Administration's Share of Personnel in Veterans Health Administration and Private Sector Care.

Importance: Health care administrative overhead is greater in the US than some other nations but has not been assessed in the Veterans Health Administration (VHA). Objective: To compare administrative staffing patterns in the VHA and private (non-VHA) sectors. Design, Setting, and Participants: This cross-sectional study was conducted using US employment data from 2019, prior to pandemic-related disruptions in health care staffing, and was carried out between January 14 and August 10, 2023. A nationally representative sample of federal and nonfederal personnel in hospitals and ambulatory care settings from the American Community Survey (ACS), all employees reported in VHA personnel records, and personnel in health insurance carriers and brokers tabulated by the Bureau of Labor Statistics (BLS) were analyzed. Exposure: VHA vs private sector health care employment, including 397 occupations grouped into 18 categories. Main Outcome and Measure: The proportion of staff working in administrative occupations. Results: Among 3 239 553 persons surveyed in the ACS, 122 315 individuals (weighted population, 12 501 185 individuals) were civilians working in hospitals or ambulatory care; of the weighted population, 12 156 988 individuals (mean age, 42.6 years [95% CI, 42.5-42.7 years]; 76.2% [95% CI, 75.9%-76.5%] females) were private sector personnel and 344 197 individuals (mean age, 46.2 years [95% CI, 45.7-46.7 years]; 63.8% [95% CI, 61.8%-65.8%] females) were federal employees. In clinical settings, administrative occupations accounted for 23.4% (95% CI, 23.1%-23.8%) of private sector vs 19.8% (95% CI, 18.1%-21.4%) of VHA personnel. After including 1 000 800 employees at private sector health insurers and brokers and 13 956 VHA Central Office personnel with administrative occupations, administration accounted for 3 851 374 of 13 157 788 private sector employees (29.3%) vs 77 500 of 343 721 VHA employees (22.5%). Physicians represented approximately 7% of personnel in the VHA (7.2% [95% CI, 6.1%-8.2%]) and private sector (6.5% [95% CI, 6.3%-6.7%]), while the VHA deployed more registered nurses (23.7% [95% CI, 21.6%-25.8%] vs 21.2% [95% CI, 20.9%-21.5%]) and social service personnel (6.3% [95% CI, 5.4%-7.1%] vs 4.9% [95% CI, 4.7%-5.0%]) than the private sector. Conclusions and Relevance: In this study, administrative occupations accounted for a smaller share of personnel in the VHA compared with private sector care, a difference possibly attributable to the VHA's simpler financing system. These findings suggest that if staffing patterns in the private sector mirrored those of the VHA, nearly 900 000 fewer administrative staff might be needed.

Primary Care's Effects on Costs in the US Veterans Health Administration, 2016-2019: an Observational Cohort Study.

BACKGROUND: Enhancing primary care is a promising strategy for improving the efficiency of health care. Previous studies of primary care's effects on health expenditures have mostly relied on ecological analyses comparing region-wide expenditures rather than spending for individual patients. OBJECTIVE: To compare overall medical expenditures for individual patients enrolled vs. those not enrolled in primary care in the Veterans Health Administration (VHA). DESIGN: Cohort study with stratification for clinical risk and multivariable linear regression models adjusted for clinical and demographic confounders of expenditures. PARTICIPANTS: In total, 6,009,973 VHA patients in fiscal year (FY) 2019-5,410,034 enrolled with a primary care provider (PCP) and 599,939 without a PCP-and similar numbers in FYs 2016-2018. MAIN MEASURES: Total annual cost per patient to the VHA (including VHA payments to non-VHA providers) stratified by a composite health risk score previously shown to predict VHA expenditures, and multivariate models additionally adjusted for VHA regional differences, patients' demographic characteristics, non-VHA insurance coverage, and driving time to the nearest VHA facility. Sensitivity analyses explored different modeling strategies and risk adjusters, as well as the inclusion of expenditures by the Medicare program that covers virtually all elderly VHA patients for care not paid for by the VHA. KEY RESULTS: Within each health-risk decile, non-PCP patients had higher outpatient, inpatient, and total costs than those with a PCP. After adjustment for health risk and other factors, lack of a PCP was associated 27.4% higher VHA expenditures, $3274 per patient annually (p < .0001). Sensitivity analyses using different risk adjusters and including Medicare's spending for VHA patients yielded similar results. CONCLUSIONS: In the VHA system, primary care is associated with substantial cost savings. Investments in primary care in other settings might also be cost-effective.

Primary care collaborative practice in quality improvement: Description of an interprofessional curriculum.

PURPOSE: An innovative quality improvement (QI)-focused interprofessional training curriculum for pharmacy residents and other healthcare trainees is described. SUMMARY: Effective interprofessional collaboration and the ability to carry out QI initiatives are important skills for all healthcare trainees to develop when they are in training. To cultivate those skills, in 2011 a Veterans Affairs medical center in Idaho implemented a unique yearlong interprofessional curriculum for healthcare trainees, including postgraduate year 1 (PGY1) and postgraduate year 2 (PGY2) pharmacy residents, physician trainees in internal medicine, nurses, and psychologists. The curriculum has both didactic and experiential components. After attending a series of 1-hour workshops early in the academic year, trainees are assigned to interprofessional teams and work for the remainder of the year to complete QI projects. Over 100 trainees have participated in the interprofessional QI curriculum, with the majority of trainee projects based in the primary care setting. Pharmacy residents were involved in 62% of the projects completed in the 6 academic years ending with the 2016-17 year. CONCLUSION: Establishing an interprofessional QI curriculum allowed pharmacy residents in PGY1 and PGY2 programs to collaborate with other members of the healthcare team. Benefits include QI skills development, a greater understanding of QI initiatives at the institution, stronger relationships with other healthcare trainees and mentors, and improvements to patient care and safety and facility performance.

Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured.

OBJECTIVES: We sought to determine the association between Medicaid coverage and the receipt of appropriate clinical care. METHODS: Using the 1999 to 2012 National Health and Nutritional Examination Surveys, we identified adults aged 18 to 64 years with incomes below the federal poverty level, and compared outpatient visit frequency, awareness, and control of chronic diseases between the uninsured (n = 2975) and those who had Medicaid (n = 1485). RESULTS: Respondents with Medicaid were more likely than the uninsured to have at least 1 outpatient physician visit annually, after we controlled for patient characteristics (odds ratio [OR] = 5.0; 95% confidence interval [CI] = 3.8, 6.6). Among poor persons with evidence of hypertension, Medicaid coverage was associated with greater awareness (OR = 1.83; 95% CI = 1.26, 2.66) and control (OR = 1.69; 95% CI = 1.32, 2.27) of their condition. Medicaid coverage was also associated with awareness of being overweight (OR = 1.30; 95% CI = 1.02, 1.67), but not with awareness or control of diabetes or hypercholesterolemia. CONCLUSIONS: Among poor adults nationally, Medicaid coverage appears to facilitate outpatient physician care and to improve blood pressure control.

Instituting systems-based practice and practice-based learning and improvement: a curriculum of inquiry.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires that training programs integrate system-based practice (SBP) and practice-based learning and improvement (PBLI) into internal medicine residency curricula. CONTEXT AND SETTING: We instituted a seminar series and year-long-mentored curriculum designed to engage internal medicine residents in these competencies. METHODS: Residents participate in a seminar series that includes assigned reading and structured discussion with faculty who assist in the development of quality improvement or research projects. Residents pursue projects over the remainder of the year. Monthly works in progress meetings, protected time for inquiry, and continued faculty mentorship guide the residents in their project development. Trainees present their work at hospital-wide grand rounds at the end of the academic year. We performed a survey of residents to assess their self-reported knowledge, attitudes and skills in SBP and PBLI. In addition, blinded faculty scored projects for appropriateness, impact, and feasibility. OUTCOMES: We measured resident self-reported knowledge, attitudes, and skills at the end of the academic year. We found evidence that participants improved their understanding of the context in which they were practicing, and that their ability to engage in quality improvement projects increased. Blinded faculty reviewers favorably ranked the projects' feasibility, impact, and appropriateness. The 'Curriculum of Inquiry' generated 11 quality improvement and research projects during the study period. Barriers to the ongoing work include a limited supply of mentors and delays due to Institutional Review Board approval. Hospital leadership recognizes the importance of the curriculum, and our accreditation manager now cites our ongoing work. CONCLUSIONS: A structured residency-based curriculum facilitates resident demonstration of SBP and practice-based learning and improvement. Residents gain knowledge and skills though this enterprise and hospitals gain access to trainees who help to solve ongoing problems and meet accreditation requirements.

Undiagnosed and uncontrolled hypertension and hyperlipidemia among immigrants in the US.

Cardiovascular disease is a major cause of mortality and disability. We analyzed the National Health and Nutrition Examination Survey (1998-2008). We used logistic regression analysis to compare the odds of having undiagnosed and uncontrolled hypertension and hyperlipidemia among FB and US born adults sequentially adjusting for (1) age and gender, (2) income and education, and (3) insurance status. Among FB individuals, we identified factors independently associated with having each outcome using logistic regression analyses. Of 27,596 US adults, 22.6 % were foreign-born. In age- and -gender adjusted analyses, FB were more likely to have undiagnosed hypertension (OR 1.35, 95 % CI 1.13-1.63, p < 0.001), uncontrolled hypertension (OR 1.37, 95 % CI 1.15-1.64, p < 0.001), and uncontrolled hyperlipidemia (OR 1.35, 95 % CI 1.11-1.63, p = 0.002), while undiagnosed hyperlipidemia approached significance (OR 1.24, 95 % CI 0.99-1.56, p = 0.057). Having insurance was associated with a 5-15 % decrease in FB-US born disparities. Immigrants are at increased risk of undiagnosed and uncontrolled hypertension and hyperlipidemia.

The effect of rural training experiences during residency on the selection of primary care careers: a retrospective cohort study from a single large internal medicine residency program.

BACKGROUND: Little is known about the factors during internal medicine residency that influence career choice. PURPOSE: To determine if rural training experiences were associated with primary care career choice. METHODS: We conducted a retrospective cohort study at a single, large, internal medicine residency program. We reviewed self-reported career plan at the time of graduation. Independent variables obtained from curricular data included track (categorical or primary care), gender, year of graduation, timing of clinic block, and having had a rural training experience. We studied 451 program graduates who completed all three years of training between the years 1996 and 2006. RESULTS: Factors associated with an intended primary care career at the time of graduation were: primary care track (OR 4.5, 95% CI 2.4-8.6) and a rural training experience (OR 2.1, 95% CI 1.3-3.4). CONCLUSIONS: These data suggest that provision of more rural training experiences might increase interest in primary care careers.

Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006.

OBJECTIVES: This study assessed whether sociodemographic differences exist in triage assignment and whether these differences affect initial diagnostic testing in the emergency department (ED) for patients presenting with chest pain. METHODS: A nationally representative ED data sample for all adults (>or=18 years) was obtained from the National Hospital Ambulatory Health Care Survey of EDs for 1997-2006. Weighted logistic regression was used to examine the associations between race and presenting symptom, triage assignment, and test ordering, adjusting for patient and hospital characteristics. RESULTS: Over 10 years, an estimated 78 million visits to the ED presented with a complaint of chest pain. Of those presenting with chest pain, African Americans (odds ratio [OR] = 0.70; 99% confidence interval [CI] = 0.53 to 0.92), Hispanics (OR = 0.74; 99% CI = 0.51 to 0.99), Medicaid patients (OR = 0.72; 99% CI = 0.54 to 0.94), and uninsured patients (OR = 0.65; 99% CI = 0.51 to 0.84) were less likely to be triaged emergently. African Americans (OR = 0.86; 99% CI = 0.70 to 0.99), Medicaid patients (OR = 0.70; 99% CI = 0.55 to 0.88), and uninsured patients (OR = 0.70; 99% CI = 0.55 to 0.89) were less likely to have an electrocardiogram (ECG) ordered. African Americans (OR = 0.69; 99% CI = 0.49 to 0.97), Medicaid patients (OR = 0.67; 99% CI = 0.47 to 0.95), and uninsured patients (OR = 0.66; 99% CI = 0.44 to 0.96) were less likely to have cardiac enzymes ordered. Similarly, African Americans and Hispanics were less likely to have a cardiac monitor and pulse oximetry ordered, and Medicaid and uninsured patients were less likely to have a cardiac monitor ordered. CONCLUSIONS: Persistent racial, sex, and insurance differences in triage categorization and basic cardiac testing exist. Eliminating triage disparities may affect "downstream" clinical care and help eliminate observed disparities in cardiac outcomes.

Impact of insurance status on migraine care in the United States: a population-based study.

OBJECTIVE: To determine whether insurance status is associated with differential outpatient treatment of migraine in the United States. METHODS: We analyzed 11 years of data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1997-2007), which survey patient visits to doctors' offices, hospital outpatient departments, and emergency departments (EDs) in the United States. We used logistic regression to determine whether insurance status was associated with the prescription of standard migraine therapy, defined as 1) a triptan or dihydroergotamine and 2) a prophylactic agent. RESULTS: We identified 6,814 individual patient visits for migraine, representing 68.6 million visits nationally. After controlling for age, gender, race/ethnicity, geographic location, and year, migraineurs with no insurance or Medicaid were less likely than the privately insured to receive abortive therapy (odds ratio [OR] for failure to receive medication 2.0 [95% confidence interval (CI) 1.3, 3.0] and 1.6 [95% CI 1.1, 2.3]) and prophylactic therapy (OR 2.0 [95% CI 1.3, 2.9] and 1.5 [95% CI 1.0, 2.1]). Adding site of care to the regression model suggested that one mechanism for this discrepancy was the reliance of the uninsured on EDs for migraine care, a site where standard migraine care is often omitted (OR for failure to receive abortive and prophylactic medication in the ED relative to physicians' offices 4.8 [95% CI 3.6, 6.3] and 8.7 [95% CI 6.4, 11.7]). CONCLUSIONS: The uninsured, and those with Medicaid, receive substandard therapy for migraine, at least in part because they receive more care in emergency departments and less in physicians' offices.

Hypertension, diabetes, and elevated cholesterol among insured and uninsured U.S. adults.

In this paper we explore whether uninsured Americans with three chronic conditions were less likely than the insured to be aware of their illness or to have it controlled. Among those with diabetes and elevated cholesterol, the uninsured were more often undiagnosed. Among hypertensives and people with elevated cholesterol, the uninsured more often had uncontrolled conditions. Undiagnosed and uncontrolled chronic illness, which is common among insured people, is even more frequent among the uninsured.

Health insurance and mortality in US adults.

OBJECTIVES: A 1993 study found a 25% higher risk of death among uninsured compared with privately insured adults. We analyzed the relationship between uninsurance and death with more recent data. METHODS: We conducted a survival analysis with data from the Third National Health and Nutrition Examination Survey. We analyzed participants aged 17 to 64 years to determine whether uninsurance at the time of interview predicted death. RESULTS: Among all participants, 3.1% (95% confidence interval [CI]=2.5%, 3.7%) died. The hazard ratio for mortality among the uninsured compared with the insured, with adjustment for age and gender only, was 1.80 (95% CI=1.44, 2.26). After additional adjustment for race/ethnicity, income, education, self- and physician-rated health status, body mass index, leisure exercise, smoking, and regular alcohol use, the uninsured were more likely to die (hazard ratio=1.40; 95% CI=1.06, 1.84) than those with insurance. CONCLUSIONS: Uninsurance is associated with mortality. The strength of that association appears similar to that from a study that evaluated data from the mid-1980s, despite changes in medical therapeutics and the demography of the uninsured since that time.

Increasing length of stay among adult visits to U.S. Emergency departments, 2001-2005.

BACKGROUND: Emergency departments (EDs) are traditionally designed to provide rapid evaluation and stabilization and are neither staffed nor equipped to provide prolonged care. Longer ED length of stay (LOS) may compromise quality of care and contribute to delays in the emergency evaluation of other patients. OBJECTIVES: The objective was to determine whether ED LOS increased between 2001 and 2005 and whether trends varied by patient and hospital factors. METHODS: This was a retrospective analysis of a nationally representative sample of 138,569 adult ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2001 to 2005. ED LOS was measured from registration to discharge. RESULTS: Median ED LOS increased 3.5% per year from 132 minutes in 2001 to 154 minutes in 2005 (p-value for trend < 0.001). There was a larger increase among critically ill patients for whom ED LOS increased 7.0% annually from 185 minutes in 2001 to 254 minutes in 2005 (p-value for trend < 0.01). ED LOS was persistently longer for black/African American, non-Hispanic patients (10.6% longer) and Hispanic patients (13.9% longer) than for non-Hispanic white patients, and these differences did not diminish over time. Among factors potentially associated with increasing ED LOS, a large increase was found (60.1%, p-value for trend < 0.001) in the use of advanced diagnostic imaging (computed tomography [CT], magnetic resonance imaging [MR], and ultrasound [US]) and in the proportion of ED visits at which five or more diagnostic or screening tests were ordered (17.6% increase, p-value for trend = 0.001). The proportion of uninsured patients was stable throughout the study period, and EDs with predominately privately insured patients experienced significant increases in ED LOS (4.0% per year from 2001 to 2005, p-value for trend < 0.01). CONCLUSIONS: Emergency department LOS in the United States is increasing, especially for critically ill patients for whom time-sensitive interventions are most important. The disparity of longer ED LOS for African Americans and Hispanics is not improving.

The health and health care of US prisoners: results of a nationwide survey.

OBJECTIVES: We analyzed the prevalence of chronic illnesses, including mental illness, and access to health care among US inmates. METHODS: We used the 2002 Survey of Inmates in Local Jails and the 2004 Survey of Inmates in State and Federal Correctional Facilities to analyze disease prevalence and clinical measures of access to health care for inmates. RESULTS: Among inmates in federal prisons, state prisons, and local jails, 38.5% (SE = 2.2%), 42.8% (SE = 1.1%), and 38.7% (SE = 0.7%), respectively, suffered a chronic medical condition. Among inmates with a mental condition ever treated with a psychiatric medication, only 25.5% (SE = 7.5%) of federal, 29.6% (SE = 2.8%) of state, and 38.5% (SE = 1.5%) of local jail inmates were taking a psychiatric medication at the time of arrest, whereas 69.1% (SE = 4.8%), 68.6% (SE = 1.9%), and 45.5% (SE = 1.6%) were on a psychiatric medication after admission. CONCLUSIONS: Many inmates with a serious chronic physical illness fail to receive care while incarcerated. Among inmates with mental illness, most were off their treatments at the time of arrest. Improvements are needed both in correctional health care and in community mental health services that might prevent crime and incarceration.

A national study of chronic disease prevalence and access to care in uninsured U.S. adults.

BACKGROUND: No recent national studies have assessed chronic illness prevalence or access to care among persons without insurance in the United States. OBJECTIVE: To compare reports of chronic conditions and access to care among U.S. adults, by self-reported insurance status. DESIGN: Population-based survey. SETTING: National Health and Nutritional Examination Survey (1999-2004). PARTICIPANTS: 12,486 patients age 18 to 64 years. MEASUREMENTS: Estimates of national rates of cardiovascular disease, hypertension, diabetes, hypercholesterolemia, active asthma or chronic obstructive pulmonary disease, previous cancer, and measures of access to care. RESULTS: On the basis of National Health and Nutrition Examination Survey (1999-2004) responses, an estimated 11.4 million (95% CI, 9.8 million to 13.0 million) working-age Americans with chronic conditions were uninsured, including 16.1% (CI, 12.6% to 19.6%) of the 7.8 million with cardiovascular disease, 15.5% (CI, 13.4% to 17.6%) of the 38.2 million with hypertension, and 16.6% (CI, 13.2% to 20.0%) of the 8.5 million with diabetes. After the authors controlled for age, sex, and race or ethnicity, chronically ill patients without insurance were more likely than those with coverage to have not visited a health professional (22.6% vs. 6.2%) and to not have a standard site for care (26.1% vs. 6.2%) but more likely to identify their standard site for care as an emergency department (7.1% vs. 1.1%) (P <0.001 for all comparisons). LIMITATION: The study was cross-sectional and used self-reported insurance and disease status. CONCLUSION: Millions of U.S. working-age adults with chronic conditions do not have insurance and have poorer access to medical care than their insured counterparts.

Waits to see an emergency department physician: U.S. trends and predictors, 1997-2004.

As emergency department (ED) patient volumes increase throughout the United States, are patients waiting longer to see an ED physician? We evaluated the change in wait time to see an ED physician from 1997 to 2004 for all adult ED patients, patients diagnosed with acute myocardial infarction (AMI), and patients whom triage personnel designated as needing "emergent" attention. Increases in wait times of 4.1 percent per year occurred for all patients but were especially pronounced for patients with AMI, for whom waits increased 11.2 percent per year. Blacks, Hispanics, women, and patients seen in urban EDs waited longer than other patients did.