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PubMed2004

Psychiatric and neurocognitive disorders among HIV-positive and negative veterans in care: Veterans Aging Cohort Five-Site Study.

BACKGROUND: The risk for psychiatric and neurocognitive disorders among middle-aged and older individuals with HIV infection has not been well characterized. METHODS: The Veterans Aging Cohort 5-Site Study enrolled 1803 patients (1047 HIV-positive) from VA infectious disease and general medicine clinics from September 2001 to June 2002. A convenience subset of 10 patients from each site (n = 50) was consented for formal neurocognitive and psychiatric (NCP) testing. Data from this subset were linked to the larger sample. RESULTS: Kappa scores for agreement beyond chance were fair for available measures when compared with formal NCP testing. Using available measures, depressive symptoms (PHQ-9 and provider reported), alcohol abuse or dependence (ICD-9 codes), and drug abuse or dependence (DAST-10) decreased with age in HIV-negative subjects (P trend <0.05) but did not among HIV-positive subjects (P > 0.05). HIV-positive subjects demonstrated higher prevalence of these conditions with increasing age when compared to HIV-negative subjects. Patient report of memory problems increased with age among both groups after excluding those reporting symptoms of depression (PHQ-9e > or = 10). CONCLUSION: Available measures were no substitute for formal NCP testing. Older HIV-positive veterans demonstrate greater prevalence of depressive symptoms, alcohol abuse or dependence, and drug abuse or dependence than age-matched, HIV-negative veterans. Both groups reported increased memory problems with advancing age. This preliminary work suggests a substantial prevalence of psychiatric and neurocognitive problems among middle-aged and older HIV-infected individuals.

Adult↗
PubMed1998

Private health insurance and veterans use of Veterans Affairs care. RATE Project Committee. Rate Alternative Technical Evaluation.

OBJECTIVES: This study examined the effect of private health insurance on the use of medical, surgical, psychiatric, and addiction services for patients eligible for publicly supported care. METHODS: The authors assembled administrative databases describing 350,000 noninstitutionalized veterans who had been discharged from a Veterans Affairs (VA) inpatient medicine or surgery bed section during a 1-year period. Patient use of care was followed for 1 year after the index discharge. Patient insurance information came from Medical Care Cost Recovery Billing and Collection files obtained separately from each of 162 VA Medical Centers. Distances between VA and non-VA sources of care were estimated from the Health Care Financing Administration's Hospital Distance File. RESULTS: Insured patients were less likely to seek surgical care but were 12 times (65 years of age and older) and 73 times (63 years of age and younger) more likely to initiate outpatient medical visits than were their counterparts, adjusted for patient demographic, diagnostic, and index facility characteristics. Patients who had private health insurance also were 3.4 (> or = 65) and 2.6 (< or = 64) times less likely to use VA surgical care in response to changes in available surgical staff-to-patient ratios than were their uninsured counterparts. CONCLUSIONS: Private health insurance may substitute (reduce) or complement (increase) the continued use of publicly supported health care services, depending on patient age, care setting, and service type.

Adult↗
PubMed2000

Automated computerized intensive care unit severity of illness measure in the Department of Veterans Affairs: preliminary results. SISVistA Investigators. Scrutiny of ICU Severity Veterans Health Sysyems Technology Architecture.

OBJECTIVE: To evaluate the feasibility of an automated intensive care unit (ICU) risk adjustment tool (acronym: SISVistA) developed by selecting a subset of predictor variables from the Acute Physiology and Chronic Health Evaluation (APACHE) III available in the existing computerized database of the Department of Veterans Affairs (VA) healthcare system and modifying the APACHE diagnostic and comorbidity approach. DESIGN: Retrospective cohort study. SETTING: Six ICUs in three Ohio Veterans Affairs hospitals. PATIENT SELECTION: The first ICU admission of all patients from February 1996 through July 1997. OUTCOME MEASURE: Mortality at hospital discharge. METHODS: The predictor variables, including age, comorbidity, diagnosis, admission source (direct or transfer), and laboratory results (from the +/- 24-hr period surrounding admission), were extracted from computerized VA databases, and APACHE III weights were applied using customized software. The weights of all laboratory variables were added and treated as a single variable in the model. A logistic regression model was fitted to predict the outcome and the model was validated using a boot-strapping technique (1,000 repetitions). MAIN RESULTS: The analysis included all 4,651 eligible cases (442 deaths). The cohort was predominantly male (97.5%) and elderly (63.6 +/- 12.0 yrs). In multivariate analysis, significant predictors of hospital mortality included age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.04-1.09), comorbidity (OR, 1.11; 95% CI, 1.08-1.15), total laboratory score (OR, 1.07; 95% CI, 1.06-1.08), direct ICU admission (OR, 0.39; 95% CI, 0.31-0.49), and several broad ICU diagnostic categories. The SISVistA model had excellent discrimination and calibration (C statistic = 0.86, goodness-of-fit statistics; p > .20). The area under the receiver operating characteristic curve of the validated model was 0.86. CONCLUSIONS: Using common data elements often found in hospital computer systems, SISVistA predicts hospital mortality among patients in Ohio VA ICUs. This preliminary study supports the development of an automated ICU risk prediction system on a more diverse population.

APACHE↗
PubMed2005

Measurement in Veterans Affairs Health Services Research: veterans as a special population.

OBJECTIVE: To introduce this supplemental issue on measurement within health services research by using the population of U.S. veterans as an illustrative example of population and system influences on measurement quality. PRINCIPAL FINDINGS: Measurement quality may be affected by differences in demographic characteristics, illness burden, psychological health, cultural identity, or health care setting. The U.S. veteran population and the VA health system represent a microcosm in which a broad range of measurement issues can be assessed. CONCLUSIONS: Measurement is the foundation on which health decisions are made. Poor measurement quality can affect both the quality of health care decisions and decisions about health care policy. The accompanying articles in this issue highlight a subset of measurement issues that have applicability to the broad community of health services research. It is our hope that they stimulate a broad discussion of the measurement challenges posed by conducting "state-of-the-art" health services research.

Data Collection↗
PubMed1982

Assessment of Viet Nam veterans for posttraumatic stress disorder in Veterans Administration disability claims.

Since the Veterans Administration (VA) authorized compensation and other benefits for posttraumatic stress disorder, delayed type, in October 1980, the agency has received an increasingly large number of claims--mainly from Viet Nam veterans--for this disorder. An unprecedented challenge of the adequacy of psychiatric disability evaluation in the VA has thus been created. The authors describe efforts in one large program to meet this challenge and review 12 problems in the diagnostic process. Cooperation of all parties in claims transactions, thorough claimant assessment, reliance on DSM-III criteria and methods and consultation with examiners are essential principles for this work.

Adult↗
PubMed2006

Predictors of exercise compliance in individuals with Gulf War veterans illnesses: Department of Veterans Affairs Cooperative Study 470.

Although the health benefits of exercise for individuals with Persian Gulf War veterans illnesses (GWVI) are documented, many of these individuals do not exercise regularly enough to obtain benefits. The purpose of this study was to investigate factors predicting exercise compliance among individuals with GWVI in a multicenter, randomized, clinical trial. Participants were 1,092 veterans who reported at least two of the following cardinal symptoms of GWVI: (1) fatigue, (2) musculoskeletal pain, and (3) cognitive problems. Participants received exercise alone or exercise and cognitive-behavioral therapy. The overall level of compliance was relatively low during the exercise treatment phase (46.2%) and decreased by one-half during the follow-up period (23.0%). Predictors of compliance during treatment included less pain and greater age, motivation, and body mass index. Predictors of compliance during the follow-up period included less pain and greater age. The results highlight factors that affect adoption and maintenance of physical activity in a population with GWVI.

Adult↗
PubMed1991

Hematopoietic and lymphoproliferative cancer among male veterans using the Veterans Administration Medical System.

Hematopoietic and lymphoproliferative cancer risk among the 3.7 million United States male veterans who use the Veterans Administration (VA) medical system annually was assessed using age-specific incidence curves and cumulative incidence rates. Relative risk comparing the VA with general population risk estimates from the Surveillance, Epidemiology, and End Results (SEER) data were increased significantly for all malignancies examined. The VA sample showed risk increases of 93% for Hodgkin's disease, 20% for non-Hodgkin's lymphomas, 51% for multiple myelomas, and 40% for all leukemias. Among the leukemia subtypes, the observed risk increases were 54%, 23%, 80%, and 46% for lymphocytic, granulocytic, monocytic, and other forms of leukemia, respectively. The large size of the sample and the consistency of risk estimates with two different methods confer validity and strength to these findings. The possible relevance of the high prevalence of tobacco and alcohol use in this population sample to the current findings is discussed and the need for further analytic investigations to explain the increases in risk is emphasized.

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↗
PubMed1998

Characteristics of ambulatory care clinics and pharmacists in Veterans Affairs medical centers. IMPROVE investigators. Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers.

The type and extent of ambulatory care clinical pharmaceutical services in selected Veterans Affairs medical centers (VAMCs) were studied as part of a larger project. Questionnaires were sent to the 174 VAMCs to determine the extent of clinical pharmacy activity in ambulatory care clinics, characteristics of outpatient pharmacies and clinics, and characteristics of ambulatory care pharmacists in VAMCs and to identify sites for the IMPROVE (Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers) project. Fifty VAMCs responded to the survey. There were 512 ambulatory care clinics within these VAMCs. There was some pharmacist coverage in 75% of the clinics. The highest pharmacist coverage was in walk-in refill, therapeutic drug monitoring, and anticoagulation clinics. Clinical pharmacists at 68% of the VAMCs had prescribing privileges in ambulatory care clinics. Clinical pharmacists managed 29.9% of the clinics. The types of clinics most commonly managed by pharmacists were therapeutic drug monitoring, anticoagulation, walk-in refill, and lipid clinics. Nurse practitioners or physician assistants also were providing primary care in 41% of the clinics. There were 242 ambulatory care clinical pharmacy specialists practicing in the 50 VAMCs. Of these, 41.3% had three years or less of ambulatory care experience. Most pharmacists were in the clinic five days per week. A Pharm.D. degree was the highest degree obtained for 76.9%. Ambulatory care pharmaceutical services are common in VAMCs and are being provided by numerous clinical pharmacists.

Data Collection↗
PubMedDate not supplied

Do poor health behaviors affect health-related quality of life and healthcare utilization among veterans? The Veterans Health Study.

The impact of health behaviors on Health-Related Quality of Life (HRQoL) and HealthCare Utilization (HCU) was examined in a sample of male veterans. We examined the relationship between health behaviors (cigarette smoking, alcohol use, exercise, seat belt use, cholesterol level, and body mass index [BMI]), and HRQoL and HCU, among Veterans Health Study participants providing complete baseline (t0) and 12-month follow-up (t12) data. (Respective sample sizes were 1242 and 1397.) HRQoL measures were derived from the SF-36, expressed as physical component summary (PCS) and mental component summary (MCS) scores. Prospective 12-month outpatient and inpatient utilization data were obtained from a VA administrative database. Exercise and BMI were significant PCS predictors at t0 and t12, adjusting for age, social supports, education, employment status, and comorbidities. Smoker status was negatively associated with PCS only at t0. Nonproblem (no abuse) alcohol users had significantly higher t0 PCS scores than nonusers. Only current problem alcohol use was associated with lower MCS at t0 and t12 in multivariate analyses. Regarding HCU, current smokers had fewer medical visits than never smokers; alcohol nonusers had more medical visits than current alcohol users, current problem users, and former problem users. No behaviors were associated with mental health visits or inpatient stays. HRQoL is negatively affected by poor health behaviors. HRQoL and physical health may be improved by practitioners targeting these behaviors for preventive interventions. This study did not support an association between poor health behaviors and higher HCU. Future research should consider the effect of moderating variables on this relationship.

Aged↗
PubMed1998

Antihypertensive efficacy of treatment regimens used in Veterans Administration hypertension clinics. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents.

There is continuing uncertainty about whether morbidity and mortality of treated hypertensive patients depends on the drug(s) used to treat or only on the level of blood pressure achieved. This study was undertaken in a sample of special Veterans Administration hypertension clinics to determine which antihypertensive drugs were selected by the involved healthcare providers and how effective they were in achieving normotension. Hypertensive veterans (n = 6100) were followed in six VA Hypertension Screening and Treatment Program clinics for 46 months beginning in May 1989. Their average age was 60.7 years; 53% lived in the Stroke Belt; 46% had target organ damage, 36% were black, 23% smoked, and 10% had diabetes mellitus. Antihypertensive regimens were divided into 12 all-inclusive categories. Blood pressures were averaged at the last study visit for all patients on a regimen. The regimens of diuretic or diuretic plus beta-blocker gave the lowest average pressures (140.6/82.3 mm Hg) and calcium antagonist the highest (149.0/86.5 mm Hg). ANOVA indicated that differences between seven common regimens and also between the four single drug regimens were highly significant (P<.0001). This pattern of low treated pressure with the "old" agents and higher treated pressure with newer agents was reflected in the percentage of patients controlled below 140/90 mm Hg and the percentage uncontrolled above 159/94 mm Hg. Blacks and patients with target organ damage resembled the entire cohort in average treated diastolic blood pressure, but the former had lower and the latter had higher treated systolic blood pressure than the entire cohort.

Analysis of Variance↗
PubMed2004

Comparison of comorbid physical illnesses among veterans with PTSD and veterans with alcohol dependence.

Posttraumatic stress disorder (PTSD) is associated with high rates of medical service use and with self-reported poor health. Male veterans admitted to a rehabilitation unit for PTSD (N=55) or alcohol dependence (N=38) were evaluated for comorbid psychiatric and medical conditions and health risk factors. Patients with PTSD were more likely to have osteoarthritis, diabetes, heart disease, comorbid depression, obesity, and elevated lipid levels. These findings suggest that there may be a relationship between specific medical conditions, possibly mediated by behavioral risk factors, among the aging population of veterans with PTSD.

Adult↗
PubMed2000

The Veterans Millennium Health Care and Benefits Act. Department of Veterans Affairs. Final rule.

This document amends Department of Veterans Affairs (VA) adjudication regulations to reflect changes made by the Veterans Millennium Health Care and Benefits Act. These changes concern payment of dependency and indemnity compensation to the surviving spouses of certain former prisoners of war; the provision of health care, education and home loan benefits to surviving spouses upon termination of their remarriages; and the addition of bronchiolo-alveolar carcinoma to the list of diseases that VA presumes are the result of exposure to radiation during active military service.

Humans↗
PubMed2003

Utilization of laparoscopic antireflux surgery at a single Veterans Affairs facility compared with the Veterans Affairs national trend.

BACKGROUND: The widespread use of laparoscopy in the early 1990s has led to an increase in the utilization of antireflux procedures for the treatment of gastroesophageal reflux disease (GERD). This trend has been observed in the private sector, but not within the Department of Veterans Affairs (VA) health care system. Published data suggest that among patients undergoing antireflux surgical procedures, those in the VA were less likely than those in the private sector to undergo laparoscopic surgery. The objective of this study was to determine the trend in the use of laparoscopic antireflux surgical procedures at our VA facility and compare it with the national VA trend. METHODS: All antireflux operations performed at our VA facility from 1991 to 2002 were recorded along with techniques used. National VA data on the utilization of antireflux procedures from 1991 to 1999 was extracted from a recent publication by Finlayson et al. RESULTS: In contrast to the trend observed nationally across VA hospitals, the rate of utilization of antireflux surgery at our VA facility has increased compared with baseline in 1991. Of 83 fundoplications performed from 1991 to 2002, 76 (92%) were attempted or completed laparoscopically. The conversion rate from laparoscopic to open approach was 6.6%. CONCLUSIONS: We have observed an increase in the utilization of antireflux surgery since 1991 at our VA facility. In addition, most fundoplications were performed laparoscopically. These findings are in contrast to published national VA data. The presence of surgeons with interest in laparoscopy, institutional support, and a dedicated esophageal function laboratory may explain these findings.

Fundoplication↗
PubMedDate not supplied

Treatment outcome of an outpatient treatment program for dually-diagnosed veterans: the Cincinnati Veterans Affairs Medical Center.

The Dual Diagnosis Clinic at the Cincinnati VA Medical Center is an integrated treatment program for veterans who have an Axis I psychiatric illness in addition to a substance dependence problem. With a high staff-to-patient ratio and an individualized approach, the DDC treats many dual diagnosis patients effectively. To demonstrate the effectiveness of this approach, an outcome study was conducted looking at the psychiatric emergency room visits, hospitalization rates, and the average length of stay for 557 DDC patients. Patients were divided into two groups: those who completed the assessment period, and those who did not. Equal periods of time before and after this assessment period were studied. Those who completed were more likely to have had fewer psychiatric emergency room visits (p < 0.000001) after the assessment period than before when compared to dropouts. The engaged group had the same or more hospital admissions after the assessment period than before, while the dropout group had fewer. This suggests that there is a significant disorder of engagement for the dual diagnosis populations, and that the first impact of successful treatment is engagement.

Ambulatory Care↗
PubMed2003

Intensified blood glucose monitoring improves glycemic control in stable, insulin-treated veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study (DOVES).

OBJECTIVE: To examine the effect of intensified self-monitored blood glucose (SMBG) testing on glycemic control. RESEARCH DESIGN AND METHODS: Subjects with stable, insulin-treated type 2 diabetes performed SMBG using an electronic blood glucose meter before all meals and at bedtime for 8 weeks. Baseline data were collected on demographics, clinical characteristics, diet, and exercise. HbA(1c) was measured at baseline, at 4 weeks, and at 8 weeks. After the intensified monitoring period, subjects resumed their usual monitoring. HbA(1c) was then measured at 24, 37, and 52 weeks. Multivariate linear regression was used to determine the effect of monitoring on glycemic control. RESULTS: A total of 201 subjects completed the monitoring period. The baseline HbA(1c) (8.10 +/- 1.67%) decreased during the monitoring period by 0.30 +/- 0.68% (P < 0.001) at 4 weeks and by 0.36 +/- 0.88% (P < 0.001) at 8 weeks. Although entry HbA(1c) and compliance independently predicted the week 8 HbA(1c) (r = 0.862, P < 0.001), standardized regression analysis found that compliance with the SMBG protocol influenced the week 8 HbA(1c) more than age, sex, BMI, exercise level, carbohydrate consumption, or treatment intensity at baseline. However, SMBG benefited only subjects whose testing compliance exceeded 75% or with an entry HbA(1c) >8.0%. Decreases in HbA(1c) (-0.31 +/- 1.17%, P = 0.001) persisted in the 159 subjects followed for 52 weeks. CONCLUSIONS: Intensified blood glucose monitoring improved glycemic control in a large cohort of stable, insulin-treated veterans with type 2 diabetes. SMBG provided a strong stimulus for improved self-care resulting in clinically important and sustained reductions in HbA(1c).

Biomarkers↗
PubMed1980

Veterans Administration--Veterans education; eligibility for vocational rehabilitation and educational assistance--character of discharge. Final regulations.

The Veterans Administration is amending its regulations concerning eligibility for vocational rehabilitation and educational assistance under chapters 31 and 34, title 38, United States Code. These changes are necessary in order to implement a law enacted October 8, 1977. Most of the changes are of a minor technical nature. The regulatory amendments will implement the provisions of the law.

Eligibility Determination↗