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1.
BMC Health Serv Res ; 22(1): 1500, 2022 Dec 09.
Artigo em Inglês | MEDLINE | ID: mdl-36494829

RESUMO

OBJECTIVE: The Department of Veterans Affairs' (VA) electronic health records (EHR) offer a rich source of big data to study medical and health care questions, but patient eligibility and preferences may limit generalizability of findings. We therefore examined the representativeness of VA veterans by comparing veterans using VA healthcare services to those who do not. METHODS: We analyzed data on 3051 veteran participants age ≥ 18 years in the 2019 National Health Interview Survey. Weighted logistic regression was used to model participant characteristics, health conditions, pain, and self-reported health by past year VA healthcare use and generate predicted marginal prevalences, which were used to calculate Cohen's d of group differences in absolute risk by past-year VA healthcare use. RESULTS: Among veterans, 30.4% had past-year VA healthcare use. Veterans with lower income and members of racial/ethnic minority groups were more likely to report past-year VA healthcare use. Health conditions overrepresented in past-year VA healthcare users included chronic medical conditions (80.6% vs. 69.4%, d = 0.36), pain (78.9% vs. 65.9%; d = 0.35), mental distress (11.6% vs. 5.9%; d = 0.47), anxiety (10.8% vs. 4.1%; d = 0.67), and fair/poor self-reported health (27.9% vs. 18.0%; d = 0.40). CONCLUSIONS: Heterogeneity in veteran sociodemographic and health characteristics was observed by past-year VA healthcare use. Researchers working with VA EHR data should consider how the patient selection process may relate to the exposures and outcomes under study. Statistical reweighting may be needed to generalize risk estimates from the VA EHR data to the overall veteran population.


Assuntos
United States Department of Veterans Affairs , Veteranos , Estados Unidos/epidemiologia , Humanos , Adolescente , Registros Eletrônicos de Saúde , Etnicidade , Acessibilidade aos Serviços de Saúde , Grupos Minoritários , Dor
2.
J Am Heart Assoc ; 11(17): e025607, 2022 09 06.
Artigo em Inglês | MEDLINE | ID: mdl-36056726

RESUMO

Background It is unclear how to geographically distribute percutaneous coronary intervention (PCI) programs to optimize patient outcomes. The Washington State Certificate of Need program seeks to balance hospital volume and patient access through regulation of elective PCI. Methods and Results We performed a retrospective cohort study of all non-Veterans Affairs hospitals with PCI programs in Washington State from 2009 to 2018. Hospitals were classified as having (1) full PCI services and surgical backup (legacy hospitals, n=17); (2) full services without surgical backup (new certificate of need [CON] hospitals, n=9); or (3) only nonelective PCI without surgical backup (myocardial infarction [MI] access hospitals, n=9). Annual median hospital-level volumes were highest at legacy hospitals (605, interquartile range, 466-780), followed by new CON, (243, interquartile range, 146-287) and MI access, (61, interquartile range, 23-145). Compared with MI access hospitals, risk-adjusted mortality for nonelective patients was lower for legacy (odds ratio [OR], 0.59 [95% CI, 0.48-0.72]) and new-CON hospitals (OR, 0.55 [95% CI, 0.45-0.65]). Legacy hospitals provided access within 60 minutes for 90% of the population; addition of new CON and MI access hospitals resulted in only an additional 1.5% of the population having access within 60 minutes. Conclusions Many PCI programs in Washington State do not meet minimum volume standards despite regulation designed to consolidate elective PCI procedures. This CON strategy has resulted in a tiered system that includes low-volume centers treating high-risk patients with poor outcomes, without significant increase in geographic access. CON policies should re-evaluate the number and distribution of PCI programs.


Assuntos
Infarto do Miocárdio , Intervenção Coronária Percutânea , Regulamentação Governamental , Humanos , Avaliação de Resultados em Cuidados de Saúde , Intervenção Coronária Percutânea/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Washington/epidemiologia
3.
JAMA Netw Open ; 4(10): e2130581, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34677595

RESUMO

Importance: Most clinical practice guidelines recommend stopping cancer screenings when risks exceed benefits, yet low-value screenings persist. The Veterans Health Administration focuses on improving the value and quality of care, using a patient-centered medical home model that may affect cancer screening behavior. Objective: To understand rates and factors associated with outpatient low-value cancer screenings. Design, Setting, and Participants: This cohort study assessed the receipt of low-value cancer screening and associated factors among 5 993 010 veterans. Four measures of low-value cancer screening defined by validated recommendations of practices to avoid were constructed using administrative data. Patients with cancer screenings in 2017 at Veterans Health Administration primary care clinics were included. Excluded patients had recent symptoms or historic high-risk diagnoses that may affect test appropriateness (eg, melena preceding colonoscopy). Data were analyzed from December 23, 2019, to June 21, 2021. Exposures: Receipt of cancer screening test. Main Outcomes and Measures: Low-value screenings were defined as occurring for average-risk patients outside of guideline-recommended ages or if the 1-year mortality risk estimated using a previously validated score was at least 50%. Factors evaluated in multivariable regression models included patient, clinician, and clinic characteristics and patient-centered medical home domain performance for team-based care, access, and continuity previously developed from administrative and survey data. Results: Of 5 993 010 veterans (mean [SD] age, 63.1 [16.8] years; 5 496 976 men [91.7%]; 1 027 836 non-Hispanic Black [17.2%] and 4 539 341 non-Hispanic White [75.7%] race and ethnicity) enrolled in primary care, 903 612 of 4 647 479 men of average risk (19.4%) underwent prostate cancer screening; 299 765 of 5 770 622 patients of average risk (5.2%) underwent colorectal cancer screening; 21 930 of 469 045 women of average risk (4.7%) underwent breast cancer screening; and 65 511 of 458 086 women of average risk (14.3%) underwent cervical cancer screening. Of patients screened, low-value testing was rare for 3 cancers, with receipt of a low-value test in 633 of 21 930 of women screened for breast cancer (2.9%), 630 of 65 511 of women screened for cervical cancer (1.0%), and 6790 of 299 765 of patients screened for colorectal cancer (2.3%). However, 350 705 of 4 647 479 of screened men (7.5%) received a low-value prostate cancer test. Patient race and ethnicity, sociodemographic factors, and illness burden were significantly associated with likelihood of receipt of low-value tests among screened patients. No single patient-, clinician-, or clinic-level factor explained the receipt of a low-value test across cancer screening cohorts. Conclusions and Relevance: This large cohort study found that low-value breast, cervical, and colorectal cancer screenings were rare in the Veterans Health Administration, but more than one-third of patients screened for prostate cancer were tested outside of clinical practice guidelines. Guideline-discordant care has quality implications and is not consistently explained by associated multilevel factors.


Assuntos
Programas de Rastreamento/normas , Neoplasias/diagnóstico , United States Department of Veterans Affairs , Feminino , Humanos , Masculino , Estados Unidos
4.
J Am Heart Assoc ; 9(11): e015317, 2020 06 02.
Artigo em Inglês | MEDLINE | ID: mdl-32456522

RESUMO

Background Patient selection and outcomes for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) have changed over the past decade. However, there is limited information on outcomes for both revascularization strategies in the same population. The study evaluated temporal changes in risk profile, procedural characteristics, and clinical outcomes for PCI- and CABG-treated patients. Methods and Results We analyzed all PCI and isolated CABG between 2005 and 2017 in nonfederal hospitals in Washington State. Descriptive analysis was performed to evaluate temporal changes in risk profile and, risk-adjusted in-hospital mortality. Over the study period, 178 474 PCI and 36 592 CABG procedures were performed. PCI and CABG volume decreased by 2.9% and 22.6%, respectively. Compared with 2005-2009, patients receiving either form of revascularization between 2014 and 2017 had a higher prevalence of comorbidities including diabetes mellitus and hypertension and dialysis. Presentation with ST-segment-elevation myocardial infarction (17% versus 20%) and cardiogenic shock (2.4% versus 3.4%) increased for patients with PCI compared with CABG. Conversely, clinical acuity decreased for patients receiving CABG over the study period. From 2005 to 2017, mean National Cardiovascular Data Registry CathPCI mortality score increased for patients treated with PCI (20.1 versus 22.4, P<0.0001) and decreased for patients treated with CABG (18.8 versus 17.8, P<0.0001). Adjusted observed/expected in-hospital mortality ratio increased for PCI (0.98 versus 1.19, P<0.0001) but decreased for CABG (1.21 versus 0.74, P<0.0001) over the study period. Conclusions Clinical acuity increased for patients treated with PCI rather than CABG. This resulted in an increase in adjusted observed/expected mortality ratio for patients undergoing PCI and a decrease for CABG. These shifts may reflect an increased use of PCI instead of CABG for patients considered to be at high surgical risk.


Assuntos
Ponte de Artéria Coronária/tendências , Doença da Artéria Coronariana/terapia , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Intervenção Coronária Percutânea/tendências , Padrões de Prática Médica/tendências , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Washington
6.
J Am Heart Assoc ; 7(19): e010010, 2018 10 02.
Artigo em Inglês | MEDLINE | ID: mdl-30371315

RESUMO

Background Cardiac rehabilitation (CR) is strongly recommended after percutaneous coronary intervention (PCI), but it is underused. We sought to evaluate CR participation variation after PCI and its association with mortality among veterans. Methods and Results Patients undergoing PCI between 2007 and 2011 were identified in the Veterans Affairs Clinical Assessment, Reporting, and Tracking database and followed up until January 25, 2017. We excluded patients who died within 30 days of PCI and calculated the percentage participating in ≥1 outpatient CR visits within 12 months after PCI. We constructed multivariable hierarchical logistic regression models for CR participation, clustered by facility. We estimated propensity scores for CR participation, matched participants and nonparticipants by propensity score, calculated mortality rates, and estimated the association with mortality using Cox proportional hazards models. Participation in CR after PCI was 6.9% (2986/43 319) and varied significantly by PCI facility (range, 0%-36%). After 6.1 years median follow-up, CR participants had a 33% lower mortality rate than all nonparticipants (3.8 versus 5.7 deaths/100 person-years; hazard ratio, 0.67; 95% confidence interval, 0.61-0.75; P<0.001) and a 26% lower mortality rate than 2986 propensity-matched nonparticipants (3.8 versus 5.1 deaths/100 person-years; hazard ratio, 0.74; 95% confidence interval, 0.65-0.84; P<0.001). Participants attending ≥36 sessions had the lowest mortality rate (2.4 deaths/100 person-years; hazard ratio, 0.47; 95% confidence interval, 0.36-0.60; P<0.001). Conclusions CR participation after PCI among veterans is low overall, with significant facility-level variation. CR participation is associated with lower mortality rates in veterans. Additional efforts are needed to promote CR participation after PCI among veterans.


Assuntos
Reabilitação Cardíaca/estatística & dados numéricos , Doença da Artéria Coronariana/mortalidade , Avaliação de Resultados em Cuidados de Saúde/métodos , Intervenção Coronária Percutânea , Pontuação de Propensão , United States Department of Veterans Affairs/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Idoso , Doença da Artéria Coronariana/reabilitação , Doença da Artéria Coronariana/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo , Estados Unidos/epidemiologia
7.
Public Health Rep ; 133(6): 692-699, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30223760

RESUMO

OBJECTIVES: Military service is associated with an increased risk of disability and death after discharge. This study determined the relationships among characteristics, disability ratings, and 1-year mortality risks of veterans receiving compensation for service-connected health conditions (ie, conditions related to illnesses or injuries incurred or aggravated during military service). METHODS: This study included 4 010 720 living veterans who had ≥1 service-connected health condition and were receiving disability compensation on October 1, 2016. We obtained data on veteran demographic, military service, and disability characteristics from the Veterans Benefits Administration VETSNET file and on 1-year mortality from the Veterans Administration vital status file. We compared veteran characteristics and 1-year mortality rates within and between the following combined service-connected disability rating categories: low, 10% to 40% disability; medium, 50% to 90% disability; high, 100% disability. We used logistic regression analysis to determine the relationships between disability ratings and 1-year mortality rates. RESULTS: Of 4 010 720 veterans, 515 095 (12.8%) had high disability ratings, 1 600 786 (39.9%) had medium disability ratings, and 1 894 839 (47.2%) had low disability ratings. The 1-year mortality rates were 4.5% for those with high disability, 1.9% for those with medium disability, and 1.9% for those with low disability ratings. Compared with veterans with low disability ratings, veterans with high disability ratings had more than twice the odds of 1-year mortality (odds ratio = 2.45; 95% confidence interval, 2.40-2.50). CONCLUSIONS: The combined disability rating is an important determinant of short-term survival among veterans with service-connected health conditions. Veterans with a 100% disability rating comprise a highly select group with increased short-term risk of death due at least in part to their military service. Future studies assessing the relationships among combat exposure, age, duration of disability, disability ratings, and survival would be valuable.


Assuntos
Pessoas com Deficiência/estatística & dados numéricos , Mortalidade , Ajuda a Veteranos de Guerra com Deficiência/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Idoso , Compensação e Reparação , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Estados Unidos/epidemiologia
8.
BMC Cardiovasc Disord ; 18(1): 164, 2018 08 13.
Artigo em Inglês | MEDLINE | ID: mdl-30103677

RESUMO

BACKGROUND: The use of inappropriate elective Percutaneous Coronary Intervention (PCI) has decreased over time, but hospital-level variation in the use of inappropriate PCI persists. Understanding the barriers and facilitators to the implementation of Appropriate Use Criteria (AUC) guidelines may inform efforts to improve elective PCI appropriateness. METHODS: All hospitals performing PCI in Washington State were categorized by their use of inappropriate elective PCI in 2010 to 2013. Semi-structured, qualitative telephone interviews were then conducted with 17 individual interviews at 13 sites in Washington State to identify barriers and facilitators to the implementation of the AUC guidelines. An inductive and deductive, team-based analytical approach, drawing primarily on Matrix analysis was performed to identify factors affecting implementation of the AUC. RESULTS: Specific facilitators were identified that supported successful implementation of the AUC. These included collaborative catheterization laboratory environments that allow all staff to participate with questions and opinions; ongoing AUC education with catheterization laboratory teams and referring providers; internal AUC peer review processes; interventional cardiologist be directly involved with the pre-procedural review process; checklist-based algorithms for pre-procedural documentation; systems redesign to include insurance companies; and AUC educational information with patients. Barriers to implementation of the AUC included external pressures, such as competition for patients, and the lack of shared medical records with sites that referred patients for coronary angiography. CONCLUSIONS: The identified facilitators enabled sites to successfully implement the AUC. Catheterization laboratories struggling to successfully implement the AUC may consider utilizing these strategies to improve their processes to improve patient selection for elective PCI.


Assuntos
Fidelidade a Diretrizes/normas , Isquemia Miocárdica/cirurgia , Intervenção Coronária Percutânea/normas , Guias de Prática Clínica como Assunto/normas , Padrões de Prática Médica/normas , Serviço Hospitalar de Cardiologia/normas , Educação Médica Continuada/normas , Procedimentos Cirúrgicos Eletivos , Pesquisas sobre Atenção à Saúde , Hospitais com Alto Volume de Atendimentos/normas , Hospitais com Baixo Volume de Atendimentos/normas , Humanos , Capacitação em Serviço/normas , Isquemia Miocárdica/diagnóstico , Equipe de Assistência ao Paciente/normas , Pesquisa Qualitativa , Encaminhamento e Consulta/normas , Washington
9.
Mil Med ; 183(11-12): e371-e376, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-29590473

RESUMO

Introduction: The association between disability and cause of death in Veterans with service-connected disabilities has not been studied. The objective of this study was to compare age at death, military service and disability characteristics, including disability rating, and cause of death by year of birth. We also examined cause of death for specific service-connected conditions. Materials and methods: This study used information from the VETSNET file, which is a snapshot of selected items from the Veterans Benefits Administration corporate database. We also used the National Death Index (NDI) for Veterans which is part of the VA Suicide Data Repository. In VETSNET, there were 758,324 Veterans who had a service-connected condition and died between the years 2004 and 2014. Using the scrambled social security number to link the two files resulted in 605,493 (80%) deceased Veterans. Age at death, sex, and underlying cause of death were obtained from the NDI for Veterans and military service characteristics and types of disability were acquired from VETSNET. We constructed age categories corresponding to period of service; birth years 1938 and earlier corresponded to Korea and World War II ("oldest"), birth years 1939-1957 to the Vietnam era ("middle"), and birth years 1958 and later to post Vietnam, Gulf War, and the more recent conflicts in Iraq and Afghanistan ("youngest"). Results: Sixty-two percent were in the oldest age category, 34% in the middle group, and 4% in the youngest one. The overall age at death was 75 ± 13 yr. Only 1.6% of decedents were women; among women 25% were in the youngest age group, while among men only 4% were in the youngest group. Most decedents were enlisted personnel, and 60% served in the U.S. Army. Nearly 61% had a disability rating of >50% and for the middle age group 54% had a disability rating of 100%. The most common service-connected conditions were tinnitus, hearing loss, and post-traumatic stress disorder (PTSD). In the oldest group, nearly half of deaths were due to cancer or cardiovascular conditions and <2% were due to external causes. In the youngest group, cardiovascular disease and cancer accounted for about 1/3 of deaths, whereas external causes or deaths due to accidents, suicide, or assault accounted for nearly 33% of deaths. For Veterans with service-connected PTSD or major depression; 6.5% of deaths were due to external causes whereas for Veterans without these conditions, only 3.1% were due to external causes. Conclusion: The finding of premature death due to external causes in the youngest age group as well as the finding of higher proportions of external causes in those with PTSD or major depression should be of great concern to those who care for Veterans.


Assuntos
Fatores Etários , Causas de Morte , Pessoas com Deficiência/classificação , Veteranos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , United States Department of Veterans Affairs/organização & administração , United States Department of Veterans Affairs/estatística & dados numéricos
10.
Artigo em Inglês | MEDLINE | ID: mdl-28619725

RESUMO

BACKGROUND: Despite guideline recommendations that patients undergoing percutaneous coronary intervention (PCI), coronary artery bypass surgery, or valve surgery be referred to cardiac rehabilitation, cardiac rehabilitation is underused. The objective of this study was to examine hospital-level variation in cardiac rehabilitation referral after PCI, coronary artery bypass surgery, and valve surgery. METHODS AND RESULTS: We analyzed data from the Clinical Outcomes Assessment Program, a registry of all nonfederal hospitals performing PCI and cardiac surgery in Washington State. We included eligible PCI, coronary artery bypass surgery, and valve surgery patients from 2010 to 2015. We analyzed PCI and cardiac surgery separately by performing multivariable hierarchical logistic regression for the outcome of cardiac rehabilitation referral at discharge, clustered by hospital. Patient-level covariates included age, sex, race/ethnicity, comorbidities, and procedure indication/status. Cardiac rehabilitation referral was reported in 48% (34 047/71 556) of PCI patients and 91% (21 831/23 972) of cardiac surgery patients. The hospital performing the procedure was a stronger predictor of referral than any individual patient characteristic for PCI (hospital referral range 3%-97%; median odds ratio, 5.94; 95% confidence interval, 4.10-9.49) and cardiac surgery (range 54%-100%; median odds ratio, 7.09; 95% confidence interval, 3.79-17.80). Hospitals having an outpatient cardiac rehabilitation program explained only 10% of PCI variation and 0% of cardiac surgery variation. CONCLUSIONS: Cardiac rehabilitation referral at discharge was less prevalent after PCI than cardiac surgery. The strongest predictor of cardiac rehabilitation referral was the hospital performing the procedure. Efforts to improve cardiac rehabilitation referral should focus on increasing referral after PCI, especially in low referral hospitals.


Assuntos
Reabilitação Cardíaca/tendências , Ponte de Artéria Coronária/reabilitação , Disparidades em Assistência à Saúde/tendências , Implante de Prótese de Valva Cardíaca/reabilitação , Intervenção Coronária Percutânea/reabilitação , Padrões de Prática Médica/tendências , Encaminhamento e Consulta/tendências , Idoso , Distribuição de Qui-Quadrado , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Alta do Paciente , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Cuidados Pós-Operatórios , Avaliação de Programas e Projetos de Saúde , Indicadores de Qualidade em Assistência à Saúde/tendências , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Washington
12.
J Am Heart Assoc ; 5(1)2016 Jan 25.
Artigo em Inglês | MEDLINE | ID: mdl-26811165

RESUMO

BACKGROUND: We hypothesized that nebivolol, a ß-blocker with nitric oxide-mediated activity, compared with atenolol, a ß-blocker without such activity, would decrease oxidative stress and improve the effects of endothelial dysfunction and wall shear stress (WSS), thereby reducing atherosclerosis progression and vulnerability in patients with nonobstructive coronary artery disease. METHODS AND RESULTS: In this pilot double-blinded randomized controlled trial, 24 patients treated for 1 year with nebivolol 10 mg versus atenolol 100 mg plus standard medical therapy underwent baseline and follow-up coronary angiography with assessments of inflammatory and oxidative stress biomarkers, microvascular function, endothelial function, and virtual histology intravascular ultrasound. WSS was calculated from computational fluid dynamics. Virtual histology intravascular ultrasound segments were assessed for vessel volumetrics and remodeling. There was a trend toward more low-WSS segments in the nebivolol cohort (P=0.06). Low-WSS regions were associated with greater plaque progression (P<0.0001) and constrictive remodeling (P=0.04); conversely, high-WSS segments demonstrated plaque regression and excessive expansive remodeling. Nebivolol patients had decreased lumen and vessel areas along with increased plaque area, resulting in more constrictive remodeling (P=0.002). There were no significant differences in biomarker levels, microvascular function, endothelial function, or number of thin-capped fibroatheromas per vessel. Importantly, after adjusting for ß-blocker, low-WSS segments remained significantly associated with lumen loss and plaque progression. CONCLUSION: Nebivolol, compared with atenolol, was associated with greater plaque progression and constrictive remodeling, likely driven by more low-WSS segments in the nebivolol arm. Both ß-blockers had similar effects on oxidative stress, microvascular function, and endothelial function. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov/. Unique identifier: NCT01230892.


Assuntos
Agonistas de Receptores Adrenérgicos beta 3/uso terapêutico , Antagonistas Adrenérgicos beta/uso terapêutico , Atenolol/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Circulação Coronária/efeitos dos fármacos , Vasos Coronários/efeitos dos fármacos , Diagnóstico por Imagem , Nebivolol/uso terapêutico , Placa Aterosclerótica , Adulto , Biomarcadores/sangue , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/fisiopatologia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/fisiopatologia , Diagnóstico por Imagem/métodos , Método Duplo-Cego , Ecocardiografia Doppler , Feminino , Georgia , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Estresse Oxidativo/efeitos dos fármacos , Projetos Piloto , Valor Preditivo dos Testes , Estresse Mecânico , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção , Remodelação Vascular/efeitos dos fármacos
13.
J Am Board Fam Med ; 28(5): 605-16, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26355132

RESUMO

INTRODUCTION: Illicit drug use is a serious public health problem associated with significant co-occurring medical disorders, mental disorders, and social problems. Yet most individuals with drug use disorders have never been treated, though they often seek medical treatment in primary care. The purpose of this study was to examine the baseline characteristics of people presenting in primary care with a range of problem drug use severity to identify their clinical needs. METHODS: We examined sociodemographic characteristics, medical and psychiatric comorbidities, drug use severity, social and legal problems, and service utilization for 868 patients with drug problems. These patients were recruited from primary care clinics in a medical safety net setting. Based on Drug Abuse Screening Test results, individuals were categorized as having low, intermediate, or substantial/severe drug use severity. RESULTS: Patients with substantial/severe drug use severity had serious drug use (opiates, stimulants, sedatives, intravenous drugs); high levels of homelessness (50%), psychiatric comorbidity (69%), and arrests for serious crimes (24%); and frequent use of expensive emergency department and inpatient hospitals. Patients with low drug use severity were primarily users of marijuana, with little reported use of other drugs, less psychiatric comorbidity, and more stable lifestyles. Patients with intermediate drug use severity fell in between the substantial/severe and low drug use severity subgroups on most variables. CONCLUSIONS: Patients with the highest drug use severity are likely to require specialized psychiatric and substance abuse care, in addition to ongoing medical care that is equipped to address the consequences of severe/substantial drug use, including intravenous drug use. Because of their milder symptoms, patients with low drug use severity may benefit from a collaborative care model that integrates psychiatric and substance abuse care in the primary care setting. Patients with intermediate drug use severity may benefit from selective application of interventions suggested for patients with the highest and lowest drug use severity. Primary care safety net clinics are in a key position to serve patients with problem drug use by developing a range of responses that are locally effective and that may also inform national efforts to establish patient-centered medical homes and to implement the Affordable Care Act.


Assuntos
Prestação Integrada de Cuidados de Saúde/métodos , Necessidades e Demandas de Serviços de Saúde , Assistência ao Paciente/métodos , Atenção Primária à Saúde/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Educação de Pacientes como Assunto , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Substâncias/terapia , Resultado do Tratamento
14.
Circulation ; 132(1): 20-6, 2015 Jul 07.
Artigo em Inglês | MEDLINE | ID: mdl-26022910

RESUMO

BACKGROUND: It is unknown whether the appropriate use of percutaneous coronary intervention (PCI) has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the use of PCI. METHODS AND RESULTS: We applied appropriate use criteria to determine the appropriateness of all 51 872 PCI performed in Washington State from 2010 through 2013. We evaluated the number of PCIs performed from 2006 through 2013 to provide a comparator period that preceded statewide appropriateness assessment beginning in 2010. Between 2010 and 2013, the overall number of PCI decreased by 6.8% (13 267 PCIs in 2010 to 12 193 in 2013) with a 43% decline in the number of PCIs for elective indications (3818 PCIs in 2010 to 2193 PCIs in 2013). The decline in the use of elective PCI was significantly larger after the onset of statewide PCI appropriateness assessment in 2010 (P=0.03). The proportion of elective PCIs classified as appropriate increased from 26% in 2010 to 38% in 2013, whereas the proportion of inappropriate PCIs decreased from 16% to 13% (P<0.001 for trends). Significant improvements in the proportion of inappropriate PCI were limited to the tertile of hospitals with the largest decline in PCIs classified as inappropriate (25% in 2010 to 12% in 2013; P=0.03). CONCLUSIONS: In Washington State, the use of PCI for elective indications has decreased over time with concurrent improvements in PCI appropriateness. However, improvements in PCI appropriateness were limited to a minority of hospitals. Understanding processes at these high-performing hospitals may inform efforts to improve PCI appropriateness.


Assuntos
Hospitais/tendências , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Intervenção Coronária Percutânea/normas , Intervenção Coronária Percutânea/tendências , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Sistema de Registros , Fatores de Tempo , Washington/epidemiologia
15.
J Thorac Cardiovasc Surg ; 148(6): 3084-9, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25227699

RESUMO

OBJECTIVE: A number of established regional quality improvement collaboratives have partnered to assess and improve care across their regions under the umbrella of the Cardiac Surgery Quality Improvement (IMPROVE) Network. The first effort of the IMPROVE Network has been to assess regional differences in potentially discretionary transfusions (<3 units red blood cells [RBCs]). METHODS: We examined 11,200 patients undergoing isolated nonemergent coronary artery bypass graft surgery across 56 medical centers in 4 IMPROVE Network regions between January 2008 and June 2012. Each center submitted the most recent 200 patients who received 0, 1, or 2 units of RBC transfusion during the index admission. Patient and disease characteristics, intraoperative practices, and percentage of patients receiving RBC transfusions were collected. Region-specific transfusion rates were calculated after adjusting for pre- and intraoperative factors among region-specific centers. RESULTS: There were small but significant differences in patient case mix across regions. RBC transfusions of 1 or 2 units occurred among 25.2% of coronary artery bypass graft procedures (2826 out of 11,200). Significant variation in the number of RBC units used existed across regions (no units, 74.8% [min-max, 70.0%-84.1%], 1 unit, 9.7% [min-max, 5.1%-11.8%], 2 units, 15.5% [min-max, 9.1%-18.2%]; P < .001). Variation in overall transfusion rates remained after adjustment (9.1%-31.7%; P < .001). CONCLUSIONS: Delivery of small volumes of RBC transfusions was common, yet varied across geographic regions. These data suggest that differences in regional practice environments, including transfusion triggers and anemia management, may contribute to variability in RBC transfusion rates.


Assuntos
Ponte de Artéria Coronária/tendências , Transfusão de Eritrócitos/tendências , Disparidades em Assistência à Saúde/tendências , Padrões de Prática Médica/tendências , Melhoria de Qualidade/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Características de Residência , Idoso , Ponte de Artéria Coronária/efeitos adversos , Transfusão de Eritrócitos/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Estados Unidos
16.
J Ambul Care Manage ; 37(4): 331-8, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25180648

RESUMO

Care continuity, access, and coordination are important features of the patient-centered medical home model and have been emphasized in the Veterans Health Administration patient-centered medical home implementation, called the Patient Aligned Care Team. Data from more than 4.3 million Veterans were used to assess the relationship between these attributes of Patient Aligned Care Team and Veterans Health Administration hospitalization and mortality. Controlling for demographics and comorbidity, we found that continuity with a primary care provider was associated with a lower likelihood of hospitalization and mortality among a large population of Veterans receiving VA primary care.


Assuntos
Avaliação de Resultados em Cuidados de Saúde , Assistência Centrada no Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Idoso , Causas de Morte , Feminino , Acessibilidade aos Serviços de Saúde , Pesquisa sobre Serviços de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Organizacionais , Estados Unidos , United States Department of Veterans Affairs
17.
Am J Manag Care ; 19(7): e263-72, 2013 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-23919446

RESUMO

BACKGROUND: The Veterans Health Administration (VHA) is the largest integrated US health system to implement the patient-centered medical home. The Patient Aligned Care Team (PACT) initiative (implemented 2010-2014) aims to achieve team based care, improved access, and care management for more than 5 million primary care patients nationwide. OBJECTIVES: To describe PACT and evaluate interim changes in PACT-related care processes. STUDY DESIGN: Data from the VHA Corporate Data Warehouse were obtained from April 2009 (pre- PACT) to September 2012. All patients assigned to a primary care provider (PCP) at all VHA facilities were included. METHODS: Nonparametric tests of trend across time points. RESULTS: VHA increased primary care staff levels from April 2010 to December 2011 (2.3 to 3.0 staff per PCP full-time equivalent). In-person PCP visit rates slightly decreased from April 2009 to April 2012 (53 to 43 per 100 patients per calendar quarter; P < .01), while in-person nurse encounter rates remained steady. Large increases were seen in phone encounters (2.7 to 28.8 per 100 patients per quarter; P < .01), enhanced personal health record use (3% to 13% of patients enrolled), and electronic messaging to providers (0.01% to 2.3% of patients per quarter). Post hospitalization follow-up improved (6.6% to 61% of VA hospital discharges), but home telemonitoring (0.8% to 1.4% of patients) and group visits (0.2 to 0.65 per 100 patients per quarter; P < .01) grew slowly. CONCLUSIONS: Thirty months into PACT, primary care staff levels and phone and electronic encounters have greatly increased; other changes have been positive but slower.


Assuntos
Assistência Centrada no Paciente/normas , United States Department of Veterans Affairs , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Bases de Dados Factuais , Difusão de Inovações , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Humanos , Equipe de Assistência ao Paciente/estatística & dados numéricos , Assistência Centrada no Paciente/organização & administração , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estatísticas não Paramétricas , Estados Unidos
18.
Am Heart J ; 165(3): 332-7, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23453101

RESUMO

BACKGROUND: Transradial percutaneous coronary intervention (tPCI) as opposed to the femoral approach (fPCI) is associated with lower rates of bleeding. The purposes of this study were to describe the use of tPCI in the Washington State Clinical Outcomes Assessment Program, identify the predictors of bleeding, and determine whether tPCI was associated with less bleeding in women vs men, age <75 years vs ≥75 years, and baseline creatinine <2.0 mg/dL vs ≥2.0 mg/dL. METHODS: This study included 23,599 individuals who had a first tPCI or fPCI performed in 30 centers in Washington State in 2010 and 2011. Data were collected according to specifications from the American College of Cardiology National Cardiovascular Data Registry Cath-PCI version 4.3. The American College of Cardiology National Cardiovascular Data Registry bleeding model was used to calculate adjusted rates. RESULTS: Transradial percutaneous coronary intervention was used in only 5% of procedures, and in just 3 centers, tPCI was used in >10% of cases. Patient demographics and medical histories were similar in tPCI and fPCI, although the percent of acute cases was higher in fPCI (68% vs 45%, P < .0001). The overall bleeding rate was 2.2%, and the 3 most important predictors of bleeding were acute procedure, women, and age ≥75 years. For women, unadjusted rates of bleeding were 1.4% for tPCI and 4.0% for fPCI (P = .013). Among women, adjusted rates were almost 20% lower for tPCI (3.3% vs 4.1%). CONCLUSION: In Washington State, tPCI was used infrequently, although it was associated with lower bleeding rates in high-risk groups including women.


Assuntos
Intervenção Coronária Percutânea/estatística & dados numéricos , Artéria Radial/cirurgia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Hemorragia Pós-Operatória/epidemiologia , Avaliação de Programas e Projetos de Saúde , Fatores Sexuais , Resultado do Tratamento , Washington
19.
Vaccine ; 30(43): 6150-6, 2012 Sep 21.
Artigo em Inglês | MEDLINE | ID: mdl-22874851

RESUMO

CONTEXT: To protect troops against the use of anthrax as a biological weapon, the US Department of Defense began an anthrax vaccination program in 1998. 14 years after the inception of the vaccination program, there is no evidence suggesting vaccination against anthrax carries long-term health risks for Active Duty Soldiers. OBJECTIVE: To investigate the association between Anthrax Vaccine Adsorbed (AVA) received while on Active Duty and subsequent disability determined by the Veterans Benefits Administration. DESIGN, SETTING AND PARTICIPANTS: Case-control study nested in the cohort of all Active Duty personnel known to have separated from the US Army between December 1, 1997 and December 31, 2005. Cases were ≥10% disabled, determined either by the Army prior to separation (N=5846) or by the Veterans Benefits Administration (VBA) after separation (N=148,934). Controls (N=937,705) separated from the Army without disability, and were not receiving pensions from the VBA as of April 2007. Data were from the Total Army Injury and Health Outcomes Database and the VBA Compensation and Pension and Benefits database. MAIN OUTCOMES: Disability status (yes/no); for primary disability, percent disabled (≥10%, 20%, >20%) and type of disability. RESULTS: Vaccination against anthrax was four times more likely among disabled Veterans with hostile fire pay records (HFP, a surrogate for deployment). Vaccinated Soldiers with HFP had lower odds of disability separation from the Army 0.89 (0.80, 0.98); there was no association between vaccine and receiving Army disability benefits among those without HFP (OR=1.05, CI: 0.96, 1.14). Vaccination was negatively associated with receiving VA disability benefits for those with HFP (OR=0.66, CI: 0.65, 0.67), but there was little or no association between vaccine and receipt of VA disability benefits for those without HFP (OR=0.95, CI: 0.93, 0.97). CONCLUSIONS: Risk of disability separation from the Army and receipt of disability compensation from the VA were not increased in association with prior exposure to AVA. This study provides evidence that vaccination against anthrax is not associated with long term disability.


Assuntos
Vacinas contra Antraz/administração & dosagem , Avaliação da Deficiência , Vacinação/efeitos adversos , Ajuda a Veteranos de Guerra com Deficiência/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Adolescente , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Modelos Logísticos , Masculino , Estados Unidos , United States Department of Veterans Affairs , Adulto Jovem
20.
Med Care ; 50(2): 117-23, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-21993058

RESUMO

BACKGROUND: Most public reporting and pay for performance (P4P) programs in the United States continue to be organized and implemented by single insurers. Adequate medical group-level reliability on clinical care process measures is possible in multistakeholder initiatives because patient samples can be pooled across payers. However, the extent to which reliable measurement is achievable in single insurer P4P initiatives remains unclear. METHODS: This study uses 7 years (2001 to 2007) of patient-level clinical care process data from an insurer in Washington State involving 20 medical groups. Eight clinical care process measures were analyzed. We compared the medical group-level reliability and resulting sample size requirements for each of the 8 measures using unadjusted and adjusted binary mixed models. The relation of baseline intraclass correlation coefficients (ICCs) and medical group performance change over time was examined for each clinical care process measure. RESULTS: Only 45% of all medical group measurements (group-years for all observations) had sufficient sample sizes to achieve reliable estimates of group performance. Measures with the largest deficiencies in patient samples per group included appropriate asthma treatment and low-density lipoprotein screening for patients with coronary artery disease. There was an inconsistent relationship between the size of baseline ICCs and medical group performance improvement over time. CONCLUSIONS: Unreliable performance measurement is an important consequence of the prevailing organization and implementation of public reporting and P4P programs in the US. Multi-payer collaborations may be an important vehicle for ensuring reliable medical group performance measurement and comparisons on clinical care process measures.


Assuntos
Indicadores de Qualidade em Assistência à Saúde/normas , Reembolso de Incentivo/normas , Asma/terapia , Doença da Artéria Coronariana/sangue , Hemoglobinas Glicadas/análise , Humanos , Seguradoras/normas , Lipoproteínas LDL/sangue , Reembolso de Incentivo/organização & administração , Reprodutibilidade dos Testes , Tamanho da Amostra , Fatores de Tempo , Washington
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