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Mary Jo V Pugh,
Zachary A Marcum,
Laurel A Copeland,
Eric M Mortensen,
John E Zeber,
Polly H Noël, Dan R Berlowitz,
John R Downs,
Chester B Good,
Carlos Alvarez,
Megan E Amuan,
Joseph T Hanlon
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ABSTRACT: BACKGROUND: Clinical validation studies of the Healthcare Effectiveness Data and Information Set (HEDIS(®)) measures of inappropriate prescribing in the elderly are limited. OBJECTIVES: The objective of this study was to examine associations of new exposure to high-risk medication in the elderly (HRME) and drug-disease interaction (Rx-DIS) with mortality, hospital admission, and emergency care. METHODS: A retrospective database study was conducted examining new use of HRME and Rx-DIS in fiscal year 2006 (Oct 2005-Sep 2006; FY06), with index date being the date of first HRME/Rx-DIS exposure, or first day of FY07 if no HRME/Rx-DIS exposure. Outcomes were assessed 1 year after the index date. The participants were veterans who were ≥65 years old in FY06 and received Veterans Health Administration (VA) care in FY05-06. A history of falls/hip fracture, chronic renal failure, and/or dementia per diagnosis codes defined the Rx-DIS subsample. The variables included a number of new unique HRME drug exposures and new unique Rx-DIS drug exposure (0, 1, >1) in FY06, and outcomes (i.e., 1-year mortality, hospital admission, and emergency care) up to 1 year after exposure. Descriptive statistics summarized variables for the overall HRME cohort and the Rx-DIS subset. Multivariable statistical analyses using generalized estimating equations (GEE) models with a logit link accounted for nesting of patients within facilities. For these latter analyses, we controlled for demographic characteristics, chronic disease states, and indicators of disease burden the previous year (e.g., number of prescriptions, emergency/hospital care). RESULTS: Among the 1,807,404 veterans who met inclusion criteria, 5.2 % had new HRME exposure. Of the 256,388 in the Rx-DIS cohort, 3.6 % had new Rx-DIS exposure. Multivariable analyses found that HRME was significantly associated with mortality [1: adjusted odds ratio (AOR) = 1.62, 95 % CI 1.56-1.68; >1: AOR = 1.80, 95 % CI 1.45-2.23], hospital admission (1: AOR = 2.31, 95 % CI 2.22-2.40; >1: AOR = 3.44, 95 % CI 3.06-3.87), and emergency care (1: AOR = 2.59, 95 % CI 2.49-2.70; >1: AOR = 4.18, 95 % CI 3.71-4.71). Rx-DIS exposure was significantly associated with mortality (1: AOR = 1.60, 95 % CI 1.51-1.71; >1: AOR = 2.00, 95 % CI 1.38-2.91), hospital admission for one exposure (1: AOR = 1.12, 95 % CI 1.03-1.27; >1: AOR = 1.18, 95 % CI 0.71-1.95), and emergency care for two or more exposures (1: AOR = 1.06, 95 % CI 0.97-1.15; >1: AOR = 2.0, 95 % CI 1.35-3.10). CONCLUSIONS: Analyses support the link between HRME/Rx-DIS exposure and clinically significant outcomes in older veterans. Now is the time to begin incorporating input from both patients who receive these medications and providers who prescribe to develop approaches to reduce exposure to these agents.
Drugs & Aging 05/2013; · 2.67 Impact Factor
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ABSTRACT: BACKGROUND: Warfarin is effective in preventing thromboembolic events, but concerns exist regarding its use in patients with substance abuse. OBJECTIVE: Identify which patients with substance abuse who receive warfarin are at risk for poor outcomes. DESIGN: Retrospective cohort study. Diagnostic codes, lab values, and other factors were examined to identify risk of adverse outcomes. PATIENTS: Veterans AffaiRs Study to Improve Anticoagulation (VARIA) database of 103,897 patients receiving warfarin across 100 sites. MAIN MEASURES: Outcomes included percent time in therapeutic range (TTR), a measure of anticoagulation control, and major hemorrhagic events by ICD-9 codes. RESULTS: Nonusers had a higher mean TTR (62 %) than those abusing alcohol (53 %), drugs (50 %), or both (44 %, p < 0.001). Among alcohol abusers, an increasing ratio of the serum hepatic transaminases aspartate aminotransferase/alanine aminotransferase (AST:ALT) correlated with inferior anticoagulation control; normal AST:ALT ≤ 1.5 predicted relatively modest decline in TTR (54 %, p < 0.001), while elevated ratios (AST:ALT 1.50-2.0 and > 2.0) predicted progressively poorer anticoagulation control (49 % and 44 %, p < 0.001 compared to nonusers). Age-adjusted hazard ratio for major hemorrhage was 1.93 in drug and 1.37 in alcohol abuse (p < 0.001 compared to nonusers), and remained significant after also controlling for anticoagulation control and other bleeding risk factors (1.69 p < 0.001 and 1.22 p = 0.003). Among alcohol abusers, elevated AST:ALT >2.0 corresponded to more than three times the hemorrhages (HR 3.02, p < 0.001 compared to nonusers), while a normal ratio AST:ALT ≤ 1.5 predicted a rate similar to nonusers (HR 1.19, p < 0.05). CONCLUSIONS: Anticoagulation control is particularly poor in patients with substance abuse. Major hemorrhages are more common in both alcohol and drug users. Among alcohol abusers, the ratio of AST/ALT holds promise for identifying those at highest risk for adverse events.
Journal of General Internal Medicine 04/2013; · 2.83 Impact Factor
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ABSTRACT: This study evaluated the quality of epilepsy care in an ambulatory population of a major medical center and determined if there were any racial/ethnic variations. The well-established 'Quality Indicators in Epilepsy Treatment (QUIET)' study dataset was used. Medical record, phone interview, and mail-out survey data of 311 patients with epilepsy were linked and analyzed. Evaluation of care from provider and patient perspectives was performed. Overall, the patients with epilepsy received 40.9% of QI recommended care. The black patients were more likely to receive 50% or more QI recommended care compared with non-Hispanic whites (odds ratio [OR]=2.16, 95% confidence interval [CI] 1.09-4.27). Black patients scored significantly worse than non-Hispanic whites for two patient-reported measures - perceived racial/ethnic disparities (OR=3.14, 95% CI 1.15-8.53) and difficulties getting follow-up appointments (OR=3.37, 95% CI 1.55-7.32). The results indicate the need to evaluate both provider- and patient-centered measures in quality-of-care studies in disparities research.
Epilepsy & Behavior 02/2013; 27(1):95-101. · 2.34 Impact Factor
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ABSTRACT: INTRODUCTION: Identifying major bleeding is fundamental to assessing the outcomes of anticoagulation therapy. This drives the need for a credible implementation in automated data for the International Society of Thrombosis and Haemostasis (ISTH) definition of major bleeding. MATERIALS AND METHODS: We studied 102,395 patients who received 158,511 person-years of warfarin treatment from the Veterans Health Administration (VA) between 10/1/06-9/30/08. We constructed a list of ICD-9-CM codes of "candidate" bleeding events. Each candidate event was identified as a major hemorrhage if it fulfilled one of four criteria: 1) associated with death within 30days; 2) bleeding in a critical anatomic site; 3) associated with a transfusion; or 4) was coded as the event that precipitated or was responsible for the majority of an inpatient hospitalization. RESULTS: This definition classified 11,240 (15.8%) of 71, 338 candidate events as major hemorrhage. Typically, events more likely to be severe were retained at higher rates than those less likely to be severe. For example, Diverticula of Colon with Hemorrhage (562.12) and Hematuria (599.7) were retained 46% and 4% of the time, respectively. Major, intracranial, and fatal hemorrhage were identified at rates comparable to those found in randomized clinical trials however, higher than those reported in observational studies: 4.73, 1.29, and 0.41 per 100 patient years, respectively. CONCLUSIONS: We describe here a workable definition for identifying major hemorrhagic events from large automated datasets. This method of identifying major bleeding may have applications for quality measurement, quality improvement, and comparative effectiveness research.
Thrombosis Research 11/2012; · 2.44 Impact Factor
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ABSTRACT: ABSTRACT BACKGROUND: Among patients receiving oral anticoagulation, a gap of >56 days between INR tests suggests loss to follow-up that could lead to poor anticoagulation control and serious adverse events. METHODS: We studied long-term oral anticoagulation care for 56,490 patients age 65 and older at 100 sites of care in the Veterans Health Administration. We used the rate of gaps in monitoring per patient-year to predict percent time in therapeutic range (TTR) at the 100 sites. RESULTS: Many patients (45%) had at least one gap in monitoring during an average of 1.6 years of observation; 5% had 2 or more gaps per year. The median gap duration was 74 days (IQR 62-107). The average TTR for patients with 2+ gaps per year was 10 percentage points lower than for patients without gaps (p < 0.001). Patient-level predictors of gaps included nonwhite race, area poverty, greater distance from care, dementia, and major depression. Site-level gaps per patient-year varied from 0.19 to 1.78; each one unit increase was associated with a 9.2 percentage point decrease in site-level TTR (p < 0.001). CONCLUSIONS: Site-level gap rates varied widely within an integrated care system. Sites with more gaps per patient-year had worse anticoagulation control. Strategies to address and reduce gaps in monitoring may improve anticoagulation control.From the: 1Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford, MA;2Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA;3Department of Health Policy and Management, Boston University School of Public Health, Boston, MA;4Biostatistics Section, Boston Children's Hospital, Boston, MA;5Department of Quantitative Health Sciences, Division of Biostatistics and Health Services Research, University of Massachusetts School of Medicine, Worcester, MA.Address for Correspondence and Requests for Reprints: Adam J. Rose, MD MSc FACP, Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, 200 Springs Road, Building 70, Bedford, MA 01730 E-mail: adamrose@bu.eduFunding Sources: This project was supported by a grant from the Veterans Affairs Health Services Research and Development Service (IIR-10-374). Dr. Rose is supported by a Career Development Award from the Veterans Affairs Health Services Research and Development Service (CDA-2-08-017).
Chest 09/2012; · 5.25 Impact Factor
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ABSTRACT: While developed for managing individuals with atrial fibrillation, risk stratification schemes for stroke, such as CHADS2, may be useful in population-based studies, including those assessing process of care. We investigated how certain decisions in identifying diagnoses from administrative data affect the apparent prevalence of CHADS2-associated diagnoses and distribution of scores. Two sets of ICD-9 codes (more restrictive/ more inclusive) were defined for each CHADS2-associated diagnosis. For stroke/transient ischemic attack (TIA), the more restrictive set was applied to only inpatient data. We varied the number of years (1-3) in searching for relevant codes, and, except for stroke/TIA, the number of instances (1 vs. 2) that diagnoses were required to appear. The impact of choices on apparent disease prevalence varied by type of choice and condition, but was often substantial. Choices resulting in substantial changes in prevalence also tended to be associated with more substantial effects on the distribution of CHADS2 scores.
American journal of cardiovascular disease. 01/2012; 2(3):184-91.
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ABSTRACT: We evaluated the validity of questions designed to identify lifetime and active epilepsy, medication use, and seizure occurrence on population-based surveys. Subjects were interviewed by telephone, and responses were compared with information in their medical records. Prevalence, sensitivity, specificity, and positive predictive value (PPV) were calculated. The prevalence of ever having been diagnosed with epilepsy was 3.1% by self-report and 2.7% by medical record review. Sensitivity was 84.2%, specificity was 99.2%, and PPV was 73.5% for self-reported lifetime epilepsy, and values were similar for active epilepsy. By comparison, sensitivity was higher and specificity was lower for epilepsy medication use and seizure occurrence. The PPV for seizure occurrence was substantially higher for a recall period of 12 months than for 3 months. These results compare favorably with results for other chronic conditions, such as diabetes and arthritis, and indicate that questionnaires can be used to identify epilepsy at a population level.
Epilepsy & Behavior 12/2011; 23(1):57-63. · 2.34 Impact Factor
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ABSTRACT: To examine the change in use of high-risk medications for the elderly (HRME), as defined by the National Committee on Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) quality measure (HEDIS HRME), by older outpatient veterans over a 3-year period and to identify risk factors for HEDIS HRME exposure overall and for the most commonly used drug classes.
Longitudinal retrospective database analysis.
Outpatient clinics within the Department of Veterans Affairs (VA).
Veterans aged 65 by October 1, 2003, and who received VA care at least once each year until September 30, 2006.
Rates of use of HEDIS HRME overall and according to specific drug classes each year from fiscal year 2004 (FY04) to FY06.
In a cohort of 1,567,467, high-risk medication exposure fell from 13.1% to 12.3% between FY04 and FY06 (P<.001). High-risk antihistamines (e.g., diphenhydramine), opioid analgesics (e.g., propoxyphene), skeletal muscle relaxants (e.g., cyclobenzaprine), psychotropics (e.g., long half-life benzodiazepines), endocrine (e.g., estrogen), and cardiac medications (e.g., short-acting nifedipine) had modest but statistically significant (P<.001) reductions (range -3.8% to -16.0%); nitrofurantoin demonstrated a statistically significant increase (+36.5%; P<.001). Overall HEDIS HRME exposure was more likely for men, Hispanics, those receiving more medications, those with psychiatric comorbidity, and those without prior geriatric care. Exposure was lower for individuals exempt from copayment. Similar associations were seen between ethnicity, polypharmacy, psychiatric comorbidity, access-to-care factors, and use of individual HEDIS HRME classes.
HEDIS HRME drug exposure decreased slightly in an integrated healthcare system. Risk factors for exposure were not consistent across drug groups. Future studies should examine whether interventions to further reduce HEDIS HRME use improve health outcomes.
Journal of the American Geriatrics Society 08/2011; 59(10):1891-8. · 3.74 Impact Factor
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ABSTRACT: To identify prevalence and risk factors for exposure to drug-disease interactions included in the Healthcare Effectiveness Data and Information Set (HEDIS) Drug-Disease Interaction (Rx-DIS) measure.
Cross-sectional retrospective database analysis.
Outpatient clinics within the Department of Veterans Affairs (VA).
Individuals aged 65 and older who received VA outpatient care between October 1, 2003, and September 30, 2006.
Rx-DIS exposure based on the HEDIS measure was identified in VA patients with dementia, falls, and chronic renal failure using VA pharmacy and administrative databases. Factors associated with Rx-DIS exposure were examined, including demographic, health status, and access-to-care factors, including VA outpatient health services use and copayment status.
Of the 305,041 older veterans who met criteria for inclusion, the 1-year prevalence of Rx-DIS exposure was 15.2%; prevalence was 20.2% for dementia, 16.2% for falls, and 8.5% for chronic renal failure. Patients with high disease burden (physical, psychiatric, number of medications) were significantly more likely to have Rx-DIS exposure, regardless of condition. Hispanics and individuals with no copayments were more likely to have Rx-DIS exposure than whites or those with required copayments. There was variation in other predictors based on the type of Rx-DIS.
The prevalence of Rx-DIS was common in older VA outpatients. Future studies should examine the risk of Rx-DIS exposure on health outcomes using separate analyses for each type of Rx-DIS separately before combining all Rx-DIS into a single measure of exposure. Studies that examine the effectiveness of interventions to reduce Rx-DIS exposure will also be helpful in improving the quality of care for older adults.
Journal of the American Geriatrics Society 08/2011; 59(9):1673-8. · 3.74 Impact Factor
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ABSTRACT: To examine prevalence and resident- and site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants in older Veterans Affairs (VA) Community Living Center (CLC) residents.
Longitudinal study.
One hundred thirty-three VA CLCs.
Three thousand six hundred ninety-two veterans aged 65 and older admitted between January 1, 2004, and June 3, 2005, with long stays (≥ 90 days).
Prevalence of potential underuse, inappropriate use, and overuse of antidepressants in residents with and without depression (as documented according to International Classification of Diseases, Ninth Revision, Clinical Modification, codes or Depression Rating Scale).
Selective serotonin reuptake inhibitors were the most commonly prescribed antidepressant. Of the 877 residents with depression, 25.4% did not receive an antidepressant, suggesting potential underuse. Of residents with depression who received antidepressants, 57.5% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. Of the 2,815 residents who did not have depression, 1,190 (42.3%) were prescribed one or more antidepressants; only 48 (4.0%) of these had a Food and Drug Administration-approved labeled indication, suggesting potential overuse. Overall, only 17.6% of antidepressant use was appropriate (324/1,844). The only consistent resident factor associated with potential underuse and overuse use was taking an antipsychotic without evidence of schizophrenia (underuse: adjusted relative risk ratio (ARRR)=0.56, 95% confidence interval (CI)=0.33-0.94; overuse: adjusted odds ratio=1.52, 95% CI=1.21-1.91). Having moderate to severe pain (ARRR=1.54, 95% CI=1.08-2.20) and the prescribing of an anxiolytic or hypnotic (ARRR=1.33, 95% CI=1.02-1.74) increased the risk of potential inappropriate antidepressant use.
Potential problems with the use of antidepressants were frequently observed in older U.S. veteran CLC residents. Future studies are needed to examine the true risks and benefits of antidepressant use in CLC and non-VA nursing homes.
Journal of the American Geriatrics Society 08/2011; 59(8):1412-20. · 3.74 Impact Factor
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ABSTRACT: The potential to save money within a short time frame provides a more compelling "business case" for quality improvement than merely demonstrating cost-effectiveness. Our objective was to demonstrate the potential for cost savings from improved control in patients anticoagulated for atrial fibrillation.
Our population consisted of 67 077 Veterans Health Administration patients anticoagulated for atrial fibrillation between October 1, 2006, and September 30, 2008. We simulated the number of adverse events and their associated costs and utilities, both before and after various degrees of improvement in percent time in therapeutic range (TTR). The simulation had a 2-year time horizon, and costs were calculated from the perspective of the payer. In the base-case analysis, improving TTR by 5% prevented 1114 adverse events, including 662 deaths; it gained 863 quality-adjusted life-years and saved $15.9 million compared with the status quo, not accounting for the cost of the quality improvement program. Improving TTR by 10% prevented 2087 events, gained 1606 quality-adjusted life-years, and saved $29.7 million. In sensitivity analyses, costs were most sensitive to the estimated risk of stroke and the expected stroke reduction from improved TTR. Utilities were most sensitive to the estimated risk of death and the expected mortality benefit from improved TTR.
A quality improvement program to improve anticoagulation control probably would be cost-saving for the payer, even if it were only modestly effective in improving control and even without considering the value of improved health. This study demonstrates how to make a business case for a quality improvement initiative.
Circulation Cardiovascular Quality and Outcomes 06/2011; 4(4):416-24. · 4.91 Impact Factor
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ABSTRACT: Improved control of oral anticoagulation reduces adverse events. A program of quality measurement is needed for oral anticoagulation. The interval until the next test after an out-of-range International Normalized Ratio (INR) value (the "follow-up interval") could serve as a process of care measure.
We studied 104 451 patients cared for by 100 anticoagulation clinics in the Veterans Health Administration (VA). For each site, we computed the average follow-up interval after low (≤1.5) or high (≥4.0) INR. Our outcome was each site's average anticoagulation control, measured by percent time in therapeutic range (TTR); 59 837 patients (57%) contributed to the low INR analysis, 37 697 (36%) contributed to the high INR analysis, and all patients contributed to the dependent variable (mean site TTR). After a low INR, site mean follow-up interval ranged from 10 to 24 days. Longer follow-up intervals were associated with worse site-level control (1.04% lower for each additional day, P<0.001). After a high INR, site mean follow-up interval ranged from 6 to 18 days, with longer follow-up intervals associated with worse site-level control (1.12% lower for each additional day, P<0.001). These relationships were somewhat attenuated but still highly statistically significant when the proportion of INR values in-range was used as the dependent variable rather than TTR.
Prompt repeat testing after out-of-range INR values is associated with better anticoagulation control at the site level and could be an important part of a quality improvement effort for oral anticoagulation.
Circulation Cardiovascular Quality and Outcomes 05/2011; 4(3):276-82. · 4.91 Impact Factor
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ABSTRACT: To describe variations in the structure of anticoagulation clinic (ACC) care within the Veterans Health Administration (VA) and to identify structures of care that are associated with better site-level anticoagulation control.
Questionnaire correlated with automated clinical data.
We characterized 90 VA ACCs using a questionnaire administered by the VA Central Office. Site descriptors included staffing levels, provider training, visit modalities, quality improvement programs, documentation, and care coordination. Patient outcomes were measured by site mean risk-adjusted percentage time in therapeutic range, a measure of anticoagulation control over time. Our study was powered to detect a 3% difference in risk-adjusted percentage time in therapeutic range, a small-to-moderate effect size, between sites with and without a certain characteristic.
We observed considerable variation in the structure of ACC care. For example, 48 sites had fewer than 400 patients per provider, 25 sites had 400 to 599 patients per provider, and 17 sites had 600 patients or more per provider. However, none of the site characteristics measured were significantly related to anticoagulation control.
We found substantial variation in guideline-targeted organizational and management features of ACC care within the VA. However, no single feature was associated with better anticoagulation control. Current guidelines for organizing an ACC may have limited relevance for improving patient outcomes.
The American journal of managed care 04/2011; 17(4):284-9. · 2.46 Impact Factor
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ABSTRACT: We sought to describe how patient characteristics influence the frequency of red blood cell (RBC) transfusions among critically ill patients after taking into account hemoglobin (Hgb) level.
This was a retrospective cohort study using secondary analysis of administrative data of Veterans Affairs intensive care unit (ICU) admissions. The outcome of interest was RBC transfusion during the first 30 days of ICU admission. Besides Hgb level, explanatory variables included demographics, admission-related information, comorbid conditions, ICU admission diagnosis, and selected laboratory test results. Logistic regression modeling quantified associations between explanatory variables and transfusion.
For 259 281 ICU admissions from 2001 to 2005, the overall incidence of RBC transfusion was 12.5%. Increased age, male gender, admission for acute myocardial infarction (AMI), and comorbid heart disease were independently associated with transfusion. Compared with admission for reference diagnoses, transfusions were more likely for admissions for AMI, unstable angina, and congestive heart failure only at Hgb levels below 11, 9, and 6 g/dL, respectively.
Intensive care unit patients admitted for AMI, unstable angina, and congestive heart-failure had higher likelihood of receiving RBC transfusions below specific Hgb levels varying from 6 to 11 g/dL. Further research is needed to determine how these transfusion practices influence outcomes.
Journal of critical care 03/2011; 26(4):431.e1-9. · 2.13 Impact Factor
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ABSTRACT: Patients receiving oral anticoagulation therapy should be tested often enough to optimize control, but excessive testing increases burden and cost. We examined the relationship between follow-up intervals after obtaining an in-range (2.0-3.0) international normalized ratio (INR) and anticoagulation control.
We studied 104,451 patients who were receiving anticoagulation therapy from 100 anticoagulation clinics in the US Veterans Health Administration. Most patients (98,877) had at least one in-range INR followed by another INR within 56 days. For each such patient, we selected the last in-range INR and characterized the interval between this index value and the next INR. The independent variable was the site mean follow-up interval after obtaining an in-range INR. The dependent variable was the site mean risk-adjusted percentage of time in the therapeutic range (TTR).
The site mean follow-up interval varied from 25 to 38 days. As the site mean follow-up interval became longer, the risk-adjusted TTR was worse (-0.51% per day, P = .004). This relationship persisted when the index value was the first consecutive in-range INR (-0.63%, P < .001) or the second (-0.58%, P < .001), but not the third or greater (-0.12%, P = .46).
Sites varied widely regarding follow-up intervals after obtaining an in-range INR (25-38 days). Shorter intervals were generally associated with better anticoagulation control, but after obtaining a third consecutive in-range value, this relationship was greatly attenuated and no longer statistically significant. Our results suggest that a maximum interval of 28 days after obtaining the first or second in-range value and consideration of a longer interval after obtaining the third or greater consecutive in-range value may be appropriate.
Chest 02/2011; 140(2):359-65. · 5.25 Impact Factor
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ABSTRACT: Oral anticoagulation is safer and more effective when patients receive high-quality care. However, there have been no prior efforts to measure quality of oral anticoagulation care or to risk adjust it to ensure credible comparisons. Our objective was to profile site performance in the Veterans Health Administration (VA) using risk-adjusted percent time in therapeutic range (TTR).
We included 124 551 patients who received outpatient oral anticoagulation from 100 VA sites of care for indications other than valvular heart disease from October 1, 2006, to September 30, 2008. We calculated TTR for each patient and mean TTR for each site of care. Expected TTR was calculated for each patient and each site based on the variables in the risk adjustment model, which included demographics, comorbid conditions, medications, and hospitalizations. Mean TTR for the entire sample was 58%. Site-observed TTR varied from 38% to 69% or from poor to excellent. Site-expected TTR varied from 54% to 62%. Site risk-adjusted performance ranged from 18% below expected to 12% above expected. Risk adjustment did not alter performance rankings for many sites, but for other sites, it made an important difference. For example, the site ranked 27th of 100 before risk adjustment was one of the best (risk-adjusted rank, 7). Risk-adjusted site rankings were consistent from year to year (correlation between years, 0.89).
Risk-adjusted TTR can be used to profile the quality of outpatient oral anticoagulation in a large, integrated health system. This measure can serve as the basis for quality measurement and quality improvement efforts.
Circulation Cardiovascular Quality and Outcomes 01/2011; 4(1):22-9. · 4.91 Impact Factor
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ABSTRACT: We examined the quality of adult epilepsy care using the Quality Indicators in Epilepsy Treatment (QUIET) measure, and variations in quality based on the source of epilepsy care.
We identified 311 individuals with epilepsy diagnosis between 2004 and 2007 in a tertiary medical center in New England. We abstracted medical charts to identify the extent to which participants received quality indicator (QI) concordant care for individual QI's and the proportion of recommended care processes completed for different aspects of epilepsy care over a two year period. Finally, we compared the proportion of recommended care processes completed for those receiving care only in primary care, neurology clinics, or care shared between primary care and neurology providers.
The mean proportion of concordant care by indicator was 55.6 (standard deviation = 31.5). Of the 1985 possible care processes, 877 (44.2%) were performed; care specific to women had the lowest concordance (37% vs. 42% [first seizure evaluation], 44% [initial epilepsy treatment], 45% [chronic care]). Individuals receiving shared care had more aspects of QI concordant care performed than did those receiving neurology care for initial treatment (53% vs. 43%; X(2) = 9.0; p = 0.01) and chronic epilepsy care (55% vs. 42%; X(2) = 30.2; p < 0.001).
Similar to most other chronic diseases, less than half of recommended care processes were performed. Further investigation is needed to understand whether a shared-care model enhances quality of care, and if so, how it leads to improvements in quality.
BMC Health Services Research 01/2011; 11:1. · 1.66 Impact Factor
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ABSTRACT: Disparities in blood pressure (BP) control may be a function of disparities in treatment intensification (TI).
To examine racial differences in TI, understand modifiable factors that may mediate this relationship, and explore the relative effects of TI and race on blood pressure.
Prospective cohort study.
Participants were 819 black and white patients with hypertension from an urban, safety-net hospital
We sequentially explored the effects of patient race, sociodemographic and clinical characteristics, beliefs about BP/medications, perceptions of provider/discrimination, sodium intake, medication adherence, and provider counseling on TI, performing a series of random effects analyses. To assess the effects of race and TI on BP, we performed linear regressions, using systolic BP (SBP) as the outcome.
Unadjusted analyses and those including sociodemographic and clinical characteristics revealed that black patients had less TI than whites (-0.31 vs.-0.24, p < 0.001), but adjustment for patient beliefs and experiences eliminated the effects of race (beta =-0.02, p = 0.5). Increased patient concerns about BP medications were related to lower TI, as was more provider counseling (beta =-0.06, p = 0.02 and beta = -0.01, p = 0.001, respectively). In the unadjusted analysis, black race was a significant predictor of SBP (134 mm/Hg for blacks vs. 131 mm/Hg for whites, p = 0.009), but when both race and TI were included in the model, TI was a significant predictor of SBP (final SBP 2.0 mm/Hg lower for each additional therapy increase per 10 visits, p < 0.001), while race was not (Blacks 1.6 mm/Hg higher than whites, p = 0.17).
Improved patient-provider communication targeted towards addressing patient concerns about medications may have the potential to reduce racial disparities in TI and ultimately, BP control.
Journal of General Internal Medicine 04/2010; 25(8):819-25. · 2.83 Impact Factor
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ABSTRACT: To identify clinically meaningful potential drug-drug interactions (PDIs) with antiepileptic drugs (AEDs), the AEDs and co-administered drugs commonly associated with AED-PDIs, and characteristics of patients with high likelihood of AED-PDI exposure.
Five-year retrospective cohort study of veterans with new-onset epilepsy.
National Veterans Affairs and Medicare databases.
Veterans aged 66 and older with a new diagnosis of epilepsy between October 1, 1999, and September 30, 2004 (N=9,682).
AED-PDI was restricted to clinically meaningful PDIs identified using prior literature review. AED-PDIs were identified using participants' date of initial AED prescription and overlapping concomitant medications. Logistic regression analysis identified factors associated with AED-PDI, including demographic characteristics, chronic disease states, and diagnostic setting.
AED-PDI exposure was found in 45.5% (4,406/9,682); phenytoin, a drug with many PDIs, was the most commonly prescribed AED. Cardiovascular drugs, lipid-lowering medications, and psychotropic agents were the most commonly co-administered AED-PDI medications. Individuals with AED-PDI exposure were more likely to have hypertension (odds ratio (OR)=1.46, 99% confidence interval (CI)=1.24-1.82) and hypercholesterolemia (OR=1.40, 99% CI=1.24-1.57) than those without and to be diagnosed in an emergency or primary care setting than a neurology setting (emergency: OR=1.30, 99% CI=1.08-1.58; primary care: OR=1.29 99% CI=1.12-1.49).
Exposure to AED-PDI was substantial but less common in patients with epilepsy diagnosed in a neurology setting. Because potential outcomes associated with AED-PDI include stroke and myocardial infarction in a population already at high risk, clinicians should closely monitor blood pressure, coagulation, and lipid measures to minimize adverse effects of AED-PDIs. Interventions to reduce AED-PDIs may improve patient outcomes.
Journal of the American Geriatrics Society 03/2010; 58(3):465-71. · 3.74 Impact Factor
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Susan M Frayne,
MD,
MPH,
MS Eric Berg,
PhD Tyson H. Holmes,
BA Kaajal Laungani, Dan R Berlowitz,
ScD Donald R. Miller,
Leonard Pogach,
MBA,
MPH Valerie W. Jackson,
PhD Rudolf Moos
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ABSTRACT: Methodological challenges arise when one uses various Veterans Health Administration (VHA) data sources, each created for distinct purposes, to characterize length of stay (LOS). To illustrate this issue, we examined how algorithm choice affects conclusions about mental health condition (MHC)-related differences in LOS for VHA patients with diabetes nationally (n = 784,321). We assembled a record-level database of all fiscal year (FY) 2003 inpatient care. In 10 steps, we sequentially added instances of inpatient care from various VHA sources. We processed databases in three stages, truncating stays at the beginning and end of FY03 and consolidating overlapping stays. For patients with MHCs versus those without MHCs, mean LOS was 17.7 versus 13.6 days, respectively (p < 0.001), for the crudest algorithm and 37.2 versus 21.7 days, respectively (p < 0.001), for the most refined algorithm. Researchers can improve the quality of data applied to VHA systems redesign by applying methodological considerations raised by this study to inform LOS algorithm choice.
Journal of Rehabilitation Research and Development. 01/2010;
