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IMPORTANCE: Screening for diabetes might be more widespread if adverse associations with cardiovascular disease (CVD), resource use, and costs were known to occur earlier than conventional clinical diagnosis. OBJECTIVE: The purpose of this study was to determine whether adverse effects associated with diabetes begin prior to clinical diagnosis. DESIGN: Veterans with diabetes were matched 1:2 with controls by follow-up, age, race/ethnicity, gender, and VA facility. CVD was obtained from ICD-9 codes, and resource use and costs from VA datasets. SETTING: VA facilities in SC, GA, and AL. PARTICIPANTS: Patients with and without diagnosed diabetes. MAIN OUTCOME MEASURES: Diagnosed CVD, resource use, and costs. RESULTS: In this study, the 2,062 diabetic patients and 4,124 controls were 63 years old on average, 99 % male, and 29 % black; BMI was 30.8 in diabetic patients vs. 27.8 in controls (p<0.001). CVD prevalence was higher and there were more outpatient visits in Year -4 before diagnosis through Year +4 after diagnosis among diabetic vs. control patients (all p<0.01); in Year -2, CVD prevalence was 31 % vs. 24 %, and outpatient visits were 22 vs. 19 per year, respectively. Total VA costs/year/veteran were higher in diabetic than control patients from Year -4 ($4,083 vs. $2,754) through Year +5 ($8,347 vs. $5,700) (p<0.003) for each, reflecting underlying increases in outpatient, inpatient, and pharmacy costs (p<0.05 for each). Regression analysis showed that diabetes contributed an average of $1,748/year to costs, independent of CVD (p<0.001). CONCLUSIONS AND RELEVANCE: VA costs per veteran are higher--over $1,000/year before and $2,000/year after diagnosis of diabetes--due to underlying increases in outpatient, inpatient, and pharmacy costs, greater number of outpatient visits, and increased CVD. Moreover, adverse associations with veterans' health and the VA healthcare system occur early in the natural history of the disease, several years before diabetes is diagnosed. Since adverse associations begin before diabetes is recognized, greater consideration should be given to systematic screening in order to permit earlier detection and initiation of preventive management. Keeping frequency of CVD and marginal costs in line with those of patients before diabetes is currently diagnosed has the potential to save up to $2 billion a year.
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Doenças Cardiovasculares/epidemiologia , Diabetes Mellitus/economia , Custos de Cuidados de Saúde , Recursos em Saúde/estatística & dados numéricos , Veteranos , Doenças Cardiovasculares/diagnóstico , Estudos de Casos e Controles , Diabetes Mellitus/diagnóstico , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Sudeste dos Estados Unidos/epidemiologiaRESUMO
BACKGROUND: This is the first study of suicide attempts and completions in the emergency department (ED) in a large national medical system. METHODS: All root cause analysis (RCA) reports completed of suicides and suicide attempts that occurred in ED in the Veterans Health Administration between 1 December 1999 and 31 December 2009 were reviewed. The method, location, anchor point for hanging and implement for cutting as well as the root causes were categorised. RESULTS: Ten per cent of all RCA reports of suicides and suicide attempts that occur within the hospital occur in the ED. Hanging, cutting and strangulation were the most common methods. The most common anchor point for hanging was doors, and the most common implement for cutting was a razor blade. In eight of the 10 cases of cutting, the implement was brought into the ED. The most common root causes were problems communicating risk and being short-staffed. CONCLUSIONS: Based on these results the following recommendations are made for helping to reduce suicide attempts in the ED: (1) use a systematic protocol and checklist to review mental health holding areas periodically in the ED for suicidal hazards; (2) develop and implement specialised protocols for suicidal patients that include continuous observation when possible; (3) conduct thorough contraband searches with suicidal patients; (4) designate specialised holding areas, when practically possible, for suicidal patients that are free of anchor points for hanging, sharps and medications, and medical equipment; and are isolated from exits to reduce the risk of elopement.
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Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitais de Veteranos/estatística & dados numéricos , Análise de Causa Fundamental , Suicídio/estatística & dados numéricos , Adulto , Análise de Variância , Causas de Morte , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Tentativa de Suicídio/estatística & dados numéricos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The importance and complexity of handovers is well-established. Progress for intervening in the emergency department change of shift handovers may be hampered by lack of a conceptual framework. The objectives were to gain a better understanding of strategies used for change of shift handovers in an emergency care setting and to further expand current understanding and conceptualizations. METHODS: Observations, open-ended questions and interviews about handover strategies were collected at a Veteran's Health Administration Medical Center in the United States. All relevant staff in the emergency department was observed; 31 completed open-ended surveys; 10 completed in-depth interviews. The main variables of interest were strategies used for handovers at change of shift and obstacles to smooth handovers. RESULTS: Of 21 previously identified strategies, 8 were used consistently, 4 were never used, and 9 were used occasionally. Our data support ten additional strategies. Four agent types and 6 phases of the process were identified via grounded theory analysis. Six general themes or clusters emerged covering factors that intersect to define the degree of handover smoothness. CONCLUSION: Including phases and agents in conceptualizations of handovers can help target interventions to improve patient safety. The conceptual model also clarifies unique handover considerations for the emergency department setting.
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Continuidade da Assistência ao Paciente/organização & administração , Eficiência Organizacional , Serviço Hospitalar de Emergência/organização & administração , Hospitais de Veteranos/organização & administração , Planejamento de Assistência ao Paciente/organização & administração , Pessoal de Saúde , Humanos , Entrevistas como Assunto , Estudos de Casos Organizacionais , Recursos Humanos , Carga de TrabalhoRESUMO
BACKGROUND: Many individuals with diabetes remain undiagnosed, leading to delays in treatment and higher risk for subsequent diabetes complications. Despite recommendations for diabetes screening in high-risk groups, the optimal approach is not known. We evaluated the utility of inpatient glucose levels as an opportunistic screening tool for identifying patients at high risk for diabetes. METHODS: We retrospectively examined 462,421 patients in the US Department of Veterans Affairs healthcare system, hospitalized on medical/surgical services in 2000-2010, for ≥3 days, with ≥2 inpatient random plasma glucose (RPG) measurements. All had continuity of care: ≥1 primary care visit and ≥1 glucose measurement within 2 years before hospitalization and yearly for ≥3 years after discharge. Glucose levels during hospitalization and incidence of diabetes within 3 years after discharge in patients without diabetes were evaluated. RESULTS: Patients had a mean age of 65.0 years, body mass index of 29.9 kg/m2, and were 96% male, 71% white, and 18% black. Pre-existing diabetes was present in 39.4%, 1.3% were diagnosed during hospitalization, 8.1% were diagnosed 5 years after discharge, and 51.3% were never diagnosed (NonDM). The NonDM group had the lowest mean hospital RPG value (112 mg/dL [6.2 mmol/L]). Having at least 2 RPG values >140 mg/dL (>7.8 mmol/L), the 95th percentile of NonDM hospital glucose, provided 81% specificity for identifying incident diabetes within 3 years after discharge. CONCLUSIONS: Screening for diabetes could be considered in patients with at least 2 hospital glucose values at/above the 95th percentile of the nondiabetic range (141 mg/dL [7.8 mmol/L]).
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Glicemia/análise , Diabetes Mellitus Tipo 2/sangue , Hospitais de Veteranos , Pacientes Internados , Programas de Rastreamento/métodos , Idoso , Diabetes Mellitus Tipo 2/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Estados Unidos/epidemiologiaRESUMO
INTRODUCTION: Lifestyle change programs implemented within healthcare systems could reach many Americans, but their impact on cardiovascular disease (CVD) remains unclear. The MOVE! program is the largest lifestyle change program implemented in a healthcare setting in the U.S. This study aimed to determine whether MOVE! participation was associated with reduced CVD incidence. METHODS: This retrospective cohort study, analyzed in 2013-2015, used national Veterans Health Administration databases to identify MOVE! participants and eligible non-participants for comparison (2005-2012). Patients eligible for MOVE!-obese or overweight with a weight-related health condition, and no baseline CVD-were examined (N=1,463,003). Of these, 169,248 (12%) were MOVE! PARTICIPANTS: Patients were 92% male, 76% white, with mean age 52 years and BMI of 32. The main outcome was incidence of CVD (ICD-9 and procedure codes for coronary artery disease, cerebrovascular disease, peripheral vascular disease, and heart failure). RESULTS: Adjusting for age, race, sex, BMI, statin use, and baseline comorbidities, over a mean 4.9 years of follow-up, MOVE! participation was associated with lower incidence of total CVD (hazard ratio [HR]=0.83, 95% CI=0.80, 0.86); coronary artery disease (HR=0.81, 95% CI=0.77, 0.86); cerebrovascular disease (HR=0.87, 95% CI=0.82, 0.92); peripheral vascular disease (HR=0.89, 95% CI=0.83, 0.94); and heart failure (HR=0.78, 95% CI=0.74, 0.83). The association between MOVE! participation and CVD incidence remained significant when examined across categories of race/ethnicity, BMI, diabetes, hypertension, smoking status, and statin use. CONCLUSIONS: Although participation was limited, MOVE! was associated with reduced CVD incidence in a nationwide healthcare setting.
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Doenças Cardiovasculares/prevenção & controle , Estilo de Vida , Programas de Redução de Peso/estatística & dados numéricos , Adulto , Doenças Cardiovasculares/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia , United States Department of Veterans Affairs , Saúde dos VeteranosRESUMO
AIMS: Clinical trials show lifestyle change programs are beneficial, yet large-scale, successful translation of these programs is scarce. We investigated the association between participation in the largest U.S. lifestyle change program, MOVE!, and diabetes control outcomes. METHODS: This longitudinal, retrospective cohort study used Veterans Health Administration databases of patients with diabetes who participated in MOVE! between 2005 and 2012, or met eligibility criteria (BMI ≥25kg/m2) but did not participate. Main outcomes were diabetic eye disease, renal disease, and medication intensification. RESULTS: There were 400,170 eligible patients with diabetes, including 87,366 (22%) MOVE! PARTICIPANTS: Included patients were 96% male, 77% white, with mean age 58years and BMI 34kg/m2. Controlling for baseline measurements and age, race, sex, BMI, and antidiabetes medications, MOVE! participants had lower body weight (-0.6kg), random plasma glucose (-2.8mg/dL), and HbA1c (-0.1%) at 12months compared to nonparticipants (each p<0.001). In multivariable Cox models, MOVE! participants had lower incidence of eye disease (hazard ratio 0.80, 95% CI 0.75-0.84) and renal disease (HR 0.89, 95% CI 0.86-0.92) and reduced medication intensification (HR 0.82, 95% CI 0.80-0.84). CONCLUSIONS: If able to overcome participation challenges, lifestyle change programs in U.S. health systems may improve health among the growing patient population with diabetes.
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Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapia , Participação do Paciente/estatística & dados numéricos , Comportamento de Redução do Risco , Veteranos/estatística & dados numéricos , Programas de Redução de Peso , Idoso , Índice de Massa Corporal , Complicações do Diabetes/epidemiologia , Complicações do Diabetes/prevenção & controle , Diabetes Mellitus/sangue , Feminino , Humanos , Incidência , Estilo de Vida , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Serviços Preventivos de Saúde/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Saúde dos Veteranos , Programas de Redução de Peso/estatística & dados numéricosRESUMO
BACKGROUND: The most efficacious strategies to improve diabetes control include case management, health care team changes, patient education, and facilitated transmission of patient data to clinicians ("facilitated relay"), but these strategies have not been translated to permit general use in clinical practice. METHODS: A web-based decision support program was developed to include these features, and assessed in patients who had A1c ≥7.0% despite using metformin with/without sulfonylureas or insulin. Staff entered patients' glucose data, obtained management recommendations, reviewed the plan with a clinician, and discussed the new plan with patients. RESULTS: 113 subjects were 96% male and 32% black, with average age 65.6 years and BMI 32.8. During prior primary care, A1c averaged 8.32 ± 0.16% (SEM). In all patients, baseline A1c was 8.18 ± 0.11%, and decreased to 7.54 ± 0.12%, 7.16 ± 0.13%, and 7.54 ± 0.16% at 3, 6, and 12 months, respectively, all P < .001. In 42 subjects who provided glucose data and made requested changes in medications, A1c was 8.12 ± 0.09% at baseline and fell to 7.29 ± 0.11%, 6.98 ± 0.10%, and 7.05 ± 0.10% at 3, 6, and 12 months, respectively, all P < .001. Chart review of 16 subjects followed for 12 months demonstrated that hypoglycemia (symptoms and/or glucose <70 mg/dl) averaged less than 1 episode/patient/month, and there was no severe hypoglycemia. CONCLUSIONS: A novel decision support program improved A1c with little hypoglycemia. Use of this approach should allow primary care teams to keep patients well controlled, and reduce the need for specialist referrals.
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Sistemas de Apoio a Decisões Clínicas , Diabetes Mellitus/terapia , Hemoglobinas Glicadas/análise , Pesquisa Translacional Biomédica/métodos , Idoso , Algoritmos , Glicemia/análise , Método Duplo-Cego , Exenatida , Feminino , Georgia , Hospitais de Veteranos , Humanos , Hipoglicemiantes/uso terapêutico , Insulina/administração & dosagem , Internet , Masculino , Metformina/administração & dosagem , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Equipe de Assistência ao Paciente , Educação de Pacientes como Assunto , Peptídeos/administração & dosagem , Atenção Primária à Saúde/organização & administração , Desenvolvimento de Programas , Projetos de Pesquisa , Compostos de Sulfonilureia/administração & dosagem , Estados Unidos , Peçonhas/administração & dosagem , VeteranosRESUMO
BACKGROUND: Programmes for lifestyle change are aimed at improving health but little is known about their effectiveness in clinical settings. The Veterans Health Administration (VA) MOVE! lifestyle change programme is the largest in the USA. We investigated whether participation in MOVE! is associated with reduced incidence of diabetes. METHODS: We did a retrospective observational analysis of data from VA databases in overweight patients and obese patients with a weight-related disorder who had undergone at least 3 years of continuous outpatient care in 2005-12. We used generalised estimating equations to assess characteristics associated with MOVE! participation, and Cox's proportional hazards regression to analyse the association between participation and diabetes incidence. FINDINGS: Of 1·8 million eligible individuals, 238â540 (13%) participated in the MOVE! programme. 19â367 (1% overall, 8% of participants) met criteria for intense and sustained participation (at least eight sessions within 6 months over at least a 4-month span), which was associated with greater weight loss at 3 years than low-intensity or no participation (-2·2% vs -0·64% or 0·46%). Compared with non-participation, incidence of diabetes was reduced by intense and sustained participation (hazard ratio 0·67, 95% CI 0·61-0·74) and low-intensity participation (0·80, 0·77-0·83) in MOVE!. These patterns were consistent across sex, ethnic origin, and age. Participation was most beneficial in patients with high BMI or high random glucose concentrations at baseline (both pinteraction<0·0001). INTERPRETATION: Participation in the MOVE! programme was associated with weight loss and reduced incidence of diabetes, but the rate of participation was low and, therefore, selection bias could have exaggerated these effects. FUNDING: US Department of Veterans Affairs, National Institutes of Health.
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Diabetes Mellitus/epidemiologia , Diabetes Mellitus/prevenção & controle , Comportamento de Redução do Risco , Saúde dos Veteranos/tendências , Programas de Redução de Peso/estatística & dados numéricos , Humanos , Incidência , Pacientes Ambulatoriais , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Estados Unidos/epidemiologia , United States Department of Veterans AffairsRESUMO
BACKGROUND: Although practice-based learning and improvement (PBLI) is now recognized as a fundamental and necessary skill set, we are still in need of tools that yield specific information about gaps in knowledge and application to help nurture the development of quality improvement (QI) skills in physicians in a proficient and proactive manner. We developed a questionnaire and coding system as an assessment tool to evaluate and provide feedback regarding PBLI self-efficacy, knowledge, and application skills for residency programs and related professional requirements. METHODS: Five nationally recognized QI experts/leaders reviewed and completed our questionnaire. Through an iterative process, a coding system based on identifying key variables needed for ideal responses was developed to score project proposals. The coding system comprised 14 variables related to the QI projects, and an additional 30 variables related to the core knowledge concepts related to PBLI. A total of 86 residents completed the questionnaire, and 2 raters coded their open-ended responses. Interrater reliability was assessed by percentage agreement and Cohen κ for individual variables and Lin concordance correlation for total scores for knowledge and application. Discriminative validity (t test to compare known groups) and coefficient of reproducibility as an indicator of construct validity (item difficulty hierarchy) were also assessed. RESULTS: Interrater reliability estimates were good (percentage of agreements, above 90%; κ, above 0.4 for most variables; concordances for total scores were R â=â .88 for knowledge and R â=â .98 for application). CONCLUSION: Despite the residents' limited range of experiences in the group with prior PBLI exposure, our tool met our goal of differentiating between the 2 groups in our preliminary analyses. Correcting for chance agreement identified some variables that are potentially problematic. Although additional evaluation is needed, our tool may prove helpful and provide detailed information about trainees' progress and the curriculum.
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BACKGROUND: We developed a practice-based learning and improvement (PBLI) curriculum to address important gaps in components of content and experiential learning activities through didactics and participation in systems-level quality improvement projects that focus on making changes in health care processes. METHODS: We evaluated the impact of our curriculum on resident PBLI knowledge, self-efficacy, and application skills. A quasi-experimental design assessed the impact of a curriculum (PBLI quality improvement systems compared with non-PBLI) on internal medicine residents' learning during a 4-week ambulatory block. We measured application skills, self-efficacy, and knowledge by using the Systems Quality Improvement Training and Assessment Tool. Exit evaluations assessed time invested and experiences related to the team projects and suggestions for improving the curriculum. RESULTS: The 2 groups showed differences in change scores. Relative to the comparison group, residents in the PBLI curriculum demonstrated a significant increase in the belief about their ability to implement a continuous quality improvement project (P â=â .020), comfort level in developing data collection plans (P â=â .010), and total knowledge scores (P < .001), after adjusting for prior PBLI experience. Participants in the PBLI curriculum also demonstrated significant improvement in providing a more complete aim statement for a proposed project after adjusting for prior PBLI experience (P â=â .001). Exit evaluations were completed by 96% of PBLI curriculum participants who reported high satisfaction with team performance. CONCLUSION: Residents in our curriculum showed gains in areas fundamental for PBLI competency. The observed improvements were related to fundamental quality improvement knowledge, with limited gain in application skills. This suggests that while heading in the right direction, we need to conceptualize and structure PBLI training in a way that integrates it throughout the residency program and fosters the application of this knowledge and these skills.
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PURPOSE: Electronic software packages to support patient tracking and disposition decision making in emergency departments (EDs) are being considered for implementation in many hospitals. We compared extent of use, information accuracy, and functions of manual and electronic patient status boards at 2 EDs where both were continuously in use. METHODS: Ethnographic observations were conducted at 2 Veterans Affairs Medical Center Emergency Departments using both manual and electronic patient status boards (100 h, 9 physicians at Site 1; 64 h, 14 physicians at Site 2). Data included board information collected at 20-min intervals, observable behavior while using boards, and interviews. RESULTS: Few physicians (3/9 [33%] Site 1; 0/14 [0%] Site 2) used the e-board, whereas all physicians used the whiteboards. Whiteboards had fewer inaccuracies (6/462 [1%] Site 1; 21/864 [3%] Site 2) than e-boards (62/462 [13%] Site 1; 107/864 [12%] Site 2). The primary functions of the whiteboard were to track real-time changes to patient identifiers, locations, nursing assignments, and pending activities; facilitate patient handoffs; inform physicians and nurses about newly arrived patients assigned to them; inform nurses of physicians' orders; and inform physicians of the status of ordered items. The primary functions of the e-board were to support electronic data entry (by clerks) of patient admitting and departure times; and highlight patients who had been in the ED for longer than 6 h. CONCLUSIONS: Whiteboards were more extensively used and had greater information accuracy than e-boards. Nevertheless, e-boards provided functionality not easily achievable with whiteboards.