Health Care for Our Nation's Veterans: A Policy Paper From the American College of Physicians.

The Veterans Health Administration (VHA) is the United States' largest integrated health care delivery system, serving over 9 million enrollees at nearly 1300 health care facilities. In addition to providing health care to the nation's military veterans, the VHA has a research and development program, trains thousands of medical residents and other health care professionals, and conducts emergency preparedness and response activities. The VHA has been celebrated for delivering high-quality care to veterans, early adoption of electronic medical records, and high patient satisfaction. However, the system faces challenges, including implementation of an expanded community care program, modernization of its electronic medical records system, and providing care to a population with complex needs. The position paper offers policy recommendations on VHA funding, the community care program, medical and health care professions training, and research and development.

Hospital Factors, Performance on Process Measures After Transient Ischemic Attack, and 90-Day Ischemic Stroke Incidence.

Background and Purpose: We determined the association between hospital factors, performance on transient ischemic attack (TIA) process measures, and 90-day ischemic stroke incidence. Methods: Longitudinal analysis of retrospectively obtained data on 9168 veterans ≥18 years with TIA presenting to the emergency department or inpatient unit at 69 Veterans Affairs hospitals with ≥10 eligible patients per year in fiscal years 2015 to 2018. Process measures were high/moderate potency statin within 7 days of discharge, antithrombotic by day 2, and hypertension control (<140/90 mm Hg) at 90 days. The outcome was 90-day stroke incidence. Results: During the 4-year study period, hospitals significantly increased statin use (adjusted odds ratio [aOR] per 1-year increase, 1.24 [95% CI, 1.17­1.32]; P<0.001), whereas neither hypertension control (P=0.44) nor antithrombotic use (P=0.82) improved over time. Hospitals that admitted a higher proportion of TIA patients versus emergency department discharge had significantly greater use of statins (aOR per 10-percentage point increase in the proportion of TIA patients admitted, 1.09 [1.03­1.16]; P=0.003) and antithrombotics (aOR per 10-percentage point increase in TIA patients admitted, 1.14 [1.06­1.23]; P<0.001). Hospitals with higher emergency physician staffing and lower TIA patient volume had greater use of antithrombotics (aOR per 1 full-time physician increase, 1.05 [1.01­1.08]; P=0.008 and aOR per 10-patient decrease in volume, 1.09 [1.01­1.16]; P=0.02). Higher emergency physician staffing was associated with lower 90-day stroke incidence (aOR per 1 full-time physician increase, 0.96 [0.92­0.99]; P=0.02) but other hospital factors were not. Conclusions: Hospitals admitting higher percentages of TIA patients and having higher emergency physician staffing have greater performance on select guideline-concordant process measures for TIA. Higher emergency physician staffing was associated with improved outcomes 90 days after TIA.

The Influence of the Availability Heuristic on Physicians in the Emergency Department.

STUDY OBJECTIVE: Heuristics, or rules of thumb, are hypothesized to influence the care physicians deliver. One such heuristic is the availability heuristic, under which assessments of an event's likelihood are affected by how easily the event comes to mind. We examined whether the availability heuristic influences physician testing in a common, high-risk clinical scenario: assessing patients with shortness of breath for the risk of pulmonary embolism. METHODS: We performed an event study from 2011 to 2018 of emergency physicians caring for patients presenting with shortness of breath to 104 Veterans Affairs (VA) hospitals. Our measures were physician rates of pulmonary embolism testing (D-dimer and/or computed tomography scan) for subsequent patients after having a patient visit with a pulmonary embolism discharge diagnosis, hypothesizing that physician rates of pulmonary embolism testing would increase after having a recent patient visit with a pulmonary embolism diagnosis due to the availability heuristic. RESULTS: The sample included 7,370 emergency physicians who had 416,720 patient visits for shortness of breath. The mean rate of pulmonary embolism testing was 9.0%. For physicians who had a recent patient visit with a pulmonary embolism diagnosis, their rate of pulmonary embolism testing for subsequent patients increased by 1.4 percentage points (95% confidence interval 0.42 to 2.34) in the 10 days after, which is approximately 15% relative to the mean rate of pulmonary embolism testing. We failed to find statistically significant changes in rates of pulmonary embolism testing in the subsequent 50 days following these first 10 days. CONCLUSION: After having a recent patient visit with a pulmonary embolism diagnosis, physicians increase their rates of pulmonary embolism testing for subsequent patients, but this increase does not persist. These results provide large-scale evidence that the availability heuristic may play a role in complex testing decisions.

Simplifying Measurement of Adenoma Detection Rates for Colonoscopy.

BACKGROUND: Adenoma detection rate (ADR) is the colonoscopy quality metric with the strongest association to interval or "missed" cancer. Accurate measurement of ADR can be laborious and costly. AIMS: Our aim was to determine if administrative procedure codes for colonoscopy and text searches of pathology results for adenoma mentions could estimate ADR. METHODS: We identified US Veterans with a colonoscopy using Current Procedure Terminology (CPT) codes between January 2013 and December 2016 at ten Veterans Affairs sites. We applied simple text searches using Microsoft SQL Server full-text searches to query all pathology notes for "adenoma(s)" or "adenomatous" text mentions to calculate ADRs. To validate our identification of colonoscopy procedures, endoscopists of record, and adenoma detection from the electronic health record, we manually reviewed a random sample of 2000 procedure and pathology notes from the 10 sites. RESULTS: Structured data fields were accurate in identification of colonoscopies being performed (PPV = 0.99; 95% CI 0.99-1.00) and identifying the endoscopist of record (PPV of 0.95; 95% CI 0.94-0.96) for ADR measurement. Simple text searches of pathology notes for adenoma mentions had excellent performance statistics as follows: sensitivity 0.99 (95% CI 0.98-1.00), specificity 0.93 (95% CI 0.92-0.95), NPV 0.99 (95% CI 0.98-1.00), and PPV 0.93 (0.91-0.94) for measurement of ADR. There was no clinically significant difference in the estimates of overall ADR vs. screening ADR (p > 0.05). CONCLUSIONS: Measuring ADR using administrative codes and text searches from pathology results is an efficient method to broadly survey colonoscopy quality.

External Correlates of the MMPI-2-Restructured Form across a National Sample of Veterans.

This study examines the convergent validity of the substantive scales of the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) in the Veteran Affairs (VA) population. The sample includes test protocols drawn from all administrations of the MMPI-2-RF or MMPI-2 entered into the electronic medical record system between January 1, 2008 and May 31, 2015 at any VA across the United States. After excluding invalid protocols, substantive scale scores were correlated with external measures of depression, anxiety, and posttraumatic stress disorder if they were administered within |14| days of the MMPI-2/-RF. Results supported the convergent validity of the MMPI-2-RF emotional dysfunction domain scores. Discriminant validity for the remaining MMPI-2-RF substantive scale scores was also adequate. Limitations and implications of these findings are discussed.

Validity testing in veterans with epileptic seizures and psychogenic nonepileptic seizures.

OBJECTIVE: Identification of clinically meaningful subgroups among patients with psychogenic nonepileptic seizures (PNES) or epileptic seizures (ES) is of potential value for assessing prognosis and predicting therapeutic response. Invalid performance on validity tests has been associated with noncredible complaints and worse cognitive test scores, and may be one such classification criteria. We studied invalid performance in Veterans with PNES or ES, and the association of invalid performance with cognitive test scores and subjective complaints. METHODS: Patients were consecutive admissions to three veterans affairs (VA) epilepsy monitoring units. Evaluations included two validity tests: the Test of Memory Malingering (TOMM); and the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) over-reporting validity scales. We compared the frequency of invalid performance on the TOMM or MMPI-2-RF in patients diagnosed with PNES vs. ES. We evaluated the association of invalid performance with scores on the Repeatable Battery for Assessment of Neuropsychological Status (RBANS), and four subjective symptom measures including the Beck Depression Inventory-II, and Quality of Life in Epilepsy-31. RESULTS: Invalid TOMM performance was found in 25.3% of Veterans diagnosed with PNES and 10.8% of those with ES (p = .03). Invalid reporting on the MMPI-2-RF was found in 35.9% of the PNES group vs. 15.3% of the ES group (p = .01). Effects of valid vs. invalid reporting on external measures were similar for ES and PNES groups. Patients with invalid vs. valid TOMM performance had lower scores on the RBANS (p < .001). Patients with invalid performance had greater complaints on all subjective measures, with largest effect sizes for the MMPI-2-RF validity scales (p < .001). SIGNIFICANCE: In Veterans admitted for evaluation of poorly controlled seizures, invalid performance on validity tests was not uncommon. Cognitive test results and subjective reports from patients with invalid performance may not be credible. These observations have implications for the analysis of clinical trials, where primary and secondary outcomes often rely on self-report measures.

Measuring the Quality of Palliative Care for Patients with End-Stage Liver Disease.

BACKGROUND/AIMS: We examined the quality of palliative care received by patients with decompensated cirrhosis using an explicit set of palliative care quality indicators (QIs) for patients with end-stage liver disease (PC-ESLD). METHODS: We identified patients newly diagnosed with decompensated cirrhosis at a single veterans health center and followed up them for 2 years or until death. We piloted measurement of PC-ESLD QIs in all patients confirmed to have ESLD using a chart abstraction tool. RESULTS: Out of 167 patients identified using at least one sampling strategy, 62 were confirmed to meet ESLD criteria with chart abstraction. Ninety-eight percent of veterans in the cohort were male, mean age at diagnosis was 61 years, and 74% were White. The overall QI pass rate was 68% (64% for information care planning QIs and 76% for supportive care QIs). Patients receiving specialty palliative care consultation were more likely to receive information care planning QIs (67% vs. 37%, p = 0.02). The best performing sampling strategy had a sensitivity of 62% and specificity of 60%. CONCLUSION: Measuring the quality of palliative care for patients with ESLD is feasible in the veteran population. Our single-center data suggest that the quality of palliative care is inadequate in the veteran population with ESLD, though patients offered specialty palliative care consultation and those affected by homelessness, drug, and alcohol abuse may receive better care. Our combination of ICD-9 codes can be used to identify a cohort of patients with ESLD, though better sensitivity and specificity may be needed.

Measurement-Based Care in the Veteran's Health Administration: A Critique and Recommendations for Future Use in Mental Health Practice.

Measurement-based care (MBC), a mechanism through which feedback is given to providers and patients, is increasingly being used in mental health care and has a number of benefits. These include providing information about treatment progress, encouraging a discussion around these topics, providing a method for shared decision-making and personalized treatment, and improving treatment outcomes. Although there are many benefits to using MBC, it is still not being used regularly. Barriers include time to administer measures and uncertainty regarding which measures to administer. This paper will briefly describe MBC and its use in mental health care and then will focus on the use and implementation of MBC within the Veteran's Health Administration (VHA). The VHA is a large healthcare system in which there have been ongoing efforts to implement MBC. Suggestions for successful implementation will be discussed.

"Do You Know What I Know?": How Communication Norms and Recipient Design Shape the Content and Effectiveness of Patient Handoffs.

BACKGROUND: Poor communication during end-of-shift transfers of care (handoffs) is associated with safety risks and patient harm. Despite the common perception that handoffs are largely a one-way transfer of information, researchers have documented that they are complex interactions, guided by implicit social norms and mental frameworks. OBJECTIVES: We investigated communication strategies that resident physicians report deploying to tailor information during face-to-face handoffs that are often based on their implicit inferences about the perceived information needs and potential harm to patients. METHODS/PARTICIPANTS: We interviewed 35 residents in Medicine and Surgery wards at three VA Medical Centers (VAMCs). MAIN MEASURES: We conducted qualitative interviews using audio-recorded semi-structured cognitive task interviews. KEY RESULTS: The effectiveness of handoff communication depends upon three factors: receiver characteristics, type of shift, and patient's condition and perceived acuity. Receiver characteristics, including subjective perceptions about an incoming resident's training or ability levels and their assumed preferences for information (e.g., detailed/comprehensive vs. minimal/"big picture"), influenced content shared during handoffs. Residents handing off to the night team provided more information about patients' medical histories and care plans than residents handing off to the day team, and higher patient acuity merited more detailed information and the medical service(s) involved dictated the types of information conveyed. CONCLUSIONS: We found that handoff communication involves a complex combination of socio-technical information where residents balance relational factors against content and risk. It is not a mechanistic process of merely transferring clinical data but rather is based on learned habits of communication that are context-sensitive and variable, what we refer to as "recipient design." Interventions should focus on raising awareness of times when information is omitted, customized, or expanded based on implicit judgments, the emerging threats such judgments pose to patient care and quality, and the competencies needed to be more explicit in handoff interactions.

Use of PROMIS-29® in US Veterans: Diagnostic Concordance and Domain Comparisons with the General Population.

BACKGROUND: PROMIS® items have not been widely or systematically used within the Veterans Health Administration (VA). OBJECTIVE: To examine the concordance of PROMIS-29® scores and medical record diagnosis in US Veterans and to compare Veteran scores relative to US population norms. DESIGN/PARTICIPANTS: Cross-sectional multi-site survey of Veterans (n = 3221) provided sociodemographic and PROMIS-29® domain data. Electronic medical records provided health condition (depression, anxiety, sleep disorders, pain disorders) diagnosis data. MAIN MEASURES: For each domain, we calculated PROMIS® standardized T scores and used t tests to compare PROMIS® scores for Veterans diagnosed with each targeted health condition vs. those without that documented clinical diagnosis and compare mean Veterans' PROMIS-29® with US adult population norms. KEY RESULTS: Veterans with (vs. without) a depression diagnosis reported significantly higher PROMIS® depression scores (60.3 vs. 49.6, p < .0001); those with an anxiety diagnosis (vs. without) reported higher average PROMIS® anxiety scores (62.7 vs. 50.9, p < .0001). Veterans with (vs. without) a pain disorder reported higher pain interference (65.3 vs. 57.7, p < .0001) and pain intensity (6.4 vs. 4.4, p < .0001). Veterans with (vs. without) a sleep disorder reported higher sleep disturbance (55.8 vs. 51.2, p < .0001) and fatigue (57.5 vs. 51.8, p < .0001) PROMIS® scores. Compared with the general population norms, Veterans scored worse across all PROMIS-29® domains. CONCLUSIONS: We found that PROMIS-29® domains are selectively sensitive to expected differences between clinically-defined groups, suggesting their appropriateness as indicators of condition symptomology among Veterans. Notably, Veterans scored worse across all PROMIS-29(R) domains compared with population norms. Taken collectively, our findings suggest that PROMIS-29® may be a useful tool for VA providers to assess patient's physical and mental health, and because PROMIS® items are normed to the general population, this offers a way to compare the health of Veterans with the adult population at large and identify disparate areas for intervention.

Psychometric Evaluation of a Pain Intensity Measure for Persons with Dementia.

OBJECTIVE: The goal of this study was to conduct initial psychometric analyses of a seven-item pain intensity measure for persons with dementia (PIMD) that was developed using items from existing pain observational measures. DESIGN AND METHODS: We evaluated validity by examining associations with an expert clinician's pain intensity rating (ECPIR) and an established pain observation tool (Mobilization Observation Behaviour Intensity Dementia [MOBID]). We also examined correlations between the PIMD and known correlates of pain: depression, sleep disturbances, agitation, painful diagnoses, and caregiver pain reports. We examined the differences between PIMD scores for "at rest" and "during movement" observations. We assessed reliability by calculating Cronbach's alpha and estimating inter-rater reliability using intraclass correlations (ICCs). Finally, we examined whether six additional "recent changes in behavior" items improved the PIMD's ability to predict expert clinicians' pain ratings. SETTING: Sixteen nursing homes located in Alabama, Georgia, Pennsylvania, and New Jersey. PARTICIPANTS: One hundred ninety residents with moderate to severe cognitive impairment, mean age of 84 years, 49.5% female, and 70% white. RESULTS: PIMD during movement scores were highly correlated with the ECPIR and overall MOBID scores. As expected, there were large differences between at rest and during movement PIMD scores. Associations of PIMD with known correlates of pain were generally low and statistically nonsignificant. Internal consistency was supported with a Cronbach alpha of 0.72 and an inter-rater ICC of 0.82 for during movement PIMD scores. CONCLUSIONS: Initial evaluation of the PIMD supports its validity and reliability. Additional testing is needed to evaluate the tool's sensitivity to changes in pain intensity.

Key Characteristics for Successful Adoption and Implementation of Home Telehealth Technology in Veterans Affairs Home-Based Primary Care: An Exploratory Study.

BACKGROUND/OBJECTIVES: The Department of Veteran Affairs (VA) Home-Based Primary Care (HBPC) program provides care to over 37,000 high-risk, high-need, medically complex, and costly patients in their home. The VA's Home Telehealth (HT) program can potentially amplify HBPC's efficiency and reach, yet scarce data on use and experience with HT in HBPC exist. This exploratory study sought to provide a glimpse of HT use in HBPC and identify drivers and barriers for HT implementation. DESIGN: National VA data were used to evaluate HBPC patients concurrently using HT. We conducted a cross-sectional survey of HBPC program directors to explore HT use, understand communication processes, and elicit open comments. Semistructured interviews were conducted of 18 HBPC program directors with varying HT use to clarify themes and understand HBPC experience with HT. RESULTS: Fifteen percent of the overall HBPC patients used HT in 2011, with a wide variation in HT use by HBPC site. The national survey and semistructured interviews revealed that most HBPC staff recognized advantages of using HT, including increased patient engagement and staff efficiency. Crucial practices among sites with successful telehealth adoption included HT staff attending HBPC meetings and evaluating all HBPC patients for HT. CONCLUSION: Much remains to be done for effective HT integration in HBPC. Improving communication between HT and HBPC programs and establishing a system for identifying suitable patients for HT are vital. Future studies need to delineate operational processes and gather data on the added value of HT in HBPC to guide evidence-based integration of HT in VA and Medicare HBPC programs.

The VA and Non-VA Experience of Tracking Good Care.

The VA Mission Act of 2018 allows for choice of health care for 9 million veterans in their community, but deciding where the best care is requires transparency. Recent reports questioning the transparency of reporting health care outcomes in the Department of Veterans Affairs (VA), the largest US health care organization, pointed to flaws in how VA tracks and improves performance, and posed questions about the validity and transparency of using popular hospital ratings systems to define good care. To explore this further, the authors examined 3 widely referenced public health care ranking models - U.S. News America's Best Hospitals, Truven Health Analytics, and Hospital Compare - and the VA model. Upon examination, the authors find that metrics used across the 4 models are neither comparable nor transparent. Between 6%-46% reporting deficiencies were found in reporting of hospital metrics in non-VA hospitals, which reduces transparency for the public. In contrast, VA reporting is 100%. Comparing VA health care and Hospital Compare quality outcomes showed similar or better outcomes for VA for the same metrics of quality and for comparable health care costs. VA inpatient satisfaction falls significantly short of the private sector, but no individual VA outcome measure was found to contribute significantly to inpatient satisfaction. However, overall inpatient satisfaction increased over time with higher global hospital ranking in both VA and non-VA health care. Encouraging use of uniform rating models and reporting of metrics from all hospitals would improve transparency of current health care reporting to the consumer.

Efficacy of telehealth visits for postoperative care at the Minneapolis VA.

BACKGROUND: About half of Minneapolis VA patients reside in rural areas, receiving their primary care at a Community Based Outpatient Clinic (CBOC). Although some CBOC's are over 200 miles away, patients must travel to the Twin Cities for surgical services. METHODS: The 167 consecutive patients who opted for telehealth postoperative visits were surveyed. Data collected included travel time and distance to the Minneapolis VA and their local CBOC, need for transportation assistance to the clinic/VA, complications as a result of telehealth and a 1-10 overall satisfaction score. RESULTS: Respondents reported a mean ± SD satisfaction score of 9.60 ± 1.20, with a mean cost savings of $51.94 ± $40.92, decrease in travel time of 99.4 ± 76.6 min and no post-surgical complications missed. CONCLUSIONS: The telehealth program appears to be safe, saves time and money for veterans and results in extremely high patient satisfaction.

Palliative Care and End-of-Life Outcomes Following High-risk Surgery.

Importance: Palliative care has the potential to improve care for patients and families undergoing high-risk surgery. Objective: To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation. Design, Setting, and Participants: This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included. Exposures: Palliative-care consultation within 30 days before or 90 days after surgery. Main Outcomes and Measures: The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes. Results: A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P = .007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P = .004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P = .05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery. Conclusions and Relevance: Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.

Regional variations in cardiovascular risk factors and access to care among US veterans with cardiovascular disease.

BACKGROUND: It remains unclear whether cardiovascular risk factors and access to healthcare for veterans with cardiovascular disease (CVD) vary among US regions. This study sought to determine the extent of regional variations in cardiovascular risk factors and access to medical care in a cohort of veterans with CVD in the USA. METHODS: The 2016 Centers for Disease Control Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of veteran patients with CVD. Participants were classified based on four US regions: (1) Northeast, (2) Midwest, (3) South, and (4) West. We compared demographic data, medical history, and access to care for veterans of each US region. The outcomes of interest included financial barriers to medical care and annual medical checkup. RESULTS: Among the 13 835 veterans, 18.3% were from the Northeast, while 23.5, 37.1, and 21.1% were from the Midwest, South, and West, respectively. Veterans of each region differed significantly with respect to demographic characteristics, prior medical history, and access to care. Rates of financial barriers to medical care were similar across the four regions (7.3 vs. 7.1 vs. 8.0 vs. 6.9%, P = 0.203). Veterans from the West had the lowest rates of medical checkup within the past year (91.7 vs. 89.5 vs. 91.4 vs. 86.6%). On multivariate analysis, the Midwest [odds ratio (OR) 0.69; 95% CI, 0.53-0.89] and West (OR 0.53; 95% CI 0.41-0.68) regions were independently associated with lower rates of medical checkup within the past year compared to the Northeast. CONCLUSIONS: In this observational study involving US veterans with CVD, cardiovascular risk factors and frequency of annual medical checkup differed amongst each US region. Further large-scale studies examining the prevalence of impaired access to care and quality of care in US veterans with CVD are warranted.