A Safe Transitions Pathway for post-craniotomy neurological surgery patients: high-value care that bypasses the intensive care unit.

OBJECTIVE: High-value medical care is described as care that leads to excellent patient outcomes, high patient satisfaction, and efficient costs. Neurosurgical care in particular can be expensive for the hospital, as substantial costs are accrued during the operation and throughout the postoperative stay. The authors developed a "Safe Transitions Pathway" (STP) model in which select patients went to the postanesthesia care unit (PACU) and then the neuro-transitional care unit (NTCU) rather than being directly admitted to the neurosciences intensive care unit (ICU) following a craniotomy. They sought to evaluate the clinical and financial outcomes as well as the impact on the patient experience for patients who participated in the STP and bypassed the ICU level of care. METHODS: Patients were enrolled during the 2018 fiscal year (FY18; July 1, 2017, through June 30, 2018). The electronic medical record was reviewed for clinical information and the hospital cost accounting record was reviewed for financial information. Nurses and patients were given a satisfaction survey to assess their respective impressions of the hospital stay and of the recovery pathway. RESULTS: No patients who proceeded to the NTCU postoperatively were upgraded to the ICU level of care postoperatively. There were no deaths in the STP group, and no patients required a return to the operating room during their hospitalization (95% CI 0%-3.9%). There was a trend toward fewer 30-day readmissions in the STP patients than in the standard pathway patients (1.2% [95% CI 0.0%-6.8%] vs 5.1% [95% CI 2.5%-9.1%], p = 0.058). The mean number of ICU days saved per case was 1.20. The average postprocedure length of stay was reduced by 0.25 days for STP patients. Actual FY18 direct cost savings from 94 patients who went through the STP was $422,128. CONCLUSIONS: Length of stay, direct cost per case, and ICU days were significantly less after the adoption of the STP, and ICU bed utilization was freed for acute admissions and transfers. There were no substantial complications or adverse patient outcomes in the STP group.

Cigarette Smoking and Sociodemographic, Military, and Health Characteristics of Operation Enduring Freedom and Operation Iraqi Freedom Veterans: 2009-2011 National Health Study for a New Generation of US Veterans.

OBJECTIVE: We examined the sociodemographic, military, and health characteristics of current cigarette smokers, former smokers, and nonsmokers among Operation Enduring Freedom (OEF) / Operation Iraqi Freedom (OIF) veterans and estimated smoking prevalence to better understand cigarette use in this population. METHODS: We analyzed data from the US Department of Veterans Affairs (VA) 2009-2011 National Health Study for a New Generation of US Veterans. On the basis of a stratified random sample of 60 000 OEF/OIF veterans, we sought responses to a 72-item questionnaire via mail, telephone, or Internet. Cigarette smoking status was based on self-reported cigarette use in the past year. We used multinomial logistic regression to evaluate associations between smoking status and sociodemographic, military, and health characteristics. RESULTS: Among 19 911 veterans who provided information on cigarette smoking, 5581 were current smokers (weighted percentage: 32.5%, 95% confidence interval [CI]: 31.7-33.2). Current smokers were more likely than nonsmokers or former smokers to be younger, to have less education or income, to be separated/divorced or never married/single, and to have served on active duty or in the army. Comparing current smokers and nonsmokers, some significant associations from adjusted analyses included the following: having a Mental Component Summary score (a measure of overall mental health) above the mean of the US population relative to below the mean (adjusted odds ratio [aOR] = 0.81, 95% CI: 0.73-0.90); having physician-diagnosed depression (aOR = 1.52, 95% CI: 1.33-1.74), respiratory conditions (aOR = 1.16, 95% CI: 1.04-1.30), or repeated seizures/blackouts/convulsions (aOR = 1.80, 95% CI: 1.22-2.67); heavy alcohol use vs never use (aOR = 5.49, 95% CI: 4.57-6.59); a poor vs excellent perception of overall health (aOR = 3.79, 95% CI: 2.60-5.52); and being deployed vs nondeployed (aOR = 0.87, 95% CI: 0.78-0.96). Using health care services from the VA protected against current smoking. CONCLUSION: Mental and physical health, substance use, and military service characteristics shape cigarette-smoking patterns in OEF/OIF veterans.

Health care expenditures attributable to smoking in military veterans.

INTRODUCTION: The health effects of cigarette smoking have been estimated to account for between 6%-8% of U.S. health care expenditures. We estimated Veterans Health Administration (VHA) health care costs attributable to cigarette smoking. METHODS: VHA survey and administrative data provided the number of Veteran enrollees, current and former smoking prevalence, and the cost of 4 types of care for groups defined by age, gender, and region. Cost and smoking status could not be linked at the enrollee level, so we used smoking attributable fractions estimated in sample of U.S. residents where the linkage could be made. RESULTS: The 7.7 million Veterans enrolled in VHA received $40.2 billion in VHA provided health services in 2010. We estimated that $2.7 billion in VHA costs were attributable to the health effects of smoking. This was 7.6% of the $35.3 billion spent on the types of care for which smoking-attributable fractions could be determined. The fraction of inpatient costs that was attributable to smoking (11.4%) was greater than the fraction of ambulatory care cost attributable to smoking (5.3%). More cost was attributable to current smokers ($1.7 billion) than to former smokers ($983 million). CONCLUSIONS: The fraction of VHA costs attributable to smoking is similar to that of other health care systems. Smoking among Veterans is slowly decreasing, but prevalence remains high in Veterans with psychiatric and substance use disorders, and in younger and female Veterans. VHA has adopted a number of smoking cessation programs that have the potential for reducing future smoking-attributable costs.

Public health clinical demonstration project for smoking cessation in veterans with posttraumatic stress disorder.

Veterans with posttraumatic stress disorder are at high risk for smoking and experience difficulty with smoking cessation. We designed this clinical demonstration project to provide a low-cost, feasibly implemented smoking cessation intervention that would maximize the number of smokers who accessed the intervention. Five hundred eighty-four veteran smokers were contacted by invitational letters. Interested veterans received follow-up telephone calls using standardized scripts offering three intervention resources: 1) a referral to the National Cancer Institute's Smoking Quitline, 2) web-based counseling, and 3) local Veteran Affairs pharmacologic treatment for smoking cessation. Twenty-three percent of survey recipients participated in the clinical program. Two months after these resources were offered by phone, follow-up phone calls indicated that 25% of participants providing follow-up information reported maintaining smoking abstinence. This clinical demonstration project was associated with a 2.6% impact (i.e., reach [31.1% of smokers accessed intervention] by efficacy [8.4% of those accessing intervention quit]), meaning that 2.6% of the total number of targeted smokers reported 8 week abstinence. Results suggested that this brief, low-cost intervention was feasible and promoted smoking cessation in veterans with posttraumatic stress disorder.

Evidence-based national initiatives to address tobacco use as a public health priority in the Veterans Health Administration.

Historically, the prevalence of smoking and smoking-related illnesses has been higher among veteran patients in the Veterans Health Administration (VHA) in comparison to that of the general population. Although rates of tobacco use have remained high, smoking cessation interventions continued to be greatly underutilized in VHA clinical settings just as they have been nationally. To address tobacco use as a public health priority, VHA has implemented a number of evidence-based national initiatives in recent years. This paper describes these initiatives, including: adoption of a population-health approach to smoking cessation; increased access to nicotine replacement therapy and/or smoking cessation medications; elimination of outpatient copayments for smoking cessation counseling; clinical practice guidelines; and collaboration with mental health and substance use disorder health care providers to promote integration of smoking cessation into routine treatment of psychiatric populations. The context of tobacco use among the newest veteran populations is also discussed, as well as recent efforts to evaluate the current state of smoking cessation care in VHA.

National trends in the provision of smoking cessation aids within the Veterans Health Administration.

OBJECTIVES: To evaluate the effectiveness of the Veterans Health Administration (VHA) in providing treatment for tobacco dependence, accomplished by estimating national trends in the number and percent of smokers receiving smoking cessation aids (SCAs) within the VHA, trends in SCA utilization and expenditures, and the impact of lifting restrictions on patient access to SCAs. STUDY DESIGN AND METHODS: All patients receiving an outpatient SCA prescription were identified within the Veterans Affairs (VA) Pharmacy Benefits Management database over a 4-year period- October 1, 1998 (n = 61 968) to September 30, 2002 (n = 76 641). Smoking prevalence was based on data from the VA's 1999 Large Health Survey of Enrollees. A subsample of sites was classified as having restricted access to SCAs if patients were required to attend smoking cessation classes. Changes in annual SCA utilization rates and expenditures by SCA type and restriction status were measured to assess changes in treatment of tobacco dependence. RESULTS: Approximately 7% of smokers received SCA prescriptions, and SCAs accounted for less than 1% of the VHA's annual outpatient pharmacy budget in any given year. Following downward trends in the cost of 30-day SCA prescriptions, annual SCA expenditures per patient decreased over time. Expenditures were lower for restricted than unrestricted sites. More than two thirds of smokers who were prescribed medications received the nicotine patch, a quarter received bupropion sustained-release, and fewer than 10% received nicotine gum. CONCLUSIONS: Measures of SCA utilization and cost are low, stable, and less than the recommended rates in national smoking cessation guidelines, suggesting that this population of smokers is undertreated. Removing SCA restrictions is not prohibitively expensive and improves access to cost-effective care.