Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain.

As a large national healthcare system, Veterans Health Administration (VHA) is ideally suited to build on its work to date and develop a safe, evidence-based, and comprehensive approach to the care of chronic musculoskeletal pain conditions that de-emphasizes opioid use and emphasizes non-pharmacological strategies. The VHA Office of Health Services Research and Development (HSR&D) held a state-of-the-art (SOTA) conference titled "Non-pharmacological Approaches to Chronic Musculoskeletal Pain Management" in November 2016. Goals of the conference were (1) to establish consensus on the current state of evidence regarding non-pharmacological approaches to chronic musculoskeletal pain to inform VHA policy in this area and (2) to begin to identify priorities for the future VHA research agenda. Workgroups were established and asked to reach consensus recommendations on clinical and research priorities for the following treatment strategies: psychological/behavioral therapies, exercise/movement therapies, manual therapies, and models for delivering multimodal pain care. Participants in the SOTA identified nine non-pharmacological therapies with sufficient evidence to be implemented across the VHA system as part of pain care. Participants further recommended that effective integration of these non-pharmacological approaches across the VHA and especially into VHA primary care, pain care, and mental health settings should be a priority, and that these treatments should be offered early in the course of pain treatment and delivered in a team-based, multimodal treatment setting concurrently with active self-care and self-management approaches. In addition, we recommend that VHA leadership and policy makers systematically address the barriers to implementation of these approaches by expanding opportunities for clinician and veteran education on the effectiveness of these strategies; supporting and funding further research to determine optimal dosage, duration, sequencing, combination, and frequency of treatment; emphasizing multimodal care with rigorous evaluation grounded in team-based approaches to test integrated models of delivery and stepped-care approaches; and working to address socioeconomic and cultural barriers to veterans' access to non-pharmacological approaches.

Risk of stroke, heart attack, and diabetes complications among veterans with spinal cord injury.

OBJECTIVES: To compare the rates of diabetes and macrovascular conditions in veterans with spinal cord injury (SCI) and to examine variations by patient-level demographic, socioeconomic, access, and health status factors. DESIGN: A retrospective analysis. Diabetes status was classified by merging with diabetes epidemiology cohort using a validated algorithm. Chi-square tests and logistic regressions used to compare rates in macro- and microvascular conditions in veterans with and without diabetes. SETTING: Veteran Health Administration clinic users in fiscal year (FY) 1999 to FY 2001. PARTICIPANTS: SCI patients (N=8769) with diabetes (n=1333), in FY 2000, identified through the SCI registry. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Macrovascular and microvascular conditions in the next year (February 2001). Derived from International Statistical Classification of Diseases, 9th Revision, Clinical Modification, codes in the patient treatment files. RESULTS: Overall, 15% of SCI veterans were identified with diabetes but this was an underestimate due to high mortality (8%). Among SCI veterans with diabetes, 49% had at least one macrovascular condition and 54% had microvascular conditions compared with 24% and 25% of those without diabetes (P<.001). CONCLUSIONS: Our study highlights the highly significant relationship between diabetes and macro- and microvascular conditions in veterans with SCI. Neurologic deficit combined with increased insulin resistance has a greater macrovascular impact on SCI veterans than on those who do not have diabetes. Increasing age and physical comorbidities compound the problem.

Excess mortality associated with mental illness and substance use disorders among veteran clinic users with spinal cord injury.

PURPOSE: Among veterans with traumatic spinal cord injury (SCI) or disease aetiologies, examine the association between diagnosed mental illness (MI) and substance use disorders (SUD) on mortality after controlling for demographic and socioeconomic factors, SCI severity, injury duration and chronic physical illnesses. METHOD: Longitudinal analysis of Veteran Health Administration(VHA) administrative data and Medicare claims for FY 1999-2004 matched with Spinal Cord Dysfunction-Registry (SCD-R) of VHA clinic users (N = 8334) with SCI. SCI was identified through SCD-R; individual MIs (anxiety, bipolar, depressive disorders, psychoses, post-traumatic disorder and schizophrenia) and SUDs (tobacco, alcohol and/or drug) were identified through ICD-9-CM codes. Cox-proportional hazards regressions were used to examine association between MI and SUD and time to death in years. RESULTS: Among veterans with SCI, 17% died by the end of FY 2004. Veterans with psychosis (35%), depression (22%) and alcohol and/or drug use (20%) had significantly higher rates of mortality compared to those without these diagnoses. After adjusting for other independent variables in the study, hazards ratios for psychosis was 1.47 (95%CI = 1.24, 1.75), for alcohol and/or drug use was 1.30 (95% CI = 1.11, 1.53). CONCLUSIONS: Some types of MI and SUD were associated with excess mortality among veterans with SCI. Care for MI and SUD needs to be routinely integrated into SCI management. Future research is needed to determine whether depression and SUD treatment provides opportunity to improve survival.

Depressive disorders among cohorts of women veterans with diabetes, heart disease, and hypertension.

OBJECTIVES: To compare the rates of major and minor depression in cohorts of women veterans with diabetes or heart disease or hypertension and examine variations in these rates by demographic, socioeconomic, and health status among these women. METHODS: This was a retrospective cross-sectional analysis of fiscal year 2002 and 2003 data on 13,430 women veterans with diabetes or heart disease or hypertension who were diagnosed with depression and used Veteran Health Administration (VHA) clinics. International Classification of Diseases, 9th ed. Clinical Modification codes from merged VHA and Medicare claims files were used to identify diabetes, heart disease, hypertension, and depression. Chi-square tests and multinomial logistic regressions were used to characterize women veterans with major and minor depression. RESULTS: Of all the women veterans diagnosed with diabetes or heart disease or hypertension and using the VHA clinics, 27% were diagnosed with depression. Of these 13,430 women with any depression, 60% were diagnosed with minor depression and 40% had major depressive disorders (MDD). Compared to major depression, minor depression was significantly more likely among women veterans who were older, without any other psychiatric condition and substance use disorders. CONCLUSIONS: Minor depression is highly prevalent among women veterans with complex chronic illness, such as diabetes or heart disease or hypertension (i.e., women at risk or with cardiovascular conditions), suggesting a need to closely monitor these women to reduce the risk of major depression. Some subgroups of women were more likely to have minor depression than major depression; studies that exclusively focus on major depression will selectively miss these subgroups of women veterans.

Depression treatment patterns among women veterans with cardiovascular conditions or diabetes.

The study aimed to examine treatment patterns for depression among women veterans diagnosed with cardiovascular conditions or diabetes. We used longitudinal data from the 2002-2003 merged Veteran Health Administration (VHA) and Medicare files. Chi-square tests and multinomial logistic regression were performed to analyse depression treatment among veteran women with incident depressive episode and one of the following chronic conditions: diabetes or coronary artery disease or hypertension. Overall, 77% received treatment for depression, 54% with only antidepressants, 4% with only psychotherapy, and 19% with both. Multinomial logistic regression revealed that African American women were more likely to be in the no treatment group and were more likely than white women to receive psychotherapy rather than antidepressants. Older women and women with coronary artery disease only were less likely to receive treatment.

Organization of care and diagnosed depression among women veterans.

OBJECTIVE: To analyze the association between the organizational features of integration of physical and mental healthcare in womens health clinics and the diagnosis of depression among women veterans with or at risk for cardiovascular conditions (ie, diabetes mellitus, heart disease, or hypertension). STUDY DESIGN: Retrospective and observational secondary data analyses. METHODS: We studied 27,972 women veterans from 118 facilities with diagnosed cardiovascular conditions in fiscal year 2001 (FY2001) using merged Medicare claims and Veterans Health Administration (VHA) data merged with the 1999 VHA Survey of Primary Care Practices and the 2001 VHA Survey of Women Veterans Health Programs and Practices. The dependent variable was a binary indicator for diagnosed depression during FY2001 at the individual level. We used a multilevel logistic regression model to control for clustering of women veterans within facilities. Individual-level independent variables included demographics, socioeconomic characteristics, and chronic physical conditions. RESULTS: Overall, 27% of women veterans using the VHA were diagnosed as having depression in FY2001. Across facilities, rates of diagnosed depression varied from 13% to 41%. After controlling for individual-level and facility-level independent variables, women veterans who were served in separate women's health clinics with integrated physical and mental healthcare were more likely to have diagnosed depression. The adjusted odds ratio was 1.12 (95% confidence interval, 1.01-1.25). CONCLUSIONS: Existing women-specific VHA organizational features with integration of primary care and mental health seem effective in diagnosing depression. Emerging patient-centered medical home models may facilitate diagnosis and treatment of mental health issues among women with complex chronic conditions.

Mental illness and substance use disorders among women veterans with diabetes.

OBJECTIVES: We sought to estimate the prevalence of mental illness (MI) and substance use disorders (SUD) and determine the predictors of MI/SUD categories among veteran women with diabetes. METHODS: We evaluated a cross-sectional analysis of 16,368 women veterans with diabetes in fiscal 1999 and 2000. SUD, MI, and diabetes were identified using validated algorithms based on diagnosis codes. Chi-square and multinomial logistic regressions were used to examine associations between SUD, MI, demographic, socioeconomic, and health status variables. RESULTS: Overall, 45% of women had a MI, SUD, or both. SUD rates were high among those with serious MI. The associations between MI/SUD and independent variables were not uniformly significant, except for macrovascular conditions; women veterans were more likely to have combinations of MI/SUD. CONCLUSION: A high rate of MI/SUD suggests that care for mental and physical illness needs to be integrated into health care planning and delivery of services to veteran women with diabetes.

Obesity and expenditures among elderly Veterans Health Administration users with diabetes.

A retrospective cross-sectional analysis of Veterans Health Administration (VHA) administrative and Medicare fee-for-service (FFS) claims data was used to evaluate the association between body mass index (BMI) categories and expenditures among elderly VHA users with diabetes. The study sample included respondents to the 1999 Large Health Survey of Veteran Enrollees who were diagnosed with diabetes in fiscal year 1999, age 65 or older, and enrolled in Medicare FFS (N = 79,934). Types of expenditures included inpatient, outpatient, and a summation of the 2 in the fiscal year 1999. VHA expenditures were from the Health Economics Resource Center Average Cost Database and Medicare expenditures were the paid amounts recorded in the claims. BMI was grouped into 4 exclusive categories: normal (18.5-24.9), overweight (25-29.9), obese (30-34.9), and morbidly obese (> or =35). Generalized linear models with the log-link function were used to examine the association between BMI categories and expenditures, controlling for sociodemographic factors, diabetes duration, health status, and health behavior. Almost half of the study sample was overweight (47.6%), followed by obese (22.6%), normal (20.7%), and morbidly obese (9.1%). Patients with normal BMI had the highest average total expenditures ($10,470) followed by overweight ($7526). Total expenditure was not significantly different between obese and morbidly obese BMI groups ($6597 vs. $6772). After controlling for all other variables, normal weight patients with diabetes had greater total, inpatient, and outpatient expenditures. The study showed that elderly diabetes patients with normal weight incur much higher costs than obese or morbidly obese patients. Further research is needed to examine the causes of high cost among normal weight patients with diabetes to better understand resource needs and to improve resource allocations.

Disparities in preventive care by body mass index categories among women.

OBJECTIVE: The present analyses examined the relationship of body mass index (BMI) categories to receiving age-appropriate preventive services among women. METHOD: Data from the Medical Expenditure Panel Survey (2003, N = 10,954) were analyzed using multiple logistic regressions. Outcomes were: age-appropriate Pap-test, mammography, colorectal, cholesterol and blood pressure screening, and influenza immunization. RESULTS: Overall, 3% of participants were underweight, and 26.3% were obese. Obese women were less likely to receive Pap-tests (p < .01), and underweight women less likely to receive mammography (p < .001). Dental care was less likely across all BMI groups outside the normal weight range. CONCLUSIONS: The association between BMI categories and preventive services use varied by type of preventive care.

Expenditures in mental illness and substance use disorders among veteran clinic users with diabetes.

Few studies have looked at the health-care expenditures of diabetes patients based on the type of co-occurring conditions of mental illness (MI) or substance use disorders (SUD). Our study analyzes the health-care expenditures associated with various diagnostic clusters of co-occurring drug, alcohol, tobacco use, and mental illness in veterans with diabetes. We merged Veteran Health Administration and Medicare fee-for-service claims database (fiscal years 1999 and 2000) for analysis (N = 390,253) using generalized linear models; SUD/MI were identified using International Classification of Diseases, 9th edition codes. The total average expenditures (fiscal year 2000) were lowest ($6,185) in the "No MI and No SUD" and highest ($19,801) for individuals with schizophrenia/other psychoses and alcohol/drug use. High expenditures were associated with both SUD and MI conditions in diabetes patients, and veterans with alcohol/drug use had the highest expenditures across all groups of MI. These findings reinforce the need to target groups with multiple comorbidities specifically those with serious mental illnesses and alcohol/drug use for interventions to reduce health-care expenditures.

Chronic illness with complexities: mental illness and substance use among Veteran clinic users with diabetes.

OBJECTIVE: Create a taxonomy and examine the predictors of the often co-occurring conditions of substance use disorders and mental illness in veterans with diabetes. DESIGN: Merged Veteran Health Administration and Medicare fee-for-service claims data (N = 485,893). RESULTS: Thirty-one percent of patients with diabetes were diagnosed with either mental illness or substance use and had higher rates of diabetes-related complications. Women were more likely to have serious mental illness; African Americans and Latinos more likely to have drug and/or alcohol use. CONCLUSION: Prevalence of substance use disorder and mental illness differed by socio-demographics, suggesting the need for tailored diabetes management interventions.