Trends in the Timing and Clinical Context of Maintenance Dialysis Initiation.

Whether secular trends in eGFR at dialysis initiation reflect changes in clinical presentation over time is unknown. We reviewed the medical records of a random sample of patients who initiated maintenance dialysis in the Department of Veterans Affairs (VA) in fiscal years 2000-2009 (n=1691) to characterize trends in clinical presentation in relation to eGFR at initiation. Between fiscal years 2000-2004 and 2005-2009, mean eGFR at initiation increased from 9.8±5.8 to 11.0±5.5 ml/min per 1.73 m(2) (P<0.001), the percentage of patients with an eGFR of 10-15 ml/min per 1.73 m(2) increased from 23.4% to 29.9% (P=0.002), and the percentage of patients with an eGFR>15 ml/min per 1.73 m(2) increased from 12.1% to 16.3% (P=0.01). The proportion of patients who were acutely ill at the time of initiation and the proportion of patients for whom the decision to initiate dialysis was based only on level of kidney function did not change over time. Frequencies of documented clinical signs and/or symptoms were similar during both time periods. The adjusted odds of initiating dialysis at an eGFR of 10-15 or >15 ml/min per 1.73 m(2) (versus <10 ml/min per 1.73 m(2)) during the later versus earlier time period were 1.43 (95% confidence interval [95% CI], 1.13 to 1.81) and 1.46 (95% CI, 1.09 to 1.97), respectively. In conclusion, trends in eGFR at dialysis initiation at VA medical centers do not seem to reflect changes in the clinical context in which dialysis is initiated.

Association between local area unemployment rates and use of Veterans Affairs outpatient health services.

BACKGROUND: Prior research indicates that federal spending on Medicare, Medicaid, and other government health programs accelerated during the Great Recession. OBJECTIVES: To examine whether local unemployment was associated with utilization of Veterans Affairs Health Care System (VA) primary care, specialty care, and mental health services during 2004-2012. RESEARCH DESIGN: We analyzed utilization of VA health services at the clinic level using fixed-effects negative binomial models. We stratified analyses by veterans' copayment status (exempt and nonexempt) and age (under 65 and 65+) to account for differences in VA utilization because of Medicare eligibility. SUBJECTS: A total of 11,041,855 veterans assigned to 892 clinics identified in the VA Primary Care Management Module, representing nearly all veterans receiving primary care from VA, were included. MEASURES: Clinic-level utilization was calculated quarterly as the total number of visits for patients assigned to a clinic. Local area unemployment rates were defined as quarterly unemployment rates within VA geographical planning sectors. RESULTS: Higher local unemployment was associated with greater use of VA care in all categories among veterans exempt from copayments. The association between local unemployment and utilization differed by age group among veterans subject to copayments. Higher local unemployment was associated with lower use of primary and specialty care among Medicare-eligible veterans aged 65+, but greater use of primary care among veterans under age 65. CONCLUSIONS: Our findings highlight the importance of the state of the economy in interpreting and forecasting demand for government health programs including VA, particularly during periods focused on deficit reduction.

Factors affecting medication adherence: patient perspectives from five veterans affairs facilities.

BACKGROUND: In the United States, more than 25 million people have diabetes. Medication adherence is known to be important for disease control. However, factors that consistently predict medication adherence are unclear and the literature lacks patient perspectives on how health care systems affect adherence to oral hypoglycemic agents (OHAs). This study explored facilitators and barriers to OHA adherence by obtaining the perspectives of Veterans Affairs (VA) patients with OHA prescriptions. METHODS: A total of 45 patients participated in 12 focus groups that explored a wide range of issues that might affect medication adherence. Participants were patients at clinics in Seattle, Washington; San Antonio, Texas; Portland, Oregon; Salem, Oregon, and Warrenton, Oregon. RESULTS: Key system-level facilitators of OHA adherence included good overall pharmacy service and several specific mechanisms for ordering and delivering medications (automated phone refill service, Web-based prescription ordering), as well as providing pillboxes and printed lists of current medications to patients. Barriers mirrored many of the facilitators. Poor pharmacy service quality and difficulty coordinating multiple prescriptions emerged as key barriers. CONCLUSIONS: VA patient focus groups provided insights on how care delivery systems can encourage diabetes medication adherence by minimizing the barriers and enhancing the facilitators at both the patient and system levels. Major system-level factors that facilitated adherence were overall pharmacy service quality, availability of multiple systems for reordering medications, having a person to call when questions arose, counseling about the importance of adherence and providing tools such as pillboxes and updated medication lists.

Survey nonresponders incurred higher medical utilization and lower medication adherence.

OBJECTIVES: To compare healthcare costs, utilization, and medication adherence between diabetic responders and nonresponders to a patient satisfaction survey. STUDY DESIGN: We performed a retrospective cohort study of 40,766 patients with diabetes who had been randomly selected to receive the 2006 Veterans Affairs' Survey of Healthcare Experiences of Patients. Outcomes were measured during the following year. METHODS: We used multivariable models to compare healthcare costs (generalized linear models), utilization (negative binomial regression), and adherence to oral hypoglycemic medications (logistic regression) between survey responders and nonresponders. RESULTS: There were 26,051 patients (64%) who responded to the survey. Survey nonresponders incurred significantly higher healthcare costs (incremental effect, $792; 95% CI, $599-$986; P < .01). Nonresponders had a modest increase in primary care (incidence rate ratio [IRR], 1.06; 95% CI, 1.05-1.08; P < .01) and specialty care visits (IRR, 1.17; 95% CI, 1.12-1.22; P < .01), but more substantial increases in mental health visits (IRR, 1.74; 95% CI, 1.62-1.87; P < .01) and hospitalizations (IRR, 1.60; 95% CI, 1.46-1.75; P < .01). Medication adherence was significantly lower among survey nonresponders (odds ratio, 0.68; 95% CI, 0.65-0.74; P < .01). CONCLUSIONS: Nonresponders to a patient satisfaction survey incurred higher healthcare costs and utilization, but had lower medication adherence. Understanding these characteristics helps to assess the impact of nonresponse bias on patient satisfaction surveys and identifies clinical practices to improve care delivery.

Perceptions of advantages and barriers to radial-access percutaneous coronary intervention in VA cardiac catheterization laboratories.

BACKGROUND/PURPOSE: Compared with trans-femoral percutaneous coronary intervention (TFI), trans-radial PCI (TRI) has a lower risk of bleeding, access site complications and hospital costs, and is preferred by patients. However, TRI accounts for a minority of PCIs in the US, and there is currently little research that explores why. METHODS/MATERIAL: We conducted a national survey in February 2013 to assess perceptions of TRI vs. TFI, and barriers to TRI adoption and implementation among interventional cardiologists employed by the US Veterans Health Administration (VHA), and linked these data to site-level TRI annual rates for 2013. RESULTS: We received 78 completed surveys (32% response rate). Respondents at sites that perform few or no TRIs identified increased radiation exposure as the greatest barrier while at sites that perform a high percentage of TRIs respondents identified the steep learning curve as the greatest barrier. Majorities of survey respondents at all sites rated TRI as superior on 5 of 7 criteria, including patient comfort and bleeding complications, but rated TFI as superior on procedure time and procedure success. CONCLUSIONS: Even interventional cardiologists at sites that perform few or any TRIs recognized the superiority of TRI for patient comfort and safety, but rated it inferior to TFI on procedure time and technical results. Interventional cardiologists at high-TRI labs rated TRI as equivalent on procedure time and technical results. Efforts to increase TRI adoption and implementation may be more successful if they emphasize that procedure times and technical results depend on achieving proficiency.

Patient-centered medical home initiative produced modest economic results for Veterans Health Administration, 2010-12.

In 2010 the Veterans Health Administration (VHA) began a nationwide initiative called Patient Aligned Care Teams (PACT) that reorganized care at all VHA primary care clinics in accordance with the patient-centered medical home model. We analyzed data for fiscal years 2003-12 to assess how trends in health care use and costs changed after the implementation of PACT. We found that PACT was associated with modest increases in primary care visits and with modest decreases in both hospitalizations for ambulatory care-sensitive conditions and outpatient visits with mental health specialists. We estimated that these changes avoided $596 million in costs, compared to the investment in PACT of $774 million, for a potential net loss of $178 million in the study period. Although PACT has not generated a positive return, it is still maturing, and trends in costs and use are favorable. Adopting patient-centered care does not appear to have been a major financial risk for the VHA.