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Anne E Sales

Publications and source records attributed to Anne E Sales.

At least 19 recordsLinked to original sources
PubMed2006

The use of percutaneous coronary intervention in black and white veterans with acute myocardial infarction.

BACKGROUND: It is uncertain whether black white differences in the use of percutaneous coronary intervention (PCI) persist in the era of drug eluting stents. The purpose of this study is to determine if black veterans with acute myocardial infarction (AMI) are less likely to receive PCI than their white counterparts. METHODS: This study included 680 black and 3529 white veterans who were admitted to Veterans Health Administration (VHA) medical centers between July 2003 and August 2004. Information for this study was collected as part of the VHA External Peer Review Program for quality monitoring and improvement for a variety of medical conditions and procedures, including AMI. In addition, Department of Veterans Affairs workload files were used to determine PCI utilization after hospital discharge. Standard statistical methods including the Chi-square, 2 sample t-test, and logistic regression with a cluster correction for medical center were used to assess the association between race and the use of PCI < or = 30 days from admission. RESULTS: Black patients were younger, more often had diabetes mellitus, renal disease, or dementia and less often had lipid disorders, previous coronary artery bypass surgery, or chronic obstructive pulmonary disease than their white counterparts. Equal proportions of blacks and whites underwent cardiac catheterization < or = 30 days after admission, but the former were less likely to undergo PCI (32% vs. 40%, p < 0.0001). This difference persisted after multivariate adjustment, although measures of the extent of coronary artery disease were not available. CONCLUSION: Given the equivalent use of cardiac catheterization, it is possible that less extensive or minimal coronary artery disease in black patients could account for the observed difference.

Black or African American↗
PubMed2006

Racial and ethnic differences in diabetes care and health care use and costs.

INTRODUCTION: Previous studies have shown racial and ethnic differences in diabetes complication rates and diabetes control. The objective of this study was to examine racial and ethnic differences in diabetes care and health care use and costs for adults with diabetes using a nationally representative sample of the U.S. noninstitutionalized civilian population. METHODS: We performed a cross-sectional analysis of the 2000 Medical Expenditure Panel Survey (MEPS) and its related Diabetes Care Survey. The respondents were adults (aged 18 years and older) with diabetes, including non-Hispanic whites, non-Hispanic African Americans, and Hispanics. Racial and ethnic differences were examined in diabetes process of care and health care use and costs using logistic regression, negative binomial regression, and ordinary least squares regression with log cost. RESULTS: Most of the outcomes in diabetes care management, treatment, and complications were not significantly different among race groups. After adjusting for socioeconomic and demographic characteristics, Hispanics were more likely to have eye problems than whites (odds ratio, 1.56; 95% confidence interval, 1.03-2.56). African Americans and Hispanics had lower total health care costs, lower ambulatory care costs, and lower prescription drug costs than whites (P < .01 for all). CONCLUSION: We found differences in ambulatory care and prescription drug fills among white, African American, and Hispanic adults with diabetes. However, most of the diabetes care measures were not significantly different among the three racial and ethnic groups. Understanding the reason outcomes do not differ when health care use and costs differ significantly should be a focus of future studies.

Adolescent↗
PubMed2006

The association between processes, structures and outcomes of secondary prevention care among VA ischemic heart disease patients.

BACKGROUND: Hyperlipidemia and hypertension are well-established risk factors for recurrent cardiovascular events among patients with ischemic heart disease (IHD). Despite national recommendations, concordance with guidelines for LDL cholesterol and blood pressure remains inadequate. The objectives of this study were to 1) determine concordance rates with LDL cholesterol and BP recommendations; and 2) identify patient factors, processes and structures of care associated with guideline concordance among VA IHD patients. METHODS: This was a cross sectional study of veterans with IHD from 8 VA hospitals. Outcomes were concordance with LDL guideline recommendations (LDL<100 mg/dl), and BP recommendations (<140/90 mm Hg). Cumulative logit and hierarchical logistic regression analyses were performed to identify patient factors, processes, and structures of care independently associated with guideline concordance. RESULTS: Of 14,114 veterans with IHD, 55.7% had hypertension, 71.5% had hyperlipidemia, and 41.6% had both conditions. Guideline concordance for LDL and BP were 38.9% and 53.4%, respectively. However, only 21.9% of the patients achieved both LDL <100 mg/dl and BP <140/90 mm Hg. In multivariable analyses, patient factors including older age and the presence of vascular disease were associated with worse guideline concordance. In contrast, diabetes was associated with better guideline concordance. Several process of care variables, including higher number of outpatient visits, higher number of prescribed medications, and a recent cardiac hospitalization were associated with better guideline concordance. Among structures of care, having on-site cardiology was associated with a trend towards better guideline concordance. CONCLUSION: Guideline concordance with secondary prevention measures among IHD patients remains suboptimal. It is hoped that the findings of this study can serve as an impetus for quality improvement efforts to improve upon secondary prevention measures and reduce the morbidity and mortality of patients with known IHD.

Adult↗
PubMed2006

Outcomes after acute coronary syndrome admission to primary versus tertiary Veterans Affairs medical centers: the Veterans Affairs Access to Cardiology study.

BACKGROUND: There is a concern that patients with acute coronary syndrome (ACS) admitted to primary care hospitals (without on-site cardiac procedures) may be at risk for worse outcomes compared with patients admitted to tertiary care hospitals. In addition to mortality, one way to assess patient outcomes is via health status and rehospitalization rates. We compared the health status and rehospitalization of patients with ACS admitted to primary versus tertiary care Veterans Affairs hospitals. METHODS: This was a cohort study of 2132 patients with ACS admitted to 21 Veterans Affairs hospitals (12 primary care and 9 tertiary care) from 1998 to 1999. Primary outcomes were 7-month health status as measured by the Seattle Angina Questionnaire and rehospitalization. Hierarchical multivariable regression was used to evaluate the association between admission to a primary (vs tertiary) care hospital and these outcomes. Discharge medications and 7-month cardiac procedure rates were also compared. RESULTS: There were no significant differences in discharge medication rates between primary and tertiary hospital patients. Forty-two percent of the patients admitted to a primary care hospital was transferred to a tertiary care hospital during index admission. Primary hospital patients had significantly lower 7-month rates of cardiac catheterization (36% vs 51%, P < .001) and percutaneous coronary intervention (11% vs 20%, P < .001), but there were no differences in coronary artery bypass graft surgery rates. After risk adjustment, there were no significant differences in 7-month angina frequency (odds ratio [OR] 0.98, 95% CI 0.78-1.22), physical limitation (OR 0.97, 95% CI 0.77-1.23), quality of life (OR 1.12, 95% CI 0.89-1.40), or rehospitalization (OR 1.07, 95% CI 0.54-2.14) between the 2 groups. CONCLUSIONS: These results suggest that an integrated health care system can achieve similar intermediate-term health status and rehospitalization outcomes for patients with ACS irrespective of the site of admission despite the lower rates of cardiac procedures for the primary care hospital patients.

Acute Disease↗
PubMed2006

Nurse executive and staff nurse perceptions of the effects of reorganization in Veterans Health Administration hospitals.

OBJECTIVE: To examine nurse executive perceptions of effects of service line reorganization on nurse executive roles, nursing staff and patient care, and compare nurse executive responses to staff nurse reports of job satisfaction and quality of care in the same types of Veterans Health Administration facilities. BACKGROUND: Although a growing body of research focuses on the association between nurse staffing structures, nurse satisfaction, and patient outcomes, relatively little attention has been paid to the effects of hospital restructuring on nursing management and nursing staff. METHODS: Data on hospital and nursing service organization and nurse executive perceptions were collected through structured interviews with 125 nurse executives conducted from December 2002 through May 2003. Staff nurse data were derived from a survey of Veterans Health Administration nursing staff conducted from February through June 2003 at the same facilities. RESULTS: Nurse executives in Veterans Health Administration described significant changes in the nurse executive role, and new challenges for managing nursing practice and achieving consistent quality of nursing care. Although nursing management perceived differences in the overall effects of restructuring on nursing staff depending on the type of reorganization, staff nurses reported significant differences in perceived quality of patient care across organization types.

Attitude of Health Personnel↗
PubMed2006

Lessons learned about implementing research evidence into clinical practice. Experiences from VA QUERI.

The mission of the Veterans Health Administration's (VHA) quality enhancement research initiative (QUERI) is to enhance the quality of VHA health care by implementing clinical research findings into routine care. This paper presents lessons that QUERI investigators have learned through their initial attempts to pursue the QUERI mission. The lessons in this paper represent those that were common across multiple QUERI projects and were mutually agreed on as having substantial impact on the success of implementation. While the lessons are consistent with commonly recognized ingredients of successful implementation efforts, the examples highlight the fact that, even with a thorough knowledge of the literature and thoughtful planning, unexpected circumstances arise during implementation efforts that require flexibility and adaptability. The findings stress the importance of utilizing formative evaluation techniques to identify barriers to successful implementation and strategies to address these barriers.

Benchmarking↗
PubMed2005

Utilization of drug-eluting stents in the Veterans Health Administration.

Little is known about how drug-eluting stents (DESs) are used and perform in everyday clinical practice. This report identifies factors associated with the use of DESs in the Veterans Health Administration and compares mortality and the need for coronary artery bypass graft surgery in patients who received DESs or bare metal stents. There was rapid adoption of DESs from the end of 2002 to September 2004, when 52% of percutaneous coronary interventions used DESs. Ten-day death rates in DES and bare metal stent groups were similar (0.8% vs 1.1%), as were 10-day bypass surgery rates (0.2% vs 0.4%). In summary, in a large health care system, DESs were used widely with low rates of death and bypass surgery.

Aged↗
PubMed2005

Adherence to heart-healthy behaviors in a sample of the U.S. population.

INTRODUCTION: Following national recommendations for physical activity, diet, and nonsmoking can reduce both incident and recurrent coronary heart disease. Prevalence data about combinations of behaviors are lacking. This study describes the prevalence of full adherence to national recommendations for physical activity, fruit and vegetable consumption, and nonsmoking among individuals with and without coronary heart disease and examines characteristics associated with full adherence. METHODS: We performed a cross-sectional analysis of data from the 2000 Behavioral Risk Factor Surveillance System, a national population-based survey. We included respondents to the cardiovascular disease module and excluded individuals with poor physical health or activity limitations. RESULTS: Subjects were most adherent to smoking recommendations (approximately 80%) and less adherent to fruit and vegetable consumption and physical activity (approximately 20% for both). Only 5% of those without coronary heart disease and 7% of those with coronary heart disease were adherent to all three behaviors (P < .01). Among those without a history of coronary heart disease, female sex (odds ratio [OR] 1.47; 95% confidence interval [CI], 1.23-1.76), highest age quintile (OR 1.67; 95% CI, 1.28-2.19), more education (OR 2.48; 95% CI, 1.69-3.64), and more income (OR 1.19; 95% CI, 1.04-1.36) were associated with full adherence. Among those with coronary heart disease, mid-age quintile (OR 3.79; 95% CI, 1.35-10.68), good general health (OR 2.05; 95% CI, 1.07-3.94), and more income (OR 1.51; 95% CI, 1.06-2.16) were associated with full adherence. CONCLUSION: These data demonstrate the lack of a heart-healthy lifestyle among a sample of U.S. adults with and without coronary heart disease. Full adherence to combined behaviors is far below adherence to any of the individual behaviors.

Cardiovascular Diseases↗
PubMed2005

The association between clinical integration of care and transfer of veterans with acute coronary syndromes from primary care VHA hospitals.

BACKGROUND: Few studies report on the effect of organizational factors facilitating transfer between primary and tertiary care hospitals either within an integrated health care system or outside it. In this paper, we report on the relationship between degree of clinical integration of cardiology services and transfer rates of acute coronary syndrome (ACS) patients from primary to tertiary hospitals within and outside the Veterans Health Administration (VHA) system. METHODS: Prospective cohort study. Transfer rates were obtained for all patients with ACS diagnoses admitted to 12 primary VHA hospitals between 1998 and 1999. Binary variables measuring clinical integration were constructed for each primary VHA hospital reflecting: presence of on-site VHA cardiologist; referral coordinator at the associated tertiary VHA hospital; and/or referral coordinator at the primary VHA hospital. We assessed the association between the integration variables and overall transfer from primary to tertiary hospitals, using random effects logistic regression, controlling for clustering at two levels and adjusting for patient characteristics. RESULTS: Three of twelve hospitals had a VHA cardiologist on site, six had a referral coordinator at the tertiary VHA hospital, and four had a referral coordinator at the primary hospital. Presence of a VHA staff cardiologist on site and a referral coordinator at the tertiary VHA hospital decreased the likelihood of any transfer (OR 0.45, 95% CI 0.27-0.77, and 0.46, p = 0.002, CI 0.27-0.78). Conversely, having a referral coordinator at the primary VHA hospital increased the likelihood of transfer (OR 6.28, CI 2.92-13.48). CONCLUSIONS: Elements of clinical integration are associated with transfer, an important process in the care of ACS patients. In promoting optimal patient care, clinical integration factors should be considered in addition to patient characteristics.

Acute Disease↗
PubMed2005

Impact of palliative care case management on resource use by patients dying of cancer at a Veterans Affairs medical center.

BACKGROUND: The VA Puget Sound Health Care System (VAPSHCS) started a palliative care service (PCS) in October 2001 to provide case management for patients with advanced cancer. OBJECTIVE: To examine resource use during the last 60 days of life for patients dying of cancer who received PCS compared to patients receiving usual care (non-PCS) during the same time period. DESIGN: Retrospective nonrandomized comparison of resource use using administrative data. SETTING: Tertiary care Veterans Affairs medical center. PARTICIPANTS: All patients who died of cancer between October 1, 2001 and October 31, 2002 at VAPSHCS. RESULTS: Two hundred sixty-five patients died of cancer during the specified time period, including 82 PCS and 183 non-PCS patients. PCS patients received case management for a mean of 79 days, and were younger, had more comorbid conditions, and were more likely to have had chemotherapy in the last 60 days of life than non-PCS patients. Variables associated with more acute care bed days in the last 60 days of life included: chemotherapy in the last 60 days of life, and a length of stay on PCS less than 60 days. Variables associated with fewer acute care bed days within the last 60 days of life included: being married, and a length of stay on PCS 60 days or more. Compared to non-PCS patients, the place of death for PCS patients was less likely to be acute care. CONCLUSION: PCS for 60 or more days prior to death was associated with decreased use of acute care hospital resources for patients dying of cancer.

Aged↗
PubMed2005

Nurse staffing and patient outcomes in Veterans Affairs hospitals.

OBJECTIVE: To assess characteristics and perceptions of nurses working in the Veterans Health Administration (VHA), comparing types of nursing personnel, to benchmark to prior studies across healthcare systems. BACKGROUND: Prior studies have shown relationships between positive registered nurse (RN) perceptions of the practice environment and patient outcomes. To date, no study has reported the comparison of RN perceptions of the practice environment in hospital nursing with those of non-RN nursing personnel. This study is the first to offer a more comprehensive look at perceptions of practice environment from the full range of the nursing work force and may shed light on issues such as the relationship of skill mix to nurse and patient outcomes. METHODS: Cross-sectional observational study with a mailed survey administered to all nursing personnel in 125 VA Medical Centers between February and June 2003. RESULTS: Compared with other types of nursing personnel in the VHA, RNs are generally less positive about their practice environments. However, compared with RNs in other countries and particularly with other RNs in the United States (Pennsylvania), VHA RNs are generally more positive about their practice environment and express more job satisfaction. CONCLUSIONS: The nursing work force of the VHA has some unique characteristics. The practice environment for nurses in the VHA is relatively positive, and may indicate that the VHA, as a system, provides an environment that is more like magnet hospitals. This is significant for a public sector hospital system.

Adult↗
PubMed2004

Assessing response bias from missing quality of life data: the Heckman method.

BACKGROUND: The objective of this study was to demonstrate the use of the Heckman two-step method to assess and correct for bias due to missing health related quality of life (HRQL) surveys in a clinical study of acute coronary syndrome (ACS) patients. METHODS: We analyzed data from 2,733 veterans with a confirmed diagnosis of acute coronary syndromes (ACS), including either acute myocardial infarction or unstable angina. HRQL outcomes were assessed by the Short-Form 36 (SF-36) health status survey which was mailed to all patients who were alive 7 months following ACS discharge. We created multivariable models of 7-month post-ACS physical and mental health status using data only from the 1,660 survey respondents. Then, using the Heckman method, we modeled survey non-response and incorporated this into our initial models to assess and correct for potential bias. We used logistic and ordinary least squares regression to estimate the multivariable selection models. RESULTS: We found that our model of 7-month mental health status was biased due to survey non-response, while the model for physical health status was not. A history of alcohol or substance abuse was no longer significantly associated with mental health status after controlling for bias due to non-response. Furthermore, the magnitude of the parameter estimates for several of the other predictor variables in the MCS model changed after accounting for bias due to survey non-response. CONCLUSION: Recognition and correction of bias due to survey non-response changed the factors that we concluded were associated with HRQL seven months following hospital admission for ACS as well as the magnitude of some associations. We conclude that the Heckman two-step method may be a valuable tool in the assessment and correction of selection bias in clinical studies of HRQL.

Acute Disease↗
PubMed2004

Cardiology management improves secondary prevention measures among patients with coronary artery disease.

OBJECTIVES: The goal of this study was to determine if cardiology subspecialty involvement improves the attainment of recommended low-density lipoprotein (LDL) cholesterol and blood pressure (BP) targets in coronary artery disease (CAD) patients. BACKGROUND: The impact of physician specialty on secondary prevention measures for CAD in ambulatory care is unknown. METHODS: This was a retrospective cohort study of 13,995 patients with CAD seen at eight ambulatory care Veteran Affairs facilities from 1998 to 2000. Patients with cardiology involvement were defined as those seen in cardiology clinic in addition to primary care. The main outcomes of interest were LDL cholesterol < or =100 mg/dl and BP < or =130/85 mm Hg. Multivariable hierarchical regression analyses were used to determine the independent association of cardiology involvement with improved LDL cholesterol and BP control. RESULTS: Overall, 3,771 (27.0%) patients had cardiology involvement. A higher proportion of patients with cardiology involvement achieved LDL cholesterol (55.6% vs. 45.6%; p < 0.01) and BP (45.3% vs. 35.9%; p < 0.01) goals. In multivariable hierarchical regression analysis, cardiology involvement was independently associated with better LDL cholesterol (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.40 to 1.82) and BP (OR, 1.52; 95% CI, 1.32 to 1.77) control. The benefit of cardiology involvement was consistent across a range of LDL and BP targets, in analysis of LDL and BP as continuous outcomes, and among subgroups of high-risk patients, including diabetic patients, the elderly, and those with prior revascularization. CONCLUSIONS: Cardiology involvement is associated with better LDL cholesterol and BP control among CAD patients. However, significant room for improvement in secondary prevention measures remains, irrespective of physician specialty.

Adrenergic beta-Antagonists↗
PubMed2004

Improving care to patients with ischemic heart disease: experiences in a single network of the Veterans Health Administration.

BACKGROUND: Ischemic heart disease (IHD) is the leading cause of death in the United States. Lowering serum cholesterol levels reduces coronary events and mortality; this effect is most evident in patients with preexisting IHD. AIMS: The primary aim of this article is to describe a set of interventions that were piloted in a single, regional Veterans Integrated Service Network (VISN) to promote secondary prevention among patients with IHD and to explore the effect of those interventions on patient outcomes. METHODS: An observational, before-and-after study of clinical interventions to improve lipid guideline compliance in VISN 20 (the Veterans Administration Northwest Network) was conducted. A total of 2,467 patients with established coronary artery disease from three medical facilities in VISN 20 were included. Each medical facility chose different interventions to lower low-density lipoprotein cholesterol (LDL-c) levels in their patients. One facility chose a paper point-of-care reminder, a second chose a lipid clinic, and a third chose audit/feedback to clinicians in addition to a patient-education component. Data came from a relational database that mirrors the clinical information system at each site. Outcomes included the proportion of patients who had their LDL-c measured, the proportion of patients who had lipid-lowering agents prescribed, and the proportion of patients at LDL-c goal of lower than 100 mg/dL measured before, during, and after the intervention period. RESULTS: Statistically significant improvements were observed within sites after the interventions were implemented. IMPLICATIONS FOR PRACTICE: Interventions that focused on secondary prevention in this high-risk group were moderately successful in changing practice. Tailoring interventions to the needs of a specific site of care is feasible and may add to the likelihood of succeeding. CONCLUSION: Overall, the three facilities improved in lipid measurement and management for patients with coronary artery disease.

Cholesterol, LDL↗
PubMed2004

A qualitative study to identify barriers and facilitators to implementation of pilot interventions in the Veterans Health Administration (VHA) Northwest Network.

OBJECTIVE: To identify barriers and facilitators to implementation of pilot interventions designed to improve measurement and management of low-density lipoprotein cholesterol (LDL-c) levels in coronary heart disease patients using the evidence/context/facilitation model of implementation of evidence-based practice. DESIGN: Theory-based conceptual content analysis of structured interviews conducted between January and April 2001. SETTING: Six medical centers in the United States Veterans Health Administration Northwest Network. PARTICIPANTS: Fifty-one of 64 individuals (physicians, nurses, pharmacists, dieticians, quality managers, and other clinical and nonclinical staff) who participated in planning and/or implementing pilot interventions. MAIN FINDINGS: Barriers to successful implementation related primarily to the intervention process and secondarily to characteristics of the intervention context. Interview responses indicated that planning, including identification of resources and assessment of potential barriers and facilitators, was a critical and universally underutilized step in the intervention process. CONCLUSIONS: Organized team process, documented plans for intervention activities, and ongoing evaluation are essential for sustaining intervention activities. A top priority for facilitating interventions should be the development of educational materials, such as "how to" guides, that teach intervention teams how to anticipate barriers and make plans to address them, as well as identifying and fostering local experts in planning and implementing interventions.

Attitude of Health Personnel↗
PubMed2003

Changes in the use of coronary artery revascularization procedures in the Department of Veterans Affairs, the National Hospital Discharge Survey, and the Nationwide Inpatient Sample, 1991-1999.

BACKGROUND: There have been dramatic increases in the number of coronary artery bypass surgeries (CABS) and percutaneous coronary interventions (PCI) performed during the last decade. Whether this finding is true for revascularization procedures performed in Department of Veterans Affairs (VA) medical centers is the subject of this paper. METHODS: This study compared the number of revascularization procedures and rates of use in the VA, the National Hospital Discharge Survey, and the Nationwide Inpatient Sample. Included were men who underwent isolated CABS and/or PCI, including stenting, between 1991 and 1999, although data for the Nationwide Inpatient Sample were available only between 1993 and 1997. Age adjusted use rates were calculated with the direct method of standardization. RESULTS: The percent of users of VA healthcare 75 years and older increased from 10% in 1991 to 20% in 1999. In the VA, the number of isolated CABS declined from 6227 in 1991 to 6147 in 1999, whereas age adjusted rates declined from 167.6 per 100,000 in 1991 to 107.9 per 100,000 in 1999. In the 2 national surveys, both the estimated numbers of procedures and use rates increased over time. In all 3 settings, there were increases in both numbers and rate of PCI from 1993, although in the VA, use rates decreased from 191.2 per 100,000 in 1996 to 139.7 per 100,000 in 1999. VA use rates for both CABS and PCI were lower than those in the 2 national surveys. CONCLUSION: Age adjusted rates of CABS and PCI were lower in the VA than in 2 national surveys. Since 1996, there has been a decrease in the rate of use of revascularization procedures in the VA.

Adult↗