The whole is greater than the sum of its parts: the anatomy of the Department of Veterans Affairs Medical District 17 Health Services Research and Development Field Program.

The Medical District 17 Health Services Research and Development (HSR&D) Field Program was funded by the Veterans Administration (now the Department of Veterans Affairs--VA) in January 1983. This article describes the organization, progress, and accomplishments of this field program, and it provides a review of the breadth of health services research that is being conducted in Medical District 17. Overall, the field program has conducted research that addresses significant problems in the delivery of health care within the VA system. Resource utilization, cost effectiveness, and the care of geriatric patients have been some of the areas in which the Medical District 17 HSR&D Field Program has provided important research findings for VA. The field program plans to continue its response to the needs of VA. Moreover, HSR&D investigators will be collaborating with researchers of other services to conduct research that is both enlightening and highly relevant to the delivery of health care to the nation's veterans. The proposal for an HSR&D field program was developed by the Edward A. Hines Jr. VA Hospital in collaboration with the Center for Health Services and Policy Research (CHSPR) of Northwestern University. The program was funded in January 1983, as the result of a national competition to establish an HSR&D field program in each of the VA regions. The goals of the Medical District 17 Field Program are to improve the health care of veterans by conducting relevant research on the processes and outcomes of patient care; to provide comprehensive technical research assistance; and to educate VA managers, planners, and clinicians, as well as the general medical community, about advances in health care delivery. The field program's commitment to excellence is strengthened by its multidisciplinary approach, which enables physicians, nurses, social workers, psychologists, sociologists, economists, statisticians, administrators, and individuals in various related disciplines to cooperate in efforts to address a wide range of topical issues. These collaborations are a major strength of the field program. Primary research priorities of the field program are cost effectiveness of VA services (e.g., patient care technologies, delivery systems), long-term care, and rehabilitation. Investigators, however, are not limited to these topics and explore many other health services research issues of particular interest to them.

The impact of parenteral nutrition preparation on bloodstream infection risk and costs.

BACKGROUND: Catheter-related bloodstream infections (BSIs) are a serious problem leading to increased morbidity, longer hospital stay, and hence, additional costs. This study evaluated the risk of BSI and the cost of parenteral nutrition (PN) in Germany. SUBJECTS/METHODS: A retrospective observational chart review of patients hospitalized from October 2009 to April 2011 and receiving PN via ready-to-use three-chamber bag (MCB), single bottle (SB) or hospital compounded admixture (CPN) was conducted across Germany. Propensity score-adjusted models were used to evaluate the association between the type of PN, BSI (Cox Proportional Hazards) and hospitalization cost (generalized linear models) within a subgroup receiving all three macronutrients (lipids, amino acids, glucose). RESULTS: Of the 1995 patient records reviewed (MCB=816; CPN=584; SB=595), 1457 patients received all three macronutrients. After adjustment, SB was associated with an increased hazard of BSI, vs MCB without additions (hazard ratio (HR) (95% confidence interval (CI))=2.53 (1.66-3.86)) in the total cohort. Adding supplements to MCB on the ward also increased the BSI risk in both total and subgroup analyses. In patients receiving all three macronutrients, adjusted total costs were MCB (no additions): \[euro]6,572 (95% CI: \[euro]6,896-6263); CPN: \[euro]6,869 (\[euro]7,283-6479); SB: \[euro]6,872 (\[euro]7,242-6521); MCB (ward additions): \[euro]7,402 (\[euro]7,878-6955); P<0.001; P<0.001. CONCLUSION: Use of MCB does not appear to increase treatment costs, possibly by reducing the risk of infection. This study identified several PN preparation methods associated with a significantly increased hazard for BSI; definitive CPN findings are limited by our inability to distinguish automated from manual pharmacy compounding.

A method to risk-adjust rehabilitation outcomes using functional related groups.

In our rapidly changing and increasingly expensive health care environment, payers, patients, and other consumers are beginning to demand that rehabilitation providers demonstrate their value through outcomes data. Although self-assessment is not new to rehabilitation, the instruments and databases at our disposal generally do not fully adjust for severity of disability, health status, or other factors that may affect outcomes. This paper demonstrates a technique using functional related groups (FRGs) to adjust inpatient length of stay and treatment efficiency to reflect relative risk. This paper describes the application of an analytic method and does not involve hypothesis testing. The method uses a simple hand calculator or spreadsheet software to risk-adjust outcomes using FRGs. Steps in the analysis consist of the following: (1) determining FRG categorization for each patient; (2) estimating the expected number of patients in each FRG, given total provider population; (3) comparing the expected with the actual number of patients in each FRG; (4) adjusting length of stay and length of stay efficiency to reflect these differences. The technique described in this paper can be used by any inpatient rehabilitation providers who collect Functional Independence MeasureSM (FIMSM) data and patient diagnostic and demographic data. It is easily updated on an ongoing basis. Without adjustments for risk, outcomes may mislead providers, payers, and other users of the information, and limited resources may be expended in tracking a problem that does not exist. Even small adjustments for severity may shift perceptions regarding provider efficiency and quality.

Assessing health care delivery to male versus female veterans.

The study reported was undertaken to explore allegations that women veterans have not received the quality of care in the Department of Veterans Affairs (VA) that is typical of that being received by their male counterparts. The study consisted of a chart review of male and female inpatients (n = 114) and telephone interviews with a subsample of these veterans (n = 55) treated at a large metropolitan VA hospital. Overall, chart documentation was poor, regardless of gender. On average, two-thirds of males and females receive regular gender-specific examinations, although the number is somewhat lower for females. Both women and men were quite satisfied with the care they received. Future studies should focus on the evaluation of workable solutions to providing equitable health care to women veterans that are already in operation.

A model to assess the usefulness of performance indicators.

This paper describes the Perception-Action-Impact (PAI) model used for testing the usefulness of health care organization performance indicators, and reports preliminary data in support of this model. Two hundred and ninety six hospitals contributed 500,000 obstetrical cases, and responded to surveys to assess various aspects of indicator usefulness. Domains of interest that were assessed include relevance of the measures, whether the measures identified opportunities for improvement, whether the health care organization took any action in response to the data, health care organizational structure for data use, and methods for dissemination of the indicator data. Findings from this study provide support for the PAI model. Consequently, perceptions regarding the indicators apparently have a significant impact on the usefulness of the data. When action was taken in response to the indicator data, a positive impact on patient care processes and outcomes was the typical result. Additional research is needed in the areas of data dissemination effectiveness, and the impact of attitude change on the use of performance measures.