Boris Kader

Inadequate management of blood pressure in a hypertensive population.

BACKGROUND Many patients with hypertension have inadequate control of their blood pressure. Improving the treatment of hypertension requires an understanding of the ways in which physicians manage this condition and a means of assessing the efficacy of this care. METHODS We examined the care of 800 hypertensive men at five Department of Veterans Affairs sites in New England over a two-year period. Their mean (+/-SD) age was 65.5+/-9.1 years, and the average duration of hypertension was 12.6+/-5.3 years. We used recursive partitioning to assess the probability that antihypertensive therapy would be increased at a given clinic visit using several variables. We then used these predictions to define the intensity of treatment for each patient during the study period, and we examined the associations between the intensity of treatment and the degree of control of blood pressure. RESULTS Approximately 40 percent of the patients had a blood pressure of > or =160/90 mm Hg despite an average of more than six hypertension-related visits per year. Increases in therapy occurred during 6.7 percent of visits. Characteristics associated with an increase in antihypertensive therapy included increased levels of both systolic and diastolic blood pressure at that visit (but not previous visits), a previous change in therapy, the presence of coronary artery disease, and a scheduled visit. Patients who had more intensive therapy had significantly (P<0.01) better control of blood pressure. During the two-year period, systolic blood pressure declined by 6.3 mm Hg among patients with the most intensive treatment, but increased by 4.8 mm Hg among the patients with the least intensive treatment. CONCLUSIONS In a selected population of older men, blood pressure was poorly controlled in many. Those who received more intensive medical therapy had better control. Many physicians are not aggressive enough in their approach to hypertension.

Measuring the quality of depression care in a large integrated health system.

Background. Guideline-based depression process measures provide a powerful way to monitor depression care and target areas needing improvement. Objectives. To assess the adequacy of depression care in the Veterans Health Administration (VHA) using guideline-based process measures derived from administrative and centralized pharmacy records, and to identify patient and provider characteristics associated with adequate depression care. Research Design. This is a cohort study of patients from 14 VHA hospitals in the Northeastern United States which relied on existing databases. Subject eligibility criteria: at least one depression diagnosis during 1999, neither schizophrenia nor bipolar disease, and at least one antidepressant prescribed in the VHA during the period of depression care profiling (June 1, 1999 through August 31, 1999). Depression care was evaluated with process measures defined from the 1997 VHA depression guidelines: antidepressant dosage and duration adequacy. We used multivariable regression to identify patient and provider characteristics predicting adequate care. Subjects. There were 12,678 patients eligible for depression care profiling. Results. Adequate dosage was identified in 90%; 45% of patients had adequate duration of antidepressants. Significant patient and provider characteristics predicting inadequate depression care were younger age (<65), black race, and treatment exclusively in primary care. Conclusions. Under-treatment of depression exists in the VHA, despite considerable mental health access and generous pharmacy benefits. Certain patient populations may be at higher risk for inadequate depression care. More work is needed to align current practice with best-practice guidelines and to identify optimal ways of using available data sources to monitor depression care quality.

Are we improving the quality of nursing home care : The case of pressure ulcers

BACKGROUND: There are widespread concerns regarding the quality of nursing home care and whether care is improving. We evaluated a large provider of nursing home care to determine whether risk‐adjusted rates of pressure ulcer development have changed.

Deriving a Risk-Adjustment Model for Pressure Ulcer Development Using the Minimum Data Set

OBJECTIVE: To use the Minimum Data Set (MDS) to derive a risk‐adjustment model for pressure ulcer development that may be used in assessing the quality of nursing home care.

Racial differences in the prevalence of atrial fibrillation among males.

BACKGROUND Despite being the most common cardiac arrhythmia, little is known about racial differences in atrial fibrillation (AF) prevalence and whether differences persist after accounting for known risk factors. METHODS We identified male respondents to the 1999 Large Health Survey of Veteran Enrollees who had an AF diagnosis in the VA administrative database during the preceding two years. RESULTS Of 664,754 male respondents, 5.3% had AF. By race, age-adjusted prevalence was 5.7% in whites, 3.4% in blacks, 3.0% in Hispanics, 5.4% in native Americans/Alaskans, 3.6% in Asians and 5.2% in Pacific Islanders (p<0.001). Of predisposing conditions, whites were more likely to have valvular heart disease, coronary artery disease and congestive heart failure, blacks had the highest hypertension prevalence; Hispanics had the highest diabetes prevalence. Racial differences remained after adjustment for age, body mass index and these comorbidities. White males were significantly more likely to have AF compared to all races but Pacific Islanders [versus blacks, OR=1.84 (95% CI: 1.71-1.98); versus Hispanics, OR=1.77 (1.60-1.97); vs Native Americans, OR 1.15 [1.04-1.27]; versus Asians, OR=1.41 (1.12-1.77) versus Pacific Islanders, OR=1.16 (0.88-1.53)]. CONCLUSIONS AF prevalence varies by race. White males have the highest AF burden even after adjustment for known risk factors. Recognition of the high AF prevalence, especially among whites, as well as native Americans and Pacific Islanders, should help guide provider practices for screening among older male patients. Further research is necessary to verify and establish reasons for these racial differences.

Using administrative data to identify mental illness: what approach is best?

The authors estimated the validity of algorithms for identification of mental health conditions (MHCs) in administrative data for the 133 068 diabetic patients who used Veterans Health Administration (VHA) nationally in 1998 and responded to the 1999 Large Health Survey of Veteran Enrollees. They compared various algorithms for identification of MHCs from International Classification of Diseases, 9th Revision (ICD-9) codes with self-reported depression, posttraumatic stress disorder, or schizophrenia from the survey. Positive predictive value (PPV) and negative predictive value (NPV) for identification of MHC varied by algorithm (0.65-0.86, 0.68-0.77, respectively). PPV was optimized by requiring ≥2 instances of MHC ICD-9 codes or by only accepting codes from mental health visits. NPV was optimized by supplementing VHA data with Medicare data. Findings inform efforts to identify MHC in quality improvement programs that assess health care disparities. When using administrative data in mental health studies, researchers should consider the nature of their research question in choosing algorithms for MHC identification.

Monitoring depression care: in search of an accurate quality indicator.

Background:Linking process and outcomes is critical to accurately estimating healthcare quality and quantifying its benefits. Objectives:The objective of this study was to explore the relationship of guideline-based depression process measures with subsequent overall and psychiatric hospitalizations. Research Design:This is a retrospective cohort study during which we used administrative and centralized pharmacy records for sample identification, derivation of guideline-based process measures (antidepressant dosage and duration adequacy), and subsequent hospitalization ascertainment. Depression care was measured from June 1, 1999, through August 31, 1999. We used multivariable regression to evaluate the link between depression care and subsequent overall and psychiatric hospitalization, adjusting for patient age, race, sex, socioeconomic status, comorbid illness, and hospitalization in the prior 12 months. Subjects:We studied a total of 12,678 patients from 14 Northeastern VHA hospitals. Results:We identified adequate antidepressant dosage in 90% and adequate duration in 45%. Those with adequate duration of antidepressants were less likely to be hospitalized in the subsequent 12 months than those with inadequate duration (odds ratio [OR], .90; 95% confidence interval [CI], .81–1.00). Those with adequate duration of antidepressants were less likely to have a psychiatric hospitalization in the subsequent 12 months than those with inadequate duration (OR, .82; 95% CI, .69–.96). We did not demonstrate a significant link between dosage adequacy and subsequent overall or psychiatric hospitalization. Conclusions:Guideline-based depression process measures derived from centralized data sources offer an important method of depression care surveillance. Their accuracy in capturing depression care quality is supported by their link to healthcare utilization. Further work is needed to assess the effect of implementing these quality indicators on depression care.

Evaluation of a risk-adjustment model for pressure ulcer development using the Minimum Data Set

OBJECTIVE: To validate a previously derived risk‐adjustment model for pressure ulcer development in a separate sample of nursing home residents and to determine the extent to which use of this model affects judgments of nursing home performance.

Health care reorganization and quality of care: unintended effects on pressure ulcer prevention.

Background.Health care reorganizations, with a change in focus from inpatient to outpatient care, are becoming increasingly frequent. Little is known regarding how reorganizations may affect risk-adjusted outcomes for those programs, usually inpatient, that lose resources as a result of the change in organizational focus. Objectives.To determine changes in risk-adjusted rates of pressure ulcer development over an 8-year period, the final 3 of which were characterized by a significant reorganization of the health care system. Design.This was an observational study that used an existing database. Subjects.Subjects were residents of Department of Veterans Affairs long-term care units between 1990 and 1997 who were without a pressure ulcer at an index assessment. Measures.The study examined risk-adjusted rates of pressure ulcer development, and proportions of new ulcers that were severe (stages 3 or 4) were calculated for successive 6-month periods. Results.Between 1990 and 1994, risk-adjusted rates of pressure ulcer development declined significantly, by 27%. However, beginning in 1995, rates began to increase, and in 1997 they were similar to those in 1990. The proportion of new ulcers that were severe increased significantly over time (P = 0.01). Conclusions.The reorganization of the VA that began in 1995, with its emphasis on outpatient care, was associated with an increase in rates of pressure ulcer development. This highlights the need to carefully monitor the quality of care in programs that may be losing resources as a result of the reorganization.

Profiling Nursing Homes Using Bayesian Hierarchical Modeling

OBJECTIVES: New methods developed to improve the statistical basis of provider profiling may be particularly applicable to nursing homes. We examine the use of Bayesian hierarchical modeling in profiling nursing homes on their rate of pressure ulcer development.