Benchmark findings from a veteran electronic patient-reported outcomes evaluation from a chronic pain management telehealth program.

BACKGROUND: Chronic pain is a leading cause of disability and negatively impacts biological/physical, psychological, and social aspects of life resulting in significant pain interference or disability. This project was part of a longitudinal mixed-methods implementation evaluation of the TelePain-Empower Veterans Program (EVP), a non-pharmacological chronic pain intervention. The purpose of this quality management project was to examine electronic patient-reported outcome measures (ePROs) including primary pain-related (intensity, interference, catastrophizing, kinesiophobia) and secondary outcomes (physical, psychological, acceptance, social) to determine TelePain-EVP effectiveness. Secondary purpose was to examine dosing effects to better understand potential dose relationships between EVP use and ePROs. METHODS: Standardized ePRO measures were examined at week 1 (baseline), week 10 (post-EVP), and week 26 (follow-up). Qualtrics, a cloud-based platform was used to collect ePRO data at each time point. Veterans that completed at-least one survey at any specified time point were categorized as responders (n = 221). Linear-mixed models (LMMs) were fit to assess changes for each primary and secondary ePRO. RESULTS: Participants ranged from 24 to 81 years old; veterans were typically male (65.16%), black or African American (76.47%), married or partnered (41.63%), attended at-least some college or vocational school (67.87%), and reported low back as their primary pain location (29.41%). There was a significant decrease in pain catastrophizing from baseline to post-TelePain-EVP (p < .001). However, pain catastrophizing improvement from baseline was not present at week 26 (p = .116). Pain interference also decreased from baseline to post-treatment (p = .05), but this improvement did not exceed the adjusted significance threshold. Additional pre-post improvements were also observed for certain secondary ePROs: psychological (anxiety, depression), acceptance (activities engagement). Only the activities engagement effect remained 26 weeks from baseline. Mixed results were observed for EVP dose across primary and secondary outcomes. CONCLUSIONS: Evidence from this evaluation indicate that TelePain-EVP has positive outcomes for certain pain (catastrophizing), psychological (anxiety, depression), and acceptance (activities engagement) for veterans with chronic pain. More TelePain related studies and enterprise-wide evaluations are needed along with comparative and cost effectiveness methods to determine patient benefits and the economic value gained of treatment options such as TelePain-EVP.

Risk of Parkinson Disease Among Service Members at Marine Corps Base Camp Lejeune.

Importance: An increased risk of Parkinson disease (PD) has been associated with exposure to the solvent trichloroethylene (TCE), but data are limited. Millions of people in the US and worldwide are exposed to TCE in air, food, and water. Objective: To test whether the risk of PD is higher in veterans who served at Marine Corps Base Camp Lejeune, whose water supply was contaminated with TCE and other volatile organic compounds (VOCs), compared with veterans who did not serve on that base. Design, Setting, and Participants: This population-based cohort study examined the risk for PD among all Marines and Navy personnel who resided at Camp Lejeune, North Carolina (contaminated water) (n = 172 128), or Camp Pendleton, California (uncontaminated water) (n = 168 361), for at least 3 months between 1975 and 1985, with follow-up from January 1, 1997, until February 17, 2021. Veterans Health Administration and Medicare databases were searched for International Classification of Diseases diagnostic codes for PD or other forms of parkinsonism and related medications and for diagnostic codes indicative of prodromal disease. Parkinson disease diagnoses were confirmed by medical record review. Exposures: Water supplies at Camp Lejeune were contaminated with several VOCs. Levels were highest for TCE, with monthly median values greater than 70-fold the permissible amount. Main Outcome and Measures: Risk of PD in former residents of Camp Lejeune relative to residents of Camp Pendleton. In those without PD or another form of parkinsonism, the risk of being diagnosed with features of prodromal PD were assessed individually and cumulatively using likelihood ratio tests. Results: Health data were available for 158 122 veterans (46.4%). Demographic characteristics were similar between Camp Lejeune (5.3% women, 94.7% men; mean [SD] attained age of 59.64 [4.43] years; 29.7% Black, 6.0% Hispanic, 67.6% White; and 2.7% other race and ethnicity) and Camp Pendleton (3.8% women, 96.2% men; mean [SD] age, 59.80 [4.62] years; 23.4% Black, 9.4% Hispanic, 71.1% White, and 5.5% other race and ethnicity). A total of 430 veterans had PD, with 279 from Camp Lejeune (prevalence, 0.33%) and 151 from Camp Pendleton (prevalence, 0.21%). In multivariable models, Camp Lejeune veterans had a 70% higher risk of PD (odds ratio, 1.70; 95% CI, 1.39-2.07; P < .001). No excess risk was found for other forms of neurodegenerative parkinsonism. Camp Lejeune veterans also had a significantly increased risk of prodromal PD diagnoses, including tremor, anxiety, and erectile dysfunction, and higher cumulative prodromal risk scores. Conclusions and Relevance: The study's findings suggest that the risk of PD is higher in persons exposed to TCE and other VOCs in water 4 decades ago. Millions worldwide have been and continue to be exposed to this ubiquitous environmental contaminant.

Comparing Service Use and Costs of Individual Placement and Support With Usual Vocational Services for Veterans With PTSD.

Objective: Among veterans with posttraumatic stress disorder (PTSD), supported employment that utilizes the individual placement and support (IPS) model has resulted in consistently better employment and functional outcomes than usual vocational rehabilitation services. This study aimed to compare these two approaches in terms of health services use and associated costs. Methods: A secondary analysis of a multisite randomized controlled trial of 541 unemployed veterans with PTSD used archival data from electronic medical records to assess the use and costs of health services of IPS and usual care (i.e., a transitional work [TW] program) over 18 months. Comparisons were also made to an 18-month postintervention period. Results: The two study groups did not differ in number of inpatient days or in utilization or cost of high-intensity services. Annual per-person costs of health services were approximately 20% higher for IPS than for TW participants (mean difference=$4,910 per person per year, p<0.05) during the intervention period, largely driven by higher utilization and costs for vocational services in the IPS group (p<0.001). These costs declined postintervention to nonsignificant differences. The mean annual per-person vocational service cost was $6,388 for IPS and $2,549 for TW (mean difference=$3,839, p<0.001) during the intervention period. Conclusions: In keeping with IPS's intensive case management approach, veterans receiving IPS used more vocational services and had correspondingly higher costs than veterans receiving TW. The two groups did not differ in use or cost of other types of health services. Future research should examine whether higher short-term costs associated with IPS relative to usual care result in long-term cost savings or higher quality of life for persons with PTSD.

Opioid-related emergency department visits and hospitalizations among patients with chronic gastrointestinal symptoms and disorders dually enrolled in the Department of Veterans Affairs and Medicare Part D.

PURPOSE: We examined the prevalence of, and factors associated with, serious opioid-related adverse drug events (ORADEs) that led to an emergency department (ED) visit or hospitalization among patients with chronic gastrointestinal (GI) symptoms and disorders dually enrolled in the Department of Veterans Affairs (VA) and Medicare Part D. METHODS: In this retrospective cohort study, we used linked national patient-level data (April 1, 2011, to October 31, 2014) from the VA and Centers for Medicare and Medicaid Services to identify serious ORADEs among dually enrolled veterans with a chronic GI symptom or disorder. Outcome measures included serious ORADEs, defined as an ED visit attributed to an ORADE or a hospitalization where the principal or secondary reason for admission involved an opioid. We used multiple logistic regression models to determine factors independently associated with a serious ORADE. RESULTS: We identified 3,430 veterans who had a chronic GI symptom or disorder; were dually enrolled in the VA and Medicare Part D; and had a serious ORADE that led to an ED visit, hospitalization, or both. The period prevalence of having a serious ORADE was 2.4% overall and 4.4% among veterans with chronic opioid use (≥90 consecutive days). Veterans with serious ORADEs were more likely to be less than 40 years old, male, white, and to have chronic abdominal pain, functional GI disorders, chronic pancreatitis, or Crohn's disease. They were also more likely to have used opioids chronically and at higher daily doses. CONCLUSION: There may be a considerable burden of serious ORADEs among patients with chronic GI symptoms and disorders. Future quality improvement efforts should target this vulnerable population.

Cost-Effectiveness of Individual Placement and Support Compared to Transitional Work Program for Veterans with Post-traumatic Stress Disorder.

Post-traumatic stress disorder (PTSD) leads to significant disability, unemployment, and substantial healthcare costs. The cost-effectiveness of vocational rehabilitation (VR) interventions is important to consider when determining which services to offer. This study assesses the cost-effectiveness and return on investment of Individual Placement and Support (IPS) compared to transitional work (TW) programs. Employment outcomes from a multisite randomized trial comparing IPS to TW in military veterans with PTSD (n = 541) were linked to Veterans Health Administration (VHA) archival medical record databases to examine the comparative cost-effectiveness and return on investment. Effectiveness was defined as hours worked and income earned in competitive jobs. Costs for VR, mental health, and medical care and income earned from competitive sources were annualized and adjusted to 2019 US dollars. The annualized mean cost per person of outpatient (including vocational services) were $3970 higher for IPS compared to TW ($23,245 vs. $19,276, respectively; P = 0.004). When TW income was included in costs, mean grand total costs per person per year were similar between groups ($29,828 IPS vs. $26,772 TW; P = 0.17). The incremental cost-effectiveness analysis showed that while IPS is more costly, it is also more effective. The return on investment (excluding TW income) was 32.9% for IPS ($9762 mean income/$29,691 mean total costs) and 29.6% for TW ($7326 mean income/$24,781 mean total costs). IPS significantly improves employment outcomes for individuals with PTSD with negligible increase in healthcare costs and yields very good return on investment compared to non-IPS VR services.

Web-based patient portal use and medication overlap from VA and private-sector pharmacies among older veterans.

BACKGROUND: The availability of Medicare Part D pharmacy coverage may increase veterans' options for obtaining medications outside of the Department of Veterans Affairs (VA) pharmacies. However, availability of Part D coverage raises the potential that veterans may be receiving similar medications from VA and non-VA pharmacies. The VA's personal health record portal, My HealtheVet, allows veterans to self-enter the non-VA medications that they obtained from community-based pharmacies, including those reimbursed by Medicare Part D. The Blue Button medication view feature of My HealtheVet allows veterans to view and download their VA and self-entered non-VA medication history. OBJECTIVE: To examine whether the use by veterans of the Blue Button feature of My HealtheVet was associated with less acquisition of similar medications from VA and community-based pharmacies reimbursed by Medicare Part D. METHODS: This study included a national sample of veterans who were new My HealtheVet users during fiscal year 2013 (October 1, 2012-September 30, 2013) and who used the Blue Button medication view feature of My HealtheVet at least once (users). We compared these veterans with a random sample of veterans who were not registered to use My HealtheVet (nonusers). From these groups, we identified veterans who were enrolled in Part D. We used multiple logistic regression analysis to assess the association of Blue Button medication view use with obtaining medications from the same drug classes (with overlap of 7 or more days) from VA and Part D-reimbursed pharmacies. RESULTS: There were 7,973 My HealtheVet medication view users and 65,985 nonusers. During a 12-month period, medication view users received more 30-day supplies of medications (one 90-day supply equals three 30-day supplies) than nonusers, on average (152.1 vs 71.3, P < 0.001). A larger percentage of users than nonusers obtained medications from VA and Part D-reimbursed pharmacies with overlapping days supply from the same drug classes (30% vs 23%, P < 0.001). However, for veterans who obtained greater numbers of 30-day supplies (82 or more), a significantly smaller percentage of users than nonusers obtained overlapping medications from VA and Part D-reimbursed pharmacies. Moreover, controlling for the total number of 30-day supplies that veterans received, the odds of obtaining medications from VA and Part D-reimbursed pharmacies with days supply that overlapped by at least 7 days for the same drug classes was 18% lower for users than nonusers (P=0.002). CONCLUSIONS: Veterans who used the Blue Button medication view feature of My HealtheVet obtained a larger number of 30-day supplies of medications from VA pharmacies than nonusers. For veterans who obtained a larger number of 30-day supplies of medications, use of the Blue Button medication view feature of My HealtheVet was associated with less overlap in days supply of medication from the same drug class from VA and Part D-reimbursed pharmacies. DISCLOSURES: This study was funded by the Department of Veterans Affairs, Office of Research and Development, Health Services Research and Development Service project IIR 14-041-2. The sponsor provided funding but was not involved in the development of the manuscript. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the Health Services Research and Development Service. All authors are employed in some capacity with the Department of Veterans Affairs and have no conflicts of interest to disclose.

Characteristics of Opioid Prescriptions to Veterans With Chronic Gastrointestinal Symptoms and Disorders Dually Enrolled in the Department of Veterans Affairs and Medicare Part D.

INTRODUCTION: Gastrointestinal (GI) symptoms and disorders affect an increasingly large group of veterans. Opioid use may be rising in this population, but this is concerning from a patient safety perspective, given the risk of dependence and lack of evidence supporting opioid use to manage chronic pain. We examined the characteristics of opioid prescriptions and factors associated with chronic opioid use among chronic GI patients dually enrolled in the DVA and Medicare Part D. MATERIALS AND METHODS: In this retrospective cohort study, we used linked, national patient-level data (from April 1, 2011, to December 31, 2014) from the VA and Centers for Medicare & Medicaid Services to identify chronic GI patients and observe opioid use. Veterans who had a chronic GI symptom or disorder were dually enrolled in VA and Part D and received ≥1 opioid prescription dispensed through the VA, Part D, or both. Chronic GI symptoms and disorders included chronic abdominal pain, chronic pancreatitis, inflammatory bowel diseases, and functional GI disorders. Key outcome measures were outpatient opioid prescription dispensing overall and chronic opioid use, defined as ≥90 consecutive days of opioid receipt over 12 months. We described patient characteristics and opioid use measures using descriptive statistics. Using multiple logistic regression modeling, we generated adjusted odds ratios and 95% CIs to determine variables independently associated with chronic opioid use. The final model included variables outlined in the literature and our conceptual framework. RESULTS: We identified 141,805 veterans who had a chronic GI symptom or disorder, were dually enrolled in VA and Part D, and received ≥1 opioid prescription dispensed from the VA, Part D, or both. Twenty-six percent received opioids from the VA only, 69% received opioids from Medicare Part D only, and 5% were "dual users," receiving opioids through both VA and Part D. Compared to veterans who received opioids from the VA or Part D only, dual users had a greater likelihood of potentially unsafe opioid use outcomes, including greater number of days on opioids, higher daily doses, and higher odds of chronic use. CONCLUSIONS: Chronic GI patients in the VA may be frequent users of opioids and may have a unique set of risk factors for unsafe opioid use. Careful monitoring of opioid use among chronic GI patients may help to begin risk stratifying this group. and develop tailored approaches to minimize chronic use. The findings underscore potential nuances within the opioid epidemic and suggest that components of the VA's Opioid Safety Initiative may need to be adapted around veterans at a higher risk of opioid-related adverse events.

Impact of Patient Portal Use on Duplicate Laboratory Tests in Diabetes Management.

Background: Patients seek care across multiple health care settings. One coordination issue is the unnecessary duplication of laboratory across different health care settings. This analysis examined the association between patient portal use and duplication of laboratory testing among Veterans who are dual users of Veterans Affairs (VA) and non-VA providers. Materials and Methods: A national sample of Veterans who were newly authenticated users of the portal during fiscal year (FY) 2013 who used Blue Button at least once were compared with a random sample of Veterans who were not registered to use the portal. From these two groups, Veterans who were also Medicare-eligible users in FY2014 were identified. Duplicate testing was defined as receipt of more than five HbA1c (hemoglobin A1c) in 1 year. Results: Use of the Blue Button decreased the odds of duplicate HbA1c testing in VA and Medicare-covered facilities across three comparisons: (1) overall between users and nonusers: portal users were less likely to have duplicate testing; (2) pre-post comparison: there was a trend toward lower duplicate testing in both groups across time; and (3) pre-post comparisons accounting for use of the portal: the trend toward lower duplicate testing was greater in Blue Button users. Conclusion: Duplicate HbA1c testing was significantly lower in dual users of VA and Medicare services who used the Blue Button feature of their VA patient portal. Non-VA providers encounter barriers to access of complete information about Veterans who also use VA health care. Provider endorsement of consumer-mediated health information exchange could help further this model of sharing information.

Healthcare Utilization and Costs for Patients With Parkinson's Disease After Deep Brain Stimulation.

OBJECTIVE: To compare the complications, healthcare utilization and costs following DBS or medical management for patients with Parkinson's disease (PD). METHODS: We examined healthcare utilization and costs for up to 5 years between veterans with DBS and those with medical management for PD. Veterans who received DBS between 2007 and 2013 were matched with veterans who received medical management using propensity score approaches. Healthcare utilization and costs were obtained from national VA and Medicare data sources and compared using procedures to adjust for potential differences in length of follow-up. RESULTS: We identified 611 veterans who had received DBS and a matched group of 611 veterans who did not undergo DBS. Among DBS patients, 59% had the electrodes and generator implanted during separate admissions. After 5 years of follow-up, average total healthcare costs, including DBS procedures and complications, were $77,131 (95% confidence interval: $66,095-$88,168; P < 0.001) higher per person for patients who received DBS ($162,489) than patients who received medical management ($85,358). In contrast, excluding the costs of the DBS procedures and complications, average total costs were not significantly different between patients who received DBS and patients who received medical management after 5 years of follow-up. CONCLUSIONS: Healthcare costs over 5 years were higher for veterans who received DBS. These higher healthcare costs may reflect the costs of DBS procedures and any follow-up required plus greater surveillance by healthcare professionals following DBS as well as unobserved differences in the patients who received medical management or DBS.

Cost of deep brain stimulation for the treatment of Parkinson's disease by surgical stimulation sites.

OBJECTIVE: To assess costs and effectiveness of deep brain stimulation (DBS) of the internal globus pallidum (GPi) versus subthalamic nucleus (STN) from the provider and societal perspectives for Parkinson's disease (PD) patients in a multicenter randomized trial. METHODS: All costs from randomization to 36 months were included. Costs were from Department of Veterans Affairs (VA) and Medicare databases and clinical trial data. Quality adjusted life years (QALYs) were from Quality of Well Being questionnaires. RESULTS: Provider costs were similar for the 144 GPi and 130 STN patients (GPi: $138,044 vs. STN: $131,822; difference = $6,222, 95% confidence interval [CI]: -$42,125 to $45,343). Societal costs were also similar (GPi: $171,061 vs. STN: $167,706; difference = $3,356, 95% CI: -$57,371 to $60,294). The GPi patients had nonsignificantly more QALYs. CONCLUSIONS: The QALYs and costs were similar; the level of uncertainty given the sample size suggests that these factors should not direct treatment or resource allocation decisions in selecting or making available either procedure for eligible PD patients.

Parkinson's disease medication use and costs following deep brain stimulation.

The costs of treating Parkinson's disease (PD) are significant. Medication reductions usually occur following deep brain stimulation (DBS), but less is known about the relative costs of DBS targets, the globus pallidum (GPi) or the subthalamic nucleus (STN). This article reports medication costs between best medical therapy (BMT) and DBS over 6 months postintervention and by DBS target over 36 months postsurgery. Prescription use and costs for patients (n = 161) with advanced PD from a multisite randomized trial of BMT and DBS were examined overall and by drug category. Medication adjustment occurred at the discretion of the neurologists. PD medications were extracted from the Department of Veterans Affairs Decision Support System database. Levodopa equivalents (LEDD) were significantly lower for DBS than for BMT patients at 6 months (1101 vs 1398 mg; P = .005), but costs were similar (US$1750 vs US$1589; P = .55). LEDD decreased following GPi and STN DBS (1395-1161 mg, P = .014; and 1347-891 mg, P < .0001, respectively) in the first 6 months, but was lower for STN than for GPi over 36 months following DBS (P = .03). Total PD medication costs per 6-month intervals decreased over 36 months (P < .0001), but did not differ by target (P = .50) in the mixed-model analysis. However, cumulative medication costs over 36 months were lower for the STN than for GPi patients. PD medication use and costs decreased following DBS in either target over 36 months, but cumulative costs were less for STN than for GPi.

Effect of increased copayments on pharmacy use in the Department of Veterans Affairs.

OBJECTIVES: In February 2002, the Department of Veterans Affairs (VA) raised medication copayments from $2 to $7 per 30-day supply of medication for certain veteran groups. We examined the impact of the copayment increase on medication acquisition from VA. METHODS: This was a retrospective cohort study using data from national VA databases from February 2001 through February 2003. We took a random sample of over 5% of male VA users in 2001. Of 149,107 veterans sampled, 19,504 (13%) had copayments for no drugs, 101,410 (68%) had copayments for some drugs, and 28,193 (19%) had copayments for all drugs. We used multivariable count models to examine changes in the number of 30-day medication supplies after the increase. RESULTS: After the copayment increase, veterans subject to copayments for all drugs received 8% fewer 30-day supplies of medication annually relative to veterans with no copayments (P < 0.001). The effect of the copayment increased as the number of different medications veterans received increased. Among veterans subject to copayments for all drugs, acquisition of lower-cost drugs fell by 36%, higher-cost medications fell by 6%, over-the-counter medications fell by 40%, and prescription-only medications fell by 4% relative to veterans with no drug copayments. CONCLUSIONS: The number of medications veterans obtained from VA decreased after the copayment increase. There were relatively larger impacts on veterans with higher medication use and on lower-cost and over-the-counter medications.

Cost-effectiveness of coronary artery bypass grafts versus percutaneous coronary intervention for revascularization of high-risk patients.

BACKGROUND: A Department of Veterans Affairs Cooperative Study randomized high-risk patients with medically refractory myocardial ischemia, a group largely excluded from previous trials, to urgent revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The present study examined the cost-effectiveness of PCI versus CABG for these high-risk patients. METHODS AND RESULTS: Of 454 patients at 16 Department of Veterans Affairs medical centers, 445 were available for the economic analysis (218 PCI and 227 CABG patients). Total costs were assessed at 3 and 5 years from the third-party payer's perspective, and effectiveness was measured by survival. After 3 years, average total costs were 63,896 dollars for PCI versus 84,364 dollars for CABG patients, a difference of 20,468 dollars (95% confidence interval [CI] 13,918 dollars to 27,569 dollars). CIs were estimated by bootstrapping. Survival at 3 years was 0.82 for PCI versus 0.79 for CABG patients (P=0.34). Precision of the cost-effectiveness estimates were assessed by bootstrapping. PCI was less costly and more effective at 3 years in 92.6% of the bootstrap replications. After 5 years, average total costs were 81,790 dollars for PCI versus 100,522 dollars for CABG patients, a difference of 18,732 dollars (95% CI 9873 dollars to 27,831 dollars), whereas survival at 5 years was 0.75 for PCI patients versus 0.70 for CABG patients (P=0.21). At 5 years, PCI remained less costly and more effective in 89.4% of the bootstrap replications. CONCLUSIONS: PCI was less costly and at least as effective for the urgent revascularization of medically refractory, high-risk patients over 5 years.