Kevin L. Sloan

Construction and characteristics of the RxRisk-V: a VA-adapted pharmacy-based case-mix instrument.

Background. Assessment of disease burden is the key to many aspects of health care management. Patient diagnoses are commonly used for case-mix assessment. However, issues pertaining to diagnostic data availability and reliability make pharmacy-based strategies attractive. Our goal was to provide a reliable and valid pharmacy-based case-mix classification system for chronic diseases found in the Veterans Health Administration (VHA) population. Objective. To detail the development and category definitions of a VA-adapted version of the RxRisk (formerly the Chronic Disease Score); to describe category prevalence and reliability; to check category criterion validity against ICD-9 diagnoses; and to assess category-specific regression coefficients in concurrent and prospective cost models. Research Design. Clinical and pharmacological review followed by cohort analysis of diagnostic, pharmacy, and utilization databases. Subjects. 126,075 veteran users of VHA services in Washington, Oregon, Idaho, and Alaska. Methods. We used Kappa statistics to evaluate RxRisk category reliability and criterion validity, and multivariate regression to estimate concurrent and prospective cost models. Results. The RxRisk-V classified 70.5% of the VHA Northwest Network 1998 users into an average of 2.61 categories. Of the 45 classes, 33 classes had good-excellent 1-year reliability and 25 classes had good-excellent criterion validity against ICD-9 diagnoses. The RxRisk-V accounts for a distinct proportion of the variance in concurrent (R2 = 0.18) and prospective cost (R2 = 0.10) models. Conclusions. The RxRisk-V provides a reliable and valid method for administrators to describe and understand better chronic disease burden of their treated populations. Tailoring to the VHA permits assessment of disease burden specific to this population.

Predicting costs of care using a pharmacy-based measure risk adjustment in a veteran population.

Background. Although most widely used risk adjustment systems use diagnosis data to classify patients, there is growing interest in risk adjustment based on computerized pharmacy data. The Veterans Health Administration (VHA) is an ideal environment in which to test the efficacy of a pharmacy-based approach. Objective. To examine the ability of RxRisk-V to predict concurrent and prospective costs of care in VHA and compare the performance of RxRisk-V to a simple age/gender model, the original RxRisk, and two leading diagnosis-based risk adjustment approaches: Adjusted Clinical Groups and Diagnostic Cost Groups/Hierarchical Condition Categories. Methods. The study population consisted of 161,202 users of VHA services in Washington, Oregon, Idaho, and Alaska during fiscal years (FY) 1996 to 1998. We examined both concurrent and predictive model fit for two sequential 12-month periods (FY 98 and FY 99) with the patient-year as the unit of analysis, using split-half validation. Results. Our results show that the Diagnostic Cost Group /Hierarchical Condition Categories model performs best (R2 = 0.45) among concurrent cost models, followed by ADG (0.31), RxRisk-V (0.20), and age/sex model (0.01). However, prospective cost models other than age/sex showed comparable R2: Diagnostic Cost Group /Hierarchical Condition Categories R2 = 0.15, followed by ADG (0.12), RxRisk-V (0.12), and age/sex (0.01). Conclusions. RxRisk-V is a clinically relevant, open source risk adjustment system that is easily tailored to fit specific questions, populations, or needs. Although it does not perform better than diagnosis-based measures available on the market, it may provide a reasonable alternative to proprietary systems where accurate computerized pharmacy data are available.

Randomized trial of onsite versus referral primary medical care for veterans in addictions treatment.

Background:Patients presenting for treatment of substance use disorders (SUDs) often exhibit medical comorbidities that affect functional health status and healthcare costs. Providing primary care within addictions clinics (onsite care) may improve medical and SUD treatment outcomes in this population. Objective:The objective of this study was to compare outcomes among Veterans’ Administration (VA) patients who receive medical care within the SUD clinic and those referred to a general medicine clinic at the same facility. Methods:Veterans entering SUD treatment with a chronic medical condition and no current primary care were randomized to receive primary medical care: 1) onsite in the VA SUD clinic (n = 358), or 2) in the VA general internal medicine clinic (n = 362). Subjects were assessed at baseline and at 3, 6, and 12 months postrandomization. Intention-to-treat analyses used random-effects regression. Measures:Measures included SF-36 Physical and Mental Component Summaries (PCS, MCS), VA service utilization, SUD treatment retention, Addiction Severity Index (ASI) scores, 30-day abstinence, and total VA healthcare costs. Results:Over the study year, patients assigned to onsite care were more likely to attend primary care (adjusted odds ratio [OR] = 2.20; 95% confidence interval [CI] = 1.53–3.15) and to remain engaged in SUD treatment at 3 months (adjusted OR = 1.36; 1.00–1.84). Overall, outcomes on the MCS (but not the PCS) and the ASI improved significantly over time but did not differ by treatment condition. Total VA healthcare costs did not differ reliably across conditions. Conclusions:Compared with referral care, providing primary care within a VA addiction clinic increased primary care access and initial SUD treatment retention but showed no effect on overall health status or costs.

Racial Differences in the Evaluation and Treatment of Hepatitis C Among Veterans: A Retrospective Cohort Study

OBJECTIVES We examined the association between race and hepatitis C virus (HCV) evaluation and treatment of veterans in the Northwest Network of the Department of Veterans Affairs (VA). METHODS In our retrospective cohort study, we used medical records to determine antiviral treatment of 4263 HCV-infected patients from 8 VA medical centers. Secondary outcomes included specialty referrals, laboratory evaluation, viral genotype testing, and liver biopsy. Multiple logistic regression was used to adjust for clinical (measured through laboratory results and International Classification of Diseases, Ninth Revision, codes) and sociodemographic factors. RESULTS Blacks were less than half as likely as Whites to receive antiviral treatment (odds ratio [OR]=0.38; 95% confidence interval [CI]=0.23, 0.63). Both had similar odds of referral and liver biopsy. However, Blacks were significantly less likely to have complete laboratory evaluation (OR=0.67; 95% CI=0.52, 0.88) and viral genotype testing (OR=0.68; 95% CI=0.51, 0.90). CONCLUSIONS Race is associated with receipt of medical care for various medical conditions. Further investigation is warranted to help understand whether patient preference or provider bias may explain why HCV-infected Blacks were less likely to receive medical care than Whites.

Smoking cessation treatment among dually diagnosed individuals: Preliminary evaluation of different pharmacotherapies

This descriptive, observational pilot study evaluated a smoking cessation intervention using open-label bupropion and nicotine replacement within an addiction treatment center for patients with high rates of comorbid psychiatric diagnoses. Participants were 115 veterans receiving substance abuse treatment at a Veterans Administration outpatient program who voluntarily sought smoking cessation treatment. Three fourths of participants had a psychiatric diagnosis in addition to substance dependence (i.e., dual diagnosis). The intervention consisted of a weekly smoking cessation therapy group and pharmacotherapy as determined by participant and clinician preference (none, nicotine replacement only, bupropion only, or combined nicotine and bupropion). A total of 47 participants (40.9%) completed four group smoking cessation sessions, and 17 (14.8%) completed eight sessions. Of these participants, 27 (23.5%) had breath carbon monoxide (CO) levels <9 ppm (indicating short-term abstinence) at session 4, and nine (7.8%) had CO levels <9 ppm at session 8. Participants who received nicotine replacement alone or with bupropion attended more sessions than did subjects who did not receive nicotine replacement. Participants receiving combined medications had greater reductions in CO levels at session 4 than did the other participants. There was no evidence of increased use of other substances during smoking cessation treatment. These findings indicate that many dually diagnosed individuals are willing to attempt smoking cessation with appropriate pharmacotherapy and achieve reductions in CO measures, but only minimal success was observed with respect to cessation. Additional research is needed to assess medication effects in randomized trials, to explore effects of more intensive treatments, and to assess possible harm reduction from smoking interventions within this population.

Hepatitis C tested prevalence and comorbidities among veterans in the US Northwest.

Goals (1) Investigate the epidemiology of hepatitis C virus infection among patients seen in the Veterans Administration Northwest Network; (2) examine time trends in testing practices and results; and (3) estimate the prevalence of hepatitis C virus infection among active patients. Background Hepatitis C virus infection causes chronic hepatitis and cirrhosis and is a leading cause of end-stage liver disease. Hepatitis C virus antibodies are estimated to be present in 1.8% of the US population, but reports of its prevalence among US veterans range from 1.7 to 35%. Study Retrospective review of computerized medical records of veterans tested for hepatitis C from October 1994 through December 2000 (n = 37,938) at 8 Northwest Veterans Administration Medical Centers. Results Among tested veterans, 8230 (21.7%) had evidence of hepatitis C virus infection. The number of patients tested increased annually from 2335 to 18,191, while the proportion with first-time positive hepatitis C test results decreased from 35 to 10%. This drop in tested prevalence was associated with a shift away from testing individuals at highest risk—those with positive hepatitis B serostatus, repeatedly elevated alanine transaminase levels, and drug use disorder diagnoses. We estimate that 11.4% of the Northwest Network veteran users are hepatitis C virus seropositive, with a lower bound of 4.0% and upper bound of 19.5%. Conclusions Although estimates of hepatitis C virus infection rates among veteran users of the Veterans Administration system remain higher than those for the general population, changes in testing practice make generalizations from earlier studies hazardous.

Cost Effectiveness of Testing Strategies for Chronic Hepatitis C

OBJECTIVE:This paper compares nine strategies for determining hepatitis C antibody and viral status. They combine two tests for antibodies (enzyme immunoassays (EIA), recombinant immunoblot assays (RIBA)) and one for viremia (reverse transcription polymerase chain reaction (PCR)). Using optical density to divide EIA results into three categories (high positive, low positive, negative) was also considered.METHODS:Decision analysis compared strategies on cost as well as sensitivity and specificity with regard to antibody and viral status. Parameters in the decision tree included antibody prevalence, proportion viremic, sensitivity, specificity, and cost of individual tests.RESULTS:The two best strategies are EIA followed by PCR (EIA→PCR); and EIA with three levels of optical density (EIA-OD), followed by RIBA for EIA-OD low positives, and then PCR for all positives (EIA-OD→RIBA→PCR). EIA→PCR has equal viral sensitivity, slightly lower cost, slightly higher antibody sensitivity, but lower antibody specificity compared to EIA-OD→RIBA→PCR. The cost per false antibody positive avoided using EIA-OD→RIBA→PCR rather than EIA→PCR is

Frequency of serum low-density lipoprotein cholesterol measurement and frequency of results ≤100 mg/dl among patients who had coronary events (Northwest VA Network Study) ∗

36 when prevalence is 5%, and

Efficacy of Oral β-Lactam versus Non-β-Lactam Treatment of Uncomplicated Cellulitis

193 when prevalence is 50%. Using EIA-OD→RIBA→PCR rather than EIA→PCR results in 112 false antibody positives avoided for every true antibody positive missed when prevalence is 5%; this ratio is 18:1 when prevalence is 25%; and 6:1 when prevalence is 50%.CONCLUSIONS:EIA-OD→RIBA→PCR is the best choice when prevalence in the tested group is below 20%. As prevalence increases, the choice of EIA-OD→RIBA→PCR versus EIA→PCR will depend on the relative importance of avoiding false antibody positives versus missing true antibody positives. Our analysis makes explicit the magnitude of this trade-off.

Case‐Mix Adjusting Performance Measures in a Veteran Population: Pharmacy‐ and Diagnosis‐Based Approaches

This population-based, cross-sectional analysis targeted all veterans with coronary heart disease (CHD) who were active patients in primary care or cardiology clinics in the Veterans Health Administration Northwest Network from July 1998 to June 1999. We report guideline compliance rates, including whether low-density lipoprotein (LDL) was measured, and if measured, whether the LDL was < or=100 mg/dl. In addition, we utilized multivariate logistic regression to determine patient characteristics associated with LDL measurements and levels. Of 13,891 active patients with CHD, 5,552 (40.0%) did not have a current LDL measurement. Of those with LDL measurements, 39.1% were at the LDL goal of < or =100 mg/dl, whereas 26.5% had LDL > or =130 mg/dl. Male gender, younger age, history of angioplasty or coronary artery bypass grafting, current hypertension, diabetes mellitus, and angina pectoris were associated with increased likelihood of LDL measurement. Older age and current diabetes and angina were associated with increased likelihood of LDL being < or =100 mg/dl, if measured. Although these rates of guideline adherence in the CHD population compare well to previously published results, they continue to be unacceptably low for optimal clinical outcomes. Attention to both LDL measurement and treatment (if elevated) is warranted.