Alan N. West

Health care expenditures for urban and rural veterans in Veterans Health Administration care.

OBJECTIVE To compare Veterans Health Administration (VA) patients, non-VA-using veterans, and nonveterans, separated by urban/rural residence and age group, on their use of major categories of medical care and payment sources. DATA SOURCE Expenditures for health care-using men in Medical Expenditure Panel Surveys from 1996 through 2004. STUDY DESIGN Retrospective, cross-sectional analysis. DATA COLLECTION/EXTRACTION METHODS Controlling for demographics, health status, and insurance, we compared groups on population-weighted expenditures for inpatient, hospital-based outpatient, office-based, pharmacy, and other care, by major payers (self/family, private insurance, Medicare, other sources, and VA). RESULTS VA users received most of their health care outside of the VA system, paid through private insurance or Medicare; self-payments were substantial. VA users under 65 reported worse health if they were rural residents but also lower expenditures overall and less care through private insurance. CONCLUSIONS VA health care users get most of their medical care from non-VA providers. Working-age VA users have less insurance coverage and rely more on VA care if they live in rural areas.

Rare Adverse Medical Events in VA Inpatient Care: Reliability Limits to Using Patient Safety Indicators as Performance Measures

OBJECTIVE To assess Agency for Healthcare Research and Qualitys Patient Safety Indicators (PSIs) as performance measures using Veterans Administration hospitalization data. DATA SOURCES STUDY SETTING: Nine years (1997-2005) of all Veterans Health Administration (VA) administrative hospital discharge data. STUDY DESIGN Retrospective analysis using diagnoses and procedures to derive annual rates and standard errors for 13 PSIs. DATA COLLECTION/EXTRACTION METHODS For either hospitals or hospital networks (Veterans Integrated Service Networks [VISNs]), we calculated the percentages whose PSI rates were consistently high or low across years, as well as 1-year lagged correlations, for each PSI. We related our findings to the average annual number of adverse events that each PSI represents. We also assessed time trends for the entire VA, by VISN, and by hospital. PRINCIPAL FINDINGS PSI rates are more stable for VISNs than for individual hospitals, but only for those PSIs that reflect the most frequent adverse events. Only the most frequent PSIs yield significant time trends, and only for larger systems. CONCLUSIONS Because they are so rare, PSIs are not reliable performance measures to compare individual hospitals. The most frequent PSIs are more stable when applied to hospital networks, but needing large patient samples nullifies their potential value to managers seeking to improve quality locally or to patients seeking optimal care.

Primary process content in paranoid schizophrenic speech

Free speech samples given by paranoid schizophrenics, nonschizophrenic paranoids, and nonpsychotic psychiatric patients were submitted to computerized content analysis. Speech samples were searched for words belonging to the Regressive Imagery Dictionary (Martindale, 1975), which yields a well-validated measure of primary process content. Three word-concreteness dictionaries were also employed. Compared to the other groups, paranoid schizophrenics produced speech higher in primary process content as well as in transitive verb concreteness. Results are consistent with psychoanalytic theory.

The effect of increased travel reimbursement rates on health care utilization in the VA.

PURPOSE The reimbursement rate that eligible veterans receive for travel to Department of Veterans Affairs (VA) facilities increased from 11 to 28.5 cents per mile on February 1, 2008. We examined the effect of this policy change on utilization of outpatient, inpatient, and pharmacy services, stratifying veterans based on distance from a VA facility. METHODS We compared health care utilization and costs on a sample of VA patients in the 10.5 months before the reimbursement rate increase and the 10.5 months after the reimbursement rate increase. Using a difference-in-difference technique, we ran multivariable logistic and count regressions for utilization and generalized linear models (GLM) for cost outcomes. Regressions were stratified based on urban and rural residence, as well as by distance thresholds. FINDINGS Our cohort contained 250,958 veterans, 76.7% (n = 192,559) of whom were eligible to receive a travel reimbursement. After the reimbursement rate increase, eligible veterans at all distances were 6.8% more likely to have an outpatient encounter and had 2.6% more outpatient encounters in the VA compared to those not eligible for the reimbursement (P< .001). Similar results were found for prescription fills at all distances, but inpatient encounters remained generally unaffected. CONCLUSIONS Our results suggest that this policy change was successful in increasing access to VA care for patients regardless of location of residence.

Comparing the Characteristics, Utilization, Efficiency, and Outcomes of VA and Non-VA Inpatient Care Provided to VA Enrollees : A Case Study in New York

Objective:To compare the characteristics, utilization, and outcomes of Veterans Health Administration (VA) and non-VA inpatient care provided to VA enrollees in New York. Methods:Using VA and New York State administrative and clinical databases, we conducted a retrospective study examining 110,716 residents of New York State who were enrolled in the VA and had 266,869 inpatient admissions in VA and non-VA hospitals in New York. For each admission, we determined the system of care used (VA or non-VA), patient demographics, and characteristics of the admission, and we calculated VA patients’ relative reliance on the VA for inpatient care. For each Major Diagnostic Category (MDC), we examined reliance, patient characteristics, and lengths-of-stay for 2 groups: veterans who were younger than age 65 and those age 65 or older. Results:Fifty-three percent of younger patients’ inpatient admissions were in the VA, whereas 32% of older patients’ were; however, relative reliance on the VA varied dramatically across the 19 MDCs examined. Across age groups, patients admitted to VA hospitals were younger, less likely to be white, and less likely to live in a rural setting. Those using VA hospitals had lower Charlson scores and received less complex care. For both age groups and across all MDCs, admissions to VA hospitals had substantially higher diagnosis related group-specific observed-to-expected lengths-of-stay. Conclusions:Younger and older veterans use VA and non-VA hospitals differently for inpatient services. Comprehensive inpatient datasets could inform planners about VAs service market and VA managers about achievable performance benchmarks that are relevant to VAs service population.

Rural Veterans and Access to High-Quality Care for High-Risk Surgeries

OBJECTIVES To determine whether older Veterans Health Administration (VA) health care enrollees obtain most high-risk surgeries in non-VA hospitals under Medicare, whether residence in less populous areas increases this reliance on non-VA care or the likelihood of obtaining it in hospitals with higher mortality rates, and whether directing VA enrollees to better hospitals would add a substantial travel burden. DATA SOURCES VA and Medicare hospital discharge data from 2000 and 2001 for VA enrollees 65 years or older who received any of 14 high-risk elective procedures, including heart, vascular, and cancer surgeries. STUDY DESIGN/DATA EXTRACTION: We compared urban, suburban, and rural patients on use of VA versus non-VA hospitals, use of non-VA hospitals of higher versus lower mortality rates, travel times to get to these hospitals, and the additional travel burden if they had gone to lower mortality hospitals. PRINCIPAL FINDINGS Regardless of residence, VA enrollees obtained most high-risk surgeries in non-VA hospitals. Urban veterans were most likely to get heart or cancer surgeries in lower mortality hospitals, but rural veterans were most likely to get vascular surgeries in lower mortality hospitals. Average travel times to lower or higher mortality hospitals did not differ greatly. CONCLUSIONS Accessing better hospitals need not add a great travel burden for rural veterans.

Primary Process Content in the King James Bible: The Five Stages of Christian Mysticism.

Freud (1900/1938) described primary process thought as an archaic, global, nontemporal mode of consciousness in which logic and disbelief are suspended. Hypothetically, it is the form of awareness associated with mystical experiences. The Regressive Imagery Dictionary (Martindale, 1975) is a well-validated computerized content-analytic measure of primary process thought in natural language texts. The dictionary was used to assess mystic content in the King James Bible. Across the entire Bible, primary process content best fits a fifth-degree polynomial function consistent with Underhills (1911) model of spiritual development in the prototypical Christian mystic.

When VA patients have non-VA hospitalizations, who pays for what services, and what are the research implications? A New York case study.

Objective:To determine, for Veterans Health Administration (VA) enrollees who lived and were hospitalized in New York State between 1998 and 2000, the primary payers for their non-VA admissions, whether the primary payer mix varied by condition treated, and whether the Medicare claims data that VA acquired on its Medicare-enrolled patients captured all or most of their non-VA inpatient care. Methods:Using VA and New York State administrative and clinical databases, we conducted a retrospective study examining 75,046 residents of New York State who were enrolled in the VA and had 159,843 inpatient admissions in New York hospitals not in the VA system. For each admission, we determined the major diagnostic category, the primary payer for the admission, and whether the patient was Medicare-enrolled. Our analyses separated veterans into those younger than age 65 and those ages 65 or older. Results:The payer mix for younger veterans’ non-VA admissions varied considerably by major diagnostic category. Among veterans who also were Medicare enrollees, Medicare did not pay for 10% of the non-VA hospitalizations of older patients or 20% of those for younger patients. Conclusions:Using only Medicare claims data may significantly underestimate VA patients’ reliance on non-VA inpatient care. To better inform planners about VAs service market and diagnosis-specific service utilization patterns across VA and non-VA providers, VA should work with states to develop comprehensive inpatient datasets.

Differences Among States in Rural Veterans’ Use of VHA and Non‐VHA Hospitals

PURPOSE To understand how vouchers for non-VHA care of VHA-enrolled veterans might affect rural enrollees, we determined how much enrollees use VHA and non-VHA inpatient care, and whether this use varies substantially between rural and urban residents depending on state of residence. METHODS For veterans listed in the 2007 VHA enrollment file as living in Arizona, Iowa, Louisiana, Tennessee, Florida, South Carolina, Pennsylvania, or New York, we merged 2004-2007 administrative discharge data for all VHA hospitalizations with all non-VHA hospitalizations listed in state health department or hospital association databases. Within states, rural and urban residents (RUCA-defined) were compared on VHA and non-VHA hospitalization rates, overall and for major diagnostic categories. FINDINGS Non-VHA hospital use was much greater than VHA use, though it also was more variable across states. In states with higher proportions of urban enrollees, use of non-VHA hospitals was lower for small or isolated rural town residents than urban residents; in the more rural states, it was greater. Rural enrollees also used VHA hospitals more than urban enrollees if they lived in the South, but they used VHA hospitals less in other states. Findings were consistent across principal diagnoses, except that in every state, rural veterans were hospitalized less often for mental disorders but more for respiratory diseases. Logistic regressions controlling several covariates consistently showed that very rural enrollees relied on VHA hospitals more than urban enrollees. Vouchers would likely increase non-VHA use more in states with greater rural populations. CONCLUSIONS Vouchers for non-VHA inpatient care might have greater impact in rural states.

Associations Between Childbirth and Women Veterans' VA and Non-VA Hospitalizations for Major Diagnostic Categories

Women Veterans enrolled in Veterans Affairs (VA) health care almost always use non-VA hospitals for childbirth, making it more likely they will use non-VA hospitals for other needs, as well. We compared VA and non-VA hospitalizations obtained by VA enrollees in seven states from 2004 through 2007 to determine whether women aged 18 to 44 were more likely to use VA or non-VA care for diagnoses in certain major categories, and how this use differed between women who did or did not have any pregnancy/childbirth admissions during the 4 years. We found that women were hospitalized much more in non-VA than in VA hospitals, though they were relatively more likely to use VA hospitals for mental illness, digestive system diseases, and neoplasms than other diagnoses. Women who gave birth during the time interval had very few VA admissions for any diagnosis, and compared to other women they were also less likely to be hospitalized for mental health or cancer, but more likely to be hospitalized for infectious and parasitic diseases. VA hospitals were used more by women who were slightly older, sicker, poorer, and living nearer to them. VA-using women tend to have different and greater medical needs than those having children.