Diana L. Ordin

Hospital Characteristics Associated with Timeliness of Care in Veterans with Lung Cancer

RATIONALE Timeliness is one of six important dimensions of health care quality recognized by the Institute of Medicine. OBJECTIVES To evaluate timeliness of lung cancer care and identify institutional characteristics associated with timely care within the Veterans Affairs (VA) health care system. METHODS We used data from a VA nation-wide retrospective chart review and an independent audit of VA cancer programs to examine the association between time to first treatment and potentially explanatory institutional characteristics (e.g., volume of lung cancer patients) for 2,372 veterans diagnosed with lung cancer between 1 January 2002 and 1 September 2005 at 127 VA medical centers. We developed linear mixed effects models to control for clustering of patients within hospitals and we stratified analyses by stage. MEASUREMENTS AND MAIN RESULTS Median time to treatment varied widely between (23 to 182 d) and within facilities. Median time to treatment was 90 days in patients with stage I or II cancer and 52 days in those with more advanced disease (P < 0.0001). Factors associated with shorter times to treatment included a nonacademic setting and the existence of a specialized diagnostic clinic (in patients with limited-stage disease), performing a patient flow analysis (in patients with advanced disease), and leadership beliefs about providing timely care (in both groups). However, institutional characteristics explained less than 1% of the observed variation in treatment times. CONCLUSIONS Time to lung cancer treatment in U.S. veterans is highly variable. The numerous institutional characteristics we examined explained relatively little of this variability, suggesting that patient, clinician, and/or unmeasured institutional characteristics may be more important determinants of timely care.

Estimating and Reporting on the Quality of Inpatient Stroke Care by Veterans Health Administration Medical Centers

Background— Reporting of quality indicators (QIs) in Veterans Health Administration Medical Centers is complicated by estimation error caused by small numbers of eligible patients per facility. We applied multilevel modeling and empirical Bayes (EB) estimation in addressing this issue in performance reporting of stroke care quality in the Medical Centers. Methods and Results— We studied a retrospective cohort of 3812 veterans admitted to 106 Medical Centers with ischemic stroke during fiscal year 2007. The median number of study patients per facility was 34 (range, 12–105). Inpatient stroke care quality was measured with 13 evidence-based QIs. Eligible patients could either pass or fail each indicator. Multilevel modeling of a patients pass/fail on individual QIs was used to produce facility-level EB-estimated QI pass rates and confidence intervals. The EB estimation reduced interfacility variation in QI rates. Small facilities and those with exceptionally high or low rates were most affected. We recommended 8 of the 13 QIs for performance reporting: dysphagia screening, National Institutes of Health Stroke Scale documentation, early ambulation, fall risk assessment, pressure ulcer risk assessment, Functional Independence Measure documentation, lipid management, and deep vein thrombosis prophylaxis. These QIs displayed sufficient variation across facilities, had room for improvement, and identified sites with performance that was significantly above or below the population average. The remaining 5 QIs were not recommended because of too few eligible patients or high pass rates with little variation. Conclusions— Considerations of statistical uncertainty should inform the choice of QIs and their application to performance reporting.

Patient Preference and Contraindications in Measuring Quality of Care: What Do Administrative Data Miss?

PURPOSE Prior studies report that half of patients with lung cancer do not receive guideline-concordant care. With data from a national Veterans Health Administration (VHA) study on quality of care, we sought to determine what proportion of patients refused or had a contraindication to recommended lung cancer therapy. PATIENTS AND METHODS Through medical record abstraction, we evaluated adherence to six quality indicators addressing lung cancer-directed therapy for patients diagnosed within the VHA during 2007 and calculated the proportion of patients receiving, refusing, or having contraindications to recommended treatment. RESULTS Mean age of the predominantly male population was 67.7 years (standard deviation, 9.4 years), and 15% were black. Adherence to quality indicators ranged from 81% for adjuvant chemotherapy to 98% for curative resection; however, many patients met quality indicator criteria without actually receiving recommended therapy by having a refusal (0% to 14%) or contraindication (1% to 30%) documented. Less than 1% of patients refused palliative chemotherapy. Black patients were more likely to refuse or bear a contraindication to surgery even when controlling for comorbidity; race was not associated with refusals or contraindications to other treatments. CONCLUSION Refusals and contraindications are common and may account for previously demonstrated low rates of recommended lung cancer therapy performance at the VHA. Racial disparities in treatment may be explained, in part, by such factors. These results sound a cautionary note for quality measurement that depends on data that do not reflect patient preference or contraindications in conditions where such considerations are important.

Prevalence of Inadequate Blood Pressure Control Among Veterans After Acute Ischemic Stroke Hospitalization A Retrospective Cohort

Background—Reducing blood pressure (BP) after stroke reduces risk for recurrent events. Our aim was to describe hypertension care among veterans with ischemic stroke including BP control by discharge and over the 6 months after the stroke event. Methods and Results—The Office of Quality and Performance Stroke Special Study included a systematic sample of veterans hospitalized for ischemic stroke in 2007. We examined BP control (<140/90 mm Hg) at discharge excluding those who died, enrolled in hospice, or had unknown discharge disposition (n=3640, n=3382 adjusted analysis). The second outcome was BP control (<140/90 mm Hg) within 6-months after stroke, excluding patients who died/readmitted within 30 days, were lost to follow-up, or did not have a BP recorded (n=2054, n=1915 adjusted analysis). The population was 62.7% white and 97.7% men; 46.9% were <65 years of age; and 29% and 37% had a history of cerebrovascular or cardiovascular disease, respectively. Among the 3640 stroke patients, 1573 (43%) had their last documented BP before discharge as >140/90 mm Hg. Black race (adjusted odds ratio, 0.77; 95% confidence interval, 0.65 to 0.91), diabetes (odds ratio, 0.73; 95% confidence interval, 0.62 to 0.86), and hypertension history (odds ratio, 0.51; 95% confidence interval, 0.42 to 0.63) were associated with lower odds for controlled BP at discharge. Of the 2054 stroke patients seen within 6 months from their index event, 673 (32.8%) remained uncontrolled. By 6 months after the event, neither race nor diabetes was associated with BP control, whereas history of hypertension continued to have lower odds of BP control. For each 10-point increase in systolic BP >140 mm Hg at discharge, odds of BP control within 6 months after discharge decreased by 12% (95% confidence interval [8%, 18%]). Conclusions—BP values in excess of national guidelines are common after stroke. Forty-three percent of patients were discharged with an elevated BP, and 33% remained uncontrolled by 6 months.

Timeliness Across the Continuum of Care in Veterans with Lung Cancer

Introduction: By providing timely care at all steps along the continuum of lung cancer care, providers may be able to limit disease progression before treatment and possibly improve clinical outcomes. This study examines the timeliness of key events in the process of care between initial radiograph and first treatment. Methods: Dates of key events were extracted from the medical records of 2463 veterans receiving lung cancer care at 133 Department of Veterans Affairs (VA) facilities. After reviewing their site’s abstraction results, facility leaders completed a survey on their perceptions of their local processes of lung cancer care. Results: Median time from first radiography to first treatment was 71 days. The longest intermediate time interval examined was between first treatment referral and first treatment (median = 12 days). Time from first to last diagnostic test was most variable (interquartile range = 0–27 days). We found a significant trend indicating that the time interval from first radiograph to treatment was shorter for patients with more advanced disease. This effect was also significant within six of the seven intermediate time intervals we examined. Survey responses indicated that the chart review process stimulated improvement activity. Conclusions: Although patients with earlier stage disease benefit more from treatment, they do not proceed as quickly through the continuum of care as patients with more advanced disease. By measuring variability in timeliness of care at multiple steps in the lung cancer care process, facilities may identify opportunities for improvement.

Timely Follow-Up of Positive Fecal Occult Blood Tests Strategies Associated with Improvement

BACKGROUND In light of previous research indicating that many patients fail to receive timely diagnostic follow-up of positive colorectal cancer (CRC) screening tests, the Veterans Health Administration (VA) initiated a national CRC diagnosis quality-improvement (QI) effort. PURPOSE This article documents the percent of patients receiving follow-up within 60 days of a positive CRC screening fecal occult blood test (FOBT) and identifies improvement strategies that predict timely follow-up. METHODS In 2007, VA facilities completed a survey in which they indicated the degree to which they had implemented a series of improvement strategies and described barriers to improvement. Three types of strategies were assessed: developing QI infrastructure, improving care delivery processes, and building gastroenterology capacity. Survey data were merged with a measure of 60-day positive-FOBT follow-up. Facility-level predictors of timely follow-up were identified and relationships among categories of improvement strategies were assessed. Data were analyzed in 2008. RESULTS The median facility-reported 60-day follow-up rate for positive screening FOBTs was 24.5%. Several strategies were associated with timeliness of follow-up. The relationship between the implementation of QI infrastructure strategies and timely follow-up was mediated by the implementation of process-change strategies. Although constraints on gastroenterology capacity were often sited as a key barrier, implementation of strategies to address this issue was unassociated with timely follow-up. CONCLUSIONS Developing QI infrastructure appears to be an effective strategy for improving FOBT follow-up when this work is followed by process improvements. Increasing gastroenterology capacity may be more difficult than improving processes of care.

Lower use of carotid artery imaging at minority-serving hospitals

Objective: We determined whether site of care explains a previously identified racial disparity in carotid artery imaging. Methods: In this retrospective cohort study, data were obtained from a chart review of veterans hospitalized with ischemic stroke at 127 Veterans Administration hospitals in 2007. Extensive exclusion criteria were applied to obtain a sample who should have received carotid artery imaging. Minority-serving hospitals were defined as the top 10% of hospitals ranked by the proportion of stroke patients who were black. Population level multivariate logistic regression models with adjustment for correlation of patients in hospitals were used to calculate predictive probabilities of carotid artery imaging by race and minority-service hospital status. Bootstrapping was used to obtain 95% confidence intervals (CIs). Results: The sample consisted of 1,534 white patients and 628 black patients. Nearly 40% of all black patients were admitted to 1 of 13 minority-serving hospitals. No racial disparity in receipt of carotid artery imaging was detected within nonminority serving hospitals. However, the predicted probability of receiving carotid artery imaging for white patients at nonminority-serving hospitals (89.7%, 95% CI [87.3%, 92.1%]) was significantly higher than both white patients (78.0% [68.3%, 87.8%] and black patients (70.5% [59.3%, 81.6%]) at minority-serving hospitals. Conclusions: Underuse of carotid artery imaging occurred most often among patients hospitalized at minority-serving hospitals. Further work is required to explore why site of care is a mechanism for racial disparities in this clinically important diagnostic test.

Correlation of Inpatient and Outpatient Measures of Stroke Care Quality Within Veterans Health Administration Hospitals

Background and Purpose— Quality of care delivered in the inpatient and ambulatory settings may be correlated within an integrated health system such as the Veterans Health Administration. We examined the correlation between stroke care quality at hospital discharge and within 6 months postdischarge. Methods— We conducted a cross-sectional hospital-level correlation analyses of chart-abstracted data for 3467 veterans discharged alive after an acute ischemic stroke from 108 Veterans Health Administration medical centers and 2380 veterans with postdischarge follow-up within 6 months in fiscal year 2007. Four risk-standardized processes of care represented discharge care quality: prescription of antithrombotic and antilipidmic therapy, anticoagulation for atrial fibrillation, and tobacco cessation counseling along with a composite measure of defect-free care. Five risk-standardized intermediate outcomes represented postdischarge care quality: achievement of blood pressure, low-density lipoprotein, international normalized ratio, and glycosylated hemoglobin target levels, and delivery of appropriate treatment for poststroke depression along with a composite measure of achieved outcomes. Results— Median risk-standardized composite rate of defect-free care at discharge was 79%. Median risk-standardized postdischarge rates of achieving goal were 56% for blood pressure, 36% for low-density lipoprotein, 41% for international normalized ratio, 40% for glycosylated hemoglobin, and 39% for depression management and the median risk-standardized composite 6-month outcome rate was 44%. The hospital composite rate of defect-free care at discharge was correlated with meeting the low-density lipoprotein goal (r=0.31; P=0.007) and depression management (r=0.27; P=0.03) goal but was not correlated with blood pressure, international normalized ratio, glycosylated hemoglobin goals, nor with the composite measure of achieved postdischarge outcomes (probability values >0.13). Conclusions— Hospital discharge care quality was not consistently correlated with ambulatory care quality.

The use and misuse of thrombolytic therapy within the veterans health administration

Background:Within the Veterans Health Administration (VHA), approximately 6000 veterans are hospitalized with acute ischemic stroke annually. We examined the use and misuse of thrombolytic therapy with tissue plasminogen activator (tPA) in a national sample of veterans who were admitted to a VHA Medical Center (VAMC) with acute ischemic stroke. Methods:Medical record reviews were conducted on 5000 acute stroke patients who were admitted to a VAMC in 2007. Patients were defined as eligible to receive tPA if they arrived at the hospital within 3 hours of stroke symptom onset and had no contraindications to tPA. We compared eligible patients who received tPA to those who did not and examined the distribution of eligible patients across the 129 VAMCs included in this study. Results:Among the 3931 ischemic stroke patients, 174 (4.4%) were eligible for tPA. Among the 135 patients who arrived within 2 hours of symptom onset which allowed adequate time for testing and evaluation, 19 (14.1%) received tPA. An additional 11 patients received tPA but did not meet eligibility criteria. Eligible patients receiving tPA were similar to eligible patients not receiving tPA in terms of clinical conditions and time to brain imaging. Among the 30 patients that received tPA, 5 (16.6%) received the wrong dose. Among the 85 VAMCs that received ≥1 eligible patient, on average 2.3 patients were eligible for tPA annually. Conclusions:Relatively few eligible veterans receive thrombolysis across the VHA system. Strategies to improve thrombolysis delivery will have to account for the low annual volume of eligible stroke patients cared for at individual VAMCs.

Does Inpatient Quality of Care Differ by Age Among US Veterans with Ischemic Stroke

BACKGROUND Some studies have found that older individuals are not as likely as their younger counterparts to be treated with some guideline-based stroke therapies. We examined whether age-related differences in inpatient quality of care exist among US veterans with ischemic stroke. METHODS This was a retrospective study of a national sample of veterans admitted to 129 Veterans Affairs medical centers for ischemic stroke during fiscal year 2007. Inpatient stroke care quality was examined across 14 inpatient processes of care, including dysphagia screening, National Institutes of Health Stroke Scale (NIHSS) score documentation, thrombolysis, deep venous thrombosis prophylaxis, antithrombotic therapy by hospital day 2 and at discharge, early ambulation, fall risk assessment, pressure ulcer risk assessment, rehabilitation needs assessment, atrial fibrillation management, lipid management, smoking cessation counseling, and stroke education. RESULTS Among the 3939 veterans with ischemic stroke, the mean age was 67.8 years (standard deviation, 11.5). The overall performance rate was >70% for 10 of the 14 quality indicators. In unadjusted analyses, older patients were less likely to receive lipid management, smoking cessation, NIHSS documentation, and early ambulation compared with younger patients; conversely, older patients were more likely to receive dysphagia screening and stroke education. After adjusting for demographic, clinical, and hospital level characteristics, the age-related differences in processes of care were less consistent; however, the youngest patients were more likely to receive smoking cessation counseling and the oldest patients were less likely to receive lipid management. CONCLUSIONS Risk-adjusted inpatient stroke care quality varies little with age for veterans admitted to a Veterans Affairs medical center for acute ischemic stroke.