; Madaras-Kelly, Karl J; Simbartl, Loretta A; Morreale, Anthony P; Neuhauser, Melinda M; Roselle, Gary A

2017-05-01

OBJECTIVE To detail the activities of the Veterans Health Administration (VHA) Antimicrobial Stewardship Initiative and evaluate outcomes of the program. DESIGN Observational analysis. SETTING The VHA is a large integrated healthcare system serving approximately 6 million individuals annually at more than 140 medical facilities. METHODS Utilization of nationally developed resources, proportional distribution of antibiotics, changes in stewardship practices and patient safety measures were reported. In addition, inpatient antimicrobial use was evaluated before and after implementation of national stewardship activities. RESULTS Nationally developed stewardship resources were well utilized, and many stewardship practices significantly increased, including development of written stewardship policies at 92% of facilities by 2015 (P<.05). While the proportional distribution of antibiotics did not change, inpatient antibiotic use significantly decreased after VHA Antimicrobial Stewardship Initiative activities began (P<.0001). A 12% decrease in antibiotic use was noted overall. The VHA has also noted significantly declining use of antimicrobials prescribed for resistant Gram-negative organisms, including carbapenems, as well as declining hospital readmission and mortality rates. Concurrently, the VHA reported decreasing rates of Clostridium difficile infection. CONCLUSIONS The VHA National Antimicrobial Stewardship Initiative includes continuing education, disease-specific guidelines, and development of example policies in addition to other highly utilized resources. While no specific ideal level of antimicrobial utilization has been established, the VHA has shown that improving antimicrobial usage in a large healthcare system may be achieved through national guidance and resources with local implementation of antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2017;38:513-520.

Nationwide Interdisciplinary E-Consultation on Transgender Care in the Veterans Health Administration.

PubMed

Shipherd, Jillian C; Kauth, Michael R; Matza, Alexis

2016-12-01

Veteran's Health Administration (VHA) requires the provision of quality transgender care for the relatively large number of transgender veterans using VHA services. The Office of Patient Care Services has taken a multimethod approach to improving provider knowledge and skill for transgender veteran care. However, unique patient-specific questions can arise. Thus, VHA implemented a 3-year feasibility program to determine if nationwide interdisciplinary e-consultation can offer veteran-specific consultation to providers who treat transgender veterans in VHA. Launch of this program is described along with use to date, types of questions submitted by providers, and length of time to complete a response in the veteran's electronic medical record. In 17 months, the program responded to 303 e-consults, with consultation provided on the care of 230 unique veterans. Nationwide coverage was achieved 1 year after the launch of the program. Common consult questions have been about medications, including hormones (n = 125); primary care concerns (n = 97); mental health evaluations (n = 63); and psychotherapy (n = 18). Consistent with the interdisciplinary model, multiple disciplines typically responded to each consult (x = 2.27). Average time to completion of a consult was 5.9 calendar days (range = 2.4-7.7 days). VHA has established a nationwide interdisciplinary e-consultation program. Additional outreach about the program will be needed if funding is continued. E-consultation on transgender health within VHA is feasible and complements the suite of trainings offered within VHA. Other healthcare organizations may benefit from a similar program.

Utilization of travel reimbursement in the Veterans Health Administration.

PubMed

Nelson, Richard E; Hicken, Bret; Cai, Beilei; Dahal, Arati; West, Alan; Rupper, Randall

2014-01-01

To improve access to care, the Veterans Health Administration (VHA) increased its patient travel reimbursement rate from 11 to 28.5 cents per mile on February 1, 2008, and again to 41.5 cents per mile on November 17, 2008. We identified characteristics of veterans more likely to receive travel reimbursements and evaluated the impact of these increases on utilization of the benefit. We examined the likelihood of receiving any reimbursement, number of reimbursements, and dollar amount of reimbursements for VHA patients before and after both reimbursement rate increases. Because of our data's longitudinal nature, we used multivariable generalized estimating equation models for analysis. Rurality and categorical distance from the nearest VHA facility were examined in separate regressions. Our cohort contained 214,376 veterans. During the study period, the average number of reimbursements per veteran was higher for rural patients compared to urban patients, and for those living 50-75 miles from the nearest VHA facility compared to those living closer. Higher reimbursement rates led to more veterans obtaining reimbursement regardless of urban-rural residence or distance traveled to the nearest VHA facility. However, after the rate increases, urban veterans and veterans living <50 miles from the nearest VHA facility increased their travel reimbursement utilization slightly more than other patients. Our findings suggest an inverted U-shaped relationship between veterans' utilization of the VHA travel reimbursement benefit and travel distance. Both urban and rural veterans responded in roughly equal manner to changes to this benefit. © 2013 National Rural Health Association.

Rehabilitation and Prosthetic Services

MedlinePlus

... VA Learning University (VALU) SimLearn Libraries (VALNET) VA Software Documentation Library (VDL) About VHA Learn about VHA Forms & ... & Sensory Aids Service (PSAS) Our Mission The mission of the Prosthetic & ...

Women veterans' preferences for intimate partner violence screening and response procedures within the Veterans Health Administration.

PubMed

Iverson, Katherine M; Huang, Kristin; Wells, Stephanie Y; Wright, Jason D; Gerber, Megan R; Wiltsey-Stirman, Shannon

2014-08-01

Intimate partner violence (IPV) is a significant health issue faced by women veterans, but little is known about their preferences for IPV-related care. Five focus groups were conducted with 24 women Veterans Health Administration (VHA) patients with and without a lifetime history of IPV to understand their attitudes and preferences regarding IPV screening and responses within VHA. Women veterans wanted disclosure options, follow-up support, transparency in documentation, and VHA and community resources. They supported routine screening for IPV and articulated preferences for procedural aspects of screening. Women suggested that these procedures could be provided most effectively when delivered with sensitivity and connectedness. Findings can inform the development of IPV screening and response programs within VHA and other healthcare settings. © 2014 Wiley Periodicals, Inc.

Adopting a corporate perspective on databases. Improving support for research and decision making.

PubMed

Meistrell, M; Schlehuber, C

1996-03-01

The Veterans Health Administration (VHA) is at the forefront of designing and managing health care information systems that accommodate the needs of clinicians, researchers, and administrators at all levels. Rather than using one single-site, centralized corporate database VHA has constructed several large databases with different configurations to meet the needs of users with different perspectives. The largest VHA database is the Decentralized Hospital Computer Program (DHCP), a multisite, distributed data system that uses decoupled hospital databases. The centralization of DHCP policy has promoted data coherence, whereas the decentralization of DHCP management has permitted system development to be done with maximum relevance to the users'local practices. A more recently developed VHA data system, the Event Driven Reporting system (EDR), uses multiple, highly coupled databases to provide workload data at facility, regional, and national levels. The EDR automatically posts a subset of DHCP data to local and national VHA management. The development of the EDR illustrates how adoption of a corporate perspective can offer significant database improvements at reasonable cost and with modest impact on the legacy system.

Positive selection of the peripheral B cell repertoire in gut-associated lymphoid tissues.

PubMed

Rhee, Ki-Jong; Jasper, Paul J; Sethupathi, Periannan; Shanmugam, Malathy; Lanning, Dennis; Knight, Katherine L

2005-01-03

Gut-associated lymphoid tissues (GALTs) interact with intestinal microflora to drive GALT development and diversify the primary antibody repertoire; however, the molecular mechanisms that link these events remain elusive. Alicia rabbits provide an excellent model to investigate the relationship between GALT, intestinal microflora, and modulation of the antibody repertoire. Most B cells in neonatal Alicia rabbits express V(H)n allotype immunoglobulin (Ig)M. Within weeks, the number of V(H)n B cells decreases, whereas V(H)a allotype B cells increase in number and become predominant. We hypothesized that the repertoire shift from V(H)n to V(H)a B cells results from interactions between GALT and intestinal microflora. To test this hypothesis, we surgically removed organized GALT from newborn Alicia pups and ligated the appendix to sequester it from intestinal microflora. Flow cytometry and nucleotide sequence analyses revealed that the V(H)n to V(H)a repertoire shift did not occur, demonstrating the requirement for interactions between GALT and intestinal microflora in the selective expansion of V(H)a B cells. By comparing amino acid sequences of V(H)n and V(H)a Ig, we identified a putative V(H) ligand binding site for a bacterial or endogenous B cell superantigen. We propose that interaction of such a superantigen with V(H)a B cells results in their selective expansion.

Insights from advanced analytics at the Veterans Health Administration.

PubMed

Fihn, Stephan D; Francis, Joseph; Clancy, Carolyn; Nielson, Christopher; Nelson, Karin; Rumsfeld, John; Cullen, Theresa; Bates, Jack; Graham, Gail L

2014-07-01

Health care has lagged behind other industries in its use of advanced analytics. The Veterans Health Administration (VHA) has three decades of experience collecting data about the veterans it serves nationwide through locally developed information systems that use a common electronic health record. In 2006 the VHA began to build its Corporate Data Warehouse, a repository for patient-level data aggregated from across the VHA's national health system. This article provides a high-level overview of the VHA's evolution toward "big data," defined as the rapid evolution of applying advanced tools and approaches to large, complex, and rapidly changing data sets. It illustrates how advanced analysis is already supporting the VHA's activities, which range from routine clinical care of individual patients--for example, monitoring medication administration and predicting risk of adverse outcomes--to evaluating a systemwide initiative to bring the principles of the patient-centered medical home to all veterans. The article also shares some of the challenges, concerns, insights, and responses that have emerged along the way, such as the need to smoothly integrate new functions into clinical workflow. While the VHA is unique in many ways, its experience may offer important insights for other health care systems nationwide as they venture into the realm of big data. Project HOPE—The People-to-People Health Foundation, Inc.

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

PubMed

Bangerter, Ann; Gravely, Amy; Cutting, Andrea; Clothier, Barb; Spoont, Michele; Sayer, Nina

2010-01-01

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.

Health Care Expenditures Attributable to Smoking in Military Veterans

PubMed Central

Hamlett-Berry, Kim; Sung, Hai-Yen; Max, Wendy

2015-01-01

Introduction: The health effects of cigarette smoking have been estimated to account for between 6%–8% of U.S. health care expenditures. We estimated Veterans Health Administration (VHA) health care costs attributable to cigarette smoking. Methods: VHA survey and administrative data provided the number of Veteran enrollees, current and former smoking prevalence, and the cost of 4 types of care for groups defined by age, gender, and region. Cost and smoking status could not be linked at the enrollee level, so we used smoking attributable fractions estimated in sample of U.S. residents where the linkage could be made. Results: The 7.7 million Veterans enrolled in VHA received $40.2 billion in VHA provided health services in 2010. We estimated that $2.7 billion in VHA costs were attributable to the health effects of smoking. This was 7.6% of the $35.3 billion spent on the types of care for which smoking-attributable fractions could be determined. The fraction of inpatient costs that was attributable to smoking (11.4%) was greater than the fraction of ambulatory care cost attributable to smoking (5.3%). More cost was attributable to current smokers ($1.7 billion) than to former smokers ($983 million). Conclusions: The fraction of VHA costs attributable to smoking is similar to that of other health care systems. Smoking among Veterans is slowly decreasing, but prevalence remains high in Veterans with psychiatric and substance use disorders, and in younger and female Veterans. VHA has adopted a number of smoking cessation programs that have the potential for reducing future smoking-attributable costs. PMID:25239960

Partnerships Between Health Care and Legal Providers in the Veterans Health Administration.

PubMed

Tsai, Jack; Middleton, Margaret; Retkin, Randye; Johnson, Cindy; Kenneally, Kevin; Sherman, Scott; Rosenheck, Robert A

2017-04-01

Medical-legal partnerships (MLPs) represent an innovative service model in which lawyers are integrated into health care teams to address diverse legal problems that affect vulnerable populations. The Veterans Health Administration (VHA) operates the largest safety-net health care system in the country and serves many low-income and disabled veterans who could benefit from MLP services. In this column, the authors describe the development and operations of MLPs at four VHA medical centers that serve veterans who are homeless or who have serious mental illness. The authors also briefly report on the characteristics of 700 veterans served by these MLPs from 2014 to 2016. MLPs can fit within the interdisciplinary, comprehensive system of care provided by VHA, and they offer opportunities to expand VHA-community partnerships to address social determinants of health.

Military sexual trauma among homeless veterans.

PubMed

Pavao, Joanne; Turchik, Jessica A; Hyun, Jenny K; Karpenko, Julie; Saweikis, Meghan; McCutcheon, Susan; Kane, Vincent; Kimerling, Rachel

2013-07-01

Military sexual trauma (MST) is the Veteran Health Administration's (VHA) term for sexual assault and/or sexual harassment that occurs during military service. The experience of MST is associated with a variety of mental health conditions. Preliminary research suggests that MST may be associated with homelessness among female Veterans, although to date MST has not been examined in a national study of both female and male homeless Veterans. To estimate the prevalence of MST, examine the association between MST and mental health conditions, and describe mental health utilization among homeless women and men. National, cross-sectional study of 126,598 homeless Veterans who used VHA outpatient care in fiscal year 2010. All variables were obtained from VHA administrative databases, including MST screening status, ICD-9-CM codes to determine mental health diagnoses, and VHA utilization. Of homeless Veterans in VHA, 39.7 % of females and 3.3 % of males experienced MST. Homeless Veterans who experienced MST demonstrated a significantly higher likelihood of almost all mental health conditions examined as compared to other homeless women and men, including depression, posttraumatic stress disorder, other anxiety disorders, substance use disorders, bipolar disorders, personality disorders, suicide, and, among men only, schizophrenia and psychotic disorders. Nearly all homeless Veterans had at least one mental health visit and Veterans who experienced MST utilized significantly more mental health visits compared to Veterans who did not experience MST. A substantial proportion of homeless Veterans using VHA services have experienced MST, and those who experienced MST had increased odds of mental health diagnoses. Homeless Veterans who had experienced MST had higher intensity of mental health care utilization and high rates of MST-related mental health care. This study highlights the importance of trauma-informed care among homeless Veterans and the success of VHA homeless

78 FR 50144 - Rehabilitation Research and Development Service Scientific Merit Review Board; Notice of Meetings

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-16

... Office. Research Career Scientists August 10, 2013....... * VA Central Office. Rehabilitation Engineering...: Subcommittee Date(s) Location Career Development Award Program.... August 6, 2013........ VHA National.... August 8, 2013........ VHA National Conference Center. Career Development Award Program.... August 8...

Association between health literacy and medical care costs in an integrated healthcare system: a regional population based study.

PubMed

Haun, Jolie N; Patel, Nitin R; French, Dustin D; Campbell, Robert R; Bradham, Douglas D; Lapcevic, William A

2015-06-27

Low health literacy is associated with higher health care utilization and costs; however, no large-scale studies have demonstrated this in the Veterans Health Administration (VHA). This research evaluated the association between veterans' health literacy and their subsequent VHA health care costs across a three-year period. This retrospective study used a Generalized Linear Model to estimate the relative association between a patient's health literacy and VHA medical costs, adjusting for covariates. Secondary data sources included electronic health records and administrative data in the VHA (e.g., Medical and DCG SAS Datasets and DSS-National Data Extracts). Health literacy assessments and identifiers were electronically retrieved from the originating health system. Demographic and cost data were retrieved from the VHA centralized databases for the corresponding patients who had VHA use in all three years. In a study of 92,749 veterans with service utilization from 2007-2009, average per patient cost for those with inadequate and marginal health literacy was significantly higher ($31,581 [95 % CI: $30,186 - $32,975]; $23,508 [95 % CI: $22,749 - $24,268]) than adequate health literacy ($17,033 [95 % CI: $16,810 - $17,255]). Estimated three-year cost associated with veterans' with marginal and inadequate health literacy was $143 million dollars more than those with adequate health literacy. Analyses suggest when controlling for other person-level factors within the VHA integrated healthcare system, lower health literacy is a significant independent factor associated with increased health care utilization and costs. This study confirms the association of lower health literacy with higher medical service utilization and pharmacy costs for veterans enrolled in the VHA. Confirmation of higher costs of care associated with lower health literacy suggests that interventions might be designed to remediate health literacy needs and reduce expenditures. These analyses suggest

The Department of Veterans Affairs' role in Federal Emergency Management.

PubMed

Kizer, K W; Cushing, T S; Nishimi, R Y

2000-09-01

The Veterans Health Administration (VHA) has been increasingly called on to provide disaster relief health care personnel and other emergency assistance since the role of the Department of Veterans Affairs in emergency management was expanded by the Federal Response Plan in 1992. This article briefly reviews the VHA's emergency management functions currently specified by the Federal Response Plan and its present activities in procuring and maintaining antidotes, antibiotics, and other pharmaceutical stockpiles to be used in response to terrorist incidents involving weapons of mass destruction. In view of VHA's national scope and extensive assets, its administration by the government, and its critical role in health professional training, there are several additional ways that VHA could economically augment the federal government's efforts to better support and prepare local jurisdictions for disasters or incidents involving weapons of mass destruction, if the required authorization and funding were provided.

Health Policy Initiatives for African American Women Veterans.

PubMed

McClerking, Carolyn A; Wood, Felecia

2016-08-01

America's military has experienced great changes in the demographic makeup of its veterans over the past few decades. In fact, the fastest growing group in the U.S. military is women. This demographic trend has also brought new challenges in dealing with gender issues, something that the Veterans Health Administration (VHA) has only recently begun to acknowledge. The VHA has responded in several ways to gender issues in health care and health outcomes. And, although the VHA is dealing with multiple gender matters, this article will focus on initiatives to combat cardiovascular disease (CVD) in women veterans. It will also highlight the significance of CVD, both to women veterans in general and to African American women veterans specifically. The article concludes with a discussion of VHA activities and strategies to improve the cardiovascular health of African American women veterans. © The Author(s) 2016.

Anticipating the traumatic brain injury-related health care needs of women veterans after the Department of Defense change in combat assignment policy.

PubMed

Amara, Jomana; Iverson, Katherine M; Krengel, Maxine; Pogoda, Terri K; Hendricks, Ann

2014-01-01

Female service members' presence in combat zones during Operation Enduring Freedom and Operation Iraqi Freedom is unprecedented both in terms of the number of women deployed and the nature of their involvement. In light of changing Department of Defense policy governing the deployment of women in combat zones, this article intends to set the groundwork for estimating future combat-related injuries and subsequent Veterans Health Administration (VHA) utilization while focusing on traumatic brain injury (TBI). The article summarizes and presents the results of a study that examines veterans who present to VHA for TBI evaluation. For a national sample of veterans, a dataset including information on post-screening utilization, diagnoses, and location of care was constructed. The dataset included self-reported health symptoms and other information obtained from a standardized national VHA post-screening clinical evaluation, the comprehensive TBI evaluation (CTBIE). Both women and men utilize high levels of VHA health care after a CTBIE. However, there are gender differences in the volume and types of services used, with women utilizing different services than their male counterparts and incurring higher costs, including higher overall and outpatient costs. As women veterans seek more of their health care from the VHA, there will be a need for more coordinated care to identify and manage deployment-related TBI and common comorbidities such as posttraumatic stress disorder, depression, and chronic pain. Deployment-connected injuries are likely to rise because of the rescinding of the ban on women in combat. This in turn has critical implications for VHA strategic planning and budgeting. Published by Elsevier Inc.

Innovating team-based outpatient mental health care in the Veterans Health Administration: Staff-perceived benefits and challenges to pilot implementation of the Behavioral Health Interdisciplinary Program (BHIP).

PubMed

Barry, Catherine N; Abraham, Kristen M; Weaver, Kendra R; Bowersox, Nicholas W

2016-05-01

In the past decade, the demand for Veterans Health Administration (VHA) mental health care has increased rapidly. In response to the increased demand, the VHA developed the Behavioral Health Interdisciplinary Program (BHIP) team model as an innovative approach to transform VHA general outpatient mental health delivery. The present formative evaluation gathered information about pilot implementation of BHIP to understand the struggles and successes that staff experienced during facility transitions to the BHIP model. Using a purposive, nonrandom sampling approach, we conducted 1-on-1, semistructured interviews with 37 licensed and nonlicensed clinical providers and 13 clerical support staff assigned to BHIP teams in 21 facilities across the VHA. Interviews revealed that having actively involved facility mental health leaders, obtaining adequate staffing for teams to meet the requirements of the BHIP model, creating clear descriptions and expectations for team member roles within the BHIP framework, and allocating designated time for BHIP team meetings challenged many VHA sites but are crucial for successful BHIP implementation. Despite the challenges, staff reported that the transition to BHIP improved team work and improved patient care. Staff specifically highlighted the potential for the BHIP model to improve staff working relationships and enhance communication, collaboration, morale, and veteran treatment consistency. Future evaluations of the BHIP implementation process and BHIP team functioning focusing on patient outcomes, organizational outcomes, and staff functioning are recommended for fully understanding effects of transitioning to the BHIP model within VHA general mental health clinics and to identify best practices and areas for improvement. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Creating a culture of safety: why CEOs hold the key to improved outcomes.

PubMed

Birk, Susan

2009-01-01

When the nonprofit VHA foundation, created by VHA Inc., Irving, Texas, embarked on a national patient safety initiative it looked first to outside industries, gathering information and ideas from pioneers in nuclear energy, aviation, the military and other innovation-rich fields known for safety excellence.

[Viral hepatitis A - possible diagnostic and therapeutic problems].

PubMed

Husa, Petr; Husa, Petr

Viral hepatitis A (VHA) is the disease which has an ancient history. Reports of epidemic jaundice were described by Hippocrates in Greece during the 5th century B.C. Incidence of VHA in developed countries is dropping in last decades. What was once common disease is now very rare, usually emerging in local epidemies. With decreasing incidence of hepatitis A clinicians losing practical experiences with disease. Authors present possible diagnostic and therapeutic problems based on their experience with large epidemic of hepatitis A, which occurred in 2016-2017 in Brno area.Key words: hepatitis A (VHA) - hepatitis A virus (HAV).

The psychologist's role in transgender-specific care with U.S. veterans.

PubMed

Johnson, Laura; Shipherd, Jillian; Walton, Heather M

2016-02-01

Psychologists are integral to the care of transgender individuals. This article details the many roles for psychologists in transgender-specific care, including diagnosing and treating gender dysphoria; providing treatment for comorbid conditions; referring to medical services such as gender confirmation surgeries, voice modification, and cross-sex hormone therapies; serving as consultants within health care systems; and advocating for addressing barriers in systems in which transgender individuals live and work. Transgender veterans have unique experiences and vulnerabilities related to their military service that are detailed from a review of the literature, and we make the case that Veterans Health Administration (VHA) and community psychologists are well-positioned to provide care to transgender veterans (trans-vets). In this article, the authors describe the experiences that many trans-vets have faced, identify the importance of treatment for gender dysphoria (and draw the distinction between gender identity disorder and gender dysphoria) as well as psychologists' roles, and clarify which transgender-related services are available to eligible veterans though VHA per policy and how VHA providers have access to training to provide that care. In addition, we describe how veterans can connect to the VHA, even if they have (and want to continue working with) non-VHA psychologists or other community providers. (c) 2016 APA, all rights reserved).

Obsessive-compulsive disorder in the Veterans Health Administration.

PubMed

Barrera, Terri L; McIngvale, Elizabeth; Lindsay, Jan A; Walder, Annette M; Kauth, Michael R; Smith, Tracey L; Van Kirk, Nathaniel; Teng, Ellen J; Stanley, Melinda A

2018-05-24

Little is known about the diagnosis and treatment of obsessive-compulsive disorder (OCD) in the Veterans Health Administration (VHA). This study examined diagnostic rates of OCD in a national sample of veterans as well as clinical comorbidities and mental health service use following an OCD diagnosis. This study used administrative data extracted from VHA medical records to identify patients with an OCD diagnosis between 2010 and 2011 (N = 20,364). Descriptive analyses examined demographic, clinical, and system-level variables associated with OCD diagnosis as well as mental health service use in a subset of patients newly diagnosed with OCD (n = 5,229). The OCD diagnosis rate in VHA medical records was 0.31% of VHA patients seen in 2010-2011. Examination of new-onset OCD diagnoses in 2010-2011 revealed that OCD was most likely to be diagnosed by physicians (48.6%) and behavioral health providers (31.9%), predominantly in mental health settings (87.5%). In the year following OCD diagnosis, veterans had an average of 3.9 individual psychotherapy and 3.5 psychiatric medication visits. These findings suggest that OCD is likely underrecognized and inadequately treated in the VHA and highlight the need for improved diagnostic and treatment services for veterans with OCD. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Responding to traveling patients' seasonal demand for health care services.

PubMed

Al-Haque, Shahed; Ceyhan, Mehmet Erkan; Chan, Stephanie H; Nightingale, Deborah J

2015-01-01

The Veterans Health Administration (VHA) provides care to over 8 million Veterans and operates over 1,700 sites of care across 21 regional networks in the United States. Health care providers within VHA report large seasonal variation in the demand for services, especially in the southern United States because of arrival of "snowbirds" during the winter. Because resource allocation activities are primarily carried out through an annual budgeting process, the seasonal load imposed by "traveling Veterans"-Veterans that seek care at VHA sites outside of their home network-make providing high-quality services more challenging. This work constitutes the first major effort within VHA to understand the impact of traveling Veterans. We discovered strong seasonal fluctuations in demand at a clinic located in the southeastern United States and developed a seasonal autoregressive integrated moving average model to help the clinic forecast demand for its services with significantly less error than historical averaging. Monte Carlo simulation of the clinic revealed that physicians are overutilized, suggesting the need to re-evaluate how the clinic is currently staffed. More broadly, this study demonstrates how operations management methods can assist operational decision making at other clinics and medical centers both within and outside VHA. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

Opting out of an integrated healthcare system: dual-system use is associated with poorer glycemic control in veterans with diabetes.

PubMed

Helmer, Drew; Sambamoorthi, Usha; Shen, Yujing; Tseng, Chin-Lin; Rajan, Mangala; Tiwari, Anjali; Maney, Miriam; Pogach, Leonard

2008-06-01

To test for an association between quality of care and patient choice to obtain care outside an integrated healthcare delivery system. We used administrative data to define dual-system use (Veterans Health Administration (VHA) and Medicare) in 1999 for VHA users with diabetes over 65 years old. Quality of diabetes care was determined by the last hemoglobin A1c (HA1c) value in 2000. The distance to nearest VHA facility minus the distance to nearest non-federal hospital was the instrumental variable in a two-part regression model which controlled for observed and unobserved factors. In 1999, 57.4% of subjects received care from both VHA and Medicare providers; their mean proportion of visits to Medicare providers was 0.41 (median 0.38). After controlling for observed and unobserved factors, higher proportions of Medicare visits were significantly associated with higher HA1c values; a 40% increase in the proportion of Medicare visits by those who did not use Medicare was associated with a 0.23% point increase in HA1c value. Dual-system use was associated with higher HA1c values, suggesting that veterans who chose to receive care outside the integrated VHA may have worse intermediate clinical outcomes than those who received care exclusively within the system.

Survival of Older Patients With Cancer in the Veterans Health Administration Versus Fee-for-Service Medicare

PubMed Central

Landrum, Mary Beth; Keating, Nancy L.; Lamont, Elizabeth B.; Bozeman, Samuel R.; Krasnow, Steven H.; Shulman, Lawrence; Brown, Jennifer R.; Earle, Craig C.; Rabin, Michael; McNeil, Barbara J.

2012-01-01

Purpose The Veterans Health Administration (VHA) provides high-quality preventive chronic care and cancer care, but few studies have documented improved patient outcomes that result from this high-quality care. We compared the survival rates of older patients with cancer in the VHA and fee-for-service (FFS) Medicare and examined whether differences in the stage at diagnosis, receipt of guideline-recommended therapies, and unmeasured characteristics explain survival differences. Patients and Methods We used propensity-score methods to compare all-cause and cancer-specific survival rates for men older than age 65 years who were diagnosed or received their first course of treatment for colorectal, lung, lymphoma, or multiple myeloma in VHA hospitals from 2001 to 2004 to similar FFS-Medicare enrollees diagnosed in Surveillance, Epidemiology, and End Results (SEER) areas in the same time frame. We examined the role of unmeasured factors by using sensitivity analyses. Results VHA patients versus similar FFS SEER-Medicare patients had higher survival rates of colon cancer (adjusted hazard ratio [HR], 0.87; 95% CI, 0.82 to 0.93) and non–small-cell lung cancer (NSCLC; HR, 0.91; 95% CI, 0.88 to 0.95) and similar survival rates of rectal cancer (HR, 1.05; 95% CI, 0.95 to 1.16), small-cell lung cancer (HR, 0.99; 95% CI, 0.93 to 1.05), diffuse large–B-cell lymphoma (HR, 1.02; 95% CI, 0.89 to 1.18), and multiple myeloma (HR, 0.92; 95% CI, 0.83 to 1.03). The diagnosis of VHA patients at earlier stages explained much of the survival advantages for colon cancer and NSCLC. Sensitivity analyses suggested that additional adjustment for the severity of comorbid disease or performance status could have substantial effects on estimated differences. Conclusion The survival rate for older men with cancer in the VHA was better than or equivalent to the survival rate for similar FFS-Medicare beneficiaries. The VHA provision of high-quality care, particularly preventive care, can result

Survival of older patients with cancer in the Veterans Health Administration versus fee-for-service Medicare.

PubMed

Landrum, Mary Beth; Keating, Nancy L; Lamont, Elizabeth B; Bozeman, Samuel R; Krasnow, Steven H; Shulman, Lawrence; Brown, Jennifer R; Earle, Craig C; Rabin, Michael; McNeil, Barbara J

2012-04-01

The Veterans Health Administration (VHA) provides high-quality preventive chronic care and cancer care, but few studies have documented improved patient outcomes that result from this high-quality care. We compared the survival rates of older patients with cancer in the VHA and fee-for-service (FFS) Medicare and examined whether differences in the stage at diagnosis, receipt of guideline-recommended therapies, and unmeasured characteristics explain survival differences. We used propensity-score methods to compare all-cause and cancer-specific survival rates for men older than age 65 years who were diagnosed or received their first course of treatment for colorectal, lung, lymphoma, or multiple myeloma in VHA hospitals from 2001 to 2004 to similar FFS-Medicare enrollees diagnosed in Surveillance, Epidemiology, and End Results (SEER) areas in the same time frame. We examined the role of unmeasured factors by using sensitivity analyses. VHA patients versus similar FFS SEER-Medicare patients had higher survival rates of colon cancer (adjusted hazard ratio [HR], 0.87; 95% CI, 0.82 to 0.93) and non-small-cell lung cancer (NSCLC; HR, 0.91; 95% CI, 0.88 to 0.95) and similar survival rates of rectal cancer (HR, 1.05; 95% CI, 0.95 to 1.16), small-cell lung cancer (HR, 0.99; 95% CI, 0.93 to 1.05), diffuse large-B-cell lymphoma (HR, 1.02; 95% CI, 0.89 to 1.18), and multiple myeloma (HR, 0.92; 95% CI, 0.83 to 1.03). The diagnosis of VHA patients at earlier stages explained much of the survival advantages for colon cancer and NSCLC. Sensitivity analyses suggested that additional adjustment for the severity of comorbid disease or performance status could have substantial effects on estimated differences. The survival rate for older men with cancer in the VHA was better than or equivalent to the survival rate for similar FFS-Medicare beneficiaries. The VHA provision of high-quality care, particularly preventive care, can result in improved patient outcomes.

Prevalence of Intimate Partner Violence among Women Veterans who Utilize Veterans Health Administration Primary Care.

PubMed

Kimerling, Rachel; Iverson, Katherine M; Dichter, Melissa E; Rodriguez, Allison L; Wong, Ava; Pavao, Joanne

2016-08-01

The objectives of this study were to identify the prevalence of past-year intimate partner violence (IPV) among women Veterans utilizing Veterans Health Administration (VHA) primary care, and to document associated demographic, military, and primary care characteristics. This was a retrospective cohort design, where participants completed a telephone survey in 2012 (84% participation rate); responses were linked to VHA administrative data for utilization in the year prior to the survey. A national stratified random sample of 6,287 women Veteran VHA primary care users participated in the study. Past-year IPV was assessed using the HARK screening tool. Self-report items and scales assessed demographic and military characteristics. Primary care characteristics were assessed via self-report and VHA administrative data. The prevalence of past-year IPV among women Veterans was 18.5% (se = 0.5%), with higher rates (22.2% - 25.5%) among women up to age 55. Other demographic correlates included indicators of economic hardship, lesbian or bisexual orientation, and being a parent/guardian of a child less than 18 years old. Military correlates included service during Vietnam to post-Vietnam eras, less than 10 years of service, and experiences of Military Sexual Trauma (MST). Most (77.3%, se = 1.2%) women who experienced IPV identified a VHA provider as their usual provider. Compared with women who did not report past-year IPV, women who reported IPV had more primary care visits, yet experienced lower continuity of care across providers. The high prevalence of past-year IPV among women beyond childbearing years, the majority of whom primarily rely on VHA as a source of health care, reinforces the importance of screening all women for IPV in VHA primary care settings. Key considerations for service implementation include sensitivity with respect to sexual orientation, race/ethnicity, and other aspects of diversity, as well as care coordination and linkages with social

Applying Lean Six Sigma to improve medication management.

PubMed

Nayar, Preethy; Ojha, Diptee; Fetrick, Ann; Nguyen, Anh T

2016-01-01

A significant proportion of veterans use dual care or health care services within and outside the Veterans Health Administration (VHA). In this study conducted at a VHA medical center in the USA, the authors used Lean Six Sigma principles to develop recommendations to eliminate wasteful processes and implement a more efficient and effective process to manage medications for dual care veteran patients. The purpose of this study is to: assess compliance with the VHA's dual care policy; collect data and describe the current process for co-management of dual care veterans' medications; and draft recommendations to improve the current process for dual care medications co-management. Input was obtained from the VHA patient care team members to draw a process map to describe the current process for filling a non-VHA prescription at a VHA facility. Data were collected through surveys and direct observation to measure the current process and to develop recommendations to redesign and improve the process. A key bottleneck in the process that was identified was the receipt of the non-VHA medical record which resulted in delays in filling prescriptions. The recommendations of this project focus on the four domains of: documentation of dual care; veteran education; process redesign; and outreach to community providers. This case study describes the application of Lean Six Sigma principles in one urban Veterans Affairs Medical Center (VAMC) in the Mid-Western USA to solve a specific organizational quality problem. Therefore, the findings may not be generalizable to other organizations. The Lean Six Sigma general principles applied in this project to develop recommendations to improve medication management for dual care veterans are applicable to any process improvement or redesign project and has valuable lessons for other VAMCs seeking to improve care for their dual care veteran patients. The findings of this project will be of value to VA providers and policy makers and health

76 FR 63355 - Proposed Information Collection (Regulation on Application for Fisher Houses and Other Temporary...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-12

... (Regulation on Application for Fisher Houses and Other Temporary Lodging and VHA Fisher House Application... information technology. Title: Regulation on Application for Fisher Houses and Other Temporary Lodging and VHA Fisher House Application, VA Forms 10-0408 and 10-0408a. OMB Control Number: 2900-0630. Type of Review...

76 FR 78739 - Agency Information Collection (Regulation on Application for Fisher Houses and Other Temporary...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-12-19

... (Regulation on Application for Fisher Houses and Other Temporary Lodging and VHA Fisher House Application... INFORMATION: Title: Regulation on Application for Fisher Houses and Other Temporary Lodging and VHA Fisher House Application, VA Forms 10-0408 and 10-0408a. OMB Control Number: 2900-0630. Type of Review...

Rates and correlates of tobacco cessation service use nationally in the Veterans Health Administration.

PubMed

Kelly, Megan M; Sido, Hannah; Rosenheck, Robert

2016-05-01

Tobacco use is a substantial problem for veterans using Veterans Health Administration (VHA) services, but relatively little is known about the association of specific patient characteristics, patterns of service use, the amount of such services, and the frequency of their use. Analysis of national VHA administrative data (N = 5,531,379) from fiscal year 2012 (FY2012) were used to identify use of tobacco cessation counseling services among veterans with a diagnosed tobacco use disorder, and to examine correlates of such use. Only 3.8% of veterans diagnosed with a tobacco use disorder used VHA tobacco cessation services, and only 0.9% met U.S. Public Health Service clinical practice guidelines for the recommended amount of counseling (i.e., 4 or more sessions). Veterans who used intensive tobacco cessation counseling services were more likely to be homeless, had comorbid mental health and substance use disorders, and used more VHA services overall than veterans who did not use tobacco cessation services. An analysis of the supply of tobacco cessation services (counseling visits provided per 100 veteran users of any services at each facility) showed that increasing the supply by just 1 visit for every 100 veterans would increase the percentage of veterans involved in tobacco cessation counseling by 35%. Veterans diagnosed with tobacco use disorder substantially underuse VHA tobacco cessation counseling services, and use is greatest at facilities that provide more tobacco cessation counseling services. Future efforts should focus on increasing the amount of VHA tobacco cessation services and encouraging veterans' awareness of and motivation to use these services. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Receipt of Prescription Opioids in a National Sample of Pregnant Veterans Receiving Veterans Health Administration Care.

PubMed

Kroll-Desrosiers, Aimee R; Skanderson, Melissa; Bastian, Lori A; Brandt, Cynthia A; Haskell, Sally; Kerns, Robert D; Mattocks, Kristin M

2016-01-01

A growing number of reproductive-age women veterans are returning from Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). In 2010, 42% of women veterans receiving Veterans Health Administration (VHA) services were aged 18 to 45. Prescription opioid use has increased among all veterans over the past decade; however, exposure among pregnant veterans has not been examined. We identified 2,331 women who delivered babies within the VHA system between 2001 and 2010. Delivery, opioid prescribing history, and demographic and health-related variables were obtained from a national database of veterans receiving VHA services. Receipt of an opioid prescription was defined as any filled VHA prescription for opioids in the 280-day pregnancy window before delivery. We developed a multivariable logistic regression model adjusted for sociodemographic, service-related, psychiatric diagnosis, and physical health variables to examine the odds of filling an opioid prescription during the pregnancy window. Ten percent of pregnant veterans received VHA prescription opioids during their pregnancy window. Significant factors associated with opioid prescriptions included presence of any psychiatric diagnosis (adjusted odds ratio [aOR], 1.67; 95% CI, 1.24-2.26), diagnosis of back problems (aOR, 2.94; 95% CI, 1.92-4.49), or other nontraumatic joint disorders (aOR, 2.20; 95% CI, 1.36-3.58). This study suggests that a substantial proportion of women veterans received VHA prescriptions for opioids during pregnancy. Providers should be aware of the potential risks of prescription opioid use during pregnancy, assess for potential undertreatment of psychiatric diagnoses, and consider alternate pain management strategies when possible. Published by Elsevier Inc.

Defining "Rural" for Veterans' Health Care Planning

ERIC Educational Resources Information Center

West, Alan N.; Lee, Richard E.; Shambaugh-Miller, Michael D.; Bair, Byron D.; Mueller, Keith J.; Lilly, Ryan S.; Kaboli, Peter J.; Hawthorne, Kara

2010-01-01

Purpose: The Veterans Health Administration (VHA) devised an algorithm to classify veterans as Urban, Rural, or Highly Rural residents. To understand the policy implications of the VHA scheme, we compared its categories to 3 Office of Management and Budget (OMB) and 4 Rural-Urban Commuting Area (RUCA) geographical categories. Method: Using…

Clinical information seeking in traumatic brain injury: a survey of Veterans Health Administration polytrauma care team members.

PubMed

Hogan, Timothy; Martinez, Rachael; Evans, Charlesnika; Saban, Karen; Proescher, Eric; Steiner, Monica; Smith, Bridget

2018-03-01

The polytraumatic nature of traumatic brain injury (TBI) makes diagnosis and treatment difficult. To (1) characterise information needs among Veterans Health Administration (VHA) polytrauma care team members engaged in the diagnosis and treatment of TBI; (2) identify sources used for TBI related information; and (3) identify barriers to accessing TBI related information. Cross-sectional online survey of 236 VHA polytrauma care team members. Most respondents (95.8%) keep at least somewhat current regarding TBI, but 31.5% need more knowledge on diagnosing TBI and 51.3% need more knowledge on treating TBI. Respondents use VHA affiliated sources for information, including local colleagues (81.7%), VHA offsite conferences/meetings (78.3%) and onsite VHA educational offerings (73.6%); however, limited time due to administrative responsibilities (50.9%), limited financial resources (50.4%) and patient care (50.4%) were prominent barriers. Medical librarians are in a unique position to develop information services, resources and other electronic tools that reflect the clinical context in which polytrauma care team members practice, and the different tasks they perform. Polytrauma care team members could benefit from additional information regarding the diagnosis and treatment of TBI. Addressing their information needs and supporting their information seeking requires a mulit-pronged approach to time and financial constraints. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Soluble adenylyl cyclase is an acid-base sensor in epithelial base-secreting cells.

PubMed

Roa, Jinae N; Tresguerres, Martin

2016-08-01

Blood acid-base regulation by specialized epithelia, such as gills and kidney, requires the ability to sense blood acid-base status. Here, we developed primary cultures of ray (Urolophus halleri) gill cells to study mechanisms for acid-base sensing without the interference of whole animal hormonal regulation. Ray gills have abundant base-secreting cells, identified by their noticeable expression of vacuolar-type H(+)-ATPase (VHA), and also express the evolutionarily conserved acid-base sensor soluble adenylyl cyclase (sAC). Exposure of cultured cells to extracellular alkalosis (pH 8.0, 40 mM HCO3 (-)) triggered VHA translocation to the cell membrane, similar to previous reports in live animals experiencing blood alkalosis. VHA translocation was dependent on sAC, as it was blocked by the sAC-specific inhibitor KH7. Ray gill base-secreting cells also express transmembrane adenylyl cyclases (tmACs); however, tmAC inhibition by 2',5'-dideoxyadenosine did not prevent alkalosis-dependent VHA translocation, and tmAC activation by forskolin reduced the abundance of VHA at the cell membrane. This study demonstrates that sAC is a necessary and sufficient sensor of extracellular alkalosis in ray gill base-secreting cells. In addition, this study indicates that different sources of cAMP differentially modulate cell biology. Copyright © 2016 the American Physiological Society.

38 CFR 1.485a - Eye, organ and tissue donation.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 38 Pensions, Bonuses, and Veterans' Relief 1 2010-07-01 2010-07-01 false Eye, organ and tissue... GENERAL PROVISIONS Disclosures Without Patient Consent § 1.485a Eye, organ and tissue donation. A VHA... organ, eye, or tissue donor if: (a) The individual is currently an inpatient in a VHA health care...

38 CFR 1.485a - Eye, organ and tissue donation.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 38 Pensions, Bonuses, and Veterans' Relief 1 2011-07-01 2011-07-01 false Eye, organ and tissue... GENERAL PROVISIONS Disclosures Without Patient Consent § 1.485a Eye, organ and tissue donation. A VHA... organ, eye, or tissue donor if: (a) The individual is currently an inpatient in a VHA health care...

HIGH PREVALENCE OF AGENT ORANGE EXPOSURE AMONG THYROID CANCER PATIENTS IN THE NATIONAL VA HEALTHCARE SYSTEM.

PubMed

Le, Karen T; Sawicki, Mark P; Wang, Marilene B; Hershman, Jerome M; Leung, Angela M

2016-06-01

Thyroid cancer is the most common endocrine malignancy and the most rapidly increasing cancer in the U.S. Little is known regarding the epidemiology and characteristics of patients with thyroid cancer within the national Veterans Health Administration (VHA) integrated healthcare system. The aim of this study was to further understand the characteristics of thyroid cancer patients in the VHA population, particularly in relation to Agent Orange exposure. This is a descriptive analysis of the VA (Veterans Affairs) Corporate Data Warehouse database from all U.S. VHA healthcare sites from October1, 1999, to December 31, 2013. Information was extracted for all thyroid cancer patients based on International Classification of Diseases-ninth revision diagnosis codes; histologic subtypes of thyroid cancer were not available. There were 19,592 patients (86% men, 76% white, 58% married, 42% Vietnam-era Veteran) in the VHA system with a diagnosis of thyroid cancer within this 14-year study period. The gender-stratified prevalence rates of thyroid cancer among the Veteran population during the study period were 1:1,114 (women) and 1:1,023 (men), which were lower for women but similar for men, when compared to the U.S. general population in 2011 (1:350 for women and 1:1,219 for men). There was a significantly higher proportion of self-reported Agent Orange exposure among thyroid cancer patients (10.0%), compared to the general VHA population (6.2%) (P<.0001). Thyroid cancer patients, in this sample, have a higher prevalence of self-reported Agent Orange exposure compared to the overall national VA patient population. T4 = thyroxine TCDD = 2, 3, 7, 8-tetrachlorodibenzo-p-dioxin TSH = thyroid-stimulating hormone VA = Veterans Affairs VHA = Veterans Health Administration.

Examining Wrong Eye Implant Adverse Events in the Veterans Health Administration With a Focus on Prevention: A Preliminary Report.

PubMed

Neily, Julia; Chomsky, Amy; Orcutt, James; Paull, Douglas E; Mills, Peter D; Gilbert, Christina; Hemphill, Robin R; Gunnar, William

2018-03-01

The study goals were to examine wrong intraocular lens (IOL) implant adverse events in the Veterans Health Administration (VHA), identify root causes and contributing factors, and describe system changes that have been implemented to address this challenge. This study represents collaboration between the VHA's National Center for Patient Safety (NCPS) and the National Surgery Office (NSO). This report includes 45 wrong IOL implant surgery adverse events reported to established VHA NCPS and NSO databases between July 1, 2006, and June 31, 2014. There are approximately 50,000 eye implant procedures performed each year in the VHA. Wrong IOL implant surgery adverse events are reported by VHA facilities to the NCPS and the NSO. Two authors (A.C. and J.N.) coded the reports for event type (wrong lens or expired lens) and identified the primary contributing factor (coefficient κ = 0.837). A descriptive analysis was conducted, which included the reported yearly event rate. The main outcome measure was the reported wrong IOL implant surgery adverse events. There were 45 reported wrong IOL implant surgery adverse events. Between 2011 and June 30, 2014, there was a significant downward trend (P = 0.02, R = 99.7%) at a pace of -0.08 (per 10,000 cases) every year. The most frequently coded primary contributing factor was incomplete preprocedure time-out (n = 12) followed by failure to perform double check of preprocedural calculations based upon original data and implant read-back at the time the surgical eye implant was performed (n = 10). Preventing wrong IOL implant adverse events requires diligence beyond performance of the preprocedural time-out. In 2013, the VHA has modified policy to ensure double check of preprocedural calculations and implant read-back with positive impact. Continued analysis of contributing human factors and improved surgical team communication are warranted.

Understanding and Applying Emotional Intelligence: A Qualitative Study of Tampa Veterans Administration Hospital Employees

ERIC Educational Resources Information Center

Johnson, Brenda Webb

2017-01-01

Emotional intelligence (EI) has not been studied extensively within the Veterans' Health Administration (VHA). The VHA is the largest healthcare organization in America with over 360,000 employees and the organization invests heavily in competency development. The Tampa VA is a level 1 facility with over 5,000 employees in the Tampa Bay area. The…

Symptom validity test performance and consistency of self-reported memory functioning of Operation Enduring Freedom/Operation Iraqi freedom veterans with positive Veteran Health Administration Comprehensive Traumatic Brain Injury evaluations.

PubMed

Russo, Arthur C

2012-12-01

Operation Enduring Freedom and Operation Iraqi Freedom combat veterans given definite diagnoses of mild Traumatic Brain Injury (TBI) during the Veteran Health Administration (VHA) Comprehensive TBI evaluation and reporting no post-deployment head injury were examined to assess (a) consistency of self-reported memory impairment and (b) symptom validity test (SVT) performance via a two-part study. Study 1 found that while 49 of 50 veterans reported moderate to very severe memory impairment during the VHA Comprehensive TBI evaluation, only 7 had reported any memory problem at the time of their Department of Defense (DOD) post-deployment health assessment. Study 2 found that of 38 veterans referred for neuropsychological evaluations following a positive VHA Comprehensive TBI evaluation, 68.4% failed the Word Memory Test, a forced choice memory recognition symptom validity task. Together, these studies raise questions concerning the use of veteran symptom self-report for TBI assessments and argue for the inclusion of SVTs and the expanded use of contemporaneous DOD records to improve the diagnostic accuracy of the VHA Comprehensive TBI evaluation.

The Veterans Health Administration and military sexual trauma.

PubMed

Kimerling, Rachel; Gima, Kristian; Smith, Mark W; Street, Amy; Frayne, Susan

2007-12-01

We examined the utility of the Veterans Health Administration (VHA) universal screening program for military sexual violence. We analyzed VHA administrative data for 185,880 women and 4139888 men who were veteran outpatients and were treated in VHA health care settings nationwide during 2003. Screening was completed for 70% of patients. Positive screens were associated with greater odds of virtually all categories of mental health comorbidities, including posttraumatic stress disorder (adjusted odds ratio [AOR]=8.83; 99% confidence interval [CI] = 8.34, 9.35 for women; AOR = 3.00; 99% CI = 2.89, 3.12 for men). Associations with medical comorbidities (e.g., chronic pulmonary disease, liver disease, and for women, weight conditions) were also observed. Significant gender differences emerged. The VHA policies regarding military sexual trauma represent a uniquely comprehensive health care response to sexual trauma. Results attest to the feasibility of universal screening, which yields clinically significant information with particular relevance to mental health and behavioral health treatment. Women's health literature regarding sexual trauma will be particularly important to inform health care services for both male and female veterans.

Using IHE and HL7 conformance to specify consistent PACS interoperability for a large multi-center enterprise.

PubMed

Henderson, Michael L; Dayhoff, Ruth E; Titton, Csaba P; Casertano, Andrew

2006-01-01

As part of its patient care mission, the U.S. Veterans Health Administration performs diagnostic imaging procedures at 141 medical centers and 850 outpatient clinics. VHA's VistA Imaging Package provides a full archival, display, and communications infrastructure and interfaces to radiology and other HIS modules as well as modalities and a worklist provider In addition, various medical center entities within VHA have elected to install commercial picture archiving and communications systems to enable image organization and interpretation. To evaluate interfaces between commercial PACS, the VistA hospital information system, and imaging modalities, VHA has built a fully constrained specification that is based on the Radiology Technical Framework (Rad-TF) Integrating the Healthcare Enterprise. The Health Level Seven normative conformance mechanism was applied to the IHE Rad-TF and agency requirements to arrive at a baseline set of message specifications. VHA provides a thorough implementation and testing process to promote the adoption of standards-based interoperability by all PACS vendors that want to interface with VistA Imaging.

The reality of virtual learning for nurses in the largest integrated health care system in the nation.

PubMed

Rick, Cathy; Kearns, Martha A; Thompson, Nancy A

2003-01-01

The health care network and hospital system within the Department of Veterans Affairs (VA), the Veterans Health Administration (VHA), provides employment to more than 56,000 nursing personnel and serves as clinical education site to countless other nursing and health professional students. Nurse administrators and educators are posed with the challenge of providing an environment in which each nurse is able to gain needed knowledge, learn new skills, and share and communicate this knowledge with other colleagues. The education of nurses improves the health status of veterans while also realizing individual professional enhancement. Regional and cultural diversity of the system present challenges to education, in both delivery and content. VHA's learning organizations, the Employee Education System and the Office of Special Projects, have maximized new technologies and information systems to provide innovative, virtual education opportunities, capitalizing on the benefits of informal and formal learning, thus moving VHA to the forefront in knowledge sharing and dissemination. The Virtual Learning Center, VA Knowledge Network, Learning Catalog, and VA Learning Online provide VHA's nurses with interactive, desktop virtual learning opportunities.

A Comparison of Mental Health Diagnoses Treated via Interactive Video and Face to Face in the Veterans Healthcare Administration.

PubMed

Grubbs, Kathleen M; Fortney, John C; Dean, Tisha; Williams, James S; Godleski, Linda

2015-07-01

This study compares the mental health diagnoses of encounters delivered face to face and via interactive video in the Veterans Healthcare Administration (VHA). We compiled 1 year of national-level VHA administrative data for Fiscal Year 2012 (FY12). Mental health encounters were those with both a VHA Mental Health Stop Code and a Mental Health Diagnosis (n=11,906,114). Interactive video encounters were identified as those with a Mental Health Stop Code, paired with a VHA Telehealth Secondary Stop Code. Primary diagnoses were grouped into posttraumatic stress disorder (PTSD), depression, anxiety, bipolar disorder, psychosis, drug use, alcohol use, and other. In FY12, 1.5% of all mental health encounters were delivered via interactive video. Compared with face-to-face encounters, a larger percentage of interactive video encounters was for PTSD, depression, and anxiety, whereas a smaller percentage was for alcohol use, drug use, or psychosis. Providers and patients may feel more comfortable treating depression and anxiety disorders than substance use or psychosis via interactive video.

Reduced Gut Acidity Induces an Obese-Like Phenotype in Drosophila melanogaster and in Mice

PubMed Central

Yen, Jui-Hung; Kuo, Ping-Chang; Yeh, Sheng-Rong; Lin, Hung-Yu; Fu, Tsai-Feng; Wu, Ming-Shiang; Wang, Horng-Dar; Wang, Pei-Yu

2015-01-01

In order to identify genes involved in stress and metabolic regulation, we carried out a Drosophila P-element-mediated mutagenesis screen for starvation resistance. We isolated a mutant, m2, that showed a 23% increase in survival time under starvation conditions. The P-element insertion was mapped to the region upstream of the vha16-1 gene, which encodes the c subunit of the vacuolar-type H+-ATPase. We found that vha16-1 is highly expressed in the fly midgut, and that m2 mutant flies are hypomorphic for vha16-1 and also exhibit reduced midgut acidity. This deficit is likely to induce altered metabolism and contribute to accelerated aging, since vha16-1 mutant flies are short-lived and display increases in body weight and lipid accumulation. Similar phenotypes were also induced by pharmacological treatment, through feeding normal flies and mice with a carbonic anhydrase inhibitor (acetazolamide) or proton pump inhibitor (PPI, lansoprazole) to suppress gut acid production. Our study may thus provide a useful model for investigating chronic acid suppression in patients. PMID:26436771

Evaluating current automatic de-identification methods with Veteran's health administration clinical documents.

PubMed

Ferrández, Oscar; South, Brett R; Shen, Shuying; Friedlin, F Jeffrey; Samore, Matthew H; Meystre, Stéphane M

2012-07-27

The increased use and adoption of Electronic Health Records (EHR) causes a tremendous growth in digital information useful for clinicians, researchers and many other operational purposes. However, this information is rich in Protected Health Information (PHI), which severely restricts its access and possible uses. A number of investigators have developed methods for automatically de-identifying EHR documents by removing PHI, as specified in the Health Insurance Portability and Accountability Act "Safe Harbor" method.This study focuses on the evaluation of existing automated text de-identification methods and tools, as applied to Veterans Health Administration (VHA) clinical documents, to assess which methods perform better with each category of PHI found in our clinical notes; and when new methods are needed to improve performance. We installed and evaluated five text de-identification systems "out-of-the-box" using a corpus of VHA clinical documents. The systems based on machine learning methods were trained with the 2006 i2b2 de-identification corpora and evaluated with our VHA corpus, and also evaluated with a ten-fold cross-validation experiment using our VHA corpus. We counted exact, partial, and fully contained matches with reference annotations, considering each PHI type separately, or only one unique 'PHI' category. Performance of the systems was assessed using recall (equivalent to sensitivity) and precision (equivalent to positive predictive value) metrics, as well as the F(2)-measure. Overall, systems based on rules and pattern matching achieved better recall, and precision was always better with systems based on machine learning approaches. The highest "out-of-the-box" F(2)-measure was 67% for partial matches; the best precision and recall were 95% and 78%, respectively. Finally, the ten-fold cross validation experiment allowed for an increase of the F(2)-measure to 79% with partial matches. The "out-of-the-box" evaluation of text de

Adaptation of Lean Six Sigma Methodologies for the Evaluation of Veterans Choice Program at 3 Urban Veterans Affairs Medical Centers.

PubMed

Ball, Sherry L; Stevenson, Lauren D; Ladebue, Amy C; McCreight, Marina S; Lawrence, Emily C; Oestreich, Taryn; Lambert-Kerzner, Anne C

2017-07-01

The Veterans Health Administration (VHA) is adapting to meet the changing needs of our Veterans. VHA leaders are promoting quality improvement strategies including Lean Six Sigma (LSS). This study used LSS tools to evaluate the Veterans Choice Program (VCP), a program that aims to improve access to health care services for eligible Veterans by expanding health care options to non-VHA providers. LSS was utilized to assess the current process and efficiency patterns of the VCP at 3 VHA Medical Centers. LSS techniques were used to assess data obtained through semistructured interviews with Veterans, staff, and providers to describe and evaluate the VCP process by identifying wastes and defects. The LSS methodology facilitated the process of targeting priorities for improvement and constructing suggestions to close identified gaps and inefficiencies. Identified key process wastes included inefficient exchange of clinical information between stakeholders in and outside of the VHA; poor dissemination of VCP programmatic information; shortages of VCP-participating providers; duplication of appointments; declines in care coordination; and lack of program adaptability to local processes. Recommendations for improvement were formulated using LSS. This evaluation illustrates how LSS can be utilized to assess a nationally mandated health care program. By focusing on stakeholder, staff, and Veteran perspectives, process defects in the VCP were identified and improvement recommendations were made. However, the current LSS language used is not intuitive in health care and similar applications of LSS may consider using new language and goals adapted specifically for health care.

The V-ATPase subunit A is essential for salt tolerance through participating in vacuolar Na+ compartmentalization in Salicornia europaea.

PubMed

Lv, Sulian; Jiang, Ping; Tai, Fang; Wang, Duoliya; Feng, Juanjuan; Fan, Pengxiang; Bao, Hexigeduleng; Li, Yinxin

2017-12-01

The V-ATPase subunit A participates in vacuolar Na + compartmentalization in Salicornia europaea regulating V-ATPase and V-PPase activities. Na + sequestration into the vacuole is an efficient strategy in response to salinity in many halophytes. However, it is not yet fully understood how this process is achieved. Particularly, the role of vacuolar H + -ATPase (V-ATPase) in this process is controversial. Our previous proteomic investigation in the euhalophyte Salicornia europaea L. found a significant increase of the abundance of V-ATPase subunit A under salinity. Here, the gene encoding this subunit named SeVHA-A was characterized, and its role in salt tolerance was demonstrated by RNAi directed downregulation in suspension-cultured cells of S. europaea. The transcripts of genes encoding vacuolar H + -PPase (V-PPase) and vacuolar Na + /H + antiporter (SeNHX1) also decreased significantly in the RNAi cells. Knockdown of SeVHA-A resulted in a reduction in both V-ATPase and vacuolar H + -PPase (V-PPase) activities. Accordingly, the SeVHA-A-RNAi cells showed increased vacuolar pH and decreased cell viability under different NaCl concentrations. Further Na + staining showed the reduced vacuolar Na + sequestration in RNAi cells. Taken together, our results evidenced that SeVHA-A participates in vacuolar Na + sequestration regulating V-ATPase and V-PPase activities and thereby vacuolar pH in S. europaea. The possible mechanisms underlying the reduction of vacuolar V-PPase activity in SeVHA-A-RNAi cells were also discussed.

Veterans Experiencing Elder Abuse: Improving Care of a High-Risk Population About Which Little Is Known.

PubMed

Makaroun, Lena K; Taylor, Laura; Rosen, Tony

2018-02-01

At least 10% of older adults experience abuse, neglect, or exploitation annually in the United States, and this problem is expected to grow as our population ages. Little is known about the prevalence and characteristics of elder abuse of veterans, but it is likely that this population is at high risk based on established elder abuse risk factors. Veterans who receive their care through the Veterans Health Administration (VHA) have a higher prevalence of poor psychological health, poor physical health, functional impairment, cognitive impairment, and social isolation than the general population. As the largest integrated healthcare system in the United States, the VHA has long been a leader in the development of innovative, integrated care programs for older adults. The VHA has another opportunity to lead by promoting research, clinical care, and education on elder abuse, furthering their mission of serving those who served. This article outlines the rationale for developing a research agenda for elder abuse in the VHA, as well as potential first steps toward understanding more about this complex problem affecting veterans. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

The Veterans Health Administration and Military Sexual Trauma

PubMed Central

Kimerling, Rachel; Gima, Kristian; Smith, Mark W.; Street, Amy; Frayne, Susan

2007-01-01

Objectives. We examined the utility of the Veterans Health Administration (VHA) universal screening program for military sexual violence. Methods. We analyzed VHA administrative data for 185 880 women and 4139888 men who were veteran outpatients and were treated in VHA health care settings nationwide during 2003. Results. Screening was completed for 70% of patients. Positive screens were associated with greater odds of virtually all categories of mental health comorbidities, including posttraumatic stress disorder (adjusted odds ratio [AOR]=8.83; 99% confidence interval [CI] = 8.34, 9.35 for women; AOR = 3.00; 99% CI = 2.89, 3.12 for men). Associations with medical comorbidities (e.g., chronic pulmonary disease, liver disease, and for women, weight conditions) were also observed. Significant gender differences emerged. Conclusions. The VHA policies regarding military sexual trauma represent a uniquely comprehensive health care response to sexual trauma. Results attest to the feasibility of universal screening, which yields clinically significant information with particular relevance to mental health and behavioral health treatment. Women’s health literature regarding sexual trauma will be particularly important to inform health care services for both male and female veterans. PMID:17971558

A Qualitative Evaluation of Web-Based Cancer Care Quality Improvement Toolkit Use in the Veterans Health Administration.

PubMed

Bowman, Candice; Luck, Jeff; Gale, Randall C; Smith, Nina; York, Laura S; Asch, Steven

2015-01-01

Disease severity, complexity, and patient burden highlight cancer care as a target for quality improvement (QI) interventions. The Veterans Health Administration (VHA) implemented a series of disease-specific online cancer care QI toolkits. To describe characteristics of the toolkits, target users, and VHA cancer care facilities that influenced toolkit access and use and assess whether such resources were beneficial for users. Deductive content analysis of detailed notes from 94 telephone interviews with individuals from 48 VHA facilities. We evaluated toolkit access and use across cancer types, participation in learning collaboratives, and affiliation with VHA cancer care facilities. The presence of champions was identified as a strong facilitator of toolkit use, and learning collaboratives were important for spreading information about toolkit availability. Identified barriers included lack of personnel and financial resources and complicated approval processes to support tool use. Online cancer care toolkits are well received across cancer specialties and provider types. Clinicians, administrators, and QI staff may benefit from the availability of toolkits as they become more reliant on rapid access to strategies that support comprehensive delivery of evidence-based care. Toolkits should be considered as a complement to other QI approaches.

Disaster preparedness and response practices among providers from the Veterans Health Administration and Veterans with spinal cord injuries and/or disorders

PubMed Central

Hogan, Timothy P.; Holmes, Sally A.; Rapacki, Lauren M.; Evans, Charlesnika T.; Lindblom, Laurie; Hoenig, Helen; Goldstein, Barry; Hahm, Bridget; Weaver, Frances M.

2011-01-01

Objectives Few empirical studies have examined the disaster preparedness and response practices of individuals with spinal cord injuries and/or disorders (SCI/D) and the healthcare providers who serve them. This study was conducted to understand the experiences of Veterans Health Administration (VHA) providers and Veterans with SCI/D in recent natural disasters, and to identify lessons learned for disaster preparedness and response in the context of SCI/D. Design Semi-structured interviews were conducted with providers and Veterans recruited through seven VHA facilities that had sustained a disaster since 2003. Audio recordings of the interviews were transcribed; transcripts were analyzed using constant comparative techniques. Results Forty participants completed an interview, including 21 VHA SCI/D providers and 19 Veterans with SCI/D. Disasters experienced by participants were weather related. While many Veterans were evacuated or admitted to nearby VHA facilities, others chose to stay in their communities. All facilities had formal disaster plans and engaged in related training; however, participants explained that many aspects of a response take shape ‘in the moment,’ and must address both provider and Veteran needs. Dispersion of resources hindered well-coordinated care, but effective communication, teamwork, advanced warnings, and VHA's electronic medical record facilitated efforts. Conclusions Even in the case of thorough planning, Veterans with SCI/D and their healthcare providers are faced with pressing needs during disasters, and identifying strategies to coordinate care is critical. The lessons learned are intended to inform the efforts of healthcare providers who may be involved in the care of individuals with SCI/D in future disasters. PMID:21903009

Accelerating Research Impact in a Learning Health Care System

PubMed Central

Elwy, A. Rani; Sales, Anne E.; Atkins, David

2017-01-01

Background: Since 1998, the Veterans Health Administration (VHA) Quality Enhancement Research Initiative (QUERI) has supported more rapid implementation of research into clinical practice. Objectives: With the passage of the Veterans Access, Choice and Accountability Act of 2014 (Choice Act), QUERI further evolved to support VHA’s transformation into a Learning Health Care System by aligning science with clinical priority goals based on a strategic planning process and alignment of funding priorities with updated VHA priority goals in response to the Choice Act. Design: QUERI updated its strategic goals in response to independent assessments mandated by the Choice Act that recommended VHA reduce variation in care by providing a clear path to implement best practices. Specifically, QUERI updated its application process to ensure its centers (Programs) focus on cross-cutting VHA priorities and specify roadmaps for implementation of research-informed practices across different settings. QUERI also increased funding for scientific evaluations of the Choice Act and other policies in response to Commission on Care recommendations. Results: QUERI’s national network of Programs deploys effective practices using implementation strategies across different settings. QUERI Choice Act evaluations informed the law’s further implementation, setting the stage for additional rigorous national evaluations of other VHA programs and policies including community provider networks. Conclusions: Grounded in implementation science and evidence-based policy, QUERI serves as an example of how to operationalize core components of a Learning Health Care System, notably through rigorous evaluation and scientific testing of implementation strategies to ultimately reduce variation in quality and improve overall population health. PMID:27997456

Which veterans enroll in a VA health information exchange program?

PubMed

Dixon, Brian E; Ofner, Susan; Perkins, Susan M; Myers, Laura J; Rosenman, Marc B; Zillich, Alan J; French, Dustin D; Weiner, Michael; Haggstrom, David A

2017-01-01

To characterize patients who voluntarily enrolled in an electronic health information exchange (HIE) program designed to share data between Veterans Health Administration (VHA) and non-VHA institutions. Patients who agreed to participate in the HIE program were compared to those who did not. Patient characteristics associated with HIE enrollment were examined using a multivariable logistic regression model. Variables selected for inclusion were guided by a health care utilization model adapted to explain HIE enrollment. Data about patients' sociodemographics (age, gender), comorbidity (Charlson index score), utilization (primary and specialty care visits), and access (distance to VHA medical center, insurance, VHA benefits) were obtained from VHA and HIE electronic health records. Among 57 072 patients, 6627 (12%) enrolled in the HIE program during its first year. The likelihood of HIE enrollment increased among patients ages 50-64, of female gender, with higher comorbidity, and with increasing utilization. Living in a rural area and being unmarried were associated with decreased likelihood of enrollment. Enrollment in HIE is complex, with several factors involved in a patient's decision to enroll. To broaden HIE participation, populations less likely to enroll should be targeted with tailored recruitment and educational strategies. Moreover, inclusion of special populations, such as patients with higher comorbidity or high utilizers, may help refine the definition of success with respect to HIE implementation. Published by Oxford University Press on behalf of the American Medical Informatics Association 2016. This work is written by US Government employees and is in the public domain in the United States.

Organization of care and diagnosed depression among women veterans.

PubMed

Sambamoorthi, Usha; Bean-Mayberry, Bevanne; Findley, Patricia A; Yano, Elizabeth M; Banerjea, Ranjana

2010-09-01

To analyze the association between the organizational features of integration of physical and mental healthcare in womens health clinics and the diagnosis of depression among women veterans with or at risk for cardiovascular conditions (ie, diabetes mellitus, heart disease, or hypertension). Retrospective and observational secondary data analyses. We studied 27,972 women veterans from 118 facilities with diagnosed cardiovascular conditions in fiscal year 2001 (FY2001) using merged Medicare claims and Veterans Health Administration (VHA) data merged with the 1999 VHA Survey of Primary Care Practices and the 2001 VHA Survey of Women Veterans Health Programs and Practices. The dependent variable was a binary indicator for diagnosed depression during FY2001 at the individual level. We used a multilevel logistic regression model to control for clustering of women veterans within facilities. Individual-level independent variables included demographics, socioeconomic characteristics, and chronic physical conditions. Overall, 27% of women veterans using the VHA were diagnosed as having depression in FY2001. Across facilities, rates of diagnosed depression varied from 13% to 41%. After controlling for individual-level and facility-level independent variables, women veterans who were served in separate women's health clinics with integrated physical and mental healthcare were more likely to have diagnosed depression. The adjusted odds ratio was 1.12 (95% confidence interval, 1.01-1.25). Existing women-specific VHA organizational features with integration of primary care and mental health seem effective in diagnosing depression. Emerging patient-centered medical home models may facilitate diagnosis and treatment of mental health issues among women with complex chronic conditions.

Posttraumatic stress disorder and suicide in 5.9 million individuals receiving care in the veterans health administration health system.

PubMed

Conner, Kenneth R; Bossarte, Robert M; He, Hua; Arora, Jyoti; Lu, Naiji; Tu, Xin M; Katz, Ira R

2014-09-01

Post-traumatic stress disorder (PTSD) confers risk for suicidal ideation and suicide attempts but a link with suicide is not yet established. Prior analyses of users of the Veterans health administration (VHA) Health System suggest that other mental disorders strongly influence the association between PTSD and suicide in this population. We examined the association between PTSD and suicide in VHA users, with a focus on the influence of other mental disorders. Data were based on linkage of VA National Patient Care Database records and the Centers for Disease Control and Prevention׳s National Death Index, with data from fiscal year 2007-2008. Analyses were based on multivariate logistic regression and structural equation models. Among users of VHA services studied (N=5,913,648), 0.6% (N=3620) died by suicide, including 423 who had had been diagnosed with PTSD. In unadjusted analysis, PTSD was associated with increased risk for suicide, with odds ratio, OR (95% confidence interval, 95% CI)=1.34 (1.21, 1.48). Similar results were obtained after adjustment for demographic variables and veteran characteristics. After adjustment for multiple other mental disorder diagnoses, PTSD was associated with decreased risk for suicide, OR (95% CI)=0.77 (0.69, 0.86). Major depressive disorder (MDD) had the largest influence on the association between PTSD and suicide. The analyses were cross-sectional. VHA users were studied, with unclear relevance to other populations. The findings suggest the importance of identifying and treating comorbid MDD and other mental disorders in VHA users diagnosed with PTSD in suicide prevention efforts. Published by Elsevier B.V.

Evaluation of safety climate and employee injury rates in healthcare.

PubMed

Cook, Jacqueline M; Slade, Martin D; Cantley, Linda F; Sakr, Carine J

2016-09-01

Safety climates that support safety-related behaviour are associated with fewer work-related injuries, and prior research in industry suggests that safety knowledge and motivation are strongly related to safety performance behaviours; this relationship is not well studied in healthcare settings. We performed analyses of survey results from a Veterans Health Administration (VHA) Safety Barometer employee perception survey, conducted among VHA employees in 2012. The employee perception survey assessed 6 safety programme categories, including management participation, supervisor participation, employee participation, safety support activities, safety support climate and organisational climate. We examined the relationship between safety climate from the survey results on VHA employee injury and illness rates. Among VHA facilities in the VA New England Healthcare System, work-related injury rate was significantly and inversely related to overall employee perception of safety climate, and all 6 safety programme categories, including employee perception of employee participation, management participation, organisational climate, supervisor participation, safety support activities and safety support climate. Positive employee perceptions of safety climate in VHA facilities are associated with lower work-related injury and illness rates. Employee perception of employee participation, management participation, organisational climate, supervisor participation, safety support activities and safety support climate were all associated with lower work-related injury rates. Future implications include fostering a robust safety climate for patients and healthcare workers to reduce healthcare worker injuries. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Defense Health Care: DOD Needs to Clarify Policies Related to Occupational and Environmental Health Surveillance and Monitor Risk Mitigation Activities

DTIC Science & Technology

2015-05-01

information on the types of illnesses that may result from an exposure. VBA officials told us that they have access to unclassified POEMS through a MESL...Environmental Monitoring Summaries USARCENT U.S. Army Central VA Department of Veterans Affairs VBA Veterans Benefits Administration VHA...Administration ( VBA ) and the Veterans Health Administration (VHA) to identify the ways in which OEHS data is being used, including its use in

A break-even analysis for dementia care collaboration: Partners in Dementia Care.

PubMed

Morgan, Robert O; Bass, David M; Judge, Katherine S; Liu, C F; Wilson, Nancy; Snow, A Lynn; Pirraglia, Paul; Garcia-Maldonado, Maurilio; Raia, Paul; Fouladi, N N; Kunik, Mark E

2015-06-01

Dementia is a costly disease. People with dementia, their families, and their friends are affected on personal, emotional, and financial levels. Prior work has shown that the "Partners in Dementia Care" (PDC) intervention addresses unmet needs and improves psychosocial outcomes and satisfaction with care. We examined whether PDC reduced direct Veterans Health Administration (VHA) health care costs compared with usual care. This study was a cost analysis of the PDC intervention in a 30-month trial involving five VHA medical centers. Study subjects were veterans (N = 434) 50 years of age and older with dementia and their caregivers at two intervention (N = 269) and three comparison sites (N = 165). PDC is a telephone-based care coordination and support service for veterans with dementia and their caregivers, delivered through partnerships between VHA medical centers and local Alzheimer's Association chapters. We tested for differences in total VHA health care costs, including hospital, emergency department, nursing home, outpatient, and pharmacy costs, as well as program costs for intervention participants. Covariates included caregiver reports of veterans' cognitive impairment, behavior problems, and personal care dependencies. We used linear mixed model regression to model change in log total cost post-baseline over a 1-year follow-up period. Intervention participants showed higher VHA costs than usual-care participants both before and after the intervention but did not differ significantly regarding change in log costs from pre- to post-baseline periods. Pre-baseline log cost (p ≤ 0.001), baseline cognitive impairment (p ≤ 0.05), number of personal care dependencies (p ≤ 0.01), and VA service priority (p ≤ 0.01) all predicted change in log total cost. These analyses show that PDC meets veterans' needs without significantly increasing VHA health care costs. PDC addresses the priority area of care coordination in the National Plan to Address Alzheimer

Implementation of Lung Cancer Screening in the Veterans Health Administration.

PubMed

Kinsinger, Linda S; Anderson, Charles; Kim, Jane; Larson, Martha; Chan, Stephanie H; King, Heather A; Rice, Kathryn L; Slatore, Christopher G; Tanner, Nichole T; Pittman, Kathleen; Monte, Robert J; McNeil, Rebecca B; Grubber, Janet M; Kelley, Michael J; Provenzale, Dawn; Datta, Santanu K; Sperber, Nina S; Barnes, Lottie K; Abbott, David H; Sims, Kellie J; Whitley, Richard L; Wu, R Ryanne; Jackson, George L

2017-03-01

The US Preventive Services Task Force recommends annual lung cancer screening (LCS) with low-dose computed tomography for current and former heavy smokers aged 55 to 80 years. There is little published experience regarding implementing this recommendation in clinical practice. To describe organizational- and patient-level experiences with implementing an LCS program in selected Veterans Health Administration (VHA) hospitals and to estimate the number of VHA patients who may be candidates for LCS. This clinical demonstration project was conducted at 8 academic VHA hospitals among 93 033 primary care patients who were assessed on screening criteria; 2106 patients underwent LCS between July 1, 2013, and June 30, 2015. Implementation Guide and support, full-time LCS coordinators, electronic tools, tracking database, patient education materials, and radiologic and nodule follow-up guidelines. Description of implementation processes; percentages of patients who agreed to undergo LCS, had positive findings on results of low-dose computed tomographic scans (nodules to be tracked or suspicious findings), were found to have lung cancer, or had incidental findings; and estimated number of VHA patients who met the criteria for LCS. Of the 4246 patients who met the criteria for LCS, 2452 (57.7%) agreed to undergo screening and 2106 (2028 men and 78 women; mean [SD] age, 64.9 [5.1] years) underwent LCS. Wide variation in processes and patient experiences occurred among the 8 sites. Of the 2106 patients screened, 1257 (59.7%) had nodules; 1184 of these patients (56.2%) required tracking, 42 (2.0%) required further evaluation but the findings were not cancer, and 31 (1.5%) had lung cancer. A variety of incidental findings, such as emphysema, other pulmonary abnormalities, and coronary artery calcification, were noted on the scans of 857 patients (40.7%). It is estimated that nearly 900 000 of a population of 6.7 million VHA patients met the criteria for LCS. Implementation of

Geriatric-focused educational offerings in the Department of Veterans Affairs from 1999 to 2009.

PubMed

Thielke, Stephen; Tumosa, Nina; Lindenfeld, Rivkah; Shay, Kenneth

2011-01-01

The scope of geriatrics-related educational offerings in large health care systems, in either the target audiences or topics covered, has not previously been analyzed or reported in the professional literature. The authors reviewed the geriatrics-related educational sessions that were provided between 1999 and 2009 by the Geriatrics Research, Education, and Clinical Centers (GRECCs) and the Employee Education System (EES) of the United States' largest integrated health care system, the Veterans Health Administration (VHA). Using records of attendance and content at local training events and regional and national conferences, the authors estimated the number of attendees in different health disciplines and the number and types of lectures. During the past 11 years, GRECCs and EES provided geriatric-related educational sessions to about one third of a million attendees, most of them nurses and physicians, in about 15,000 lectures. About three-fourths of the educational events occurred through local, rather than regional or national, events. Lectures covered a wide variety of topics, with a particular emphasis on dementia and other mental health topics. A comparison of the number of potential learners in VHA with the number of geriatric-related educational presentations over this time period yields an average of one offering per VHA provider every 3 years; most providers likely never received any. Since 1999 the GRECCs have been the dominant source for geriatrics-related education for VHA health professionals, but given that about one half of VHA patients are older than age 65, there is still a large unmet need to provide geriatric education to VHA providers. Examination of the GRECC resources that have been put to use in the past to develop and deliver the face-to-face education experiences described sheds light on the magnitude of resources that might be required to address remaining unmet need in the future, and supports the prediction that there will need to be

The influence of trauma and patient characteristics on provider burnout in VA post-traumatic stress disorder specialty programmes.

PubMed

Garcia, Hector A; McGeary, Cindy A; Finley, Erin P; McGeary, Donald D; Ketchum, Norma S; Peterson, Alan L

2016-03-01

Prolonged exposure (PE) and cognitive processing therapy (CPT) - post-traumatic stress disorder (PTSD) treatments now available at the Veterans Health Administration (VHA) - expose the provider to graphic traumatic material. Little is known about the impact of traumatic material on VHA providers. The purpose of this study was to examine the relationship between trauma content, patient characteristics, and burnout among VHA PTSD Clinical Team (PCT) providers. It was hypothesized that trauma content and patient characteristics would significantly predict burnout in this population. This cross-sectional study consisted of 137 participants. The sample was mostly female (67%), Caucasian (non-Hispanic; 81%), and married (70%) with a mean age of 44.3 years (SD = 11.3). Participants completed an electronic survey that assessed demographics, patient characteristics (i.e., anger, personality disorder, malingering), trauma content characteristics (e.g., killing of women and children) as well as burnout as measured by the Maslach Burnout Inventory-General Survey (MBI-GS; Maslach et al., 1996, Burnout inventory manual. Palo Alto: Consulting Psychologist Press). Over half of the study population reported being bothered by trauma content; however, trauma content did not predict burnout. Treating patients with personality disorders and suspected malingering predicted burnout in PCT providers. High numbers (77%) reported perceiving that emotional exhaustion impacted the quality of care they provided. These findings suggest an important role of burnout assessment, prevention, and treatment strategies at the VHA. This paper addresses the impact of provider burnout on perceived quality of care. This paper also addresses potential predictors of burnout in PCT settings. This paper outlines potential remedies to provider burnout in the VHA. © 2015 The British Psychological Society.

Validation of a Screening Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose in a US Commercial Health Plan Claims Database

PubMed Central

Zedler, Barbara K; Saunders, William B; Joyce, Andrew R; Vick, Catherine C; Murrelle, E Lenn

2018-01-01

Abstract Objective To validate a risk index that estimates the likelihood of overdose or serious opioid-induced respiratory depression (OIRD) among medical users of prescription opioids. Subjects and Methods A case-control analysis of 18,365,497 patients with an opioid prescription from 2009 to 2013 in the IMS PharMetrics Plus commercially insured health plan claims database (CIP). An OIRD event occurred in 7,234 cases. Four controls were selected per case. Validity of the Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (RIOSORD), developed previously using Veterans Health Administration (VHA) patient data, was assessed. Multivariable logistic regression was used within the CIP study population to develop a slightly refined RIOSORD. The composition and performance of the CIP-based RIOSORD was evaluated and compared with VHA-based RIOSORD. Results VHA-RIOSORD performed well in discriminating OIRD events in CIP (C-statistic = 0.85). Additionally, re-estimation of logistic model coefficients in CIP yielded a 0.90 C-statistic. The resulting comorbidity and pharmacotherapy variables most highly associated with OIRD and retained in the CIP-RIOSORD were largely concordant with VHA-RIOSORD. These variables included neuropsychiatric and cardiopulmonary disorders, impaired drug excretion, opioid characteristics, and concurrent psychoactive medications. The average predicted probability of OIRD ranged from 2% to 83%, with excellent agreement between predicted and observed incidence across risk classes. Conclusions RIOSORD had excellent predictive accuracy in a large population of US medical users of prescription opioids, similar to its performance in VHA. This practical risk index is designed to support clinical decision-making for safer opioid prescribing, and its clinical utility should be evaluated prospectively. PMID:28340046

Strategic plan for geriatrics and extended care in the veterans health administration: background, plan, and progress to date.

PubMed

Shay, Kenneth; Hyduke, Barbara; Burris, James F

2013-04-01

The leaders of Geriatrics and Extended Care (GEC) in the Veterans Health Administration (VHA) undertook a strategic planning process that led to approval in 2009 of a multidisciplinary, evidence-guided strategic plan. This article reviews the four goals contained in that plan and describes VHA's progress in addressing them. The goals included transforming the healthcare system to a veteran-centric approach, achieving universal access to a panel of services, ensuring that the Veterans Affair's (VA) healthcare workforce was adequately prepared to manage the needs of the growing elderly veteran population, and integrating continuous improvement into all care enhancements. There has been substantial progress in addressing all four goals. All VHA health care has undergone an extensive transformation to patient-centered care, has enriched the services it can offer caregivers of dependent veterans, and has instituted models to better integrate VA and non-VA cares and services. A range of successful models of geriatric care described in the professional literature has been adapted to VA environments to gauge suitability for broader implementation. An executive-level task force developed a three-pronged approach for enhancing the VA's geriatric workforce. The VHA's performance measurement approaches increasingly include incentives to enhance the quality of management of vulnerable elderly adults in primary care. The GEC strategic plan was intended to serve as a road map for keeping VHA aligned with an ambitious but important long-term vision for GEC services. Although no discrete set of resources was appropriated for fulfillment of the plan's recommendations, this initial report reflects substantial progress in addressing most of its goals. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.

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

PubMed

Washington, Donna L; Sun, Su; Canning, Mark

2010-01-01

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.

Pain research using Veterans Health Administration electronic and administrative data sources.

PubMed

Abel, Erica A; Brandt, Cynthia A; Czlapinski, Rebecca; Goulet, Joseph L

2016-01-01

Health services researchers are using Veterans Health Administration (VHA) electronic health record (EHR) data sources to examine the prevalence, treatment, and outcomes of pain among Veterans in VHA care. Little guidance currently exists on using these data; thus, findings may vary depending on the methods, data sources, and definitions used. We sought to identify current practices in order to provide guidance to future pain researchers. We conducted an anonymous survey of VHA-affiliated researchers participating in a monthly national pain research teleconference. Thirty-two researchers (89%) responded: 75% conducted pain-focused research, 78% used pain intensity numeric rating screening scale (NRS) scores to identify pain, 41% used International Classification of Diseases-9th Revision codes, and 57% distinguished between chronic and acute pain using either NRS scores or pharmacy data. The NRS and pharmacy data were rated as the most valid pain data sources. Of respondents, 48% reported the EHR data sources were adequate for pain research, while 45% had published peer-reviewed articles based on the data. Despite limitations, VHA researchers are increasingly using EHR data for pain research, and several common methods were identified. More information on the performance characteristics of these data sources and definitions is needed.

Control of lysosomal biogenesis and Notch-dependent tissue patterning by components of the TFEB-V-ATPase axis in Drosophila melanogaster.

PubMed

Tognon, Emiliana; Kobia, Francis; Busi, Ilaria; Fumagalli, Arianna; De Masi, Federico; Vaccari, Thomas

2016-01-01

In vertebrates, TFEB (transcription factor EB) and MITF (microphthalmia-associated transcription factor) family of basic Helix-Loop-Helix (bHLH) transcription factors regulates both lysosomal function and organ development. However, it is not clear whether these 2 processes are interconnected. Here, we show that Mitf, the single TFEB and MITF ortholog in Drosophila, controls expression of vacuolar-type H(+)-ATPase pump (V-ATPase) subunits. Remarkably, we also find that expression of Vha16-1 and Vha13, encoding 2 key components of V-ATPase, is patterned in the wing imaginal disc. In particular, Vha16-1 expression follows differentiation of proneural regions of the disc. These regions, which will form sensory organs in the adult, appear to possess a distinctive endolysosomal compartment and Notch (N) localization. Modulation of Mitf activity in the disc in vivo alters endolysosomal function and disrupts proneural patterning. Similar to our findings in Drosophila, in human breast epithelial cells we observe that impairment of the Vha16-1 human ortholog ATP6V0C changes the size and function of the endolysosomal compartment and that depletion of TFEB reduces ligand-independent N signaling activity. Our data suggest that lysosomal-associated functions regulated by the TFEB-V-ATPase axis might play a conserved role in shaping cell fate.

Effective antibiotic stewardship in spinal cord injury: Challenges and a way forward.

PubMed

Skelton, Felicia; Suda, Katie; Evans, Charlesnika; Trautner, Barbara

2018-01-11

Context Antibiotic stewardship, defined as a multidisciplinary program to reduce the misuse of antibiotics, and in turn, antibiotic resistance, is a high priority. Persons with spinal cord injury/disorder (SCI/D) are vulnerable to receiving multiple courses of antibiotics over their lifetime given frequent healthcare exposure, and have high rates of bacterial infection with multi-drug resistant organisms. Additional challenges to evaluating appropriate use of antibiotics in this population include bacterial colonization in the urine and the differences in the presenting signs and symptoms of infection. Therefore, Veterans Health Administration (VHA) facilities with SCI/D centers need effective antibiotic stewardship programs. Results We analyzed the results of a 2012 VHA-wide survey evaluating available antibiotic stewardship resources, and compared the resources present at facilities with SCI/D (n=23) versus non-SCI/D facilities (n=107). VHA facilities with SCI/D centers are more likely to have components of an antibiotic stewardship program that have led to reduced antibiotic use in previous studies. They are also more likely to have personnel with infectious diseases training. Conclusion VHA facilities with SCI/D centers have the resources needed for antibiotic stewardship. The next step will be to determine how to implement effective antibiotic stewardship tailored for this patient care setting.

A Clinical Nurse Leader (CNL) practice development model to support integration of the CNL role into microsystem care delivery.

PubMed

Kaack, Lorraine; Bender, Miriam; Finch, Michael; Borns, Linda; Grasham, Katherine; Avolio, Alice; Clausen, Shawna; Terese, Nadine A; Johnstone, Diane; Williams, Marjory

The Veterans Health Administration (VHA) Office of Nursing Services (ONS) was an early adopter of Clinical Nurse Leader (CNL) practice, generating some of the earliest pilot data of CNL practice effectiveness. In 2011 the VHA ONS CNL Implementation & Evaluation Service (CNL I&E) piloted a curriculum to facilitate CNL transition to effective practice at local VHA settings. In 2015, the CNL I&E and local VHA setting stakeholders collaborated to refine the program, based on lessons learned at the national and local level. The workgroup reviewed the literature to identify theoretical frameworks for CNL practice and practice development. The workgroup selected Benner et al.'s Novice-to-Expert model as the defining framework for CNL practice development, and Bender et al.'s CNL Practice Model as the defining framework for CNL practice integration. The selected frameworks were cross-walked against existing curriculum elements to identify and clarify additional practice development needs. The work generated key insights into: core stages of transition to effective practice; CNL progress and expectations for each stage; and organizational support structures necessary for CNL success at each stage. The refined CNL development model is a robust tool that can be applied to support consistent and effective integration of CNL practice into care delivery. Published by Elsevier Inc.

From the laboratory to the therapy room: National dissemination and implementation of evidence-based psychotherapies in the U.S. Department of Veterans Affairs Health Care System.

PubMed

Karlin, Bradley E; Cross, Gerald

2014-01-01

Despite their established efficacy and recommendation--often as first-line treatments--in clinical practice guidelines, evidence-based psychotherapies (EBPs) have largely failed to make their way into mainstream clinical settings. Numerous attempts over the years to promote the translation of EBPs from science to practice, typically relying on one-dimensional dissemination approaches, have yielded limited success. As part of the transformation of its mental health care system, the Veterans Health Administration (VHA) of the U.S. Department of Veterans Affairs (VA) is working to disseminate and implement a number of EBPs for various mental and behavioral health conditions throughout the VA health care system. This article examines VHA's multidimensional model and specific strategies, involving policy, provider, local systems, patient, and accountability levels, for promoting the national dissemination and implementation of EBPs in VHA. In addition, the article identifies key lessons learned and next steps for further promoting EBP delivery and sustainability in the VA health care system. Beyond promoting the availability of effective treatments for veterans returning from Iraq and Afghanistan and for veterans of previous combat eras, VHA's EBP dissemination and implementation model and key lessons learned may help to inform other private and public health care systems interested in disseminating and implementing EBPs. PsycINFO Database Record (c) 2014 APA, all rights reserved.

The influence of gender on suicidal ideation following military sexual trauma among Veterans in the Veterans Health Administration.

PubMed

Monteith, Lindsey L; Bahraini, Nazanin H; Matarazzo, Bridget B; Gerber, Holly R; Soberay, Kelly A; Forster, Jeri E

2016-10-30

No studies have examined whether military sexual trauma, as measured and defined within the Veterans Health Administration (VHA), is associated with suicidal ideation among Veterans in VHA care, when taking prior suicide attempts into account. Research regarding the role of gender in this association is also limited. The present study examined: (1) whether military sexual trauma was associated with the presence of past-week suicidal ideation among 354 Veterans in VHA (310 men, 44 women); (2) whether gender moderated the association between military sexual trauma and suicidal ideation. Information regarding military sexual trauma, suicidal ideation, suicide attempt, and psychiatric diagnoses was obtained from self-report instruments and medical records. Adjusting for age, gender, combat, posttraumatic stress disorder, depressive disorders, negative affect, and lifetime suicide attempt, Veterans with military sexual trauma were significantly more likely to report suicidal ideation, compared to Veterans without military sexual trauma. Furthermore, the association between military sexual trauma and suicidal ideation was stronger for men compared to women. These results contribute to a growing literature identifying military sexual trauma as a risk factor for suicidal thoughts and behaviors among Veterans in VHA care and emphasize the importance of screening for suicidal ideation among survivors of military sexual trauma. Published by Elsevier Ireland Ltd.

Military service and other socioecological factors influencing weight and health behavior change in overweight and obese Veterans: a qualitative study to inform intervention development within primary care at the United States Veterans Health Administration.

PubMed

Jay, Melanie; Mateo, Katrina F; Squires, Allison P; Kalet, Adina L; Sherman, Scott E

2015-01-01

Obesity affects 37 % of patients at Veterans Health Administration (VHA) medical centers. The VHA offers an intensive weight management program (MOVE!) but less than 10 % of eligible patients ever attend. However, VHA patients see their primary care provider about 3.6 times per year, supporting the development of primary care-based weight management interventions. To address gaps in the literature regarding Veterans' experiences with weight management and determine whether and how to develop a primary care-based weight management intervention to both improve obesity counseling and increase attendance to MOVE!, we conducted a qualitative study to assess: 1) Veterans' personal experiences with healthy weight-related behavior change (including barriers and facilitators to behavior change and experiences with primary care providers, staff, and the MOVE! program), and 2) potential new approaches to improve weight management within primary care at the VHA including goal setting and technology. Overweight/obese VHA patients (aged 18-75, BMI greater than 30 or greater than 25 with at least 1 co-morbidity) were recruited for focus group sessions stratified by gender, MOVE! referral, and attendance. Each session was facilitated by a trained moderator, audio-recorded, and professionally transcribed. Using an iterative coding approach, two coders separately reviewed and coded transcripts, and met frequently to negotiate codes and synthesize emerging themes. Of 161 eligible patients, 54 attended one of 6 focus groups (2 female, 4 male, 9-11 participants per session): 63 % were male, 46 % identified as African-American, 32 % White/Caucasian, 74 % were college-educated or higher, and 61 % reported having attended MOVE!. We identified two major themes: Impact of Military Service and Promotion and Sustainability of Healthy Behaviors. After service in a highly structured military environment, Veterans had difficulty maintaining weight on their own. They perceived physical

Engagement in the Hepatitis C Care Cascade Among Homeless Veterans, 2015.

PubMed

Noska, Amanda J; Belperio, Pamela S; Loomis, Timothy P; O'Toole, Thomas P; Backus, Lisa I

The Veterans Health Administration (VHA) is the largest provider of hepatitis C virus (HCV) care nationally and provides health care to >200 000 homeless veterans each year. We used the VHA's Corporate Data Warehouse and HCV Clinical Case Registry to evaluate engagement in the HCV care cascade among homeless and nonhomeless veterans in VHA care in 2015. We estimated that, among 242 740 homeless veterans in care and 5 424 712 nonhomeless veterans in care, 144 964 (13.4%) and 188 156 (3.5%), respectively, had chronic HCV infection. Compared with nonhomeless veterans, homeless veterans were more likely to be diagnosed with chronic HCV infection and linked to HCV care but less likely to have received antiviral therapy despite comparable sustained virologic response rates. Homelessness should not necessarily preclude HCV treatment eligibility with available all-oral antiviral regimens.

Disproportionate Mental Health Burden Associated With Past-Year Intimate Partner Violence Among Women Receiving Care in the Veterans Health Administration.

PubMed

Dichter, Melissa E; Sorrentino, Anneliese; Bellamy, Scarlett; Medvedeva, Elina; Roberts, Christopher B; Iverson, Katherine M

2017-12-01

Experience of intimate partner violence (IPV) can lead to mental health conditions, including anxiety, depression, and unhealthy substance use. Women seen in the Veterans Health Administration (VHA) face high rates of both IPV and mental health morbidity. This study aimed to identify associations between recent IPV experience and mental health diagnoses among women VHA patients. We examined medical records data for 8,888 female veteran and nonveteran VHA patients across 13 VHA facilities who were screened for past-year IPV between April, 2014 and April, 2016. Compared with women who screened negative for past-year IPV (IPV-), those who screened positive (IPV+; 8.7%) were more than twice as likely to have a mental health diagnosis, adjusted odds ratio (AOR) = 2.27, 95% confidence interval (CI) [1.95, 2.64]; or more than two mental health diagnoses, AOR = 2.29, 95% CI [1.93, 2.72]). Screening IPV+ was also associated with significantly higher odds of each type of mental health morbidity (AOR range = 1.85-3.19) except psychoses. Over half (53.5%) of the women who screened IPV+ had a mental health diagnosis, compared with fewer than one-third (32.6%) of those who screened IPV-. Each subtype of IPV (psychological, physical, and sexual violence) was significantly associated with having a mental health diagnosis (AOR range = 2.25-2.37) or comorbidity (AOR range = 2.17-2.78). Associations remained when adjusting for military sexual trauma and combat trauma among the veteran subsample. These findings highlight the mental health burden associated with past-year IPV among female VHA patients and underscore the need to address psychological and sexual IPV, in addition to physical violence. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Differences in Experiences With Care Between Homeless and Nonhomeless Patients in Veterans Affairs Facilities With Tailored and Nontailored Primary Care Teams.

PubMed

Jones, Audrey L; Hausmann, Leslie R M; Kertesz, Stefan; Suo, Ying; Cashy, John P; Mor, Maria K; Schaefer, James H; Gundlapalli, Adi V; Gordon, Adam J

2018-05-12

Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients. To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities). We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities. Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941). Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support. In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0). VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.

Restricted VH gene usage and generation of antibody diversity in rabbit.

PubMed

Knight, K L

1992-01-01

The presence of VHa allotypic specificities on nearly all rabbit Ig molecules has perplexed immunologists for many years. How could these allotypic specificities be inherited as if controlled by alleles if the germline has hundreds of VHa allotype-encoding genes and if most of these genes are used in VDJ gene rearrangements. I review recent data indicating that the allelic inheritance of the VHa allotypes can be explained by preferential utilization of the D-proximal VH gene VH1 in VDJ gene rearrangements. The preferential usage of one VH gene, however, limits the contribution of combinatorial joining of multiple VH, D and JH gene segments to the generation of antibody diversity. The roles of somatic gene conversion and somatic mutation in generating antibody diversity are discussed. Further, the limited usage of germline VH genes in normal, allotype-suppressed and the mutant Alicia rabbit as well as the molecular basis of latent allotypes and VH/CH recombinants is reviewed.

A System-Level Approach to Overweight and Obesity in the Veterans Health Administration.

PubMed

Raffa, Susan D; Maciejewski, Matthew L; Zimmerman, Lindsey E; Damschroder, Laura J; Estabrooks, Paul A; Ackermann, Ronald T; Tsai, Adam G; Histon, Trina; Goldstein, Michael G

2017-04-01

Healthcare systems are challenged by steady increases in the number of patients who are overweight and obese. Large-scale, evidence-based behavioral approaches for addressing overweight and obesity have been successfully implemented in systems such as the Veterans Health Administration (VHA). These population-based interventions target reduction in risk for obesity-associated conditions through lifestyle change and weight loss, and are associated with modest weight loss. Despite the fact that VHA has increased the overall reach of these behavioral interventions, the number of high-risk overweight and obese patients continues to rise. Recommendations for weight loss medications and bariatric surgery are included in clinical practice guidelines for the management of overweight and obesity, but these interventions are underutilized. During a recent state of the art conference on weight management held by VHA, subject matter experts identified challenges and gaps, as well as potential solutions and overarching policy recommendations, for implementing an integrated system-wide approach for improving population-based weight management.

PTSD Care Among Veterans With and Without Co-Occurring Substance Use Disorders.

PubMed

Mansfield, Alyssa J; Greenbaum, Mark A; Schaper, Kim M; Banducci, Anne N; Rosen, Craig S

2017-06-01

This study examined whether a co-occurring substance use disorder contributed to disparities in receipt of Veterans Health Administration (VHA) posttraumatic stress disorder (PTSD) specialty care or psychotherapy. Logistic regression, controlling for sociodemographic characteristics, was used to examine predictors of PTSD care among 424,211 veterans with confirmed PTSD (two or more PTSD diagnosis encounters) who accessed care in a VHA facility between fiscal years 2009 and 2010. Overall, 16% of veterans had PTSD and a co-occurring substance use disorder diagnosis. In adjusted analyses, veterans with a co-occurring substance use disorder were more likely than veterans with PTSD alone to receive any outpatient PTSD specialty care and complete eight or more sessions of outpatient psychotherapy within 14 weeks, but they were less likely to be treated in inpatient PTSD specialty units. Co-occurring substance use disorders did not appear to hinder receipt of outpatient specialty PTSD treatment or of sufficient psychotherapy among VHA-enrolled veterans.

Psychopharmacologic Services for Homeless Veterans: Comparing Psychotropic Prescription Fills Among Homeless and Non-Homeless Veterans with Serious Mental Illness.

PubMed

Hermes, Eric; Rosenheck, Robert

2016-02-01

Using national Veterans Health Administration (VHA) administrative data, this study evaluated differences in psychotropic medication use between homeless and non-homeless adults with serious mental illness (SMI) who used VHA services in 2010. The adjusted mean number of psychotropic prescription fills associated with homeless individuals were identified using regression models adjusted for socio-demographics, diagnoses, and use of health services. Of the 876,989 individuals with SMI using VHA services, 7.2 % were homeless at some time during 2010. In bivariate analysis, homeless individuals filled more psychotropic medication prescriptions compared with non-homeless individuals. However, after adjusting for potentially confounding variables, homeless individuals were found to have filled 16.2 % fewer prescriptions than non-homeless individuals when all psychotropics were analyzed together (F = 6947.1, p < .001) and for most individual classes of psychotropics. Greater use of residential/inpatient mental health services by the homeless was the most important single factor associated with filling more psychotropic prescriptions than non-homeless individuals.

Redesign of a computerized clinical reminder for colorectal cancer screening: a human-computer interaction evaluation

PubMed Central

2011-01-01

Background Based on barriers to the use of computerized clinical decision support (CDS) learned in an earlier field study, we prototyped design enhancements to the Veterans Health Administration's (VHA's) colorectal cancer (CRC) screening clinical reminder to compare against the VHA's current CRC reminder. Methods In a controlled simulation experiment, 12 primary care providers (PCPs) used prototypes of the current and redesigned CRC screening reminder in a within-subject comparison. Quantitative measurements were based on a usability survey, workload assessment instrument, and workflow integration survey. We also collected qualitative data on both designs. Results Design enhancements to the VHA's existing CRC screening clinical reminder positively impacted aspects of usability and workflow integration but not workload. The qualitative analysis revealed broad support across participants for the design enhancements with specific suggestions for improving the reminder further. Conclusions This study demonstrates the value of a human-computer interaction evaluation in informing the redesign of information tools to foster uptake, integration into workflow, and use in clinical practice. PMID:22126324

Educational Preferences and Outcomes From Suicide Prevention Training in the Veterans Health Administration: One-Year Follow-Up With Healthcare Employees in Upstate New York

PubMed Central

Matthieu, Monica M.; Chen, Yufei; Schohn, Mary; Lantinga, Larry J.; Knox, Kerry L.

2016-01-01

This study identifies training outcomes and educational preferences of employees who work within the Veterans Health Administration (VHA). Using a longitudinal pre-postsurvey design, 71 employees from one geographic region of VHA healthcare facilities participated in an evaluation of a brief standardized gatekeeper program and a needs assessment on training preferences for suicide and suicide prevention. Results indicate significant differences in knowledge and self-efficacy from pre to post (p < 0.001), although only self-efficacy remained significant at 1 year follow-up, (M = 3.01; SD = 0.87) as compared to pretraining (M = 2.50, SD = 1.05) (t = −5.64, p < 0.001). At post-training, 90% of the participants were willing to learn more about suicide, with 88% willing to spend more than 1 hour in future training activities on more advanced topics. This training program can increase the knowledge and abilities of VHA staff to engage, identify, and refer veterans at risk for suicide to appropriate care. PMID:19960817

Decreasing Physical Inactivity in the Veterans Health Administration Employee Population.

PubMed

Schult, Tamara M; Schmunk, Sandra K; Awosika, Ebi R

2016-12-01

The aim of this study was to describe a comprehensive approach to decrease physical inactivity in the Veterans Health Administration (VHA) employee population. The approach included (1) initiatives to decrease physical inactivity in the workplace; (2) two operational surveys to assess system-wide service provision; and (3) two national employee surveys. From 2010 to 2012, 86 employee fitness centers were completed in VA medical centers. A grants program (2010 to 2015) funded smaller projects designed to decrease physical inactivity in the workplace. Projects involved the provision of equipment to decrease sedentary behaviors, including stability balls, treadmill and sit-to-stand desks, stairwell projects, and funding for on-site fitness classes, bicycle racks, and outdoor par courses and walking paths among others. A comprehensive approach to decrease physical inactivity in VHA employees was successful. Overall, self-reported, age-adjusted physical inactivity in VHA employees decreased from 25.3% in 2010 to 16.1% in 2015.

Coral host cells acidify symbiotic algal microenvironment to promote photosynthesis

PubMed Central

Barott, Katie L.; Venn, Alexander A.; Perez, Sidney O.; Tambutté, Sylvie; Tresguerres, Martin

2015-01-01

Symbiotic dinoflagellate algae residing inside coral tissues supply the host with the majority of their energy requirements through the translocation of photosynthetically fixed carbon. The algae, in turn, rely on the host for the supply of inorganic carbon. Carbon must be concentrated as CO2 in order for photosynthesis to proceed, and here we show that the coral host plays an active role in this process. The host-derived symbiosome membrane surrounding the algae abundantly expresses vacuolar H+-ATPase (VHA), which acidifies the symbiosome space down to pH ∼4. Inhibition of VHA results in a significant decrease in average H+ activity in the symbiosome of up to 75% and a significant reduction in O2 production rate, a measure of photosynthetic activity. These results suggest that host VHA is part of a previously unidentified carbon concentrating mechanism for algal photosynthesis and provide mechanistic evidence that coral host cells can actively modulate the physiology of their symbionts. PMID:25548188

Telehealth forging ahead: overcoming barriers in licensure to improve access to care for service members.

PubMed

Stout, Katie Ambrose; Martinez, Kristina

2011-01-01

The telehealth initiatives of the Department of Defense (DoD) and Veterans' Health Administration (VHA) continue to test the limits of technology to provide the best care to our service members, veterans and their families. The DoD and VHA have credentialing systems in place to allow clinical practice between facilities. New legislation in the form of the Servicemembers' Telemedicine and E-Health Portability (STEP) Act will potentially expand telehealth clinical services across state lines into the homes of our service members and veterans.

Barriers, facilitators, and benefits of implementation of dialectical behavior therapy in routine care: results from a national program evaluation survey in the Veterans Health Administration.

PubMed

Landes, Sara J; Rodriguez, Allison L; Smith, Brandy N; Matthieu, Monica M; Trent, Lindsay R; Kemp, Janet; Thompson, Caitlin

2017-12-01

National implementation of evidence-based psychotherapies (EBPs) in the Veterans Health Administration (VHA) provides important lessons on the barriers and facilitators to implementation in a large healthcare system. Little is known about barriers and facilitators to the implementation of a complex EBP for emotional and behavioral dysregulation-dialectical behavioral therapy (DBT). The purpose of this study was to understand VHA clinicians' experiences with barriers, facilitators, and benefits from implementing DBT into routine care. This national program evaluation survey measured site characteristics of VHA sites (N = 59) that had implemented DBT. DBT was most often implemented in general mental health outpatient clinics. While 42% of sites offered all four modes of DBT, skills group was the most frequently implemented mode. Fifty-nine percent of sites offered phone coaching in any form, yet only 11% of those offered it all the time. Providers were often provided little to no time to support implementation of DBT. Barriers that were difficult to overcome were related to phone coaching outside of business hours. Facilitators to implementation included staff interest and expertise. Perceived benefits included increased hope and functioning for clients, greater self-efficacy and compassion for providers, and ability to treat unique symptoms for clinics. There was considerable variability in the capacity to address implementation barriers among sites implementing DBT in VHA routine care. Mental health policy makers should note the barriers and facilitators reported here, with specific attention to phone coaching barriers.

Mental Health Service Utilization before and after Receipt of a Service-Connected Disability Award for PTSD: Findings from a National Sample.

PubMed

Sripada, Rebecca K; Hannemann, Claire M; Schnurr, Paula P; Marx, Brian P; Pollack, Stacey J; McCarthy, John F

2018-04-17

To determine patterns of mental health service use before and after VA disability compensation awards for posttraumatic stress disorder (PTSD). A 10 percent random sample of VHA-enrolled Veterans with new or increased PTSD service connection between 2012 and 2014 (n = 22,249). We used latent trajectory analysis to identify utilization patterns and multinomial logistic regression to assess associations between Veteran characteristics and trajectory membership. We assessed receipt of VHA mental health encounters in each of the 52 weeks prior to and following PTSD disability rating or rating increase. The best fitting model had five groups: No Use (36.6 percent), Low Use (37.7 percent), Increasing Use (9.4 percent), Decreasing Use (11.2 percent), and High Use (5.1 percent). Adjusting for demographic characteristics and compared with the No Use group, Veterans in the other groups were more likely to reside closer to a VHA facility, receive a higher PTSD disability rating, and screen positive for military sexual trauma. Service use remained stable (80 percent) or increased (9 percent) for the vast majority of Veterans. Service utilization declined for only 11 percent. Data did not indicate substantial service discontinuation following rating. Low VHA service utilization suggests opportunities to enhance outreach for Veterans with PTSD-related disability benefits. © Published 2018. This article is a U.S. Government work and is in the public domain in the USA.

The impact of a national prescription drug formulary on prices, market share, and spending: lessons for Medicare?

PubMed

Huskamp, Haiden A; Epstein, Arnold M; Blumenthal, David

2003-01-01

Several recent bills in Congress to add a Medicare prescription drug benefit would allow the use of formularies to control costs. However, there is little empirical evidence of the impact of formularies among elderly and disabled populations. We assess the effect of a closed formulary implemented by the Veterans Health Administration (VHA) in 1997 on drug prices, market share, and drug spending. We find that the VHA National Formulary was effective at shifting prescribing behavior toward the selected drugs, achieving sizable price reductions from manufacturers, and greatly decreasing drug spending.

Informatics can identify systemic sclerosis (SSc) patients at risk for scleroderma renal crisis

PubMed Central

Redd, Doug; Frech, Tracy M.; Murtaugh, Maureen A.; Rhiannon, Julia; Zeng, Qing T.

2016-01-01

Background Electronic medical records (EMR) provide an ideal opportunity for the detection, diagnosis, and management of systemic sclerosis (SSc) patients within the Veterans Health Administration (VHA). The objective of this project was to use informatics to identify potential SSc patients in the VHA that were on prednisone, in order to inform an outreach project to prevent scleroderma renal crisis (SRC). Methods The electronic medical data for this study came from Veterans Informatics and Computing Infrastructure (VINCI). For natural language processing (NLP) analysis, a set of retrieval criteria was developed for documents expected to have a high correlation to SSc. The two annotators reviewed the ratings to assemble a single adjudicated set of ratings, from which a support vector machine (SVM) based document classifier was trained. Any patient having at least one document positively classified for SSc was considered positive for SSc and the use of prednisone ≥ 10 mg in the clinical document was reviewed to determine whether it was an active medication on the prescription list. Results In the VHA, there were 4,272 patients that have a diagnosis of SSc determined by the presence of an ICD-9 code. From these patients, 1,118 patients (21%) had the use of prednisone ≥_10 mg. Of these patients, 26 had a concurrent diagnosis of hypertension, thus these patients should not be on prednisone. By the use of natural language processing (NLP) an additional 16,522 patients were identified as possible SSc, highlighting that cases of SSc in the VHA may exist that are unidentified by ICD-9. A 10-fold cross validation of the classifier resulted in a precision (positive predictive value) of 0.814, recall (sensitivity) of 0.973, and f-measure of 0.873. Conclusions Our study demonstrated that current clinical practice in the VHA includes the potentially dangerous use of prednisone for veterans with SSc. This present study also suggests there may be many undetected cases of SSc

Informatics can identify systemic sclerosis (SSc) patients at risk for scleroderma renal crisis.

PubMed

Redd, Doug; Frech, Tracy M; Murtaugh, Maureen A; Rhiannon, Julia; Zeng, Qing T

2014-10-01

Electronic medical records (EMR) provide an ideal opportunity for the detection, diagnosis, and management of systemic sclerosis (SSc) patients within the Veterans Health Administration (VHA). The objective of this project was to use informatics to identify potential SSc patients in the VHA that were on prednisone, in order to inform an outreach project to prevent scleroderma renal crisis (SRC). The electronic medical data for this study came from Veterans Informatics and Computing Infrastructure (VINCI). For natural language processing (NLP) analysis, a set of retrieval criteria was developed for documents expected to have a high correlation to SSc. The two annotators reviewed the ratings to assemble a single adjudicated set of ratings, from which a support vector machine (SVM) based document classifier was trained. Any patient having at least one document positively classified for SSc was considered positive for SSc and the use of prednisone≥10mg in the clinical document was reviewed to determine whether it was an active medication on the prescription list. In the VHA, there were 4272 patients that have a diagnosis of SSc determined by the presence of an ICD-9 code. From these patients, 1118 patients (21%) had the use of prednisone≥10mg. Of these patients, 26 had a concurrent diagnosis of hypertension, thus these patients should not be on prednisone. By the use of natural language processing (NLP) an additional 16,522 patients were identified as possible SSc, highlighting that cases of SSc in the VHA may exist that are unidentified by ICD-9. A 10-fold cross validation of the classifier resulted in a precision (positive predictive value) of 0.814, recall (sensitivity) of 0.973, and f-measure of 0.873. Our study demonstrated that current clinical practice in the VHA includes the potentially dangerous use of prednisone for veterans with SSc. This present study also suggests there may be many undetected cases of SSc and NLP can successfully identify these

Sleep Disturbance Preceding Suicide Among Veterans

PubMed Central

Britton, Peter C.; Ilgen, Mark A.; Chapman, Ben; Conner, Kenneth R.

2012-01-01

Objectives. We examined the role of sleep disturbance in time to suicide since the last treatment visit among veterans receiving Veterans Health Administration (VHA) services. Methods. Among 423 veteran suicide decedents from 2 geographic areas, systematic chart reviews were conducted on the 381 (90.1%) who had a VHA visit in the last year of life. Veteran suicides with a documented sleep disturbance (45.4%) were compared with those without sleep disturbance (54.6%) on time to death since their last VHA visit using an accelerated failure time model. Results. Veterans with sleep disturbance died sooner after their last visit than did those without sleep disturbance, after we adjusted for the presence of mental health or substance use symptoms, age, and region. Conclusions. Findings indicated that sleep disturbance was associated with time to suicide in this sample of veterans who died by suicide. The findings had implications for using the presence of sleep disturbance to detect near-term risk for suicide and suggested that sleep disturbance might provide an important intervention target for a subgroup of at-risk veterans. PMID:22390611

PA and NP productivity in the Veterans Health Administration.

PubMed

Moran, Eileen A; Basa, Edesha; Gao, Jian; Woodmansee, Denni; Almenoff, Peter L; Hooker, Roderick S

2016-07-01

This study assessed the 2014 clinical productivity of 5,959 physician assistants (PAs) and nurse practitioners (NPs) in the US Department of Veterans Affairs' Veterans Health Administration (VHA). Total work relative value units divided by the direct clinical full-time equivalent measured annual productivity, and correlated factors were examined using weighted analysis of variance. PAs and NPs in adult primary care roles were more productive than those in other specialties. Both providers were more productive in rural than in nonrural settings and less productive in teaching than nonteaching hospitals. Men were slightly more productive than women but age and years of VHA employment were not correlates of productivity. PAs were more productive when their scope of practice allowed significant autonomy; NP productivity was unaffected by supervisory requirements. PAs and NPs are an important component of the VHA provider workforce, and their productivity correlates with a number of factors. More organizational research is necessary to better understand the contributing roles PAs and NPs provide in a rapidly evolving, vertically integrated, national health delivery system.

Patient-centered medical home initiative produced modest economic results for Veterans Health Administration, 2010-12.

PubMed

Hebert, Paul L; Liu, Chuan-Fen; Wong, Edwin S; Hernandez, Susan E; Batten, Adam; Lo, Sophie; Lemon, Jaclyn M; Conrad, Douglas A; Grembowski, David; Nelson, Karin; Fihn, Stephan D

2014-06-01

In 2010 the Veterans Health Administration (VHA) began a nationwide initiative called Patient Aligned Care Teams (PACT) that reorganized care at all VHA primary care clinics in accordance with the patient-centered medical home model. We analyzed data for fiscal years 2003-12 to assess how trends in health care use and costs changed after the implementation of PACT. We found that PACT was associated with modest increases in primary care visits and with modest decreases in both hospitalizations for ambulatory care-sensitive conditions and outpatient visits with mental health specialists. We estimated that these changes avoided $596 million in costs, compared to the investment in PACT of $774 million, for a potential net loss of $178 million in the study period. Although PACT has not generated a positive return, it is still maturing, and trends in costs and use are favorable. Adopting patient-centered care does not appear to have been a major financial risk for the VHA. Project HOPE—The People-to-People Health Foundation, Inc.

Teleretinal Imaging to Screen for Diabetic Retinopathy in the Veterans Health Administration

PubMed Central

Cavallerano, Anthony A.; Conlin, Paul R.

2008-01-01

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. PMID:19885175

Implementation of an established algorithm and modifications for the identification of epilepsy patients in the veterans health administration.

PubMed

Rehman, Rizwana; Everhart, Amanda; Frontera, Alfred T; Kelly, Pamela R; Lopez, Maria; Riley, Denise; Sajan, Sheela; Schooff, David M; Tran, Tung T; Husain, Aatif M

2016-11-01

Identification of epilepsy patients from administrative data in large managed healthcare organizations is a challenging task. The objectives of this report are to describe the implementation of an established algorithm and different modifications for the estimation of epilepsy prevalence in the Veterans Health Administration (VHA). For the prevalence estimation during a given time period patients prescribed anti-epileptic drugs and having seizure diagnoses on clinical encounters were identified. In contrast to the established algorithm, which required inclusion of diagnoses data from the time period of interest only, variants were tested by considering diagnoses data beyond prevalence period for improving sensitivity. One variant excluded data from diagnostic EEG and LTM clinics to improve specificity. Another modification also required documentation of seizures on the problem list (electronic list of patients' established diagnoses). Of the variants tested, the one excluding information from diagnostic clinics and extending time beyond base period of interest for clinical encounters was determined to be superior. It can be inferred that the number of patients receiving care for epilepsy in the VHA ranges between 74,000 and 87,000. In the wake of the recent implementation of ICD-10 codes in the VHA, minor tweaks are needed for future prevalence estimation due to significant efforts presented. This review is not only beneficial for researchers interested in VHA related data but can also be helpful for managed healthcare organizations involved in epilepsy care aiming at accurate identification of patients from large administrative databases. Published by Elsevier B.V.

Factor structure of posttraumatic stress disorder symptoms in OEF/OIF veterans presenting to a polytrauma clinic.

PubMed

Maestas, Kacey Little; Benge, Jared F; Pastorek, Nicholas J; Lemaire, Ashley; Darrow, Rachel

2011-11-01

A significant number of Operation Iraqi Freedom/Operation Enduring Freedom (OEF/OIF) veterans are returning from deployment and presenting to Veterans Health Administration (VHA) polytrauma clinics with elevated rates of posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI). Inherent to the accurate assessment and treatment of this diagnostically complex group of veterans is the assumption that the construct of PTSD is the same in this population as in other trauma groups. To our knowledge, no previous study has examined the structure of PTSD in this relevant and fast-growing population of treatment-seeking OEF/OIF veterans. Evidence suggests that the latent structure of PTSD symptoms is best represented by a four-factor model, rather than the three-factor model found in the current DSM-IV-TR. Thus, we examined the three and four-factor models using the PTSD Check List-Civilian (PCL-C) in a sample of treatment-seeking OEF/OIF veterans seen through a VHA polytrauma clinic. A chart review was conducted for OEF/OIF veterans (N = 361) seen through a VHA outpatient polytrauma clinic from September 2007 through August 2008. Participants completed the PCL-C as part of a comprehensive polytrauma evaluation. Confirmatory factor analyses showed that the DSM-IV-TR three-factor model did not fit the data well. A direct comparison showed that the four-factor model provided a superior fit relative to the three-factor model. Results extend the generalizability of the four-factor model to OEF/OIF veterans presenting to Veterans Health Administration (VHA) polytrauma clinics.

Telemental health for our soldiers: a brief review and a new pilot program.

PubMed

Nieves, J Edwin; Candelario, Joseph; Short, Delmar; Briscoe, Gregory

2009-12-01

This small but significant telemental health clinical pilot could easily serve as a "best practice" model for resource utilization between the nation's VHA/DOD institutions that wish to form partnerships and capitalize on resources. It demonstrates several potential areas of collaboration for TMH projects. For example, this study also points out requisite preparation needs, e.g., an information technology (IT) needs assessment, and gap analysis between neighboring VHA/DOD installations should be considered beforehand. This would address equipment compatibility and address protected health information privacy concerns. This preparation would also lead to savings by avoiding equipment redundancy and minimize infrastructure (space) investment. While in this instance the equipment proved compatible, that may not always be the case. Second, regional strategic mapping of staff and services between institutions could help in specialty service utilization. This would improve recourse allocation, trim numerous costs, and avoid service duplication. A third area of collaboration would be the creation of a DOD/VHA electronic credentialing packet. This would simplify the preparation phase for TMH delivery and expand the availability of scarce medical specialty consultants for both the VHA and DOD. This would serve to streamline medical care and expedite the deployment of "virtual" practitioners in the event of a national disaster or emergency. To date there have not been any technical difficulties at either site and PC-PTSD-positive soldiers continue to be evaluated at the SVMAC. Anecdotal reports from both clinicians and patients are that they are highly satisfied with TMH delivery services.

The petrology and geochemistry of impact melts, granulites, and hornfelses from consortium breccia 61175

NASA Technical Reports Server (NTRS)

Winzer, S. R.; Meyerhoff, M.; Nava, D. F.; Schuhmann, S.; Philpotts, J. A.; Lindstrom, D. J.; Lum, R. K. L.; Lindstrom, M. M.; Schuhmann, P.

1977-01-01

The matrix and 58 clasts from breccia 61175 were analyzed for major, minor, and trace elements. The matrix is anorthositic and has lithophile trace element abundances 20 to 40 times chondrite. Clasts comprise impact melt rocks, xenocryst and xenolith-free very high aluminum (VHA) and anorthositic basalts, anorthosite, anorthosite-norite-troctolite granulites, and hornfelses. The VHA and anorthositic basalts are considered to be impact melts, and the hornfelses were probably formed by incorporation of breccias or preexisting melt rocks into a melt sheet prior to cooling. The range of melt-rock lithophile trace element abundances might indicate more than one melt sheet.

Hospital CEOs' priorities and perceptions regarding industry issues and the Virginia Hospital Association's activities.

PubMed

McDermott, D R; Gerardo, E F; Duguid, D A; Cooning, P J

1991-01-01

Based on a survey of Virginia hospital CEOs, it was revealed that four industry issues are causing a high degree of concern, namely Medicare/Medicaid reimbursement policies, personnel shortages, indigent care, and increased operating expenses. Each of these issues will be discussed regarding the VHA's activities to devise possible solutions. Regarding Medicare, the VHA has worked closely with the American Hospital Association in their federal advocacy efforts encouraging members to write, call, and visit their Congressional representatives to persuade them to pass legislation increasing the Medicare budget. Regarding Medicaid, which is administered by each state and in Virginia involves a 50/50 sharing of the funding between the federal and state governments, the VHA has challenged what it believes to be an illegal hospital reimbursement system through the federal judicial system. While the process is continuing, the VHA is encouraged by the U.S. Supreme Court's decision (July 1990) affirming hospitals' and all other health care providers' right, to pursue via the judicial process their allegation that a state is violating federal law by setting inadequate and inequitable Medicaid reimbursement rates to hospitals. In order to address the personnel shortages issue, the VHA has actively addressed recruitment and retention challenges by establishing a Health Manpower Resource Center and hiring a full-time director. This office targets high school students, second-career adults, and current health care professionals through communication and education programs. The area of indigent care represents one of the VHA's most notable achievements to date. This entails the recent Virginia legislation creating the Indigent Care Trust Fund. This fund's initial amount is some $15 million and represents an approximate 60/40 contribution ratio involving both the State of Virginia and hospitals in Virginia. A formula has been developed for each hospital in Virginia to assess how

Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use.

PubMed

Nelson, Karin M; Helfrich, Christian; Sun, Haili; Hebert, Paul L; Liu, Chuan-Fen; Dolan, Emily; Taylor, Leslie; Wong, Edwin; Maynard, Charles; Hernandez, Susan E; Sanders, William; Randall, Ian; Curtis, Idamay; Schectman, Gordon; Stark, Richard; Fihn, Stephan D

2014-08-01

In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation. To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes. We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care. Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout. Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency

Reduced cost and mortality using home telehealth to promote self-management of complex chronic conditions: a retrospective matched cohort study of 4,999 veteran patients.

PubMed

Darkins, Adam; Kendall, Stephen; Edmonson, Ellen; Young, Michele; Stressel, Pamela

2015-01-01

This retrospective analysis of 2009-2012 Veterans Health Administration (VHA) administrative data assessed the efficacy of care coordination home telehealth (CCHT), a model of care designed to reduce institutional care. Outcomes for 4,999 CCHT-non-institutional care (NIC) patients were compared with usual (non-CCHT) care in a matched cohort group (MCG) of 183,872 Veterans. Both cohorts were comprised of patients with complex chronic conditions with statistically similar baseline (pre-CCHT enrollment) healthcare costs, when adjusted for age, sex, chronic disease, emergency room (ER) visits, hospital admissions, hospital lengths of stay, and pharmacy costs. Subsequent analyses after 12 months of CCHT-NIC enrollment showed mean annual healthcare costs for CCHT-NIC patients fell 4%, from $21,071 to $20,206, whereas the corresponding costs for MCG patients increased 48%, from $20,937 to $31,055. Higher mean annual pharmacy expenditure of 22% ($470 over baseline) for CCHT-NIC patients versus 15% for MCG patients ($326 over baseline) was attributable to the medication compliance effect of better care coordination. Several healthcare cost drivers (e.g., ER visits and admissions) had sizable declines in the CCHT-NIC group. Medicare usage review in both cohorts excluded this as a confounding factor in cost analyses. Prefinal case selection criteria analysis of both cohorts yielded a 9.8% mortality rate in CCHT patients versus 16.58% in non-CCHT patients. This study corroborates previous positive VHA analyses of CCHT but contradicts results from recent non-VHA studies, highlighting the efficacy of the VHA's standardized CCHT model, which incorporates a biopsychosocial approach to care that emphasizes patient self-management.

Addressing the Needs of Transgender Military Veterans: Better Access and More Comprehensive Care.

PubMed

Dietert, Michelle; Dentice, Dianne; Keig, Zander

2017-01-01

Purpose: There is a gap in social science literature addressing issues of access and quality of care for transgender military veterans. Psychologists, medical doctors, and other health professionals are beginning to address some of the barriers present in the Department of Veterans Affairs (VA) system that affect veterans who are also transgender and intersex. Over a 7-year period, between 2006 and 2013, 2600 transgender veterans were served by the VA. Data from several surveys revealed that most transgender veterans perceive the Veterans Health Administration (VHA) to be less than accommodating for their special needs. The goal of this study was to investigate the experiences of a sample of transgender veterans with regard to their experiences with healthcare services provided by the VHA. Methods: Using snowball sampling techniques, we were able to recruit 22 transgender military veterans to participate in our study. A combination of telephone interviews and questionnaires provided data from veterans in various branches of the military throughout the United States. Results: Findings indicate that even though the VHA is working to address issues of inequality for transgender veterans, our participants indicated that there are still some problems with administration of care, proper training of staff and physicians, and availability of comprehensive services for the unique healthcare needs of transgender individuals. Conclusion: Since our data were collected, the VA has worked to bridge the gap by focusing on increased training for VHA providers and staff and establishing LGBT programs at VA facilities. However, we suggest that one key area of importance should continue to focus on how mental health and medical providers and ancillary staff are trained to interact with and provide care for their transgender patients.

Provider practices in the primary care behavioral health (PCBH) model: an initial examination in the Veterans Health Administration and United States Air Force.

PubMed

Funderburk, Jennifer S; Dobmeyer, Anne C; Hunter, Christopher L; Walsh, Christine O; Maisto, Stephen A

2013-12-01

The goals of this study were to identify characteristics of both behavioral health providers (BHPs) and the patients seen in a primary care behavioral health (PCBH) model of service delivery using prospective data obtained from BHPs. A secondary objective was to explore similarities and differences between these variables within the Veterans Health Administration (VHA) and United States Air Force (USAF) primary care clinics. A total of 159 VHA and 23 USAF BHPs, representing almost every state in the United States, completed the study, yielding data from 403 patient appointments. BHPs completed a web-based questionnaire that assessed BHP and setting characteristics, and a separate questionnaire after each patient seen on one day of clinical service. Data demonstrated that there are many similarities between the VHA and USAF BHPs and practices. Both systems tend to use well-trained psychologists as BHPs, had systems that support the BHP being in close proximity to the primary care providers, and have seamless operational elements (i.e., shared record, one waiting room, same-day appointments, and administrative support for BHPs). Comorbid anxiety and depression was the most common presenting problem in both systems, but overall rates were higher in VHA clinics, and patients were significantly more likely to meet diagnostic criteria for mental health conditions. This study provides the first systematic, prospective examination of BHPs and practices within a PCBH model of service delivery in two large health systems with well over 5 years of experience with behavioral health integration. Many elements of the PCBH model were implemented in a manner consistent with the model, although some variability exists within both settings. These data can help guide future implementation and training efforts.

Rationale and study design of a trial of mindfulness-based cognitive therapy for preventing suicidal behavior (MBCT-S) in military veterans.

PubMed

Kline, Anna; Chesin, Megan; Latorre, Miriam; Miller, Rachael; St Hill, Lauren; Shcherbakov, Anton; King, Arlene; Stanley, Barbara; Weiner, Marc D; Interian, Alejandro

2016-09-01

Although suicide ranks 10th as a cause of death in the United States, and 1st among active military personnel, there are surprisingly few evidence-based therapies addressing suicidality, and development of new treatments is limited. This paper describes a clinical trial testing a novel therapy for reducing suicide risk in military veterans. The intervention, Mindfulness-Based Cognitive Therapy for Preventing Suicide Behavior (MBCT-S), is a 10-week group intervention adapted from an existing treatment for depression (Mindfulness-Based Cognitive Therapy - MBCT). MBCT-S incorporates the Safety Planning Intervention, which is currently implemented throughout the Veterans Health Administration (VHA) for veterans at high suicide risk. MBCT-S is being tested in a VHA setting using an intention-to-treat, two-group randomized trial design in which 164 high suicide risk veterans are randomized to either VHA Treatment As Usual (TAU; n=82) or TAU+MBCT-S (n=82). Our primary outcome measure, suicide-related event, defined to include suicide preparatory behaviors, self-harm behavior with suicidal or indeterminate intent, suicide-related hospitalizations and Emergency Department (ED) visits, will be measured through five assessments administered by blinded assessors between baseline and 12months post-baseline. We will measure suicide attempts and suicide deaths as a secondary outcome, because of their anticipated low incidence during the study period. Secondary outcomes also include severity of suicidal ideation, hopelessness and depression. This study has the potential to significantly enhance the quality and efficiency of VHA care for veterans at suicide risk and to substantially improve the quality of life for veterans and their families. Copyright © 2016 Elsevier Inc. All rights reserved.

Pregnancy and Mental Health Among Women Veterans Returning from Iraq and Afghanistan

PubMed Central

Skanderson, Melissa; Goulet, Joseph L.; Brandt, Cynthia; Womack, Julie; Krebs, Erin; Desai, Rani; Justice, Amy; Yano, Elizabeth; Haskell, Sally

2010-01-01

Abstract Background Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) may experience significant stress during military service that can have lingering effects. Little is known about mental health problems or treatment among pregnant OEF/OIF women veterans. The aim of this study was to determine the prevalence of mental health problems among veterans who received pregnancy-related care in the Veterans Health Administration (VHA) system. Methods Data from the Defense Manpower Data Center (DMDC) deployment roster of military discharges from October 1, 2001, through April 30, 2008, were used to assemble an administrative cohort of female OEF/OIF veterans enrolled in care at the VHA (n = 43,078). Pregnancy and mental health conditions were quantified according to ICD-9-CM codes and specifications. Mental healthcare use and prenatal care were assessed by analyzing VHA stop codes. Results During the study period, 2966 (7%) women received at least one episode of pregnancy-related care, and 32% of veterans with a pregnancy and 21% without a pregnancy received one or more mental health diagnoses (p < 0.0001). Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, or schizophrenia as those without a pregnancy. Conclusions Women OEF/OIF veterans commonly experience mental health problems after military service. The burden of mental health conditions is higher among women with an identified instance of pregnancy than among those without. Because women do not receive pregnancy care at the VHA, however, little is known about ongoing concomitant prenatal and mental healthcare or about pregnancy outcomes among these women veterans. PMID:21039234

Reducing Avoidable Deaths Among Veterans: Directing Private-Sector Surgical Care to High-Performance Hospitals

PubMed Central

Weeks, William B.; West, Alan N.; Wallace, Amy E.; Lee, Richard E.; Goodman, David C.; Dimick, Justin B.; Bagian, James P.

2007-01-01

Objectives. We quantified older (65 years and older) Veterans Health Administration (VHA) patients’ use of the private sector to obtain 14 surgical procedures and assessed the potential impact of directing that care to high-performance hospitals. Methods. Using a merged VHA–Medicare inpatient database for 2000 and 2001, we determined where older VHA enrollees obtained 6 cardiovascular surgeries and 8 cancer resections and whether private-sector care was obtained in high- or low-performance hospitals (based on historical performance and determined 2 years in advance of the service year). We then modeled the mortality and travel burden effect of directing private-sector care to high-performance hospitals. Results. Older veterans obtained most of their procedures in the private sector, but that care was equally distributed across high- and low-performance hospitals. Directing private-sector care to high-performance hospitals could have led to the avoidance of 376 to 584 deaths, most through improved cardiovascular care outcomes. Using historical mortality to define performance would produce better outcomes with lower travel time. Conclusions. Policy that directs older VHA enrollees’ private-sector care to high-performance hospitals promises to reduce mortality for VHA’s service population and warrants further exploration. PMID:17971543

Predictive Modeling and Concentration of the Risk of Suicide: Implications for Preventive Interventions in the US Department of Veterans Affairs

PubMed Central

McCarthy, John F.; Katz, Ira R.; Thompson, Caitlin; Kemp, Janet; Hannemann, Claire M.; Nielson, Christopher; Schoenbaum, Michael

2015-01-01

Objectives. The Veterans Health Administration (VHA) evaluated the use of predictive modeling to identify patients at risk for suicide and to supplement ongoing care with risk-stratified interventions. Methods. Suicide data came from the National Death Index. Predictors were measures from VHA clinical records incorporating patient-months from October 1, 2008, to September 30, 2011, for all suicide decedents and 1% of living patients, divided randomly into development and validation samples. We used data on all patients alive on September 30, 2010, to evaluate predictions of suicide risk over 1 year. Results. Modeling demonstrated that suicide rates were 82 and 60 times greater than the rate in the overall sample in the highest 0.01% stratum for calculated risk for the development and validation samples, respectively; 39 and 30 times greater in the highest 0.10%; 14 and 12 times greater in the highest 1.00%; and 6.3 and 5.7 times greater in the highest 5.00%. Conclusions. Predictive modeling can identify high-risk patients who were not identified on clinical grounds. VHA is developing modeling to enhance clinical care and to guide the delivery of preventive interventions. PMID:26066914

Predictive Modeling and Concentration of the Risk of Suicide: Implications for Preventive Interventions in the US Department of Veterans Affairs.

PubMed

McCarthy, John F; Bossarte, Robert M; Katz, Ira R; Thompson, Caitlin; Kemp, Janet; Hannemann, Claire M; Nielson, Christopher; Schoenbaum, Michael

2015-09-01

The Veterans Health Administration (VHA) evaluated the use of predictive modeling to identify patients at risk for suicide and to supplement ongoing care with risk-stratified interventions. Suicide data came from the National Death Index. Predictors were measures from VHA clinical records incorporating patient-months from October 1, 2008, to September 30, 2011, for all suicide decedents and 1% of living patients, divided randomly into development and validation samples. We used data on all patients alive on September 30, 2010, to evaluate predictions of suicide risk over 1 year. Modeling demonstrated that suicide rates were 82 and 60 times greater than the rate in the overall sample in the highest 0.01% stratum for calculated risk for the development and validation samples, respectively; 39 and 30 times greater in the highest 0.10%; 14 and 12 times greater in the highest 1.00%; and 6.3 and 5.7 times greater in the highest 5.00%. Predictive modeling can identify high-risk patients who were not identified on clinical grounds. VHA is developing modeling to enhance clinical care and to guide the delivery of preventive interventions.

Addressing the Needs of Transgender Military Veterans: Better Access and More Comprehensive Care

PubMed Central

Dietert, Michelle; Dentice, Dianne; Keig, Zander

2017-01-01

Abstract Purpose: There is a gap in social science literature addressing issues of access and quality of care for transgender military veterans. Psychologists, medical doctors, and other health professionals are beginning to address some of the barriers present in the Department of Veterans Affairs (VA) system that affect veterans who are also transgender and intersex. Over a 7-year period, between 2006 and 2013, 2600 transgender veterans were served by the VA. Data from several surveys revealed that most transgender veterans perceive the Veterans Health Administration (VHA) to be less than accommodating for their special needs. The goal of this study was to investigate the experiences of a sample of transgender veterans with regard to their experiences with healthcare services provided by the VHA. Methods: Using snowball sampling techniques, we were able to recruit 22 transgender military veterans to participate in our study. A combination of telephone interviews and questionnaires provided data from veterans in various branches of the military throughout the United States. Results: Findings indicate that even though the VHA is working to address issues of inequality for transgender veterans, our participants indicated that there are still some problems with administration of care, proper training of staff and physicians, and availability of comprehensive services for the unique healthcare needs of transgender individuals. Conclusion: Since our data were collected, the VA has worked to bridge the gap by focusing on increased training for VHA providers and staff and establishing LGBT programs at VA facilities. However, we suggest that one key area of importance should continue to focus on how mental health and medical providers and ancillary staff are trained to interact with and provide care for their transgender patients. PMID:28861546

Innovation in a Learning Health Care System: Veteran-Directed Home- and Community-Based Services.

PubMed

Garrido, Melissa M; Allman, Richard M; Pizer, Steven D; Rudolph, James L; Thomas, Kali S; Sperber, Nina R; Van Houtven, Courtney H; Frakt, Austin B

2017-11-01

A path-breaking example of the interplay between geriatrics and learning healthcare systems is the Veterans Health Administration's (VHA's) planned roll-out of a program for providing participant-directed home- and community-based services to veterans with cognitive and functional limitations. We describe the design of a large-scale, stepped-wedge, cluster-randomized trial of the Veteran-Directed Home- and Community-Based Services (VD-HCBS) program. From March 2017 through December 2019, up to 77 Veterans Affairs Medical Centers will be randomized to times to begin offering VD-HCBS to veterans at risk of nursing home placement. Services will be provided to community-dwelling participants with support from Aging and Disability Network Agencies. The VHA Partnered Evidence-based Policy Resource Center (PEPReC) is coordinating the evaluation, which includes collaboration from operational stakeholders from the VHA and Administration for Community Living and interdisciplinary researchers from the Center of Innovation in Long-Term Services and Supports and the Center for Health Services Research in Primary Care. For older veterans with functional limitations who are eligible for VD-HCBS, we will evaluate health outcomes (hospitalizations, emergency department visits, nursing home admissions, days at home) and healthcare costs associated with VD-HCBS availability. Learning healthcare systems facilitate diffusion of innovation while enabling rigorous evaluation of effects on patient outcomes. The VHA's randomized rollout of VD-HCBS to veterans at risk of nursing home placement is an example of how to achieve these goals simultaneously. PEPReC's experience designing an evaluation with researchers and operations stakeholders may serve as a framework for others seeking to develop rapid, rigorous, large-scale evaluations of delivery system innovations targeted to older adults. © 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.

Risk factors for biopsy-proven advanced non-alcoholic fatty liver disease in the Veterans Health Administration.

PubMed

Patel, Y A; Gifford, E J; Glass, L M; McNeil, R; Turner, M J; Han, B; Provenzale, D; Choi, S S; Moylan, C A; Hunt, C M

2018-01-01

With its increasing incidence, nonalcoholic fatty liver disease (NAFLD) is of particular concern in the Veterans Health Administration (VHA). To evaluate risk factors for advanced fibrosis in biopsy-proven NAFLD in the VHA, to identify patients at risk for adverse outcomes. In randomly selected cases from VHA databases (2005-2015), we performed a retrospective case-control study in adults with biopsy-defined NAFLD or normal liver. Of 2091 patients reviewed, 399 met inclusion criteria. Normal controls (n = 65) had normal liver function. The four NAFLD cohorts included: NAFL steatosis (n = 76), nonalcoholic steatohepatitis (NASH) without fibrosis (n = 68), NAFLD/NASH stage 1-3 fibrosis (n = 82), and NAFLD/NASH cirrhosis (n = 70). NAFLD with hepatocellular carcinoma (HCC) was separately identified (n = 38). Most patients were older White men. NAFLD patients with any fibrosis were on average severely obese (BMI>35 kg/m 2 ). Diabetes (54.4%-79.6%) and hypertension (85.8%-100%) were more common in NAFLD with fibrosis or HCC. Across NAFLD, 12.3%-19.5% were enrolled in diet/exercise programs and 0%-2.6% had bariatric surgery. Hispanics exhibited higher rates of NASH (20.6%), while Blacks had low NAFLD rates (1.4%-11.8%), particularly NAFLD cirrhosis and HCC (1.4%-2.6%). Diabetes (OR 11.8, P < .001) and BMI (OR 1.4, P < .001) were the most significant predictors of advanced fibrosis. In the VHA, diabetes and severe obesity increased risk for advanced fibrosis in NAFLD. Of these patients, only a small proportion (~20%) had enrolled in diet/exercise programs or had bariatric surgery (~2%). These results suggest that providers should focus/tailor interventions to improve outcomes, particularly in those with diabetes and severe obesity. © 2017 John Wiley & Sons Ltd.

Results from the Veterans Health Administration ICD-10-CM/PCS Coding Pilot Study.

PubMed

Weems, Shelley; Heller, Pamela; Fenton, Susan H

2015-01-01

The Veterans Health Administration (VHA) of the US Department of Veterans Affairs has been preparing for the October 1, 2015, conversion to the International Classification of Diseases, Tenth Revision, Clinical Modification and Procedural Coding System (ICD-10-CM/PCS) for more than four years. The VHA's Office of Informatics and Analytics ICD-10 Program Management Office established an ICD-10 Learning Lab to explore expected operational challenges. This study was conducted to determine the effects of the classification system conversion on coding productivity. ICD codes are integral to VHA business processes and are used for purposes such as clinical studies, performance measurement, workload capture, cost determination, Veterans Equitable Resource Allocation (VERA) determination, morbidity and mortality classification, indexing of hospital records by disease and operations, data storage and retrieval, research purposes, and reimbursement. The data collection for this study occurred in multiple VHA sites across several months using standardized methods. It is commonly accepted that coding productivity will decrease with the implementation of ICD-10-CM/PCS. The findings of this study suggest that the decrease will be more significant for inpatient coding productivity (64.5 percent productivity decrease) than for ambulatory care coding productivity (6.7 percent productivity decrease). This study reveals the following important points regarding ICD-10-CM/PCS coding productivity: 1. Ambulatory care ICD-10-CM coding productivity is not expected to decrease as significantly as inpatient ICD-10-CM/PCS coding productivity. 2. Coder training and type of record (inpatient versus outpatient) affect coding productivity. 3. Inpatient coding productivity is decreased when a procedure requiring ICD-10-PCS coding is present. It is highly recommended that organizations perform their own analyses to determine the effects of ICD-10-CM/PCS implementation on coding productivity.

Results from the Veterans Health Administration ICD-10-CM/PCS Coding Pilot Study

PubMed Central

Weems, Shelley; Heller, Pamela; Fenton, Susan H.

2015-01-01

The Veterans Health Administration (VHA) of the US Department of Veterans Affairs has been preparing for the October 1, 2015, conversion to the International Classification of Diseases, Tenth Revision, Clinical Modification and Procedural Coding System (ICD-10-CM/PCS) for more than four years. The VHA's Office of Informatics and Analytics ICD-10 Program Management Office established an ICD-10 Learning Lab to explore expected operational challenges. This study was conducted to determine the effects of the classification system conversion on coding productivity. ICD codes are integral to VHA business processes and are used for purposes such as clinical studies, performance measurement, workload capture, cost determination, Veterans Equitable Resource Allocation (VERA) determination, morbidity and mortality classification, indexing of hospital records by disease and operations, data storage and retrieval, research purposes, and reimbursement. The data collection for this study occurred in multiple VHA sites across several months using standardized methods. It is commonly accepted that coding productivity will decrease with the implementation of ICD-10-CM/PCS. The findings of this study suggest that the decrease will be more significant for inpatient coding productivity (64.5 percent productivity decrease) than for ambulatory care coding productivity (6.7 percent productivity decrease). This study reveals the following important points regarding ICD-10-CM/PCS coding productivity: Ambulatory care ICD-10-CM coding productivity is not expected to decrease as significantly as inpatient ICD-10-CM/PCS coding productivity.Coder training and type of record (inpatient versus outpatient) affect coding productivity.Inpatient coding productivity is decreased when a procedure requiring ICD-10-PCS coding is present. It is highly recommended that organizations perform their own analyses to determine the effects of ICD-10-CM/PCS implementation on coding productivity. PMID:26396553

Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans Health Administration's "Homeless Patient Aligned Care Team" Program.

PubMed

O'Toole, Thomas P; Johnson, Erin E; Aiello, Riccardo; Kane, Vincent; Pape, Lisa

2016-03-31

Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a "homeless medical home" initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites. We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services. More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies. Integrating social determinants of health into clinical care can be effective for high-risk homeless veterans.

Long-acting Reversible Contraception Among Homeless Women Veterans With Chronic Health Conditions: A Retrospective Cohort Study.

PubMed

Gawron, Lori M; Redd, Andrew; Suo, Ying; Pettey, Warren; Turok, David K; Gundlapalli, Adi V

2017-09-01

US women Veterans are at increased risk of homelessness and chronic health conditions associated with unintended pregnancy. Veterans Health Administration (VHA) provision of long-acting reversible contraception (LARC) can assist in healthy pregnancy planning. To evaluate perinatal risk factors and LARC exposure in ever-homeless women Veterans. A retrospective cohort study of women Veterans using VHA administrative data from fiscal years 2002-2015. We included 41,747 ever-homeless women Veterans age 18-44 years and 46,391 housed women Veterans matched by military service period. A subgroup of 7773 ever-homeless and 8674 matched housed women Veterans deployed in Iraq and Afghanistan [Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND)] conflicts comprised a second analytic cohort. Descriptive statistics compared demographic, military, health conditions, and LARC exposure in ever-homeless versus housed women Veterans. Multivariable logistic regression explored factors associated with LARC exposure in the OEF/OIF/OND subgroup. All health conditions were significantly higher in ever-homeless versus housed Veterans: mental health disorder in 84.5% versus 48.7% (P<0.001), substance abuse in 35.8% versus 8.6% (P<0.001), and medical conditions in 74.7% versus 55.6% (P<0.001). LARC exposure among all VHA users was 9.3% in ever-homeless Veterans versus 5.4% in housed Veterans (P<0.001). LARC exposure in the OEF/OIF/OND cohort was 14.1% in ever-homeless Veterans versus 8.2% in housed Veterans (P<0.001). In the OEF/OIF/OND cohort, homelessness along Veterans with medical and mental health indicators were leading LARC exposure predictors. The VHA is successfully engaging homeless women Veterans and providing LARC access. The prevalence of perinatal risk factors in ever-homeless women Veterans highlights a need for further programmatic enhancements to improve reproductive planning.

The Association Between Neighborhood Environment and Mortality: Results from a National Study of Veterans.

PubMed

Nelson, Karin; Schwartz, Greg; Hernandez, Susan; Simonetti, Joseph; Curtis, Idamay; Fihn, Stephan D

2017-04-01

As the largest integrated US health system, the Veterans Health Administration (VHA) provides unique national data to expand knowledge about the association between neighborhood socioeconomic status (NSES) and health. Although living in areas of lower NSES has been associated with higher mortality, previous studies have been limited to higher-income, less diverse populations than those who receive VHA care. To describe the association between NSES and all-cause mortality in a national sample of veterans enrolled in VHA primary care. One-year observational cohort of veterans who were alive on December 31, 2011. Data on individual veterans (vital status, and clinical and demographic characteristics) were abstracted from the VHA Corporate Data Warehouse. Census tract information was obtained from the US Census Bureau American Community Survey. Logistic regression was used to model the association between NSES deciles and all-cause mortality during 2012, adjusting for individual-level income and demographics, and accounting for spatial autocorrelation. Veterans who had vital status, demographic, and NSES data, and who were both assigned a primary care physician and alive on December 31, 2011 (n = 4,814,631). Census tracts were used as proxies for neighborhoods. A summary score based on census tract data characterized NSES. Veteran addresses were geocoded and linked to census tract NSES scores. Census tracts were divided into NSES deciles. In adjusted analysis, veterans living in the lowest-decile NSES tract were 10 % (OR 1.10, 95 % CI 1.07, 1.14) more likely to die than those living in the highest-decile NSES tract. Lower neighborhood SES is associated with all-cause mortality among veterans after adjusting for individual-level socioeconomic characteristics. NSES should be considered in risk adjustment models for veteran mortality, and may need to be incorporated into strategies aimed at improving veteran health.

Contribution of patient, physician, and environmental factors to demographic and health variation in colonoscopy follow-up for abnormal colorectal cancer screening test results.

PubMed

Partin, Melissa R; Gravely, Amy A; Burgess, James F; Haggstrom, David A; Lillie, Sarah E; Nelson, David B; Nugent, Sean M; Shaukat, Aasma; Sultan, Shahnaz; Walter, Louise C; Burgess, Diana J

2017-09-15

Patient, physician, and environmental factors were identified, and the authors examined the contribution of these factors to demographic and health variation in colonoscopy follow-up after a positive fecal occult blood test/fecal immunochemical test (FOBT/FIT) screening. In total, 76,243 FOBT/FIT-positive patients were identified from 120 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011 and were followed for 6 months. Patient demographic (race/ethnicity, sex, age, marital status) and health characteristics (comorbidities), physician characteristics (training level, whether primary care provider) and behaviors (inappropriate FOBT/FIT screening), and environmental factors (geographic access, facility type) were identified from VHA administrative records. Patient behaviors (refusal, private sector colonoscopy use) were estimated with statistical text mining conducted on clinic notes, and follow-up predictors and adjusted rates were estimated using hierarchical logistic regression. Roughly 50% of individuals completed a colonoscopy at a VHA facility within 6 months. Age and comorbidity score were negatively associated with follow-up. Blacks were more likely to receive follow-up than whites. Environmental factors attenuated but did not fully account for these differences. Patient behaviors (refusal, private sector colonoscopy use) and physician behaviors (inappropriate screening) fully accounted for the small reverse race disparity and attenuated variation by age and comorbidity score. Patient behaviors (refusal and private sector colonoscopy use) contributed more to variation in follow-up rates than physician behaviors (inappropriate screening). In the VHA, blacks are more likely to receive colonoscopy follow-up for positive FOBT/FIT results than whites, and follow-up rates markedly decline with advancing age and comorbidity burden. Patient and physician behaviors explain race variation in follow-up rates and contribute to

Military sexual trauma is associated with post-deployment eating disorders among Afghanistan and Iraq veterans.

PubMed

Blais, Rebecca K; Brignone, Emily; Maguen, Shira; Carter, Marjorie E; Fargo, Jamison D; Gundlapalli, Adi V

2017-07-01

Evaluate the association of military sexual trauma (MST) screen status with eating disorder diagnoses among veterans within 1- and 5-years after initiating Veterans Health Administration (VHA) care, and whether the association varied by sex. Retrospective cohort study of US Afghanistan/Iraq veterans who used VHA services between FY 2004 and 2014 (N = 595,525). This study used VHA administrative data to assess the presence of eating disorder diagnoses in medical records within 1- and 5-years of initiating VHA care, and whether a positive screen for MST was associated with eating disorders. Three percent (n = 18,488) screened positive for MST. At 1- and 5-year follow up, 0.1% (n= 513, 74% female), and 0.2% (n = 504, 71% female) were diagnosed with an eating disorder, respectively. In regression models adjusted for demographic variables, military service, and psychiatric comorbidities, the presence of an eating disorder diagnosis was nearly two times higher among those with a positive screen for MST in the 1-year (adjusted odds ratio [AOR] = 1.94, 95% confidence interval [CI] = 1.57-2.40) and 5-year (AOR = 1.86, 95%CI = 1.49-2.32) cohorts. The increased likelihood conferred by MST for an eating disorder diagnosis was differentially stronger among male veterans than female veterans in the 1-year cohort only (AOR = 2.13, 95%CI = 1.01-4.50). Veterans with a positive screen for MST, especially male veterans, had a nearly two-fold increased likelihood of having an eating disorder diagnosis. Screening for eating disorders may be important in both male and female veterans who report MST. © 2017 Wiley Periodicals, Inc.

Effects of performance measure implementation on clinical manager and provider motivation.

PubMed

Damschroder, Laura J; Robinson, Claire H; Francis, Joseph; Bentley, Douglas R; Krein, Sarah L; Rosland, Ann-Marie; Hofer, Timothy P; Kerr, Eve A

2014-12-01

Clinical performance measurement has been a key element of efforts to transform the Veterans Health Administration (VHA). However, there are a number of signs that current performance measurement systems used within and outside the VHA may be reaching the point of maximum benefit to care and in some settings, may be resulting in negative consequences to care, including overtreatment and diminished attention to patient needs and preferences. Our research group has been involved in a long-standing partnership with the office responsible for clinical performance measurement in the VHA to understand and develop potential strategies to mitigate the unintended consequences of measurement. Our aim was to understand how the implementation of diabetes performance measures (PMs) influences management actions and day-to-day clinical practice. This is a mixed methods study design based on quantitative administrative data to select study facilities and quantitative data from semi-structured interviews. Sixty-two network-level and facility-level executives, managers, front-line providers and staff participated in the study. Qualitative content analyses were guided by a team-based consensus approach using verbatim interview transcripts. A published interpretive motivation theory framework is used to describe potential contributions of local implementation strategies to unintended consequences of PMs. Implementation strategies used by management affect providers' response to PMs, which in turn potentially undermines provision of high-quality patient-centered care. These include: 1) feedback reports to providers that are dissociated from a realistic capability to address performance gaps; 2) evaluative criteria set by managers that are at odds with patient-centered care; and 3) pressure created by managers' narrow focus on gaps in PMs that is viewed as more punitive than motivating. Next steps include working with VHA leaders to develop and test implementation approaches to help

Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans Health Administration’s “Homeless Patient Aligned Care Team” Program

PubMed Central

Johnson, Erin E.; Aiello, Riccardo; Kane, Vincent; Pape, Lisa

2016-01-01

Introduction Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a “homeless medical home” initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites. Methods We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services. Results More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies. Conclusion Integrating social determinants of health into clinical care can be effective for high

Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.

PubMed

Oliva, Elizabeth M; Bowe, Thomas; Tavakoli, Sara; Martins, Susana; Lewis, Eleanor T; Paik, Meenah; Wiechers, Ilse; Henderson, Patricia; Harvey, Michael; Avoundjian, Tigran; Medhanie, Amanuel; Trafton, Jodie A

2017-02-01

Concerns about opioid-related adverse events, including overdose, prompted the Veterans Health Administration (VHA) to launch an Opioid Safety Initiative and Overdose Education and Naloxone Distribution program. To mitigate risks associated with opioid prescribing, a holistic approach that takes into consideration both risk factors (e.g., dose, substance use disorders) and risk mitigation interventions (e.g., urine drug screening, psychosocial treatment) is needed. This article describes the Stratification Tool for Opioid Risk Mitigation (STORM), a tool developed in VHA that reflects this holistic approach and facilitates patient identification and monitoring. STORM prioritizes patients for review and intervention according to their modeled risk for overdose/suicide-related events and displays risk factors and risk mitigation interventions obtained from VHA electronic medical record (EMR)-data extracts. Patients' estimated risk is based on a predictive risk model developed using fiscal year 2010 (FY2010: 10/1/2009-9/30/2010) EMR-data extracts and mortality data among 1,135,601 VHA patients prescribed opioid analgesics to predict risk for an overdose/suicide-related event in FY2011 (2.1% experienced an event). Cross-validation was used to validate the model, with receiver operating characteristic curves for the training and test data sets performing well (>.80 area under the curve). The predictive risk model distinguished patients based on risk for overdose/suicide-related adverse events, allowing for identification of high-risk patients and enrichment of target populations of patients with greater safety concerns for proactive monitoring and application of risk mitigation interventions. Results suggest that clinical informatics can leverage EMR-extracted data to identify patients at-risk for overdose/suicide-related events and provide clinicians with actionable information to mitigate risk. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

78 FR 55778 - Geriatrics and Gerontology Advisory Committee, Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2013-09-11

... health care facilities and programs to meet the medical, psychological, and social needs of older... research activities; training, recruitment and retention approaches; Veterans Health Administration (VHA...

76 FR 54536 - Geriatrics and Gerontology Advisory Committee; Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2011-09-01

... health care facilities and programs to meet the medical, psychological, and social needs of older..., recruitment and retention approaches), Veterans Health Administration (VHA) strategic planning activities in...

Burnout in Veterans Health Administration Mental Health Providers in Posttraumatic Stress Clinics

PubMed Central

Garcia, Hector A.; McGeary, Cindy A.; McGeary, Donald D.; Finley, Erin P.; Peterson, Alan L.

2015-01-01

The purpose of this study was to conduct the first assessment of burnout among Veterans Health Administration (VHA) mental health clinicians providing evidence-based posttraumatic stress disorder (PTSD) care. This study consisted of 138 participants and the sample was mostly female (67%), Caucasian (non-Hispanic; 81%), and married (70%) with a mean age of 44.3 years (SD = 11.2). Recruitment was directed through VHA PTSD Clinical Teams (PCT) throughout the United States based on a nationwide mailing list of PCT Clinic Directors. Participants completed an electronic survey that assessed demographics, organizational work factors, absenteeism, and burnout (assessed through the Maslach Burnout Inventory-General Survey, MBI-GS). Twelve percent of the sample reported low Professional Efficacy, 50% reported high levels of Exhaustion, and 47% reported high levels of Cynicism as determined by the MBI-GS cut-off scores. Only workplace characteristics were significantly associated with provider scores on all 3 scales. Exhaustion and Cynicism were most impacted by perceptions of organizational politics/bureaucracy, increased clinical workload and control over how work is done. Organizational factors were also significantly associated with provider absenteeism and intent to leave his/her job. Findings suggest that providers in VHA specialty PTSD care settings may benefit from programs or supports aimed at preventing and/or ameliorating burnout. PMID:24564443

A Health Services Research Agenda for Bariatric Surgery Within the Veterans Health Administration.

PubMed

Funk, L M; Gunnar, W; Dominitz, J A; Eisenberg, D; Frayne, S; Maggard-Gibbons, M; Kalarchian, M A; Livingston, E; Sanchez, V; Smith, B R; Weidenbacher, H; Maciejewski, Matthew L

2017-04-01

In 2016, the Veterans Health Administration (VHA) held a Weight Management State of the Art conference to identify evidence gaps and develop a research agenda for population-based weight management for veterans. Included were behavioral, pharmacologic, and bariatric surgery workgroups. This article summarizes the bariatric surgery workgroup (BSWG) findings and recommendations for future research. The BSWG agreed that there is evidence from randomized trials and large observational studies suggesting that bariatric surgery is superior to medical therapy for short- and intermediate-term remission of type 2 diabetes, long-term weight loss, and long-term survival. Priority evidence gaps include long-term comorbidity remission, mental health, substance abuse, and health care costs. Evidence of the role of endoscopic weight loss options is also lacking. The BSWG also noted the limited evidence regarding optimal timing for bariatric surgery referral, barriers to bariatric surgery itself, and management of high-risk bariatric surgery patients. Clinical trials of pre- and post-surgery interventions may help to optimize patient outcomes. A registry of overweight and obese veterans and a workforce assessment to determine the VHA's capacity to increase bariatric surgery access were recommended. These will help inform policy modifications and focus the research agenda to improve the ability of the VHA to deliver population-based weight management.

Dialectical Behavior Therapy Training and Desired Resources for Implementation: Results From a National Program Evaluation in the Veterans Health Administration.

PubMed

Landes, Sara J; Matthieu, Monica M; Smith, Brandy N; Trent, Lindsay R; Rodriguez, Allison L; Kemp, Janet; Thompson, Caitlin

2016-08-01

Little is known about nonresearch training experiences of providers who implement evidence-based psychotherapies for suicidal behaviors among veterans. This national program evaluation identified the history of training, training needs, and desired resources of clinicians who work with at-risk veterans in a national health care system. This sequential mixed methods national program evaluation used a post-only survey design to obtain needs assessment data from clinical sites (N = 59) within Veterans Health Administration (VHA) facilities that implemented dialectical behavior therapy (DBT). Data were also collected on resources preferred to support ongoing use of DBT. While only 33% of clinical sites within VHA facilities reported that staff attended a formal DBT intensive training workshop, nearly 97% of participating sites reported having staff who completed self-study using DBT manuals. Mobile apps for therapists and clients and templates for documentation in the electronic health records to support measurement-based care were desired clinical resources. Results indicate that less-intensive training models can aid staff in implementing DBT in real-world health care settings. While more training is requested, a number of VHA facilities have successfully implemented DBT into the continuum of care for veterans at risk for suicide. Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.

Activation of microglia and astrocytes in the nucleus tractus solitarius during ventilatory acclimatization to 10% hypoxia in unanesthetized mice.

PubMed

Tadmouri, A; Champagnat, J; Morin-Surun, M P

2014-05-01

Nucleus tractus solitarius (NTS) is the integrative sensory relay of autonomic functions in the brainstem. To explore the nonneuronal cellular basis of central chemosensitivity during the first 24 hr of ventilatory acclimatization to hypoxia (VHA), we have investigated glial activation markers in the NTS. Conscious mice (C57/BL6) were placed in a hermetic hypoxia chamber containing a plethysmograph to record ventilation. After 4 days of habituation to the normoxic environment, mice were subjected to physiological hypoxia (10% O2 ) for 1, 6, or 24 hr. To dissociate interactions between microglia and astrocytes, another group received daily minocycline, a microglia activation blocker. By immunochemical localization of astrocytes (GFAP), activated microglia (Cd11b), and total microglia (Iba-1), we identified an oxygen-sensing glial layer in the NTS, in which astrocytes are first activated after 1-6 hr of hypoxia, followed by microglia after 6-24 hr of hypoxia. Minocycline administration suppressed microglial activation and decreased astrocyte activation at 6 hr and VHA at 24 hr of hypoxia. These results suggest that astrocytes contribute to the neuronal response during the first hour of hypoxia, whereas microglial cells, via cross-talk with astrocytes, are involved in the VHA during the first 24 hr of acclimatization. Copyright © 2014 Wiley Periodicals, Inc.

Coaching and leadership for the diffusion of innovation in health care: a different type of multi-organization improvement collaborative.

PubMed

Green, Paul L; Plsek, Paul E

2002-02-01

Health care organizations have suffered a steady decrease in operating margins in recent years while facing increased competition and pressure to provide ever-higher levels of customer service, quality of care, and innovation in delivery methodologies. The ability to rapidly find and implement changes that will lead to strategic improvement is critical. To assist member organizations in dealing with these issues, VHA Upper Midwest launched the Coaching and Leadership Initiative (VHA-CLI) in January 1999. The initiative was intended to develop new methods of collaborating for organizational learning of best practices, with a focus on generalizable change and deliberate leadership supports for deployment, diffusion, and sustainability. The emphasis was on the spread of ideas for improvement into all relevant corners of the organization. The structure of the VHA-CLI collaborative involved four waves of demonstration teams during 2 years. Each meeting of the collaborative included an executive session, team learning sessions (concepts applied to their improvement projects), and planning for the 6-month action period following the meeting. An important feature of the collaborative is the way in which teams in the various waves overlapped. For example, the Wave 1 team for a given organization came to a learning session in January 1999. At the second collaborative meeting in June 1999, the Wave 1 teams reported on the progress in their pilot sites. This meeting was also the kick-off session for the Wave 2 teams, which could learn about organizational culture and the improvement model from the efforts of their colleagues on Wave 1. Wave 1 teams also learned about and planned for spreading their efforts to other sites beyond the pilot. The pattern of multiple teams stretching across two waves of activity was repeated at every meeting of the collaborative. Each organization in the collaborative has achieved improved outcomes around its selected clinical topics. In total, 26

78 FR 6406 - Geriatrics and Gerontology Advisory Committee, Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2013-01-30

... facilities and programs to meet the medical, psychological, and social needs of older Veterans and evaluates..., recruitment and retention approaches), Veterans Health Administration (VHA) strategic planning activities in...

77 FR 14860 - Geriatrics and Gerontology Advisory Committee, Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-13

... facilities and programs to meet the medical, psychological, and social needs of older Veterans and evaluates..., recruitment and retention approaches), Veterans Health Administration (VHA) strategic planning activities in...

77 FR 4405 - Advisory Committee: National Academic Affiliations Council; Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2012-01-27

... recommendations of the Blue Ribbon Panel on VA Medical School Affiliations and VHA's present educational portfolio and recent educational innovations; and from the VA Office of General Counsel on government ethics...

78 FR 51276 - Proposed Information Collection (Access to Care Dialysis Pilot Survey and Interview); Activity...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-20

... the treatment of End Stage Renal Disease (ESRD) to improve access to dialysis care for Veterans. DATES... performance of VHA's functions, including whether the information will have practical utility; (2) the...

Targeted Coagulation Management in Severe Trauma: The Controversies and the Evidence.

PubMed

Winearls, James; Reade, Michael; Miles, Helen; Bulmer, Andrew; Campbell, Don; Görlinger, Klaus; Fraser, John F

2016-10-01

Hemorrhage in the setting of severe trauma is a leading cause of death worldwide. The pathophysiology of hemorrhage and coagulopathy in severe trauma is complex and remains poorly understood. Most clinicians currently treating trauma patients acknowledge the presence of a coagulopathy unique to trauma patients-trauma-induced coagulopathy (TIC)-independently associated with increased mortality. The complexity and incomplete understanding of TIC has resulted in significant controversy regarding optimum management. Although the majority of trauma centers utilize fixed-ratio massive transfusion protocols in severe traumatic hemorrhage, a widely accepted "ideal" transfusion ratio of blood to blood products remains elusive. The recent use of viscoelastic hemostatic assays (VHAs) to guide blood product replacement has further provoked debate as to the optimum transfusion strategy. The use of VHA to quantify the functional contributions of individual components of the coagulation system may permit targeted treatment of TIC but remains controversial and is unlikely to demonstrate a mortality benefit in light of the heterogeneity of the trauma population. Thus, VHA-guided algorithms as an alternative to fixed product ratios in trauma are not universally accepted, and a hybrid strategy starting with fixed-ratio transfusion and incorporating VHA data as they become available is favored by some institutions. We review the current evidence for the management of coagulopathy in trauma, the rationale behind the use of targeted and fixed-ratio approaches and explore future directions.

National evaluation of obesity screening and treatment among veterans with and without mental health disorders.

PubMed

Littman, Alyson J; Damschroder, Laura J; Verchinina, Lilia; Lai, Zongshan; Kim, Hyungjin Myra; Hoerster, Katherine D; Klingaman, Elizabeth A; Goldberg, Richard W; Owen, Richard R; Goodrich, David E

2015-01-01

The objective was to determine whether obesity screening and weight management program participation and outcomes are equitable for individuals with serious mental illness (SMI) and depressive disorder (DD) compared to those without SMI/DD in Veterans Health Administration (VHA), the largest integrated US health system, which requires obesity screening and offers weight management to all in need. We used chart-reviewed, clinical and administrative VHA data from fiscal years 2010-2012 to estimate obesity screening and participation in the VHA's weight management program (MOVE!) across groups. Six- and 12-month weight changes in MOVE! participants were estimated using linear mixed models adjusted for confounders. Compared to individuals without SMI/DD, individuals with SMI or DD were less frequently screened for obesity (94%-94.7% vs. 95.7%) but had greater participation in MOVE! (10.1%-10.4% vs. 7.4%). MOVE! participants with SMI or DD lost approximately 1 lb less at 6 months. At 12 months, average weight loss for individuals with SMI or neither SMI/DD was comparable (-3.5 and -3.3 lb, respectively), but individuals with DD lost less weight (mean=-2.7 lb). Disparities in obesity screening and treatment outcomes across mental health diagnosis groups were modest. However, participation in MOVE! was low for every group, which limits population impact. Published by Elsevier Inc.

The R2R3-MYB transcription factor MdMYB73 is involved in malate accumulation and vacuolar acidification in apple.

PubMed

Hu, Da-Gang; Li, Yuan-Yuan; Zhang, Quan-Yan; Li, Ming; Sun, Cui-Hui; Yu, Jian-Qiang; Hao, Yu-Jin

2017-08-01

Malate, the predominant organic acid in many fruits, is a crucial component of the organoleptic quality of fruit, including taste and flavor. The genetic and environmental mechanisms affecting malate metabolism in fruit cells have been studied extensively. However, the transcriptional regulation of malate-metabolizing enzymes and vacuolar transporters remains poorly understood. Our previous studies demonstrated that MdMYB1 modulates anthocyanin accumulation and vacuolar acidification by directly activating vacuolar transporters, including MdVHA-B1, MdVHA-E, MdVHP1 and MdtDT. Interestingly, we isolated and identified a MYB transcription factor, MdMYB73, a distant relative of MdMYB1 in this study. It was subsequently found that MdMYB73 protein bound directly to the promoters of MdALMT9 (aluminum-activated malate transporter 9), MdVHA-A (vacuolar ATPase subunit A) and MdVHP1 (vacuolar pyrophosphatase 1), transcriptionally activating their expression and thereby enhancing their activities. Analyses of transgenic apple calli demonstrated that MdMYB73 influenced malate accumulation and vacuolar pH. Furthermore, MdCIbHLH1 interacted with MdMYB73 and enhanced its activity upon downstream target genes. These findings help to elucidate how MdMYB73 directly modulates the vacuolar transport system to affect malate accumulation and vacuolar pH in apple. © 2017 The Authors The Plant Journal © 2017 John Wiley & Sons Ltd.

Mortality Among Veterans with Transgender-Related Diagnoses in the Veterans Health Administration, FY2000-2009.

PubMed

Blosnich, John R; Brown, George R; Wojcio, Sybil; Jones, Kenneth T; Bossarte, Robert M

2014-12-01

The aims of this project were to document all-cause and suicide mortality among Veteran Healthcare Administration (VHA) utilizers with The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis consistent with transgender status. The study population consisted of VHA patients identified as having any one of four diagnosis codes indicating transgender status (n=5,117) gathered from the VA National Patient Care Database. Mortality data were gathered from the National Death Index from 2000-2009 for 1,277 veterans with transgender-related ICD-9-CM diagnoses. The remaining 3,840 were not searched because they had VHA utilization after 2009 (indicating they were alive). Person-time at risk (person-years) for crude rates were calculated based on the time from an individual's index diagnosis to either death or the end of FY 2009. Causes of death were categorized using ICD-10 code groups. Approximately 9.3% (n=309) veterans with transgender-related ICD-9-CM diagnoses died across the study period. Although diseases of the circulatory system and neoplasms were the first and second leading causes of death, respectively, the other ranked causes of mortality differed somewhat from patterns for the US during the same time span. The crude suicide rate among veterans with transgender-related ICD-9-CM diagnoses across the 10-year period was approximately 82/100,000 person-years, which approximated the crude suicide death rates for other serious mental illness in VHA (e.g., depression, schizophrenia). The average age of suicide decedents was 49.4 years. The crude suicide rate among veterans with transgender-related ICD-9-CM diagnoses is higher than in the general population, and they may be dying by suicide at younger ages than their veteran peers without transgender-related ICD-9-CM diagnoses. Future research, such as age-adjusted rates or accounting for psychiatric co-morbidities, will help to better clarify if the all-cause and suicide

Stroke survivors with severe mental illness: Are they at-risk for increased non-psychiatric hospitalizations?

PubMed

Lilly, Flavius Robert; Culpepper, Joel; Stuart, Mary; Steinwachs, Donald

2017-01-01

This study examined outcomes for two groups of stroke survivors treated in Veteran Health Administration (VHA) hospitals, those with a severe mental illness (SMI) and those without prior psychiatric diagnoses, to examine risk of non-psychiatric medical hospitalizations over five years after initial stroke. This retrospective cohort study included 523 veterans who survived an initial stroke hospitalization in a VHA medical center during fiscal year 2003. The survivors were followed using administrative data documenting inpatient stroke treatment, patient demographics, disease comorbidities, and VHA hospital admissions. Multivariate Poisson regression was used to examine the relationship between patients with and without SMI diagnosis preceding the stroke and their experience with non-psychiatric medical hospitalizations after the stroke. The study included 100 patients with SMI and 423 without SMI. Unadjusted means for pre-stroke non-psychiatric hospitalizations were higher (p = 0.0004) among SMI patients (1.47 ± 0.51) compared to those without SMI (1.00 ± 1.33), a difference which persisted through the first year post-stroke (SMI: 2.33 ± 2.46; No SMI: 1.74 ± 1.86; p = 0.0004). Number of non-psychiatric hospitalizations were not significantly different between the two groups after adjustment for patient sociodemographic, comorbidity, length of stay and inpatient stroke treatment characteristics. Antithrombotic medications significantly lowered risk (OR = 0.61; 95% CI: 0.49-0.73) for stroke-related readmission within 30 days of discharge. No significant differences in medical hospitalizations were present after adjusting for comorbid and sociodemographic characteristics between SMI and non-SMI stroke patients in the five-year follow-up. However, unadjusted results continue to draw attention to disparities, with SMI patients experiencing more non-psychiatric hospitalizations both prior to and up to one year after their initial stroke. Additionally, stroke

78 FR 73926 - Veterans' Rural Health Advisory Committee; Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-09

... Administration (VHA) Office of Rural Health (ORH). The Committee will hear a presentation on the Women's Health... Manager, Regulation Policy and Management, Office of the General Counsel. [FR Doc. 2013-29301 Filed 12-6...

[Vaccination against viral hepatitis A and B in adults aged over 40 years--antibody persistence and immune memory].

PubMed

Chlibek, R; Smetana, J; Bostíková, V; Splino, M

2011-09-01

Primary vaccination with combined vaccine against viral hepatitis A (VHA) and viral hepatitis B (VHB) induces higher anti-hepatitis B surface (anti-HBs) antibody responses and similar anti-hepatitis A virus (anti-HAV) antibody responses in adults aged over 40 years in comparison with concomitant monovalent vaccines against VHA and VHB. Th e objectives were to assess, in a clinical study, persistence of anti-HAV and anti-HBs antibodies in adults aged over 40 years four years after primary VHA/VHB vaccination and antibody response following a booster dose of the vaccine. Five hundred and ninety-six subjects aged > 40 years were vaccinated with three doses of the combined VHA/VHB vaccine at Months 0, 1, 6 (HAB group) or with concomitant VHA and VHB vaccines at Months 0, 6 and 0, 1, 6 (ENG+HAV and HBVX+VAQ, respectively). Blood samples were collected one month following primary vaccination (Month 7) and then at one-year intervals for four years after the booster dose with the same vaccine as used for the primary vaccination. The anti-HBs and anti-HAV antibody levels were determined prior to the booster dose and at days 14 and 30 after the booster dose. At Month 7, > 97% of study subjects were seropositive for anti-HAV antibodies in all groups analyzed. Four years after primary vaccination, anti-HAV antibody seropositivity persisted in > 93% of study subjects, increasing to > 99% after the booster dose. At Month 7, the highest proportion of study subjects with anti-HBs antibody levels > or = 10 mIU/ml was found in the HAB group (91.7% versus 79.7% in the ENG+HAV group versus 71.0% in the HBVX+VAQ group). Four years after vaccination, anti-HBs antibody levels of 10 mIU/ml persisted in 57.1% of the HAB study subjects in comparison with 40.1% and 26.6% of the study subjects in the ENG+HAV and HBVX+VAQ groups, respectively. One month after the booster dose, anti-HBs antibody levels increased and antibody levels > or = 10 mIU/ml was achived in 95.2% of study subjects in the

Using Human Factors Methods to Design a New Interface for an Electronic Medical Record

PubMed Central

Saleem, Jason J.; Patterson, Emily S.; Militello, Laura; Asch, Steven M.; Doebbeling, Bradley N.; Render, Marta L.

2007-01-01

The Veterans Health Administration (VHA) is a leader in development and use of electronic patient records and clinical decision support. The VHA is currently reengineering a somewhat dated platform for its Computerized Patient Record System (CPRS). This process affords a unique opportunity to implement major changes to the current design and function of the system. We report on two human factors studies designed to provide input and guidance during this reengineering process. One study involved a card sort to better understand how providers tend to cognitively organize clinical data, and how that understanding can help guide interface design. The other involved a simulation to assess the impact of redesign modifications on computerized clinical reminders, a form of clinical decision support in the CPRS, on the learnability of the system for first-time users. PMID:18693914

77 FR 65056 - Advisory Committee on Minority Veterans, Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-24

... Disadvantaged Business Utilization. On November 16, the Committee will hold an exit briefing with VBA, VHA and... of their comments at the time of the meeting for inclusion in the official meeting record. Members of...

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... data collected on VA Form 10-10069 will be used as a grant to evaluate patient and provider attitudes... innovation program by assessing the perceptions and attitudes of patients; and (2) produce guidelines for VHA...

77 FR 21622 - Special Medical Advisory Group; Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2012-04-10

... Affiliations Council, ethics, an update on social services, and the White House initiative, ``Joining Forces... Administrative Operations (10B), VHA, 810 Vermont Avenue NW., Washington, DC 20420, or by email at j.t[email protected

Homelessness in a national sample of incarcerated veterans in state and federal prisons.

PubMed

Tsai, Jack; Rosenheck, Robert A; Kasprow, Wesley J; McGuire, James F

2014-05-01

The Veterans Health Administration (VHA) has been increasing efforts to reach out to assist incarcerated veterans. While previous studies have shown strong associations between incarceration and homelessness, few studies have examined distinctive characteristics of incarcerated homeless and non-homeless veterans. National administrative data on 30,348 incarcerated veterans served by the Health Care for Re-entry Veterans (HCRV) program were analyzed. Incarcerated veterans were classified into four groups based on their history of past homelessness: not homeless, transiently homeless, episodically homeless, and chronically homeless. Multinomial logistic regression was used to compare groups on sociodemographic characteristics, criminal justice status, clinical status, and their interest in using VHA services. Of the sample, 70 % were classified as not homeless, 8 % as transiently homeless, 11 % as episodically homeless, and 11 % as chronically homeless. Thus, 30 % of the sample had a homeless history, which is five times the 6 % rate of past homelessness among adult men in the general population. Compared to non-homeless incarcerated veterans, all three homeless groups reported significantly more mental health problems, more substance abuse, more times arrested in their lifetime, more likely to be incarcerated for a non-violent offense, and were more interested in receiving VHA services after release from prison. Together, these findings suggest re-entry programs, like HCRV, can address relevant mental health-related service needs, especially among formerly homeless veterans and veterans in need of services are receptive to the offer of assistance.

The costs of critical care telemedicine programs: a systematic review and analysis.

PubMed

Kumar, Gaurav; Falk, Derik M; Bonello, Robert S; Kahn, Jeremy M; Perencevich, Eli; Cram, Peter

2013-01-01

Implementation of telemedicine programs in ICUs (tele-ICUs) may improve patient outcomes, but the costs of these programs are unknown. We performed a systematic literature review to summarize existing data on the costs of tele-ICUs and collected detailed data on the costs of implementing a tele-ICU in a network of Veterans Health Administration (VHA) hospitals. We conducted a systematic review of studies published between January 1, 1990, and July 1, 2011, reporting costs of tele-ICUs. Studies were summarized, and key cost data were abstracted. We then obtained the costs of implementing a tele-ICU in a network of seven VHA hospitals and report these costs in light of the existing literature. Our systematic review identified eight studies reporting tele-ICU costs. These studies suggested combined implementation and first year of operation costs for a tele-ICU of $50,000 to $100,000 per monitored ICU-bed. Changes in patient care costs after tele-ICU implementation ranged from a $3,000 reduction to a $5,600 increase in hospital cost per patient. VHA data suggested a cost for implementation and first year of operation of $70,000 to $87,000 per ICU-bed, depending on the depreciation methods applied. The cost of tele-ICU implementation is substantial, and the impact of these programs on hospital costs or profits is unclear. Until additional data become available, clinicians and administrators should carefully weigh the clinical and economic aspects of tele-ICUs when considering investing in this technology.

VA staff perceptions of the role of the extended care referral process in home and community-based services versus nursing home use posthospital discharge.

PubMed

Miller, Edward Alan; Intrator, Orna; Gadbois, Emily; Gidmark, Stefanie; Rudolph, James L

2017-01-01

Little is known about how the extended care referral process-its structure and participants-influences Veterans' use of home and community-based services (HCBS) over nursing home care within the Veterans Health Administration (VHA). This study thus characterizes the extended care referral process within the VHA and its impact on HCBS versus nursing home use at hospital discharge. Data derive from 35 semistructured interviews at 12 Veterans Affairs Medical Centers (VAMCs). Findings indicate that the referral process is characterized by a commitment by care teams to consider HCBS if possible, varied practice depending on the clinician that most heavily influences care team recommendations, and care team emphasis on respecting Veteran/family preferences even when they are contrary to care team recommendations. Potential modifications include adopting systematic assessment practices; improving Veteran, family, and provider education; and promoting informed selection through shared decision making.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kuypers, Marshall A.; Lambert, Gregory Joseph; Moore, Thomas W.

Chronic infection with Hepatitis C virus (HCV) results in cirrhosis, liver cancer and death. As the nations largest provider of care for HCV, US Veterans Health Administration (VHA) invests extensive resources in the diagnosis and treatment of the disease. This report documents modeling and analysis of HCV treatment dynamics performed for the VHA aimed at improving service delivery efficiency. System dynamics modeling of disease treatment demonstrated the benefits of early detection and the role of comorbidities in disease progress and patient mortality. Preliminary modeling showed that adherence to rigorous treatment protocols is a primary determinant of treatment success. In depthmore » meta-analysis revealed correlations of adherence and various psycho-social factors. This initial meta-analysis indicates areas where substantial improvement in patient outcomes can potentially result from VA programs which incorporate these factors into their design.« less

78 FR 66105 - Agency Information Collection Activities Under OMB Review

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... Rights Discrimination Complaint) Activity Under OMB Review AGENCY: Veterans Health Administration... refer to ``OMB Control No. 2900-0662.'' SUPPLEMENTARY INFORMATION: Title: Civil Rights Discrimination... collection. Abstract: Veterans and other VHA customers who believe that their civil rights were violated by...

76 FR 56504 - Proposed Information Collection (Spinal Cord Injury Patient Care Survey) Activity: Comment Request

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2011-09-13

... Collection (Spinal Cord Injury Patient Care Survey) Activity: Comment Request AGENCY: Veterans Health Administration, Department of Veterans Affairs. ACTION: Notice. SUMMARY: The Veterans Health Administration (VHA... satisfaction with VA rehabilitation and health care. DATES: Written comments and recommendations on the...

77 FR 15187 - Proposed Information Collection; Comment Request; Deployment Risk and Resilience Inventory (DRRI)

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-14

...; Comment Request; Deployment Risk and Resilience Inventory (DRRI) AGENCY: Veterans Health Administration, Department of Veterans Affairs. ACTION: Notice. SUMMARY: The Veterans Health Administration (VHA), Department...-Pryor, Veterans Health Administration (193E1), Department of Veterans Affairs, 810 Vermont Avenue NW...

78 FR 65452 - Proposed Information Collection (Veterans, Researchers, and IRB Members Experiences With...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-10-31

... qualitative research methods to understand Veterans' preferences on research recruitment methods. The data... research study subjects and to explore Veterans views on recruitment procedures. DATES: Written comments... Members Experiences with Recruitment Restrictions). Type of Review: New collection. Abstracts: The VHA...

76 FR 30244 - Veterans' Rural Health Advisory Committee; Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-24

... Integrated Service Network (VISN) 19 Women Veterans Healthcare Coordinator, Montana and surrounding region rural health project managers, the Veterans Rural Health Resource Center--Western Region Native Domain... Network Director, VISN 19 Telehealth Manager, Veterans Health Administration (VHA) lead for the Supporting...

Substance use disorders and the risk of suicide mortality among men and women in the US Veterans Health Administration.

PubMed

Bohnert, Kipling M; Ilgen, Mark A; Louzon, Samantha; McCarthy, John F; Katz, Ira R

2017-07-01

Limited information is available regarding links between specific substance use disorders (SUDs) and suicide mortality; however, the preliminary evidence that is available suggests that suicide risk associated with SUDs may differ for men and women. This study aimed to estimate associations between SUDs and suicide for men and women receiving Veterans Health Administration (VHA) care. A cohort study using national administrative health records. National VHA system, USA. All VHA users in fiscal year (FY) 2005 who were alive at the beginning of FY 2006 (n = 4 863 086). The primary outcome of suicide mortality was assessed via FY 2006-2011 National Death Index (NDI) records. Current SUD diagnoses were the primary predictors of interest, and were assessed via FY 2004-2005 VHA National Patient Care Database (NPCD) records. In unadjusted analyses, a diagnosis of any current SUD and the specific current diagnoses of alcohol, cocaine, cannabis, opioid, amphetamine and sedative use disorders were all associated significantly with increased risk of suicide for both males and females [hazard ratios (HRs)] ranging from 1.35 for cocaine use disorder to 4.74 for sedative use disorder for men, and 3.89 for cannabis use disorder to 11.36 for sedative use disorder for women]. Further, the HR estimates for the relations between any SUD, alcohol, cocaine and opioid use disorders and suicide were significantly stronger for women than men (P < 0.05). After adjustment for other factors, most notably comorbid psychiatric diagnoses, associations linking SUDs with suicide were attenuated markedly and the greater suicide risk among females was observed for only any SUD and opioid use disorder (P < 0.05). Current substance use disorders (SUDs) signal increased suicide risk, especially among women, and may be important markers to consider including in suicide risk assessment strategies. None the less, other co-occurring psychiatric disorders may partially explain associations

Be on the lookout.

PubMed

Hudson, T

1999-04-01

The cost coil tightens. The Net widens. Alternative care booms. And higher tech means more trade-offs. These and other trends play out in a new health care environmental assessment created by VHA and Deloitte & Touche--an Executive Chartbook exclusive to H&HN.

Patient-centered medical home implementation and primary care provider turnover.

PubMed

Sylling, Philip W; Wong, Edwin S; Liu, Chuan-Fen; Hernandez, Susan E; Batten, Adam J; Helfrich, Christian D; Nelson, Karin; Fihn, Stephan D; Hebert, Paul L

2014-12-01

The Veterans Health Administration (VHA) began implementing a patient-centered medical home (PCMH) model of care delivery in April 2010 through its Patient Aligned Care Team (PACT) initiative. PACT represents a substantial system reengineering of VHA primary care and its potential effect on primary care provider (PCP) turnover is an important but unexplored relationship. This study examined the association between a system-wide PCMH implementation and PCP turnover. This was a retrospective, longitudinal study of VHA-employed PCPs spanning 29 calendar quarters before PACT and eight quarters of PACT implementation. PCP employment periods were identified from administrative data and turnover was defined by an indicator on the last quarter of each uncensored period. An interrupted time series model was used to estimate the association between PACT and turnover, adjusting for secular trend and seasonality, provider and job characteristics, and local unemployment. We calculated average marginal effects (AME), which reflected the change in turnover probability associated with PACT implementation. The quarterly rate of PCP turnover was 3.06% before PACT and 3.38% after initiation of PACT. In adjusted analysis, PACT was associated with a modest increase in turnover (AME=4.0 additional PCPs per 1000 PCPs per quarter, P=0.004). Models with interaction terms suggested that the PACT-related change in turnover was increasing in provider age and experience. PACT was associated with a modest increase in PCP turnover, concentrated among older and more experienced providers, during initial implementation. Our findings suggest that policymakers should evaluate potential workforce effects when implementing PCMH.

Salt stress in Thellungiella halophila activates Na+ transport mechanisms required for salinity tolerance.

PubMed

Vera-Estrella, Rosario; Barkla, Bronwyn J; García-Ramírez, Liliana; Pantoja, Omar

2005-11-01

Salinity is considered one of the major limiting factors for plant growth and agricultural productivity. We are using salt cress (Thellungiella halophila) to identify biochemical mechanisms that enable plants to grow in saline conditions. Under salt stress, the major site of Na+ accumulation occurred in old leaves, followed by young leaves and taproots, with the least accumulation occurring in lateral roots. Salt treatment increased both the H+ transport and hydrolytic activity of salt cress tonoplast (TP) and plasma membrane (PM) H(+)-ATPases from leaves and roots. TP Na(+)/H+ exchange was greatly stimulated by growth of the plants in NaCl, both in leaves and roots. Expression of the PM H(+)-ATPase isoform AHA3, the Na+ transporter HKT1, and the Na(+)/H+ exchanger SOS1 were examined in PMs isolated from control and salt-treated salt cress roots and leaves. An increased expression of SOS1, but no changes in levels of AHA3 and HKT1, was observed. NHX1 was only detected in PM fractions of roots, and a salt-induced increase in protein expression was observed. Analysis of the levels of expression of vacuolar H(+)-translocating ATPase subunits showed no major changes in protein expression of subunits VHA-A or VHA-B with salt treatment; however, VHA-E showed an increased expression in leaf tissue, but not in roots, when the plants were treated with NaCl. Salt cress plants were able to distribute and store Na+ by a very strict control of ion movement across both the TP and PM.

Salt Stress in Thellungiella halophila Activates Na+ Transport Mechanisms Required for Salinity Tolerance1

PubMed Central

Vera-Estrella, Rosario; Barkla, Bronwyn J.; García-Ramírez, Liliana; Pantoja, Omar

2005-01-01

Salinity is considered one of the major limiting factors for plant growth and agricultural productivity. We are using salt cress (Thellungiella halophila) to identify biochemical mechanisms that enable plants to grow in saline conditions. Under salt stress, the major site of Na+ accumulation occurred in old leaves, followed by young leaves and taproots, with the least accumulation occurring in lateral roots. Salt treatment increased both the H+ transport and hydrolytic activity of salt cress tonoplast (TP) and plasma membrane (PM) H+-ATPases from leaves and roots. TP Na+/H+ exchange was greatly stimulated by growth of the plants in NaCl, both in leaves and roots. Expression of the PM H+-ATPase isoform AHA3, the Na+ transporter HKT1, and the Na+/H+ exchanger SOS1 were examined in PMs isolated from control and salt-treated salt cress roots and leaves. An increased expression of SOS1, but no changes in levels of AHA3 and HKT1, was observed. NHX1 was only detected in PM fractions of roots, and a salt-induced increase in protein expression was observed. Analysis of the levels of expression of vacuolar H+-translocating ATPase subunits showed no major changes in protein expression of subunits VHA-A or VHA-B with salt treatment; however, VHA-E showed an increased expression in leaf tissue, but not in roots, when the plants were treated with NaCl. Salt cress plants were able to distribute and store Na+ by a very strict control of ion movement across both the TP and PM. PMID:16244148

The Costs of Critical Care Telemedicine Programs

PubMed Central

Falk, Derik M.; Bonello, Robert S.; Kahn, Jeremy M.; Perencevich, Eli; Cram, Peter

2013-01-01

Background: Implementation of telemedicine programs in ICUs (tele-ICUs) may improve patient outcomes, but the costs of these programs are unknown. We performed a systematic literature review to summarize existing data on the costs of tele-ICUs and collected detailed data on the costs of implementing a tele-ICU in a network of Veterans Health Administration (VHA) hospitals. Methods: We conducted a systematic review of studies published between January 1, 1990, and July 1, 2011, reporting costs of tele-ICUs. Studies were summarized, and key cost data were abstracted. We then obtained the costs of implementing a tele-ICU in a network of seven VHA hospitals and report these costs in light of the existing literature. Results: Our systematic review identified eight studies reporting tele-ICU costs. These studies suggested combined implementation and first year of operation costs for a tele-ICU of $50,000 to $100,000 per monitored ICU-bed. Changes in patient care costs after tele-ICU implementation ranged from a $3,000 reduction to a $5,600 increase in hospital cost per patient. VHA data suggested a cost for implementation and first year of operation of $70,000 to $87,000 per ICU-bed, depending on the depreciation methods applied. Conclusions: The cost of tele-ICU implementation is substantial, and the impact of these programs on hospital costs or profits is unclear. Until additional data become available, clinicians and administrators should carefully weigh the clinical and economic aspects of tele-ICUs when considering investing in this technology. PMID:22797291

Virtual Breakthrough Series, Part 1: Preventing Catheter-Associated Urinary Tract Infection and Hospital-Acquired Pressure Ulcers in the Veterans Health Administration.

PubMed

Zubkoff, Lisa; Neily, Julia; King, Beth J; Dellefield, Mary Ellen; Krein, Sarah; Young-Xu, Yinong; Boar, Shoshana; Mills, Peter D

2016-11-01

In 2014 the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) implemented a Virtual Breakthrough Series (VBTS) collaborative to help VHA facilities prevent hospital-acquired conditions: catheter-associated urinary tract infection (CAUTI) and hospital-acquired pressure ulcers (HAPUs). During the prework phase, participating facilities assembled a multidisciplinary team, assessed their current system for CAUTI or HAPU prevention, and examined baseline data to set improvement aims. The action phase consisted of educational conference calls, coaching, and monthly team reports. Learning was conducted via phone, web-based options, and e-mail. The CAUTI bundle focused on four key principles: (1) avoidance of indwelling urinary catheters, (2) proper insertion technique, (3) proper catheter maintenance, and (4) timely removal of the indwelling catheter. The HAPU bundle focused on assessment and inspection, pressure-relieving surfaces, turning and repositioning, incontinence management, and nutrition/hydration assessment and intervention. For the 18 participating units, the mean aggregated CAUTI rate decreased from 2.37 during the prework phase to 1.06 per 1,000 catheter-days during the action (implementation) phase (p < 0.001); the rate did not change for CAUTI nonparticipating sites. HAPU data were available only for 21 of the 31 participating units, whose mean aggregated HAPU rate decreased from 1.80 to 0.99 from prework to continuous improvement (p < 0.001). Staff education and documentation improvement were the most frequently implemented changes. This project helped improve CAUTI and HAPU rates in the VHA and presents a promising model for implementing a virtual model for improvement. Copyright 2016 The Joint Commission.

Cognitive-behavioral treatments for criminogenic thinking: Barriers and facilitators to implementation within the Veterans Health Administration.

PubMed

Blonigen, Daniel M; Rodriguez, Allison L; Manfredi, Luisa; Nevedal, Andrea; Rosenthal, Joel; McGuire, James F; Smelson, David; Timko, Christine

2018-02-01

Cognitive-behavioral treatments for criminogenic thinking (i.e., antisocial cognitions, attitudes, and traits) are regarded as best practices for reducing criminal recidivism among justice-involved adults. However, the barriers and facilitators to implementation of these treatments within large health care systems such as the Veterans Health Administration (VHA) are largely unknown. To address this gap, we conducted qualitative interviews with 22 Specialists from the VHA's Veterans Justice Programs who had been trained in a cognitive-behavioral treatment for criminogenic thinking (i.e., Moral Reconation Therapy [MRT], Thinking for a Change [T4C]). The time-intensiveness of these treatments emerged as a barrier to implementation. Potential solutions identified were patient incentives for treatment engagement, streamlining the curriculum, and implementing the treatments within long-term/residential programs. At the program level, providers' stigma/bias toward patients with antisocial tendencies was seen as a barrier to implementation, as were time/resource constraints on providers. To address the latter, use of peer providers to deliver the treatments and partnerships between justice programs and behavioral health services were suggested. At the system level, lack of recognition of criminogenic treatments as evidence based, and uncertainty of sustained funds to support ongoing costs of these treatments emerged as implementation barriers. To address the latter, a train-the-trainers model was suggested. Our findings serve as a guide for implementation of criminogenic treatments for providers and policymakers in VHA and other large health care systems, which are increasingly called upon to provide care to justice-involved adults in the community. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

77 FR 50549 - Agency Information Collection: Emergency Submission for OMB Review (VISN 23 PACT Demonstration...

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2012-08-21

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Correction to: Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol.

PubMed

Sales, Anne E; Ersek, Mary; Intrator, Orna K; Levy, Cari; Carpenter, Joan G; Hogikyan, Robert; Kales, Helen C; Landis-Lewis, Zach; Olsan, Tobie; Miller, Susan C; Montagnini, Marcos; Periyakoil, Vyjeyanthi S; Reder, Sheri

2018-02-09

The authors would like to correct errors in the original article [1] that may have lead readers to misinterpret the scope, evidence base and target population of VHA Handbook 1004.03 "Life-Sustaining Treatment (LST) Decisions: Eliciting, Documenting, and Honoring Patients' Values, Goals, and Preferences".

Apollo 16 impact-melt splashes - Petrography and major-element composition

NASA Technical Reports Server (NTRS)

See, Thomas H.; Horz, Friedrich; Morris, Richard V.

1986-01-01

Petrographic and major-element analyses are applied to 50 Apollo 16 impact-melt splash (IMS) samples in order to determine their origin and assess the nature of the subregolith source. The macroscopic analyses reveal that the IMSs exhibit a glassy appearance, but the textures range from holohyaline to hyalopilitic. Schlieren-rich glasses dominate the holohyaline areas, and the crystalline areas are mainly spherulitic. It is observed that most IMSs contain feldspathic monomineralic and lithic clasts and no regolithic materials. It is detected that the chemistry of most IMSs is not like the local regolith and appears to represent varied mixtures of VHA impact-melt breccias and anorthosite; the host rocks are mainly dimict breccias. It is concluded that the Cayley Formation is a polymict deposit composed of VHA impact-melt breccias and anorthosites. Tables revealing the macroscopic characteristics of the IMSs and the major-element composition of IMSs and various host rock are presented.

Organization Complexity and Primary Care Providers' Perceptions of Quality Improvement Culture Within the Veterans Health Administration.

PubMed

Korom-Djakovic, Danijela; Canamucio, Anne; Lempa, Michele; Yano, Elizabeth M; Long, Judith A

2016-01-01

This study examined how aspects of quality improvement (QI) culture changed during the introduction of the Veterans Health Administration (VHA) patient-centered medical home initiative and how they were influenced by existing organizational factors, including VHA facility complexity and practice location. A voluntary survey, measuring primary care providers' (PCPs') perspectives on QI culture at their primary care clinics, was administered in 2010 and 2012. Participants were 320 PCPs from hospital- and community-based primary care practices in Pennsylvania, West Virginia, Delaware, New Jersey, New York, and Ohio. PCPs in community-based outpatient clinics reported an improvement in established processes for QI, and communication and cooperation from 2010 to 2012. However, their peers in hospital-based clinics did not report any significant improvements in QI culture. In both years, compared with high-complexity facilities, medium- and low-complexity facilities had better scores on the scales assessing established processes for QI, and communication and cooperation. © The Author(s) 2014.

Integrating Diabetes Guidelines into a Telehealth Screening Tool.

PubMed

Gervera, Kelly; Graves, Barbara Ann

2015-01-01

Diabetes is the seventh leading cause of death in the United States and contributes to long-term complications that are costly to healthcare systems. Twenty-five percent of all veterans in the Veterans Health Administration (VHA) have diabetes. The purpose of this article is to describe the development and implementation of a quality improvement project to embed an evidence-based diabetes screening tool, based on Veterans Affairs/Department of Defense diabetes clinical practice guidelines, into the VHA electronic medical record. The objectives of the screening tool were threefold: to promote evidence-based care, to standardize care coordination, and to promote self-management and proper utilization of resources. Record reviews were conducted to evaluate the effectiveness of the screening tool. Results showed an 88 percent increase in the assessment of annual exams and/or labs, a 16.5 percent increase in disease management assessment and offering of services, and a 50 percent increase in goal-setting activity.

Differential Risk for Homelessness Among US Male and Female Veterans With a Positive Screen for Military Sexual Trauma.

PubMed

Brignone, Emily; Gundlapalli, Adi V; Blais, Rebecca K; Carter, Marjorie E; Suo, Ying; Samore, Matthew H; Kimerling, Rachel; Fargo, Jamison D

2016-06-01

Military sexual trauma (MST) is associated with adverse physical and mental health outcomes following military separation. Recent research suggests that MST may be a determinant in several factors associated with postdeployment homelessness. To evaluate MST as an independent risk factor for homelessness and to determine whether risk varies by sex. A retrospective cohort study of US veterans who used Veterans Health Administration (VHA) services between fiscal years 2004 and 2013 was conducted using administrative data from the Department of Defense and VHA. Included in the study were 601 892 US veterans deployed in Iraq or Afghanistan who separated from the military between fiscal years 2001 and 2011 and subsequently used VHA services. Positive response to screen for MST administered in VHA facilities. Administrative evidence of homelessness within 30 days, 1 year, and 5 years following the first VHA encounter after last deployment. The mean (SD) age of the 601 892 participants was 38.9 (9.4) years, 527 874 (87.7%) were male, 310 854 (51.6%) were white, and 382 361 (63.5%) were enlisted in the Army. Among veterans with a positive screen for MST, rates of homelessness were 1.6% within 30 days, 4.4% within 1 year, and 9.6% within 5 years, more than double the rates of veterans with a negative MST screen (0.7%, 1.8%, and 4.3%, respectively). A positive screen for MST was significantly and independently associated with postdeployment homelessness. In regression models adjusted for demographic and military service characteristics, odds of experiencing homelessness were higher among those who screened positive for MST compared with those who screened negative (30-day: adjusted odds ratio [AOR], 1.89; 95% CI, 1.58-2.24; 1-year: AOR, 2.27; 95% CI, 2.04-2.53; and 5-year: AOR, 2.63; 95% CI, 2.36-2.93). Military sexual trauma screen status remained independently associated with homelessness after adjusting for co-occurring mental health and substance abuse diagnoses

38 CFR 21.155 - Services to a veteran's family.

Code of Federal Regulations, 2010 CFR

2010-07-01

... training, counseling, and mental health services of brief duration which are designed to enable the family... furnished to family members under these provisions. (c) Providing services to a veteran's family. VR&E Staff... Veterans Health Administration (VHA) to family members of veterans eligible for Chapter 31 should be used...

38 CFR 21.155 - Services to a veteran's family.

Code of Federal Regulations, 2011 CFR

2011-07-01

... training, counseling, and mental health services of brief duration which are designed to enable the family... furnished to family members under these provisions. (c) Providing services to a veteran's family. VR&E Staff... Veterans Health Administration (VHA) to family members of veterans eligible for Chapter 31 should be used...

78 FR 50144 - Health Services Research and Development Service, Scientific Merit Review Board; Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-16

... Organization and Delivery; Research Methods and Models on August 27-28, 2013, at the VHA National Conference... DEPARTMENT OF VETERANS AFFAIRS Health Services Research and Development Service, Scientific Merit... Advisory Committee Act, 5 U.S.C. App. 2, that the Health Services Research and Development Service (HSR&D...

75 FR 60170 - Proposed Information Collection (Claim for Payment of Cost of Unauthorized Medical Services...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-29

.... Request for Payment of Beneficiary Travel After the Date of Service--417. Estimated Average Burden per... information will have practical utility; (2) the accuracy of VHA's estimate of the burden of the proposed... collected; and (4) ways to minimize the burden of the collection of information on respondents, including...

38 CFR 70.3 - Determination of Secretary.

Code of Federal Regulations, 2011 CFR

2011-07-01

... Secretary. 70.3 Section 70.3 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS (CONTINUED) VHA BENEFICIARY TRAVEL UNDER 38 U.S.C. 111 § 70.3 Determination of Secretary. For each fiscal year, the Secretary of Veterans Affairs will determine whether funds are available for paying expenses...

38 CFR 70.3 - Determination of Secretary.

Code of Federal Regulations, 2010 CFR

2010-07-01

... Secretary. 70.3 Section 70.3 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS (CONTINUED) VHA BENEFICIARY TRAVEL UNDER 38 U.S.C. 111 § 70.3 Determination of Secretary. For each fiscal year, the Secretary of Veterans Affairs will determine whether funds are available for paying expenses...

75 FR 26847 - Privacy Act of 1974; System of Records

Federal Register 2010, 2011, 2012, 2013, 2014

2010-05-12

..., encrypted VHA servers, personal computers, laptops, or media. All e-mail transmissions of such files use... requested in connection with appeals, special studies of the civil service and other merit systems, reviews... connection with appeals, special studies of the civil service and other merit systems, reviews of rules and...

B lymphocyte selection and age-related changes in VH gene usage in mutant Alicia rabbits.

PubMed

Zhu, X; Boonthum, A; Zhai, S K; Knight, K L

1999-09-15

Young Alicia rabbits use VHa-negative genes, VHx and VHy, in most VDJ genes, and their serum Ig is VHa negative. However, as Alicia rabbits age, VHa2 allotype Ig is produced at high levels. We investigated which VH gene segments are used in the VDJ genes of a2 Ig-secreting hybridomas and of a2 Ig+ B cells from adult Alicia rabbits. We found that 21 of the 25 VDJ genes used the a2-encoding genes, VH4 or VH7; the other four VDJ genes used four unknown VH gene segments. Because VH4 and VH7 are rarely found in VDJ genes of normal or young Alicia rabbits, we investigated the timing of rearrangement of these genes in Alicia rabbits. During fetal development, VH4 was used in 60-80% of nonproductively rearranged VDJ genes, and VHx and VHy together were used in 10-26%. These data indicate that during B lymphopoiesis VH4 is preferentially rearranged. However, the percentage of productive VHx- and VHy-utilizing VDJ genes increased from 38% at day 21 of gestation to 89% at birth (gestation day 31), whereas the percentage of VH4-utilizing VDJ genes remained at 15%. These data suggest that during fetal development, either VH4-utilizing B-lineage cells are selectively eliminated, or B cells with VHx- and VHy-utilizing VDJ genes are selectively expanded, or both. The accumulation of peripheral VH4-utilizing a2 B cells with age indicates that these B cells might be selectively expanded in the periphery. We discuss the possible selection mechanisms that regulate VH gene segment usage in rabbit B cells during lymphopoiesis and in the periphery.

Rural access to clinical pharmacy services.

PubMed

Patterson, Brandon J; Kaboli, Peter J; Tubbs, Traviss; Alexander, Bruce; Lund, Brian C

2014-01-01

To examine the impact of rural residence and primary care site on use of clinical pharmacy services (CPS) and to describe the use of clinical telepharmacy within the Veterans Health Administration (VHA) health care system. Using 2011 national VHA data, the frequency of patients with CPS encounters was compared across patient residence (urban or rural) and principal site of primary care (medical center, urban clinic, or rural clinic). The likelihood of CPS utilization was estimated with random effects logistic regression. Individual service types (e.g., anticoagulation clinics) and delivery modes (e.g., telehealth) were also examined. Of 3,040,635 patients, 711,348 (23.4%) received CPS. Service use varied by patient residence (urban: 24.9%; rural: 19.7%) and principal site of primary care (medical center: 25.9%; urban clinic: 22.5%; rural clinic: 17.6%). However, in adjusted analyses, urban-rural differences were explained primarily by primary care site and less so by patient residence. Similar findings were observed for individual CPS types. Telehealth encounters were common, accounting for nearly one-half of patients receiving CPS. Video telehealth was infrequent (<0.2%), but more common among patients of rural clinics than those receiving CPS at medical centers (odds ratio [OR] = 9.7; 95% CI 9.0-10.5). We identified a potential disparity between rural and urban patients' access to CPS, which was largely explained by greater reliance on community clinics for primary care than on medical centers. Future research is needed to determine if this disparity will be alleviated by emerging organizational changes, including expanding telehealth capacity and integrating pharmacists into primary care teams, and whether lessons learned at VHA translate to other settings.

Risk Factors for Serious Prescription Opioid-Induced Respiratory Depression or Overdose: Comparison of Commercially Insured and Veterans Health Affairs Populations

PubMed Central

Nadpara, Pramit A; Joyce, Andrew R; Murrelle, E Lenn; Carroll, Nathan W; Carroll, Norman V; Barnard, Marie; Zedler, Barbara K

2018-01-01

Abstract Objective To characterize the risk factors associated with overdose or serious opioid-induced respiratory depression (OIRD) among medical users of prescription opioids in a commercially insured population (CIP) and to compare risk factor profiles between the CIP and Veterans Health Administration (VHA) population. Subjects and Methods Analysis of data from 18,365,497 patients in the IMS PharMetrics Plus health plan claims database (CIP) who were dispensed a prescription opioid in 2009 to 2013. Baseline factors associated with an event of serious OIRD among 7,234 cases and 28,932 controls were identified using multivariable logistic regression. The CIP risk factor profile was compared with that from a corresponding logistic regression among 817 VHA cases and 8,170 controls in 2010 to 2012. Results The strongest associations with serious OIRD in CIP were diagnosed substance use disorder (odds ratio [OR] = 10.20, 95% confidence interval [CI] = 9.06–11.40) and depression (OR = 3.12, 95% CI = 2.84–3.42). Other strongly associated factors included other mental health disorders; impaired liver, renal, vascular, and pulmonary function; prescribed fentanyl, methadone, and morphine; higher daily opioid doses; and concurrent psychoactive medications. These risk factors, except depression, vascular disease, and specific opioids, largely aligned with VHA despite CIP being substantially younger, including more females and less chronic disease, and having greater prescribing prevalence of higher daily opioid doses, specific opioids, and most selected nonopioids. Conclusions Risk factor profiles for serious OIRD among US medical users of prescription opioids with private or public health insurance were largely concordant despite substantial differences between the populations in demographics, clinical conditions, health care delivery systems, and clinical practices. PMID:28419384

Persistent pain and comorbidity among Operation Enduring Freedom/Operation Iraqi Freedom/operation New Dawn veterans.

PubMed

Higgins, Diana M; Kerns, Robert D; Brandt, Cynthia A; Haskell, Sally G; Bathulapalli, Harini; Gilliam, Wesley; Goulet, Joseph L

2014-05-01

Chronic pain is a significant concern for the Veterans Health Administration (VHA), with chronic pain conditions among those most frequently reported by Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) veterans. The current study examined VHA electronic medical record data to examine variation in demographics and high prevalence and high impact medical and mental health conditions in order to characterize the differences between patients with persistent pain and no pain. A conservative operational definition of chronic or "persistent pain" based on multiple indicators of pain (i.e., pain intensity ratings, prescription opioids, pain clinic visits, International Classification of Diseases, Ninth Revision codes) was employed. Analyses included the entire roster of longitudinal clinical data on OEF/OIF/OND veterans who used VHA care to compare those with persistent pain with those with no clinical evidence of pain. Results of logistic regression models suggest that sex, race, education, military variables, body mass index (BMI), traumatic brain injury (TBI), and mental health conditions, but not age, reliably discriminate the two groups. Those with persistent pain were more likely to be Black, female, on active duty, enlisted, Army service members, have a high school education or less, and have diagnoses of mood disorders, post-traumatic stress disorder, substance use disorders, anxiety disorders, TBI, and have a BMI consistent with overweight and obesity. The operational definition of chronic pain used in this study may have research implications for examining predictors of incident and chronic pain. These data have important clinical implications in that addressing comorbid conditions of persistent pain may improve adaptive coping and functioning in these patients. Wiley Periodicals, Inc.

Guideline concordance of new statin prescriptions: who got a statin?

PubMed

Cascino, Thomas; Vali, Marzieh; Redberg, Rita; Bravata, Dawn M; Boscardin, John; Eilkhani, Elnaz; Keyhani, Salomeh

2017-09-01

Statins are recommended to reduce serum cholesterol in patients at risk for atherosclerotic cardiovascular disease. Despite the prevalence of statin use, little is known about the indications for new prescriptions. We assessed the concordance of new statin prescriptions in the Veterans Health Administration (VHA) compared with the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP III) guidelines (the guidelines in force in 2012) and the American College of Cardiology (ACC)-American Heart Association (AHA) 2013 guidelines. Cross-sectional study. We identified every patient who received a new prescription (no statin use in the prior year) in the VHA in 2012. Patients were excluded if they had incomplete data, triglycerides greater than 400 mg/dL, or fewer than 2 primary care visits to ensure adequate baseline data to calculate Framingham and ACC-AHA 2013 risk scores. We identified 250,243 new statin prescriptions in 2012 in the VHA, with 121,081 meeting inclusion criteria. Among new prescriptions, 68% were prescribed for primary prevention and 32% were prescribed for secondary prevention. Among patients receiving new statins for primary prevention, 48% did not have an indication supported by the ATP III guideline and 20% did not have an indication supported by the ACC/AHA guideline. Overall, approximately 19% of patients may have received a statin for an indication not supported by either guideline. Veterans are commonly prescribed statins for indications not supported by professional society guidelines. The finding of common use of statins outside established guidelines represents an opportunity to improve the quality and value of the healthcare delivery.

Na+/K+-ATPase and vacuolar-type H+-ATPase in the gills of the aquatic air-breathing fish Trichogaster microlepis in response to salinity variation.

PubMed

Huang, Chun-Yen; Chao, Pei-Lin; Lin, Hui-Chen

2010-03-01

The aquatic air-breathing fish, Trichogaster microlepis, can be found in fresh water and estuaries. We further evaluated the changes in two important osmoregulatory enzymes, Na(+)/K(+)-ATPase (NKA) and vacuolar-type H(+)-ATPase (VHA), in the gills when fish were subjected to deionized water (DW), fresh water (FW), and salinated brackish water (salinity of 10 g/L). Fish were sampled only 4 days after experimental transfer. The mortality, plasma osmolality, and Na(+) concentration were higher in 10 g/L acclimated fish, while their muscle water content decreased with elevated external salinity. The highest NKA protein abundance was found in the fish gills in 10 g/L, and NKA activity was highest in the DW and 10 g/L acclimated fish. The VHA protein levels were highest in 10 g/L, and VHA activity was highest in the DW treatment. From immunohistochemical results, we found three different cell populations: (1) NKA-immunoreactive (NKA-IR) cells, (2) both NKA-IR and HA-IR cells, and (3) HA-IR cells. NKA-IR cells in the lamellar and interlamellar regions significantly increased in DW and 10 g/L treatments. Only HA-IR cells in the lamellar region were significantly increased in DW. In the interlamellar region, there was no difference in the number of HA-IR cells among the three treated. From these results, T. microlepis exhibited osmoregulatory ability in DW and 10 g/L treatments. The cell types involved in ionic regulation were also examined with immunofluorescence staining; three ionocyte types were found which were similar to the zebrafish model. Copyright 2009 Elsevier B.V. All rights reserved.

Risk Factors for Serious Prescription Opioid-Induced Respiratory Depression or Overdose: Comparison of Commercially Insured and Veterans Health Affairs Populations.

PubMed

Nadpara, Pramit A; Joyce, Andrew R; Murrelle, E Lenn; Carroll, Nathan W; Carroll, Norman V; Barnard, Marie; Zedler, Barbara K

2018-01-01

To characterize the risk factors associated with overdose or serious opioid-induced respiratory depression (OIRD) among medical users of prescription opioids in a commercially insured population (CIP) and to compare risk factor profiles between the CIP and Veterans Health Administration (VHA) population. Analysis of data from 18,365,497 patients in the IMS PharMetrics Plus health plan claims database (CIP) who were dispensed a prescription opioid in 2009 to 2013. Baseline factors associated with an event of serious OIRD among 7,234 cases and 28,932 controls were identified using multivariable logistic regression. The CIP risk factor profile was compared with that from a corresponding logistic regression among 817 VHA cases and 8,170 controls in 2010 to 2012. The strongest associations with serious OIRD in CIP were diagnosed substance use disorder (odds ratio [OR] = 10.20, 95% confidence interval [CI] = 9.06-11.40) and depression (OR = 3.12, 95% CI = 2.84-3.42). Other strongly associated factors included other mental health disorders; impaired liver, renal, vascular, and pulmonary function; prescribed fentanyl, methadone, and morphine; higher daily opioid doses; and concurrent psychoactive medications. These risk factors, except depression, vascular disease, and specific opioids, largely aligned with VHA despite CIP being substantially younger, including more females and less chronic disease, and having greater prescribing prevalence of higher daily opioid doses, specific opioids, and most selected nonopioids. Risk factor profiles for serious OIRD among US medical users of prescription opioids with private or public health insurance were largely concordant despite substantial differences between the populations in demographics, clinical conditions, health care delivery systems, and clinical practices. © 2017 American Academy of Pain Medicine.

Branchial osmoregulation in the euryhaline bull shark, Carcharhinus leucas: a molecular analysis of ion transporters.

PubMed

Reilly, Beau D; Cramp, Rebecca L; Wilson, Jonathan M; Campbell, Hamish A; Franklin, Craig E

2011-09-01

Bull sharks, Carcharhinus leucas, are one of only a few species of elasmobranchs that live in both marine and freshwater environments. Osmoregulation in euryhaline elasmobranchs is achieved through the control and integration of various organs (kidney, rectal gland and liver) in response to changes in environmental salinity. However, little is known regarding the mechanisms of ion transport in the gills of euryhaline elasmobranchs and how they are affected by osmoregulatory challenges. This study was conducted to gain insight into the branchial ion and acid-base regulatory mechanisms of C. leucas by identifying putative ion transporters and determining whether their expression is influenced by environmental salinity. We hypothesised that expression levels of the Na(+)/K(+)-ATPase (NKA) pump, Na(+)/H(+) exchanger 3 (NHE3), vacuolar-type H(+)-ATPase (VHA) and anion exchanger pendrin (PDN) would be upregulated in freshwater (FW) C. leucas. Immunohistochemistry was used to localise all four ion transporters in gills of bull sharks captured in both FW and estuarine/seawater (EST/SW) environments. NHE3 immunoreactivity occurred in the apical region of cells with basolateral NKA expression whereas PDN was apically expressed in cells that also exhibited basolateral VHA immunoreactivity. In accordance with our hypotheses, quantitative real-time PCR showed that the mRNA expression of NHE3 and NKA was significantly upregulated in gills of FW-captured C. leucas relative to EST/SW-captured animals. These data suggest that NHE3 and NKA together may be important in mediating branchial Na(+) uptake in freshwater environments, whereas PDN and VHA might contribute to Cl(-)/HCO(3)(-) transport in marine and freshwater bull shark gills.

Text de-identification for privacy protection: a study of its impact on clinical text information content.

PubMed

Meystre, Stéphane M; Ferrández, Óscar; Friedlin, F Jeffrey; South, Brett R; Shen, Shuying; Samore, Matthew H

2014-08-01

As more and more electronic clinical information is becoming easier to access for secondary uses such as clinical research, approaches that enable faster and more collaborative research while protecting patient privacy and confidentiality are becoming more important. Clinical text de-identification offers such advantages but is typically a tedious manual process. Automated Natural Language Processing (NLP) methods can alleviate this process, but their impact on subsequent uses of the automatically de-identified clinical narratives has only barely been investigated. In the context of a larger project to develop and investigate automated text de-identification for Veterans Health Administration (VHA) clinical notes, we studied the impact of automated text de-identification on clinical information in a stepwise manner. Our approach started with a high-level assessment of clinical notes informativeness and formatting, and ended with a detailed study of the overlap of select clinical information types and Protected Health Information (PHI). To investigate the informativeness (i.e., document type information, select clinical data types, and interpretation or conclusion) of VHA clinical notes, we used five different existing text de-identification systems. The informativeness was only minimally altered by these systems while formatting was only modified by one system. To examine the impact of de-identification on clinical information extraction, we compared counts of SNOMED-CT concepts found by an open source information extraction application in the original (i.e., not de-identified) version of a corpus of VHA clinical notes, and in the same corpus after de-identification. Only about 1.2-3% less SNOMED-CT concepts were found in de-identified versions of our corpus, and many of these concepts were PHI that was erroneously identified as clinical information. To study this impact in more details and assess how generalizable our findings were, we examined the overlap between

75 FR 9278 - Proposed Information Collection (Regulation for Reconsideration of Denied Claims) Activity...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-03-01

... formal appeals and allows decision making to be more responsive to veterans using the VA healthcare... have practical utility; (2) the accuracy of VHA's estimate of the burden of the proposed collection of information; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4...

78 FR 21711 - Proposed Information Collection (Regulation for Reconsideration of Denied Claims) Activity...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-04-11

... reduces both formal appeals and allows decision making to be more responsive to veterans using the VA... information will have practical utility; (2) the accuracy of VHA's estimate of the burden of the proposed collection of information; (3) ways to enhance the quality, utility, and clarity of the information to be...

Projected Use of Long-Term-Care Services by Enrolled Veterans

ERIC Educational Resources Information Center

Kinosian, Bruce; Stallard, Eric; Wieland, Darryl

2007-01-01

Purpose: The purpose of this article is to describe the projected use for long-term-care services through 2012. Design and Methods: We constructed a static-component projection model using age, function, and other covariates. We obtained enrollee projections from the Veterans Health Administration (VHA) and combined these with nursing home and…

Supporting Veteran Transitions to the Academic Setting: VA on Campus

ERIC Educational Resources Information Center

O'Connor, Ashley; Herbst, Ellen; McCaslin, Shannon; Armstrong, Keith; Leach, Bridget; Jersky, Brandina

2018-01-01

In this case study, we assessed academic functioning, service satisfaction, and needs of student veterans at a community college who had accessed the Veterans Health Administration (VHA) Student Veteran Health Program (SVHP) (n = 36). The SVHP provides outreach and behavioral health services directly on a large community college campus to overcome…

The experience of Patient Aligned Care Team (PACT) members.

PubMed

Ladebue, Amy C; Helfrich, Christian D; Gerdes, Zachary T; Fihn, Stephan D; Nelson, Karin M; Sayre, George G

2016-01-01

In April 2010, the Veterans Health Administration (VHA) launched the Patient Aligned Care Team (PACT) initiative to implement a patient-centered medical home (PCMH) model. Few evaluations have addressed the effects of PCMH on health care professionals' experiences. The aim of this study was to contribute to evaluation of the PACT initiative and the broader literature on PCMH by assessing respondents' experiences of implementing a PCMH model and becoming a teamlet. A retrospective qualitative analysis of open-text responses in a survey fielded to all VHA Primary Care personnel (VHA Primary Care physicians, nurse practitioners, physician assistants, nurse care managers, clinical associates, and administrative clerks) in May and June 2012 (approximately 2 years into the 5-year planned implementation of PACT) using deductive and inductive content analysis. The main measures were two open-response fields: "Is there anything else you would like us to relay to the VA leadership in Central Office?" and "Do you have any other comments or feedback on PACT?" The data consisted of free text responses of 3,868 survey participants who provided text for one or both of the open-response fields. Although respondents viewed PACT positively as a model and reported it improved relationships with patients and increased patient satisfaction, they described multiple barriers to achieving functioning teamlets and unintended consequences, including reduced time with patients, increased participant burnout, and decreased team efficacy because of low-performing team members. A central theme related to staffing being insufficient for the new model. Insufficient staffing of PCMH teams is a critical barrier to realizing the benefits of the new model. Frontline staff have concrete recommendations for other problems, such as using back-up teams to cover during absences, but that will require providing more opportunities for feedback from staff to be heard.

Restricted utilization of germ-line VH genes in rabbits: implications for inheritance of VH allotypes and generation of antibody diversity.

PubMed

Knight, K L; Becker, R S; DiPietro, L A

1991-01-01

The presence of inherited VH region allotypic specificities, a1, a2 or a3, on nearly all rabbit immunoglobulins has presented a paradox. We know the germline contains hundreds of VH genes, and if we assume that most of these are used in the generation of antibody diversity, then we must ask how have the a allotype-encoding regions been maintained over time? On the other hand, if we assume that only one (or a small number) of these VH gene(s) is (are) used in VDJ gene rearrangements, then, how is antibody diversity generated? To address these questions, we have cloned and determined the nucleotide sequence of the 3'-most germline VH genes from the a1, a2 and a3 chromosomes and shown in each case that the 3'-most H gene, VH1-a1, VH1-a2, or VH1-a3, encodes an a1, a2 or a3 VH region, respectively. Analysis of rearranged VDJ genes from leukemic B cells showed that VH1 was utilized in these rearrangements. Based on these data, we propose that the allelic inheritance of the VH allotypes is explained by the preferential usage of the VH1 gene in VDJ rearrangements. Support for this hypothesis was obtained from analysis of the mutant rabbit Alicia in which most serum Ig molecules do not have VHa allotypic specificities, but instead have so-called VHa-negative Ig molecules. In this rabbit, VH1 is not expressed as it has been deleted. Analysis of cDNA clones from spleen of Alicia rabbits suggests that the expressed VHa-negative molecules also are encoded by a single germline VH gene. Thus, we suggest that nearly all rabbit VH regions are encoded by one to two germline VH genes and that antibody diversity is generated primarily by somatic hypermutation and gene conversion.

Apple fruit acidity is genetically diversified by natural variations in three hierarchical epistatic genes MdSAUR37, MdPP2CH and MdALMTII.

PubMed

Jia, Dongjie; Shen, Fei; Wang, Yi; Wu, Ting; Xu, Xuefeng; Zhang, Xinzhong; Han, Zhenhai

2018-05-11

Many efforts have been made to map quantitative trait loci (QTLs) to facilitate practical marker-assisted selection (MAS) in plants. In the present study, we identified four genome-wide major QTLs responsible for apple fruit acidity by MapQTL and BSA-seq analyses using two independent pedigree-based populations. Candidate genes were screened in major QTL regions, and three functional gene markers, including a non-synonymous A/G single nucleotide polymorphism (SNP) in the coding region of MdPP2CH, a 36-bp insertion in the promoter of MdSAUR37, and a previously reported SNP in MdALMTII, were validated to influence the malate content of apple fruits. In addition, MdPP2CH inactivated three vacuolar H + -ATPases (MdVHA-A3, MdVHA-B2 and MdVHA-D2) and one aluminium-activated malate transporter (MdALMTII) via dephosphorylation and negatively influenced fruit malate accumulation. The dephosphotase activity of MdPP2CH was suppressed by MdSAUR37, which implied a higher hierarchy of genetic interaction. Therefore, the MdSAUR37/MdPP2CH/MdALMTII chain cascaded hierarchical epistatic genetic effects to precisely determine apple fruit malate content. An A/G SNP (-1010) on MdMYB44 promoter region from a major QTL (qtl08.1) was closely associated with fruit malate content. The predicted phenotype values (PPVs) were estimated using the tentative genotype values of the gene markers, and the PPVs were significantly correlated with the observed phenotype values. Our findings provide an insight into plant genome-based selection in apples and will aid in conducting research to understand the physiological fundamentals of quantitative genetics. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Conflict of interest issues pertinent to Veterans Affairs Medical Centers.

PubMed

Hanna, Jennifer; Simiele, Ernest; Lawson, D Curtis; Tyler, Douglas

2011-09-01

Conflicts of interest exist when an arrangement potentially exerts inappropriate influence on decision making or professional judgment, or is perceived to do so, and can thus damage the public trust and undermine the integrity of those decisions. Concerns regarding financial conflicts of interest in the medical arena have reached their height as of late, given that physicians now function in a milieu of complex and delicate relationships with pharmaceutical, biotechnology, and medical device industries. Even when such relationships do not correlate with actual compromise of judgment or patient care, it threatens the credibility of both the health care professional and the institution because of the social perception of the effect of these relationships. Although most institutions in the Western world set forth a code of ethics and conflict-of-interest policies to be followed under threat of termination, the Veterans Health Administration (VHA) presents itself as a unique environment in which conflicts of interest are subject to governmental laws, violation of which may not only result in employment-related discipline, but may be sanctioned by civil and criminal penalties. Moreover, these provisions are developed by a national authoritative organization rather than being institution-specific guidelines. Given that many academic physicians working within the VHA may also have a component of their practice in a University setting, it becomes important to understand the differences in policy between these contexts so as not to threaten the public trust in the veracity of decisions made and, therefore, maintain the integrity of the relationship between physician and patient. This article will review aspects of conflict-of-interest policies in the realm of research, financial relationships, foreign travel, and vendor contracting that are particular to the VHA and make it a unique environment to function in as a physician and scientist. Copyright © 2011 Society for

Health Care Costs for Patients With Chronic Spinal Cord Injury in the Veterans Health Administration

PubMed Central

French, Dustin D; Campbell, Robert R; Sabharwal, Sunil; Nelson, Audrey L; Palacios, Polly A; Gavin-Dreschnack, Deborah

2007-01-01

Background/Objective: Recurring annual costs of caring for patients with chronic spinal cord injury (SCI) is a large economic burden on health care systems, but information on costs of SCI care beyond the acute and initial postacute phase is sparse. The objective of this study was to establish a frame of reference and estimate of the annual direct medical costs associated with health care for a sample of patients with chronic SCI (ie, >2 years after injury). Methods: Patients were recruited from 3 Veterans Health Administration (VHA) SCI facilities; baseline patient information was cross-referenced to the Decision Support System (DSS) National Data Extracts (NDE) to obtain patient-specific health care costs in VHA. Descriptive statistical analysis of annual DSS-NDE cost of patients with SCI (N = 675) for fiscal year (FY) 2005 by level and completeness of injury was conducted. Results: Total (inpatient and outpatient) annual (FY 2005) direct medical costs for 675 patients with SCI exceeded $14.47 million or $21,450 per patient. Average annual total costs varied from $28,334 for cervical complete SCI to $16,792 for thoracic incomplete SCI. Two hundred thirty-three of the 675 patients with SCI who were hospitalized over the study period accounted for a total of 378 hospital discharges, costing in excess of $7.19 million. This approximated a cost of outpatient care received of $7.28 million for our entire sample. Conclusions: The comprehensive nature of health care delivery and related cost capture for people with chronic SCI in the VHA provided us the opportunity to accurately determine health care costs for this population. Future SCI postacute care cost analyses should consider case-mix adjusting patients at high risk for rehospitalization. PMID:18092564

Organizational correlates of implementation of colocation of mental health and primary care in the Veterans Health Administration.

PubMed

Guerrero, Erick G; Heslin, Kevin C; Chang, Evelyn; Fenwick, Karissa; Yano, Elizabeth

2015-07-01

This study explored the role of organizational factors in the ability of Veterans Health Administration (VHA) clinics to implement colocated mental health care in primary care settings (PC-MH). The study used data from the VHA Clinical Practice Organizational Survey collected in 2007 from 225 clinic administrators across the United States. Clinic degree of implementation of PC-MH was the dependent variable, whereas independent variables included policies and procedures, organizational context, and leaders' perceptions of barriers to change. Pearson bivariate correlations and multivariable linear regression were used to test hypotheses. Results show that depression care training for primary care providers and clinics' flexibility and participation were both positively correlated with implementation of PC-MH. However, after accounting for other factors, regressions show that only training primary care providers in depression care was marginally associated with degree of implementation of PC-MH (p = 0.051). Given the importance of this topic for implementing integrated care as part of health care reform, these null findings underscore the need to improve theory and testing of more proximal measures of colocation in future work.

Organizational Correlates of Implementation of Colocation of Mental Health and Primary Care in the Veterans Health Administration

PubMed Central

Guerrero, Erick G.; Heslin, Kevin C.; Chang, Evelyn; Fenwick, Karissa; Yano, Elizabeth

2014-01-01

This study explored the role of organizational factors in the ability of Veterans Health Administration (VHA) clinics to implement colocated mental health care in primary care settings (PC-MH). The study used data from the VHA Clinical Practice Organizational Survey collected in 2007 from 225 clinic administrators across the United States. Clinic degree of implementation of PC-MH was the dependent variable, whereas independent variables included policies and procedures, organizational context, and leaders’ perceptions of barriers to change. Pearson bivariate correlations and multivariable linear regression were used to test hypotheses. Results show that depression care training for primary care providers and clinics’ flexibility and participation were both positively correlated with implementation of PC-MH. However, after accounting for other factors, regressions show that only training primary care providers in depression care was marginally associated with degree of implementation of PC-MH (p = 0.051). Given the importance of this topic for implementing integrated care as part of health care reform, these null findings underscore the need to improve theory and testing of more proximal measures of colocation in future work. PMID:25096986

Prevalence of Suicidality Among Hispanic and African American Veterans Following Surgery

PubMed Central

McIntyre, Raphael T.; Stock, Eileen M.; Zeber, John E.; MacCarthy, Daniel J.; Pugh, Mary Jo

2014-01-01

Objectives. We evaluated factors associated with suicidal behavior and ideation (SBI) during 3 years of follow-up among 89 995 Veterans Health Administration (VHA) patients who underwent major surgery from October 2005 to September 2006. Methods. We analyzed administrative data using Cox proportional hazards models. SBI was ascertained by International Classification of Disease, 9th Revision codes. Results. African Americans (18% of sample; 16 252) were at an increased risk for SBI (hazard ratio [HR] = 1.21; 95% confidence interval [CI]  = 1.10, 1.32), whereas Hispanics were not (HR = 1.10; 95% CI = 0.95, 1.28). Other risk factors included schizophrenia, bipolar disorder, depression, posttraumatic stress disorder, pain disorders, postoperative new-onset depression, and postoperative complications; female gender and married status were protective against SBI. Conclusions. The postoperative period might be a time of heightened risk for SBI among minority patients in the VHA. Tailored monitoring and postoperative management by minority status might be required to achieve care equity. PMID:25100427

Phosphatidylinositol 3-Kinase Promotes V-ATPase Activation and Vacuolar Acidification and Delays Methyl Jasmonate-Induced Leaf Senescence1

PubMed Central

Liu, Jian; Ji, Yingbin; Zhou, Jun; Xing, Da

2016-01-01

PI3K and its product PI3P are both involved in plant development and stress responses. In this study, the down-regulation of PI3K activity accelerated leaf senescence induced by methyl jasmonate (MeJA) and suppressed the activation of vacuolar H+-ATPase (V-ATPase). Yeast two-hybrid analyses indicated that PI3K bound to the V-ATPase B subunit (VHA-B). Analysis of bimolecular fluorescence complementation in tobacco guard cells showed that PI3K interacted with VHA-B2 in the tonoplasts. Through the use of pharmacological and genetic tools, we found that PI3K and V-ATPase promoted vacuolar acidification and stomatal closure during leaf senescence. Vacuolar acidification was suppressed by the PIKfyve inhibitor in 35S:AtVPS34-YFP Arabidopsis during MeJA-induced leaf senescence, but the decrease was lower than that in YFP-labeled Arabidopsis. These results suggest that PI3K promotes V-ATPase activation and consequently induces vacuolar acidification and stomatal closure, thereby delaying MeJA-induced leaf senescence. PMID:26739232

IRS: where's the charity? Rural hospital manager may lose federal tax exemption.

PubMed

Hallam, K

1998-06-08

A rural hospital management company with ties to VHA may lose its federal tax exemption because, according to the Internal Revenue Service, there's nothing charitable about operating a hospital under contract. The case against the company is significant because it calls into question the tax exemptions of any not-for-profit corporation that manages or leases hospitals.

Veterans Affairs: Sustained Management Attention Needed to Address Numerous IT Challenges

DTIC Science & Technology

2016-06-22

territories and the Philippines. The department’s three major components—the Veterans Benefits Administration ( VBA ), the Veterans Health Administration...VHA), and the National Cemetery Administration (NCA)—are primarily responsible for carrying out its mission. More specifically, VBA provides a...used for the determination of benefits, benefits claims processing, patient admission to hospitals and clinics, and access to health records, among

Implementation of a Data-Based Medical Event Reporting System in the U.S. Department of Defense

DTIC Science & Technology

2005-05-01

where patient safety events warrant further investigation. Introduction Department of Defense Instruction 6025.17 established the Military Health ...Administration (VHA) Patient Safety Reporting Program for error tracking and reporting within all military health care facilities. 5 On August 16, 2001...DoD Instruction number 6025.17 “established a Military Health System Patient Safety Center (MHSPSC), including a MHS Patient Safety Registry (MHSPSR

Options Available for Providing Family Housing to Navy Families in the Continental United States

DTIC Science & Technology

1994-06-01

the Revitalization Backlog 64 4. Revise VHA and BAQ Determination Procedures 65 C. FUTURE RESEARCH ........ ................ .. 65 APPENDIX...OVERVIEW Succeeding chapters will research the three family housing options in detail and conclude with recommendations. Chapter II will provide an...advantages and disadvantages of each of the three options. Chapter VI will provide an analysis of the research leading to the conclusions and recommendations

Removal of humic acid using TiO2 photocatalytic process--fractionation and molecular weight characterisation studies.

PubMed

Liu, Sanly; Lim, May; Fabris, Rolando; Chow, Christopher; Chiang, Ken; Drikas, Mary; Amal, Rose

2008-05-01

The photocatalytic removal of humic acid (HA) using TiO2 under UVA irradiation was examined by monitoring changes in the UV(254) absorbance, dissolved organic carbon (DOC) concentration, apparent molecular weight distribution, and trihalomethane formation potentials (THMFPs) over treatment time. A resin fractionation technique in which the samples were fractionated into four components: very hydrophobic acids (VHA), slightly hydrophobic acids, hydrophilic charged (CHA) and hydrophilic neutral (NEU) was also employed to elucidate the changes in the chemical nature of the HA components during treatment. The UVA/TiO2 process was found to be effective in removing more than 80% DOC and 90% UV(254) absorbance. The THMFPs of samples were decreased to below 20 microg l(-1) after treatments, which demonstrate the potential to meet increasingly stringent regulatory level of trihalomethanes in water. Resin fractionation analysis showed that the VHA fraction was decreased considerably as a result of photocatalytic treatments, forming CHA intermediates which were further degraded with increased irradiation time. The NEU fraction, which comprised of non-UV-absorbing low molecular weight compounds, was found to be the most persistent component.

Screening for Homelessness in the Veterans Health Administration: Monitoring Housing Stability through Repeat Screening.

PubMed

Byrne, Thomas; Fargo, Jamison D; Montgomery, Ann Elizabeth; Roberts, Christopher B; Culhane, Dennis P; Kane, Vincent

2015-01-01

This study examined veterans' responses to the Veterans Health Administration's (VHA's) universal screen for homelessness and risk of homelessness during the first 12 months of implementation. We calculated the baseline annual frequency of homelessness and risk of homelessness among all veterans who completed an initial screen during the study period. We measured changes in housing status among veterans who initially screened positive and then completed a follow-up screen, assessed factors associated with such changes, and identified distinct risk profiles of veterans who completed a follow-up screen. More than 4 million veterans completed an initial screen; 1.8% (n=77,621) screened positive for homelessness or risk of homelessness. Of those who initially screened positive for either homelessness or risk of homelessness and who completed a second screen during the study period, 85.0% (n=15,060) resolved their housing instability prior to their second screen. Age, sex, race, VHA eligibility, and screening location were all associated with changes in housing stability. We identified four distinct risk profiles for veterans with ongoing housing instability. To address homelessness among veterans, efforts should include increased and targeted engagement of veterans experiencing persistent housing instability.

Empowering Staff Nurses With Essential Skills: Training Strategies for Success.

PubMed

Czekanski, Elizabeth

2016-01-01

Nurse leaders in the mental health field are challenged to ensure the mental health environment is safe and therapeutic. They must also continually evaluate whether nurses are effectively engaging therapeutically with patients in their care. Undergraduate nursing students and practicing nurses usually receive little or no training in facilitating nurse-led groups. Nurses who are trained and capable of facilitating groups may enhance therapeutic relationships and engage patients to improve treatment outcomes. Training staff and disseminating educational materials in an efficient manner are often challenges for nurse leaders. The Veterans Health Administration (VHA) Office of Nursing Services (ONS) Mental Health Field Advisory Committee (MH-FAC) developed a nursing guide for conducting psychoeducation groups. This was followed up with a complementary live virtual training with "on-demand" features that included discussion and demonstration of nurse-led group implementation strategies. Both products were disseminated to nurse leaders throughout the VHA ONS Web site. Responses to both the guide and video were overwhelmingly positive. This article discusses the importance of nurse-led psychoeducational groups and describes a project implemented by the ONS MH-FAC, which helped provide an essential training to more than 1100 RNs within the Veterans Affairs Health System nationally.

A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration.

PubMed

Rosen, C S; Matthieu, M M; Wiltsey Stirman, S; Cook, J M; Landes, S; Bernardy, N C; Chard, K M; Crowley, J; Eftekhari, A; Finley, E P; Hamblen, J L; Harik, J M; Kehle-Forbes, S M; Meis, L A; Osei-Bonsu, P E; Rodriguez, A L; Ruggiero, K J; Ruzek, J I; Smith, B N; Trent, L; Watts, B V

2016-11-01

Since 2006, the Veterans Health Administration (VHA) has instituted policy changes and training programs to support system-wide implementation of two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). To assess lessons learned from this unprecedented effort, we used PubMed and the PILOTS databases and networking with researchers to identify 32 reports on contextual influences on implementation or sustainment of EBPs for PTSD in VHA settings. Findings were initially organized using the exploration, planning, implementation, and sustainment framework (EPIS; Aarons et al. in Adm Policy Ment Health Health Serv Res 38:4-23, 2011). Results that could not be adequately captured within the EPIS framework, such as implementation outcomes and adopter beliefs about the innovation, were coded using constructs from the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (Glasgow et al. in Am J Public Health 89:1322-1327, 1999) and Consolidated Framework for Implementation Research (CFIR; Damschroder et al. in Implement Sci 4(1):50, 2009). We highlight key areas of progress in implementation, identify continuing challenges and research questions, and discuss implications for future efforts to promote EBPs in large health care systems.

Oversight overload: harried hospitals say the growing number of billing audits they face could actually increase costs.

PubMed

Daly, Rich

2011-11-21

Providers say the administration's growing emphasis on billing audits is pushing them to the limit and threatens to increase their costs. Many billing problems stem from simple errors, not fraud, they say. "When you get into the nuts and bolts of some of these programs you realize it's not as easy as taking the overpayment line out of the budget," says Michael Regier, of VHA.

100 most powerful.

PubMed

Romano, Michael

2002-08-26

Compiling a list of the 100 Most Powerful People in Healthcare requires some contemplation. Exactly what is power in this industry? C. Thomas Smith, president and CEO of VHA, calls power simply "the ability to make a difference." The influential figures chosen by Modern Healthcare readers represent a broadly varied and diverse group of movers and shakers. But they share the ability to change things.

Web-Based Predictive Analytics to Improve Patient Flow in the Emergency Department

NASA Technical Reports Server (NTRS)

Buckler, David L.

2012-01-01

The Emergency Department (ED) simulation project was established to demonstrate how requirements-driven analysis and process simulation can help improve the quality of patient care for the Veterans Health Administration's (VHA) Veterans Affairs Medical Centers (VAMC). This project developed a web-based simulation prototype of patient flow in EDs, validated the performance of the simulation against operational data, and documented IT requirements for the ED simulation.

Everybody's doing it. With the U.S. economy limping along, the unlikeliest marketers are trying to claim a niche in healthcare.

PubMed

Becker, Cinda

2003-05-05

The hospital outlook might seem bleak to some investors, but a bevy of diverse companies are seeking the financial cure they believe the healthcare industry can provide. Everyone from carpet companies to trucking firms has been drawn to healthcare because of its seemingly endless consumer demand. Jeannine Rossignol, left, senior marketing manager at Xerox Corp., demonstrates a product at the recent VHA Leadership Conference in Boston.

Population-Tailored Care for Homeless Veterans and Acute Care Use, Cost, and Satisfaction: A Prospective Quasi-Experimental Trial

PubMed Central

Johnson, Erin E.; Borgia, Matthew; Noack, Amy; Yoon, Jean; Gehlert, Elizabeth; Lo, Jeanie

2018-01-01

Introduction Although traditional patient-centered medical homes (PCMHs) are effective for patients with complex needs, it is unclear whether homeless-tailored PCMHs work better for homeless veterans. We examined the impact of enrollment in a Veterans Health Administration (VHA) homeless-tailored PCMH on health services use, cost, and satisfaction compared with enrollment in a traditional, nontailored PCMH. Methods We conducted a prospective, multicenter, quasi-experimental, single-blinded study at 2 VHA medical centers to assess health services use, cost, and satisfaction during 12 months among 2 groups of homeless veterans: 1) veterans receiving VHA homeless-tailored primary care (Homeless-Patient Aligned Care Team [H-PACT]) and 2) veterans receiving traditional primary care services (PACT). A cohort of 266 homeless veterans enrolled from June 2012 through January 2014. Results Compared with PACT patients, H-PACT patients had more social work visits (4.6 vs 2.7 visits) and fewer emergency department (ED) visits for ambulatory care-sensitive conditions (0 vs 0.2 visits); a significantly smaller percentage of veterans in H-PACT were hospitalized (23.1% vs 35.4%) or had mental health–related ED visits (34.1% vs 47.6%). We found significant differences in primary care provider–specific visits (H-PACT, 5.1 vs PACT, 3.6 visits), mental health care visits (H-PACT, 8.8 vs PACT, 13.4 visits), 30-day prescription drug fills (H-PACT, 40.5 vs PACT, 58.8 fills), and use of group therapy (H-PACT, 40.1% vs PACT, 53.7%). Annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036). In logistic regression model of acute care use, assignment to the H-PACT model was protective as was rating health “good” or better. Conclusion Homeless veterans enrolled in the population-tailored primary care approach used less acute care and costs were lower. Tailored-care models have implications for care coordination in the US Department

Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women's health primary care.

PubMed

Hamilton, Alison B; Brunner, Julian; Cain, Cindy; Chuang, Emmeline; Luger, Tana M; Canelo, Ismelda; Rubenstein, Lisa; Yano, Elizabeth M

2017-09-01

The Veterans Health Administration (VHA) has undertaken primary care transformation based on patient-centered medical home (PCMH) tenets. VHA PCMH models are designed for the predominantly male Veteran population, and require tailoring to meet women Veterans' needs. We used evidence-based quality improvement (EBQI), a stakeholder-driven implementation strategy, in a cluster randomized controlled trial across 12 sites (eight EBQI, four control) that are members of a Practice-Based Research Network. EBQI involves engaging multilevel, inter-professional leaders and staff as stakeholders in reviewing evidence and setting QI priorities. The goal of this analysis was to examine processes of engaging stakeholders in early implementation of EBQI to tailor VHA's medical home for women. Four inter-professional regional stakeholder planning meetings were conducted; these meetings engaged stakeholders by providing regional data about gender disparities in Veterans' care experiences. Subsequent to each meeting, qualitative interviews were conducted with 87 key stakeholders (leaders and staff). Stakeholders were asked to describe QI efforts and the use of data to change aspects of care, including women's health care. Interview transcripts were summarized and coded using a hybrid deductive/inductive analytic approach. The presentation of regional-level data about gender disparities resulted in heightened awareness and stakeholder buy-in and decision-making related to women's health-focused QI. Interviews revealed that stakeholders were familiar with QI, with regional and facility leaders aware of inter-disciplinary committees and efforts to foster organizational change, including PCMH transformation. These efforts did not typically focus on women's health, though some informal efforts had been undertaken. Barriers to engaging in QI included lack of communication across clinical service lines, fluidity in staffing, and lack of protected time. Inter-professional, multilevel

Women's Healthcare Utilization Following Routine Screening for Past-Year Intimate Partner Violence in the Veterans Health Administration.

PubMed

Dichter, Melissa E; Sorrentino, Anneliese E; Haywood, Terri N; Bellamy, Scarlett L; Medvedeva, Elina; Roberts, Christopher B; Iverson, Katherine M

2018-06-01

Experience of intimate partner violence (IPV) can have adverse health impacts and has been associated with elevated rates of healthcare service utilization. Healthcare encounters present opportunities to identify IPV-related concerns and connect patients with services. The Veterans Health Administration (VHA) conducts IPV screening within an integrated healthcare system. The objectives of this study were to compare service utilization in the 6 months following IPV screening between those screening positive and negative for past-year IPV (IPV+, IPV-) and to examine the timing and types of healthcare services accessed among women screening IPV+. A retrospective chart review was conducted for 8888 female VHA patients across 13 VHA facilities who were screened for past-year IPV between April 2014 and April 2016. Demographic characteristics (age, race, ethnicity, marital status, veteran status), IPV screening response, and healthcare encounters (based on visit identification codes). In the 6 months following routine screening for past-year IPV, patients screening IPV+ were more likely to utilize outpatient care (aOR = 1.85 [CI 1.26, 2.70]), including primary care or psychosocial care, and to have an inpatient stay (aOR = 2.09 [CI 1.23, 3.57]), compared with patients screening IPV-. Among those with any utilization, frequency of outpatient encounters within the 6-month period following screening was higher among those screening IPV+ compared with those screening IPV-. The majority of patients screening positive for past-year IPV returned for an outpatient visit within a brief time frame following the screening visit (> 70% within 14 days, >95% within 6 months). More than one in four patients screening IPV+ had an emergency department visit within the 6 months following screening. Women who screen positive for past-year IPV have high rates of return to outpatient visits following screening, presenting opportunities for follow-up support. Higher rates of

Correlates and Consequences Central Sleep Apnea in a National Sample of U.S. Veterans.

PubMed

Ratz, David; Wiitala, Wyndy; Badr, M S; Burns, Jennifer; Chowdhuri, Susmita

2018-03-28

The prevalence and consequences of central sleep apnea (CSA) in adults are not well- described. By utilizing the large Veterans Health Administration (VHA) national administrative databases, we sought to determine the incidence, clinical correlates and impact of CSA on healthcare utilization in Veterans. Analysis of a retrospective cohort of patients with sleep disorders was performed from outpatient visits and inpatient admissions from fiscal years 2006 through 2012. The CSA group, defined by International Classification of Diseases-9, was compared to a non-CSA group. The number of newly diagnosed CSA cases increased 5-fold during this timeframe; however, the prevalence was highly variable depending on the VHA site. The important predictors of CSA were male gender (Odds Ratio(OR)=2.31, 95% C.I.:1.94-2.76, p<0.0001), heart failure(HF) (OR=1.78, 95% C.I.:1.64-1.92, p<0.0001), atrial fibrillation (OR=1.83, 95% C.I.: 1.69-2.00, p<0.0001), pulmonary hypertension (OR=1.38, 95% C.I.:1.19-1.59, p<0.0001), stroke (OR=1.65, 95% C.I.:1.50-1.82, p<0.0001), and chronic prescription opioid use (OR=1.99, 95% C.I.:1.87-2.13, p<0.0001). Veterans with CSA were at an increased risk for hospital admissions related to cardiovascular disorders compared to the control group (Incidence Rate Ratio(IRR)=1.50, 95% C.I.:1.16-1.95, p=0.002). Additionally, the effect of prior HF on future admissions was greater in the CSA group (IRR: 4.78,95% C.I.: 3.87-5.91, p<0.0001) compared to the comparison group (IRR=3.32, 95% C.I.: 3.18-3.47, P<0.0001). Thus, CSA in Veterans is associated with cardiovascular disorders, chronic prescription opioid use and increased admissions related to the comorbid cardiovascular disorders. Furthermore, there is a need for standardization of diagnostics methods across the VHA to accurately diagnose CSA in high-risk populations.

Out-of-range international normalized ratio values and healthcare cost among new warfarin patients with non-valvular atrial fibrillation.

PubMed

Nelson, Winnie W; Wang, Li; Baser, Onur; Damaraju, C V; Schein, Jeffrey R

2015-05-01

Patients with out-of-range international normalized ratio (INR) values <2.0 and >3.0 have been associated with increased risk of thromboembolic and bleeding events. INR monitoring is costly, because of associated physician and nurse time, laboratory resource use, and dose adjustments. This study assessed the healthcare cost burden associated with out-of-range INR among warfarin initiator patients diagnosed with non-valvular atrial fibrillation (NVAF) in the US Veterans Health Administration (VHA) population. Adult NVAF patients (≥18 years) initiating warfarin were selected from the VHA dataset for the study period October 1, 2007-September 30, 2012. Only valid INR measurements (0.5 ≤ INR ≤ 20) were examined for the follow-up period, from the index date (warfarin initiation date) until the end of warfarin exposure or death. All-cause healthcare costs within 30 days were measured starting from the second month (31 days post-index date) to the end of the study period. Costs for inpatient stays, emergency room, outpatient facility, physician office visits, and other services were computed separately. Multiple regression was performed using the generalized linear model for overall cost analysis. In total, 29,463 patients were included in the study sample. Mean costs for out-of-range INR ranged from $3419 to $5126. Inpatient, outpatient, outpatient pharmacy, and total costs were significantly higher after patients experienced out-of-range results (INR < 2, INR > 3), compared with in-range INR (2 ≤ INR ≤ 3). When exposed to out-of-range INR, patients also incurred higher mean total costs within 2-6 months ($3840-$5820) than after the first 6 months ($2789-$3503) of warfarin therapy. In the VHA population, INR measures outside of the 2-3 range were associated with significantly higher healthcare costs. Increased costs were especially apparent when INR values were below 2, although INR measures above 3 were also associated with higher costs

Predictors of Use of Monitored Anesthesia Care for Outpatient Gastrointestinal Endoscopy in a Capitated Payment System.

PubMed

Adams, Megan A; Prenovost, Katherine M; Dominitz, Jason A; Holleman, Robert G; Kerr, Eve A; Krein, Sarah L; Saini, Sameer D; Rubenstein, Joel H

2017-12-01

Use of monitored anesthesia care (MAC) for gastrointestinal endoscopy has increased in the Veterans Health Administration (VHA) as in fee-for-service environments, despite the absence of financial incentives. We investigated factors associated with use of MAC in an integrated health care delivery system with a capitated payment model. We performed a retrospective cohort study using multilevel logistic regression, with MAC use modeled as a function of procedure year, patient- and provider-level factors, and facility effects. We collected data from 2,091,590 veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy during fiscal years 2000-2013 at 133 facilities. The adjusted rate of MAC use in the VHA increased 17% per year (odds ratio for increase, 1.17; 95% confidence interval, 1.09-1.27) from fiscal year 2000 through 2013. The most rapid increase occurred starting in 2011. VHA use of MAC was associated with patient-level factors that included obesity, obstructive sleep apnea, higher comorbidity, and use of prescription opioids and/or benzodiazepines, although the magnitude of these effects was small. Provider-level and facility factors were also associated with use of MAC, although again the magnitude of these associations was small. Unmeasured facility-level effects had the greatest effect on the trend of MAC use. In a retrospective study of veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy from fiscal year 2000 through 2013, we found that even in a capitated system, patient factors are only weakly associated with use of MAC. Facility-level effects are the most prominent factor influencing increasing use of MAC. Future studies should focus on better defining the role of MAC and facility and organizational factors that affect choice of endoscopic sedation. It will also be important to align resources and incentives to promote appropriate allocation of MAC based on clinically meaningful patient factors. Copyright

[Seroprevalence of antibodies against hepatitis A virus and hepatitis B virus in nonvaccinated adult population over 40 years of age].

PubMed

Chlíbek, R; Cecetková, B; Smetana, J; Prymula, R; Kohl, I

2006-08-01

To determine prevalence rates of antibodies against hepatitis A virus (HAV) and hepatitis B virus (HBV) in the general adult male and female population over 40 years of age with no history of viral hepatitis A (VHA) and viral hepatitis B (VHB) who have never been vaccinated against hepatitis and to assess the cost-effectiveness of the pre-vaccination serological screening. In 2003-2004, a total of 972 persons of three age categories: 41-50 years, 51-60 years, 61 and more years, were screened. Persons with a history of VHA and/or VHB and those who had been vaccinated against hepatitis were not included in the study. The following four indicators were determined from a 5 ml specimen of whole venous blood by electrochemiluminiscence assay: total anti-HAV antibodies, total anti-HBc antibodies, anti-HBs antibodies and HBsAg, as the most suitable markers of experienced hepatitis or previous vaccination. The prevalence rates of anti-HAV antibodies were lower in females compared to males for all of the three age categories. These antibodies were detected in 16.8%, 52.9% and 77.5% of 41-50-year-olds, 51-60-year-olds and > or = 61-year-olds, respectively. The total prevalence rate for the three age groups was 61.6%. The anti-HBc antibody seroprevalence rates were 1.9%, 5.3% and 6.1%, respectively. The results show high prevalence of VHA in higher age groups. Such a high seroprevalence of antibodies in nonvaccinated persons with no history of viral hepatitis is suggestive of a very frequent incidence of asymptomatic infection. For this reason, the prevaccination screening of anti-HAV antibodies is cost-effective in the population over 50 years of age but is not justified in persons under 40 years of age. Prevaccination screening for anti-HBc antibodies appears not to be cost-effective regardless of age in view of their low prevalence in the Czech population.

Assessment of Service Members Knowledge and Trust of the Department of Veterans Affairs

DTIC Science & Technology

2015-06-12

www.va.gov/health/aboutVHA.asp. 24 Veterans Benefits Administration, “About VBA ,” last updated December 18, 2014, accessed May 10, 2015, http...Department of Veterans Affairs, 2014. Veterans Benefits Administration. “About VBA .” Last updated December 18, 2014. Accessed May 10, 2015. http...OIF Operation Iraqi Freedom VA Department of Veterans Affairs VA OIG Department of Veterans Affairs Office of Inspector General VBA Veterans Benefits

Developing Military Health Care Leaders: Insights from the Military, Civilian, and Government Sectors

DTIC Science & Technology

2011-01-01

6 mentoring, career counseling, feedback, and self- development . Organizations differ in terms of how much emphasis they place on particular...deliberate sample of health care organizations in the private sector that were most likely to offer lessons learned for DoD. Our interviews were conducted...the eight sampled organizations , for a total of eight interviews. VHA Case Study. In addition to the private - sector interviews, we examined public

VA Mental Health: Clearer Guidance on Access Policies and Wait-Time Data Needed

DTIC Science & Technology

2015-10-01

that may be associated with depression , post-traumatic stress disorder (PTSD), substance abuse disorder, or who may have experienced military sexual... depression , and substance abuse.1 VHA provides mental health care in its more than 1,200 facilities in both specialty settings—those that primarily... depression , PTSD, and substance abuse disorders, and to promote recovery.19 When needed 18Transfer lists are lists that select VAMCs use to manage

Patient and Facility Variation in Costs of VHA Heart Failure Patients

PubMed Central

Yoon, Jean; Fonarow, Gregg C.; Groeneveld, Peter W.; Teerlink, John; Whooley, Mary A.; Sahay, Anju; Heidenreich, Paul

2017-01-01

Objectives To determine the variation in annual health care costs among heart failure patients in the VA system. Background Heart failure is associated with considerable use of health care resources, but little is known about patterns in patient characteristics related to higher costs. Methods We obtained VA utilization and cost records for all patients with a diagnosis of heart failure in fiscal year 2010. We compared total VA costs by patient demographic factors, comorbid conditions, and facility where they were treated in bivariate analyses. We regressed total costs on patient factors alone; VA facility alone; and all factors combined to determine the relative contribution of patient factors and facility to explaining cost differences. Results There were 117,870 patients with heart failure, and their mean annual VA costs were $30,719 (SD=49,180) with more than half of their costs due to inpatient care. Patients at younger ages, of Hispanic or black race/ethnicity, diagnosed with comorbid drug use disorders, or who died during the year had the highest costs (all P<0.01). There was variation in costs by facility as mean adjusted costs ranged from approximately $15,000 to $48,000. In adjusted analyses patient factors alone explained more of the variation in health care costs (R2=0.116) compared to the facility where the patient was treated (R2=0.018). Conclusion A large variation in costs of heart failure patients was observed across facilities although this was explained largely by patient factors. Improving the efficiency of VA resource utilization may require increased scrutiny of high-cost patients to determine if adequate value is being delivered to those patients. PMID:26970829

Caregivers Create a Veteran-Centric Community in VHA Medical Foster Homes.

PubMed

Haverhals, Leah M; Manheim, Chelsea E; Gilman, Carrie V; Jones, Jacqueline; Levy, Cari

2016-01-01

The Veteran's Health Administration's Medical Foster Home program offers a unique long-term care option for veterans who require nursing-home- or assisted-living-level care. Veterans in a medical foster home reside with community-based caregivers who provide 24-hr-a-day care and monitoring. The veterans often remain in the medical foster home until end of life. Support and oversight is provided to the caregiver from the Veteran's Health Administration's community-based medical team. This qualitative descriptive study is based on secondary analysis of interviews with 20 medical foster home caregivers from 7 programs across the United States. The study's research aims are to describe and explain (a) the type of care backgrounds and skills these caregivers possess, (b) caregivers' primary motivations to open their homes to veterans who often have complex medical and social needs, and (c) how caregivers function in their role as primary caregiver for veterans. Findings indicated that caregivers interviewed had worked in long-term care settings and/or cared for family members. A strong desire to serve veterans was a primary motivation for caregivers, rather than financial gain. The caregivers' long-term care skills aided them in building and sustaining the unique medical foster home family-like community.

Use of outpatient mental health services by homeless veterans after hurricanes.

PubMed

Brown, Lisa M; Barnett, Scott; Hickling, Edward; Frahm, Kathryn; Campbell, Robert R; Olney, Ronald; Schinka, John A; Casey, Roger

2013-05-01

Little is known about the impact of hurricanes on people who are homeless at the time a disaster occurs. Although researchers have extensively studied the psychosocial consequences of disaster produced homelessness on the general population, efforts focused on understanding how homeless people fare have been limited to a few media reports and the gray literature. In the event of a hurricane, homeless veterans may be at increased risk for negative outcomes because of their cumulative vulnerabilities. Health care statistics consistently document that homeless veterans experience higher rates of medical, emotional, substance abuse, legal, and financial problems compared with the general population. This study used the 2004 to 2006 Veterans Health Administration (VHA) Outpatient Medical Dataset to examine the effects of hurricanes on use of outpatient mental health services by homeless veterans. Homeless veterans residing in hurricane-affected counties were significantly more likely to participate in group psychotherapy (32.4% vs. 13.4%, p < .002), but less likely to participate in individual 30-40-min sessions with medical evaluations (3.5% vs. 17.3%, p < .001). The study findings have implications for homeless programs and the provision of VHA mental health services to homeless veterans postdisaster. PsycINFO Database Record (c) 2013 APA, all rights reserved.

Job satisfaction of advanced practice nurses in the Veterans Health Administration.

PubMed

Faris, Judith A; Douglas, Marilyn K; Maples, Deanna C; Berg, Laurie R; Thrailkill, Ann

2010-01-01

The purpose of this study was to describe the level of job satisfaction and barriers to practice for advanced practice nurses (APNs) employed by the Veterans Health Administration (VHA). The Misener Nurse Practitioner Job Satisfaction Survey (MNPJSS) and an investigator-developed questionnaire were completed by a self-selected, convenience sample of 1,983 APNs who responded to an internal VHA email invitation (61% response rate) to participate in an anonymous on-line survey. Respondents reported being minimally satisfied with their job overall, most satisfied with their benefits and least satisfied with professional growth and intrapractice collegiality. They scored lower than their private sector peers for total job satisfaction and all subscales except benefits, as compared to samples of three smaller studies. Clinical nurse specialists reported greater job satisfaction then NPs. The most frequently cited barriers to practice were: too many non-APN tasks, lack of administrative support, and inadequate time to do research. Strategies for improving professional growth and intra-practice collegiality are needed. APNs' job satisfaction may be improved in these areas by mentoring of new APN graduates and administrative approval for participating in research. Additional administrative support is needed to decrease the amount of non-APN tasks and clerical duties.

Patient Privacy, Consent, and Identity Management in Health Information Exchange

PubMed Central

Hosek, Susan D.; Straus, Susan G.

2013-01-01

Abstract The Military Health System (MHS) and the Veterans Health Administration (VHA) have been among the nation's leaders in health information technology (IT), including the development of health IT systems and electronic health records that summarize patients' care from multiple providers. Health IT interoperability within MHS and across MHS partners, including VHA, is one of ten goals in the current MHS Strategic Plan. As a step toward achieving improved interoperability, the MHS is seeking to develop a research roadmap to better coordinate health IT research efforts, address IT capability gaps, and reduce programmatic risk for its enterprise projects. This article contributes to that effort by identifying gaps in research, policy, and practice involving patient privacy, consent, and identity management that need to be addressed to bring about improved quality and efficiency of care through health information exchange. Major challenges include (1) designing a meaningful patient consent procedure, (2) recording patients' consent preferences and designing procedures to implement restrictions on disclosures of protected health information, and (3) advancing knowledge regarding the best technical approaches to performing patient identity matches and how best to monitor results over time. Using a sociotechnical framework, this article suggests steps for overcoming these challenges and topics for future research. PMID:28083296

Patient Privacy, Consent, and Identity Management in Health Information Exchange: Issues for the Military Health System.

PubMed

Hosek, Susan D; Straus, Susan G

2013-01-01

The Military Health System (MHS) and the Veterans Health Administration (VHA) have been among the nation's leaders in health information technology (IT), including the development of health IT systems and electronic health records that summarize patients' care from multiple providers. Health IT interoperability within MHS and across MHS partners, including VHA, is one of ten goals in the current MHS Strategic Plan. As a step toward achieving improved interoperability, the MHS is seeking to develop a research roadmap to better coordinate health IT research efforts, address IT capability gaps, and reduce programmatic risk for its enterprise projects. This article contributes to that effort by identifying gaps in research, policy, and practice involving patient privacy, consent, and identity management that need to be addressed to bring about improved quality and efficiency of care through health information exchange. Major challenges include (1) designing a meaningful patient consent procedure, (2) recording patients' consent preferences and designing procedures to implement restrictions on disclosures of protected health information, and (3) advancing knowledge regarding the best technical approaches to performing patient identity matches and how best to monitor results over time. Using a sociotechnical framework, this article suggests steps for overcoming these challenges and topics for future research.

Not of one mind: mental models of clinical practice guidelines in the Veterans Health Administration.

PubMed

Hysong, Sylvia J; Best, Richard G; Pugh, Jacqueline A; Moore, Frank I

2005-06-01

The purpose of this paper is to present differences in mental models of clinical practice guidelines (CPGs) among 15 Veterans Health Administration (VHA) facilities throughout the United States. Two hundred and forty-four employees from 15 different VHA facilities across four service networks around the country were invited to participate. Participants were selected from different levels throughout each service setting from primary care personnel to facility leadership. This qualitative study used purposive sampling, a semistructured interview process for data collection, and grounded theory techniques for analysis. A semistructured interview was used to collect information on participants' mental models of CPGs, as well as implementation strategies and barriers in their facility. Analysis of these interviews using grounded theory techniques indicated that there was wide variability in employees' mental models of CPGs. Findings also indicated that high-performing facilities exhibited both (a) a clear, focused shared mental model of guidelines and (b) a tendency to use performance feedback as a learning opportunity, thus suggesting that a shared mental model is a necessary but not sufficient step toward successful guideline implementation. We conclude that a clear shared mental model of guidelines, in combination with a learning orientation toward feedback are important components for successful guideline implementation and improved quality of care.

Veterans Health Administration: Management Attention Is Needed to Address Systemic, Long standing Human Capital Challenges

DTIC Science & Technology

2016-12-01

Effort through Strategic Human Capital Management , GAO-04-85 (Washington, D.C.: Oct. 20, 2003); and A Model of Strategic Human Capital Management , GAO...Washington, D.C.: Jan. 30, 2015). 60See GAO-15-290 for the most recent update on strategic human capital management . VHA Reports Critical HR Competency...systems to obtain and process information to meet operational needs.71 Likewise, our prior work on strategic human capital management notes that high

Effect of Diabetes and Obesity on Disparities in Prostate Cancer Outcomes

DTIC Science & Technology

2015-10-01

AWARD NUMBER: W81XWH-14-1-0503 TITLE: “Effect of Diabetes and Obesity on Disparities in Prostate Cancer Outcomes PRINCIPAL INVESTIGATOR: Bettina F...and Obesity on Disparities in Prostate Cancer Outcomes 5a. CONTRACT NUMBER 5b. GRANT NUMBER W81XWH-14-1-0503 5c. PROGRAM ELEMENT NUMBER 6. AUTHOR...death by identifying potential modifiable factors. 15. SUBJECT TERMS Prostate cancer, disparities, VHA and VACCR data, obesity , mortality, survival

Battlefield-Acquired Immunogenicity to Metals Affects Orthopaedic Implant Outcome

DTIC Science & Technology

2012-10-01

Attending Physician #N/A Control cpm 1308.0 Positive control (PHA) cpm 38247.3 29.2 Mildly Reactive 2 to 4 Reactive 4 to 8 Highly Reactive above 8...Kyron, The Veterans Health Administration has to follow Handbook 1200.05, which states: VHA HANDBOOK 1200.05 October 15, 2010 n. Advertising ...The facility Director is responsible for ensuring that recruiting documents, flyers, and advertisements for non-VA research are not posted within or

Effect of Diabetes and Obesity on Disparities in Prostate Cancer Outcomes

DTIC Science & Technology

2016-10-01

AWARD NUMBER: W81XWH-14-1-0503 TITLE: Effect of Diabetes and Obesity on Disparities in Prostate Cancer Outcomes PRINCIPAL INVESTIGATOR: Bettina F...Effect of Diabetes and Obesity on Disparities in Prostate Cancer Outcomes 5a. CONTRACT NUMBER 5b. GRANT NUMBER W81XWH-14-1-0503 5c. PROGRAM ELEMENT...prostate cancer related death by identifying potential modifiable factors. 15. SUBJECT TERMS Prostate cancer, disparities, VHA and VACCR data, obesity

Chemical, mineralogical and textural systematics of non-mare melt rocks: Implications for lunar impact and volcanic processes

NASA Technical Reports Server (NTRS)

Irving, A. J.

1975-01-01

Based on a synthesis of chemical data for over 200 samples, the nonmare rocks with fine grained melt textures can be classified into 7 major groups: anorthositic basalts, troctolitic basalts, VHA basalts, Apollo 14-type KREEP basalts, Apollo 15-type KREEP basalts, Apollo 17-type KREEP basalts, and aluminous mare basalts. Review of chemical, mineralogical, textural and experimental evidence leads to preferred hypotheses for the origins of these rocks; those hypotheses are discussed in detail.

Assessing an organizational culture instrument based on the Competing Values Framework: Exploratory and confirmatory factor analyses

PubMed Central

Helfrich, Christian D; Li, Yu-Fang; Mohr, David C; Meterko, Mark; Sales, Anne E

2007-01-01

Background The Competing Values Framework (CVF) has been widely used in health services research to assess organizational culture as a predictor of quality improvement implementation, employee and patient satisfaction, and team functioning, among other outcomes. CVF instruments generally are presented as well-validated with reliable aggregated subscales. However, only one study in the health sector has been conducted for the express purpose of validation, and that study population was limited to hospital managers from a single geographic locale. Methods We used exploratory and confirmatory factor analyses to examine the underlying structure of data from a CVF instrument. We analyzed cross-sectional data from a work environment survey conducted in the Veterans Health Administration (VHA). The study population comprised all staff in non-supervisory positions. The survey included 14 items adapted from a popular CVF instrument, which measures organizational culture according to four subscales: hierarchical, entrepreneurial, team, and rational. Results Data from 71,776 non-supervisory employees (approximate response rate 51%) from 168 VHA facilities were used in this analysis. Internal consistency of the subscales was moderate to strong (α = 0.68 to 0.85). However, the entrepreneurial, team, and rational subscales had higher correlations across subscales than within, indicating poor divergent properties. Exploratory factor analysis revealed two factors, comprising the ten items from the entrepreneurial, team, and rational subscales loading on the first factor, and two items from the hierarchical subscale loading on the second factor, along with one item from the rational subscale that cross-loaded on both factors. Results from confirmatory factor analysis suggested that the two-subscale solution provides a more parsimonious fit to the data as compared to the original four-subscale model. Conclusion This study suggests that there may be problems applying conventional

Alzheimer's disease. AMA Council on Scientific Affairs Reference Committee D.

PubMed

1998-08-01

This report responds to Substitute Resolution 518, I-96, which asks that the AMA, in cooperation with appropriate medical specialty societies, study Alzheimer's disease (AD) and other dementias, with particular emphasis on their diagnosis and treatment, issues relating to patient and caregiver education, the financing of care of affected individuals, the identification of research needs, and consideration of issues pertaining to the quality of life of individuals with these conditions. This report is based on a review of guidelines produced by the Agency for Health Care Policy and Research (AHCPR), the American Academy of Neurology (AAN), the Veterans Health Administration (VHA), and the American Psychiatric Association (APA), combined with review of the latest published literature on AD and related disorders and consultation with experts in the field. This analysis was used as a basis for policy formulation. The guidelines reviewed were: (1) Recognition and Initial Assessment of Alzheimer's Disease and Related Disorders, published by the AHCPR; (2) Dementia Identification and Assessment, published by the VHA; (3) Practice Parameter: Diagnosis and Evaluation of Dementia. published by the AAN; and (4) Practice Guideline for the Treatment of Patients with Alzheimer's Disease and Other Dementias of Late Life, published by the APA. These documents are targeted for the following audiences: primary care physicians (VHA and AHCPR), neurologists (AAN), and psychiatrists (APA). Only the APA guide makes provision for continuity of care. The literature review revealed that ongoing research into AD focuses on three broad areas: etiology/risk factors, diagnosis and treatment. AD is a common and costly public health problem. With the increase in life expectancy in the United States, AD is expected to afflict approximately 14 million people within the next few decades. Irreversible dementia takes a heavy economic, social, physical, and psychological toll on patients and families

Building Capacity for Complementary and Integrative Medicine Through a Large, Cross-Agency, Acupuncture Training Program: Lessons Learned from a Military Health System and Veterans Health Administration Joint Initiative Project.

PubMed

Niemtzow, Richard; Baxter, John; Gallagher, Rollin M; Pock, Arnyce; Calabria, Kathryn; Drake, David; Galloway, Kevin; Walter, Joan; Petri, Richard; Piazza, Thomas; Burns, Stephen; Hofmann, Lew; Biery, John; Buckenmaier, Chester

2018-03-26

Complementary and integrative medicine (CIM) use in the USA continues to expand, including within the Military Health System (MHS) and Veterans Health Administration (VHA). To mitigate the opioid crisis and provide additional non-pharmacological pain management options, a large cross-agency collaborative project sought to develop and implement a systems-wide curriculum, entitled Acupuncture Training Across Clinical Settings (ATACS). ATACS curriculum content and structure were created and refined over the course of the project in response to consultations with Subject Matter Experts and provider feedback. Course content was developed to be applicable to the MHS and VHA environments and training was open to many types of providers. Training included a 4-hr didactic and "hands on" clinical training program focused on a single auricular acupuncture protocol, Battlefield Acupuncture. Trainee learning and skills proficiency were evaluated by trainer-observation and written examination. Immediately following training, providers completed an evaluation survey on their ATACS experience. One month later, they were asked to complete another survey regarding their auricular acupuncture use and barriers to use. The present evaluation describes the ATACS curriculum, faculty and trainee characteristics, as well as trainee and program developer perspectives. Over the course of a 19-mo period, 2,712 providers completed the in-person, 4-hr didactic and hands-on clinical training session. Due to the increasing requests for training, additional ATACS faculty were trained. Overall, 113 providers were approved to be training faculty. Responses from the trainee surveys indicated high satisfaction with the ATACS training program and illuminated several challenges to using auricular acupuncture with patients. The most common reported barrier to using auricular acupuncture was the lack of obtaining privileges to administer auricular acupuncture within clinical practice. The ATACS program

Gender and the Association between Long-Term Prescription Opioid Use and New-Onset Depression.

PubMed

Salas, Joanne; Scherrer, Jeffrey F; Ahmedani, Brian K; Copeland, Laurel A; Bucholz, Kathleen K; Sullivan, Mark D; Burroughs, Thomas; Schneider, F David; Lustman, Patrick J

2018-01-01

Women have a higher prevalence of chronic noncancer pain conditions and report more severe pain, yet, it is not known if the association between long-term opioid analgesic use (OAU) and risk of a new depression episode (NDE) differs according to gender. We analyzed patient data from the Veterans Health Administration (VHA; 2000-2012; n = 70,997) and a large private-sector health care organization (2003-2012; n = 22,981) to determine whether long-term OAU and risk of NDE differed according to gender. Patients were free of depression and OAU for 2 years before baseline. OAU duration was defined as 1 to 30, 31 to 90 and more than 90 days, and NDE was defined according to International Classification of Diseases, Ninth Revision codes. Gender-stratified Cox proportional hazard models were used to estimate hazard ratios (HRs). Propensity scores and subsequent inverse probability of treatment weighting controlled for confounding. In the VHA, more than 90 compared with 1- to 30-day OAU was more strongly associated with NDE among female than male patients (female: HR = 1.79 [95% confidence interval (CI), 1.45-2.22] vs male HR = 1.25 [95% CI, 1.16-1.34], P = .002). In private sector patients, there was no gender difference in the association between more than 90-day OAU and NDE (female HR = 1.97 [95% CI, 1.64-2.37] vs male HR = 1.99 [95% CI, 1.44-2.74]). Risk of NDE after long-term OAU is similar in men and women in private sector patients but may differ for VHA patients. Future prospective studies are needed to identify mechanisms for the association between longer OAU and NDE. Existing research is mixed regarding gender differences in outcomes after long-term prescription opioid use. This study found both genders have increased risk of an NDE after more than 90 days of opioid use. Women and men may benefit from closer monitoring of mood associated with chronic opioid use. Copyright © 2017 The American Pain Society. Published by Elsevier Inc. All

Barriers and facilitators to providing primary care-based weight management services in a patient centered medical home for Veterans: a qualitative study.

PubMed

Jay, Melanie; Chintapalli, Sumana; Squires, Allison; Mateo, Katrina F; Sherman, Scott E; Kalet, Adina L

2015-11-14

Obesity is highly prevalent among Veterans. In the United States, the Veterans Health Administration (VHA) offers a comprehensive weight management program called MOVE!. Yet, fewer than 10 % of eligible patients ever attend one MOVE! visit. The VHA has a patient-centered medical home (PCMH) model of primary care (PC) called Patient-Aligned Care Teams (PACT) at all Veterans Affairs (VA) Medical Centers. PACT teamlets conduct obesity screening, weight management counseling, and refer to MOVE!. As part of a needs assessment to improve delivery of weight management services, the purpose of this study was to assess PACT teamlet and MOVE! staff: 1) current attitudes and perceptions regarding obesity care; 2) obesity-related counseling practices 3) experiences with the MOVE! program; and 4) targets for interventions to improve implementation of obesity care in the PC setting. We recruited 25 PACT teamlet members from a single VA study site-11 PC physicians, 5 registered nurses, 5 licensed practical nurses, 1 clerical assistant, and 3 MOVE! staff (2 dietitians, 1 psychologist)-for individual interviews using a combination of convenience and snowball sampling. Audio recorded interviews were professionally transcribed and iteratively coded by two independent reviewers. The analytic process was guided by discourse analysis in order to discover how the participants perceived and provided weight management care and what specific attitudes affected their practices, all as bounded within the organization. Emerging themes included: 1) role perceptions, 2) anticipated outcomes of weight management counseling and programs, and 3) communication and information dissemination. Perceived role among PCPs was influenced by training, whereas personal experience with their own weight management impacted role perception among LPNs/RNs. Attitudes about whether or not they could impact patients' weight outcomes via counseling or referral to MOVE! varied. System-level communication about VHA

VA Health Care: Improved Monitoring Needed for Effective Oversight of Care for Women Veterans

DTIC Science & Technology

2016-12-01

November 2014. VHA officials also said that after reviewing information from sources such as veteran surveys and feedback from regional VA business...authorizations for care (of both men and women) from early calendar year 2016. In one case, almost a month and a half elapsed from the time of the...veteran’s initial pregnancy confirmation appointment at VA (when she was 6 weeks pregnant) to when the Choice authorization was sent by the VA facility to

VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events

DTIC Science & Technology

2015-07-01

has been taken to address the root cause. For example, in the case of an overdose of an anesthesia medication from a pump that held an unsafe amount...of medication, the action might be to use a different type of pump that holds less medication and prevents an accidental overdose ; an outcome...measure might be to measure patient outcomes 1 year later to ensure that no such overdoses occurred. VHA policy states that those staff directly involved

Receipt of Pharmacotherapy for Opioid Use Disorder by Justice-Involved U.S. Veterans Health Administration Patients

PubMed Central

Finlay, Andrea K.; Harris, Alex H.S.; Rosenthal, Joel; Blue-Howells, Jessica; Clark, Sean; McGuire, Jim; Timko, Christine; Frayne, Susan M.; Smelson, David; Oliva, Elizabeth; Binswanger, Ingrid

2016-01-01

Background Pharmacotherapy – methadone, buprenorphine, or naltrexone – is an evidence-based treatment for opioid use disorder, but little is known about receipt of these medications among veterans involved in the justice system. The current study examines receipt of pharmacotherapy for opioid use disorder among veterans with a history of justice involvement at U.S. Veterans Health Administration (VHA) facilities compared to veterans with no justice involvement. Methods Using national VHA clinical and pharmacy records, we conducted a retrospective cohort study of veterans with an opioid use disorder diagnosis in fiscal year 2012. Using a mixed-effects logistic regression model, we examined receipt of pharmacotherapy in the 1-year period following diagnosis as a function of justice involvement, adjusting for patient and facility characteristics. Results The 1-year rate of receipt for pharmacotherapy for opioid use disorder was 27% for prison-involved veterans, 34% for jail/court-involved veterans, and 33% for veterans not justice-involved. Compared to veterans not justice-involved, those prison-involved had 0.75 lower adjusted odds (95% confidence interval [CI]: 0.65–0.87) of receiving pharmacotherapy whereas jail/court-involved veterans did not have significantly different adjusted odds. Conclusions Targeted efforts to increase receipt of pharmacotherapy for opioid use disorder among veterans exiting prison is needed as they have lower odds of receiving these medications. PMID:26832998

How to get into bones: proton pump and carbonic anhydrase in Osedax boneworms

PubMed Central

Tresguerres, Martin; Katz, Sigrid; Rouse, Greg W.

2013-01-01

Osedax are gutless siboglinid worms that thrive on vertebrate bones lying on the ocean floor, mainly those of whales. The posterior body of female Osedax penetrates into the bone forming extensions known as ‘roots’, which host heterotrophic symbiotic bacteria in bacteriocytes beneath the epidermis. The Osedax root epithelium presumably absorbs bone collagen and/or lipids, which are metabolized by the symbiotic bacteria that in turn serve for Osedax's nutrition. Here, we show that Osedax roots express extremely high amounts of vacuolar-H+-ATPase (VHA), which is located in the apical membrane and in cytoplasmic vesicles of root and ovisac epithelial cells. The enzyme carbonic anhydrase (CA), which catalyses the hydration of CO2 into H+ and HCO3−, is also expressed in roots and throughout Osedax body. These results suggest Osedax roots have massive acid-secreting capacity via VHA, fuelled by H+ derived from the CA-catalysed hydration of CO2 produced by aerobic metabolism. We propose the secreted acid dissolves the bone carbonate matrix to then allow the absorption of bone-derived nutrients across the skin. In an exciting example of convergent evolution, this model for acid secretion is remarkably similar to mammalian osteoclast cells. However, while osteoclasts dissolve bone for repairing and remodelling, the Osedax root epithelium secretes acid to dissolve foreign bone to access nutrients. PMID:23760644

VA Suicide Prevention Applications Network

PubMed Central

Stephens, Brady; Morley, Sybil; Thompson, Caitlin; Kemp, Janet; Bossarte, Robert M.

2016-01-01

Objectives: The US Department of Veterans Affairs’ Suicide Prevention Applications Network (SPAN) is a national system for suicide event tracking and case management. The objective of this study was to assess data on suicide attempts among people using Veterans Health Administration (VHA) services. Methods: We assessed the degree of data overlap on suicide attempters reported in SPAN and the VHA’s medical records from October 1, 2010, to September 30, 2014—overall, by year, and by region. Data on suicide attempters in the VHA’s medical records consisted of diagnoses documented with E95 codes from the International Classification of Diseases, Ninth Revision. Results: Of 50 518 VHA patients who attempted suicide during the 4-year study period, data on fewer than half (41%) were reported in both SPAN and the medical records; nearly 65% of patients whose suicide attempt was recorded in SPAN had no data on attempted suicide in the VHA’s medical records. Conclusion: Evaluation of administrative data suggests that use of SPAN substantially increases the collection of data on suicide attempters as compared with the use of medical records alone, but neither SPAN nor the VHA’s medical records identify all suicide attempters. Further research is needed to better understand the strengths and limitations of both systems and how to best combine information across systems. PMID:28123228

Within-Hospital Variation in 30-Day Adverse Events: Implications for Measuring Quality.

PubMed

Burke, Robert E; Glorioso, Thomas; Barón, Anna K; Kaboli, Peter J; Ho, P Michael

Novel measures of hospital quality are needed. Because quality improvement efforts seek to reduce variability in processes and outcomes, hospitals with higher variability in adverse events may be delivering poorer quality care. We sought to evaluate whether within-hospital variability in adverse events after a procedure might function as a quality metric that is correlated with facility-level mortality rates. We analyzed all percutaneous coronary interventions (PCIs) performed in the Veterans Health Administration (VHA) system from 2007 to 2013 to evaluate the correlation between within-hospital variability in 30-day postdischarge adverse events (readmission, emergency department visit, and repeat revascularization), and facility-level mortality rates, after adjustment for patient demographics, comorbidities, PCI indication, and PCI urgency. The study cohort included 47,567 patients at 48 VHA hospitals. The overall 30-day adverse event rate was 22.0% and 1-year mortality rate was 4.9%. The most variable sites had relative changes of 20% in 30-day rates of adverse events period-to-period. However, within-hospital variability in 30-day events was not correlated with 1-year mortality rates (correlation coefficient = .06; p = .66). Thus, measuring within-hospital variability in postdischarge adverse events may not improve identification of low-performing hospitals. Evaluation in other conditions, populations, and in relationship with other quality metrics may reveal stronger correlations with care quality.

Increase in migraine diagnoses and guideline-concordant treatment in veterans, 2004-2012.

PubMed

Altalib, H H; Fenton, B T; Sico, J; Goulet, J L; Bathulapalli, H; Mohammad, A; Kulas, J; Driscoll, M; Dziura, J; Mattocks, K; Kerns, R; Brandt, C; Haskell, S

2017-01-01

Background and aim Health administrators, policy makers, and educators have attempted to increase guideline adherence of migraine medications while reducing inappropriate use of opioid- and barbiturate-containing medications. We evaluated the burden of migraine and proportion of guideline-concordant care in a large, national health care system over time. Methods We conducted a time-series study using data from the Veterans Health Administration (VHA) electronic health record. Veterans with migraines were identified by ICD-9 code (346.X). Prescriptions and comorbid conditions were evaluated before and after migraine diagnosis. Chi-square tests and logistic regression were performed. Results A total of 57,064 veterans were diagnosed with migraine headache (5.3%), with women significantly more likely diagnosed (11.6% vs. 4.4%, p < 0.0001). The number of veterans diagnosed with migraine has significantly increased over the years. By 2012, triptans were prescribed to 43% of people with migraine, with no difference by gender. However, triptan prescriptions increased from 2004 to 2012 in men, but not women, veterans. Preventive medicines showed a significant increase with the year of migraine diagnosis, after controlling for age, sex, race, and for comorbidities treated with medications used for migraine prevention. Conclusions The burden of migraines is increasing within the VHA, with a corresponding increase in the delivery of guideline-concordant acute and prophylactic migraine-specific medication.

Training Veterans to Provide Peer Support in a Weight-Management Program: MOVE!

PubMed Central

Haynes-Maslow, Lindsey; Carr, Carol; Orr, Melinda; Kahwati, Leila C.; Weiner, Bryan J.; Kinsinger, Linda

2013-01-01

Introduction The Veterans Health Administration (VHA) has implemented MOVE!, a weight-management program for veterans designed to address the increasing proportion of overweight and obese veterans. The objective of our study was to determine whether peer support employing motivational interviewing (MI) could positively influence lifestyle changes, thus expanding the reach of the MOVE! program. We describe the initial evaluation of the peer training program. Methods We developed an MI peer counselor training program for volunteer veterans, the “Buddies” program, to provide one-on-one telephone support for veterans enrolled in MOVE!. Buddies were recruited at 5 VHA sites and trained to provide peer support for the 6-month MOVE! intervention. We used a DVD to teach MI skills and followed with 2 to 3 booster sessions. We observed training, conducted pre- and posttraining surveys, and debriefed focus groups to assess training feasibility. Results Fifty-six Buddies were trained. Results indicate positive receipt of the program (89% reported learning about peer counseling and 87% reported learning communication skills). Buddies showed a small improvement in MI self-efficacy on posttraining surveys. We also identified key challenges to learning MI and training implementation. Conclusions MI training is feasible to implement and acceptable to volunteer Buddies. Trainers must assess how effectively volunteers learn MI skills in order to enhance its effective use in health promotion. PMID:24199738

Case-Mix Adjusting Performance Measures in a Veteran Population: Pharmacy- and Diagnosis-Based Approaches

PubMed Central

Liu, Chuan-Fen; Sales, Anne E; Sharp, Nancy D; Fishman, Paul; Sloan, Kevin L; Todd-Stenberg, Jeff; Nichol, W Paul; Rosen, Amy K; Loveland, Susan

2003-01-01

Objective To compare the rankings for health care utilization performance measures at the facility level in a Veterans Health Administration (VHA) health care delivery network using pharmacy- and diagnosis-based case-mix adjustment measures. Data Sources/Study Setting The study included veterans who used inpatient or outpatient services in Veterans Integrated Service Network (VISN) 20 during fiscal year 1998 (October 1997 to September 1998; N=126,076). Utilization and pharmacy data were extracted from VHA national databases and the VISN 20 data warehouse. Study Design We estimated concurrent regression models using pharmacy or diagnosis information in the base year (FY1998) to predict health service utilization in the same year. Utilization measures included bed days of care for inpatient care and provider visits for outpatient care. Principal Findings Rankings of predicted utilization measures across facilities vary by case-mix adjustment measure. There is greater consistency within the diagnosis-based models than between the diagnosis- and pharmacy-based models. The eight facilities were ranked differently by the diagnosis- and pharmacy-based models. Conclusions Choice of case-mix adjustment measure affects rankings of facilities on performance measures, raising concerns about the validity of profiling practices. Differences in rankings may reflect differences in comparability of data capture across facilities between pharmacy and diagnosis data sources, and unstable estimates due to small numbers of patients in a facility. PMID:14596393

Investigating the need for clinicians to use tablet computers with a newly envisioned electronic health record.

PubMed

Saleem, Jason J; Savoy, April; Etherton, Gale; Herout, Jennifer

2018-02-01

The Veterans Health Administration (VHA) has deployed a large number of tablet computers in the last several years. However, little is known about how clinicians may use these devices with a newly planned Web-based electronic health record (EHR), as well as other clinical tools. The objective of this study was to understand the types of use that can be expected of tablet computers versus desktops. Semi-structured interviews were conducted with 24 clinicians at a Veterans Health Administration (VHA) Medical Center. An inductive qualitative analysis resulted in findings organized around recurrent themes of: (1) Barriers, (2) Facilitators, (3) Current Use, (4) Anticipated Use, (5) Patient Interaction, and (6) Connection. Our study generated several recommendations for the use of tablet computers with new health information technology tools being developed. Continuous connectivity for the mobile device is essential to avoid interruptions and clinician frustration. Also, making a physical keyboard available as an option for the tablet was a clear desire from the clinicians. Larger tablets (e.g., regular size iPad as compared to an iPad mini) were preferred. Being able to use secure messaging tools with the tablet computer was another consistent finding. Finally, more simplicity is needed for accessing patient data on mobile devices, while balancing the important need for adequate security. Published by Elsevier B.V.

Interest in a digital health tool in veterans with epilepsy: results of a phone survey.

PubMed

Hixson, John D; Van Bebber, Stephanie L; Bertko, Kate M

2015-04-01

Online tools for managing chronic health conditions are becoming increasingly popular. Perceived benefits include ease of use, low costs, and availability but are contingent on patient engagement, Internet access, and digital literacy. This article describes data collected during the recruitment phase of a study evaluating an online self-management platform for epilepsy in a U.S. Veteran population. We used administrative data to identify and contact Veterans with a likely diagnosis of epilepsy in the Veterans Health Administration (VHA). Veterans who did not respond directly to a mailed invitation were recruited by phone to determine study interest and evaluate digital access. Of the 2,143 Veterans mailed study invitations, phone calls were made to 1,789 who did not specifically decline participation. Among those reached by phone (n = 1,053): 295 (28%) expressed interest in the study and an online tool, 333 (19%) reported a lack of computer and/or Internet access and 425 (40%) were not interested for other reasons. This study suggests an interest in online tools for managing health despite the fact that some Veterans lack computer and/or Internet access. As investment in digital health solutions grows, the VHA should prioritize the widespread provision of digital access to more Veterans. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

Not of One Mind: Mental Models of Clinical Practice Guidelines in the Veterans Health Administration

PubMed Central

Hysong, Sylvia J; Best, Richard G; Pugh, Jacqueline A; Moore, Frank I

2005-01-01

Objective The purpose of this paper is to present differences in mental models of clinical practice guidelines (CPGs) among 15 Veterans Health Administration (VHA) facilities throughout the United States. Data Sources Two hundred and forty-four employees from 15 different VHA facilities across four service networks around the country were invited to participate. Participants were selected from different levels throughout each service setting from primary care personnel to facility leadership. Study Design This qualitative study used purposive sampling, a semistructured interview process for data collection, and grounded theory techniques for analysis. Data Collection A semistructured interview was used to collect information on participants' mental models of CPGs, as well as implementation strategies and barriers in their facility. Findings Analysis of these interviews using grounded theory techniques indicated that there was wide variability in employees' mental models of CPGs. Findings also indicated that high-performing facilities exhibited both (a) a clear, focused shared mental model of guidelines and (b) a tendency to use performance feedback as a learning opportunity, thus suggesting that a shared mental model is a necessary but not sufficient step toward successful guideline implementation. Conclusions We conclude that a clear shared mental model of guidelines, in combination with a learning orientation toward feedback are important components for successful guideline implementation and improved quality of care. PMID:15960693

75 FR 41577 - VBA/VHA Musculoskeletal Forum: Improving VA's Disability Evaluation Criteria

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-16

... medical science information from presentations made by subject matter experts. VA plans to use this information to update the sections of VA's Schedule for Rating Disabilities (VASRD) that pertain to diseases... FURTHER INFORMATION CONTACT: Mr. Brad Tuttle, VASRD Coordinator, Compensation and Pension Service...

Health information technology and implementation science: partners in progress in the VHA.

PubMed

Hynes, Denise M; Whittier, Erika R; Owens, Arika

2013-03-01

The Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) has demonstrated how implementation science can enhance the quality of health care. During this time an increasing number of implementation research projects have developed or utilized health information technology (HIT) innovations to leverage the VA's electronic health record and information systems. To describe the HIT approaches used and to characterize the facilitators and barriers to progress within implementation research projects in the VA QUERI program. Nine case studies were selected from among 88 projects and represented 8 of 14 HIT categories identified. Each case study included key informants whose roles on the project were principal investigator, implementation science and informatics development. We conducted documentation analysis and semistructured in-person interviews with key informants for each of the 9 case studies. We used qualitative analysis software to identify and thematically code information and interview responses. : Thematic analyses revealed 3 domains or pathways critical to progression through the QUERI steps. These pathways addressed: (1) compliance and collaboration with information technology policies and procedures; (2) operating within organizational policies and building collaborations with end users, clinicians, and administrators; and (3) obtaining and maintaining research resources and approvals. Sustained efforts in HIT innovation and in implementation science in the Veterans Health Administration demonstrates the interdependencies of these initiatives and the critical pathways that can contribute to progress. Other health care quality improvement efforts that rely on HIT can learn from the Veterans Health Administration experience.

The Effect of Primary Care Provider Turnover on Patient Experience of Care and Ambulatory Quality of Care.

PubMed

Reddy, Ashok; Pollack, Craig E; Asch, David A; Canamucio, Anne; Werner, Rachel M

2015-07-01

Primary care provider (PCP) turnover is common and can disrupt patient continuity of care. Little is known about the effect of PCP turnover on patient care experience and quality of care. To measure the effect of PCP turnover on patient experiences of care and ambulatory care quality. Observational, retrospective cohort study of a nationwide sample of primary care patients in the Veterans Health Administration (VHA). We included all patients enrolled in primary care at the VHA between 2010 and 2012 included in 1 of 2 national data sets used to measure our outcome variables: 326,374 patients in the Survey of Healthcare Experiences of Patients (SHEP; used to measure patient experience of care) associated with 8441 PCPs and 184,501 patients in the External Peer Review Program (EPRP; used to measure ambulatory care quality) associated with 6973 PCPs. Whether a patient experienced PCP turnover, defined as a patient whose provider (physician, nurse practitioner, or physician assistant) had left the VHA (ie, had no patient encounters for 12 months). Five patient care experience measures (from SHEP) and 11 measures of quality of ambulatory care (from EPRP). Nine percent of patients experienced a PCP turnover in our study sample. Primary care provider turnover was associated with a worse rating in each domain of patient care experience. Turnover was associated with a reduced likelihood of having a positive rating of their personal physician of 68.2% vs 74.6% (adjusted percentage point difference, -5.3; 95% CI, -6.0 to -4.7) and a reduced likelihood of getting care quickly of 36.5% vs 38.5% (adjusted percentage point difference, -1.1; 95% CI, -2.1 to -0.1). In contrast, PCP turnover was not associated with lower quality of ambulatory care except for a lower likelihood of controlling blood pressure of 78.7% vs 80.4% (adjusted percentage point difference, -1.44; 95% CI, -2.2 to -0.7). In 9 measures of ambulatory care quality, the difference between patients who experienced no

Assessing business leaders' perspectives on health care issues.

PubMed

McDermott, D R; Brinkman, L H

1990-01-01

The survey results reported here shed light on how CEOs perceive various health care issues in general, and factors and proposed solutions regarding uncompensated or indigent care, in specific. The problem of indigent care has reached such dimensions that various legislative remedies are being sought, such as the Indigent Health Care Trust Fund and mandated health insurance coverage. Although the uninsured are not being denied health care, the cost of such care is rising far above that which can continue to be absorbed by hospitals and other providers. Thus, something must be done, legislatively or otherwise. In sponsoring this survey the VHA sought to gather information that would guide and facilitate their response to the problem of financing the cost of indigent health care. The CEO responses: (1) indicate the need for an education program; (2) provide support for legislative proposals; and, (3) highlight areas which need further investigation. Business leaders need to be informed as to the true causes of increasingly high health care costs, with the increasing role of indigent health care cost clearly illustrated, as well as other key areas of concern such as technology, unnecessary medical procedures, and malpractice suits. Hospital associations could develop comparative fact sheets addressing perceptions, misconceptions, and the actual causes of increased health care costs. This informational advertising campaign could eventually be broadened to encompass some of the issues which need further consideration, such as hospital inefficiency and who should pay for indigent health care. The respondent's support for and responsiveness to tax incentives to encourage employers to provide more health care coverage, and CEO support for the Indigent Health Care Trust Fund, should be used to shape legislative proposals. The CEOs' perception of the importance of health care (being third in priority out of eight key current issues) should aid the VHA in their efforts to

Determinants of the cost of health services used by veterans with HIV.

PubMed

Barnett, Paul G; Chow, Adam; Joyce, Vilija R; Bayoumi, Ahmed M; Griffin, Susan C; Nosyk, Bohdan; Holodniy, Mark; Brown, Sheldon T; Sculpher, Mark; Anis, Aslam H; Owens, Douglas K

2011-09-01

The effect of adherence, treatment failure, and comorbidities on the cost of HIV care is not well understood. To characterize the cost of HIV care including combination antiretroviral treatment (ART). Observational study of administrative data. Total 1896 randomly selected HIV-infected patients and 288 trial participants with multidrug-resistant HIV seen at the US Veterans Health Administration (VHA). Comorbidities, cost, pharmacy, and laboratory data. Many HIV-infected patients (24.5%) of the random sample did not receive ART. Outpatient pharmacy accounted for 62.8% of the costs of patients highly adherent with ART, 32.2% of the cost of those with lower adherence, and 6.2% of the cost of those not receiving ART. Compared with patients not receiving ART, high adherence was associated with lower hospital cost, but no greater total cost. Individuals with a low CD4 count (<50 cells/mm) incurred 1.9 times the cost of patients with counts >500. Most patients had medical, psychiatric, or substance abuse comorbidities. These conditions were associated with greater cost. Trial participants were less likely to have psychiatric and substance abuse comorbidities than the random sample of VHA patients with HIV. Patients receiving combination ART had higher medication costs but lower acute hospital cost. Poor control of HIV was associated with higher cost. The cost of psychiatric, substance abuse, rehabilitation, and long-term care and medications other than ART, often overlooked in HIV studies, was substantial.

How Do Healthcare Employees Rate the Ethics of Their Organization? An Analysis Based on VA IntegratedEthics@ Staff Survey Data.

PubMed

Cohen, Jennifer H; Foglia, Mary Beth; Kwong, Katherine; Pearlman, Robert; Fox, Ellen

2015-01-01

Healthcare organizations with an ethical culture experience higher levels of employee productivity, less staff turnover, better levels of patient safety, resource and cost savings, and higher levels of patient satisfaction. Employees' perceptions of the ethics of their organization are considered a good indicator of the ethics culture. How employees rate the ethics of their organization is not well understood. Previous research has identified a number of attributes that are salient to employees' perceptions in this area. However, little is known about how employees synthesize their perceptions of these attributes to rate the ethics of their organization. Without this knowledge, managers have little specific information to act on to improve practices that would in turn improve employees' perceptions of their organization's ethics. For this study, we used data from Department of Veterans Affairs' (VA) 2014 IntegratedEthics@ Staff Survey administered to Veterans Health Administration (VHA) staff. We used multivariate regression analyses to investigate how VHA employees weigh their perceptions of eight attributes of an ethical organization to inform an overall rating of the ethics of their organization. We found that employee perceptions of fairness, clarity of expectations, accountability, and leadership's prioritization of ethics had the strongest associations with the overall rating. In addition, employees disproportionately weighed their positive perceptions in determining their overall rating. Therefore, a strategy to improve employees' perceptions of these attributes could potentially have the greatest marginal return on investment with respect to improving employees' perceptions of the ethics of an organization.

Validating administrative records in post-traumatic stress disorder.

PubMed

Abrams, Thad E; Vaughan-Sarrazin, Mary; Keane, Terence M; Richardson, Kelly

2016-03-01

There is insufficient data on the accuracy of administrative coding data (ACD) for post-traumatic stress disorder (PTSD). Medical records were reviewed for (1) a diagnosis of PTSD; (2) treatment for PTSD. The records were compared against the Veterans Health Administration (VHA) data in order to determine the positive predictive value (PPV) and negative predictive value (NPV) of three commonly used approaches. The PPV and NPV varied according to the ACD approach. Relative to a medical records review, the ACD approach of one or two PTSD coded outpatient encounters had a PPV of 78% and an NPV of 91%; whereas the PPV was 97% and the NPV was 98% for three or more PTSD codes. For pharmacotherapy, the ACD approach with one or two codes for PTSD had a PPV of 33% (NPV = 93%), whereas three or more PTSD coded encounters improved the PPV to 85% (NPV = 100%). When using VHA data, we recommend tailoring the identification strategy according to the research aims. An ACD approach identifying one or more PTSD outpatient encounters should be considered sufficient for a diagnosis of PTSD. Assessments for PTSD associated pharmacotherapy require using an ACD approach that identifies veterans with the presence ≥ 3 outpatient PTSD encounters. Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

Osmoregulation in larvae and juveniles of two recently separated Macrobrachium species: Expression patterns of ion transporter genes.

PubMed

Boudour-Boucheker, Nesrine; Boulo, Viviane; Charmantier-Daures, Mireille; Anger, Klaus; Charmantier, Guy; Lorin-Nebel, Catherine

2016-05-01

In this comparative study, osmoregulatory mechanisms were analyzed in two closely related species of palaemonid shrimp from Brazil, Macrobrachium pantanalense and Macrobrachium amazonicum. A previous investigation showed that all postembryonic stages of M. pantanalense from inland waters of the Pantanal are able to hyper-osmoregulate in fresh water, while this species was not able to hypo-osmoregulate at high salinities. In M. amazonicum originating from the Amazon estuary, in contrast, all stages are able to hypo-osmoregulate, but only first-stage larvae, late juveniles and adults are able to hyper-osmoregulate in fresh water. The underlying molecular mechanisms of these physiological differences have not been known. We therefore investigated the expression patterns of three ion transporters (NKA α-subunit, VHA B-subunit and NHE3) following differential salinity acclimation in different ontogenetic stages (stage-V larvae, juveniles) of both species. Larval NKAα expression was at both salinities significantly higher in M. pantanalense than in M. amazonicum, whereas no difference was noted in juveniles. VHA was also more expressed in larvae of M. pantanalense than in those of M. amazonicum. When NHE3 expression is compared between the larvae of the two species, further salinity-related differences were observed, with generally higher expression in the inland species. Overall, a high expression of ion pumps in M. pantanalense suggests an evolutionary key role of these transporters in freshwater invasion. Copyright © 2016 Elsevier Inc. All rights reserved.

The effects of organization on medical utilization: an analysis of service line organization.

PubMed

Byrne, Margaret M; Charns, Martin P; Parker, Victoria A; Meterko, Mark M; Wray, Nelda P

2004-01-01

To determine whether clinical service lines in primary care and mental health reduces inpatient and urgent care utilization. All VHA medical centers were surveyed to determine whether service lines had been established in primary care or mental health care prior to the beginning of fiscal year 1997 (FY97). Facility-level data on medical utilization from Veterans Health Affairs (VHA) administrative databases were used for descriptive and multivariate regression analyses of utilization and of changes in measures between FY97 and FY98. Nine primary care-related and 5 mental health-related variables were analyzed. Primary care and mental health service lines had been established in approximately half of all facilities. Service lines varied in duration and extent of restructuring. Mere presence of a service line had no positive and several negative effects on measured outcome variables. More detailed analyses showed that some types of service lines have statistically significant and mostly negative effects on both mental health and primary care-related measures. Newly implemented service lines had significantly less improvement in measures over time than facilities with no service line. Health care organizations are implementing innovative organizational structures in hopes of improving quality of care and reducing resource utilization. We found that service lines in primary care and mental health may lead to an initial period of disruption, with little evidence of a beneficial effect on performance for longer duration service lines.

A Coaching by Telephone Intervention for Veterans and Care Team Engagement (ACTIVATE): A study protocol for a Hybrid Type I effectiveness-implementation randomized controlled trial.

PubMed

Oddone, Eugene Z; Damschroder, Laura J; Gierisch, Jennifer; Olsen, Maren; Fagerlin, Angela; Sanders, Linda; Sparks, Jordan; Turner, Marsha; May, Carrie; McCant, Felicia; Curry, David; White-Clark, Courtney; Juntilla, Karen

2017-04-01

A large proportion of deaths and many illnesses can be attributed to three modifiable risk factors: tobacco use, overweight/obesity, and physical inactivity. Health risk assessments (HRAs) are widely available online but have not been consistently used in healthcare systems to activate patients to participate in prevention programs aimed at improving lifestyle behaviors. The goal of this study is to test whether adding telephone-based coaching to use of a comprehensive HRA increases at-risk patients' activation and enrollment into a prevention program compared to HRA use alone. Participants were randomized to either complete an HRA alone or in conjunction with a telephone coaching intervention. To be eligible Veterans had to have at least one modifiable risk factor (current smoker, overweight/obese, or physically inactive). The primary outcome is enrollment and participation in a prevention program by 6months. Secondary outcomes include change in a Patient Activation Measure and Framingham Risk Score. This study is the first to test a web-based health risk assessment coupled with a health coaching intervention within a large healthcare system. Results from this study will help the Veterans Health Administration (VHA) implement its national plan to include comprehensive health risk assessments as a tool to engage Veterans in prevention. The results will also inform health systems outside VHA who seek to implement Medicare's advisement that health risk assessment become a mandatory component of care under the Affordable Care Act. © 2016.

John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety.

PubMed

Heget, Jeffrey R; Bagian, James P; Lee, Caryl Z; Gosbee, John W

2002-12-01

In 1998 the Veterans Health Administration (VHA) created the National Center for Patient Safety (NCPS) to lead the effort to reduce adverse events and close calls systemwide. NCPS's aim is to foster a culture of safety in the Department of Veterans Affairs (VA) by developing and providing patient safety programs and delivering standardized tools, methods, and initiatives to the 163 VA facilities. To create a system-oriented approach to patient safety, NCPS looked for models in fields such as aviation, nuclear power, human factors, and safety engineering. Core concepts included a non-punitive approach to patient safety activities that emphasizes systems-based learning, the active seeking out of close calls, which are viewed as opportunities for learning and investigation, and the use of interdisciplinary teams to investigate close calls and adverse events through a root cause analysis (RCA) process. Participation by VA facilities and networks was voluntary. NCPS has always aimed to develop a program that would be applicable both within the VA and beyond. NCPS's full patient safety program was tested and implemented throughout the VA system from November 1999 to August 2000. Program components included an RCA system for use by caregivers at the front line, a system for the aggregate review of RCA results, information systems software, alerts and advisories, and cognitive acids. Following program implementation, NCPS saw a 900-fold increase in reporting of close calls of high-priority events, reflecting the level of commitment to the program by VHA leaders and staff.

Do financial incentives in a globally budgeted healthcare payment system produce changes in the way patients are categorized? A five-year study.

PubMed

Petersen, Laura A; Urech, Tracy H; Byrne, Margaret M; Pietz, Kenneth

2007-09-01

To assess the responses to financial incentives after a change in the payment system in a capitation-style healthcare payment system over a 5-year period. Cross-sectional and longitudinal examination of cost, utilization, and diagnostic data. Using Veterans Health Administration (VHA) administrative data on healthcare users between fiscal years 1998 and 2002, we calculated the proportion of new patients entering each of the payment classes, the illness burden of patients entering the payment classes, and the profitability index (a ratio of payment to costs) for each class suspected of gaming and each control class. Our main dependent variables of interest were the differences in the measures between each utilization-based class and each diagnosis-based class. We used 2 different analytic approaches to assess whether these differences increased or decreased over time. No clear evidence of gaming behavior was present in our results. A few comparisons were significant, but they did not show a consistent pattern of responses to incentives. For example, 6 of 16 comparisons of profitability index were significant, but (contrary to the hypothesis) 4 of these had a negative value for the time parameter, indicating decreasing profitability in the utilization-based classes versus the diagnosis-based classes. Although the payment system could be manipulated to increase payment to VHA networks, no such consistent gaming behavior was observed. More research is needed to better understand the effects of financial incentives in other healthcare payment systems.

Validating Smoking Data From the Veteran’s Affairs Health Factors Dataset, an Electronic Data Source

PubMed Central

Brandt, Cynthia A.; Skanderson, Melissa; Justice, Amy C.; Shahrir, Shahida; Butt, Adeel A.; Brown, Sheldon T.; Freiberg, Matthew S.; Gibert, Cynthia L.; Goetz, Matthew Bidwell; Kim, Joon Woo; Pisani, Margaret A.; Rimland, David; Rodriguez-Barradas, Maria C.; Sico, Jason J.; Tindle, Hilary A.; Crothers, Kristina

2011-01-01

Introduction: We assessed smoking data from the Veterans Health Administration (VHA) electronic medical record (EMR) Health Factors dataset. Methods: To assess the validity of the EMR Health Factors smoking data, we first created an algorithm to convert text entries into a 3-category smoking variable (never, former, and current). We compared this EMR smoking variable to 2 different sources of patient self-reported smoking survey data: (a) 6,816 HIV-infected and -uninfected participants in the 8-site Veterans Aging Cohort Study (VACS-8) and (b) a subset of 13,689 participants from the national VACS Virtual Cohort (VACS-VC), who also completed the 1999 Large Health Study (LHS) survey. Sensitivity, specificity, and kappa statistics were used to evaluate agreement of EMR Health Factors smoking data with self-report smoking data. Results: For the EMR Health Factors and VACS-8 comparison of current, former, and never smoking categories, the kappa statistic was .66. For EMR Health Factors and VACS-VC/LHS comparison of smoking, the kappa statistic was .61. Conclusions: Based on kappa statistics, agreement between the EMR Health Factors and survey sources is substantial. Identification of current smokers nationally within the VHA can be used in future studies to track smoking status over time, to evaluate smoking interventions, and to adjust for smoking status in research. Our methodology may provide insights for other organizations seeking to use EMR data for accurate determination of smoking status. PMID:21911825

Tobacco dependence diagnosis and treatment in Veterans Health Administration residential substance use disorder treatment programs.

PubMed

Gifford, Elizabeth V; Tavakoli, Sara; Wang, Ruey; Hagedorn, Hildi J; Hamlett-Berry, Kim W

2013-06-01

To explore tobacco dependence (TD) diagnosis and treatment utilization, and identify predictors of nicotine replacement therapy (NRT) among veterans with substance use disorders (SUDs) enrolled in Veterans Health Administration (VHA) SUD residential treatment programs (SRTPs). Retrospective cohort study. VHA SRTPs, which treat veterans with SUD and multiple severe psychosocial deficits, from 1 October 2009 to 31 September 2010. Identified tobacco users among veterans with SUD treated in SRTPs during fiscal year 2010 (FY10). Rates of documented TD diagnosis and pharmacotherapy were assessed nationally, regionally and by facility. Patient-level predictors of NRT were examined using a mixed-effects logistic regression model with facility as a random effect. A total of 12 097 of the 15 320 veterans in SRTPs in FY10 (79%) were identified as probable tobacco users. Among these, 33% had a documented TD diagnosis, 34% were treated with pharmacotherapy and only 11% were both diagnosed and treated for TD while in SRTP. NRT was more common among patients with a current documented TD diagnosis, recent history of TD treatment, comorbid mental health disorder, age 55 years or younger and identified as white. Most veterans in Veterans Health Administration substance use disorders residential treatment programs appear to use tobacco, yet only one in 10 receives a documented ICD-9 TD diagnosis and pharmacotherapy while in a substance use disorders residential treatment program. © 2013 Society for the Study of Addiction.

Specifying and Pilot Testing Quality Measures for the American Society of Addiction Medicine's Standards of Care.

PubMed

Harris, Alex H S; Weisner, Constance M; Chalk, Mady; Capoccia, Victor; Chen, Cheng; Thomas, Cindy Parks

2016-01-01

In 2013, the American Society of Addiction Medicine (ASAM) approved its Standards of Care for the Addiction Specialist Physician. Subsequently, an ASAM Performance Measures Panel identified and prioritized the standards to be operationalized into performance measures. The goal of this study is to describe the process of operationalizing 3 of these standards into quality measures, and to present the initial measure specifications and results of pilot testing these measures in a large health care system. By presenting the process rather than just the end results, we hope to shed light on the measure development process to educate, and also to stimulate debate about the decisions that were made. Each measure was decomposed into major concepts. Then each concept was operationalized using commonly available administrative data sources. Alternative specifications examined and sensitivity analyses were conducted to inform decisions that balanced accuracy, clinical nuance, and simplicity. Using data from the US Veterans Health Administration (VHA), overall performance and variation in performance across 119 VHA facilities were calculated. Three measures were operationalized and pilot tested: pharmacotherapy for alcohol use disorder, pharmacotherapy for opioid use disorder, and timely follow-up after medically managed withdrawal (aka detoxification). Each measure was calculable with available data, and showed ample room for improvement (no ceiling effects) and wide facility-level variability. Next steps include conducting feasibility and pilot testing in other health care systems and other contexts such as standalone addiction treatment programs, and also to study the specification and predictive validity of these measures.

Use of electronic medical record data for quality improvement in schizophrenia treatment.

PubMed

Owen, Richard R; Thrush, Carol R; Cannon, Dale; Sloan, Kevin L; Curran, Geoff; Hudson, Teresa; Austen, Mark; Ritchie, Mona

2004-01-01

An understanding of the strengths and limitations of automated data is valuable when using administrative or clinical databases to monitor and improve the quality of health care. This study discusses the feasibility and validity of using data electronically extracted from the Veterans Health Administration (VHA) computer database (VistA) to monitor guideline performance for inpatient and outpatient treatment of schizophrenia. The authors also discuss preliminary results and their experience in applying these methods to monitor antipsychotic prescribing using the South Central VA Healthcare Network (SCVAHCN) Data Warehouse as a tool for quality improvement.

Quadrennial Review of Military Compensation (7TH). Global Subject Papers

DTIC Science & Technology

1992-08-01

the added result of reducing officers’ retired pay via a reduction in Basic Pay. The draft report recommends the continuous payment of BAS to all...being eligible for VHA is unfair. However, we also believe a minimum eligibility period is needed. The draft report recommends payment of full housing...93-12040 JOIN form Approved REPORT DOCUMENTATION PACE J No0 *flcrr t 0 datA .,-Vtr A’d :,r.¶tq. ~.-- r’ ~ (F. 0 ’ ~ ~ t’-e’,’ -o..t,7d’ A-t’trt I

Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans Health Administration: An Evidence Review and Map

PubMed Central

Anderson, Johanna; Boundy, Erin; Ferguson, Lauren; McCleery, Ellen; Waldrip, Kallie

2018-01-01

Background. Continued racial/ethnic health disparities were recently described as “the most serious and shameful health care issue of our time.” Although the 2014 US Affordable Care Act–mandated national insurance coverage expansion has led to significant improvements in health care coverage and access, its effects on life expectancy are not yet known. The Veterans Health Administration (VHA), the largest US integrated health care system, has a sustained commitment to health equity that addresses all 3 stages of health disparities research: detection, understanding determinants, and reduction or elimination. Despite this, racial disparities still exist in the VHA across a wide range of clinical areas and service types. Objectives. To inform the health equity research agenda, we synthesized evidence on racial/ethnic mortality disparities in the VHA. Search Methods. Our research librarian searched MEDLINE and Cochrane Central Registry of Controlled Trials from October 2006 through February 2017 using terms for racial groups and disparities. Selection Criteria. We included studies if they compared mortality between any racial/ethnic minority and nonminority veteran groups or between different minority groups in the VHA (PROSPERO# CRD42015015974). We made study selection decisions on the basis of prespecified eligibility criteria. They were first made by 1 reviewer and checked by a second and disagreements were resolved by consensus (sequential review). Data Collection and Analysis. Two reviewers sequentially abstracted data on prespecified population, outcome, setting, and study design characteristics. Two reviewers sequentially graded the strength of evidence using prespecified criteria on the basis of 5 key domains: study limitations (study design and internal validity), consistency, directness, precision of the evidence, and reporting biases. We synthesized the evidence qualitatively by grouping studies first by racial/ethnic minority group and then by

Client Goals for Participating in VHA Vocational Rehabilitation: Distribution and Relationship to Outcome

ERIC Educational Resources Information Center

Drebing, C.E.; Van Ormer, E.A.; Schutt, R.K.; Krebs, C.; Losardo, M.; Boyd, C.; Penk, W.; Rosenheck, R.

2004-01-01

Research into vocational rehabilitation (VR) consumer service preferences has been limited. The current study describes the self-reported goals of 228 applicants to a VR program sponsored by the Veterans Administration (VA) and documents the relationship of those goals to participant background variables and outcomes. Participants endorsed a wide…

Characterization of a rabbit germ-line VH gene that is a candidate donor for VH gene conversion in mutant Alicia rabbits.

PubMed

Chen, H T; Alexander, C B; Mage, R G

1995-06-15

Normal rabbits preferentially rearrange the 3'-most VH gene, VH1, to encode Igs with VHa allotypes, which constitute the majority of rabbit serum Igs. A gene conversion-like mechanism is employed to diversify the primary Ab repertoire. In mutant Alicia rabbits that derived from a rabbit with VHa2 allotype, the VH1 gene was deleted. Our previous studies showed that the first functional gene (VH4) or VH4-like genes were rearranged in 2- to 8-wk-old homozygous Alicia. The VH1a2-like sequences that were found in splenic mRNA from 6-wk and older Alicia rabbits still had some residues that were typical of VH4. The appearances of sequences resembling that of VH1a2 may have been caused by gene conversions that altered the sequences of the rearranged VH or there may have been rearrangement of upstream VH1a2-like genes later in development. To investigate this further, we constructed a cosmid library and isolated a VH1a2-like gene, VH12-1-6, with a sequence almost identical to VH1a2. This gene had a deleted base in the heptamer of its recombination signal sequence. However, even if this defect diminished or eliminated its ability to rearrange, the a2-like gene could have acted as a donor for gene-conversion-like alteration of rearranged VH genes. Sequence comparisons suggested that this gene or a gene like it could have acted as a donor for gene conversion in mutant Alicia and in normal rabbits.

Barriers and facilitators to provide quality TIA care in the Veterans Healthcare Administration

PubMed Central

Miech, Edward J.; Sico, Jason J.; Phipps, Michael S.; Arling, Greg; Ferguson, Jared; Austin, Charles; Myers, Laura; Baye, Fitsum; Luckhurst, Cherie; Keating, Ava B.; Moran, Eileen; Bravata, Dawn M.

2017-01-01

Objective: To identify key barriers and facilitators to the delivery of guideline-based care of patients with TIA in the national Veterans Health Administration (VHA). Methods: We conducted a cross-sectional, observational study of 70 audiotaped interviews of multidisciplinary clinical staff involved in TIA care at 14 VHA hospitals. We de-identified and analyzed all transcribed interviews. We identified emergent themes and patterns of barriers to providing TIA care and of facilitators applied to overcome these barriers. Results: Identified barriers to providing timely acute and follow-up TIA care included difficulties accessing brain imaging, a constantly rotating pool of housestaff, lack of care coordination, resource constraints, and inadequate staff education. Key informants revealed that both stroke nurse coordinators and system-level factors facilitated the provision of TIA care. Few facilities had specific TIA protocols. However, stroke nurse coordinators often expanded upon their role to include TIA. They facilitated TIA care by (1) coordinating patient care across services, communicating across service lines, and educating clinical staff about facility policies and evidence-based practices; (2) tracking individual patients from emergency departments to inpatient settings and to discharge for timely follow-up care; (3) providing and referring TIA patients to risk factor management programs; and (4) performing regular audit and feedback of quality performance data. System-level facilitators included clinical service leadership engagement and use of electronic tools for continuous care across services. Conclusions: The local organization within a health care facility may be targeted to cultivate internal facilitators and a systemic infrastructure to provide evidence-based TIA care. PMID:29117959

Psychological safety and error reporting within Veterans Health Administration hospitals.

PubMed

Derickson, Ryan; Fishman, Jonathan; Osatuke, Katerine; Teclaw, Robert; Ramsel, Dee

2015-03-01

In psychologically safe workplaces, employees feel comfortable taking interpersonal risks, such as pointing out errors. Previous research suggested that psychologically safe climate optimizes organizational outcomes. We evaluated psychological safety levels in Veterans Health Administration (VHA) hospitals and assessed their relationship to employee willingness of reporting medical errors. We conducted an ANOVA on psychological safety scores from a VHA employees census survey (n = 185,879), assessing variability of means across racial and supervisory levels. We examined organizational climate assessment interviews (n = 374) evaluating how many employees asserted willingness to report errors (or not) and their stated reasons. Finally, based on survey data, we identified 2 (psychologically safe versus unsafe) hospitals and compared their number of employees who would be willing/unwilling to report an error. Psychological safety increased with supervisory level (P < 0.001, η = 0.03) and was not meaningfully related to race (P < 0.001, η = 0.003). Twelve percent of employees would not report an error; retaliation fear was the most commonly mentioned deterrent. Furthermore, employees at the psychologically unsafe hospital (71% would report, 13% would not) were less willing to report an error than at the psychologically safe hospital (91% would, 0% would not). A substantial minority would not report an error and were willing to admit so in a private interview setting. Their stated reasons as well as higher psychological safety means for supervisory employees both suggest power as an important determinant. Intentions to report were associated with psychological safety, strongly suggesting this climate aspect as instrumental to improving patient safety and reducing costs.

Gender Differences in the Prevalence of Fibromyalgia and in Concomitant Medical and Psychiatric Disorders: A National Veterans Health Administration Study.

PubMed

Arout, Caroline A; Sofuoglu, Mehmet; Bastian, Lori A; Rosenheck, Robert A

2018-04-02

Fibromyalgia is a poorly understood, chronically disabling pain syndrome. While research has focused on its clinical presentation and treatment, less is known about fibromyalgia's clinical epidemiology in real-world healthcare systems. Gender differences have been difficult to study because relatively few males are diagnosed with fibromyalgia. Veterans Health Administration (VHA) patients diagnosed with fibromyalgia nationwide in FY 2012 were compared to Veterans with other pain diagnoses on sociodemographic characteristics, medical and psychiatric diagnoses, health service use, and opioid and psychotropic prescription fills. Additional analyses compared characteristics of men and women diagnosed with fibromyalgia. Risk ratios and Cohen's d were used for bivariate comparisons, followed by logistic regression analyses to identify independent factors associated with a diagnosis of fibromyalgia in the VHA. Altogether, 77,087 of 2,216,621 Veterans with pain diagnoses (3.48%) were diagnosed with fibromyalgia. They were more likely to be female, younger than patients with other pain conditions, more likely to have multiple psychiatric comorbidities and other types of pain, and used more medical outpatient services. Women diagnosed with fibromyalgia were younger and more likely to have headaches, connective tissue diseases (CTD), and psychiatric comorbidities, while men had more comorbid medical conditions. In this large, predominantly older male sample of Veterans with pain diagnoses, those with fibromyalgia were far more likely to be women. Gender comparisons showed women with fibromyalgia were more likely to be diagnosed with psychiatric disorders and CTD, while males were more likely to be diagnosed with medical conditions. Fibromyalgia shows a striking, gender-dependent picture of multimorbidity, which should be considered in treatment.

The Trade-Off between Costs and Outcomes: The Case of Acute Myocardial Infarction

PubMed Central

Schreyögg, Jonas; Stargardt, Tom

2010-01-01

Objective To investigate and to quantify the relationship between hospital costs and health outcomes for patients with acute myocardial infarction (AMI) in Veterans Health Administration (VHA) hospitals using individual-level data for costs and outcomes. Data Sources VHA administrative files for the fiscal years 2000–2006. Study Design Costs were defined as costs incurred during the index hospitalization for treatment of AMI. Mortality and readmission, assessed 1 year after the index hospitalization, were used as measures of clinical outcome. We examined health outcomes as a function of costs and other patient-level and hospital-level characteristics using a two-stage Cox proportional hazard model that accounted for competing risks within a multilevel framework. To control for patient comorbidities, we compiled a comprehensive list of comorbidities that have been found in other studies to affect mortality and readmissions. Principal Findings We found that costs were negatively associated with mortality and readmissions. Every U.S.$100 less spent is associated with a 0.63 percent increase in the hazard of dying and a 1.24 percent increase in the hazard to be readmitted conditional on not dying. This main finding remained unchanged after a number of sensitivity checks. Conclusions Our results suggest that there is a trade-off between costs and outcomes. The negative association between costs and mortality suggests that outcomes should be monitored closely when introducing cost-containment programs. Additional studies are needed to examine the cost–outcome relationship for conditions other than AMI to see whether our results are consistent. PMID:20819109

Validation of key behaviourally based mental health diagnoses in administrative data: suicide attempt, alcohol abuse, illicit drug abuse and tobacco use.

PubMed

Kim, Hyungjin Myra; Smith, Eric G; Stano, Claire M; Ganoczy, Dara; Zivin, Kara; Walters, Heather; Valenstein, Marcia

2012-01-23

Observational research frequently uses administrative codes for mental health or substance use diagnoses and for important behaviours such as suicide attempts. We sought to validate codes (International Classification of Diseases, 9th edition, clinical modification diagnostic and E-codes) entered in Veterans Health Administration administrative data for patients with depression versus a gold standard of electronic medical record text ("chart notation"). Three random samples of patients were selected, each stratified by geographic region, gender, and year of cohort entry, from a VHA depression treatment cohort from April 1, 1999 to September 30, 2004. The first sample was selected from patients who died by suicide, the second from patients who remained alive on the date of death of suicide cases, and the third from patients with a new start of a commonly used antidepressant medication. Four variables were assessed using administrative codes in the year prior to the index date: suicide attempt, alcohol abuse/dependence, drug abuse/dependence and tobacco use. Specificity was high (≥ 90%) for all four administrative codes, regardless of the sample. Sensitivity was ≤75% and was particularly low for suicide attempt (≤ 17%). Positive predictive values for alcohol dependence/abuse and tobacco use were high, but barely better than flipping a coin for illicit drug abuse/dependence. Sensitivity differed across the three samples, but was highest in the suicide death sample. Administrative data-based diagnoses among VHA records have high specificity, but low sensitivity. The accuracy level varies by different diagnosis and by different patient subgroup.

Using organizational and clinical performance data to increase the value of mental health care.

PubMed

Schmidt, Eric M; Krahn, Dean D; McGuire, Marsden H; Tavakoli, Sara; Wright, David M; Solares, Hugo E; Lemke, Sonne; Trafton, Jodie

2017-02-01

U.S. health systems, policy makers, and patients increasingly demand high-value care that improves health outcomes at lower cost. This study describes the initial design and analysis of the Mental Health Management System (MHMS), a performance data and quality improvement tool used by the Veterans Health Administration (VHA) to increase the value of its mental health care. The MHMS evaluates access to and quality of mental health care, organizational structure and efficiency, implementation of innovative treatment options, and, in collaboration with management, resource needs for delivering care. Performance on 31 measures was calculated for all U.S. VHA facilities (N = 139). Pearson correlations revealed that better access to care was significantly associated with fewer mental health provider staffing vacancies (r = -.24) and higher staff-to-patient ratios for psychiatrists (r = .19) and other outpatient mental health providers (r = .27). Higher staff-to-patient ratios were significantly associated with higher performance on a number of patient and provider satisfaction measures (range of r = .18-.51) and continuity of care measures (range of r = .26-.43). Relationships observed between organizational and clinical performance measures suggest that the MHMS is a robust informatics and quality improvement tool that can serve as a model for health systems planning to adopt a value perspective. Future research should expand the MHMS framework to measure patient and health systems costs and psychosocial outcomes, as well as evaluate whether quality improvement solutions implemented as a result of using organizational information leads to higher-value mental health care. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Supported Employment for Veterans With Traumatic Brain Injury: Patient Perspectives.

PubMed

Carlson, Kathleen F; Pogoda, Terri K; Gilbert, Tess A; Resnick, Sandra G; Twamley, Elizabeth W; O'Neil, Maya E; Sayer, Nina A

2018-02-01

To quantify the need for, and interest in, supported employment (SE) among recent military veterans with traumatic brain injury (TBI); and to examine characteristics associated with veterans' interest in SE. Stratified random sample of Iraq and Afghanistan War veterans confirmed to have TBI through the Veterans Health Administration (VHA) screening and evaluation system. Community-based via mailed survey. We recruited 1800 veterans with clinician-confirmed TBI (mild TBI: n=1080; moderate/severe TBI: n=720) through multiple mailings. Among 1451 surveys that were not returned undeliverable, N=616 (42%) responded. Not applicable. Veterans rated their interest in SE after reading a script describing the program. Additional measures assessed mental health and pain-related comorbidities, employment, financial/housing difficulties, demographics, and military service characteristics. Estimates were weighted to represent the population of veterans with VHA clinician-confirmed TBI. Unemployment was reported by 45% (95% confidence interval [CI], 43-47) of veterans with TBI. Although 42% (95% CI, 40-44) reported they would be interested in using SE if it were offered to them, only 12% had heard of SE (95% CI, 11-14) and <1% had used it. TBI severity and comorbidities were not associated with veterans' interest in SE. However, those who were unemployed, looking for work, experiencing financial strain, or at risk for homelessness were more likely to be interested in SE. Our research highlights an important gap between veterans' vocational needs and interests and their use of SE. Systematically identifying and referring those with employment and financial/housing difficulties may help close this gap. Published by Elsevier Inc.

America's neglected veterans: 1.7 million who served have no health coverage.

PubMed

Woolhandler, Steffie; Himmelstein, David U; Distajo, Ronald; Lasser, Karen E; McCormick, Danny; Bor, David H; Wolfe, Sidney M

2005-01-01

Many U.S. military veterans lack health insurance and are ineligible for care in Veterans Administration health care facilities. Using two recently released national government surveys--the 2004 Current Population Survey and the 2002 National Health Interview Survey--the authors examined how many veterans are uninsured (lacking health insurance coverage and not receiving care from the VA) and whether uninsured veterans have problems in access to care. In 2003, 1.69 million military veterans neither had health insurance nor received ongoing care at Veterans Health Administration (VHA) hospitals or clinics; the number of uninsured veterans increased by 235,159 since 2000. The proportion of nonelderly veterans who were uninsured rose from 9.9 percent in 2000 to 11.9 percent in 2003. An additional 3.90 million members of veterans' households were also uninsured and ineligible for VHA care. Medicare covered virtually all Korean War and World War II veterans, but 681,808 Vietnam-era veterans were uninsured (8.7 percent of the 7.85 million Vietnam-era vets). Among the 8.27 million veterans who served during "other eras" (including the Persian Gulf War), 12.1 percent (999,548) lacked health coverage. A disturbingly high number of veterans reported problems in obtaining needed medical care. By almost any measure, uninsured veterans had as much trouble getting medical care as other uninsured persons. Thus millions of U.S. veterans and their family members are uninsured and face grave difficulties in gaining access to even the most basic medical care.

Current status and strategies for the control of viral hepatitis A in Korea.

PubMed

Yoon, Eileen L; Sinn, Dong Hyun; Lee, Hyun Woong; Kim, Ji Hoon

2017-09-01

Hepatitis A virus is one of the most frequent causes of foodborne infection, which is closely associated with sanitary conditions and hygienic practices. The clinical spectrum of acute hepatitis A is wide, ranging from mild case without any noticeable symptoms to severe case with acute liver failure leading to mortality. The severity and outcome are highly correlated with age at infection. In developing countries, most people are infected in early childhood without significant symptom. Ironically, in area where sanitary condition has improved rapidly, adults who do not have immunity for viral hepatitis A (VH-A) in early childhood is accumulating. Adults without immunity are exposed to risks of symptomatic disease and large outbreaks in society. In Korea, where hygiene has improved rapidly, acute hepatitis A is a significant health burden that needs to be managed with nationwide health policy. The incidence of symptomatic VH-A has increased since 2000 and peaked in 2009. Korea has designated hepatitis A as a group 1 nationally notifiable infectious disease in 2001. Since 2001, mandatory surveillance system has been established to detect every single case of acute hepatitis A. Universal, nationwide vaccination program for newborns was introduced in 2015. In this review, we will present the current epidemiologic status of viral hepatitis A, and evaluate the effectiveness of the current nationwide strategies for the control of viral hepatitis A in Korea. Furthermore, we presented some action proposals that can help eliminate viral hepatitis A, which is a significant health burden in Korea.

Primary Care-Mental Health Integration in the Veterans Affairs Health System: Program Characteristics and Performance.

PubMed

Cornwell, Brittany L; Brockmann, Laurie M; Lasky, Elaine C; Mach, Jennifer; McCarthy, John F

2018-06-01

The Veterans Health Administration (VHA) has achieved substantial national implementation of primary care-mental health integration (PC-MHI) services. However, little is known regarding program characteristics, variation in characteristics across settings, or associations between program fidelity and performance. This study identified core elements of PC-MHI services and evaluated their associations with program characteristics and performance. A principal-components analysis (PCA) of reports from 349 sites identified factors associated with PC-MHI fidelity. Analyses assessed the correlation among factors and between each factor and facility type (medical center or community-based outpatient clinic), primary care population size, and performance indicators (receipt of PC-MHI services, same-day access to mental health and primary care services, and extended duration of services). PCA identified seven factors: core implementation, care management (CM) assessments and supervision, CM supervision receipt, colocated collaborative care (CCC) by prescribing providers, CCC by behavioral health providers, participation in patient aligned care teams (PACTs) for special populations, and treatment of complex mental health conditions. Sites serving larger populations had greater core implementation scores. Medical centers and sites serving larger populations had greater scores for CCC by prescribing providers, CM assessments and supervision, and participation in PACTs. Greater core implementation scores were associated with greater same-day access. Sites with greater scores for CM assessments and supervision had lower scores for treatment of complex conditions. Outpatient clinics and sites serving smaller populations experienced challenges in integrated care implementation. To enhance same-day access, VHA should continue to prioritize PC-MHI implementation. Providing brief, problem-focused care may enhance CM implementation.

The Effect of Primary Care Provider Turnover on Patient Experience of Care and Ambulatory Quality of Care

PubMed Central

Reddy, Ashok; Pollack, Craig E.; Asch, David A.; Canamucio, Anne; Werner, Rachel M.

2017-01-01

IMPORTANCE Primary care provider (PCP) turnover is common and can disrupt patient continuity of care. Little is known about the effect of PCP turnover on patient care experience and quality of care. OBJECTIVE To measure the effect of PCP turnover on patient experiences of care and ambulatory care quality. DESIGN, SETTING, AND PARTICIPANTS Observational, retrospective cohort study of a nationwide sample of primary care patients in the Veterans Health Administration (VHA). We included all patients enrolled in primary care at the VHA between 2010 and 2012 included in 1 of 2 national data sets used to measure our outcome variables: 326 374 patients in the Survey of Healthcare Experiences of Patients (SHEP; used to measure patient experience of care) associated with 8441 PCPs and 184 501 patients in the External Peer Review Program (EPRP; used to measure ambulatory care quality) associated with 6973 PCPs. EXPOSURES Whether a patient experienced PCP turnover, defined as a patient whose provider (physician, nurse practitioner, or physician assistant) had left the VHA (ie, had no patient encounters for 12 months). MAIN OUTCOMES AND MEASURES Five patient care experience measures (from SHEP) and 11 measures of quality of ambulatory care (from EPRP). RESULTS Nine percent of patients experienced a PCP turnover in our study sample. Primary care provider turnover was associated with a worse rating in each domain of patient care experience. Turnover was associated with a reduced likelihood of having a positive rating of their personal physician of 68.2% vs 74.6% (adjusted percentage point difference, −5.3; 95% CI, −6.0 to −4.7) and a reduced likelihood of getting care quickly of 36.5% vs 38.5% (adjusted percentage point difference, −1.1; 95% CI, −2.1 to −0.1). In contrast, PCP turnover was not associated with lower quality of ambulatory care except for a lower likelihood of controlling blood pressure of 78.7% vs 80.4% (adjusted percentage point difference, −1.44; 95

Veterans' experience in using the online Surgeon General's family health history tool.

PubMed

Arar, Nedal; Seo, Joann; Abboud, Hanna E; Parchman, Michael; Noel, Polly

2011-09-01

Administration (VHA). The results suggest that strategies that improve veterans' knowledge regarding the importance of their FHH information and that address their concerns about privacy and confidentiality may enhance the successful implementation of FHH information into VHA clinical practice. IMPLICATIONS: identifying a locally accepted method for FHH collection and documentation which can be conducted outside of the patient visit will reduce time burdens for providers and patients and allow for a focus on other important topics during clinic visits. Improvement in familial risk screening and assessment will enable the VHA to be prepared for personalized medicine and focus their resources on promoting critically important health behaviors for populations with the highest risk of developing chronic diseases and their complications.

Implementation of a novel occupational and environmental medicine specialty teleconsultation service: the VHA experience.

PubMed

Eaton, Jennifer L; Mohr, David C; Mohammad, Amir; Kirkhorn, Steven; Gerstel-Santucci, Christina; McPhaul, Kathleen; Hodgson, Michael J

2015-02-01

Occupational and environmental medicine (OEM) physician specialty practices continue to grow in scope and intensity across the Veterans Health Administration. This study characterizes the implementation of a novel, nationwide telemedicine program that provides OEM specialty consultation to providers across the Veterans Health Administration. We examined provider requests and specialist responses for a 6-month pilot from May to October 2013. Characteristics of consult users, determinants of case complexity, and specific applications of OEM specialty expertise were identified. Over a 6-month period, employee occupational health providers consulted the OEM telemedicine pilot a total of 65 times. Employee occupational health providers without formal training repeatedly identified complex cases related to work and disability. The program has created a new system management solution to deliver expert, in-depth consultation and real-time provider education in OEM.

Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study.

PubMed

Park, Tae Woo; Saitz, Richard; Ganoczy, Dara; Ilgen, Mark A; Bohnert, Amy S B

2015-06-10

To study the association between benzodiazepine prescribing patterns including dose, type, and dosing schedule and the risk of death from drug overdose among US veterans receiving opioid analgesics. Case-cohort study. Veterans Health Administration (VHA), 2004-09. US veterans, primarily male, who received opioid analgesics in 2004-09. All veterans who died from a drug overdose (n=2400) while receiving opioid analgesics and a random sample of veterans (n=420,386) who received VHA medical services and opioid analgesics. Death from drug overdose, defined as any intentional, unintentional, or indeterminate death from poisoning caused by any drug, determined by information on cause of death from the National Death Index. During the study period 27% (n=112,069) of veterans who received opioid analgesics also received benzodiazepines. About half of the deaths from drug overdose (n=1185) occurred when veterans were concurrently prescribed benzodiazepines and opioids. Risk of death from drug overdose increased with history of benzodiazepine prescription: adjusted hazard ratios were 2.33 (95% confidence interval 2.05 to 2.64) for former prescriptions versus no prescription and 3.86 (3.49 to 4.26) for current prescriptions versus no prescription. Risk of death from drug overdose increased as daily benzodiazepine dose increased. Compared with clonazepam, temazepam was associated with a decreased risk of death from drug overdose (0.63, 0.48 to 0.82). Benzodiazepine dosing schedule was not associated with risk of death from drug overdose. Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death from drug overdose in a dose-response fashion. © Park et al 2015.

VH mutant rabbits lacking the VH1a2 gene develop a2+ B cells in the appendix by gene conversion-like alteration of a rearranged VH4 gene.

PubMed

Sehgal, D; Mage, R G; Schiaffella, E

1998-02-01

We investigated the molecular basis for the appearance of V(H)a2 allotype-bearing B cells in mutant Alicia rabbits. The mutation arose in an a2 rabbit; mutants exhibit altered expression of V(H) genes because of a small deletion encompassing V(H)1a2, the 3'-most gene in the V(H) locus. The V(H)1 gene is the major source of V(H)a allotype because this gene is preferentially rearranged in normal rabbits. In young homozygous ali/ali animals, the levels of a2 molecules found in the serum increase with age. In adult ali/ali rabbits, 20 to 50% of serum Igs and B cells bear a2 allotypic determinants. Previous studies suggested that positive selection results in expansion of a2 allotype-bearing B cells in the appendix of young mutant ali/ali rabbits. We separated appendix cells from a 6-wk-old Alicia rabbit by FACS based on the expression of surface IgM and a2 allotype. The VDJ portion of the expressed Ig mRNA was amplified from the IgM+ a2+ and IgM+ a2- populations by reverse transcriptase-PCR. The cDNAs from both populations were cloned and sequenced. Analysis of these sequences suggested that, in a2+ B cells, the first D proximal functional gene in Alicia rabbits, V(H)4a2, rearranged and was altered further by a gene conversion-like mechanism. Upstream V(H) genes were identified as potential gene sequence donors; V(H)9 was found to be the most frequently used gene donor. Among the a2- B cells, y33 was the most frequently rearranged gene.

Barriers and facilitators to provide quality TIA care in the Veterans Healthcare Administration.

PubMed

Damush, Teresa M; Miech, Edward J; Sico, Jason J; Phipps, Michael S; Arling, Greg; Ferguson, Jared; Austin, Charles; Myers, Laura; Baye, Fitsum; Luckhurst, Cherie; Keating, Ava B; Moran, Eileen; Bravata, Dawn M

2017-12-12

To identify key barriers and facilitators to the delivery of guideline-based care of patients with TIA in the national Veterans Health Administration (VHA). We conducted a cross-sectional, observational study of 70 audiotaped interviews of multidisciplinary clinical staff involved in TIA care at 14 VHA hospitals. We de-identified and analyzed all transcribed interviews. We identified emergent themes and patterns of barriers to providing TIA care and of facilitators applied to overcome these barriers. Identified barriers to providing timely acute and follow-up TIA care included difficulties accessing brain imaging, a constantly rotating pool of housestaff, lack of care coordination, resource constraints, and inadequate staff education. Key informants revealed that both stroke nurse coordinators and system-level factors facilitated the provision of TIA care. Few facilities had specific TIA protocols. However, stroke nurse coordinators often expanded upon their role to include TIA. They facilitated TIA care by (1) coordinating patient care across services, communicating across service lines, and educating clinical staff about facility policies and evidence-based practices; (2) tracking individual patients from emergency departments to inpatient settings and to discharge for timely follow-up care; (3) providing and referring TIA patients to risk factor management programs; and (4) performing regular audit and feedback of quality performance data. System-level facilitators included clinical service leadership engagement and use of electronic tools for continuous care across services. The local organization within a health care facility may be targeted to cultivate internal facilitators and a systemic infrastructure to provide evidence-based TIA care. Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.

Documentation of preventive care for pressure ulcers initiated during annual evaluations in SCI

PubMed Central

2016-01-01

Objective Community-acquired pressure ulcers (PrUs) are a frequent cause of hospitalization of Veterans with spinal cord injury (SCI). The Veterans Health Administration (VHA) recommends that SCI annual evaluations include assessment of PrU risk factors, a thorough skin inspection and sharing of recommendations for PrU prevention strategies. We characterized consistency of preventive skin care during annual evaluations for Veterans with SCI as a first step in identifying strategies to more actively promote PrU prevention care in other healthcare encounters. Design/setting/participants Retrospective cross-sectional observational design, including review of electronic medical records for 206 Veterans with SCI admitted to 2 VA SCI centers from January-December, 2011. Outcome measures Proportion of applicable skin health elements documented (number of applicable elements/skin health elements documented). Results Our sample was primarily white (78%) male (96.1%), and mean age = 61 years. 40% of participants’ were hospitalized for PrU treatment, with a mean of 294 days (median = 345 days) from annual evaluation to the index admission. On average, Veterans received an average of 75.5% (IQR 68-86%) of applicable skin health elements. Documentation of applicable skin health elements was significantly higher during inpatient vs. outpatient annual evaluations (mean elements received = 80.3% and 64.3%, respectively, P > 0.001). No significant differences were observed in documentation of skin health elements by Veterans at high vs. low PrU risk. Conclusion Additional PrU preventive care in the VHA outpatient setting may increase identification and detection of PrU risk factors and early PrU damage for Veterans with SCI in the community, allowing for earlier intervention. PMID:26763668

Documentation of preventive care for pressure ulcers initiated during annual evaluations in SCI.

PubMed

Guihan, Marylou; Murphy, Deidre; Rogers, Thea J; Parachuri, Ramadevi; Sae Richardson, Michael; Lee, Kenneth K; Bates-Jensen, Barbara M

2016-05-01

Community-acquired pressure ulcers (PrUs) are a frequent cause of hospitalization of Veterans with spinal cord injury (SCI). The Veterans Health Administration (VHA) recommends that SCI annual evaluations include assessment of PrU risk factors, a thorough skin inspection and sharing of recommendations for PrU prevention strategies. We characterized consistency of preventive skin care during annual evaluations for Veterans with SCI as a first step in identifying strategies to more actively promote PrU prevention care in other healthcare encounters. Retrospective cross-sectional observational design, including review of electronic medical records for 206 Veterans with SCI admitted to 2 VA SCI centers from January-December, 2011. Proportion of applicable skin health elements documented (number of applicable elements/skin health elements documented). Our sample was primarily white (78%) male (96.1%), and mean age = 61 years. 40% of participants' were hospitalized for PrU treatment, with a mean of 294 days (median = 345 days) from annual evaluation to the index admission. On average, Veterans received an average of 75.5% (IQR 68-86%) of applicable skin health elements. Documentation of applicable skin health elements was significantly higher during inpatient vs. outpatient annual evaluations (mean elements received = 80.3% and 64.3%, respectively, P > 0.001). No significant differences were observed in documentation of skin health elements by Veterans at high vs. low PrU risk. Additional PrU preventive care in the VHA outpatient setting may increase identification and detection of PrU risk factors and early PrU damage for Veterans with SCI in the community, allowing for earlier intervention.

Building a Diabetes Registry from the Veterans Health Administration's Computerized Patient Record System

PubMed Central

F. O. Kern, Elizabeth; Beischel, Scott; Stalnaker, Randal; Aron, David C.; Kirsh, Susan R.; Watts, Sharon A.

2008-01-01

Background Little information is available describing how to implement a disease registry from an electronic patient record system. The aim of this report is to describe the technology, methods, and utility of a diabetes registry populated by the Veterans Health Information Systems Architecture (VistA), which underlies the computerized patient record system of the Veterans Health Administration (VHA) in Veteran Affairs Integrated Service Network 10 (VISN 10). Methods VISN 10 data from VistA were mapped to a relational SQL-based data system using KB_SQL software. Operational definitions for diabetes, active clinical management, and responsible providers were used to create views of patient-level data in the diabetes registry. Query Analyzer was used to access the data views directly. Semicustomizable reports were created by linking the diabetes registry to a Web page using Microsoft asp.net2. A retrospective observational study design was used to analyze trends in the process of care and outcomes. Results Since October 2001, 81,227 patients with diabetes have enrolled in VISN 10: approximately 42,000 are currently under active management by VISN 10 providers. By tracking primary care visits, we assigned 91% to a clinic group responsible for diabetes care. In the Cleveland Veterans Affairs Medical Center (VAMC), the frequency of mean annual hemoglobin A1c levels ≥9% has declined significantly over 5 years. Almost 4000 patients have been seen in diabetes intervention programs in the Cleveland VAMC over the past 4 years. Conclusions A diabetes registry can be populated from the database underlying the VHA electronic patient record database system and linked to Web-based and ad hoc queries useful for quality improvement. PMID:19885172

A national evaluation of homeless and nonhomeless veterans' experiences with primary care.

PubMed

Jones, Audrey L; Hausmann, Leslie R M; Haas, Gretchen L; Mor, Maria K; Cashy, John P; Schaefer, James H; Gordon, Adam J

2017-05-01

Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not access or receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons' avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and nonhomeless veterans with MHSUDs receiving care in the Veterans Health Administration's medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Health Care Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth "homeless") were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 veterans with MHSUDs (9.2% homeless). Compared with their nonhomeless counterparts, homeless veterans were younger, more likely to be non-Hispanic Black and nonmarried, had less education, and were more likely to live in urban areas. Homeless veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than nonhomeless veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Evaluating the Implementation of Home-Based Videoconferencing for Providing Mental Health Services.

PubMed

Interian, Alejandro; King, Arlene R; St Hill, Lauren M; Robinson, Claire H; Damschroder, Laura J

2018-01-01

The Veterans Health Administration (VHA) has recently implemented video-to-home (V2H) telehealth as part of a strategy to improve access to mental health treatment. Implementation research of this modality is needed, given that V2H telehealth transforms the traditional face-to-face delivery of mental health services. To address this need, V2H implementation was evaluated by examining barriers and facilitators that were associated with level of staff V2H experience and factors that differentiated facilities with various levels of V2H performance. Semistructured interviews with VHA personnel (N=33) from three facilities were conducted. The facilities were selected by overall number of mental health V2H visits during fiscal year (FY) 2015 as well as by growth in number of visits from FY 2014 through FY 2015. Factors influencing implementation were identified through qualitative analyses that contrasted responses by groups of participants with three different levels of V2H experience (no experience, limited experience, most experience) as well as three facilities that differed in V2H productivity (high visit count, high visit growth, and low visit count and low visit growth). Providers seemed to encounter different barriers and facilitators depending on their level of experience with V2H. Site-level analyses illustrated the importance of logistical support, especially for providers who are newly adopting the technology. Other factors that differentiated the facilities were also identified and described. Key factors related to implementation of V2H telehealth pertained to provider buy-in and logistical support. Facility-level strategies that address these factors may enhance provider progression from nonuse to sustained use.

Nurse practitioner and physician assistant scope of practice in 118 acute care hospitals.

PubMed

Kartha, Anand; Restuccia, Joseph D; Burgess, James F; Benzer, Justin; Glasgow, Justin; Hockenberry, Jason; Mohr, David C; Kaboli, Peter J

2014-10-01

Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs) are cost-effective substitutes for physicians, with similar outcomes in primary care and surgery. However, little is understood about APP roles in inpatient medicine. Describe APPs role in inpatient medicine. Observational cross-sectional cohort study. One hundred twenty-four Veterans Health Administration (VHA) hospitals. Chiefs of medicine (COMs) and nurse managers. Surveys included inpatient medicine scope of practice for APPs and perceived healthcare quality. We conducted bivariate unadjusted and multivariable adjusted analyses. One hundred eighteen COMs (95.2%) and 198 nurse managers (75.0%) completed surveys. Of 118 medicine services, 56 (47.5%) employed APPs; 27 (48.2%) used NPs only, 15 (26.8%) PAs only, and 14 (25.0%) used both. Full-time equivalents for NPs was 0.5 to 7 (mean = 2.22) and PAs was 1 to 9 (mean = 2.23). Daily caseload was similar at 4 to 10 patients (mean = 6.5 patients). There were few significant differences between tasks. The presence of APPs was not associated with patient or nurse manager satisfaction. Presence of NPs was associated with greater overall inpatient and discharge coordination ratings by COMs and nurse managers, respectively; the presence of PAs was associated with lower overall inpatient coordination ratings by nurse managers. NPs and PAs work on half of VHA inpatient medicine services with broad, yet similar, scopes of practice. There were few differences between their roles and perceptions of care. Given their very different background, regulation, and reimbursement, this has implications for inpatient medicine services that plan to hire NPs or PAs. © 2014 Society of Hospital Medicine.

Health Correlates of Criminal Justice Involvement in 4,793 Transgender Veterans.

PubMed

Brown, George R; Jones, Kenneth T

2015-12-01

Transgender (TG) persons are overrepresented in prison settings and in the U.S. veteran population. Health disparities studies of large populations of transgender people involved with the criminal justice system have not been published to date. We studied a large cohort of TG veterans who received care in Veterans Health Administration (VHA) facilities during 2007-2013 (n = 4,793) and a 3:1 matched control group of veterans without known TG identification (n = 13,625). Three hundred twenty six (n = 138 TG, 188 non-TG) had received VHA services in programs designed to address the needs of justice involved (JI) veterans. We linked patients in each of the three groups to their medical and administrative data. TG veterans were more likely to be justice involved than controls (2.88% vs. 1.38%; P < .0001). Compared to non-TG JI veterans, TG JI veterans were more likely to have a history of homelessness (80% vs. 67%; P < .05) and to have reported sexual trauma while serving in the military (23% vs. 12%; P < .01). Significant health disparities were noted for TG JI veterans for depression, hypertension, obesity, posttraumatic stress disorder, serious mental illness, and suicidal ideation/attempts. These data suggest that TG veterans experience a number of health risks compared to non-TG veterans, including an increased likelihood of justice involvement. TG veterans involved with the criminal justice system are a particularly vulnerable group and services designed to address the health care needs of this population, both while incarcerated and when in the community, should take these findings into account in the development of health screenings and treatment plans.

Veterans' voices: use of the American Customer Satisfaction Index (ACSI) Survey to identify My HealtheVet personal health record users' characteristics, needs, and preferences.

PubMed

Nazi, Kim M

2010-01-01

Consumer research reveals considerable interest in the use of Personal Health Records (PHRs), yet adoption remains relatively low. Both adopters and nonadopters represent important perspectives from which to understand this paradox. This study focuses on direct feedback from adopters obtained using the American Customer Satisfaction Index (ACSI) survey on the My HealtheVet PHR portal (http://www.myhealth.va.gov) of the Veterans Health Administration (VHA). The results represent a source of direct feedback with which to better understand veterans' needs and preferences. The ACSI Survey was implemented in October 2007 to measure satisfaction and elicit information about characteristics and preferences of My HealtheVet PHR adopters. The data represent a continuous random sample of site visitors who have navigated at least four pages on the site. A total of 100 617 surveys were completed (17.2%). Satisfaction with My HealtheVet is high (8.3/10.0), and users are highly likely to return to the site (8.6/10.0) and recommend the site to other veterans (9.1/10.0). The majority of system adopters are male (91%), between the ages of 51 and 70 (68%), and served in the Vietnam War (60%). Most veterans currently visit the site to utilize pharmacy-related features. VHA has used the ACSI to monitor satisfaction, and to better understand the characteristics, needs, and preferences of early adopters. The data provide an important source of direct feedback to inform program development. Future research will include monitoring the impact of enhancements and new features on satisfaction, and conducting additional research with nonadopters to identify barriers to adoption and use.

Cataract surgery practices in the United States Veterans Health Administration.

PubMed

Havnaer, Annika G; Greenberg, Paul B; Cockerham, Glenn C; Clark, Melissa A; Chomsky, Amy

2017-04-01

To describe current cataract surgery practices within the United States Veterans Health Administration (VHA). Veterans Health Administration hospitals in the U.S. Retrospective data analysis. An initial e-mail containing a link to an anonymous 32-question survey of cataract surgery practices was sent to participants in May 2016. Two reminder e-mails were sent to nonresponders 1 week and 2 weeks after the initial survey was sent; the remaining nonresponders were called twice over a 2-week period. The data were analyzed using descriptive statistics. The response rate was 75% (67/89). Cataract surgeons routinely ordered preoperative testing in 29 (45%) of 65 sections and preoperative consultations in 26 (39%) of 66 sections. In 22 (33%) of 66 sections, cataract surgeons administered intracameral antibiotics. In 61 (92%) of 66 sections, cataract surgeons used toric intraocular lenses (IOLs). In 20 (30%) of 66 sections, cataract surgeons used multifocal IOLs. Cataract surgeons in 6 (9%) of 66 sections performed femtosecond laser-assisted cataract surgery. In 6 (9%) of 66 sections, cataract surgeons performed immediate sequential bilateral cataract surgery. Forty-nine (74%) ophthalmology chiefs reported a high level of satisfaction with Veterans Affairs ophthalmology. The survey results indicate that in cataract surgery in the VHA, routine preoperative testing is commonly performed and emerging practices, such as femtosecond laser-assisted cataract surgery and immediate sequential bilateral cataract surgery, have limited roles. The results of this survey could benchmark future trends in U.S. cataract surgery practices, especially in teaching hospital settings. Copyright © 2017 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.

Technology Use and Interest in Computerized Psychotherapy: A Survey of Veterans in Treatment for Substance Use Disorders.

PubMed

Hermes, Eric D A; Tsai, Jack; Rosenheck, Robert

2015-09-01

This study examined interest in computerized psychotherapies (CPTs) and its relation to use of information technology among individuals receiving Veterans Health Administration (VHA) outpatient treatment. Veterans receiving treatment in a VHA substance use disorder outpatient clinic completed a self-report questionnaire. The survey addressed recent experience using information technology and potential interest in using CPTs for symptoms/functional problems associated with substance use and mental health disorders. Demographic, diagnostic, and information technology use data were compared between those expressing interest in CPT and those not expressing an interest, as well as with nationally representative veteran data from the 2010 National Survey of Veterans (NSV). Of 151 respondents, 82% were interested in CPT for at least one problem, and 60% were interested for more than one. The most commonly selected CPTs were for substance use (46%), depression (45%), problem solving (43%), and insomnia (42%). None of the 23 measures of information technology use was associated with interest in CPTs. Compared with respondents not interested in any CPTs, those interested in CPT were older (t150=2.1, p=0.042) and more likely to be African American [χ(2)(1)=8.8, p=0.032], to have reported a drug use disorder [χ(2)(1)=4.2, p=0.041], and to have reported more than one substance use or psychiatric disorder [χ(2)(1)=8.5, p=0.014]. The majority of respondents reported use of Internet and e-mail (65% and 64%, respectively), proportions comparable to respondents to the NSV. Among veterans receiving outpatient substance use treatment, interest in CPT is high and unrelated to information technology use. Efforts to implement CPTs may interest this population.

Strong Ion Regulatory Abilities Enable the Crab Xenograpsus testudinatus to Inhabit Highly Acidified Marine Vent Systems

PubMed Central

Hu, Marian Y.; Guh, Ying-Jey; Shao, Yi-Ta; Kuan, Pou-Long; Chen, Guan-Lin; Lee, Jay-Ron; Jeng, Ming-Shiou; Tseng, Yung-Che

2016-01-01

Hydrothermal vent organisms have evolved physiological adaptations to cope with extreme abiotic conditions including temperature and pH. To date, acid-base regulatory abilities of vent organisms are poorly investigated, although this physiological feature is essential for survival in low pH environments. We report the acid-base regulatory mechanisms of a hydrothermal vent crab, Xenograpsus testudinatus, endemic to highly acidic shallow-water vent habitats with average environment pH-values ranging between 5.4 and 6.6. Within a few hours, X. testudinatus restores extracellular pH (pHe) in response to environmental acidification of pH 6.5 (1.78 kPa pCO2) accompanied by an increase in blood HCO3- levels from 8.8 ± 0.3 to 31 ± 6 mM. Branchial Na+/K+-ATPase (NKA) and V-type H+-ATPase (VHA), the major ion pumps involved in branchial acid-base regulation, showed dynamic increases in response to acidified conditions on the mRNA, protein and activity level. Immunohistochemical analyses demonstrate the presence of NKA in basolateral membranes, whereas the VHA is predominantly localized in cytoplasmic vesicles of branchial epithelial- and pillar-cells. X. testudinatus is closely related to other strong osmo-regulating brachyurans, which is also reflected in the phylogeny of the NKA. Accordingly, our results suggest that the evolution of strong ion regulatory abilities in brachyuran crabs that allowed the occupation of ecological niches in euryhaline, freshwater, and terrestrial habitats are probably also linked to substantial acid-base regulatory abilities. This physiological trait allowed X. testudinatus to successfully inhabit one of the world's most acidic marine environments. PMID:26869933

Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study

PubMed Central

Saitz, Richard; Ganoczy, Dara; Ilgen, Mark A; Bohnert, Amy S B

2015-01-01

Objective To study the association between benzodiazepine prescribing patterns including dose, type, and dosing schedule and the risk of death from drug overdose among US veterans receiving opioid analgesics. Design Case-cohort study. Setting Veterans Health Administration (VHA), 2004-09. Participants US veterans, primarily male, who received opioid analgesics in 2004-09. All veterans who died from a drug overdose (n=2400) while receiving opioid analgesics and a random sample of veterans (n=420 386) who received VHA medical services and opioid analgesics. Main outcome measure Death from drug overdose, defined as any intentional, unintentional, or indeterminate death from poisoning caused by any drug, determined by information on cause of death from the National Death Index. Results During the study period 27% (n=112 069) of veterans who received opioid analgesics also received benzodiazepines. About half of the deaths from drug overdose (n=1185) occurred when veterans were concurrently prescribed benzodiazepines and opioids. Risk of death from drug overdose increased with history of benzodiazepine prescription: adjusted hazard ratios were 2.33 (95% confidence interval 2.05 to 2.64) for former prescriptions versus no prescription and 3.86 (3.49 to 4.26) for current prescriptions versus no prescription. Risk of death from drug overdose increased as daily benzodiazepine dose increased. Compared with clonazepam, temazepam was associated with a decreased risk of death from drug overdose (0.63, 0.48 to 0.82). Benzodiazepine dosing schedule was not associated with risk of death from drug overdose. Conclusions Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death from drug overdose in a dose-response fashion. PMID:26063215

Veterans' voices: use of the American Customer Satisfaction Index (ACSI) Survey to identify My HealtheVet personal health record users' characteristics, needs, and preferences

PubMed Central

2010-01-01

Background Consumer research reveals considerable interest in the use of Personal Health Records (PHRs), yet adoption remains relatively low. Both adopters and nonadopters represent important perspectives from which to understand this paradox. Objective This study focuses on direct feedback from adopters obtained using the American Customer Satisfaction Index (ACSI) survey on the My HealtheVet PHR portal (http://www.myhealth.va.gov) of the Veterans Health Administration (VHA). The results represent a source of direct feedback with which to better understand veterans' needs and preferences. Methods The ACSI Survey was implemented in October 2007 to measure satisfaction and elicit information about characteristics and preferences of My HealtheVet PHR adopters. The data represent a continuous random sample of site visitors who have navigated at least four pages on the site. A total of 100 617 surveys were completed (17.2%). Results Satisfaction with My HealtheVet is high (8.3/10.0), and users are highly likely to return to the site (8.6/10.0) and recommend the site to other veterans (9.1/10.0). The majority of system adopters are male (91%), between the ages of 51 and 70 (68%), and served in the Vietnam War (60%). Most veterans currently visit the site to utilize pharmacy-related features. Conclusion VHA has used the ACSI to monitor satisfaction, and to better understand the characteristics, needs, and preferences of early adopters. The data provide an important source of direct feedback to inform program development. Future research will include monitoring the impact of enhancements and new features on satisfaction, and conducting additional research with nonadopters to identify barriers to adoption and use. PMID:20190065

How Has Saddam Hussein Survived? Economic Sanctions, 1990-1993

DTIC Science & Technology

1993-08-01

Christy Campbell and Adrian Porter of the Lonmon Sunday Telegraph, Washington Times, 16 March 1992. The issue of who is counterfeiting Iraqi money ...ItkdIi k ( i . I ! T i ’it I ’’ I t\\IIIý, I ), I 11 1 11 r 11 111 i 1 111 1 11 t h~lVHA l uv im lt N \\ iA r~ wA W~lild lt l ’ III\\ ’ I lit’ IN l not...8217 charging high prices at the same time the government increases wages (especially to the military) which it can pay for only by printing money . 30. 1999

Patient-Centered Medical Home Implementation in the Veterans Health Administration and Primary Care Use: Differences by Patient Comorbidity Burden.

PubMed

Wong, Edwin S; Rosland, Ann-Marie; Fihn, Stephan D; Nelson, Karin M

2016-12-01

The patient-centered medical home (PCMH) model has several components to improve care for patients with high comorbidity, including greater access to face-to-face primary care. We examined whether high-comorbidity patients had larger increases in primary care provider (PCP) visits attributable to PCMH implementation in a large integrated health system relative to other patients enrolled in primary care. This longitudinal study examined a 1 % random sample of 9.3 million patients enrolled in the Veterans Health Administration (VHA) at any time between 2003 and 2013. Face-to-face visits with PCPs per quarter were identified through VHA administrative data. Comorbidity was measured using the Gagne index and patients with a weighted score of ≥ 2 were defined as high comorbidity. We applied interrupted time-series models to estimate marginal changes in PCP visits attributable to PCMH implementation. Differences in marginal changes were calculated across comorbidity groups (high vs. low). Analyses were stratified by age group to account for Medicare eligibility. Among age 65+ patients, PCMH was associated with greater PCP visits starting four and ten quarters following implementation for high- and low-comorbidity patients, respectively. Changes were larger for high-comorbidity patients (eight to 11 greater visits per 1000 patients per quarter). Among patients age < 65, PCMH was associated with greater visits for high-comorbidity patients starting eight quarters following implementation, but fewer visits for low-comorbidity patients in all quarters. The difference in visit changes across groups ranged from 18 to 67 visits per 1000 patients per quarter. Increases in PCP visits attributable to PCMH were greater among patients with higher comorbidity. Health systems implementing PCMH should account for population-level comorbidity burden when planning for PCMH-related changes in PCP utilization.

Central implementation strategies outperform local ones in improving HIV testing in Veterans Healthcare Administration facilities.

PubMed

Goetz, Matthew Bidwell; Hoang, Tuyen; Knapp, Herschel; Burgess, Jane; Fletcher, Michael D; Gifford, Allen L; Asch, Steven M

2013-10-01

Pilot data suggest that a multifaceted approach may increase HIV testing rates, but the scalability of this approach and the level of support needed for successful implementation remain unknown. To evaluate the effectiveness of a scaled-up multi-component intervention in increasing the rate of risk-based and routine HIV diagnostic testing in primary care clinics and the impact of differing levels of program support. Three arm, quasi-experimental implementation research study. Veterans Health Administration (VHA) facilities. Persons receiving primary care between June 2009 and September 2011 INTERVENTION: A multimodal program, including a real-time electronic clinical reminder to facilitate HIV testing, provider feedback reports and provider education, was implemented in Central and Local Arm Sites; sites in the Central Arm also received ongoing programmatic support. Control Arm sites had no intervention Frequency of performing HIV testing during the 6 months before and after implementation of a risk-based clinical reminder (phase I) or routine clinical reminder (phase II). The adjusted rate of risk-based testing increased by 0.4 %, 5.6 % and 10.1 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). During phase II, the adjusted rate of routine testing increased by 1.1 %, 6.3 % and 9.2 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). At study end, 70-80 % of patients had been offered an HIV test. Use of clinical reminders, provider feedback, education and social marketing significantly increased the frequency at which HIV testing is offered and performed in VHA facilities. These findings support a multimodal approach toward achieving the goal of having every American know their HIV status as a matter of routine clinical practice.

National epidemiology of initial and recurrent Clostridium difficile infection in the Veterans Health Administration from 2003 to 2014.

PubMed

Reveles, Kelly R; Lawson, Kenneth A; Mortensen, Eric M; Pugh, Mary Jo V; Koeller, Jim M; Argamany, Jacqueline R; Frei, Christopher R

2017-01-01

Prior studies demonstrated marked increases in Clostridium difficile infection (CDI) in the United States (U.S.) in recent years. The objective of this study was to describe the epidemiology of initial and recurrent CDI in a national Veterans Health Administration (VHA) cohort over a 12-year period. This was a retrospective cohort study of all adult VHA beneficiaries with CDI (ICD-9-CM code 008.45) plus a positive CDI stool test between October 1, 2002 and September 30, 2014. Data were obtained from the VA Informatics and Computing Infrastructure. Recurrence was defined as a second ICD-9-CM code plus a new course of CDI therapy following a minimum three-day gap after the initial therapy was completed. CDI incidence and outcomes were presented descriptively and longitudinally. Overall, 30,326 patients met study inclusion criteria. CDI incidence increased from FY 2003 (1.6 per 10,000) to FY 2013 (5.1 per 10,000). Thereafter, CDI incidence decreased through FY 2014 (4.6 per 10,000). A total of 5,011 patients (17%) experienced a first recurrence and, of those, 1,713 (34%) experienced a second recurrence. Recurrence incidence increased 10-fold over the study period, from (0.1 per 10,000) in FY 2003, to (1.0 per 10,000) in FY 2014. Overall, 30-day mortality and median hospital length of stay (LOS) decreased among initial episodes over the study period. Mortality was higher for initial episodes (21%) compared to first recurrences (11%) and second recurrences (7%). Median hospital LOS was longer for first episodes (13 days) compared to first (9 days) and second recurrences (8 days). Initial and recurrent CDI episodes increased among veterans over a 12-year period. Outcomes, such as mortality and hospital LOS improved in recent years; both of these outcomes are worse for initial CDI episodes than recurrent episodes.

Teamwork and delegation in medical homes: primary care staff perspectives in the Veterans Health Administration.

PubMed

True, Gala; Stewart, Greg L; Lampman, Michelle; Pelak, Mary; Solimeo, Samantha L

2014-07-01

The patient-centered medical home (PCMH) relies on a team approach to patient care. For organizations engaged in transitioning to a PCMH model, identifying and providing the resources needed to promote team functioning is essential. To describe team-level resources required to support PCMH team functioning within the Veterans Health Administration (VHA), and provide insight into how the presence or absence of these resources facilitates or impedes within-team delegation. Semi-structured interviews with members of pilot teams engaged in PCMH implementation in 77 primary care clinics serving over 300,000 patients across two VHA regions covering the Mid-Atlantic and Midwest United States. A purposive sample of 101 core members of pilot teams, including 32 primary care providers, 42 registered nurse care managers, 15 clinical associates, and 12 clerical associates. Investigators from two evaluation sites interviewed frontline primary care staff separately, and then collaborated on joint analysis of parallel data to develop a broad, comprehensive understanding of global themes impacting team functioning and within-team delegation. We describe four themes key to understanding how resources at the team level supported ability of primary care staff to work as effective, engaged teams. Team-based task delegation was facilitated by demarcated boundaries and collective identity; shared goals and sense of purpose; mature and open communication characterized by psychological safety; and ongoing, intentional role negotiation. Our findings provide a framework for organizations to identify assets already in place to support team functioning, as well as areas in need of improvement. For teams struggling to make practice changes, our results indicate key areas where they may benefit from future support. In addition, this research sheds light on how variation in medical home implementation and outcomes may be associated with variation in team-based task delegation.

Multifaceted academic detailing program to increase pharmacotherapy for alcohol use disorder: interrupted time series evaluation of effectiveness.

PubMed

Harris, Alex H S; Bowe, Thomas; Hagedorn, Hildi; Nevedal, Andrea; Finlay, Andrea K; Gidwani, Risha; Rosen, Craig; Kay, Chad; Christopher, Melissa

2016-09-15

Active consideration of effective medications to treat alcohol use disorder (AUD) is a consensus standard of care, yet knowledge and use of these medications are very low across diverse settings. This study evaluated the overall effectiveness a multifaceted academic detailing program to address this persistent quality problem in the US Veterans Health Administration (VHA), as well as the context and process factors that explained variation in effectiveness across sites. An interrupted time series design, analyzed with mixed-effects segmented logistic regression, was used to evaluate changes in level and rate of change in the monthly percent of patients with a clinically documented AUD who received naltrexone, acamprosate, disulfiram, or topiramate. Using data from a 20 month post-implementation period, intervention sites (n = 37) were compared to their own 16 month pre-implementation performance and separately to the rest of VHA. From immediately pre-intervention to the end of the observation period, the percent of patients in the intervention sites with AUD who received medication increased over 3.4 % in absolute terms and 68 % in relative terms (i.e., 4.9-8.3 %). This change was significant compared to the pre-implementation period in the intervention sites and secular trends in control sites. Sites with lower pre-implementation adoption, more person hours of detailing, but fewer people detailed, had larger immediate increases in medication receipt after implementation. The average number of detailing encounters per person was associated with steeper increases in slope over time. This study found empirical support for a multifaceted quality improvement strategy aimed at increasing access to and utilization of pharmacotherapy for AUD. Future studies should focus on determining how to enhance the programs effects, especially in non-responsive locations.

Patterns of zolpidem use among Iraq and Afghanistan veterans: A retrospective cohort analysis

PubMed Central

Amuan, Megan E.; Jaramillo, Carlos A.; Eapen, Blessen C.

2018-01-01

Background Although concern exists regarding the adverse effects and rate of zolpidem use, especially long-term use, limited information is available concerning patterns of zolpidem use. Objective To examine the prevalence and correlates of zolpidem exposure in Iraq and Afghanistan Veterans (IAVs). Methods A retrospective cohort study of zolpidem prescriptions was performed with National Veterans Health Administration (VHA) data. We gathered national VA inpatient, outpatient, and pharmacy data files for IAV’s who received VA care between fiscal years (FY) 2013 and 2014. The VA pharmacy database was used to identify the prevalence of long term (>30 days), high-dose zolpidem exposure (>10mg immediate-release; >12.5mg extended-release) and other medications received in FY14. Baseline characteristics (demographics, diagnoses) were identified in FY13. Bivariate and multivariable analyses were used to examine the demographic, clinical, and medication correlates of zolpidem use. Results Of 493,683 IAVs who received VHA care in FY 2013 and 2014, 7.6% (n = 37,422) were prescribed zolpidem in FY 2014. Women had lower odds of high-dose zolpidem exposure than men. The majority (77.3%) of IAVs who received zolpidem prescriptions had long-term use with an average days’ supply of 189.3 days and a minority (0.9%) had high-dose exposure. In multivariable analyses, factors associated with long-term zolpidem exposure included age greater than 29 years old, PTSD, insomnia, Selim Index, physical 2–3 conditions, opioids, antidepressants, benzodiazepines, atypical antipsychotics, and stimulants. High dose exposure was associated with PTSD, depression, substance use disorder, insomnia, benzodiazepines, atypical antipsychotics, and stimulant prescriptions. Conclusion The current practices of insomnia pharmacotherapy in IAVs fall short of the clinical guidelines and may reflect high-risk zolpidem prescribing practices that put Iraq and Afghanistan Veterans at risk for adverse effects

Patterns of zolpidem use among Iraq and Afghanistan veterans: A retrospective cohort analysis.

PubMed

Shayegani, Ramona; Song, Kangwon; Amuan, Megan E; Jaramillo, Carlos A; Eapen, Blessen C; Pugh, Mary Jo

2018-01-01

Although concern exists regarding the adverse effects and rate of zolpidem use, especially long-term use, limited information is available concerning patterns of zolpidem use. To examine the prevalence and correlates of zolpidem exposure in Iraq and Afghanistan Veterans (IAVs). A retrospective cohort study of zolpidem prescriptions was performed with National Veterans Health Administration (VHA) data. We gathered national VA inpatient, outpatient, and pharmacy data files for IAV's who received VA care between fiscal years (FY) 2013 and 2014. The VA pharmacy database was used to identify the prevalence of long term (>30 days), high-dose zolpidem exposure (>10mg immediate-release; >12.5mg extended-release) and other medications received in FY14. Baseline characteristics (demographics, diagnoses) were identified in FY13. Bivariate and multivariable analyses were used to examine the demographic, clinical, and medication correlates of zolpidem use. Of 493,683 IAVs who received VHA care in FY 2013 and 2014, 7.6% (n = 37,422) were prescribed zolpidem in FY 2014. Women had lower odds of high-dose zolpidem exposure than men. The majority (77.3%) of IAVs who received zolpidem prescriptions had long-term use with an average days' supply of 189.3 days and a minority (0.9%) had high-dose exposure. In multivariable analyses, factors associated with long-term zolpidem exposure included age greater than 29 years old, PTSD, insomnia, Selim Index, physical 2-3 conditions, opioids, antidepressants, benzodiazepines, atypical antipsychotics, and stimulants. High dose exposure was associated with PTSD, depression, substance use disorder, insomnia, benzodiazepines, atypical antipsychotics, and stimulant prescriptions. The current practices of insomnia pharmacotherapy in IAVs fall short of the clinical guidelines and may reflect high-risk zolpidem prescribing practices that put Iraq and Afghanistan Veterans at risk for adverse effects of zolpidem and poor health outcomes.

Practical Telemedicine for Veterans with Persistently Poor Diabetes Control: A Randomized Pilot Trial.

PubMed

Crowley, Matthew J; Edelman, David; McAndrew, Ann T; Kistler, Susan; Danus, Susanne; Webb, Jason A; Zanga, Joseph; Sanders, Linda L; Coffman, Cynthia J; Jackson, George L; Bosworth, Hayden B

2016-05-01

Telemedicine-based diabetes management improves outcomes versus clinic care but is seldom implemented by healthcare systems. In order to advance telemedicine-based management as a practical option for veterans with persistent poorly controlled diabetes mellitus (PPDM) despite clinic-based care, we evaluated a comprehensive telemedicine intervention that we specifically designed for delivery using existing Veterans Health Administration (VHA) clinical staffing and equipment. We conducted a 6-month randomized trial among 50 veterans with PPDM; all maintained hemoglobin A1c (HbA1c) levels continuously >9.0% for >1 year despite clinic-based management. Participants received usual care or a telemedicine intervention combining telemonitoring, medication management, self-management support, and depression management; existing VHA clinical staff delivered the intervention. Using linear mixed models, we examined HbA1c, diabetes self-care (measured by the Self-Care Inventory-Revised questionnaire), depression, and blood pressure. At baseline, the model-estimated common HbA1c intercept was 10.5%. By 6 months, estimated HbA1c had improved by 1.3% for intervention participants and 0.3% for usual care (estimated difference, -1.0%, 95% confidence interval [CI], -2.0%, 0.0%; p = 0.050). Intervention participants' diabetes self-care (estimated difference, 7.0; 95% CI, 0.1, 14.0; p = 0.047), systolic blood pressure (-7.7 mm Hg; 95% CI, -14.8, -0.6; p = 0.035), and diastolic blood pressure (-5.6 mm Hg; 95% CI, -9.9, -1.2; p = 0.013) were improved versus usual care by 6 months. Depressive symptoms were similar between groups. A comprehensive telemedicine intervention improved outcomes among veterans with PPDM despite clinic-based care. Because we specifically designed this intervention with scalability in mind, it may represent a practical, real-world strategy to reduce the burden of poor diabetes control among veterans.

Restructuring VA ambulatory care and medical education: the PACE model of primary care.

PubMed

Cope, D W; Sherman, S; Robbins, A S

1996-07-01

The Veterans Health Administration (VHA) Western Region and associated medical schools formulated a set of recommendations for an improved ambulatory health care delivery system during a 1988 strategic planning conference. As a result, the Department of Veterans Affairs (VA) Medical Center in Sepulveda, California, initiated the Pilot (now Primary) Ambulatory Care and Education (PACE) program in 1990 to implement and evaluate a model program. The PACE program represents a significant departure from traditional VA and non-VA academic medical center care, shifting the focus of care from the inpatient to the outpatient setting. From its inception, the PACE program has used an interdisciplinary team approach with three independent global care firms. Each firm is interdisciplinary in composition, with a matrix management structure that expands role function and empowers team members. Emphasis is on managed primary care, stressing a biopsychosocial approach and cost-effective comprehensive care emphasizing prevention and health maintenance. Information management is provided through a network of personal computers that serve as a front end to the VHA Decentralized Hospital Computer Program (DHCP) mainframe. In addition to providing comprehensive and cost-effective care, the PACE program educates trainees in all health care disciplines, conducts research, and disseminates information about important procedures and outcomes. Undergraduate and graduate trainees from 11 health care disciplines rotate through the PACE program to learn an integrated approach to managed ambulatory care delivery. All trainees are involved in a problem-based approach to learning that emphasizes shared training experiences among health care disciplines. This paper describes the transitional phases of the PACE program (strategic planning, reorganization, and quality improvement) that are relevant for other institutions that are shifting to training programs emphasizing primary and ambulatory care.

HIV quality report cards: impact of case-mix adjustment and statistical methods.

PubMed

Ohl, Michael E; Richardson, Kelly K; Goto, Michihiko; Vaughan-Sarrazin, Mary; Schweizer, Marin L; Perencevich, Eli N

2014-10-15

There will be increasing pressure to publicly report and rank the performance of healthcare systems on human immunodeficiency virus (HIV) quality measures. To inform discussion of public reporting, we evaluated the influence of case-mix adjustment when ranking individual care systems on the viral control quality measure. We used data from the Veterans Health Administration (VHA) HIV Clinical Case Registry and administrative databases to estimate case-mix adjusted viral control for 91 local systems caring for 12 368 patients. We compared results using 2 adjustment methods, the observed-to-expected estimator and the risk-standardized ratio. Overall, 10 913 patients (88.2%) achieved viral control (viral load ≤400 copies/mL). Prior to case-mix adjustment, system-level viral control ranged from 51% to 100%. Seventeen (19%) systems were labeled as low outliers (performance significantly below the overall mean) and 11 (12%) as high outliers. Adjustment for case mix (patient demographics, comorbidity, CD4 nadir, time on therapy, and income from VHA administrative databases) reduced the number of low outliers by approximately one-third, but results differed by method. The adjustment model had moderate discrimination (c statistic = 0.66), suggesting potential for unadjusted risk when using administrative data to measure case mix. Case-mix adjustment affects rankings of care systems on the viral control quality measure. Given the sensitivity of rankings to selection of case-mix adjustment methods-and potential for unadjusted risk when using variables limited to current administrative databases-the HIV care community should explore optimal methods for case-mix adjustment before moving forward with public reporting. Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.

The facilitators and barriers associated with implementation of a patient-centered medical home in VHA.

PubMed

Helfrich, Christian D; Sylling, Philip W; Gale, Randall C; Mohr, David C; Stockdale, Susan E; Joos, Sandra; Brown, Elizabeth J; Grembowski, David; Asch, Steven M; Fihn, Stephan D; Nelson, Karin M; Meredith, Lisa S

2016-02-24

The patient-centered medical home (PCMH) is a team-based, comprehensive model of primary care. When effectively implemented, PCMH is associated with higher patient satisfaction, lower staff burnout, and lower hospitalization for ambulatory care-sensitive conditions. However, less is known about what factors contribute to (or hinder) PCMH implementation. We explored the associations of specific facilitators and barriers reported by primary care employees with a previously validated, clinic-level measure of PCMH implementation, the Patient Aligned Care Team Implementation Progress Index (Pi(2)). We used a 2012 survey of primary care employees in the Veterans Health Administration to perform cross-sectional, respondent-level multinomial regressions. The dependent variable was the Pi(2) categorized as high implementation (top decile, 54 clinics, 235 respondents), medium implementation (middle eight deciles, 547 clinics, 4537 respondents), and low implementation (lowest decile, 42 clinics, 297 respondents) among primary care clinics. The independent variables were ordinal survey items rating 19 barriers to patient-centered care and 10 facilitators of PCMH implementation. For facilitators, we explored clinic Pi(2) score decile both as a function of respondent-reported availability of facilitators and of rating of facilitator helpfulness. The availability of five facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile: teamlet huddles (OR = 3.91), measurement tools (OR = 3.47), regular team meetings (OR = 2.88), information systems (OR = 2.42), and disease registries (OR = 2.01). The helpfulness of four facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile. Six barriers were associated with significantly higher odds of a respondent's clinic's Pi(2) scores being in the lowest versus highest decile, with the strongest associations for the difficulty recruiting and retaining providers (OR = 2.37) and non-provider clinicians (OR = 2.17). Results for medium versus low Pi(2) score clinics were similar, with fewer, smaller significant associations, all in the expected direction. A number of specific barriers and facilitators were associated with PCMH implementation, notably recruitment and retention of clinicians, team huddles, and local education. These findings can guide future research, and may help healthcare policy makers and leaders decide where to focus attention and limited resources.

A multilevel modelling approach to analysis of patient costs under managed care.

PubMed

Carey, K

2000-07-01

The growth of the managed care model of health care delivery in the USA has led to broadened interest in the performance of health care providers. This paper uses multilevel modelling to analyse the effects of managed care penetration on patient level costs for a sample of 24 medical centres operated by the Veterans Health Administration (VHA). The appropriateness of a two level approach to this problem over ordinary least squares (OLS) is demonstrated. Results indicate a modicum of difference in institutions' performance after controlling for patient effects. Facilities more heavily penetrated by the managed care model may be more effective at controlling costs of their sicker patients. Copyright 2000 John Wiley & Sons, Ltd.

Leveraging Electronic Health Care Record Information to Measure Pressure Ulcer Risk in Veterans With Spinal Cord Injury: A Longitudinal Study Protocol.

PubMed

Luther, Stephen L; Thomason, Susan S; Sabharwal, Sunil; Finch, Dezon K; McCart, James; Toyinbo, Peter; Bouayad, Lina; Matheny, Michael E; Gobbel, Glenn T; Powell-Cope, Gail

2017-01-19

Pressure ulcers (PrUs) are a frequent, serious, and costly complication for veterans with spinal cord injury (SCI). The health care team should periodically identify PrU risk, although there is no tool in the literature that has been found to be reliable, valid, and sensitive enough to assess risk in this vulnerable population. The immediate goal is to develop a risk assessment model that validly estimates the probability of developing a PrU. The long-term goal is to assist veterans with SCI and their providers in preventing PrUs through an automated system of risk assessment integrated into the veteran's electronic health record (EHR). This 5-year longitudinal, retrospective, cohort study targets 12,344 veterans with SCI who were cared for in the Veterans Health Administration (VHA) in fiscal year (FY) 2009 and had no record of a PrU in the prior 12 months. Potential risk factors identified in the literature were reviewed by an expert panel that prioritized factors and determined if these were found in structured data or unstructured form in narrative clinical notes for FY 2009-2013. These data are from the VHA enterprise Corporate Data Warehouse that is derived from the EHR structured (ie, coded in database/table) or narrative (ie, text in clinical notes) data for FY 2009-2013. This study is ongoing and final results are expected in 2017. Thus far, the expert panel reviewed the initial list of risk factors extracted from the literature; the panel recommended additions and omissions and provided insights about the format in which the documentation of the risk factors might exist in the EHR. This list was then iteratively refined through review and discussed with individual experts in the field. The cohort for the study was then identified, and all structured, unstructured, and semistructured data were extracted. Annotation schemas were developed, samples of documents were extracted, and annotations are ongoing. Operational definitions of structured data elements

75 FR 30914 - Proposed Information Collection (Six-Month Post-Exit Focus Interview of Former VHA Employees...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-06-02

... data collected will be used to develop talent management strategies to enhance workforce recruitment... Federal Docket Management System (FDMS) at http://www.Regulations.gov ; or to Mary Stout, Veterans Health...

Fitting parametric random effects models in very large data sets with application to VHA national data

PubMed Central

2012-01-01

Background With the current focus on personalized medicine, patient/subject level inference is often of key interest in translational research. As a result, random effects models (REM) are becoming popular for patient level inference. However, for very large data sets that are characterized by large sample size, it can be difficult to fit REM using commonly available statistical software such as SAS since they require inordinate amounts of computer time and memory allocations beyond what are available preventing model convergence. For example, in a retrospective cohort study of over 800,000 Veterans with type 2 diabetes with longitudinal data over 5 years, fitting REM via generalized linear mixed modeling using currently available standard procedures in SAS (e.g. PROC GLIMMIX) was very difficult and same problems exist in Stata’s gllamm or R’s lme packages. Thus, this study proposes and assesses the performance of a meta regression approach and makes comparison with methods based on sampling of the full data. Data We use both simulated and real data from a national cohort of Veterans with type 2 diabetes (n=890,394) which was created by linking multiple patient and administrative files resulting in a cohort with longitudinal data collected over 5 years. Methods and results The outcome of interest was mean annual HbA1c measured over a 5 years period. Using this outcome, we compared parameter estimates from the proposed random effects meta regression (REMR) with estimates based on simple random sampling and VISN (Veterans Integrated Service Networks) based stratified sampling of the full data. Our results indicate that REMR provides parameter estimates that are less likely to be biased with tighter confidence intervals when the VISN level estimates are homogenous. Conclusion When the interest is to fit REM in repeated measures data with very large sample size, REMR can be used as a good alternative. It leads to reasonable inference for both Gaussian and non-Gaussian responses if parameter estimates are homogeneous across VISNs. PMID:23095325

Language-specific skills in intercultural healthcare communication: Comparing perceived preparedness and skills in nurses' first and second languages.

PubMed

Gasiorek, Jessica; van de Poel, Kris

2018-02-01

Interactions between people from different cultures are becoming increasingly commonplace in contemporary healthcare settings. To date, most research evaluating cross-cultural preparedness has assumed that medical professionals are speaking their first language (L1). However, as healthcare workers are increasingly mobile and patient populations are increasingly diverse, more and more interactions are likely to occur in a professional's non-native language (L2). This study assessed and compared nurses' perceived cross-cultural preparedness and skillfulness in their interactions with patients from other cultures when speaking both their L1 and L2. The goal of this project was to inform the creation of a communication skills training program. Nurses reported their perceived cross-cultural preparedness and skillfulness (scales adapted from Park et al., 2009) in their L1 and L2 via an online questionnaire. This questionnaire was distributed among nurses working in Vienna, Austria, through the Vienna Hospital Association (VHA). Nurses and nurses-in-training working in VHA hospitals participated. Most participants who provided demographic information were currently nurses (n=179) with an average of 16.88years (SD=11.50) of professional experience (range: 0-40); n=40 were nurses-in-training with an average of 2.13years (SD=0.88) of experience (range: 1-5). Descriptive statistics for each cross-cultural preparedness and skillfulness (in each language) are reported; comparisons between L1 and L2 responses were also conducted. Multiple regression analyses were used to identify predictors of preparedness and L1/L2 skillfulness. Nurses reported feeling significantly less confident in their skills when working in an L2, across a range of culture-related issues. Having had previous communication skills training predicted (better) self-reported L2 skillfulness, although it did not predict L1 skillfulness. These results indicate that there is a language-specific component to cross

Health Information Seeking and Technology Use Among Veterans With Spinal Cord Injuries and Disorders.

PubMed

Hogan, Timothy P; Hill, Jennifer N; Locatelli, Sara M; Weaver, Frances M; Thomas, Florian P; Nazi, Kim M; Goldstein, Barry; Smith, Bridget M

2016-02-01

Access to health information is crucial to persons living with a spinal cord injury or disorder (SCI/D). Although previous research has provided insights on computer and Internet use among persons with SCI/D, as well as how and where persons with SCI/D gather health information, few studies have focused on U.S. veterans with SCI/D. To characterize health information seeking among veterans with SCI/D and to examine the association between technology use and the characteristics of veterans with SCI/D. Cross-sectional. Veterans Health Administration (VHA). Sample of 290 veterans with SCI/D who utilize services at 2 VHA SCI/D Centers. Postal mail survey. Extent of computer, Internet, and text messaging use, information source use, and e-Health literacy rates. The survey response rate was 38%. The majority of respondents were male (97.2%), younger than 65 years (71.0%), and white (71.7%). Of the respondents, 64.8% indicated that they use a computer, 62.9% reported use of the Internet, and 26.2% reported use of text messaging. The mean overall e-Health Literacy Scale score was 27.3 (standard deviation = 7.2). Similar to findings reported in studies focused outside the veteran population, the most frequent source that veterans turned to for information about SCI/D was a health professional (85.1%); this was also the most frequent source that veterans indicated they would turn to first to get information about SCI/D (75.9%). Other frequently reported sources of information included other persons with SCI/D (41.0%), Internet resources (31.0%), and family and friends (27.9%). Fairly high levels of computer and Internet use exist among veterans with SCI/D. Veterans with SCI/D also have a strong preference for people-particularly health professionals, and to a lesser extent peers and family and friends-as sources of information about SCI/D. These findings highlight the importance of combining technology and human interaction to meet the information needs of this population

High Temperature Induced Anthocyanin Inhibition and Active Degradation in Malus profusion

PubMed Central

Rehman, Rana Naveed Ur; You, Yaohua; Zhang, Lei; Goudia, Bachir Daoura; Khan, Abdul Rehman; Li, Pengmin; Ma, Fangwang

2017-01-01

The red fleshed fruits of Malus profusion represent gradual color loss during high temperature in summer, potentially due to active degradation of anthocyanin. The objective of this study was to examine both physiological and molecular evidence of anthocyanin degradation. Malus crabapple fruits were exposed to either room temperature (RT = 18 ± 2°C: 25 ± 2°C) or high temperature (HT = 33 ± 2°C: 25 ± 2°C) regimens (12 h: 12 h) under hypoxic (2%) or normoxic (21%) oxygen levels. The results showed that the concentration of cyanidin 3-galactoside (cy-3-gal) was dramatically reduced following HT treatments due to a significant down-regulation of anthocyanin biosynthetic genes (MpCHS, MpDFR, MpLDOX, MpUFGT, and MpMYB10). Among other repressor MYBs, MpMYB15 expression was high following HT treatment of the fruit. HT led to the generation of a substantial concentration of H2O2 due to enhanced activities of superoxide dismutase (SOD), methane dicarboxylic aldehyde (MDA) content and cell sap pH value. Similarly, transcript levels of MpVHA-B1 and MpVHA-B2 were reduced which are involved in the vacuolar transportation of anthocyanin. The enzymatic degradation of anthocyanin was eventually enhanced coupled with the oxidative activities of peroxidase (POD) and H2O2. Conversely, the RT treatments potentially enhanced anthocyanin content by stabilizing physiological attributes (such as MDA, H2O2, and pH, among others) and sustaining sufficient biosynthetic gene expression levels. Quantitative real-time PCR analysis indicated that the transcription of MpPOD1, MpPOD8 and MpPOD9 genes in fruit tissues was up-regulated due to HT treatment and that hypoxic conditions seems more compatible with the responsible POD isoenzymes involved in active anthocyanin degradation. The results of the current study could be useful for understanding as well as elucidating the physiological phenomenon and molecular signaling cascade underlying active anthocyanin degradation in Malus crops. PMID

Rapid HIV testing experience at Veterans Affairs North Texas Health Care System's Homeless Stand Downs.

PubMed

Hooshyar, Dina; Surís, Alina M; Czarnogorski, Maggie; Lepage, James P; Bedimo, Roger; North, Carol S

2014-01-01

In the USA, 21% of the estimated 1.1 million people living with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) are unaware they are HIV-infected. In 2011, Veterans Health Administration (VHA)'s Office of Public Health in conjunction with VHA's Health Care for Homeless Veterans Program funded grants to support rapid HIV testing at homeless outreach events because homeless populations are more likely to obtain emergent rather than preventive care and have a higher HIV seroprevalence as compared to the general population. Because of a Veterans Affairs North Texas Health Care System (VANTHCS)'s laboratory testing requirement, VANTHCS partnered with community agencies to offer rapid HIV testing for the first time at VANTHCS' 2011 Homeless Stand Downs in Dallas, Fort Worth, and Texoma, Texas. Homeless Stand Downs are outreach events that connect Veterans with services. Veterans who declined testing were asked their reasons for declining. Comparisons by Homeless Stand Down site used Pearson χ², substituting Fisher's Exact tests for expected cell sizes <5. Of the 910 Veterans attending the Homeless Stand Downs, 261 Veterans reported reasons for declining HIV testing, and 133 Veterans were tested, where 92% of the tested Veterans obtained their test results at the events - all tested negative. Veterans' reported reasons for declining HIV testing included previous negative result (n=168), no time to test (n=49), no risk factors (n=36), testing is not a priority (n=11), uninterested in knowing serostatus (n=6), and HIV-infected (n=3). Only "no time to test" differed significantly by Homeless Stand Down site. Nonresponse rate was 54%. Offering rapid HIV testing at Homeless Stand Downs is a promising testing venue since 15% of Veterans attending VANTHCS' Homeless Stand Downs were tested for HIV, and majority obtained their HIV test results at point-of-care while further research is needed to determine how to improve these rates.

Federal workers' compensation programs: Department of Defense and Veterans Health Administration experiences.

PubMed

Mallon, Timothy M; Grizzell, Tifani L; Hodgson, Michael J

2015-03-01

The objective of this article is to introduce the reader to this special supplement to the Journal of Occupational and Environmental Medicine regarding Federal Workers' Compensation Programs. The short history of both the VHA and DoD Federal Workers' Compensation Programs are provided and a short synopsis of each author's article is provided. The lessons learned from the articles in the supplement are summarized in this article and 6 key findings are highlighted. Cooperation between human resources workers' compensation personnel, safety and occupational health personnel is a must for successful management of the WC program. Information and data sharing are critical for root cause and injury prevention, case management, and cost containment efforts. Enhancing efforts in these areas will save an estimated $100 million through cost avoidance efforts.

Merging the Military Health System (MHS) and the Veterans Health Administration (VHA) into a Single Governance Structure

DTIC Science & Technology

2008-04-07

3 Testimony of Dr. Michael J. Kussman , Acting Undersecretary for Health, Department of Veterans Affairs, U.S. House of Representatives, Subcommittee...J. Kussman , March 8, 2007. 49 Testimony of the Honorable Patrick W. Dunne, October 17, 2007. 50 U.S. Congressional Budget Office, The Healthcare

Implementing Effective Substance Abuse Treatments in General Medical Settings: Mapping the Research Terrain

PubMed Central

Ducharme, Lori J.; Chandler, Redonna K.; Harris, Alex H. S.

2015-01-01

The National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Drug Abuse (NIDA), and Veterans Health Administration (VHA) share an interest in promoting high quality, rigorous health services research to improve the availability and utilization of evidence-based treatment for substance use disorders (SUD). Recent and continuing changes in the healthcare policy and funding environments prioritize the integration of evidence-based substance abuse treatments into primary care and general medical settings. This area is a prime candidate for implementation research. Recent and ongoing implementation projects funded by these agencies are reviewed. Research in five areas is highlighted: screening and brief intervention for risky drinking; screening and brief intervention for tobacco use; uptake of FDA-approved addiction pharmacotherapies; safe opioid prescribing; and disease management. Gaps in the portfolios, and priorities for future research, are described. PMID:26233697

Modeling veterans healthcare administration disclosure processes :

DOE Office of Scientific and Technical Information (OSTI.GOV)

Beyeler, Walter E; DeMenno, Mercy B.; Finley, Patrick D.

As with other large healthcare organizations, medical adverse events at the Department of Veterans Affairs (VA) facilities can expose patients to unforeseen negative risks. VHA leadership recognizes that properly handled disclosure of adverse events can minimize potential harm to patients and negative consequences for the effective functioning of the organization. The work documented here seeks to help improve the disclosure process by situating it within the broader theoretical framework of issues management, and to identify opportunities for process improvement through modeling disclosure and reactions to disclosure. The computational model will allow a variety of disclosure actions to be tested acrossmore » a range of incident scenarios. Our conceptual model will be refined in collaboration with domain experts, especially by continuing to draw on insights from VA Study of the Communication of Adverse Large-Scale Events (SCALE) project researchers.« less

Implementing Effective Substance Abuse Treatments in General Medical Settings: Mapping the Research Terrain.

PubMed

Ducharme, Lori J; Chandler, Redonna K; Harris, Alex H S

2016-01-01

The National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Drug Abuse (NIDA), and Veterans Health Administration (VHA) share an interest in promoting high quality, rigorous health services research to improve the availability and utilization of evidence-based treatment for substance use disorders (SUD). Recent and continuing changes in the healthcare policy and funding environments prioritize the integration of evidence-based substance abuse treatments into primary care and general medical settings. This area is a prime candidate for implementation research. Recent and ongoing implementation projects funded by these agencies are reviewed. Research in five areas is highlighted: screening and brief intervention for risky drinking; screening and brief intervention for tobacco use; uptake of FDA-approved addiction pharmacotherapies; safe opioid prescribing; and disease management. Gaps in the portfolios, and priorities for future research, are described. Published by Elsevier Inc.

Geographical diffusion of prazosin across Veterans Health Administration: Examination of regional variation in daily dosing and quality indicators among veterans with posttraumatic stress disorder.

PubMed

Abrams, Thad E; Lund, Brian C; Alexander, Bruce; Bernardy, Nancy C; Friedman, Matthew J

2015-01-01

Posttraumatic stress disorder (PTSD) is a high-priority treatment area for the Veterans Health Administration (VHA), and dissemination patterns of innovative, efficacious therapies can inform areas for potential improvement of diffusion efforts and quality prescribing. In this study, we replicated a prior examination of the period prevalence of prazosin use as a function of distance from Puget Sound, Washington, where prazosin was first tested as an effective treatment for PTSD and where prazosin use was previously shown to be much greater than in other parts of the United States. We tested the following three hypotheses related to prazosin geographic diffusion: (1) a positive geographical correlation exists between the distance from Puget Sound and the proportion of users treated according to a guideline recommended minimum therapeutic target dose (>/=6 mg/d), (2) an inverse geographic correlation exists between prazosin and benzodiazepine use, and (3) no geographical correlation exists between prazosin use and serotonin reuptake inhibitor/serotonin norepinephrine reuptake inhibitor (SSRI/SNRI) use. Among a national sample of veterans with PTSD, overall prazosin utilization increased from 5.5 to 14.8% from 2006 to 2012. During this time period, rates at the Puget Sound VHA location declined from 34.4 to 29.9%, whereas utilization rates at locations a minimum of 2,500 miles away increased from 3.0 to 12.8%. Rates of minimum target dosing fell from 42.6 to 34.6% at the Puget Sound location. In contrast, at distances of at least 2,500 miles from Puget Sound, minimum threshold dosing rates remained stable (range, 18.6 to 17.7%). No discernible association was demonstrated between SSRI/SNRI or benzodiazepine utilization and the geographic distance from Puget Sound. Minimal threshold dosing of prazosin correlated positively with increased diffusion of prazosin use, but there was still a distance diffusion gradient. Although prazosin adoption has improved, geographic

A qualitative study of implementation and adaptations to Progressive Tinnitus Management (PTM) delivery.

PubMed

Tuepker, Anaïs; Elnitsky, Christine; Newell, Summer; Zaugg, Tara; Henry, James A

2018-01-01

Tinnitus is a common condition, especially prevalent among military Veterans. Progressive Tinnitus Management (PTM) is an interdisciplinary, structured, stepped-care approach to providing clinical services, including teaching coping skills, to people bothered by tinnitus. PTM has been shown to be effective at reducing functional distress, but implementation of the intervention outside of a research setting has not been studied, even though dissemination is underway within the Veterans Health Administration (VHA) system in the United States. This study was designed to address a gap in knowledge of PTM clinical implementation to date, with a focus on factors facilitating or hindering implementation in VHA audiology and mental health clinic contexts, and whether implementing sites had developed intervention adaptations. Qualitative interviews were conducted with 21 audiology and mental health clinicians and service chiefs across a regional service network. Interviews were transcribed and coded using a hybrid inductive-deductive analytic approach guided by existing implementation research frameworks and then iteratively developed for emergent themes. PTM prioritization was rare overall, with providers across disciplines challenged by lack of capacity for implementation, but with differences by discipline in challenges to prioritization. Where PTM was prioritized and delivered, this was facilitated by perception of unique value, provider's own experience of tinnitus, observation/experience with PTM delivery, intervention fit with provider's skills, and an environment with supportive leadership and adaptive reserve. PTM was frequently adapted to local contexts to address delivery challenges and diversify patient options. Adaptations included shifting from group to individual formats, reducing or combining sessions, and employing novel therapeutic approaches. Existing adaptations highlight the need to better understand mechanisms underlying PTM's effectiveness, and

A two-state comparative implementation of peer-support intervention to link veterans to health-related services after incarceration: a study protocol.

PubMed

Simmons, Molly M; Fincke, Benjamin G; Drainoni, Mari-Lynn; Kim, Bo; Byrne, Tom; Smelson, David; Casey, Kevin; Ellison, Marsha L; Visher, Christy; Blue-Howells, Jessica; McInnes, D Keith

2017-09-12

Approximately 600,000 persons are released from prison annually in the United States. Relatively few receive sufficient re-entry services and are at risk for unemployment, homelessness, poverty, substance abuse relapse and recidivism. Persons leaving prison who have a mental illness and/or a substance use disorder are particularly challenged. This project aims to create a peer mentor program to extend the reach and effectiveness of reentry services provided by the Department of Veterans' Affairs (VA). We will implement a peer support for reentry veterans sequentially in two states. Our outcome measures are 1) fidelity of the intervention, 2) linkage to VA health care and, 3) continued engagement in health care. The aims for this project are as follows: (1) Conduct contextual analysis to identify VA and community reentry resources, and describe how reentry veterans use them. (2) Implement peer-support, in one state, to link reentry veterans to Veterans' Health Administration (VHA) primary care, mental health, and SUD services. (3) Port the peer-support intervention to another, geographically, and contextually different state. This intervention involves a 2-state sequential implementation study (Massachusetts, followed by Pennsylvania) using a Facilitation Implementation strategy. We will conduct formative and summative analyses, including assessment of fidelity, and a matched comparison group to evaluate the intervention's outcomes of veteran linkage and engagement in VHA health care (using health care utilization measures). The study proceeds in 3 phases. We anticipate that a peer support program will be effective at improving the reentry process for veterans, particularly in linking them to health, mental health, and SUD services and helping them to stay engaged in those services. It will fill a gap by providing veterans with access to a trusted individual, who understands their experience as a veteran and who has experienced justice involvement. The outputs from

Advancing patient safety: a framework for accountability and practical action.

PubMed

Wilson, N J; Hatlie, M J

2001-01-01

This article traces the development of the patient safety movement in healthcare from 1997 to the present. It reviews the findings and recommendations in the Institute of Medicine report on medical errors, which issued a call to action. Moving beyond the call to action requires aligning incentives, in both public and private sectors, consistent with complexity theory and the tenets of a systems approach to the reliable delivery of service in dynamic environments in which failure produces severe consequences. Because safety is a fundamental value of healthcare and has money-saving potential, it can be a powerful pathway forcultural change. Thisarticle explains a simple framework that requires alignment among stakeholder groups and communities. It recommends a practical problem-solving approach and explores the roles and responsibilities of each segment within the framework. Finally, it describes a VHA Inc. leadership initiative, based on the framework, to promote change within healthcare systems.

Molecular basis of the allelic inheritance of rabbit immunoglobulin VH allotypes: implications for the generation of antibody diversity.

PubMed

Knight, K L; Becker, R S

1990-03-23

Rabbits are unique in that their immunoglobulin VH regions bear allotypic markers encoded by allelic genes. The presence of these markers on most serum immunoglobulins is difficult to explain, as the germline contains several hundred VH genes. We cloned VH genes from normal rabbits of the VHa allotypes a1, a2, and a3 and from a mutant a2 rabbit, Alicia, which expresses almost no a2 allotype. The D-proximal VH gene VH1 of normal rabbits encoded prototype a1, a2, or a3 allotype VH regions in a1, a2, or a3 rabbits, respectively; VH1 was shown to be preferentially utilized in leukemic rabbit B cells. This VH1 gene was deleted from the germline of the Alicia rabbit. These data suggest that the allelic inheritance of a allotypes results from preferential utilization of VH1 in VDJ rearrangements. We suggest that antibody diversity in rabbit primarily results from somatic hypermutation and gene conversion.

Implementation evaluation of the Telephone Lifestyle Coaching (TLC) program: organizational factors associated with successful implementation.

PubMed

Damschroder, Laura J; Reardon, Caitlin M; Sperber, Nina; Robinson, Claire H; Fickel, Jacqueline J; Oddone, Eugene Z

2017-06-01

The Telephone Lifestyle Coaching (TLC) program provided telephone-based coaching for six lifestyle behaviors to 5321 Veterans at 24 Veterans Health Administration (VHA) medical facilities. The purpose of the study was to conduct an evaluation of the TLC program to identify factors associated with successful implementation. A mixed-methods study design was used. Quantitative measures of organizational readiness for implementation and facility complexity were used to purposively select a subset of facilities for in-depth evaluation. Context assessments were conducted using interview transcripts. The Consolidated Framework for Implementation Research (CFIR) was used to guide qualitative data collection and analysis. Factors most strongly correlated with referral rates included having a skilled implementation leader who used effective multi-component strategies to engage primary care clinicians as well as general clinic structures that supported implementation. Evaluation findings pointed to recommendations for local and national leaders to help anticipate and mitigate potential barriers to successful implementation.

The V0-ATPase mediates apical secretion of exosomes containing Hedgehog-related proteins in Caenorhabditis elegans

PubMed Central

Liégeois, Samuel; Benedetto, Alexandre; Garnier, Jean-Marie; Schwab, Yannick; Labouesse, Michel

2006-01-01

Polarized intracellular trafficking in epithelia is critical in development, immunity, and physiology to deliver morphogens, defensins, or ion pumps to the appropriate membrane domain. The mechanisms that control apical trafficking remain poorly defined. Using Caenorhabditis elegans, we characterize a novel apical secretion pathway involving multivesicularbodies and the release of exosomes at the apical plasma membrane. By means of two different genetic approaches, we show that the membrane-bound V0 sector of the vacuolar H+-ATPase (V-ATPase) acts in this pathway, independent of its contribution to the V-ATPase proton pump activity. Specifically, we identified mutations in the V0 “a” subunit VHA-5 that affect either the V0-specific function or the V0+V1 function of the V-ATPase. These mutations allowed us to establish that the V0 sector mediates secretion of Hedgehog-related proteins. Our data raise the possibility that the V0 sector mediates exosome and morphogen release in mammals. PMID:16785323

A chemical model for lunar non-mare rocks

NASA Technical Reports Server (NTRS)

Hubbard, N. J.; Rhodes, J. M.

1977-01-01

Nearly all rocks returned from the moon are readily divided into three broad categories on the basis of their chemical compositions: (1) mare basalts, (2) non-mare rocks of basaltic composition (KREEP, VHA), and (3) anorthositic rocks. Only mare basalts may unambiguously be considered to have original igneous textures and are widely understood to have an igneous origin. Nearly all other lunar rocks have lost their original textures during metamorphic and impact processes. For these rocks one must work primarily with chemical data in order to recognize and define rock groups and their possible modes of origin. Non-mare rocks of basaltic composition have chemical compositions consistent with an origin by partial melting of the lunar interior. The simplest origin for rocks of anorthositic chemical composition is the crystallization and removal of ferromagnesian minerals. It is proposed that the rock groups of anorthositic and non-mare basaltic chemical composition could have been generated from a single series of original, but not necessarily primitive, lunar materials.

Theodicies and professional quality of life in a nationally representative sample of chaplains in the veterans' health administration.

PubMed

Currier, Joseph M; Drescher, Kent D; Nieuwsma, Jason A; McCormick, Wesley H

2017-01-01

This study examined the role of theodicies or theological/philosophic attempts to resolve existential dilemmas related to evil and human suffering in chaplains' professional quality of life (ProQOL). A nationally representative sample of 298 VHA chaplains completed the recently developed Views of Suffering Scale (Hale-Smith, Park, & Edmondson, 2012 ) and ProQOL-5 (Stamm, 2010 ). Descriptive results revealed that 20-50% endorsed strong theistic beliefs in a compassionate deity who reciprocally suffers with hurting people, God ultimately being responsible for suffering, and that suffering can provide opportunities for intimate encounters with God and personal growth. Other results indicated that chaplains' beliefs about human suffering were differentially linked with their sense of enjoyment/purpose in working with veterans. These results suggest that theodicies might serve as a pathway to resilience for individuals in spiritual communities and traditions in USA, particularly for clinicians and ministry professionals who are committed to serving the needs of traumatized persons.

Reversal of overdose on fentanyl being illicitly sold as heroin with naloxone nasal spray: A case report.

PubMed

Fareed, Ayman; Buchanan-Cummings, Ann Marie; Crampton, Kelli; Grant, Angela; Drexler, Karen

2015-08-01

This is a case report describing a reversal of fentanyl overdose with naloxone nasal spray. The patient was not aware that he overdosed on fentanyl being sold as heroin. The Veterans Health Administration (VHA) has implemented an initiative to provide education for veterans, their families, friends and significant others about opioid overdose and use of naloxone reversal kits. The Atlanta VA Medical Center adopted this program to reduce the risk of opioid overdose in high risk patients. Over the past year, we provided educational sessions for 63 veterans and their families. We also prescribed 41 naloxone kits. We have received three reports of opioid overdose reversal with use of naloxone kits prescribed by the Atlanta VA Medical Center. The authors recommend that public health administrators and policy makers advocate for the implementation of these programs to reduce the rising number of overdose death in the United States and worldwide. © American Academy of Addiction Psychiatry.

Factors associated with receipt of pension and compensation benefits for homeless veterans in the VBA/VHA Homeless Outreach Initiative.

PubMed

Chen, Joyce H; Rosenheck, Robert A; Greenberg, Greg A; Seibyl, Catherine

2007-03-01

Public support payments may facilitate exit from homelessness for persons with mental illness. We examined data from 10,641 homeless veterans contacted from October 1, 1995 to September 30, 2002 in a collaborative outreach program designed to facilitate access to Department of Veterans Affairs (VA) disability benefits. Those who were awarded benefits (22% of contacted veterans) were more likely to report disability, poor to fair self-rated health, and were more likely to have used VA services in the past. Thus, this program achieved only modest success and was most successful with veterans who were already receiving VA services and who might have received benefits even without the outreach effort.

Drugs and falls in community-dwelling older people: a national veterans study.

PubMed

French, Dustin D; Campbell, Robert; Spehar, Andrea; Cunningham, Francesca; Bulat, Tatjana; Luther, Stephen L

2006-04-01

The aim of this study was to identify which specific medications within recognized major problematic drug categories that increase risk of falling were prescribed to veterans before their out-patient treatment for a fall. This was a retrospective, cross-sectional national secondary outpatient data analysis with an age- and sex-matched comparison group. The setting was the national Veterans Health Administration (VHA) ambulatory health care system in fiscal year (FY) 2004. The study population was VHA patients aged>or=65 years who had fall-related outpatient clinical health care encounters in FY 2004 (as indicated by diagnostic codes) and who received >or=1 outpatient medication during the study period. The age- and sex-matched comparison group consisted of an equal number of patients with nonspecific chest pain. The percentage of patients in each group receiving medications (at the time of the outpatient encounter) that affect the cardiovascular system (CVS), central nervous system (CNS), or musculoskeletal system (MSS) was compared with Bonferrom-adjusted P values. The study sample consisted of 20,551 patients; the comparison group included the same number of patients. More patients with fall-coded encounters used CNS drugs than those with nonspecific chest pain (42.05% vs 29.29%). Also, within the CNS category, more patients with fall-coded encounters used antiparkinsonian medications (3.67% vs 1.32%), Alzheimer's disease medications (ie, cholinesterase inhibitors [5.40% vs 2.35%]), anticonvulsants/barbiturates (8.95% vs 5.18%), antidepressants (22.50% vs 14.16%), antipsychotics (4.68% vs 2.01%), opioid analgesics and narcotics (11.21% vs 9.09%), and benzodiazepines (7.60% vs 5.96%) (all, P<0.002). More patients with nonspecific chest pain received CVS drugs compared with the fall-coded group (69.13% vs 63.07%; P<0.002). Within the CVS category, more patients in the nonspecific chest pain group received angiotensin-II receptor antagonists, angiotensin

The effect of acidity on gill variations in the aquatic air-breathing fish, Trichogaster lalius.

PubMed

Huang, Chun-Yen; Lin, Hui-Chen

2011-01-01

Climate change affects organisms that inhabit not only in aerial but also in aquatic environments by making water more hypoxic and acidic. In the past, we evaluated morphological and functional variations in the gills of 12 species of aquatic air-breathing fishes. The aim of the present study is to examine the degree of gill modification in the aquatic air-breathing fish, Trichogaster lalius, in response to acidic stress. This provides a link between the ecological and physiological studies. We evaluated the changes in morphology and function of the gills, labyrinth organ, and kidney when the fish were subjected to acidic water and deionized water (DW). In the first experiment, fish were sampled at 1, 2, 4, and 7 days after acidic treatment. Apparent morphological modification was observed on day 4 and recovery was noted on day 7. Protein expression and enzyme activity of vacuolar-type H+-ATPase (VHA) and the protein expression of the proliferating cell nuclear antigen (PCNA) of the 1st and 4th gill arches both increased in the 4-day and 7-day acidic groups while the enzyme activity of Na+/K+-ATPase (NKA) decreased. In the second experiment, fish were tested for changes in the 1st and 4th gill arches and kidney after exposure to DW and acidic water for 4days. The gill structure of the fish in the DW was not different from that of the control group (fresh water). The protein expression and enzyme activity of the VHA of the 1st and 4th gill arches increased in both the DW and acidic groups for 4 days. We found a decrease in the protein expression of NKA in the kidney and in the enzyme activity of NKA in the 1st and 4th gill arches in the DW and acidic groups. From these results, we suggest that T. lalius exhibited significantly different ionic regulation and acid-base regulatory abilities in the DW and acidic groups in the 1st and 4th gill arches and kidney. The responses of the gills in T. lalius were different from those fish that show apparent morphological

Implementation of new clinical programs in the VHA healthcare system: the importance of early collaboration between clinical leadership and research.

PubMed

Wu, R Ryanne; Kinsinger, Linda S; Provenzale, Dawn; King, Heather A; Akerly, Patricia; Barnes, Lottie K; Datta, Santanu K; Grubber, Janet M; Katich, Nicholas; McNeil, Rebecca B; Monte, Robert; Sperber, Nina R; Atkins, David; Jackson, George L

2014-12-01

Collaboration between policy, research, and clinical partners is crucial to achieving proven quality care. The Veterans Health Administration has expended great efforts towards fostering such collaborations. Through this, we have learned that an ideal collaboration involves partnership from the very beginning of a new clinical program, so that the program is designed in a way that ensures quality, validity, and puts into place the infrastructure necessary for a reliable evaluation. This paper will give an example of one such project, the Lung Cancer Screening Demonstration Project (LCSDP). We will outline the ways that clinical, policy, and research partners collaborated in design, planning, and implementation in order to create a sustainable model that could be rigorously evaluated for efficacy and fidelity. We will describe the use of the Donabedian quality matrix to determine the necessary characteristics of a quality program and the importance of the linkage with engineering, information technology, and clinical paradigms to connect the development of an on-the-ground clinical program with the evaluation goal of a learning healthcare organization. While the LCSDP is the example given here, these partnerships and suggestions are salient to any healthcare organization seeking to implement new scientifically proven care in a useful and reliable way.

Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics.

PubMed

Helfrich, Christian D; Dolan, Emily D; Fihn, Stephan D; Rodriguez, Hector P; Meredith, Lisa S; Rosland, Ann-Marie; Lempa, Michele; Wakefield, Bonnie J; Joos, Sandra; Lawler, Lauren H; Harvey, Henry B; Stark, Richard; Schectman, Gordon; Nelson, Karin M

2014-12-01

Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care. We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity. 4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (β=32, P<0.0001) and history of change in the clinic (β=18, P=0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (β=0.16-0.34, P=<0.0001), and lower improvements in patient-centered care (β=-0.19, P=0.001). Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures. Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics. Published by Elsevier Inc.

Development of the Veterans Healthcare Administration (VHA) Ophthalmic Surgical Outcome Database (OSOD) project and the role of ophthalmic nurse reviewers.

PubMed

Lara-Smalling, Agueda; Cakiner-Egilmez, Tulay; Miller, Dawn; Redshirt, Ella; Williams, Dale

2011-01-01

Currently, ophthalmic surgical cases are not included in the Veterans Administration Surgical Quality Improvement Project data collection. Furthermore, there is no comprehensive protocol in the health system for prospectively measuring outcomes for eye surgery in terms of safety and quality. There are 400,000 operative cases in the system per year. Of those, 48,000 (12%) are ophthalmic surgical cases, with 85% (41,000) of those being cataract cases. The Ophthalmic Surgical Outcome Database Pilot Project was developed to incorporate ophthalmology into VASQIP, thus evaluating risk factors and improving cataract surgical outcomes. Nurse reviewers facilitate the monitoring and measuring of these outcomes. Since its inception in 1778, the Veterans Administration (VA) Health System has provided comprehensive healthcare to millions of deserving veterans throughout the U.S. and its territories. Historically, the quality of healthcare provided by the VA has been the main focus of discussion because it did not meet a standard of care comparable to that of the private sector. Information regarding quality of healthcare services and outcomes data had been unavailable until 1986, when Congress mandated the VA to compare its surgical outcomes to those of the private sector (PL-99-166). 1 Risk adjustment of VA surgical outcomes began in 1987 with the Continuous Improvement in Cardiac Surgery Program (CICSP) in which cardiac surgical outcomes were reported and evaluated. 2 Between 1991 and 1993, the National VA Surgical Risk Study (NVASRS) initiated a validated risk-adjustment model for predicting surgical outcomes and comparative assessment of the quality of surgical care in 44 VA medical centers. 3 The success of NVASRS encouraged the VA to establish an ongoing program for monitoring and improving the quality of surgical care, thus developing the National Surgical Quality Improvement Program (NSQIP) in 1994. 4 According to a prospective study conducted between 1991-1997 in 123 VA medical centers by Khuri et al., the 30-day mortality and morbidity rates for major surgeries had decreased by 9% and 30%, respectively. 5 Recently renamed the VA Surgical Quality Improvement Program (VASQIP) in 2010, the quality of surgical outcomes has continued to improve among all documented surgical specialties. Ophthalmic surgery is presumed to have a very low mortality rate and therefore has not been included in the VASQIP database.

[Is hepatitis E just an imported infection in the Czech Republic?].

PubMed

Haasová, Zdenka; Kleinerová, Jana; Mestáková, Olga

2006-02-01

The article deals with the issue of virus hepatitis E (VHE) whose increased incidence emerged in some Moravian districts in the monitored period from January 2004 to June 2005. The uncoated RNA virus, which is not taxonomically classified at present, is considered to be a causative agent of VHE. In the BIO-PLUS, the company with limited liability, 1 078 sera samples from various hospital and outpatient departments were tested by the ELISA method. The positive IgG and IgM VHE antibodies were found in 24 cases, that corresponded to the clinic condition of patient and to the biochemical findings showing an acute hepatitis. Other virus hepatitis (VHA, VHB, VHC) as well as further hepatotrophic infections were negative in all cases. Until recently the VHE was considered as an imported infection from endemic areas. However, only seven of our 24 positive cases showed a stay abroad, the traveller history was negative in the rest. In our work 18 VHE cases, diagnosed in the infection departments of the hospitals in Breclav and Prostejov, are analysed in details in the referred period.

A chemical model for lunar non-mare rocks

NASA Technical Reports Server (NTRS)

Hubbard, N. J.; Rhodes, J. M.

1974-01-01

Nearly all rocks returned from the moon are readily divided into three broad categories on the basis of their chemical compositions: (1) mare basalts, (2) non-mare rocks of basaltic composition (KREEP, VHA), and (3) anorthositic rocks. Only mare basalts may unambiguously be considered to have original igneous textures and are widely understood to have an igneous origin. Nearly all other lunar rocks have lost their original textures during metamorphic and impact processes. It is shown that for these rocks one must work primarily with chemical data in order to recognize and define rock groups and their possible modes of origin. Non-mare rocks of basaltic composition have chemical compositions consistent with an origin by partial melting of the lunar interior. The simplest origin for rocks of anorthositic chemical composition is the crystallization and removal of ferromagnesian minerals. It is proposed that the rock groups of anorthositic and non-mare basaltic chemical composition could have been generated from a single series of original but not necessarily primitive lunar materials.

Priority setting and the ethics of resource allocation within VA healthcare facilities: results of a survey.

PubMed

Foglia, Mary Beth; Pearlman, Robert A; Bottrell, Melissa M; Altemose, Jane A; Fox, Ellen

2008-01-01

Setting priorities and the subsequent allocation of resources is a major ethical issue facing healthcare facilities, including the Veterans Health Administration (VHA), the largest integrated healthcare delivery network in the United States. Yet despite the importance of priority setting and its impact on those who receive and those who provide care, we know relatively little about how clinicians and managers view allocation processes within their facilities. The purpose of this secondary analysis of survey data was to characterize staff members' perceptions regarding the fairness of healthcare ethics practices related to resource allocation in Veterans Administration (VA) facilities. The specific aim of the study was to compare the responses of clinicians, clinician managers, and non-clinician managers with respect to these survey items. We utilized a paper and web-based survey and a cross-sectional design of VHA clinicians and managers. Our sample consisted of a purposive stratified sample of 109 managers and a stratified random sample of 269 clinicians employed 20 or more hours per week in one of four VA medical centers. The four medical centers were participating as field sites selected to test the logistics of administering and reporting results of the Integrated Ethics Staff Survey, an assessment tool aimed at characterizing a broad range of ethical practices within a healthcare organization. In general, clinicians were more critical than clinician managers or non-clinician managers of the institutions' allocation processes and of the impact of resource decisions on patient care. Clinicians commonly reported that they did not (a) understand their facility's decision-making processes, (b) receive explanations from management regarding the reasons behind important allocation decisions, or (b) perceive that they were influential in allocation decisions. In addition, clinicians and managers both perceived that education related to the ethics of resource

Glycemic control and hypoglycemia in Veterans Health Administration patients converted from glyburide to glipizide.

PubMed

Skoff, Rachel A; Waterbury, Nancee V; Shaw, Robert F; Egge, Jason A; Cantrell, Matthew

2011-11-01

In 2009, the Veterans Health Administration (VHA) released a national bulletin regarding the risk of hypoglycemia associated with the use of glyburide in elderly patients with renal dysfunction. Providers were encouraged to avoid glyburide and use glipizide in patients with a calculated creatinine clearance (CrCl) of less than 50 mL per minute. Since this initiative, many veterans were converted by their providers from glyburide to glipizide regardless of renal impairment. To (a) identify whether hemoglobin A1c remained equivalent in patients converted from glyburide to glipizide, (b) evaluate the prevalence of hypoglycemia during treatment with glyburide or glipizide, (c) compare change in glycemic control for renally impaired versus nonimpaired patients, and (d) analyze dosage conversion ratios selected by providers and measures of patient follow-up after conversion including time until A1c measurement and number of glipizide dose titrations. This was a single-center, retrospective analysis of veterans converted from glyburide to glipizide from January 1, 2008, through May 31, 2010, who had documented A1c values concurrent with glyburide and glipizide use. A 2-sided equivalence analysis was used for the primary outcome. Equivalence was defined as a change in mean A1c of ± 0.2. Hypoglycemia was defined as blood glucose of less than 70 mg per dL, symptoms of hypoglycemia, or hypoglycemia that led to a fall, loss of consciousness, emergency room visit, hospitalization, or death. The pre- to post-conversion change in rates of hypoglycemia was tested for significance using a McNemar's test. In the 141 (99.3% male, 53.9% CrCl less than 50 mL per minute, mean age = 74.0 years) patients meeting inclusion criteria between 2008-2010, the average change in A1c (+ 0.34) was nonequivalent after conversion from glyburide to glipizide (7.08% vs. 7.42%, respectively). Hypoglycemia occurred more frequently during treatment with glyburide than glipizide (31.2% vs. 12

Objective structured clinical interview training using a virtual human patient.

PubMed

Parsons, Thomas D; Kenny, Patrick; Ntuen, Celestine A; Pataki, Caroly S; Pato, Michele T; Rizzo, Albert A; St-George, Cheryl; Sugar, Jeffery

2008-01-01

Effective interview skills are a core competency for psychiatry residents and developing psychotherapists. Although schools commonly make use of standardized patients to teach interview skills, the diversity of the scenarios standardized patients can characterize is limited by availability of human actors. Further, there is the economic concern related to the time and money needed to train standardized patients. Perhaps most damaging is the "standardization" of standardized patients -- will they in fact consistently proffer psychometrically reliable and valid interactions with the training clinicians. Virtual Human Agent (VHA) technology has evolved to a point where researchers may begin developing mental health applications that make use of virtual reality patients. The work presented here is a preliminary attempt at what we believe to be a large application area. Herein we describe an ongoing study of our virtual patients (VP). We present an approach that allows novice mental health clinicians to conduct an interview with a virtual character that emulates an adolescent male with conduct disorder. This study illustrates the ways in which a variety of core research components developed at the University of Southern California facilitates the rapid development of mental health applications.

Dating Melt Rock 63545 By Rb-Sr and Sm-Nd: Age of Imbrium; Spa Dress Rehearsal

NASA Technical Reports Server (NTRS)

Nyquist, L. E.; Shih, C. Y.; Reese, Y. D.

2011-01-01

Apollo 16 sample 63545 was initially described as one of a group of 19 generally rounded, fine-grained, crystalline rocks that were collected as rake samples [1]. This 16 g "rocklet" was collected at Station 13 on the ejecta blanket of North Ray Crater at the foot of Smoky Mountain [2]. Originally classified as a Very High Alumina (VHA) basalt on geochemical grounds [3], it was later argued to be an impact melt rock [4]. Here we report a Rb-Sr and Sm-Nd isotopic study that shows that some portions of the rock failed to reach isotopic equilibrium on last melting in agreement with the impact melt rock interpretation. Nevertheless, by omitting mineral fractions that are discordant with the majority of the data, we arrive at the time of last melting as 3.88 plus or minus 0.05 Ga ago. This age is in agreement with the Ar-39/Ar-40 plateau age of 3839 plus or minus 23 Ma [5], if the latter is adjusted for the 1.4-1.8% revision in the age of the hornblende monitor [6]. This investigation was undertaken in part as proof-of-concept for SPA-basin sample return.

Critical issues in an electronic documentation system.

PubMed

Weir, Charlene R; Nebeker, Jonathan R

2007-10-11

The Veterans Health Administration (VHA), of the U.S. Department of Veteran Affairs has instituted a medical record (EMR) that includes electronic documentation of all narrative components of the medical record. To support clinicians using the system, multiple efforts have been instituted to ease the creation of narrative reports. Although electronic documentation is easier to read and improves access to information, it also may create new and additional hazards for users. This study is the first step in a series of studies to evaluate the issues surrounding the creation and use of electronic documentation. Eighty-eight providers across multiple clinical roles were interviewed in 10 primary care sites in the VA system. Interviews were tape-recorded, transcribed and qualitatively analyzed for themes. In addition, specific questions were asked about perceived harm due to electronic documentation practices. Five themes relating to difficulties with electronic documentation were identified: 1) information overload; 2) hidden information; 3) lack of trust; 4) communication; 5) decision-making. Three providers reported that they knew of an incident where current documentation practices had caused patient harm and over 75% of respondents reported significant mis-trust of the system.

Effects of high-involvement work systems on employee satisfaction and service costs in veterans healthcare.

PubMed

Harmon, Joel; Scotti, Dennis J; Behson, Scott; Farias, Gerard; Petzel, Robert; Neuman, Joel H; Keashly, Loraleigh

2003-01-01

Two strong imperatives for healthcare managers are reducing costs of service and attracting and retaining highly dedicated and competent patient care and support employees. Is there a trade-off or are there organizational practices that can further both objectives at the same time? High-involvement work systems (HIWS) represent a holistic work design that includes interrelated core features such as involvement, empowerment, development, trust, openness, teamwork, and performance-based rewards. HIWS have been linked to higher productivity, quality, employee and customer satisfaction, and market and financial performance in Fortune 1000 firms. Apparently, few prior studies have looked at the impacts of this holistic design within the healthcare sector. This research found that HIWS were associated with both greater employee satisfaction and lower patient service costs in 146 Veterans Health Administration centers, indicating that such practices pay off in both humanistic and financial terms. This suggests that managers implementing HIWS will incur real expenses that are likely to be more than offset by more satisfied employees, less organizational turmoil, and lower service delivery costs, which, in this study, amounted to over $1.2 million in savings for an average VHA facility.

Incidence of Mental Health Diagnoses in Veterans of Operations Iraqi Freedom, Enduring Freedom, and New Dawn, 2001-2014.

PubMed

Ramsey, Christine; Dziura, James; Justice, Amy C; Altalib, Hamada Hamid; Bathulapalli, Harini; Burg, Matthew; Decker, Suzanne; Driscoll, Mary; Goulet, Joseph; Haskell, Sally; Kulas, Joseph; Wang, Karen H; Mattocks, Kristen; Brandt, Cynthia

2017-02-01

To evaluate gender, age, and race/ethnicity as predictors of incident mental health diagnoses among Operations Iraqi Freedom, Enduring Freedom, and New Dawn veterans. We used US Veterans Health Administration (VHA) electronic health records from 2001 to 2014 to examine incidence rates and sociodemographic risk factors for mental health diagnoses among 888 142 veterans. Posttraumatic stress disorder (PTSD) was the most frequently diagnosed mental health condition across gender and age groups. Incidence rates for all mental health diagnoses were highest at ages 18 to 29 years and declined thereafter, with the exceptions of major depressive disorder (MDD) in both genders, and PTSD among women. Risk of incident bipolar disorder and MDD diagnoses were greater among women; risk of incident schizophrenia, and alcohol- and drug-use disorders diagnoses were greater in men. Compared with Whites, risk incident PTSD, MDD, and alcohol-use disorder diagnoses were lower at ages 18 to 29 years and higher at ages 45 to 64 years for both Hispanics and African Americans. Differentiating high-risk demographic and gender groups can lead to improved diagnosis and treatment of mental health diagnoses among veterans and other high-risk groups.

Dynamic Scheduling for Veterans Health Administration Patients using Geospatial Dynamic Overbooking.

PubMed

Adams, Stephen; Scherer, William T; White, K Preston; Payne, Jason; Hernandez, Oved; Gerber, Mathew S; Whitehead, N Peter

2017-10-12

The Veterans Health Administration (VHA) is plagued by abnormally high no-show and cancellation rates that reduce the productivity and efficiency of its medical outpatient clinics. We address this issue by developing a dynamic scheduling system that utilizes mobile computing via geo-location data to estimate the likelihood of a patient arriving on time for a scheduled appointment. These likelihoods are used to update the clinic's schedule in real time. When a patient's arrival probability falls below a given threshold, the patient's appointment is canceled. This appointment is immediately reassigned to another patient drawn from a pool of patients who are actively seeking an appointment. The replacement patients are prioritized using their arrival probability. Real-world data were not available for this study, so synthetic patient data were generated to test the feasibility of the design. The method for predicting the arrival probability was verified on a real set of taxicab data. This study demonstrates that dynamic scheduling using geo-location data can reduce the number of unused appointments with minimal risk of double booking resulting from incorrect predictions. We acknowledge that there could be privacy concerns with regards to government possession of one's location and offer strategies for alleviating these concerns in our conclusion.

The Violence Prevention Community Meeting: A Multi-Site Study.

PubMed

Lanza, Marilyn; Ridenour, Marilyn; Hendricks, Scott; Rierdan, Jill; Zeiss, Robert; Schmidt, Satu; Lovelace, Jeff; Amandus, Harlan

2016-06-01

The Violence Prevention Community Meeting (VPCM) is a specialized form of community meeting in which avoiding violence and promoting non-violent problem solving and interpersonal civility are focal points. A nationwide study to assess the VPCM as an effective intervention to reduce workplace violence was undertaken. Seven acute locked psychiatric units of the Veterans Health Administration (VHA) throughout the United States participated in the study. All patients and all staff on the seven in-patient locked psychiatry units participated in the intervention (VPCM) or as a control (treatment as usual). The study was 21weeks at each site. The three time periods were pre-treatment weeks 1-3, treatment weeks 4-18, and post-treatment weeks 19-21. The VPCM was conducted during the treatment weeks. Overall rates of aggression declined by 0.6% (95% CI: -5.6%, 6.5%; nonsignificant) per week in the intervention hospitals and by 5.1% (95% CI: 0.4%, 9.6%; significant) per week for the control hospitals. Aggression decreased for both the intervention and control hospitals which could be due to enrollment in a research study and thus being more aware of their ability to address workplace violence at their site. Published by Elsevier Inc.

Ectopic expression of PgRab7 in rice plants (Oryza sativa L.) results in differential tolerance at the vegetative and seed setting stage during salinity and drought stress.

PubMed

Tripathy, Manas Kumar; Tiwari, Budhi Sagar; Reddy, Malireddy K; Deswal, Renu; Sopory, Sudhir K

2017-01-01

In this work, we have overexpressed a vesicle trafficking protein, Rab7, from a stress-tolerant plant, Pennisetum glaucum, in a high-yielding but stress-sensitive rice variety Pusa Basmati-1 (PB-1). The transgenic rice plants were tested for tolerance against salinity and drought stress. The transgenic plants showed considerable tolerance at the vegetative stage against both salinity (200 mM NaCl) and drought stress (up to 12 days after withdrawing water). The protection against salt and drought stress may be by regulating Na + ion homeostasis, as the transgenic plants showed altered expression of multiple transporter genes, including OsNHX1, OsNHX2, OsSOS1, OsVHA, and OsGLRs. In addition, decreased generation and maintenance of lesser reactive oxygen species (ROS), with maintenance of chloroplast grana and photosynthetic machinery was observed. When evaluated for reproductive growth, 89-96 % of seed setting was maintained in transgenic plants during drought stress; however, under salt stress, a 33-53 % decrease in seed setting was observed. These results indicate that PgRab7 overexpression in rice confers differential tolerance at the seed setting stage during salinity and drought stress and could be a favored target for raising drought-tolerant crops.

Quantitative Proteomics of the Tonoplast Reveals a Role for Glycolytic Enzymes in Salt Tolerance[C][W

PubMed Central

Barkla, Bronwyn J.; Vera-Estrella, Rosario; Hernández-Coronado, Marcela; Pantoja, Omar

2009-01-01

To examine the role of the tonoplast in plant salt tolerance and identify proteins involved in the regulation of transporters for vacuolar Na+ sequestration, we exploited a targeted quantitative proteomics approach. Two-dimensional differential in-gel electrophoresis analysis of free flow zonal electrophoresis separated tonoplast fractions from control, and salt-treated Mesembryanthemum crystallinum plants revealed the membrane association of glycolytic enzymes aldolase and enolase, along with subunits of the vacuolar H+-ATPase V-ATPase. Protein blot analysis confirmed coordinated salt regulation of these proteins, and chaotrope treatment indicated a strong tonoplast association. Reciprocal coimmunoprecipitation studies revealed that the glycolytic enzymes interacted with the V-ATPase subunit B VHA-B, and aldolase was shown to stimulate V-ATPase activity in vitro by increasing the affinity for ATP. To investigate a physiological role for this association, the Arabidopsis thaliana cytoplasmic enolase mutant, los2, was characterized. These plants were salt sensitive, and there was a specific reduction in enolase abundance in the tonoplast from salt-treated plants. Moreover, tonoplast isolated from mutant plants showed an impaired ability for aldolase stimulation of V-ATPase hydrolytic activity. The association of glycolytic proteins with the tonoplast may not only channel ATP to the V-ATPase, but also directly upregulate H+-pump activity. PMID:20028841

Quantitative proteomics of the tonoplast reveals a role for glycolytic enzymes in salt tolerance.

PubMed

Barkla, Bronwyn J; Vera-Estrella, Rosario; Hernández-Coronado, Marcela; Pantoja, Omar

2009-12-01

To examine the role of the tonoplast in plant salt tolerance and identify proteins involved in the regulation of transporters for vacuolar Na(+) sequestration, we exploited a targeted quantitative proteomics approach. Two-dimensional differential in-gel electrophoresis analysis of free flow zonal electrophoresis separated tonoplast fractions from control, and salt-treated Mesembryanthemum crystallinum plants revealed the membrane association of glycolytic enzymes aldolase and enolase, along with subunits of the vacuolar H(+)-ATPase V-ATPase. Protein blot analysis confirmed coordinated salt regulation of these proteins, and chaotrope treatment indicated a strong tonoplast association. Reciprocal coimmunoprecipitation studies revealed that the glycolytic enzymes interacted with the V-ATPase subunit B VHA-B, and aldolase was shown to stimulate V-ATPase activity in vitro by increasing the affinity for ATP. To investigate a physiological role for this association, the Arabidopsis thaliana cytoplasmic enolase mutant, los2, was characterized. These plants were salt sensitive, and there was a specific reduction in enolase abundance in the tonoplast from salt-treated plants. Moreover, tonoplast isolated from mutant plants showed an impaired ability for aldolase stimulation of V-ATPase hydrolytic activity. The association of glycolytic proteins with the tonoplast may not only channel ATP to the V-ATPase, but also directly upregulate H(+)-pump activity.

Use of Trypanosoma equiperdum infected rabbits as a source of splenic mRNA; construction of cDNA clones and identification of a rabbit mu heavy chain clone.

PubMed

Bernstein, K E; Pavirani, A; Alexander, C; Jacobsen, F; Fitzmaurice, L; Mage, R

1983-01-01

Rabbits were infected by Trypanosoma equiperdum and the splenic mRNA was isolated. In vitro translation of this RNA and immunoprecipitation with anti-light chain, anti-heavy chain, anti-mu and anti-VH antibodies demonstrated that T. equiperdum infection elicits large quantities of splenic mRNA encoding mu and kappa chains. The mu and gamma heavy chains and the kappa light chains synthesized in the cell-free translation system were specifically immunoprecipitated by antisera to heavy chain VHa and light chain kappa b allotypes. In vitro labeling of spleen cells from trypanosome-infected animals demonstrated that the biosynthetically labeled IgM has a mu chain of higher molecular weight than the mu chain synthesized by in vitro translation, a difference that is largely abolished when cellular glycosylation is blocked with the antibiotic tunicamycin. Enrichment for heavy chain or light chain mRNA was achieved by fractionating mRNA from trypanosome-infected animals on a sucrose gradient. cDNA clones carrying mu heavy chain sequences were produced using a 'one tube' protocol and identified by cross species hybridization and hybridization selection. Infection of rabbits with T. equiperdum followed by sucrose gradient enrichment of splenic mRNA has provided sufficient quantities of mRNA encoding mu heavy chain suitable for cDNA cloning.

The effect of perceived racial discrimination on bodily pain among older African American men.

PubMed

Burgess, Diana J; Grill, Joseph; Noorbaloochi, Siamak; Griffin, Joan M; Ricards, Jennifer; van Ryn, Michelle; Partin, Melissa R

2009-11-01

We examined the extent to which experiences of racial discrimination are associated with bodily pain reported by African American men. The study sample consisted of 393 African American male veterans who responded to a national survey of patients aged 50-75 who received care from the Veterans Health Administration (VHA). Veterans were surveyed by mail, with a telephone follow-up. The response rate for African Americans in the sample was 60.5%. Pain (assessed using the bodily pain subscale of the 36-item short-form health survey), experiences of discrimination, employment, education, and income were obtained through the survey. Age, race, and mental health comorbidities were obtained from VA administrative data. Multiple regression analysis adjusting for item non-response (via imputation) and unit non-response (via propensity scores and weighting) was used to assess the association between racial discrimination and likelihood of experiencing moderate or severe pain over the past 4 weeks. Experiences of racial discrimination were associated with greater bodily pain (beta = -0.25, P < 0.0001), even after controlling for socioeconomic and health-related characteristics. Perceived racial discrimination was associated with greater pain among a sample of older African American male patients in the VA. Additional research is needed to replicate this finding among other populations of African Americans.

Do associations between employee self-reported organizational assessments and attitudinal outcomes change over time? An analysis of four Veterans Health Administration surveys using structural equation modelling.

PubMed

Das, Sonali; Chen, Ming-Hui; Warren, Nicholas; Hodgson, Michael

2011-12-01

This paper evaluates relationships between healthcare employees' perceptions of three hospital organizational constructs (Leadership, Support and Resources), and their assessment of two employee-related outcomes (employee satisfaction and retention) and two patient-related outcomes (patient satisfaction and quality of care). Using four all-employee surveys conducted by the Veterans Health Administration in the United States between 1997 and 2006, we examine the strength of these relationships and their changes over time. Exposure and outcome measures are employee-assessed in all the surveys. Because it can accommodate both latent and measured variables into the model, Structural Equation Modelling (SEM) is used to capture and quantify the relationship structure. The aim of the project is to identify possible intervention foci. The analyses revealed that employee-related outcomes are improved by increases in Leadership and Support, and, not surprisingly, the outcome variable of employee satisfaction reduced turnover intention. The employee assessed patient-related outcomes of satisfaction and quality of care were most improved by increases in Resources. Results also indicate that the three organizational constructs and the web of associations characterized by SEM underwent changes over the study period, perhaps in relation to changes in VHA policy emphases, changes in survey wording and other possible unmeasured factors. Copyright © 2010 John Wiley & Sons, Ltd.

The physical and mental health burden of obesity in U.S. veterans: Results from the National Health and Resilience in Veterans Study.

PubMed

Stefanovics, Elina A; Potenza, Marc N; Pietrzak, Robert H

2018-08-01

In this study, we provide an updated estimate of the prevalence of obesity in U.S. military veterans, and evaluate a broad range of sociodemographic, military, physical and mental health, and lifestyle characteristics associated with obesity in this population. Data were analyzed from a nationally representative sample of 3122 U.S. veterans who participated in the National Health and Resilience in Veterans Study (NHRVS). Associations between obesity status, and physical and mental health, and lifestyle variables were evaluated using multivariate logistic regression and linear regression analyses. Results revealed that 32.7% of U.S. veterans are obese, which is higher than the previously reported estimates for U.S. military veterans nationally, and was particularly high among younger and non-white veterans and those using the Veterans Heath Administration (VHA) healthcare system. Obesity was associated with greater trauma burden; elevated rates of a broad range of health conditions such as diabetes, arthritis, and heart disease, PTSD, nicotine dependence; poor physical and mental functioning and quality of life, and decreased engagement in an active lifestyle. Taken together, these results suggest that the prevalence of obesity is high in U.S. veterans and associated with substantial health burden. Results have implications for informing obesity prevention and treatment programs in veterans, and underscore the importance of assessing, monitoring, and treating obesity in this population. Copyright © 2018. Published by Elsevier Ltd.

Dissemination of CBTI to the non-sleep specialist: protocol development and training issues.

PubMed

Manber, Rachel; Carney, Colleen; Edinger, Jack; Epstein, Dana; Friedman, Leah; Haynes, Patricia L; Karlin, Bradley E; Pigeon, Wilfred; Siebern, Allison T; Trockel, Mickey

2012-04-15

Strong evidence supports the efficacy of cognitive behavioral therapy for insomnia (CBTI). A significant barrier to wide dissemination of CBTI is the lack of qualified practitioners. We describe challenges and decisions made when developing a CBTI dissemination program in the Veterans Health Administration (VHA). The program targets mental health clinicians from different disciplines (psychiatry, psychology, social work, and nursing) with varying familiarity and experience with general principles of cognitive behavioral therapies (CBT). We explain the scope of training (how much to teach about the science of sleep, comorbid sleep disorders, other medical and mental health comorbidities, and hypnotic-dependent insomnia), discuss adaptation of CBTI to address the unique challenges posed by comorbid insomnia, and describe decisions made about the strategy of training (principles, structure and materials developed/recommended). Among these decisions is the question of how to balance the structure and flexibility of the treatment protocol. We developed a case conceptualization-driven approach and provide a general session-by-session outline. Training licensed therapists who already have many professional obligations required that the training be completed in a relatively short time with minimal disruptions to training participants' routine work responsibilities. These "real-life" constraints shaped the development of this competency-based, yet pragmatic training program. We conclude with a description of preliminary lessons learned from the initial wave of training and propose future directions for research and dissemination.

Elevated extracellular pH during early shell formation in the blue mussel Mytilus edulis

NASA Astrophysics Data System (ADS)

Ramesh, K.; Melzner, F.; Himmerkus, N.; Hu, M.; Bleich, M.

2016-02-01

Marine calcifiers are amongst the most vulnerable organisms to ocean acidification (OA). However, limited studies investigate the mechanisms underlying their hindered performance under OA stress. Working with larval stages of the blue mussel, Mytilus edulis, we use microsensors to study the pH and calcium conditions necessary for shell deposition. Using 45-48 hour, D-veliger stages, we discover alkaline conditions with respect to ambient seawater pH by 0.28 pH units and higher calcium concentrations (by 0.54mM) in the extra pallial space beneath the growing shell that likely promotes the rapid synthesis of the first shell. We further use enzyme assays in combination with immuno-stainings of sodium-potassium ATPase (NKA) and proton ATPase (VHA) to provide information on the major ion regulatory pathways that enable transport of calcium carbonate required for shell formation and pH homeostasis. We also use the juvenile stages of M. edulis to understand how extracellular pH regulation close to the shell formation site will be influenced by OA stress. This allows us to describe the pH dependency of early shell formation and to begin to develop a model of the ion regulatory network that facilitates biomineralisation in the organism. The results are discussed in the context of environmental change and consequences for mollusc developmental success.

Empirical-Based Typology of Health Care Utilization by Medicare Eligible Veterans.

PubMed

Vaughan Sarrazin, Mary; Rosenthal, Gary E; Turvey, Carolyn L

2018-06-12

Up to 70 percent of patients who receive care through Veterans Health Administration (VHA) facilities also receive care from non-VA providers. Using applied classification techniques, this study sought to improve understanding of how elderly VA patients use VA services and complementary use of non-VA care. The study included 1,721,900 veterans age 65 and older who were enrolled in VA and Medicare during 2013 with at least one VA encounter during 2013. Outpatient and inpatient encounters and medications received in VA were classified, and mutually exclusive patient subsets distinguished by patterns of VA service use were derived empirically using latent class analysis (LCA). Patient characteristics and complementary use of non-VA care were compared by patient subset. Five patterns of VA service use were identified that were distinguished by quantity of VA medical and specialty services, medication complexity, and mental health services. Low VA Medical users tend to be healthier and rely on non-VA services, while High VA users have multiple high cost illnesses and concentrate their care in the VA. VA patients distinguished by patterns of VA service use differ in illness burden and the use of non-VA services. This information may be useful for framing efforts to optimize access to care and care coordination for elderly VA patients. © Health Research and Educational Trust.

Linking clinician interaction and coordination to clinical performance in Patient-Aligned Care Teams.

PubMed

Hysong, Sylvia J; Thomas, Candice L; Spitzmüller, Christiane; Amspoker, Amber B; Woodard, LeChauncy; Modi, Varsha; Naik, Aanand D

2016-01-15

Team coordination within clinical care settings is a critical component of effective patient care. Less is known about the extent, effectiveness, and impact of coordination activities among professionals within VA Patient-Aligned Care Teams (PACTs). This study will address these gaps by describing the specific, fundamental tasks and practices involved in PACT coordination, their impact on performance measures, and the role of coordination task complexity. First, we will use a web-based survey of coordination practices among 1600 PACTs in the national VHA. Survey findings will characterize PACT coordination practices and assess their association with clinical performance measures. Functional job analysis, using 6-8 subject matter experts who are 3rd and 4th year residents in VA Primary Care rotations, will be utilized to identify the tasks involved in completing clinical performance measures to standard. From this, expert ratings of coordination complexity will be used to determine the level of coordinative complexity required for each of the clinical performance measures drawn from the VA External Peer Review Program (EPRP). For objective 3, data collected from the first two methods will evaluate the effect of clinical complexity on the relationships between measures of PACT coordination and their ratings on the clinical performance measures. Results from this study will support successful implementation of coordinated team-based work in clinical settings by providing knowledge regarding which aspects of care require the most complex levels of coordination and how specific coordination practices impact clinical performance.

The influence of teamwork culture on physician and nurse resignation rates in hospitals.

PubMed

Mohr, David C; Burgess, James F; Young, Gary J

2008-02-01

Employee turnover is a critical concern, particularly for hospitals, because they face a very tight labour market for hiring replacements, and high turnover itself may have substantial negative effects on the continuity and quality of patient care. Hospitals with a stronger teamwork culture may experience lower turnover but this has not been formally studied. Research on determinants of employee turnover has not separated out resignations from the larger, more inclusive definition of turnover that includes retirement. This study investigated the relationship between the teamwork culture of hospitals and physician and nurse resignation rates. The study setting was the Veterans Health Administration (VHA). Each hospital was assessed on teamwork culture based on a survey of current employees. Hospital-level resignation rates were obtained for physicians and nurses. Separate multivariate regression models on physicians and nurses were employed. The models included hospital-level characteristics and labour market variables. Analysis of covariance was also performed to attempt to further reveal effects in high versus low teamwork culture hospitals. Teamwork culture was negatively associated with nurse and physician resignation rates, but was statistically significant in the nurse resignation model only. Additional analyses indicated a 0.47 standard deviation (SD) difference in nurse resignation rates and a 0.40 SD difference in physician resignation rates between hospitals in the top and bottom quartiles of the distribution for teamwork culture. In conclusion, these results suggest that developing and emphasizing a teamwork culture may facilitate greater retention of health-care employees, especially nurses.

Hydrogen sulfide enhances salt tolerance through nitric oxide-mediated maintenance of ion homeostasis in barley seedling roots

PubMed Central

Chen, Juan; Wang, Wen-Hua; Wu, Fei-Hua; He, En-Ming; Liu, Xiang; Shangguan, Zhou-Ping; Zheng, Hai-Lei

2015-01-01

Hydrogen sulfide (H2S) and nitric oxide (NO) are emerging as messenger molecules involved in the modulation of plant physiological processes. Here, we investigated a signalling network involving H2S and NO in salt tolerance pathway of barley. NaHS, a donor of H2S, at a low concentration of either 50 or 100 μM, had significant rescue effects on the 150 mM NaCl-induced inhibition of plant growth and modulated the K+/Na+ balance by decreasing the net K+ efflux and increasing the gene expression of an inward-rectifying potassium channel (HvAKT1) and a high-affinity K+ uptake system (HvHAK4). H2S and NO maintained the lower Na+ content in the cytoplast by increasing the amount of PM H+-ATPase, the transcriptional levels of PM H+-ATPase (HvHA1) and Na+/H+ antiporter (HvSOS1). H2S and NO modulated Na+ compartmentation into the vacuoles with up-regulation of the transcriptional levels of vacuolar Na+/H+ antiporter (HvVNHX2) and H+-ATPase subunit β (HvVHA-β) and increased in the protein expression of vacuolar Na+/H+ antiporter (NHE1). H2S mimicked the effect of sodium nitroprusside (SNP) by increasing NO production, whereas the function was quenched with the addition of NO scavenger. These results indicated that H2S increased salt tolerance by maintaining ion homeostasis, which were mediated by the NO signal. PMID:26213372

An Eye on Trafficking Genes: Identification of Four Eye Color Mutations in Drosophila

PubMed Central

Grant, Paaqua; Maga, Tara; Loshakov, Anna; Singhal, Rishi; Wali, Aminah; Nwankwo, Jennifer; Baron, Kaitlin; Johnson, Diana

2016-01-01

Genes that code for proteins involved in organelle biogenesis and intracellular trafficking produce products that are critical in normal cell function . Conserved orthologs of these are present in most or all eukaryotes, including Drosophila melanogaster. Some of these genes were originally identified as eye color mutants with decreases in both types of pigments found in the fly eye. These criteria were used for identification of such genes, four eye color mutations that are not annotated in the genome sequence: chocolate, maroon, mahogany, and red Malpighian tubules were molecularly mapped and their genome sequences have been evaluated. Mapping was performed using deletion analysis and complementation tests. chocolate is an allele of the VhaAC39-1 gene, which is an ortholog of the Vacuolar H+ ATPase AC39 subunit 1. maroon corresponds to the Vps16A gene and its product is part of the HOPS complex, which participates in transport and organelle fusion. red Malpighian tubule is the CG12207 gene, which encodes a protein of unknown function that includes a LysM domain. mahogany is the CG13646 gene, which is predicted to be an amino acid transporter. The strategy of identifying eye color genes based on perturbations in quantities of both types of eye color pigments has proven useful in identifying proteins involved in trafficking and biogenesis of lysosome-related organelles. Mutants of these genes can form the basis of valuable in vivo models to understand these processes. PMID:27558665

Adaptation of a nursing home culture change research instrument for frontline staff quality improvement use.

PubMed

Hartmann, Christine W; Palmer, Jennifer A; Mills, Whitney L; Pimentel, Camilla B; Allen, Rebecca S; Wewiorski, Nancy J; Dillon, Kristen R; Snow, A Lynn

2017-08-01

Enhanced interpersonal relationships and meaningful resident engagement in daily life are central to nursing home cultural transformation, yet these critical components of person-centered care may be difficult for frontline staff to measure using traditional research instruments. To address the need for easy-to-use instruments to help nursing home staff members evaluate and improve person-centered care, the psychometric method of cognitive-based interviewing was used to adapt a structured observation instrument originally developed for researchers and nursing home surveyors. Twenty-eight staff members from 2 Veterans Health Administration (VHA) nursing homes participated in 1 of 3 rounds of cognitive-based interviews, using the instrument in real-life situations. Modifications to the original instrument were guided by a cognitive processing model of instrument refinement. Following 2 rounds of cognitive interviews, pretesting of the revised instrument, and another round of cognitive interviews, the resulting set of 3 short instruments mirrored the concepts of the original longer instrument but were significantly easier for frontline staff to understand and use. Final results indicated frontline staff found the revised instruments feasible to use and clinically relevant in measuring and improving the lived experience of a changing culture. This article provides a framework for developing or adapting other measurement tools for frontline culture change efforts in nursing homes, in addition to reporting on a practical set of instruments to measure aspects of person-centered care. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

E-consult implementation: lessons learned using consolidated framework for implementation research.

PubMed

Haverhals, Leah M; Sayre, George; Helfrich, Christian D; Battaglia, Catherine; Aron, David; Stevenson, Lauren D; Kirsh, Susan; Ho, Michael; Lowery, Julie

2015-12-01

In 2011, the Veterans Health Administration (VHA) implemented electronic consults (e-consults) as an alternative to in-person specialty visits to improve access and reduce travel for veterans. We conducted an evaluation to understand variation in the use of the new e-consult mechanism and the causes of variable implementation, guided by the Consolidated Framework for Implementation Research (CFIR). Qualitative case studies of 3 high- and 5 low-implementation e-consult pilot sites. Participants included e-consult site leaders, primary care providers, specialists, and support staff identified using a modified snowball sample. We used a 3-step approach, with a structured survey of e-consult site leaders to identify key constructs, based on the CFIR. We then conducted open-ended interviews, focused on key constructs, with all participants. Finally, we produced structured, site-level ratings of CFIR constructs and compared them between high- and low-implementation sites. Site leaders identified 14 initial constructs. We conducted 37 interviews, from which 4 CFIR constructs distinguished high implementation e-consult sites: compatibility, networks and communications, training, and access to knowledge and information. For example, illustrating compatibility, a specialist at a high-implementation site reported that the site changed the order of consult options so that all specialties listed e-consults first to maintain consistency. High-implementation sites also exhibited greater agreement on constructs. By using the CFIR to analyze results, we facilitate future synthesis with other findings, and we better identify common patterns of implementation determinants common across settings.

Chronic disease management for recently homeless veterans: a clinical practice improvement program to apply home telehealth technology to a vulnerable population.

PubMed

Gabrielian, Sonya; Yuan, Anita; Andersen, Ronald M; McGuire, James; Rubenstein, Lisa; Sapir, Negar; Gelberg, Lillian

2013-03-01

Although vulnerable populations may benefit from in-home health information technologies (HIT) that promote disease self-management, there is a "digital divide" in which these groups are often unlikely to use such programs. We describe the early phases of applying and testing an existing Veterans Affairs (VA) HIT-care management program, Care Coordination Home Telehealth (CCHT), to recently homeless Veterans in the US Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) program. Peers were used to support patient participation. CCHT uses in-home messaging devices to provide health education and daily questions about clinical indicators from chronic illness care guidelines, with patient responses reviewed by VHA nurses. Patients could also receive adjunctive peer support. We used medical record review, Veteran interviews, and staff surveys to "diagnose" barriers to CCHT use, assess program acceptability, explore the role of peer support, and inform future quality improvement. Fourteen eligible Veterans in HUD-VASH agreed to CCHT participation. Ten of these Veterans opted to have adjunctive peer support and the other 4 enrolled in CCHT usual care. Although barriers to enrollment/engagement must be addressed, this subset of Veterans in HUD-VASH was satisfied with CCHT. Most Veterans did not require support from peers to engage in CCHT but valued peer social assistance amidst the isolation felt in their scattered-site homes. HIT tools hold promise for in-home care management for recently housed Veterans. Patient-level barriers to enrollment must be addressed in the next steps of quality improvement, testing and evaluating peer-driven CCHT recruitment.

Implementation of an Anesthesia Information Management System in an Ambulatory Surgery Center.

PubMed

Mudumbai, Seshadri C

2016-01-01

Anesthesia information management systems (AIMS) are increasingly being implemented throughout the United States. However, little information exists on the implementation process for AIMS within ambulatory surgery centers (ASC). The objectives of this descriptive study are to document: 1) the phases of implementation of an AIMS at an ASC; and 2) lessons learnt from a socio-technical perspective. The ASC, within the Veterans Health Administration (VHA), has hosted an AIMS since 2008. As a quality improvement effort, we implemented a new version of the AIMS. This new version involved fundamental software changes to enhance clinical care such as real-time importing of laboratory data and total hardware exchange. The pre-implementation phase involved coordinated preparation over six months between multiple informatics teams along with local leadership. During this time, we conducted component, integration, and validation testing to ensure correct data flow from medical devices to AIMS and centralized databases. The implementation phase occurred in September 2014 over three days and was successful. Over the next several months, during post-implementation phase, we addressed residual items like latency of the application. Important lessons learnt from the implementation included the utility of partnering early with executive leadership; ensuring end user acceptance of new clinical workflow; continuous testing of data flow; use of a staged rollout; and providing additional personnel throughout implementation. Implementation of an AIMS at an ASC can utilize methods developed for large hospitals. However, issues unique to an ASC such as limited number of support personnel and distinctive workflows must be considered.

Evaluation of a Shared Decision-Making Intervention on the Utilization of Evidence-Based Psychotherapy in a VA Outpatient PTSD Clinic.

PubMed

Hessinger, Jonathan D; London, Melissa J; Baer, Sheila M

2017-03-13

The Veterans Health Administration (VHA) has continued to emphasize the availability, access, and utilization of high quality mental health care particularly in the treatment of posttraumatic stress disorder (PTSD). While dissemination and availability of evidence-based psychotherapies (EBPs) have only increased, treatment engagement and utilization have continued to be oft-noted challenges. Administrators, researchers, and individual clinicians have continued to develop and explore novel systemic and individualized interventions to address these issues. Pilot studies utilizing shared decision-making models to aid in veteran treatment selection have demonstrated the impact this approach may have on selection of and engagement in EBPs for PTSD. Based on these promising studies, a Department of Veterans Affairs (VA) outpatient PTSD clinic began to implement a shared-decision making intervention as part of a clinic redesign. In seeking to evaluate the impact of this intervention, archival clinical data from 1,056 veterans were reviewed by the authors for rates of treatment selection, EBP initiation, session attendance, and EBP completion. Time elapsed from consult until EBP initiation was also computed by the authors. These variables were then compared on the basis of whether the veteran received the shared-decision making intervention. Veterans who received the intervention were more likely to select and thus initiate an EBP for PTSD sooner than veterans who did not receive this intervention. Veterans, whether receiving the intervention or not, did not differ in therapy session attendance and completion. Implications of these findings and directions for future study are further discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Pharmacotherapy for alcohol dependence: perceived treatment barriers and action strategies among Veterans Health Administration service providers.

PubMed

Harris, Alex H S; Ellerbe, Laura; Reeder, Rachelle N; Bowe, Thomas; Gordon, Adam J; Hagedorn, Hildi; Oliva, Elizabeth; Lembke, Anna; Kivlahan, Daniel; Trafton, Jodie A

2013-11-01

Although access to and consideration of pharmacological treatments for alcohol dependence are consensus standards of care, receipt of these medications by patients is generally rare and highly variable across treatment settings. The goal of the present project was to survey and interview the clinicians, managers, and pharmacists affiliated with addiction treatment programs within Veterans Health Administration (VHA) facilities to learn about their perceptions of barriers and facilitators regarding greater and more reliable consideration of pharmacological treatments for alcohol dependence. Fifty-nine participants from 19 high-adopting and 11 low-adopting facilities completed the survey (facility-level response rate = 50%) and 23 participated in a structured interview. The top 4 barriers to increased consideration and use of pharmacotherapy for alcohol dependence were consistent across high- and low-adopting facilities and included perceived low patient demand, pharmacy procedures or formulary restrictions, lack of provider skills or knowledge regarding pharmacotherapy for alcohol dependence, and lack of confidence in treatment effectiveness. Low patient demand was rated as the most important barrier for oral naltrexone and disulfiram, whereas pharmacy or formulary restrictions were rated as the most important barrier for acamprosate and extended-release naltrexone. The 4 strategies rated across low- and high-adopting facilities as most likely to facilitate consideration and use of pharmacotherapy for alcohol dependence were more education to patients about existing medications, more education to health care providers about medications, increased involvement of physicians in treatment for alcohol dependence, and more compelling research on existing medications. This knowledge provides a foundation for designing, deploying, and evaluating targeted implementation efforts.

The Research Implications of Prostate Specific Antigen Registry Errors: Data from the Veterans Health Administration.

PubMed

Guo, David P; Thomas, I-Chun; Mittakanti, Harsha R; Shelton, Jeremy B; Makarov, Danil V; Skolarus, Ted A; Cooperberg, Mathew R; Sonn, Geoffrey A; Chung, Benjamin I; Brooks, James D; Leppert, John T

2018-04-06

We sought to characterize the effects of prostate specific antigen registry errors on clinical research by comparing cohorts based on cancer registry prostate specific antigen values with those based directly on results in the electronic health record. We defined sample cohorts of men with prostate cancer using data from the VHA (Veterans Health Administration), including those with a prostate specific antigen value less than 4.0, 4.0 to 10.0, 10.0 to 20.0 and 20.0 to 98.0 ng/ml, respectively. We compared the composition of each cohort and overall patient survival when using PSA values from the VACCR (Veteran Affairs Central Cancer Registry) vs the gold standard electronic health record laboratory file results. There was limited agreement among cohorts when defined by cancer registry PSA values vs the laboratory file of the electronic health record. The least agreement of 58% was seen in patients with PSA less than 4.0 ng/ml and greatest agreement of 89% was noted among patients with PSA between 4.0 and 10.0 ng/ml. In each cohort patients assigned to a cohort based only on the cancer registry PSA value had significantly different overall survival when compared with patients assigned based on registry and laboratory file PSA values. Cohorts based exclusively on cancer registry PSA values may have high rates of misclassification that can introduce concerning differences in key characteristics and result in measurable differences in clinical outcomes. Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Services Receipt Following Veteran Outpatients' Positive Screen for Homelessness.

PubMed

Montgomery, Ann E; Dichter, Melissa E; Thomasson, Arwin M; Roberts, Christopher B

2016-03-01

The Veterans Health Administration seeks to reduce homelessness among Veterans by identifying, and providing prevention and supportive services to, patients with housing concerns. The objectives of this study were to assess the proportion of Veterans Health Administration patients who received homeless or social work services within 6 months of a positive screen for homelessness or risk in the Veterans Health Administration and the demographic and clinical characteristics that predicted services utilization. Data were from a cohort of 27,403 Veteran outpatients who screened positive for homelessness or risk between November 1, 2012 and January 31, 2013. During 2013, AORs were calculated using a mixed-effects logistic regression to estimate the likelihood of patients' receipt of VHA homeless or social work services based on demographic and clinical characteristics. The majority of patients received services within 6 months post-screening; predictors of services utilization varied by gender. Among women, diagnosis of drug abuse and psychosis predicted receipt of services, being unmarried increased the odds of using services among those screening positive for homelessness, and a diagnosis of post-traumatic stress disorder increased the odds of receiving services for at-risk women. Among men, being younger, unmarried, not service-connected/Medicaid-eligible, and having a medical or behavioral health condition predicted receipt of services. Receipt of housing support services among Veterans post-homelessness screening differs by patient demographic and clinical characteristics. Future research should investigate the role that primary and secondary prevention interventions play in Veterans' resolution of risk for homelessness and experience of homelessness. Published by Elsevier Inc.

Linkages between organization climate and work outcomes: perceptual differences among health service professionals as a function of customer contact intensity.

PubMed

Scotti, Dennis J; Harmon, Joel

2014-01-01

The delivery of high-quality service, rendered by health service professionals who interact with customers (patients), increases the likelihood that customers will form positive evaluations of the quality of their service encounters as well as high levels of customer satisfaction. Using linkage theory to develop our conceptual framework, we identify four clusters of variables which contribute to a chain of sequential events that connect organization climate to personal and operational work outcomes. We then examine the perceptual differences of service professionals, grouped by intensity of customer contact, with respect to these variables. National data for this project were obtained from multiple sources made available by the Veterans Healthcare Administration (VHA). Cross-group differences were tested using a series of variance analyses. The results indicate that level of customer-contact intensity plays a significant role in explaining variation in perceptions of support staff, clinical practitioners, and nurses at the multivariate and univariate levels of analysis. Contact intensity appears to be a core determinant of the nature of work performed by health service professionals as well as their psychological responses to organizational and customer-related dynamics. Health service professionals are important resources because of their specialized knowledge, labor expense, and scarcity. Based on findings from our research, managers are advised to survey employees' perceptions of their organizational environment and design practices that respond to the unique viewpoints of each of the professional groups identified in this study. Such tailoring should help executives maximize the value of investments in human resources by underwriting patient satisfaction and financial sustainability.

Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic.

PubMed

Kehle-Forbes, Shannon M; Meis, Laura A; Spoont, Michele R; Polusny, Melissa A

2016-01-01

Emerging data suggest that few veterans are initiating prolonged exposure (PE) and cognitive processing therapy (CPT) and dropout levels are high among those who do start the therapies. The goal of this study was to use a large sample of veterans seen in routine clinical care to 1) report the percent of eligible and referred veterans who (a) initiated PE/CPT, (b) dropped out of PE/CPT, (c) were early PE/CPT dropouts, 2) examine predictors of PE/CPT initiation, and 3) examine predictors of early and late PE/CPT dropout. We extracted data from the medical records of 427 veterans who were offered PE/CPT following an intake at a Veterans Health Administration (VHA) PTSD Clinical Team. Eighty-two percent (n = 351) of veterans initiated treatment by attending Session 1 of PE/CPT; among those veterans, 38.5% (n = 135) dropped out of treatment. About one quarter of veterans who dropped out were categorized as early dropouts (dropout before Session 3). No significant predictors of initiation were identified. Age was a significant predictor of treatment dropout; younger veterans were more likely to drop out of treatment than older veterans. Therapy type was also a significant predictor of dropout; veterans receiving PE were more likely to drop out late than veterans receiving CPT. Findings demonstrate that dropout from PE/CPT is a serious problem and highlight the need for additional research that can guide the development of interventions to improve PE/CPT engagement and adherence. (c) 2016 APA, all rights reserved).

Associations between AUDIT-C and mortality vary by age and sex.

PubMed

Harris, Alex H S; Bradley, Katharine A; Bowe, Thomas; Henderson, Patricia; Moos, Rudolf

2010-10-01

We sought to determine the sex- and age-specific risk of mortality associated with scores on the 3-item Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) questionnaire using data from a national sample of Veterans Health Administration (VHA) patients. Men (N = 215,924) and women (N = 9168) who completed the AUDIT-C in a patient survey were followed for 24 months. AUDIT-C categories (0, 1-4, 5-8, 9-12) were evaluated as predictors of mortality in logistic regression models, adjusted for age, race, education, marital status, smoking, depression, and comorbidities. For women, AUDIT-C scores of 9-12 were associated with a significantly increased risk of death compared to the AUDIT-C 1-4 group (odds ratio [OR] 7.09; 95% confidence interval [CI] = 2.67, 18.82). For men overall, AUDIT-C scores of 5-8 and 9-12 were associated with increased risk of death compared to the AUDIT-C 1-4 group (OR 1.13, 95% CI = 1.05, 1.21, and OR 1.63, 95% CI = 1.45, 1.84, respectively) but these associations varied by age. These results provide sex- and age-tailored risk information that clinicians can use in evidence-based conversations with patients about the health-related risks of their alcohol consumption. This study adds to the growing literature establishing the AUDIT-C as a scaled marker of alcohol-related risk or "vital sign" that might facilitate the detection and management of alcohol-related risks and problems.

"Do good and talk about it". A CHRISTUS health study emphasizes the importance of telling our stories to the public.

PubMed

Meyer, Donna; Wei, Raymond

2005-01-01

In a time of public scrutiny, it is paramount that Catholic health care organizations examine their commitments to their communities and effectively communicate community benefit activities to stakeholders-employees, physicians, patients, and the public. CHRISTUS Academy, a leadership development program at CHRISTUS Health, Irving, TX, conducted two studies regarding community benefit. The first researched community benefit practices at more than 20 highly respected, tax-exempt CHA- and VHA-member organizations, comparing them with the practices of about 40 publicly traded, for-profit organizations. The primary conclusion was that community benefit is not just about measuring the numbers-it is also about "telling the story." Unlike the for-profit organizations, tax-exempt health care organizations tend to struggle with adequately measuring and reporting their community contributions. In a second study, the academy surveyed CHRISTUS Health's employees and physicians regarding their knowledge of the system's commitment vis-à-vis identifying and meeting community needs. The vast majority said the system is important to the community and is actively involved in understanding and meeting the needs of the community. However, they also ranked the system lower in terms of working with other community organizations, being a leader in community health, and being known for sponsoring volunteer activities. These lower rankings indicate that the community benefit activities are not well publicized or known within the organization. Catholic health organizations must take an active approach in communicating their work to the public, the media, and each other. In doing so, they fulfill an integral part their mission.

The Influence of Prescription Opioid Use Duration and Dose on Development of Treatment Resistant Depression

PubMed Central

Scherrer, Jeffrey F.; Salas, Joanne; Sullivan, Mark D.; Schneider, F. David; Bucholz, Kathleen K.; Burroughs, Thomas; Copeland, Laurel; Ahmedani, Brian; Lustman, Patrick J.

2016-01-01

Long-term prescription opioid use is associated both with new-onset and recurrence of depression. Whether chronic opioid use interferes with depression management has not been reported, therefore we determined whether patients’ longer duration of opioid use and higher opioid dose are associated with new-onset treatment resistant depression (TRD) after controlling for confounding from pain and other variables. Data was obtained from Veteran Health Administration (VHA) de-identified patient medical records. We used a retrospective cohort design from 2000–2012. Eligible subjects (n=6,169) were 18–80 years of age, free of cancer and HIV, diagnosed with depression and opioid-free for the 24-month interval prior to the observation period. Duration of a new prescription for opioid analgesic was categorized as 1–30 days, 31–90 days and >90 days. Morphine-equivalent dose (MED) during follow-up categorized as ≤50 mg versus >50 mg per day. Pain and other sources of confounding were controlled by propensity scores and inverse probability of treatment weighting. Cox proportional hazard models were computed to estimate the association between duration and dose of opioid and onset of TRD. After removing confounding by weighting data, opioid use for 31–90 days and for >90 days, compared to 1–30 days, was significantly associated with new onset TRD (HR=1.25; 95%CI: 1.09–1.45 and HR=1.52; 95%CI: 1.32–1.74, respectively). MED was not associated with new onset TRD. The risk of developing TRD increased as time spent on opioid analgesics increased. Long-term opioid treatment of chronic pain may interfere with treatment of depression. PMID:27497660

Detection of Shiga toxin-producing Escherichia coli by sandwich enzyme-linked immunosorbent assay using chicken egg yolk IgY antibodies

PubMed Central

Parma, Y. R.; Chacana, P. A.; Lucchesi, P. M. A.; Rogé, A.; Granobles Velandia, C. V.; Krüger, A.; Parma, A. E.; Fernández-Miyakawa, M. E.

2012-01-01

Enterohemorrhagic Escherichia coli (EHEC), a subset of Shiga toxin producing E. coli (STEC) is associated with a spectrum of diseases that includes diarrhea, hemorrhagic colitis and a life-threatening hemolytic-uremic syndrome (HUS). Regardless of serotype, Shiga toxins (Stx1 and/or Stx2) are uniformly expressed by all EHEC, and so exploitable targets for laboratory diagnosis of these pathogens. In this study, a sandwich ELISA for determination of Shiga toxin (Stx) was developed using anti-Stx2B subunit antibodies and its performance was compared with that of the Vero cell assay and a commercial immunoassay kit. Chicken IgY was used as capture antibody and a HRP-conjugated rabbit IgG as the detection antibody. The anti-Stx2B IgY was harvested from eggs laid by hens immunized with a recombinant protein fragment. Several parameters were tested in order to optimize the sandwich ELISA assay, including concentration of antibodies, type and concentration of blocking agent, and incubation temperatures. Supernatants from 42 STEC strains of different serotypes and stx variants, including stx2EDL933, stx2vha, stx2vhb, stx2g, stx1EDL933, and stx1d were tested. All Stx variants were detected by the sandwich ELISA, with a detection limit of 115 ng/ml Stx2. Twenty three strains negative for stx genes, including different bacteria species, showed no activity in Vero cell assay and produced negative results in ELISA, except for two strains. Our results show that anti-Stx2B IgY sandwich ELISA could be used in routine diagnosis as a rapid, specific and economic method for detection of Shiga toxin-producing E. coli. PMID:22919675

Virtual Breakthrough Series, Part 2: Improving Fall Prevention Practices in the Veterans Health Administration.

PubMed

Zubkoff, Lisa; Neily, Julia; Quigley, Pat; Soncrant, Christina; Young-Xu, Yinong; Boar, Shoshana; Mills, Peter D

2016-11-01

The Veterans Health Administration (VHA) implemented a Virtual Breakthrough Series (VBTS) collaborative to help prevent falls and fall-related injuries. This project enabled teams to expand program infrastructure, redesign improvement strategies, and enhance program evaluation. A VBTS collaborative involves prework, action, and continuous improvement. Actions included educational calls, monthly reports, coaching, and feedback. Evaluation included assessment of interventions, team capacity and infrastructure changes, and rates of falls and fall-related major injuries. Fifty-nine teams completed the project. The majority submitted monthly reports. The average number of interventions per team was 6.66 (range, 1-12; mode = 6). The most frequently implemented changes were staff education; post-fall huddles; data tracking; and classifying falls, handoff communication, and intentional rounding. On a program questionnaire aggregated average summary scores improved from 136.54 (baseline) to 58.26 (follow-up; range, 0-189; p < 0.0001). The mean aggregated fall-related major injury rate for participants decreased from 6.8 to 4.8 per 100,000 bed-days of care (p = 0.02), or 5 major injuries avoided per month. No statistically significant changes occurred for nonparticipants. The mean aggregated fall rate did not change significantly from baseline to follow-up for participants (p = 0.42) or nonparticipants (p = 0.21). Teams submitted reports and implemented changes resulting in decreased major injuries related to falls for participating units. Teams also made changes in their fall prevention programs such as classifying how they analyze falls and implementing injury reduction strategies. The approaches used show promise for reducing fall-related harm for inpatients, as well as assisting teams in implementing changes. Copyright 2016 The Joint Commission.

Predictors of Start of Different Antidepressants in Patient Charts among Patients with Depression

PubMed Central

Kim, Hyungjin Myra; Zivin, Kara; Choe, Hae Mi; Stano, Clare M.; Ganoczy, Dara; Walters, Heather; Valenstein, Marcia

2016-01-01

Background In usual psychiatric care, antidepressant treatments are selected based on physician and patient preferences rather than being randomly allocated, resulting in spurious associations between these treatments and outcome studies. Objectives To identify factors recorded in electronic medical chart progress notes predictive of antidepressant selection among patients who had received a depression diagnosis. Methods This retrospective study sample consisted of 556 randomly selected Veterans Health Administration (VHA) patients diagnosed with depression from April 1, 1999 to September 30, 2004, stratified by the antidepressant agent, geographic region, gender, and year of depression cohort entry. Predictors were obtained from administrative data, and additional variables were abstracted from electronic medical chart notes in the year prior to the start of the antidepressant in five categories: clinical symptoms and diagnoses, substance use, life stressors, behavioral/ideation measures (e.g., suicide attempts), and treatments received. Multinomial logistic regression analysis was used to assess the predictors associated with different antidepressant prescribing, and adjusted relative risk ratios (RRR) are reported. Results Of the administrative data-based variables, gender, age, illicit drug abuse or dependence, and number of psychiatric medications in prior year were significantly associated with antidepressant selection. After adjusting for administrative data-based variables, sleep problems (RRR = 2.47) or marital issues (RRR = 2.64) identified in the charts were significantly associated with prescribing mirtazapine rather than sertraline; however, no other chart-based variables showed a significant association or an association with a large magnitude. Conclusion Some chart data-based variables were predictive of antidepressant selection, but we neither found many nor found them highly predictive of antidepressant selection in patients treated for depression

Occupational medicine specialist referral triggers: Mixed-methods analysis of teleconsult cases.

PubMed

Eaton, J L; Mohammad, A; Mohr, D C; Brustein, D J; Kirkhorn, S R

2017-12-30

Qualitative analyses can yield critical lessons for learning organizations in healthcare. Few studies have applied these techniques in the field of occupational and environmental medicine (OEM). To describe the characteristics of complex cases referred for OEM subspecialty evaluation and variation by referring provider's training. Using a mixed methods approach, we conducted a content analysis of clinical cases submitted to a national OEM teleconsult service. Consecutive cases entered between April 2014 and July 2015 were screened, coded and analysed. 108 cases were available for analysis. Local Veterans Health Administration (VHA) non-specialist providers entered a primary medical diagnosis in 96% of cases at the time of intake. OEM speciality physicians coded significant medical conditions based on free text comments. Coder inter-rater reliability was 84%. The most frequent medical diagnosis types associated with tertiary OEM referral by non-specialists were endocrine (19%), cardiovascular (18%) and mental health (16%). Concern for usage of controlled and/or sedating medications was cited in 1% of cases. Compared to referring non-specialists, OEM physicians were more likely to attribute case complexity to musculoskeletal (OR: 2.3, 1.68-3.14) or neurological (OR: 1.69, 1.28-2.24) conditions. Medication usage (OR: 2.2, 1.49-2.26) was more likely to be a source of clinical concern among referring providers. The findings highlight the range of triggers for OEM physician subspecialty referral in clinical practice with employee patients. The results of this study can be used to inform development of provider education, standardized clinical practice pathways, and quality review activities for occupational medicine practitioners. Published by Oxford University Press on behalf of The Society of Occupational Medicine 2017.

Cost-effectiveness of Collaborative Care for Depression in Human Immunodeficiency Virus Clinics

PubMed Central

Fortney, John C; Gifford, Allen L; Rimland, David; Monson, Thomas; Rodriguez-Barradas, Maria C.; Pyne, Jeffrey M

2015-01-01

Objective To examine the cost-effectiveness of the HITIDES intervention. Design Randomized controlled effectiveness and implementation trial comparing depression collaborative care with enhanced usual care. Setting Three Veterans Health Administration (VHA) HIV clinics in the Southern US. Subjects 249 HIV-infected patients completed the baseline interview; 123 were randomized to the intervention and 126 to usual care. Intervention HITIDES consisted of an off-site HIV depression care team that delivered up to 12 months of collaborative care. The intervention used a stepped-care model for depression treatment and specific recommendations were based on the Texas Medication Algorithm Project and the VA/Department of Defense Depression Treatment Guidelines. Main outcome measure(s) Quality-adjusted life years (QALYs) were calculated using the 12-Item Short Form Health Survey, the Quality of Well Being Scale, and by converting depression-free days to QALYs. The base case analysis used outpatient, pharmacy, patient, and intervention costs. Cost-effectiveness was calculated using incremental cost effectiveness ratios (ICERs) and net health benefit (NHB). ICER distributions were generated using nonparametric bootstrap with replacement sampling. Results The HITIDES intervention was more effective and cost-saving compared to usual care in 78% of bootstrapped samples. The intervention NHB was positive and therefore deemed cost-effective using an ICER threshold of $50,000/QALY. Conclusions In HIV clinic settings this intervention was more effective and cost-saving compared to usual care. Implementation of off-site depression collaborative care programs in specialty care settings may be a strategy that not only improves outcomes for patients, but also maximizes the efficient use of limited healthcare resources. PMID:26102447

Dissemination of CBTI to the Non-Sleep Specialist: Protocol Development and Training Issues

PubMed Central

Manber, Rachel; Carney, Colleen; Edinger, Jack; Epstein, Dana; Friedman, Leah; Haynes, Patricia L.; Karlin, Bradley E.; Pigeon, Wilfred; Siebern, Allison T.; Trockel, Mickey

2012-01-01

Strong evidence supports the efficacy of cognitive behavioral therapy for insomnia (CBTI). A significant barrier to wide dissemination of CBTI is the lack of qualified practitioners. We describe challenges and decisions made when developing a CBTI dissemination program in the Veterans Health Administration (VHA). The program targets mental health clinicians from different disciplines (psychiatry, psychology, social work, and nursing) with varying familiarity and experience with general principles of cognitive behavioral therapies (CBT). We explain the scope of training (how much to teach about the science of sleep, comorbid sleep disorders, other medical and mental health comorbidities, and hypnotic-dependent insomnia), discuss adaptation of CBTI to address the unique challenges posed by comorbid insomnia, and describe decisions made about the strategy of training (principles, structure and materials developed/recommended). Among these decisions is the question of how to balance the structure and flexibility of the treatment protocol. We developed a case conceptualization-driven approach and provide a general session-by-session outline. Training licensed therapists who already have many professional obligations required that the training be completed in a relatively short time with minimal disruptions to training participants' routine work responsibilities. These “real-life” constraints shaped the development of this competency-based, yet pragmatic training program. We conclude with a description of preliminary lessons learned from the initial wave of training and propose future directions for research and dissemination. Citation: Manber R; Carney C; Edinger J; Epstein D; Friedman L; Haynes PL; Karlin BE; Pigeon W; Siebern AT; Trockel M. Dissemination of CBTI to the non-sleep specialist: protocol development and training issues. J Clin Sleep Med 2012;8(2):209-218. PMID:22505869

Root cause analysis of serious adverse events among older patients in the Veterans Health Administration.

PubMed

Lee, Alexandra; Mills, Peter D; Neily, Julia; Hemphill, Robin R

2014-06-01

Preventable adverse events are more likely to occur among older patients because of the clinical complexity of their care. The Veterans Health Administration (VHA) National Center for Patient Safety (NCPS) stores data about serious adverse events when a root cause analysis (RCA) has been performed. A primary objective of this study was to describe the types of adverse events occurring among older patients (age > or = 65 years) in Department of Veterans Affairs (VA) hospitals. Secondary objectives were to determine the underlying reasons for the occurrence of these events and report on effective action plans that have been implemented in VA hospitals. In a retrospective, cross-sectional review, RCA reports were reviewed and outcomes reported using descriptive statistics for all VA hospitals that conducted an RCA for a serious geriatric adverse event from January 2010 to January 2011 that resulted in sustained injury or death. The search produced 325 RCA reports on VA patients (age > or = 65 years). Falls (34.8%), delays in diagnosis and/or treatment (11.7%), unexpected death (9.9%), and medication errors (9.0%) were the most commonly reported adverse events among older VA patients. Communication was the most common underlying reason for these events, representing 43.9% of reported root causes. Approximately 40% of implemented action plans were judged by local staff to be effective. The RCA process identified falls and communication as important themes in serious adverse events. Concrete actions, such as process standardization and changes to communication, were reported by teams to yield some improvement. However, fewer than half of the action plans were reported to be effective. Further research is needed to guide development and implementation of effective action plans.

Abstinence Reinforcement Therapy (ART) for Rural Veterans: Methodology for an mHealth Smoking Cessation Intervention

PubMed Central

Wilson, Sarah M.; Hair, Lauren P.; Hertzberg, Jeffrey S.; Kirby, Angela C.; Olsen, Maren K.; Lindquist, Jennifer H.; Maciejewski, Matthew L.; Beckham, Jean C.; Calhoun, Patrick S.

2016-01-01

Introduction Smoking is the most preventable cause of morbidity and mortality in U.S. veterans. Rural veterans in particular have elevated risk for smoking and smoking-related illness. However, these veterans underutilize smoking cessation treatment, which suggests that interventions for rural veterans should optimize efficacy and reach. Objective The primary goal of the current study is to evaluate the effectiveness of an intervention that combines evidenced based treatment for smoking cessation with smart-phone based, portable contingency management on smoking rates compared to a contact control intervention in a randomized controlled trial among rural Veteran smokers. Specifically, Veterans will be randomized to receive Abstinence Reinforcement Therapy (ART) which combines evidenced based cognitive-behavioral telephone counseling (TC), a tele-medicine clinic for access to nicotine replacement (NRT), and mobile contingency management (mCM) or a control condition (i.e., TC and NRT alone) that will provide controls for therapist, medication, time and attention effects. Methods Smokers were identified using VHA electronic medical records and recruited proactively via telephone. Participants (N = 310) are randomized to either ART or a best practice control consisting of telephone counseling and telemedicine. Participating patients will be surveyed at 3-months, 6-months and 12-months post-randomization. The primary outcome measure is self-reported and biochemically validated prolonged abstinence at 6-month follow-up. Discussion This trial is designed to test the relative effectiveness of ART compared to a telehealth-only comparison group. Dissemination of this mHealth intervention for veterans in a variety of settings would be warranted if ART improves smoking outcomes for rural veterans and is cost-effective. PMID:27521811

Disruption of cellulose synthesis by 2,6-dichlorobenzonitrile affects the structure of the cytoskeleton and cell wall construction in Arabidopsis.

PubMed

Peng, L; Zhang, L; Cheng, X; Fan, L-S; Hao, H-Q

2013-03-01

Cellulose is the major component of plant cell walls and is an important source of industrial raw material. Although cellulose biosynthesis is one of the most important biochemical processes in plant biology, the regulatory mechanisms of cellulose synthesis are still unclear. Here, we report that 2,6-dichlorobenzonitrile (DCB), an inhibitor of cellulose synthesis, inhibits Arabidopsis root development in a dose- and time-dependent manner. When treated with DCB, the plant cell wall showed altered cellulose distribution and intensity, as shown by calcofluor white and S4B staining. Moreover, pectin deposition was reduced in the presence of DCB when immunostained with the monoclonal antibody JIM5, which was raised against pectin epitopes. This result was confirmed using Fourier transform infrared (FTIR) analysis. Confocal microscopy revealed that the organisation of the microtubule cytoskeleton was significantly disrupted in the presence of low concentrations of DCB, whereas the actin cytoskeleton only showed changes with the application of high DCB concentrations. In addition, the subcellular dynamics of Golgi bodies labelled with N-ST-YFP and TGN labelled with VHA-a1-GFP were both partially blocked by DCB. Transmission electron microscopy indicated that the cell wall structure was affected by DCB, as were the Golgi bodies. Scanning electron microscopy showed changes in the organisation of cellulose microfibrils. These results suggest that the inhibition of cellulose synthesis by DCB not only induced changes in the chemical composition of the root cell wall and cytoskeleton structure, but also changed the distribution of cellulose microfibrils, implying that cellulose plays an important role in root development in Arabidopsis. © 2012 German Botanical Society and The Royal Botanical Society of the Netherlands.

Temperature Modulates the Effects of Ocean Acidification on Intestinal Ion Transport in Atlantic Cod, Gadus morhua

PubMed Central

Hu, Marian Y.; Michael, Katharina; Kreiss, Cornelia M.; Stumpp, Meike; Dupont, Sam; Tseng, Yung-Che; Lucassen, Magnus

2016-01-01

CO2-driven seawater acidification has been demonstrated to enhance intestinal bicarbonate secretion rates in teleosts, leading to an increased release of CaCO3 under simulated ocean acidification scenarios. In this study, we investigated if increasing CO2 levels stimulate the intestinal acid–base regulatory machinery of Atlantic cod (Gadus morhua) and whether temperatures at the upper limit of thermal tolerance stimulate or counteract ion regulatory capacities. Juvenile G. morhua were acclimated for 4 weeks to three CO2 levels (550, 1200, and 2200 μatm) covering present and near-future natural variability, at optimum (10°C) and summer maximum temperature (18°C), respectively. Immunohistochemical analyses revealed the subcellular localization of ion transporters, including Na+/K+-ATPase (NKA), Na+/H+-exchanger 3 (NHE3), Na+/HCO3− cotransporter (NBC1), pendrin-like Cl−/HCO3− exchanger (SLC26a6), V-type H+-ATPase subunit a (VHA), and Cl− channel 3 (CLC3) in epithelial cells of the anterior intestine. At 10°C, proteins and mRNA were generally up-regulated for most transporters in the intestinal epithelium after acclimation to higher CO2 levels. This supports recent findings demonstrating increased intestinal HCO3− secretion rates in response to CO2 induced seawater acidification. At 18°C, mRNA expression and protein concentrations of most ion transporters remained unchanged or were even decreased, suggesting thermal compensation. This response may be energetically favorable to retain blood HCO3− levels to stabilize pHe, but may negatively affect intestinal salt and water resorption of marine teleosts in future oceans. PMID:27313538

Temperature Modulates the Effects of Ocean Acidification on Intestinal Ion Transport in Atlantic Cod, Gadus morhua.

PubMed

Hu, Marian Y; Michael, Katharina; Kreiss, Cornelia M; Stumpp, Meike; Dupont, Sam; Tseng, Yung-Che; Lucassen, Magnus

2016-01-01

CO2-driven seawater acidification has been demonstrated to enhance intestinal bicarbonate secretion rates in teleosts, leading to an increased release of CaCO3 under simulated ocean acidification scenarios. In this study, we investigated if increasing CO2 levels stimulate the intestinal acid-base regulatory machinery of Atlantic cod (Gadus morhua) and whether temperatures at the upper limit of thermal tolerance stimulate or counteract ion regulatory capacities. Juvenile G. morhua were acclimated for 4 weeks to three CO2 levels (550, 1200, and 2200 μatm) covering present and near-future natural variability, at optimum (10°C) and summer maximum temperature (18°C), respectively. Immunohistochemical analyses revealed the subcellular localization of ion transporters, including Na(+)/K(+)-ATPase (NKA), Na(+)/H(+)-exchanger 3 (NHE3), Na(+)/[Formula: see text] cotransporter (NBC1), pendrin-like Cl(-)/[Formula: see text] exchanger (SLC26a6), V-type H(+)-ATPase subunit a (VHA), and Cl(-) channel 3 (CLC3) in epithelial cells of the anterior intestine. At 10°C, proteins and mRNA were generally up-regulated for most transporters in the intestinal epithelium after acclimation to higher CO2 levels. This supports recent findings demonstrating increased intestinal [Formula: see text] secretion rates in response to CO2 induced seawater acidification. At 18°C, mRNA expression and protein concentrations of most ion transporters remained unchanged or were even decreased, suggesting thermal compensation. This response may be energetically favorable to retain blood [Formula: see text] levels to stabilize pHe, but may negatively affect intestinal salt and water resorption of marine teleosts in future oceans.

Associations Between AUDIT-C and Mortality Vary by Age and Sex

PubMed Central

Bradley, Katharine A.; Bowe, Thomas; Henderson, Patricia; Moos, Rudolf

2010-01-01

Abstract We sought to determine the sex- and age-specific risk of mortality associated with scores on the 3-item Alcohol Use Disorder Identification Test–Consumption (AUDIT-C) questionnaire using data from a national sample of Veterans Health Administration (VHA) patients. Men (N = 215,924) and women (N = 9168) who completed the AUDIT-C in a patient survey were followed for 24 months. AUDIT-C categories (0, 1–4, 5–8, 9–12) were evaluated as predictors of mortality in logistic regression models, adjusted for age, race, education, marital status, smoking, depression, and comorbidities. For women, AUDIT-C scores of 9–12 were associated with a significantly increased risk of death compared to the AUDIT-C 1-4 group (odds ratio [OR] 7.09; 95% confidence interval [CI] = 2.67, 18.82). For men overall, AUDIT-C scores of 5–8 and 9–12 were associated with increased risk of death compared to the AUDIT-C 1-4 group (OR 1.13, 95% CI = 1.05, 1.21, and OR 1.63, 95% CI = 1.45, 1.84, respectively) but these associations varied by age. These results provide sex- and age-tailored risk information that clinicians can use in evidence-based conversations with patients about the health-related risks of their alcohol consumption. This study adds to the growing literature establishing the AUDIT-C as a scaled marker of alcohol-related risk or “vital sign” that might facilitate the detection and management of alcohol-related risks and problems. (Population Health Management 2010;13:263–268) PMID:20879907

Overall quality of life and difficulty paying for ostomy supplies in the Veterans Affairs ostomy health-related quality of life study: an exploratory analysis.

PubMed

Coons, Stephen Joel; Chongpison, Yuda; Wendel, Christopher S; Grant, Marcia; Krouse, Robert S

2007-09-01

To explore whether there was a significant relationship between difficulty paying for ostomy supplies and overall quality of life among a sample of ostomates receiving care from the Veterans Health Administration (VHA). The data were collected as part of the Veterans Affairs (VA) Ostomy Health-Related Quality of Life Study, in which 511 respondents (239 cases, 272 controls) completed a survey instrument that included the modified City of Hope Quality of Life (mCOH-QOL) Ostomy questionnaire, SF-36V, and sociodemographic items. Responses from the 239 cases (ie, patients with intestinal stomas) were used in this analysis. The modified City of Hope Quality of Life Ostomy questionnaire item, "How good is your overall quality of life?," was the dependent variable for this analysis. The primary independent variable was the response (yes/no) to the item, "If you pay for any of the (ostomy) costs, is it difficult for you?" A hierarchical regression model was used to examine whether difficulty paying was significantly related to overall quality of life after adjusting for age, income, race/ethnicity, and physical health. After accounting for the proportion of variance explained by age, income, race/ethnicity, and physical health, the additional proportion of variance explained by difficulty paying was statistically significant. Individuals reporting difficulty paying had a roughly 1 point lower (ie, beta-coefficient = -1.052; SE = 0.481) overall quality of life score on the 11-point scale. We found a significant association between difficulty paying for ostomy supplies and overall quality of life. Although the cross-sectional study design does not allow causal inference, the results suggest a relationship that merits further examination.

Elements of the Veterans Health Administration Patient-Centered Medical Home are Associated with Greater Adherence to Oral Hypoglycemic Agents in Patients with Diabetes.

PubMed

Meo, Nicholas; Wong, Edwin; Sun, Haili; Curtis, Idamay; Batten, Adam; Fihn, Stephan D; Nelson, Karin

2018-04-01

In 2010, Veterans Health Administration (VHA) primary care clinics adopted a patient-centered medical home (PCMH) model. This study sought to examine the association between the organizational features related to adoption of PCMH and the level of adherence to oral hypoglycemic agents (OHAs) among patients with diabetes. This retrospective cohort study involved 757 VA clinics that provide primary care to 440,971 patients with diabetes who were taking OHAs in fiscal year 2012. One-year refill-based medication possession ratios (MPRs) were calculated at the patient level. Clinic-level adherence was defined as the proportion of clinics with MPR ≥80%. Risk adjustment of adherence was performed using logistic regression to account for differences in patient populations at clinics. Eight domains of the PCMH model (ie, access, continuity, coordination, teamwork, comprehensive care, self-management, communication, shared decision making) were assessed using items from a previously validated index. Multivariate linear regression was applied to identify PCMH components associated with clinic-level adherence. Patients with diabetes per clinic ranged from 100 to 5011. The average level of adherence to OHAs among clinics ranged from 52.8% to 61.9% (interquartile range = 57.9% to 59.4%). In multivariate analysis, organizational features associated with higher clinic-level adherence included access to routine care (standardized beta [Sβ] = .21, P = .004), having a respectful office staff (Sβ = 0.21, P = .002), and utilization of telephone encounters (Sβ = 0.23, P < .001). Among a national cohort of veterans with diabetes, overall PCMH implementation did not significantly increase adherence to oral hypoglycemic agents, although aspects of implementation were associated with increased adherence. Measures of access to care appear the most significant.

Impact of presumed service-connected diagnosis on the Department of Veterans Affairs healthcare utilization patterns of Vietnam-Theater Veterans

PubMed Central

Fried, Dennis A.; Rajan, Mangala; Tseng, Chin-lin; Helmer, Drew

2018-01-01

Abstract During the Vietnam War, the US military sprayed almost 20 million gallons of Agent Orange (AO), an herbicide contaminated with dioxin, over Vietnam. Approximately, 2.7 million US military personnel may have been exposed to AO during their deployment. Ordinarily, veterans who can demonstrate a nexus between a diagnosed condition and military service are eligible for Department of Veterans Affairs (VA) service-connected disability compensation. Vietnam Veterans have had difficulty, however, establishing a nexus between AO exposure and certain medical conditions that developed many years after the war. In response, VA has designated certain conditions as “presumed service connected” for Vietnam Veterans who were present and possibly exposed. Veterans with any of these designated conditions do not have to document AO exposure, making it easier for them to access the VA disability system. The extent to which VA healthcare utilization patterns reflect easier access afforded those with diagnosed presumptive conditions remains unknown. In this cross-sectional study, we hypothesized that Vietnam Veterans with diagnosed presumptive conditions would be heavier users of the VA healthcare system than those without these conditions. In our analysis of 85,699 Vietnam Veterans, we used binary and cumulative logit multivariable regression to assess associations between diagnosed presumptive conditions and VA healthcare utilization in 2013. We found that diagnosed presumptive conditions were associated with higher odds of 5+ VHA primary care visits (OR = 2.01, 95% CI: 1.93–2.07), 5+ specialty care visits (OR = 2.11, 95% CI: 2.04–2.18), emergency department use (OR = 1.22, 95% CI: 1.11–1.34), and hospitalization (OR = 1.23, 95% CI: 1.17–1.29). Consistent with legislative intent, presumptive policies appear to facilitate greater VA system utilization for Vietnam Veterans who may have been exposed to AO. PMID:29742706

Women's Heart Advantage Program: the impact 3 years later.

PubMed

Gombeski, William R; Kramer, R Kyle; Freed, Lisa; Foody, JoAnne; Parkosewich, Janet; Wilson, Tammi; Wack, Jeffery T; D'Onofrio, Gail

2005-01-01

Yale-New Haven Hospital, in partnership with Voluntary Hospital Association (VHA Inc), launched the Women's Heart Advantage program in March 2001. Major program components implemented include (1) a comprehensive initial and ongoing internal communication program; (2) a health promotion initiative including a 24-hour, 7-days-a-week women's heart line staffed by nurses and an Internet health question-and-answer forum; (3) significant ongoing communication with nurses and physicians; (4) a community outreach effort to educate poor and minority women; and (5) an aggressive effort to secure financial partners to underwrite the cost of the program. Before launching the program, a telephone survey of 300 randomly selected New Haven County women ages 40 to 70 years was initiated in January 2001 and repeated in January 2002, 2003, and 2004. Findings include (1) the percentage of women who recognize heart disease as the number-one killer of women their age increased from 26% in 2001 to 59% in 2004, (2) the percentage of women who would call 9-1-1 or go directly to a hospital emergency department increased from 63% in 2002 to 83% in 2004, and (3) the percentage of women aware of recent Women's Heart Advantage program promotion grew from 33% in 2002 to 50% in 2004. Perhaps most importantly, the number of women with heart problems admitted through the hospital's emergency department increased from 1528 per year in 2001 to 1870 per year in 2004 (7.5% annual increase), whereas the number of men with heart problems admitted through the emergency department during the same time period has been relatively low (0.8% annual increase). By linking clinical, public health, and marketing expertise along with finding ways to partner with other organizations, the Women's Heart Advantage program has contributed to remarkable changes in women's awareness, knowledge, and behaviors, suggesting a model for approaching similar health-related problems.

Homeland security and public health: role of the Department of Veterans Affairs, the US Department of Homeland Security, and implications for the public health community.

PubMed

Koenig, Kristi L

2003-01-01

The terrorist attacks of 11 September 2001 led to the largest US Government transformation since the formation of the Department of Defense following World War II. More than 22 different agencies, in whole or in part, and >170,000 employees were reorganized to form a new Cabinet-level Department of Homeland Security (DHS), with the primary mission to protect the American homeland. Legislation enacted in November 2002 transferred the entire Federal Emergency Management Agency and several Department of Health and Human Services (HHS) assets to DHS, including the Office of Emergency Response, and oversight for the National Disaster Medical System, Strategic National Stockpile, and Metropolitan Medical Response System. This created a potential separation of "health" and "medical" assets between the DHS and HHS. A subsequent presidential directive mandated the development of a National Incident Management System and an all-hazard National Response Plan. While no Department of Veterans Affairs (VA) assets were targeted for transfer, the VA remains the largest integrated healthcare system in the nation with important support roles in homeland security that complement its primary mission to provide care to veterans. The Emergency Management Strategic Healthcare Group (EMSHG) within the VA's medical component, the Veteran Health Administration (VHA), is the executive agent for the VA's Fourth Mission, emergency management. In addition to providing comprehensive emergency management services to the VA, the EMSHG coordinates medical back-up to the Department of Defense, and assists the public via the National Disaster Medical System and the National Response Plan. This article describes the VA's role in homeland security and disasters, and provides an overview of the ongoing organizational and operational changes introduced by the formation of the new DHS. Challenges and opportunities for public health are highlighted.

Women Veterans’ Experience With a Web-Based Diabetes Prevention Program: A Qualitative Study to Inform Future Practice

PubMed Central

Ertl, Kristyn; Schneider, Jessica; Vasti, Elena; Makki, Fatima; Richardson, Caroline; Havens, Kathryn; Damschroder, Laura

2015-01-01

Background Diabetes prevention is a national goal and particularly important in the Veterans Health Administration (VHA) where 1 in 4 veterans has diabetes. There is growing evidence to support the use of Web-based diabetes prevention program (DPP) interventions, shown to be as effective and often more feasible than in-person interventions. Objective Our primary objective was to qualitatively explore women veterans’ early experiences with a Web-based DPP intervention. Our secondary objective was to estimate weight loss, participation, and engagement to provide context for our qualitative findings. Methods We conducted and analyzed semistructured interviews and collected data on weight change, participation, and engagement. A total of 17 women veterans with prediabetes from a Midwest VA Women’s Health Clinic were eligible to participate; 15 completed interviews. Results Participants perceived the DPP program as an appealing way of initiating lifestyle changes and made them feel accountable in achieving their daily goals. The online program was convenient because it could be accessed at any time, and many found that it integrated well into daily life. However, some did not like the logging aspect and some found it to be too impersonal. Participants logged in a mean 76 times, posted a mean 46 group messages, and sent a mean 20.5 private messages to the health coach over 16 weeks. Participants lost 5.24% of baseline weight, and 82% (14/17) of participants completed at least 9 of 16 core modules. Conclusions Women veterans’ early experiences with a Web-based DPP intervention were generally positive. Accountability and convenience were key enabling factors for participation and engagement. A Web-based DPP intervention appears to be a promising means of translating the DPP for women veterans with prediabetes. PMID:26006697

Open access in the patient-centered medical home: lessons from the Veterans Health Administration.

PubMed

True, Gala; Butler, Anneliese E; Lamparska, Bozena G; Lempa, Michele L; Shea, Judy A; Asch, David A; Werner, Rachel M

2013-04-01

The Veterans Health Administration (VHA) has undertaken a 5-year initiative to transform to a patient-centered medical home model. An early focus of implementation was on creating open access, defined as continuity and capacity in primary care. We describe the impact of readiness for implementation on efforts of pilot teams to make changes to improve access and identify successful strategies used by early adopters to overcome barriers to change. A qualitative, formative evaluation of the first 18 months of implementation in one Veterans Integrated Service Network (VISN) spread across six states. Members of local implementation teams including administrators, primary care providers, and staff from primary care clinics located at 10 medical centers and 45 outpatient clinics. We conducted site visits during the first 6 months of implementation, observations at Learning Collaboratives, semi-structured interviews, and review of internal organizational documents. All data collection took place between April 2010 and December 2011. Early adopters employed various strategies to enhance access, with a focus on decreasing demand for face-to-face care, increasing supply of different types of primary care encounters, and improving clinic efficiencies. Our interviews with key contacts revealed three important areas where readiness for implementation (or lack thereof) had an impact on interventions to improve access: leadership engagement, staffing resources, and access to information and knowledge. Key factors related to readiness for implementation had an impact on which interventions pilot teams could put into place, as well as the viability and sustainability of access gains. Wide variations in interventions to improve access occurring across sites situated within one organization have important implications for efforts to measure the impact of enhanced access on patient outcomes, costs, and other systems-level indicators of the Medical Home.

Qualitative analysis of patient-centered decision attributes associated with initiating hepatitis C treatment.

PubMed

Zuchowski, Jessica L; Hamilton, Alison B; Pyne, Jeffrey M; Clark, Jack A; Naik, Aanand D; Smith, Donna L; Kanwal, Fasiha

2015-10-01

In this era of a constantly changing landscape of antiviral treatment options for chronic viral hepatitis C (CHC), shared clinical decision-making addresses the need to engage patients in complex treatment decisions. However, little is known about the decision attributes that CHC patients consider when making treatment decisions. We identify key patient-centered decision attributes, and explore relationships among these attributes, to help inform the development of a future CHC shared decision-making aid. Semi-structured qualitative interviews with CHC patients at four Veterans Health Administration (VHA) hospitals, in three comparison groups: contemplating CHC treatment at the time of data collection (Group 1), recently declined CHC treatment (Group 2), or recently started CHC treatment (Group 3). Participant descriptions of decision attributes were analyzed for the entire sample as well as by patient group and by gender. Twenty-nine Veteran patients participated (21 males, eight females): 12 were contemplating treatment, nine had recently declined treatment, and eight had recently started treatment. Patients on average described eight (range 5-13) decision attributes. The attributes most frequently reported overall were: physical side effects (83%); treatment efficacy (79%), new treatment drugs in development (55%); psychological side effects (55%); and condition of the liver (52%), with some variation based on group and gender. Personal life circumstance attributes (such as availability of family support and the burden of financial responsibilities) influencing treatment decisions were also noted by all participants. Multiple decision attributes were interrelated in highly complex ways. Participants considered numerous attributes in their CHC treatment decisions. A better understanding of these attributes that influence patient decision-making is crucial in order to inform patient-centered clinical approaches to care (such as shared decision-making augmented

Factors associated with internal medicine physician job attitudes in the Veterans Health Administration.

PubMed

Mohr, David C; Eaton, Jennifer L; Meterko, Mark; Stolzmann, Kelly L; Restuccia, Joseph D

2018-04-05

US healthcare organizations increasingly use physician satisfaction and attitudes as a key performance indicator. Further, many health care organizations also have an academically oriented mission. Physician involvement in research and teaching may lead to more positive workplace attitudes, with subsequent decreases in turnover and beneficial impact on patient care. This article aimed to understand the influence of time spent on academic activities and perceived quality of care in relation to job attitudes among internal medicine physicians in the Veterans Health Administration (VHA). A cross-sectional survey was conducted with inpatient attending physicians from 36 Veterans Affairs Medical Centers. Participants were surveyed regarding demographics, practice settings, workplace staffing, perceived quality of care, and job attitudes. Job attitudes consisted of three measures: overall job satisfaction, intent to leave the organization, and burnout. Analysis used a two-level hierarchical model to account for the nesting of physicians within medical centers. The regression models included organizational-level characteristics: inpatient bed size, urban or rural location, hospital teaching affiliation, and performance-based compensation. A total of 373 physicians provided useable survey responses. The majority (72%) of respondents reported some level of teaching involvement. Almost half (46%) of the sample reported some level of research involvement. Degree of research involvement was a significant predictor of favorable ratings on physician job satisfaction and intent to leave. Teaching involvement did not have a significant impact on outcomes. Perceived quality of care was the strongest predictor of physician job satisfaction and intent to leave. Perceived levels of adequate physician staffing was a significant contributor to all three job attitude measures. Expanding opportunities for physician involvement with research may lead to more positive work experiences

Impact of presumed service-connected diagnosis on the Department of Veterans Affairs healthcare utilization patterns of Vietnam-Theater Veterans: A cross-sectional study.

PubMed

Fried, Dennis A; Rajan, Mangala; Tseng, Chin-Lin; Helmer, Drew

2018-05-01

During the Vietnam War, the US military sprayed almost 20 million gallons of Agent Orange (AO), an herbicide contaminated with dioxin, over Vietnam. Approximately, 2.7 million US military personnel may have been exposed to AO during their deployment. Ordinarily, veterans who can demonstrate a nexus between a diagnosed condition and military service are eligible for Department of Veterans Affairs (VA) service-connected disability compensation. Vietnam Veterans have had difficulty, however, establishing a nexus between AO exposure and certain medical conditions that developed many years after the war. In response, VA has designated certain conditions as "presumed service connected" for Vietnam Veterans who were present and possibly exposed. Veterans with any of these designated conditions do not have to document AO exposure, making it easier for them to access the VA disability system. The extent to which VA healthcare utilization patterns reflect easier access afforded those with diagnosed presumptive conditions remains unknown. In this cross-sectional study, we hypothesized that Vietnam Veterans with diagnosed presumptive conditions would be heavier users of the VA healthcare system than those without these conditions. In our analysis of 85,699 Vietnam Veterans, we used binary and cumulative logit multivariable regression to assess associations between diagnosed presumptive conditions and VA healthcare utilization in 2013. We found that diagnosed presumptive conditions were associated with higher odds of 5+ VHA primary care visits (OR = 2.01, 95% CI: 1.93-2.07), 5+ specialty care visits (OR = 2.11, 95% CI: 2.04-2.18), emergency department use (OR = 1.22, 95% CI: 1.11-1.34), and hospitalization (OR = 1.23, 95% CI: 1.17-1.29). Consistent with legislative intent, presumptive policies appear to facilitate greater VA system utilization for Vietnam Veterans who may have been exposed to AO.

Characteristics of Travellers from Bosnia and Herzegovina to Africa

PubMed Central

Obradovic, Zarema; Obradovic, Amina

2013-01-01

Conflict of interest: none declared. Introduction Travellers from Bosnia and Herzegovina (B&H) travel to different world countries. The awareness of people is changing every day and nowadays travellers seek advices related to their travel and destination more often than before. In the previous years, travellers came to Travel Clinics almost only to get the vaccines which were obligatory for entry into a country. In B&H travel clinics are a part of public health institutes. The largest Travel Clinic which provides service for the highest number of travellers is in the Public Health Institute of Sarajevo Canton, in the city of Sarajevo, which is the capital of B&H. In the last years we have seen an increasing interest for travel to Africa because the highest number of travellers travel to African countries. Objective To show the characteristics of persons travelling to Africa, the reasons of their travel, the destination countries and the types of vaccines applied. Materials and methods We used protocol books of the Travel Clinic in Public Health Institute of Sarajevo Canton and the data from individual forms of travellers. Results Persons travelling to Africa make 55% of all travellers that are advised and vaccinated in the Travel Clinic in Public Health Institute of Sarajevo Canton. There are significantly more men than women among people travelling to Africa. The highest number of travellers is in the category of working population which means age group of 20-50 years. The most visited countries are Kenya, Ethiopia, Somalia and Ghana. Travellers received the following vaccines: yellow fever, VHA, VHB, meningitis, tetanus. All travellers were given the advice on how to dress, feed and protect against malaria. PMID:24082834

Comparative Effectiveness of Insulin versus Combination Sulfonylurea and Insulin: a Cohort Study of Veterans with Type 2 Diabetes.

PubMed

Min, Jea Young; Griffin, Marie R; Hung, Adriana M; Grijalva, Carlos G; Greevy, Robert A; Liu, Xulei; Elasy, Tom; Roumie, Christianne L

2016-06-01

Type 2 diabetes patients often initiate treatment with a sulfonylurea and subsequently intensify their therapy with insulin. However, information on optimal treatment regimens for these patients is limited. To compare risk of cardiovascular disease (CVD) and hypoglycemia between sulfonylurea initiators who switch to or add insulin. This was a retrospective cohort assembled using national Veterans Health Administration (VHA), Medicare, and National Death Index databases. Veterans who initiated diabetes treatment with a sulfonylurea between 2001 and 2008 and intensified their regimen with insulin were followed through 2011. The association between insulin versus sulfonylurea + insulin and time to CVD or hypoglycemia were evaluated using Cox proportional hazard models in a 1:1 propensity score-matched cohort. CVD included hospitalization for acute myocardial infarction or stroke, or cardiovascular mortality. Hypoglycemia included hospitalizations or emergency visits for hypoglycemia, or outpatient blood glucose measurements <60 mg/dL. Subgroups included age < 65 and ≥ 65 years and estimated glomerular filtration rate ≥ 60 and < 60 ml/min. There were 1646 and 3728 sulfonylurea monotherapy initiators who switched to insulin monotherapy or added insulin, respectively. The 1596 propensity score-matched patients in each group had similar baseline characteristics at insulin initiation. The rate of CVD per 1000 person-years among insulin versus sulfonylurea + insulin users were 49.3 and 56.0, respectively [hazard ratio (HR) 0.85, 95 % confidence interval (CI) 0.64, 1.12]. Rates of first and recurrent hypoglycemia events per 1000 person-years were 74.0 and 100.0 among insulin users compared to 78.9 and 116.8 among sulfonylurea plus insulin users, yielding HR (95 % CI) of 0.94 (0.76, 1.16) and 0.87 (0.69, 1.10), respectively. Subgroup analysis results were consistent with the main findings. Compared to sulfonylurea users who added insulin, those who switched

Residential treatment for combat-related posttraumatic stress disorder: identifying trajectories of change and predictors of treatment response.

PubMed

Currier, Joseph M; Holland, Jason M; Drescher, Kent D

2014-01-01

Combat-related posttraumatic stress disorder (PTSD) can be a difficult condition to treat and has been associated with serious medical and economic issues among U.S. military veterans. Distinguishing between treatment responders vs. non-responders in this population has become an important public health priority. This study was conducted to identify pre-treatment characteristics of U.S. veterans with combat-related PTSD that might contribute to favorable and unfavorable responses to high value treatments for this condition. This study focused on 805 patients who completed a VHA PTSD residential program between 2000 and 2007. These patients completed the PTSD Clinical Checklist at pre-treatment, post-treatment, and a four-month follow-up assessment. Latent growth curve analysis (LCGA) was incorporated to determine trajectories of changes in PTSD across these assessments and whether several key clinical concerns for this population were associated with their treatment responses. LCGA indicated three distinct trajectories in PTSD outcomes and identified several clinical factors that were prospectively linked with changes in veterans' posttraumatic symptomatology. When compared to a group with high PTSD symptom severity that decreased over the program but relapsed at follow-up (41%), the near half (48.8%) of the sample with an improving trajectory had less combat exposure and superior physical/mental health. However, when compared to a minority (10.2%) with relatively low symptomatology that also remained somewhat stable, patients in the improving group were younger and also reported greater combat exposure, poorer physical/mental health status, and more problems with substance abuse before the start of treatment. Findings suggest that veterans are most likely to benefit from residential treatment in an intermediate range of symptoms and risk factors, including PTSD symptom severity, history of combat exposure, and comorbid issues with physical/mental health

Implementation and dissemination of a transition of care program for rural veterans: a controlled before and after study.

PubMed

Leonard, Chelsea; Lawrence, Emily; McCreight, Marina; Lippmann, Brandi; Kelley, Lynette; Mayberry, Ashlea; Ladebue, Amy; Gilmartin, Heather; Côté, Murray J; Jones, Jacqueline; Rabin, Borsika A; Ho, P Michael; Burke, Robert

2017-10-23

Adapting promising health care interventions to local settings is a critical component in the dissemination and implementation process. The Veterans Health Administration (VHA) rural transitions nurse program (TNP) is a nurse-led, Veteran-centered intervention designed to improve transitional care for rural Veterans funded by VA national offices for dissemination to other VA sites serving a predominantly rural Veteran population. Here, we describe our novel approach to the implementation and evaluation = the TNP. This is a controlled before and after study that assesses both implementation and intervention outcomes. During pre-implementation, we assessed site context using a mixed method approach with data from diverse sources including facility-level quantitative data, key informant and Veteran interviews, observations of the discharge process, and a group brainstorming activity. We used the Practical Robust Implementation and Sustainability Model (PRISM) to inform our inquiries, to integrate data from all sources, and to identify factors that may affect implementation. In the implementation phase, we will use internal and external facilitation, paired with audit and feedback, to encourage appropriate contextual adaptations. We will use a modified Stirman framework to document adaptations. During the evaluation phase, we will measure intervention and implementation outcomes at each site using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance). We will conduct a difference-in-differences analysis with propensity-matched Veterans and VA facilities as a control. Our primary intervention outcome is 30-day readmission and Emergency Department visit rates. We will use our findings to develop an implementation toolkit that will inform the larger scale-up of the TNP across the VA. The use of PRISM to inform pre-implementation evaluation and synthesize data from multiple sources, coupled with internal and external facilitation, is a

An implementation-focused process evaluation of an incentive intervention effectiveness trial in substance use disorders clinics at two Veterans Health Administration medical centers.

PubMed

Hagedorn, Hildi J; Stetler, Cheryl B; Bangerter, Ann; Noorbaloochi, Siamak; Stitzer, Maxine L; Kivlahan, Daniel

2014-07-09

One of the pressing concerns in health care today is the slow rate at which promising interventions, supported by research evidence, move into clinical practice. One potential way to speed this process is to conduct hybrid studies that simultaneously combine the collection of effectiveness and implementation relevant data. This paper presents implementation relevant data collected during a randomized effectiveness trial of an abstinence incentive intervention conducted in substance use disorders treatment clinics at two Veterans Health Administration (VHA) medical centers. Participants included patients entering substance use disorders treatment with diagnoses of alcohol dependence and/or stimulant dependence that enrolled in the randomized trial, were assigned to the intervention arm, and completed a post intervention survey (n = 147). All staff and leadership from the participating clinics were eligible to participate. A descriptive process evaluation was used, focused on participant perceptions and contextual/feasibility issues. Data collection was guided by the RE-AIM and PARIHS implementation frameworks. Data collection methods included chart review, intervention cost tracking, patient and staff surveys, and qualitative interviews with staff and administrators. Results indicated that patients, staff and administrators held generally positive attitudes toward the incentive intervention. However, staff and administrators identified substantial barriers to routine implementation. Despite the documented low cost and modest staff time required for implementation of the intervention, securing funding for the incentives and freeing up any staff time for intervention administration were identified as primary barriers. Recommendations to facilitate implementation are presented. Recommendations include: 1) solicit explicit support from the highest levels of the organization through, for example, performance measures or clinical practice guideline recommendations; 2

SU-F-T-223: Radiotherapy Incident Reporting and Analysis System (RIRAS):Early Experience

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kapoor, R; Palta, J; Hagan, M

Background & Purpose: RIRAS is a web-based information system deployed on the Veterans Health Administration intranet in early 2014 to collect adverse events and good catch data; analyze the causes and contributing factors; and find ways to prevent future occurrences. Material and Methods: Incident learning consists of a feedback loop which starts with reporting an event, followed by analysis of contributing factors, and culminates in the development of a patient safety work product (PSWP) to prevent recurrence. RIRAS permits both anonymous and non-anonymous reporting. Each report is analyzed by a team of medical physicists who are independent of the reportingmore » facility. The analysts usually contact the reporting facilities for additional information. We analyzed all reports and held telephonic interviews (when necessary) with the reporters. We then generated PSWPs with corrective/preventive and learning actions. Anonymous reporting is handled in the same manner, except without the ability to further interview the reporter. Results: In a significant number of reports, the causes and recommended preventive actions were considerably altered by the independent analysis and additional information from the facility. 130 reports have been entered in RIRAS; 9 misadministrations, 83 good catches, 3 anonymous good catches, and 35 earlier reported incidents from FY2005-14. 45% of the reported incidents occurred in the treatment delivery stages, 19% in on-treatment management, and 16% in pre-treatment verification. 80% of the good catches were found in the treatment delivery workflow. Majority of these incidents were due to inconsistent patient setup instructions or documentation, nonadherence to policies and procedures, lax time-out policy, distracted RTTs, and inadequate RTT staffing. Conclusion: RIRAS has identified many areas for improvement and elevated the quality and safety of radiation treatments in the VHA. We found that the ability to learn is significantly

Implementation Processes and Pay for Performance in Healthcare: A Systematic Review.

PubMed

Kondo, Karli K; Damberg, Cheryl L; Mendelson, Aaron; Motu'apuaka, Makalapua; Freeman, Michele; O'Neil, Maya; Relevo, Rose; Low, Allison; Kansagara, Devan

2016-04-01

Over the last decade, various pay-for-performance (P4P) programs have been implemented to improve quality in health systems, including the VHA. P4P programs are complex, and their effects may vary by design, context, and other implementation processes. We conducted a systematic review and key informant (KI) interviews to better understand the implementation factors that modify the effectiveness of P4P. We searched PubMed, PsycINFO, and CINAHL through April 2014, and reviewed reference lists. We included trials and observational studies of P4P implementation. Two investigators abstracted data and assessed study quality. We interviewed P4P researchers to gain further insight. Among 1363 titles and abstracts, we selected 509 for full-text review, and included 41 primary studies. Of these 41 studies, 33 examined P4P programs in ambulatory settings, 7 targeted hospitals, and 1 study applied to nursing homes. Related to implementation, 13 studies examined program design, 8 examined implementation processes, 6 the outer setting, 18 the inner setting, and 5 provider characteristics. Results suggest the importance of considering underlying payment models and using statistically stringent methods of composite measure development, and ensuring that high-quality care will be maintained after incentive removal. We found no conclusive evidence that provider or practice characteristics relate to P4P effectiveness. Interviews with 14 KIs supported limited evidence that effective P4P program measures should be aligned with organizational goals, that incentive structures should be carefully considered, and that factors such as a strong infrastructure and public reporting may have a large influence. There is limited evidence from which to draw firm conclusions related to P4P implementation. Findings from studies and KI interviews suggest that P4P programs should undergo regular evaluation and should target areas of poor performance. Additionally, measures and incentives should align

[Acute pancreatitis and acalculous cholecystitis associated with viral hepatitis A].

PubMed

Arcana, Ronald; Frisancho, Oscar

2011-01-01

We report the case of a 14 year-old male from Lima. He is a student with a history of bronchial asthma since age 4 receives conditional salbutamol, corticosteroids used for asthma attacks (a crisis in 2010, 1 month ago) Refuses surgery or transfusions. He presented with a two weeks for abdominal pain, nausea, fever, and jaundice. Epigastric pain is colicky and radiated back to righ upper quadrant, refers in addition to nausea and fever, for ten days notice jaundice of skin and sclera. On examen he was lucid, with jaundice of skin and mucous membranes. There was no palpable lymph nodes, abdomen with bowel sounds, soft, depressible, liver span of 15cm, positive Murphy, no peritonitis. The laboratory findings showed hemoglobin 13gr, MCV 90, platelets 461.000/mm3, WBC 4320/mm, lymphocytes 1700 (39%). total bilirubin: 8.8, B Direct: 7.6, ALT (alanine aminotransferase): 3016, AST (aspartate aminotransferase): 984, alkaline phosphatase: 250, albumin: 3.34gr%, globulin: 2.8, amylase: 589 (high serum amylase), TP: 17, INR: 1.6, VHA IgM positive. 89 mg glucose, urea 19 mg%, creatinine 0.5 mg Hemoglobin 13gr, MCV 90 Platelet 461000/mm3, WBC 4320/mm, Lymphocytes 1700 (39%). The nuclear magnetic resonance showed hepatomegaly associated with thickening of gallbladder wall without stones up to 11mm inside. No bile duct dilatation, bile duct 4mm, pancreas increased prevalence of body size. Mild splenomegaly and free fluid in the space of Morrison and right flank. Abdominal ultrasound revealed a gallbladder wall thickness (11mm), without stones in his light. Pancreas to increase volume with peripancreatic fluid free perivesicular with a volume of 430 cc. Findings consistent with acute acalculous cholecystitis and acute pancreatitis. CT-scan showed enlarged pancreas with predominance of body and tail with peripancreatic edema; the gallbladder was thickening. We report this case because the extrahepatic manifestations of viral hepatitis A infection are uncommon, specially the

Prevalence of Central Nervous System Polypharmacy and Associations with Overdose and Suicide-Related Behaviors in Iraq and Afghanistan War Veterans in VA Care 2010-2011.

PubMed

Collett, Garen A; Song, Kangwon; Jaramillo, Carlos A; Potter, Jennifer S; Finley, Erin P; Pugh, Mary Jo

The increase in the quantities of central nervous system (CNS)-acting medications prescribed has coincided with increases in overdose mortality, suicide-related behaviors, and unintentional deaths in military personnel deployed in support of the wars in Iraq and Afghanistan. Data on the extent and impact of prescribing multiple CNS drugs among Iraq and Afghanistan Veterans (IAVs) are sparse. We sought to identify the characteristics of IAVs with CNS polypharmacy and examine the association of CNS polypharmacy with drug overdose and suicide-related behaviors controlling for known risk factors. This cross-sectional cohort study examined national data of Iraq and Afghanistan Veterans ( N  = 311,400) who used the Veterans Health Administration (VHA) during the fiscal year 2011. CNS polypharmacy was defined as five or more CNS-acting medications; drug/alcohol overdose and suicide-related behaviors were identified using ICD-9-CM codes. Demographic and clinical characteristics associated with CNS polypharmacy were identified using a multivariable logistic regression model. We found that 25,546 (8.4 %) of Iraq and Afghanistan Veterans had CNS polypharmacy. Those with only post-traumatic stress disorder (PTSD) (adjusted odds ratio (AOR) 6.50, 99 % confidence interval (CI) 5.96-7.10), only depression (AOR 6.42, 99 % CI 5.86-7.04), co-morbid PTSD and depression (AOR 12.98, 99 % CI 11.97-14.07), and co-morbid traumatic brain injury (TBI), PTSD, and depression (AOR 15.30, 99 % CI 14.00-16.73) had the highest odds of CNS polypharmacy. After controlling for these co-morbid conditions, CNS polypharmacy was significantly associated with drug/alcohol overdose and suicide-related behavior. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI, and independently associated with overdose and suicide-related behavior after controlling for known risk factors. These findings suggest that CNS polypharmacy may be used as an indicator of risk for adverse outcomes

Prevalence of Central Nervous System Polypharmacy and Associations with Overdose and Suicide-Related Behaviors in Iraq and Afghanistan War Veterans in VA Care 2010-2011.

PubMed

Collett, Garen A; Song, Kangwon; Jaramillo, Carlos A; Potter, Jennifer S; Finley, Erin P; Pugh, Mary Jo

2016-03-01

The increase in the quantities of central nervous system (CNS)-acting medications prescribed has coincided with increases in overdose mortality, suicide-related behaviors, and unintentional deaths in military personnel deployed in support of the wars in Iraq and Afghanistan. Data on the extent and impact of prescribing multiple CNS drugs among Iraq and Afghanistan Veterans (IAVs) are sparse. We sought to identify the characteristics of IAVs with CNS polypharmacy and examine the association of CNS polypharmacy with drug overdose and suicide-related behaviors controlling for known risk factors. This cross-sectional cohort study examined national data of Iraq and Afghanistan Veterans (N = 311,400) who used the Veterans Health Administration (VHA) during the fiscal year 2011. CNS polypharmacy was defined as five or more CNS-acting medications; drug/alcohol overdose and suicide-related behaviors were identified using ICD-9-CM codes. Demographic and clinical characteristics associated with CNS polypharmacy were identified using a multivariable logistic regression model. We found that 25,546 (8.4 %) of Iraq and Afghanistan Veterans had CNS polypharmacy. Those with only post-traumatic stress disorder (PTSD) (adjusted odds ratio (AOR) 6.50, 99 % confidence interval (CI) 5.96-7.10), only depression (AOR 6.42, 99 % CI 5.86-7.04), co-morbid PTSD and depression (AOR 12.98, 99 % CI 11.97-14.07), and co-morbid traumatic brain injury (TBI), PTSD, and depression (AOR 15.30, 99 % CI 14.00-16.73) had the highest odds of CNS polypharmacy. After controlling for these co-morbid conditions, CNS polypharmacy was significantly associated with drug/alcohol overdose and suicide-related behavior. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI, and independently associated with overdose and suicide-related behavior after controlling for known risk factors. These findings suggest that CNS polypharmacy may be used as an indicator of risk for adverse outcomes

The quality of care delivered to Parkinson's disease patients in the U.S. Pacific Northwest Veterans Health System

PubMed Central

Swarztrauber, Kari; Graf, Eric; Cheng, Eric

2006-01-01

Background Parkinson's disease (PD) is the second most common chronic neurological disorder of the elderly. Despite the fact that a comprehensive review of general health care in the United States showed that the quality of care delivered to patients usually falls below professional standards, there is limited data on the quality of care for patients with PD. Methods Using the administrative database, the Pacific Northwest Veterans Health Administration (VHA) Data Warehouse, a population of PD patients with encounters from 10/1/98-12/31/04 were identified. A random sample of 350 patient charts underwent further review for diagnostic evaluation. All patients whose records revealed a physician diagnosis of definite or possible Idiopathic Parkinson's (IPD) disease (n = 150) were included in a medical chart review to evaluate adherence to five evidence-based quality of care indicators. Results For those care indicators with good inter-rater reliability, 16.6% of care received by PD patients was adherent for annual depression screening, 23.4% of care was adherent for annual fall screening and, 67.3% of care was adherent for management of urinary incontinence. Patients receiving specialty care were more likely to be adherent with fall screening than those not receiving specialty care OR = 2.3, 95%CI = 1.2–4.2, but less likely to be adherent with management of urinary incontinence, OR = 0.3, 95%CI = 0.1–0.8. Patients receiving care outside the VA system were more likely to be adherent with depression screening OR = 2.4, 95%CI = >1.0–5.5 and fall screening OR = 2.2, 95%CI = 1.1–4.4. Conclusion We found very low rates of adherence for annual screening for depression and falls for PD patients but reasonable adherence rates for management of urinary incontinence. Interestingly, receiving concurrent specialty care did not necessarily result in higher adherence for all care indicators suggesting some coordination and role responsibility confusion. The increased

Implementing electronic clinical reminders for lipid management in patients with ischemic heart disease in the veterans health administration: QUERI Series

PubMed Central

Sales, Anne; Helfrich, Christian; Ho, P Michael; Hedeen, Ashley; Plomondon, Mary E; Li, Yu-Fang; Connors, Alison; Rumsfeld, John S

2008-01-01

Background Ischemic heart disease (IHD) affects at least 150,000 veterans annually in the United States. Lowering serum cholesterol has been shown to reduce coronary events, cardiac death, and total mortality among high risk patients. Electronic clinical reminders available at the point of care delivery have been developed to improve lipid measurement and management in the Veterans Health Administration (VHA). Our objective was to report on a hospital-level intervention to implement and encourage use of the electronic clinical reminders. Methods The implementation used a quasi-experimental design with a comparison group of hospitals. In the intervention hospitals (N = 3), we used a multi-faceted intervention to encourage use of the electronic clinical reminders. We evaluated the degree of reminder use and how patient-level outcomes varied at the intervention and comparison sites (N = 3), with and without adjusting for self-reported reminder use. Results The national electronic clinical reminders were implemented in all of the intervention sites during the intervention period. A total of 5,438 patients with prior diagnosis of ischemic heart disease received care in the six hospitals (3 intervention and 3 comparison) throughout the 12-month intervention. The process evaluation showed variation in use of reminders at each site. Without controlling for provider self-report of use of the reminders, there appeared to be a significant improvement in lipid measurement in the intervention sites (OR 1.96, 95% CI 1.34, 2.88). Controlling for use of reminders, the amount of improvement in lipid measurement in the intervention sites was even greater (OR 2.35, CI 1.96, 2.81). Adjusting for reminder use demonstrated that only one of the intervention hospitals had a significant effect of the intervention. There was no significant change in management of hyperlipidemia associated with the intervention. Conclusion There may be some benefit to focused effort to implement electronic

Improving Clinical Workflow in Ambulatory Care: Implemented Recommendations in an Innovation Prototype for the Veteran’s Health Administration

PubMed Central

Patterson, Emily S.; Lowry, Svetlana Z.; Ramaiah, Mala; Gibbons, Michael C.; Brick, David; Calco, Robert; Matton, Greg; Miller, Anne; Makar, Ellen; Ferrer, Jorge A.

2015-01-01

Introduction: Human factors workflow analyses in healthcare settings prior to technology implemented are recommended to improve workflow in ambulatory care settings. In this paper we describe how insights from a workflow analysis conducted by NIST were implemented in a software prototype developed for a Veteran’s Health Administration (VHA) VAi2 innovation project and associated lessons learned. Methods: We organize the original recommendations and associated stages and steps visualized in process maps from NIST and the VA’s lessons learned from implementing the recommendations in the VAi2 prototype according to four stages: 1) before the patient visit, 2) during the visit, 3) discharge, and 4) visit documentation. NIST recommendations to improve workflow in ambulatory care (outpatient) settings and process map representations were based on reflective statements collected during one-hour discussions with three physicians. The development of the VAi2 prototype was conducted initially independently from the NIST recommendations, but at a midpoint in the process development, all of the implementation elements were compared with the NIST recommendations and lessons learned were documented. Findings: Story-based displays and templates with default preliminary order sets were used to support scheduling, time-critical notifications, drafting medication orders, and supporting a diagnosis-based workflow. These templates enabled customization to the level of diagnostic uncertainty. Functionality was designed to support cooperative work across interdisciplinary team members, including shared documentation sessions with tracking of text modifications, medication lists, and patient education features. Displays were customized to the role and included access for consultants and site-defined educator teams. Discussion: Workflow, usability, and patient safety can be enhanced through clinician-centered design of electronic health records. The lessons learned from implementing

Some things we can infer about the Moon from the Composition of the Apollo 16 Regolith

NASA Technical Reports Server (NTRS)

Korotev, Randy L.

1997-01-01

Characteristics of the regolith of Cayley plains as sampled at the Apollo 16 lunar landing site are reviewed and new compositional data are presented for samples of less than 1 mm fines ('soils') and 1-2 mm regolith particles. As a means of determining which of the many primary (igneous) and secondary (crystalline breccias) lithologic components that have been identified in the soil are volumetrically important and providing an estimate of their relative abundances, more than 3 x 10(exp 6) combinations of components representing nearly every lithology that has been observed in the Apollo 16 regolith were systematically tested to determine which combinations best account for the composition of the soils. Conclusions drawn from the modeling include the following. At the site, mature soil from the Cayley plains consists of 64.5% +/- 2.7% components representing 'prebasin' materials: anorthosites, feldspathic breccias, and a small amount (2.6% +/- 1.5% of total soil) of nonmare, mafic plutonic rocks, mostly gabbronorites. On average, these components are highly feldspathic, with average concentrations of 3l-32% Al2O3 and 2-3% FeO and a molar Mg/(Mg+Fe) ratio of O.68. The remaining 36% of the regolith is syn- and postbasin material: 28.8% +/- 2.4% mafic impact-melt breccias (MIMBS, i.e., 'LKFM' and 'VHA basalts') created at the time of basin formation, 6.0% +/- 1.4% mare-derived material (impact and volcanic glass, crystalline basalt) with an average TiO2 concentration of 2.4%, and 1% postbasin meteoritic material. The MIMBs are the principal (80-90%) carrier of incompatible trace elements (rare earths, Th, etc.) and the carrier of about one-half of the siderophile elements and elements associated with mafic mineral phases (Fe, Mg, Mn, Cr, Sc). Most (71 %) of the Fe in the present regolith derives from syn- and postbasin sources (MIMBS, mare-derived material, and meteorites). Thus, although the bulk composition of the Apollo 16 regolith is nominally that of noritic

Hurricanes Katrina and Rita and the Department of Veterans Affairs: a conceptual model for understanding the evacuation of nursing homes.

PubMed

Dobalian, Aram; Claver, Maria; Fickel, Jacqueline J

2010-01-01

Hurricanes Katrina and Rita exposed significant flaws in US preparedness for catastrophic events and the nation's capacity to respond to them. These flaws were especially evident in the affected disaster areas' nursing homes, which house a particularly vulnerable population of frail older adults. Although evacuation of a healthcare facility is a key preparedness activity, there is limited research on factors that lead to effective evacuation. Our review of the literature on evacuation is focused on developing a conceptual framework to study future evacuations rather than as a comprehensive assessment of prior work. This paper summarizes what is known thus far about disaster response activities of nursing homes following natural and human-caused disasters, describes a conceptual model to guide future inquiry regarding this topic, and suggests future areas of research to further understand the decision-making process of nursing home facilitators regarding evacuating nursing home residents. To demonstrate the utility of the conceptual model and to provide guidance about effective practices and procedures, this paper focuses on the responses of Veterans Health Administration (VHA) nursing homes to the 2 hurricanes. Quarantelli's conceptual framework, as modified by Perry and Mushkatel, is useful in guiding the development of central hypotheses related to the decision-making that occurred in VA nursing homes and other healthcare facilities following Hurricanes Katrina and Rita. However, we define evacuation somewhat differently to account for the fact that evacuation may, in some instances, be permanent. Thus, we propose modifying this framework to improve its applicability beyond preventive evacuation. We need to better understand how disaster plans can be adapted to meet the needs of frail elders and other residents in nursing homes. Moreover, we must address identified gaps in the scientific literature with respect to health outcomes by tracking outcomes over time

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: the Consortium Pain Task Force White Paper.

PubMed

Tick, Heather; Nielsen, Arya; Pelletier, Kenneth R; Bonakdar, Robert; Simmons, Samantha; Glick, Ronald; Ratner, Emily; Lemmon, Russell L; Wayne, Peter; Zador, Veronica

2018-03-01

Consortium Pain Taskforce White Paper Summary Evidence-based Nonpharmacologic Strategies for Comprehensive Pain Care Supplementary information can be found in the online version at https://doi.org/10.1016/j.explore.2018.02.001. Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base

National outpatient medication profiling: medications associated with outpatient fractures in community-dwelling elderly veterans

PubMed Central

French, Dustin D; Campbell, Robert; Spehar, Andrea; Rubenstein, Laurence Z; Branch, Laurence G; Cunningham, Francesca

2007-01-01

What is already known about this subject Polypharmacy, to include a subissue of potentially inappropriate prescribing, in community-dwelling elderly is widespread. The objective of this study was to identify the magnitude of problematic outpatient drug prescribing and its potential association as a risk factor for injuries. What this study adds This is the first national study of outpatient injuries in elderly veterans. The results are consistent with previous published literature highlighting the risks associated with prescribing central nervous system drugs in the elderly. Aims The primary objective of this retrospective case–control study in an elderly veteran population was to assess the impact of specific medications with recognized side-effects that increase the risk of a fall and were prescribed prior to fractures treated in the outpatient setting compared with patients treated for nonspecific chest pain. Methods Two national Veterans Health Administration (VHA) databases were used to identify 17 273 unique patients, aged ≥65 years, treated in outpatient settings with a fracture in fiscal year 2005, and for whom we could link to all of their outpatient prescriptions (809 536). For comparison, we identified other elderly patients with outpatient clinic visits for nonspecific chest pain (N = 62 331) for whom we could link with their 2 987 394 outpatient prescriptions. We categorized the fall-related medications as drugs that primarily affect the cardiovascular (CVS), the central nervous (CNS) or the muscular skeletal system (MSS). Results Significant differences in the two patient groups occurred in the CNS category. Approximately 41% of the patients with fracture-coded encounters were prescribed CNS drugs compared with 31% of the patients in the comparison group (P < 0.0003). Finally, the use of muscle relaxants in the MSS category was significantly higher in the fracture group than in the nonspecific chest pain group. Conclusions Studies using

Risk of future trauma based on alcohol screening scores: A two-year prospective cohort study among US veterans

PubMed Central

2012-01-01

Background Severe alcohol misuse as measured by the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) is associated with increased risk of future fractures and trauma-related hospitalizations. This study examined the association between AUDIT-C scores and two-year risk of any type of trauma among US Veterans Health Administration (VHA) patients and assessed whether risk varied by age or gender. Methods Outpatients (215, 924 male and 9168 female) who returned mailed AUDIT-C questionnaires were followed for 24 months in the medical record for any International Statistical Classification of Diseases and Related Health Problems (ICD-9) code related to trauma. The two-year prevalence of trauma was examined as a function of AUDIT-C scores, with low-level drinking (AUDIT-C 1–4) as the reference group. Men and women were examined separately, and age-stratified analyses were performed. Results Having an AUDIT-C score of 9–12 (indicating severe alcohol misuse) was associated with increased risk for trauma. Mean (SD) ages for men and women were 68.2 (11.5) and 57.2 (15.8), respectively. Age-stratified analyses showed that, for men ≤50 years, those with AUDIT-C scores ≥9 had an increased risk for trauma compared with those with AUDIT-C scores in the 1–4 range (adjusted prevalence, 25.7% versus 20.8%, respectively; OR = 1.24; 95% confidence interval [CI], 1.03–1.50). For men ≥65 years with average comorbidity and education, those with AUDIT-C scores of 5–8 (adjusted prevalence, 7.9% versus 7.4%; OR = 1.16; 95% CI, 1.02–1.31) and 9–12 (adjusted prevalence 11.1% versus 7.4%; OR = 1.68; 95% CI, 1.30–2.17) were at significantly increased risk for trauma compared with men ≥65 years in the reference group. Higher AUDIT-C scores were not associated with increased risk of trauma among women. Conclusions Men with severe alcohol misuse (AUDIT-C 9–12) demonstrate an increased risk of trauma. Men ≥65 showed an increased risk

Understanding Barriers and Facilitators to the use of Clinical Information Systems for Intensive Care Units and Anesthesia Record Keeping: A Rapid Ethnography

PubMed Central

Saleem, Jason J.; Plew, William R.; Speir, Ross C.; Herout, Jennifer; Wilck, Nancy R.; Ryan, Dale Marie; Cullen, Theresa A.; Scott, Jean M.; Beene, Murielle S.; Phillips, Toni

2017-01-01

lack of coordination among stakeholders; and (7) insufficient technical support. Many of these barriers are multi-faceted and have associated sub-barriers, which are described in detail along with relevant quotes from participants. In addition, regionalized purchases of different CIS and ARK systems, as opposed to enterprise level purchases, contributed to some of the identified barriers. Facilitators to system use included (1) automation and (2) a dedicated facility-level CIS-ARK coordinator. Conclusions We identified barriers that explain some of the challenges with the optimization of the CIS and ARK commercial systems across the Veterans Health Administration (VHA). To help address these barriers, and evolve them into facilitators, we categorized report findings as (1) interface and system-level changes that vendors or VA healthcare systems can implement; (2) implementation factors under VA control and not under VA control; and (3) factors that may be used to inform future application purchases. We outline several recommendations for improved adoption of CIS and ARK systems and further recommend that human factors engineering and usability requirements become an integral part of VA health information technology (HIT) application procurement, customization, and implementation in order to help eliminate or mitigate some of the barriers of use identified in this study. Human factors engineering methods can be utilized to apply a user-centered approach to application requirements specification, application evaluation, system integration, and application implementation. PMID:25843931

Understanding barriers and facilitators to the use of Clinical Information Systems for intensive care units and Anesthesia Record Keeping: A rapid ethnography.

PubMed

Saleem, Jason J; Plew, William R; Speir, Ross C; Herout, Jennifer; Wilck, Nancy R; Ryan, Dale Marie; Cullen, Theresa A; Scott, Jean M; Beene, Murielle S; Phillips, Toni

2015-07-01

stakeholders; and (7) insufficient technical support. Many of these barriers are multi-faceted and have associated sub-barriers, which are described in detail along with relevant quotes from participants. In addition, regionalized purchases of different CIS and ARK systems, as opposed to enterprise level purchases, contributed to some of the identified barriers. Facilitators to system use included (1) automation and (2) a dedicated facility-level CIS-ARK Coordinator. We identified barriers that explain some of the challenges with the optimization of the CIS and ARK commercial systems across the Veterans Health Administration (VHA). To help address these barriers, and evolve them into facilitators, we categorized report findings as (1) interface and system-level changes that vendors or VA healthcare systems can implement; (2) implementation factors under VA control and not under VA control; and (3) factors that may be used to inform future application purchases. We outline several recommendations for improved adoption of CIS and ARK systems and further recommend that human factors engineering and usability requirements become an integral part of VA health information technology (HIT) application procurement, customization, and implementation in order to help eliminate or mitigate some of the barriers of use identified in this study. Human factors engineering methods can be utilized to apply a user-centered approach to application requirements specification, application evaluation, system integration, and application implementation. Published by Elsevier Ireland Ltd.

Compositional Variation in Apollo 16 Impact-Melt Breccias and Inferences for the Geology and Bombardment History of the Central Highlands of the Moon

NASA Technical Reports Server (NTRS)

Korotev, Randy L.

1994-01-01

High-precision data for the concentrations of a number of lithophile and siderophile elements were obtained on multiple subsamples from 109 impact-melt rocks and breccias (mostly crystalline) from the Apollo 16 site. Compositions of nearly all Apollo 16 melt rocks fall on one of two trends of increasing Sm concentration with increasing Sc concentration. The Eastern trend (lower Sm/Sc, Mg/Fe, and Sm/Yb ratios) consists of compositional groups 3 and 4 of previous classification schemes. These melt rocks are feldspathic, poor in incompatible and siderophile elements, and appear to have provenance in the Descartes formation to the east of the site. The Western trend (higher Sm/Sc. Mg/Fe, and Sm/ Yb ratios) consists of compositional groups 1 and 2. These relatively mafic, KREEP-bearing breccias are a major component (approx.35%) of the Cayley plains west of the site and are unusual, compared to otherwise similar melt breccias from other sites, in having high concentrations of Fe-Ni metal ( 1-2 %). The metal is the carrier of the low-Ir/Au (approx. 0.3 x chondritic) siderophile-element signature that is characteristic of the Apollo 16 site. Four compositionally distinct groups (1M, 1F, 2DB, and 2NR) of Western-trend melt breccias occur that are each represented by at least six samples. Compositional group 1 or previous classification schemes (the 'poikilitic' or 'LKFM' melt breccias) can be subdivided into two groups. Group 1M (represented by six samples, including 60315) is characterized by lower Al2O3 concentrations, higher MgO and alkali concentrations, and higher Mg/Fe and Cr/Sc ratios than group 1F (represented by fifteen samples, including 65015). Group 1M also has siderophile-element concentrations averaging about twice those of group lF and Ir/Au and Ir/Ni ratios that are even lower than those of other Western-trend melt rocks (Ir/Au = 0.24 +/- 0.03. CI-normalized). At the mafic extreme of group 2 ('VHA' melt breccias), the melt lithology occurring as clasts in