Beyond Hospital-Level Aggregated Data: A Methodology to Adapt Clinical Data From the Electronic Health Record for Nursing Unit-Level Research.

BACKGROUND: Studies of nurse staffing frequently use data aggregated at the hospital level that do not provide the appropriate context to inform unit-level decisions, such as nurse staffing. OBJECTIVES: Describe a method to link patient data collected during the provision of routine care and recorded in the electronic health record (EHR) to the nursing units where care occurred in a national dataset. RESEARCH DESIGN: We identified all Veterans Health Administration acute care hospitalizations in the calendar year 2019 nationwide. We linked patient-level EHR and bar code medication administration data to nursing units using a crosswalk. We divided hospitalizations into segments based on the patient's time-stamped location (ward stays). We calculated the number of ward stays and medication administrations linked to a nursing unit and the unit-level and facility-level mean patient risk scores. RESULTS: We extracted data on 1117 nursing units, 3782 EHR patient locations associated with 1,137,391 ward stays, and 67,772 bar code medication administration locations associated with 147,686,996 medication administrations across 125 Veterans Health Administration facilities. We linked 89.46% of ward stays and 93.10% of medication administrations to a nursing unit. The average (standard deviation) unit-level patient severity across all facilities is 4.71 (1.52), versus 4.53 (0.88) at the facility level. CONCLUSIONS: Identification of units is indispensable for using EHR data to understand unit-level phenomena in nursing research and can provide the context-specific information needed by managers making frontline decisions about staffing.

Nurse Leader Perceptions of Data in the Veterans Health Administration: A Qualitative Evaluation.

Healthcare systems and nursing leaders aim to make evidence-based nurse staffing decisions. Understanding how nurses use and perceive available data to support safe staffing can strengthen learning healthcare systems and support evidence-based practice, particularly given emerging data availability and specific nursing challenges in data usability. However, current literature offers sparse insight into the nature of data use and challenges in the inpatient nurse staffing management context. We aimed to investigate how nurse leaders experience using data to guide their inpatient staffing management decisions in the Veterans Health Administration, the largest integrated healthcare system in the United States. We conducted semistructured interviews with 27 Veterans Health Administration nurse leaders across five management levels, using a constant comparative approach for analysis. Participants primarily reported using data for quality improvement, organizational learning, and organizational monitoring and support. Challenges included data fragmentation, unavailability and unsuitability to user need, lack of knowledge about available data, and untimely reporting. Our findings suggest that prioritizing end-user experience and needs is necessary to better govern evidence-based data tools for improving nursing care. Continuous nurse leader involvement in data governance is integral to ensuring high-quality data for end-user nurses to guide their decisions impacting patient care.

Correlates of SGLT-2-inhibitiors use among patients with atherosclerotic cardiovascular disease and type 2 diabetes mellitus: Insights from the department of veterans affairs.

This study using data from the Veterans Affairs (VA) administrative and clinical dataset examined determinants of sodium-glucose cotransporter-2 inhibitors (SGLT-2i) use among patients with concomitant atherosclerotic cardiovascular disease (ASCVD) and diabetes mellitus. The aim of the present analysis was to identify barriers and facilitators associated with SGLT-2i in a real-world contemporary patient population in order to improve utilization of these guideline-directed agents.

Significant Facility-Level Variation in Utilization of and Adherence with Secondary Prevention Therapies Among Patients with Premature Atherosclerotic Cardiovascular Disease: Insights from the VITAL (Veterans wIth premaTure AtheroscLerosis) Registry7.

PURPOSE: We investigated facility-level variation in the use and adherence with antiplatelets and statins among patients with premature and extremely premature ASCVD. METHODS: Using the 2014-2015 nationwide Veterans wIth premaTure AtheroscLerosis (VITAL) registry, we assessed patients with premature (age at first ASCVD event: males < 55 years, females < 65 years) and extremely premature ASCVD (< 40 years). We examined frequency and facility-level variation in any statin, high-intensity statin (HIS), antiplatelet use (aspirin, clopidogrel, ticagrelor, prasugrel, and ticlopidine), and statin adherence (proportion of days covered ≥ 0.8) across 130 nationwide VA healthcare facilities. Facility-level variation was computed using median rate ratios (MRR), a measure of likelihood that two random facilities differ in use of statins or antiplatelets and statin adherence. RESULTS: Our analysis included 135,703 and 7716 patients with premature and extremely premature ASCVD, respectively. Across all facilities, the median (IQR) prescription rate of any statin therapy, HIS therapy, and antiplatelets among patients with premature ASCVD was 0.73 (0.70-0.75), 0.36 (0.32-0.41), and 0.77 (0.73-0.81), respectively. MRR (95% CI) for any statin use, HIS use, and antiplatelet use were 1.53 (1.44-1.60), 1.58 (1.49-1.66), and 1.49 (1.42-1.56), respectively, showing 53, 58, and 49% facility-level variation. The median (IQR) facility-level rate of statin adherence was 0.58 (0.55-0.62) and MRR for statin adherence was 1.13 (1.10-1.15), showing 13% facility-level variation. Similar median facility-level rates and variation were observed among patients with extremely premature ASCVD. CONCLUSIONS: There is suboptimal use and significant facility-level variation in the use of statin and antiplatelet therapy among patients with premature and extremely premature ASCVD. Interventions are needed to optimize care and minimize variation among young ASCVD patients.

Facility-Level Variation in Reported Statin-Associated Side Effects Among Patients with Atherosclerotic Cardiovascular Disease-Perspective from the Veterans Affair Healthcare System.

PURPOSE: Statin-associated side effects (SASEs) can limit statin adherence and present a potential barrier to optimal statin utilization. How standardized reporting of SASEs varies across medical facilities has not been well characterized. METHODS: We assessed facility-level variation in SASE reporting among patients with atherosclerotic cardiovascular disease receiving care across the Veterans Affairs (VA) healthcare system from October 1, 2014, to September 30, 2015. The facility rates for SASE reporting were expressed as cases per 1000 patients with ASCVD. Facility-level variation was determined using hierarchical regression analysis to calculate median rate ratios (MRR [95% confidence interval]) by first using an unadjusted model and then adjusting for patient, provider, and facility characteristics. RESULTS: Of the 1,248,158 patients with ASCVD included in our study across 130 facilities, 13.7% had at least one SASE reported. Individuals with a history of SASE were less likely to be on a statin at follow-up compared with those without SASE (72.0% vs 80.8%, p < 0.01). The median (interquartile range) facility rate of SASE reported was 140.5 (109.4-167.7) cases per 1000 patients with ASCVD. Significant facility-level variation in the rate of SASE reported was observed: MRR 1.38 (1.33-1.44) in the unadjusted model and MRR 1.56 (1.47-1.65) in the adjusted model. CONCLUSION: Significant facility-level variation in SASE reporting was found within the VA healthcare system suggesting room for improvement in standardized documentation of SASEs among medical facilities. This has the potential to lead to improvement in statin utilization.

A Mistake Not to Be Repeated: What Can We Learn from the Underutilization of Statin Therapy for Efficient Dissemination of Cardioprotective Glucose Lowering Agents?

PURPOSE OF REVIEW: To review the factors contributing to underutilization of guideline-directed therapies, identify strategies to alleviate these factors, and apply these strategies for effective and timely dissemination of novel cardioprotective glucose-lowering agents. RECENT FINDINGS: Recent analyses demonstrate underutilization of cardioprotective glucose lowering agents despite guideline recommendations for their use. Major contributors to underutilization of guideline-directed therapies include therapeutic inertia, perceptions about side effects, and factors found at the level of the clinicians, patients, and the healthcare system. The recent emergence of several novel therapies, such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, for use in cardiovascular disease provides a unique avenue to improve patient outcomes. To effectively utilize novel cardioprotective glucose lowering agents to improve cardiovascular outcomes, clinicians must recognize and learn from prior barriers to application of guideline-directed therapies. Further endeavors are prudent to ensure uptake of novel agents.

An Alternative Method of Public Reporting of Comparative Hospital Quality and Performance Data for Transparency Initiatives.

BACKGROUND: Hospital performance comparisons for transparency initiatives may be inadequate if peer comparison groups are poorly defined. OBJECTIVE: The objective of this study was to evaluate a new approach identifying hospital peers for comparison. DESIGN/SETTING: We used Mahalanobis distance as a new method of developing peer-specific groupings for hospitals to incorporate both external and internal complexity. We compared the overlap in groups with an existing method used by the Veterans' Health Administration's Office for Productivity, Efficiency, and Staffing (OPES). PARTICIPANTS: One hundred twenty-two acute-care Veterans' Health Administration's Medical Facilities as defined in the OPES fiscal year 2014 report. MEASURES: Using 15 variables in 9 categories developed from expert input, including both hospital internal measures and community-based external measures, we used principal components analysis and calculated Mahalanobis distance between each hospital pair. This method accounts for correlation between variables and allows for variables having different variances. We identified the 50 closest hospitals, then eliminated any potential peer whose score on the first component was >1 SD from the reference hospital. We compared overlap with OPES measures. RESULTS: Of 15 variables, 12 have SDs exceeding 25% of their means. The first 2 components of our analysis explain 24.8% and 18.5% of variation among hospitals. Eight of 9 variables scaling positively on the first component measure internal complexity, aligning with OPES groups. Four of 5 variables scaling positively on the second component but not the first are factors from the policy environment; this component reflects a dimension not considered in OPES groups. CONCLUSION: Individualized peers that incorporate external complexity generate more nuanced comparators to evaluate quality.

Comparative Effectiveness of Risk-adjusted Cumulative Sum and Periodic Evaluation for Monitoring Hospital Perioperative Mortality.

BACKGROUND: National surgical quality improvement (QI) programs use periodic, risk-adjusted evaluation to identify hospitals with higher than expected perioperative mortality. Rapid, accurate identification of poorly performing hospitals is critical for avoiding potentially preventable mortality and represents an opportunity to enhance QI efforts. METHODS: Hospital-level analysis using Veterans Affairs (VA) Surgical Quality Improvement Program data (2011-2016) to compare identification of hospitals with excess, risk-adjusted 30-day mortality using observed-to-expected (O-E) ratios (ie, current gold standard) and cumulative sum (CUSUM) with V-mask. Various V-mask slopes and radii were evaluated-slope of 2.5 and radius of 1.0 was used as the base case. RESULTS: Hospitals identified by CUSUM and quarterly O-E were identified midway into a quarter [median 47 days; interquartile range (IQR): 24-61 days before quarter end] translating to a median of 129 (IQR: 60-187) surgical cases and 368 (IQR: 145-681) postoperative inpatient days occurring after a CUSUM signal, but before the quarter end. At hospitals identified by CUSUM but not O-E, a median of 2 deaths within a median of 5 days triggered a signal. In some cases, these clusters extended beyond CUSUM identification date with as many as 8 deaths undetected using O-E. Sensitivity and negative predictive values for CUSUM relative to O-E were 71.9% (95% confidence interval: 66.2%-77.1%) and 95.5% (94.4%-96.4%), respectively. CONCLUSIONS: CUSUM evaluation identifies hospitals with clusters of mortality in excess of expected more rapidly than periodic analysis. CUSUM represents an analytic tool national QI programs could utilize to provide participating hospitals with data that could facilitate more proactive implementation of local interventions to help reduce potentially avoidable perioperative mortality.

To Battle COVID-19's Twin Economic and Health Crises, Medicaid Needs Flexible Funding Structures for Stabilization.

Medicaid, which provides health insurance to low-income Americans, is a joint federal-state partnership that manifests as 50 unique state programs. States have policy flexibility to design programs within federal parameters. However, Medicaid also requires funding flexibility to encourage states to maintain services during times of crisis when more people need Medicaid. Currently, Medicaid's funding formula, the Federal Medical Assistance Percentage (FMAP), adjusts federal spending by state levels of economic development but fails to adjust for nationwide recessions. During economic contractions, the federal government should use its ability to run budget deficits to reimburse states at higher rates in exchange for maintaining services. In turn, during economic expansions, states should shoulder relatively more costs of Medicaid. Although the current FMAP boost provided under the Families First Coronavirus Response Act has reduced strain on state Medicaid programs, it does not account for the severity of state-specific downturns and is limited to the current emergency. Instead of ad hoc, across-the-board FMAP boosts to respond to each crisis, Congress should pass legislation making automatic adjustments based on changes in state unemployment rates.

Long-Term Implications of Post-ACA Health Reform on State Health Care Policy.

In the midst of the COVID-19 outbreak, health care reform has again taken a major role in the 2020 election, with Democrats weighing Medicare for All against extensions of the Affordable Care Act, while Republicans quietly seem to favor proposals that would eliminate much of the ACA and cut Medicaid. Although states play a major role in health care funding and administration, public and scholarly debates over these proposals have generally not addressed the potential disruption that reform proposals might create for the current state role in health care. We examine how potential reforms influence state-federal relations, and how outside factors like partisanship and exogenous shocks like the COVID-19 pandemic interact with underlying preferences of each level of government. All else equal, reforms that expand the ACA within its current framework would provide the least disruption for current arrangements and allow for smoother transitions for providers and patients, rather than the more radical restructuring proposed by Medicare for All or the cuts embodied in Republican plans.

Relationship Between Perioperative Outcomes Used for Profiling Hospital Noncardiac Surgical Quality.

BACKGROUND: Risk-adjusted morbidity and mortality are commonly used by national surgical quality improvement (QI) programs to measure hospital-level surgical quality. However, the degree of hospital-level correlation between mortality, morbidity, and other perioperative outcomes (like reoperation) collected by contemporary surgical QI programs has not been well-characterized. MATERIALS AND METHODS: Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP) data (2015-2016) were used to evaluate hospital-level correlation in performance between risk-adjusted 30-d mortality, morbidity, major morbidity, reoperation, and 2 composite outcomes (1- mortality, major morbidity, or reoperation; 2- mortality or major morbidity) after noncardiac surgery. Correlation between outcomes rates was evaluated using Pearson's correlation coefficient. Correlation between hospital risk-adjusted performance rankings was evaluated using Spearman's correlation. RESULTS: Based on a median of 232 [IQR 95-331] quarterly surgical cases abstracted by VASQIP, statistical power for identifying 30-d mortality outlier hospitals was estimated between 3.3% for an observed-to-expected ratio of 1.1 and 45.7% for 3.0. Among 230,247 Veterans who underwent a noncardiac operation at 137 VA hospitals, there were moderate hospital-level correlations between various risk-adjusted outcome rates (highest r = 0.40, mortality and composite 1; lowest r = 0.32, mortality and morbidity). When hospitals were ranked based on performance, there was low-to-moderate correlation between rankings on the various outcomes (highest ρ = 0.47, mortality and composite 1; lowest ρ = 0.37, mortality and major morbidity). CONCLUSIONS: Modest hospital-level correlations between perioperative outcomes suggests it may be difficult to identify high (or low) performing hospitals using a single measure. Additionally, while composites of currently measured outcomes may be an efficient way to improve analytic sample size (relative to evaluations based on any individual outcome), further work is needed to understand whether they provide a more robust and accurate picture of hospital quality or whether evaluating performance across a portfolio of individual measures is most effective for driving QI.

Gender disparities in difficulty accessing healthcare and cost-related medication non-adherence: The CDC behavioral risk factor surveillance system (BRFSS) survey.

Ensuring healthcare access is critical to maintain health and prevent illness. Studies demonstrate gender disparities in healthcare access. Less is known about how these vary with age, race/ethnicity, and atherosclerotic cardiovascular disease. We utilized cross-sectional data from 2016 to 2019 CDC Behavioral Risk Factor Surveillance System (BRFSS), a U.S. telephone-based survey of adults (≥18 years). Measures of difficulty accessing healthcare included absence of healthcare coverage, delay in healthcare access, absence of primary care physician, >1-year since last checkup, inability to see doctor due to cost, and cost-related medication non-adherence. We studied the association between gender and these variables using multivariable-adjusted logistic regression models, stratifying by age, race/ethnicity, and atherosclerotic cardiovascular disease status. Our population consisted of 1,737,397 individuals; 54% were older (≥45 years), 51% women, 63% non-Hispanic White, 12% non-Hispanic Black,17% Hispanic, 9% reported atherosclerotic cardiovascular disease. In multivariable-adjusted models, women were more likely to report delay in healthcare access: odds ratio (OR) and (95% confidence interval): 1.26 (1.11, 1.43) [p < 0.001], inability to see doctor due to cost: 1.29 (1.22, 1.36) [p < 0.001], cost-related medication non-adherence: 1.24 (1.01, 1.50) [p = 0.04]. Women were less likely to report lack of healthcare coverage: 0.71 (0.66, 0.75) [p < 0.001] and not having a primary care physician: 0.50 (0.48, 0.52) [p < 0.001]. Disparities were pronounced in younger (<45 years) and Black women. Identifying these barriers, particularly among younger women and Black women, is crucial to ensure equitable healthcare access to all individuals.

Prevalence and predictors of cost-related medication nonadherence in individuals with cardiovascular disease: Results from the Behavioral Risk Factor Surveillance System (BRFSS) survey.

Medication nonadherence is highly prevalent among patients with chronic cardiovascular disease. Poor adherence has been associated with increased morbidity and mortality. Medication cost is a major driver for medication nonadherence. Utilizing data from the 2016 to 2018 Behavioral Risk Factor Surveillance System (BRFSS) survey, we estimated the prevalence of cost-related medication nonadherence (CRMNA) among the overall population and among individuals who reported a history of diabetes, atherosclerotic cardiovascular disease (ASCVD), or hypertension. We then performed multivariable logistic regression to analyze sociodemographic factors associated with CRMNA. Our study population consisted of 142,577 individuals of whom 24% were older than 65 years, 47% were men, 66% were White, 17% Black, 35% had hypertension, 13% had diabetes mellitus, and 10% had ASCVD. CRMNA was reported in 10% of the overall population, 12% among those with hypertension, 17% among those with diabetes, and 17% among those with ASCVD. Age below 65 years, female gender, unemployment, lower income, lower educational attainment, having at least 1 comorbidity, and living in a state that did not expand Medicaid were independently associated with CRMNA. The prevalence of CRMNA increased with greater number of these high-risk sociodemographic factors. We conclude that the prevalence of CRMNA is 10% among U.S. adults overall and is higher among those with common chronic diseases. Risk factors associated with CRMNA should be addressed in order to improve adherence rates and health outcomes among high-risk individuals.

Eligibility for Low-Dose Rivaroxaban Based on the COMPASS Trial: Insights from the Veterans Affairs Healthcare System.

INTRODUCTION: Low-dose rivaroxaban reduced major adverse cardiac and limb events among patients with stable atherosclerotic vascular disease (ASCVD) in the COMPASS trial. The objective of our study was to evaluate the eligibility and budgetary impact of the COMPASS trial in a real-world population. METHODS: The VA administrative and clinical databases were utilized to conduct a cross-sectional study to identify patients eligible for low-dose rivaroxaban receiving care at all 141 facilities between October 1, 2014 and September 30, 2015. Proportion of patients with stable ASCVD eligible for low-dose rivaroxaban and prevalence of multiple risk enrichment criteria among eligible patients. Pharmaceutical budgetary impact using VA pharmacy pricing. Chi-squared and Student's t tests were used to compare patients eligible versus ineligible patients. RESULTS: From an initial cohort of 1,248,214 patients with ASCVD, 488,495 patients (39.1%) met trial eligibility criteria. Eligible patients were older (74.2 vs 64.5 years) with higher proportion of hypertension (84.1% vs 82.1%) and diabetes (46.2% vs 32.9) compared with ineligible patients (p < 0.001 for all comparisons). A median of 38.7% (IQR 4.6%) of total ASCVD patients per facility were rivaroxaban eligible. Estimated annual VA pharmacy budgetary impact would range from $0.47 billion to $1.88 billion for 25% to 100% treatment penetration. Annual facility level pharmaceutical budgetary impact would be a median of $12.3 million (IQR $8.0-$16.3 million) for treatment of all eligible patients. Among eligible patients, age greater than 65 years was the most common risk enrichment factor (86.9%). Prevalence of eligible patients with multiple enrichment factors varied from 34.2% (one factor) to 6.2% (four or more). CONCLUSION: Over one third of patients with stable ASCVD may qualify for low-dose rivaroxaban within the VA. Additional studies are needed to understand eligibility in other populations and a formal cost-effectiveness analysis is warranted.

Association between frequency of primary care provider visits and evidence-based statin prescribing and statin adherence: Findings from the Veterans Affairs system.

BACKGROUND: Statin use remains suboptimal in patients with atherosclerotic cardiovascular disease (ASCVD). We assessed if the frequency of visits with primary care providers (PCPs) is associated with higher use of evidence-based statin prescriptions and adherence among patients with ASCVD. METHODS: We identified patients with ASCVD aged ≥18 years receiving care in 130 facilities and associated community-based outpatient clinics in the entire Veterans Affairs Health Care System between October 1, 2013 and September 30, 2014. Patients were divided into frequent PCP visitors (annual PCP visits ≥ median number of PCP visits for the entire cohort) and infrequent PCP visitors (annual PCP visits < median number of patient visits). We assessed any- and high-intensity statin prescription as well as statin adherence which was defined by proportion of days covered (PDC). RESULTS: We included 1,249,061 patients with ASCVD (mean age was 71.9 years; 98.0% male). Median number of annual PCP visits was 3. Approximately 80.1% patients were on statins with 23.8% on high-intensity statins. Mean PDC was 0.715 ±â€¯0.336 with 58.3% patients with PDC ≥0.8. Frequent PCP visitors had higher frequency of statin use (82.2% vs 77.4%), high-intensity statin use (26.4% vs 20.3%), and statin adherence (mean PDC 0.73 vs 0.68; P < .01) compared to infrequent PCP visitors. After adjusting for covariates, frequent PCP visits was associated with greater odds of being on any statin, high intensity statin, and higher statin adherence. CONCLUSION: Frequent visits with PCPs is associated with a higher likelihood of any statin use, high intensity statin use, and statin adherence. Further research endeavors are needed to understand the reasons behind these associations.

Effects of State-level Medicaid Expansion on Veterans Health Administration Dual Enrollment and Utilization: Potential Implications for Future Coverage Expansions.

OBJECTIVE: The objective of this study was to examine how pre-Affordable Care Act (ACA) state-level Medicaid expansions affect dual enrollment and utilization of Veterans Health Administration (VA) and Medicaid-funded care. RESEARCH DESIGN: We employed difference-in-difference analysis to determine the association between pre-ACA Medicaid expansions in New York and Arizona in 2001 and VA utilization. Participants' dual enrollment in Medicaid and VA, the distribution of their annual hospital admissions and emergency department (ED) visits between VA and Medicaid were dependent variables. We controlled for age, race, sex, disease burden, distance to VA facilities and income-based eligibility for VA services. MEASURES: Secondary data collected from 1999 to 2006 in 2 states expanding Medicaid and 3 demographically similar nonexpansion states. We obtained residency, enrollment and utilization data from VA's Corporate Data Warehouse and Medicaid Analytic Extract files. RESULTS: For low-income Veterans, Medicaid expansion was associated with increased dual enrollment of 4.87 percentage points (99% confidence interval: 4.48-5.25), a 4.63-point decline in VA proportion of admissions (-5.87 to -3.38), and a 11.70-point decrease in the VA proportion of ED visits (-13.06 to -10.34). Results also showed increases in the number of total (VA plus Medicaid) annual per-capita hospitalizations and ED visits among the group of VA enrollees most likely to be eligible for expansion. CONCLUSIONS: This study shows slight usage shifts when Veterans gain access to non-VA care. It highlights the need to overcome care-coordination challenges among VA patients as states implement ACA Medicaid expansion and policymakers consider additional expansions of public health insurance programs such as Medicare-for-All.

Statin Prescription Rates, Adherence, and Associated Clinical Outcomes Among Women with PAD and ICVD.

PURPOSE: This study sought to investigate gender-based disparities in statin prescription rates and adherence among patients with peripheral arterial disease (PAD) and ischemic cerebrovascular disease (ICVD). METHODS: We identified patients with PAD or ICVD seeking primary care between 2013 and 2014 in the VA healthcare system. We assessed any statin use, high-intensity statin (HIS) use, and statin adherence among women with PAD or ICVD compared with men. We also compared proportion of days covered (PDC) as a measure of statin adherence; PDC ≥ 0.8 deemed a patient statin adherent. Association between statin use (or adherence) and odds of death or myocardial infarction (MI) at 12-month follow-up was also ascertained. RESULTS: Our analyses included 192,219 males and 3188 females with PAD and 331,352 males and 10,490 females with ICVD. Women with PAD had lower prescription rates of any statin (68.5% vs. 78.7%, OR 0.68, 95% confidence interval (CI) 0.62-0.75), HIS (21.1% vs. 23.7%, OR 0.88, 95% CI 0.79-0.97), and lower statin adherence (PDC ≥ 0.8: 34.6% vs. 45.5%, OR 0.75, 95% CI 0.69-0.82) compared with men. Similar disparities were seen in ICVD patients. Among female patients with PAD or ICVD, statin adherence was associated with lower odds of MI (OR 0.76, 95% CI 0.59-0.98), while use of any statin (OR 0.71, 95% CI 0.56-0.91) and HIS (OR 0.68, 95% CI 0.48-0.97) was associated with lower odds of death at 12 months. CONCLUSIONS: Women with PAD or ICVD had lower odds of receiving any statins, HIS, or being statin adherent. Targeted clinician- and patient-level interventions are needed to study and address these disparities among patients with PAD and ICVD.

Potential Impact of "Take the Volume Pledge" on Access and Outcomes for Gastrointestinal Cancer Surgery.

OBJECTIVE: To quantify the number of US hospitals that would meet "Take the Volume Pledge" (TVP) volume thresholds and compare outcomes at hospitals meeting and not meeting TVP thresholds. SUMMARY BACKGROUND DATA: TVP aims to regionalize complex cancer resections to hospitals meeting established annual average volume thresholds. There is little data describing the potential impact on patient access if this initiative were broadly implemented or the relationship between these volume thresholds and quality of oncologic care. METHODS: Hospitals in the National Cancer Database (2006-2012) performing esophagectomy (n = 968), proctectomy (n = 1250), or pancreatectomy (n = 1068) were categorized based on frequency meeting TVP thresholds: always low volume (LV); low annual average and intermittently low volume (ILV); high annual average and intermittently high volume (IHV); always high volume (HV). Multivariable generalized estimating equations were used to evaluate the association between hospital TVP category, oncologic care processes, and perioperative outcomes. RESULTS: Few hospitals met annual TVP thresholds (HV or IHV)-esophagectomy 1.6%; proctectomy 19.7%; pancreatectomy 6.6%. The majority of esophagectomy (77.8%) and pancreatectomy (53.4%) and 48.1% of proctectomy patients received care at hospitals not meeting annual TVP thresholds (LV or ILV). While performance for all three procedures was generally better at ILV, IHV, and HV hospitals relative to LV hospitals, there were few differences (none of which were consistent) when comparing ILV, IHV, and HV hospitals to each other. CONCLUSIONS AND RELEVANCE: Few hospitals would meet TVP volume thresholds for complex cancer resections with little difference in outcomes between ILV, IHV, and HV hospitals. While a policy to regionalize complex surgical care may have merit, it could also compromise patient autonomy and limit access to care if patients are unable or unwilling to travel.

State Governments and Judges May Moderate the Impact of the Trump Administration's Promotion of Medicaid Work Requirements.

In January 2018, the Center for Medicare and Medicaid Services (CMS) released guidance that encouraged states to submit Section 1115 waivers that impose work requirements on some Medicaid beneficiaries. To evaluate the potential impact of a policy, we need to accurately predict both how far a policy will spread and how durable it will prove over time. This commentary draws upon recent political science scholarship to describe potential constraints that changes in state-level partisan control can impose on CMS's current waiver strategy, as well as how state-level constraints might interact with judicial review to further limit the policy's spread.