Using local rather than general anesthesia for inguinal hernia repair is associated with shorter operative time and enhanced postoperative recovery.

BACKGROUND: Inguinal hernia repair is the most common general surgery procedure and can be performed under local or general anesthesia. We hypothesized that using local rather than general anesthesia would improve outcomes, especially for older adults. METHODS: This is a retrospective review of 97,437 patients in the Veterans Affairs Surgical Quality Improvement Program who had open inguinal hernia surgery under local or general anesthesia. Outcomes included 30-day postoperative complications, operative time, and recovery time. RESULTS: Our cohort included 22,333 (23%) Veterans who received local and 75,104 (77%) who received general anesthesia. Mean age was 62 years. Local anesthesia was associated with a 37% decrease in the odds of postoperative complications (95% CI 0.54-0.73), a 13% decrease in operative time (95% CI 17.5-7.5), and a 27% shorter recovery room stay (95% CI 27.5-25.5), regardless of age. CONCLUSIONS: Using local rather than general anesthesia is associated with a profound decrease in complications (equivalent to "de-aging" patients by 30 years) and could significantly reduce costs for this common procedure.

Trends in Readmission and Mortality Rates Following Heart Failure Hospitalization in the Veterans Affairs Health Care System From 2007 to 2017.

Importance: The Centers for Medicare & Medicaid Services and the Veterans Affairs Health Care System provide incentives for hospitals to reduce 30-day readmission and mortality rates. In contrast with the large body of evidence describing readmission and mortality in the Medicare system, it is unclear how heart failure readmission and mortality rates have changed during this period in the Veterans Affairs Health Care System. Objectives: To evaluate trends in readmission and mortality after heart failure admission in the Veterans Affairs Health Care System, which had no financial penalties, in a decade involving focus on heart failure readmission reduction (2007-2017). Design, Setting, and Participants: This cohort study used data from all Veterans Affairs-paid heart failure admissions from January 2007 to September 2017. All Veterans Affairs-paid hospital admissions to Veterans Affairs and non-Veterans Affairs facilities for a primary diagnosis of heart failure were included, when the admission was paid for by the Veterans Affairs. Data analyses were conducted from October 2018 to March 2020. Exposures: Admission for a primary diagnosis of heart failure at discharge. Main Outcomes and Measures: Thirty-day all-cause readmission and mortality rates. Results: A total of 164 566 patients with 304 374 hospital admissions were included. Among the 304 374 hospital admissions between 2007 and 2017, 298 260 (98.0%) were for male patients, and 195 205 (64.4%) were for white patients. The mean (SD) age was 70.8 (11.5) years. The adjusted odds ratio of 30-day readmission declined throughout the study period to 0.85 (95% CI, 0.83-0.88) in 2015 to 2017 compared with 2007 to 2008. The adjusted odds ratio of 30-day mortality remained stable, with an adjusted odds ratio of 1.01 (95% CI, 0.96-1.06) in 2015 to 2017 compared with 2007 to 2008. Stratification by left ventricular ejection fraction showed similar readmission reduction trends and no significant change in mortality, regardless of strata. Conclusions and Relevance: In this analysis of an integrated health care system that provided guidance and nonfinancial incentives for reducing readmissions, such as public reporting of readmission rates, risk-adjusted 30-day readmission declined despite inclusion of clinical variables in risk adjustment, but mortality did not decline. Future investigations should focus on evaluating the effectiveness of specific approaches to readmission reduction to inform efficient and effective application in individual health systems, hospitals, and practices.

Feasibility of a Local Anesthesia Program for Inguinal Hernia Repair at a Veteran Affairs Hospital.

BACKGROUND: Local anesthesia (LA) for open inguinal hernia repair (OIHR) is not widely used in the United States. An LA program for OIHR was initiated at the Dallas Veteran Affairs Medical Center in 2015. We hypothesize that outcomes under LA for OIHR are similar to general anesthesia with adequate patient satisfaction. METHODS: A total of 1422 groin hernias were performed by a single surgeon using a standardized technique at the Dallas Veteran Affairs Medical Center (2015-2019). Only unilateral, primary, elective, OIHRs were included (n = 1092). LA was used in 26.0% (n = 285) and compared with patients undergoing general anesthesia. Univariate analysis was performed by the Student t-test for continuous variables and χ2 test (or the Fisher exact test) for categorical variables. RESULTS: OIHR performed with LA increased from 15.5% in 2015 to 76.6% in 2019. Patients undergoing LA were older and had significantly more comorbidities. Holding time to operating room (OR), OR to start of the operation, skin-to-skin time, and end of the operation to out of the OR were all reduced with LA (all P values <0.05). Inguinodynia, recurrence, and overall complications were similar. Patients undergoing LA indicated that they were comfortable (93.0%), rated their worst pain as 2.03 ± 2.2 (of 10), and would undergo LA if they had to do it again (94.0%). CONCLUSIONS: LA was associated with decreased OR times and had good patient satisfaction. Overall complication rates were similar despite a higher burden of comorbid conditions in patients undergoing LA.

Developing a template matching algorithm for benchmarking hospital performance in a diverse, integrated healthcare system.

Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.

Hospitals lead by poor example: An assessment of snacks, soda, and junk food availability in Veterans Affairs hospitals.

OBJECTIVE: The Veterans Health Administration is the largest integrated health care system fully funded through the US government; however, compliance with government dietary recommendations within Veterans Affairs (VA) hospitals is not well known. The aim of this study was to determine which foods are available at VA hospitals and whether these foods comply with government recommendations. METHODS: Process verification for a Freedom of Information Act request was used to assess government-run inpatient and outpatient VA hospital facilities by accessing the location, quantity, and contents of vending machines. These foods and beverages were then quantified and compared with the US Department of Agriculture Dietary Guidelines for Americans 2015-2020 (eighth edition). RESULTS: Of the beverages supplied, 49% contained >55 g of sugar, supplying >10% of daily calories in added sugar in a single serving. Of all beverages, 50% contained >50 g of added sugar (range 17-77 g per bottle/can). The 65 available food items were comprised of 28% candy, 14% potato chips/puffed corn snacks, 11% pastries/frosted baked goods, 11% crackles/pretzels, and 8% nuts/trail mix, and the remainder consisted of jerky, pork rinds, gum, and popcorn. Nuts/trail mix and granola-items meeting nutritional guidelines-comprised five and three options in total, respectfully. CONCLUSIONS: All VA Hospitals contain vending machines providing a majority of soda, candy, and junk foods that directly conflict with healthy food choice recommendations from US governing health bodies. Few sources meeting US dietary guidelines are available in vending machines at these government-run facilities, which serve as poor examples for patients who are attempting to follow a healthy diet.

Root Cause Analysis of Oncology Adverse Events in the Veterans Health Administration.

PURPOSE: Oncology providers are leaders in patient safety. Despite their efforts, oncology-related medical errors still occur, sometimes resulting in patient injury or death. The Veterans Health Administration (VHA) National Center of Patient Safety used data obtained from root cause analysis (RCA) to determine how and why these adverse events occurred in the VHA, and how to prevent future reoccurrence. This study details the types of oncology adverse events reported in VHA hospitals and their root causes and suggests actions for prevention and improvement. METHODS: We searched the National Center for Patient Safety adverse event reporting database for RCA related to oncology care from October 1, 2013, to September 8, 2017, to identify event types, root causes, severity of outcomes, care processes, and suggested actions. Two independent reviewers coded these variables, and inter-rater agreement was calculated by κ statistic. Variables were evaluated using descriptive statistics. RESULTS: We identified 48 RCA reports that specifically involved an oncology provider. Event types included care delays (39.5% [n = 19]), issues with chemotherapy (25% [n = 12]) and radiation (12.5% [n = 6]), other (12.5% [n = 6]), and suicide (10.5% [n = 5]). Of the 48 events, 27.1% (n = 13) resulted in death, 4.2% (n = 2) in severe harm, 18.8% (n = 9) in temporary harm, 20.8% (n = 10) in minimal harm, and 2.1% (n = 1) in no harm. The majority of root causes identified a need to improve care processes and policies, interdisciplinary communication, and care coordination. CONCLUSION: This analysis highlights an opportunity to implement system-wide changes to prevent similar events from reoccurring. These actions include comprehensive cancer clinics, usability testing of medical equipment, and standardization of processes and policies. Additional studies are necessary to assess oncologic adverse events across specialties.

Data-driven process to improve VA surgical flow.

Purpose During years 2014-2016, Veterans Health Administration National Surgery Office conducted a surgical flow improvement initiative (SFII) to assist low-performing surgery programs to improve their operating room efficiency (ORE). The initiative was co-sponsored by VHA National Surgery Office and VHA Office of Systems Redesign and Improvement. The paper aims to discuss this issue. Design/methodology/approach An SFII algorithm, based on first-time-start (FTS), cancellation rate (CR), lag time (LT) and OR utilization, assigned an ORE performance Level (1-low to 4-high) to each VA Medical Center (VAMC). In total, 15 VAMCs with low-performance surgery programs participated in SFII to assess the current state of their surgical flow processes and used redesign methods to focus on improvement objectives. Findings At the end of the project, 14 VSAs, 40 RPIWs, 45 "90-day projects" and 73 Just-Do-It's were completed with 65 percent (158/243) improvement actions and 86 percent sites improving/sustaining all four ORE metrics. There was a statistically significant difference in improvement across the three stages (baseline, improvement, sustain) for FTS (45.6-68.7 percent; F=44.74; p<0.000); CR (16.1-9.5 percent; F=34.46; p<0.000); LT (63.1-36.3 percent; F=92.00; p<0.000); OR utilization (43.4-57.7 percent; F=6.92; p<0.001) and VAMC level (1.7-3.65; F=80.11; p<0.000). The majority developed "fair to excellent" sustainment (91 percent) and spread (82 percent) plans. The projected annual estimated return-on-investment was $27,949,966. Originality/value The SFII successfully leveraged a small number of faculty, coaches, and industrial engineers to produce significant improvement in ORE across a large national integrated health care network. This strategy can serve healthcare leaders in managing complex healthcare issues in their facilities.

Complications and Failure to Rescue After Inpatient Noncardiac Surgery in the Veterans Affairs Health System.

Importance: The quality of surgical care in the Veterans Health Administration improved markedly in the 1990s after implementation of the Veterans Affairs (VA) National Surgical Quality Improvement Program (now called the VA Surgical Quality Improvement Program). Although there have been many recent evaluations of surgical care in the private sector, to date, a contemporary global evaluation has not been performed within the VA health system. Objective: To provide a contemporaneous report of noncardiac postoperative outcomes in the VA health system during the past 15 years. Design, Setting, and Participants: A retrospective cohort study was conducted using data from the VA Surgical Quality Improvement Program among veterans who underwent inpatient general, vascular, thoracic, genitourinary, neurosurgical, orthopedic, or spine surgery from October 1, 1999, through September 30, 2014. Main Outcomes and Measures: Rates of 30-day morbidity, mortality, and failure to rescue (FTR) over time. Results: Among 704 901 patients (mean [SD] age, 63.7 [11.8] years; 676 750 [96%] male) undergoing noncardiac surgical procedures at 143 hospitals, complications occurred in 97 836 patients (13.9%), major complications occurred in 66 816 (9.5%), FTR occurred in 12 648 of the 97 836 patients with complications (12.9%), FTR after major complications occurred in 12 223 of the 66 816 patients with major complications (18.3%), and 18 924 patients (2.7%) died within 30 days of surgery. There were significant decreases from 2000 to 2014 in morbidity (8202 of 59 421 [13.8%] vs 3368 of 32 785 [10.3%]), major complications (5832 of 59 421 [9.8%] vs 2284 of 32 785 [7%]), FTR (1445 of 8202 [17.6%] vs 351 of 3368 [10.4%]), and FTR after major complications (1388 of 5832 [23.8%] vs 343 of 2284 [15%]) (trend test, P < .001 for all). Although there were no clinically meaningful differences in rates of complications and major complications across hospital risk-adjusted mortality quintiles (any complications: lowest quintile, 20 945 of 147 721 [14.2%] vs highest quintile, 18 938 of 135 557 [14%]; major complications: lowest quintile, 14 044 of 147 721 [9.5%] vs highest quintile, 12 881 of 135 557 [9.5%]), FTR rates (any complications: lowest quintile, 2249 of 20 945 [10.7%] vs highest quintile, 2769 of 18 938 [14.6%]; major complications: lowest quintile, 2161 of 14 044 [15.4%] vs highest quintile, 2663 of 12 881 [20.7%]) were significantly higher with increasing quintile (P < .001). However, across hospital quintiles, there were significant decreases in morbidity (20.6%-29.9% decrease; trend test, P < .001 for all) and FTR (29.2%-50.6% decrease; trend test, P < .001 for all) during the study period. After hierarchical modeling, the odds of postoperative mortality, FTR, and FTR after a major complication were approximately 40% to 50% lower in the most recent study year compared with 15 years ago (P < .001 for all). Conclusions and Relevance: For the past 15 years, morbidity, mortality, and FTR have improved within the VA health system. Other integrated health systems providing a high volume of surgical care for their enrollees may benefit by critically evaluating the system-level approaches of the VA health system to surgical quality improvement.

The state of Veterans Affairs sleep medicine programs: 2012 inventory results.

PURPOSE: The Veterans Health Administration (VHA) represents one of the largest integrated health-care systems in the country. In 2012, the Veterans Affairs Sleep Network (VASN) sought to identify available sleep resources at VA medical centers (VAMCs) across the country through a national sleep inventory. METHODS: The sleep inventory was administered at the annual 2012 VA Sleep Practitioners meeting and by email to sleep contacts at each VAMC. National prosthetics contacts were used to identify personnel at VAMCs without established sleep programs. Follow-up emails and telephone calls were made through March 2013. RESULTS: One hundred eleven VA medical centers were included for analysis. Thirty-nine programs did not respond, and 10 were considered "satellites," referring all sleep services to a larger neighboring VAMC. Sleep programs were stratified based on extent of services offered (i.e., in-lab and home testing, sleep specialty clinics, cognitive behavioral therapy for insomnia (CBT-i)): 28 % were complex sleep programs (CSPs), 46 % were intermediate (ISPs), 9 % were standard (SSPs), and 17 % offered no formal sleep services. Overall, 138,175 clinic visits and 90,904 sleep testing encounters were provided in fiscal year 2011 by 112.1 physicians and clinical psychologists, 100.4 sleep technologists, and 115.3 respiratory therapists. More than half of all programs had home testing and CBT-i programs, and 26 % utilized sleep telehealth. CONCLUSIONS: The 2012 VA sleep inventory suggests considerable variability in sleep services within the VA. Demand for sleep services is high, with programs using home testing, sleep telehealth, and a growing number of mid-level providers to improve access to care.

Integration of Chiropractic Services in Military and Veteran Health Care Facilities: A Systematic Review of the Literature.

This literature review examined studies that described practice, utilization, and policy of chiropractic services within military and veteran health care environments. A systematic search of Medline, CINAHL, and Index to Chiropractic Literature was performed from inception through April 2015. Thirty articles met inclusion criteria. Studies reporting utilization and policy show that chiropractic services are successfully implemented in various military and veteran health care settings and that integration varies by facility. Doctors of chiropractic that are integrated within military and veteran health care facilities manage common neurological, musculoskeletal, and other conditions; severe injuries obtained in combat; complex cases; and cases that include psychosocial factors. Chiropractors collaboratively manage patients with other providers and focus on reducing morbidity for veterans and rehabilitating military service members to full duty status. Patient satisfaction with chiropractic services is high. Preliminary findings show that chiropractic management of common conditions shows significant improvement.

Classifying the Indication for Colonoscopy Procedures: A Comparison of NLP Approaches in a Diverse National Healthcare System.

In order to measure the level of utilization of colonoscopy procedures, identifying the primary indication for the procedure is required. Colonoscopies may be utilized not only for screening, but also for diagnostic or therapeutic purposes. To determine whether a colonoscopy was performed for screening, we created a natural language processing system to identify colonoscopy reports in the electronic medical record system and extract indications for the procedure. A rule-based model and three machine-learning models were created using 2,000 manually annotated clinical notes of patients cared for in the Department of Veterans Affairs. Performance of the models was measured and compared. Analysis of the models on a test set of 1,000 documents indicates that the rule-based system performance stays fairly constant as evaluated on training and testing sets. However, the machine learning model without feature selection showed significant decrease in performance. Therefore, rule-based classification system appears to be more robust than a machine-learning system in cases when no feature selection is performed.

Association between health literacy and medical care costs in an integrated healthcare system: a regional population based study.

BACKGROUND: Low health literacy is associated with higher health care utilization and costs; however, no large-scale studies have demonstrated this in the Veterans Health Administration (VHA). This research evaluated the association between veterans' health literacy and their subsequent VHA health care costs across a three-year period. METHODS: This retrospective study used a Generalized Linear Model to estimate the relative association between a patient's health literacy and VHA medical costs, adjusting for covariates. Secondary data sources included electronic health records and administrative data in the VHA (e.g., Medical and DCG SAS Datasets and DSS-National Data Extracts). Health literacy assessments and identifiers were electronically retrieved from the originating health system. Demographic and cost data were retrieved from the VHA centralized databases for the corresponding patients who had VHA use in all three years. RESULTS: In a study of 92,749 veterans with service utilization from 2007-2009, average per patient cost for those with inadequate and marginal health literacy was significantly higher ($31,581 [95 % CI: $30,186 - $32,975]; $23,508 [95 % CI: $22,749 - $24,268]) than adequate health literacy ($17,033 [95 % CI: $16,810 - $17,255]). Estimated three-year cost associated with veterans' with marginal and inadequate health literacy was $143 million dollars more than those with adequate health literacy. CONCLUSIONS: Analyses suggest when controlling for other person-level factors within the VHA integrated healthcare system, lower health literacy is a significant independent factor associated with increased health care utilization and costs. This study confirms the association of lower health literacy with higher medical service utilization and pharmacy costs for veterans enrolled in the VHA. Confirmation of higher costs of care associated with lower health literacy suggests that interventions might be designed to remediate health literacy needs and reduce expenditures. These analyses suggest 17.2 % (inadequate & marginal) of the Veterans in this population account for almost one-quarter (24 %) of VA medical and pharmacy cost for this 3-year period. Meeting the needs of those with marginal and inadequate health literacy could produce potential economic savings of approximately 8 % of total costs for this population.

Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System.

OBJECTIVES: To investigate the relationship between multimorbidity and healthcare utilisation patterns among the highest cost patients in a large, integrated healthcare system. DESIGN: In this retrospective cross-sectional study of all patients in the U.S. Veterans Affairs (VA) Health Care System, we aggregated costs of individuals' outpatient and inpatient care, pharmacy services and VA-sponsored contract care received in 2010. We assessed chronic condition prevalence, multimorbidity as measured by comorbidity count, and multisystem multimorbidity (number of body systems affected by chronic conditions) among the 5% highest cost patients. Using multivariate regression, we examined the association between multimorbidity and healthcare utilisation and costs, adjusting for age, sex, race/ethnicity, marital status, homelessness and health insurance status. SETTING: USA VA Health Care System. PARTICIPANTS: 5.2 million VA patients. MEASURES: Annual total costs; absolute and share of costs generated through outpatient, inpatient, pharmacy and VA-sponsored contract care; number of visits to primary, specialty and mental healthcare; number of emergency department visits and hospitalisations. RESULTS: The 5% highest cost patients (n=261,699) accounted for 47% of total VA costs. Approximately two-thirds of these patients had chronic conditions affecting ≥3 body systems. Patients with cancer and schizophrenia were less likely to have documented comorbid conditions than other high-cost patients. Multimorbidity was generally associated with greater outpatient and inpatient utilisation. However, increased multisystem multimorbidity was associated with a higher outpatient share of total costs (1.6 percentage points per affected body system, p<0.01) but a lower inpatient share of total costs (-0.6 percentage points per affected body system, p<0.01). CONCLUSIONS: Multisystem multimorbidity is common among high-cost VA patients. While some patients might benefit from disease-specific programmes, for most patients with multimorbidity there is a need for interventions that coordinate and maximise efficiency of outpatient services across multiple conditions.

Variability of antithrombotic dosing among veterans presenting with acute coronary syndrome.

BACKGROUND: Antithrombotic therapy for acute coronary syndrome (ACS) patients is recommended by clinical practice guidelines. Appropriate dosing of antithrombotic therapy is necessary to ensure effectiveness and safety and is an American College of Cardiology/American Heart Association ST elevated myocardial infarction/non-ST elevated myocardial infarction performance measure. This study describes the variability in dosing of unfractionated heparin (UH) and low-molecular-weight heparin (LMWH) in an integrated health care system with electronic medical records and computerized physician order entry (CPOE). METHODS AND RESULTS: This was a mixed-methods study of veterans presenting with ACS at 135 Veterans Health Administration hospitals from 2009 to 2011. Patients hospitalized with ACS and received antithrombotic therapy were included (n=36 682). The cohort was 98% male with an average age of 66 years and median body mass index (BMI) of 28.6. The average percentage of patients by hospital who received an above-recommended dose of either antithrombotic was 7.5% and ranged 0% to 32.0%. By individual therapy, the average percentage of patients by hospital who received an above-recommended dose of UH was 1.2% and LMWH was 12.9%. Risk-adjusted analyses demonstrated that older age and higher BMI were associated with lower risk for receiving a dose above recommended levels. Additionally, there was an association between antithrombotic ordered by a resident and higher risk of the patient receiving an above-recommended dose. Qualitative interviews supported the quantitative findings by highlighting the need to use current patient weight and the need to adequately train providers on the use of CPOE to improve antithrombotic dosing. CONCLUSION: This study found wide hospital variability in dosing of antithrombotics above the recommended level for patients treated for ACS.

Characteristics of Postgraduate Year 1 Pharmacy Residency Programs at Veterans Affairs Medical Centers.

PURPOSE: Although the characteristics of pharmacy postgraduate year 1 (PGY1) residency programs have been examined among large academic medical centers, there are no identified studies comparing the attributes of individual programs in the Veterans Affairs (VA) Health Administration System. The primary objective of this study was to describe and contrast characteristics of VA PGY1 residency programs. METHODS: This was a cross-sectional survey of VA pharmacy residency programs. An online survey was distributed electronically to residency program directors of VA PGY1 residencies. RESULTS: Responses from 33 (33%) PGY1 programs were available for the analysis. Programs reported growth over the previous 2 years and expected continued expansion. There was a wide variety of learning opportunities, although experiences were customizable based on residents' interests. Notably, many programs allowed residents to seek rotations at other locations if specific experiences were not available on-site. Additionally, most programs had a mandatory staffing component and required residents to present the results of residency research projects. CONCLUSION: There is a high degree of variability among individual VA facilities with regard to the requirements and opportunities available to PGY1 pharmacy residents. This assessment is able to characterize the currently established residency programs and allows for an active comparison of programs in a nationally integrated health care system.

Racial, Income, and Marital Status Disparities in Hospital Readmissions Within a Veterans-Integrated Health Care Network.

Hospital readmission is an important indicator of health care quality and currently used in determining hospital reimbursement rates by Centers for Medicare & Medicaid Services. Given the important policy implications, a better understanding of factors that influence readmission rates is needed. Racial disparities in readmission have been extensively studied, but income and marital status (a postdischarge care support indicator) disparities have received limited attention. By employing three Poisson regression models controlling for different confounders on 8,718 patients in a veterans-integrated health care network, this study assessed racial, income, and martial disparities in relation to total number of readmissions. In contrast to other studies, no racial and income disparities were found, but unmarried patients experienced significantly more readmissions: 16%, after controlling for the confounders. These findings render unique insight into health care policies aimed to improve race and income disparities, while challenging policy makers to reduce readmissions for those who lack family support.

Use of palliative care and hospice among surgical and medical specialties in the Veterans Health Administration.

IMPORTANCE: Many hospitals have undertaken initiatives to improve care during the end of life, recognizing that some individuals have unique needs that are often not met in acute inpatient care settings. Studies of surgical patients have shown this population to receive palliative care at reduced rates in comparison with medical patients. OBJECTIVE: To determine differences in the use of palliative care and hospice between surgical and medical patients in an integrated health care system. DESIGN, SETTING, AND PARTICIPANTS: Veterans Health Administration (VHA) enrollment data and administrative data sets were used to identify 191,280 VHA patients who died between October 1, 2008, and September 30, 2012, and who had an acute inpatient episode in the VHA system in the last year of life. Patients were categorized as surgical if at any time during the year preceding death they underwent a surgical procedure (n = 42,143) or medical (n = 149,137) if the patient did not receive surgical treatment in the last year of life. MAIN OUTCOMES AND MEASURES: Receipt of palliative or hospice care and the number of days from palliative or hospice initiation to death were determined using VHA administrative inpatient, outpatient, and fee-based encounter-level data files. RESULTS: Surgical patients were significantly less likely than medical patients to receive either hospice or palliative care (odds ratio = 0.91; 95% CI, 0.89-0.94; P < .001). When adjusting for demographics and medical comorbidities, this difference was even more pronounced (odds ratio = 0.84; 95% CI, 0.81-0.86). Yet, among patients who received hospice or palliative care, surgical patients lived significantly longer than their medical counterparts (a median of 26 vs 23 days, respectively; P < .001) yet had similar relative use of these services after risk adjustment. CONCLUSIONS AND RELEVANCE: In the VHA population, surgical patients are less likely to receive either hospice or palliative care in the year prior to death compared with medical patients, yet surgical patients have a longer length of time in these services. Determining criteria for higher-risk medical and surgical patients may help with increasing the relative use of these services. Potential barriers and differences may exist among surgical and medical services that could impact the use of palliative care or hospice in the last year of life.

Impact of an intensive care unit telemedicine program on patient outcomes in an integrated health care system.

IMPORTANCE: Intensive care unit (ICU) telemedicine (TM) programs have been promoted as improving access to intensive care specialists and ultimately improving patient outcomes, but data on effectiveness are limited and conflicting. OBJECTIVE: To examine the impact of ICU TM on mortality rates and length of stay (LOS) in an integrated health care system. DESIGN, SETTING, AND PARTICIPANTS: Observational pre-post study of patients treated in 8 "intervention" ICUs (7 hospitals within the US Department of Veterans Affairs health care system) during 2011-2012 that implemented TM monitoring during the post-TM period as well as patients treated in concurrent control ICUs that did not implement an ICU TM program. INTERVENTION: Implementation of ICU TM monitoring. MAIN OUTCOMES AND MEASURES: Unadjusted and risk-adjusted ICU, in-hospital, and 30-day mortality rates and ICU and hospital LOS for patients who did or did not receive treatment in ICUs equipped with TM monitoring. RESULTS: Our study included 3355 patients treated in our intervention ICUs (1708 in the pre-TM period and 1647 in the post-TM period) and 3584 treated in the control ICUs during the same period. Patient demographics and comorbid illnesses were similar in the intervention and control ICUs during the pre-TM and post-TM periods; however, predicted ICU mortality rates were modestly lower for admissions to the intervention ICUs compared with control ICUs in both the pre-TM (3.0% vs 3.6%; P = .02) and post-TM (2.8% vs 3.5%; P < .001) periods. Implementation of ICU TM was not associated with a significant decline in ICU, in-hospital, or 30-day mortality rates or LOS in unadjusted or adjusted analyses. For example, unadjusted ICU mortality in the pre-TM vs post-TM periods were 2.9% vs 2.8% (P = .89) for the intervention ICUs and 4.0% vs 3.4% (P = .31) for the control ICUs. Unadjusted 30-day mortality during the pre-TM vs post-TM periods were 7.7% vs 7.8% (P = .91) for the intervention ICUs and 12.0% vs 10.2% (P = .08) for the control ICUs. Evaluation of interaction terms comparing the magnitude of mortality rate change during the pre-TM and post-TM periods in the intervention and control ICUs failed to demonstrate a significant reduction in mortality rates or LOS. CONCLUSIONS AND RELEVANCE: We found no evidence that the implementation of ICU TM significantly reduced mortality rates or LOS.

Quality of colorectal cancer care among veterans: a 10-year retrospective cohort.

BACKGROUND: Nearly 5,000 patients within Veterans Health Administration (VHA) are diagnosed with colorectal cancer (CRC) annually. However, the link between performance on CRC practice guidelines and outcomes is unclear. The purpose of this study was to evaluate quality of CRC care by assessing adherence to National Comprehensive Cancer Network (NCCN) guidelines and to determine if receipt of these metrics was associated with improvement in mortality. METHODS: We performed a retrospective cohort study of all patients who underwent resection for nonmetastatic CRC at VHA Tennessee Valley Healthcare System from 2001 to 2010. We defined "excellent" care as receipt of at least 75 % of eligible NCCN metrics. We also examined time to treatment and the relationship between excellent care and mortality. RESULTS: A total of 331 patients underwent resection for CRC within the study period. Only 47 % of patients received excellent care, and 9 % received 100 % of eligible metrics. The median time from diagnosis to definitive treatment was 22 days [interquartile range (IQR) 12, 41] and 37 days (IQR 24, 56) among colon and rectal cancer patients, respectively. The likelihood of receiving excellent care increased significantly over time. However, there was no association between receipt of excellent care and 5-year all-cause mortality [hazard ratio (HR) 0.85; 95 % CI 0.53-1.36]. CONCLUSIONS: Although patients received timely care overall, fewer than half of CRC patients received at least 75 % of eligible NCCN metrics. Although receipt of excellent care was not associated with reduction in all-cause mortality, further research is necessary to identify quality metrics likely to influence patient outcomes.