Laura S. Ellerbe

Preoperative Alcohol Screening Scores: Association with Complications in Men Undergoing Total Joint Arthroplasty

BACKGROUND The risks associated with preoperative alcohol misuse by patients before undergoing total joint arthroplasty are not well known, yet alcohol misuse by surgical patients is common and has been linked to an increased risk of complications after other procedures. The purpose of this study was to evaluate the association between a patients preoperative standardized alcohol-misuse screening score and his or her risk of complications after total joint arthroplasty. METHODS The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is an alcohol-misuse screening instrument administered annually to all patients receiving care through the Veterans Health Administration (VHA). The scores range from 0 to 12, with higher scores signifying greater and more frequent consumption. In a study of 185 male patients who had alcohol screening scores recorded in the year preceding surgery at a Palo Alto VHA facility, and who reported at least some alcohol use, we estimated the association between preoperative screening scores and the number of surgical complications in an age and comorbidity-adjusted regression analyses. RESULTS Of the 185 patients reporting at least some drinking in the year before their total joint replacement, 17% (thirty-two) had an alcohol screening score suggestive of alcohol misuse; six of those thirty-two patients had one complication, four had two complications, and two had three complications. The screening scores were significantly related to the number of complications in a negative binomial regression analysis (exp[β] = 1.29, p = 0.035), which demonstrated a 29% increase in the expected number of complications with every additional point of the screening score above 1, although with wide confidence intervals for the higher scores. CONCLUSIONS Complications following total joint arthroplasty were significantly related to alcohol misuse in this group of male patients treated at a VHA facility. The AUDIT-C has three simple questions that can be incorporated into a preoperative evaluation and can alert the treatment team to patients with increased postoperative risk. Preoperative screening for alcohol misuse, and perhaps preoperative counseling or referral to treatment for heavy drinkers, may be indicated for patients who are to undergo total joint arthroplasty.

Hemoglobin A1C as a Marker for Surgical Risk in Diabetic Patients Undergoing Total Joint Arthroplasty

Diabetes is a risk factor for complications following total joint arthroplasty (TJA). This retrospective cohort study of 6088 diabetic patients from the Veterans Health Administration (VHA) undergoing TJA sought to determine if hemoglobin A1c, an accessible and objective lab value, has utility as a predictor of risk of complications in TJA after controlling for demographic, surgical, and medical center effects, and to evaluate the benefits and risks of alternative thresholds. Analysis of the functional relationship between hemoglobin A1c and complications revealed that the risk linearly increases through, rather than surging at, the threshold of 7%. Before delaying surgery to achieve better diabetic control, surgeons and patients should weigh the estimated risks of TJA against the potential benefits.

Pharmacotherapy for alcohol dependence: perceived treatment barriers and action strategies among Veterans Health Administration service providers.

Although access to and consideration of pharmacological treatments for alcohol dependence are consensus standards of care, receipt of these medications by patients is generally rare and highly variable across treatment settings. The goal of the present project was to survey and interview the clinicians, managers, and pharmacists affiliated with addiction treatment programs within Veterans Health Administration (VHA) facilities to learn about their perceptions of barriers and facilitators regarding greater and more reliable consideration of pharmacological treatments for alcohol dependence. Fifty-nine participants from 19 high-adopting and 11 low-adopting facilities completed the survey (facility-level response rate = 50%) and 23 participated in a structured interview. The top 4 barriers to increased consideration and use of pharmacotherapy for alcohol dependence were consistent across high- and low-adopting facilities and included perceived low patient demand, pharmacy procedures or formulary restrictions, lack of provider skills or knowledge regarding pharmacotherapy for alcohol dependence, and lack of confidence in treatment effectiveness. Low patient demand was rated as the most important barrier for oral naltrexone and disulfiram, whereas pharmacy or formulary restrictions were rated as the most important barrier for acamprosate and extended-release naltrexone. The 4 strategies rated across low- and high-adopting facilities as most likely to facilitate consideration and use of pharmacotherapy for alcohol dependence were more education to patients about existing medications, more education to health care providers about medications, increased involvement of physicians in treatment for alcohol dependence, and more compelling research on existing medications. This knowledge provides a foundation for designing, deploying, and evaluating targeted implementation efforts.

Many diabetic total joint arthroplasty candidates are unable to achieve a preoperative hemoglobin A1c goal of 7% or less.

BACKGROUND Patients with poorly controlled diabetes have an elevated risk of complications and death following total joint arthroplasty. Some centers set a threshold hemoglobin A1c (HbA1c) value above which surgery is delayed pending better glycemic control. The purpose of this study was to examine how many diabetic patients scheduled for primary total joint arthroplasty underwent a delay because of an HbA1c value of >7.0%, how many subsequently achieved this goal, and how much time was necessary to achieve this goal. METHODS The study involved a retrospective chart review at one Veterans Affairs medical center. Patients with an HbA1c of >7.0% were referred to their primary care provider for better diabetic control. Unless reduction of the HbA1c to ≤7.0% was deemed medically inadvisable, surgery proceeded only after the patient returned with an HbA1c of ≤7.0%. RESULTS A total of 404 diabetic patients were scheduled for total joint arthroplasty. In fifty-nine cases, the surgery was delayed because of an HbA1c of >7.0%. Thirty-five of these patients were able to reduce the HbA1c level to ≤7.0% after a median of 141 days (range, seven to 1043 days), and twenty-four failed to achieve this goal. If an HbA1c goal of ≤8.0% had been used, the surgery would have been delayed in thirty cases, and twenty-one of these patients would have subsequently achieved the goal. CONCLUSIONS When establishing a goal designed to reduce perioperative risks, there should be an expectation that the goal is achievable. Overall, an HbA1c of ≤7.0% was achieved by 380 of the 404 diabetic patients (94%; 95% confidence interval [CI], 91% to 96%), but it was achieved by only thirty-five (59%; 95% CI, 46% to 72%) of the fifty-nine patients presenting with an HbA1c of >7.0%. An HbA1c of 8.0% was achieved by 395 (98%; 95% CI, 96% to 99%) of the diabetic patients and by twenty-one (70%; 95% CI, 50% to 85%) of the thirty patients presenting with an HbA1c of >8.0%. Achieving an HbA1c value of ≤7.0% may not be possible for certain diabetic patients, and such a requirement may risk access to total joint arthroplasty treatment.

Are VHA Administrative Location Codes Valid Indicators of Specialty Substance Use Disorder Treatment

Healthcare quality managers and researchers often need to identify specific healthcare events from administrative data. In this study, we examined whether Veterans Health Administration (VHA) clinic stop and bed section codes are reliable indicators of substance use disorder (SUD) treatment as documented in clinical progress notes. For outpatient records with a progress note, SUD clinic stop code, SUD diagnosis code, and mental health procedure code, we found chart documentation of SUD care in 92.0% of 601 records: 82.5% of 372 records with a SUD clinic stop code and SUD diagnosis code but no mental health procedure code, 21.9% of 379 records with a SUD clinic stop code and mental health procedure code but no SUD diagnosis code, and 55.3% of 318 records with a SUD clinic stop code but no SUD diagnosis or mental health procedure code. For inpatient stays with a SUD bed section code and a progress note, we found chart documentation of SUD care in 99.0% of 699 records accompanied by a SUD diagnosis but 0% of 39 records without a SUD diagnosis. These results provide validity evidence and caveats to researchers and VHA quality managers who might use SUD specialty location codes as indicators of SUD specialty care.

Examining the Specification Validity of the HEDIS Quality Measures for Substance Use Disorders

Accurate operationalization is a major challenge in developing quality measures for substance use disorder treatment. Specification validity is a term used to describe whether a quality measure is operationalized such that it captures the intended care processes and patients. This study assessed the specification validity of the 2009 Healthcare Effectiveness Data and Information Set (HEDIS®) substance use disorder initiation and engagement measures by examining whether encounters assumed to include relevant treatment have corroborating evidence in the clinical progress notes. The positive predictive values were excellent (>90%) for residential and outpatient records selected from addiction treatment programs but more modest for records generated in non-addiction settings, and were highly variable across facilities. Stakeholders using these measures to compare care quality should be mindful of the clinical composition of the data and determine if similar validation work has been conducted on the systems being evaluated.

Barriers to and facilitators of pharmacotherapy for alcohol use disorder in VA residential treatment programs

Among US military veterans, alcohol use disorder (AUD) is prevalent and in severe cases patients need intensive AUD treatment beyond outpatient care. The Department of Veterans Affairs (VA) delivers intensive, highly structured addiction and psychosocial treatment through residential programs. Despite the evidence supporting pharmacotherapy among the effective treatments for AUD, receipt of these medications (e.g., naltrexone, acamprosate) among patients in residential treatment programs varies widely. In order to better understand this variation, the current study examined barriers and facilitators to use of pharmacotherapy for AUD among patients in VA residential treatment programs. Semi-structured qualitative interviews with residential program management and staff were conducted and the Consolidated Framework for Implementation Research was used to guide coding and analysis of interview transcripts. Barriers to use of pharmacotherapy for AUD included cultural norms or philosophy against prescribing, lack of access to willing prescribers, lack of interest from leadership, and perceived lack of patient interest or need. Facilitators included cultural norms of openness or active promotion of pharmacotherapy; education for patients, program staff and prescribers; having prescribers on staff, and care coordination within residential treatment and with other clinic settings in and outside VA. Developing and testing improvement strategies to increase care coordination and consistent support from leadership may also yield increases in the use of pharmacotherapy for AUD among residential patients.

Predictive validity of a quality measure for intensive substance use disorder treatment

ABSTRACT Background: Measures of substance use disorder (SUD) treatment quality are essential tools for performance improvement. The Veterans Health Administration (VHA) developed a measure of access to and engagement in intensive outpatient programs (IOPs) for SUD. However, predictive validity, or associations between this measure and treatment outcomes, has not been examined. Methods: Data on veterans with SUD came from 3 samples: the Outcomes Monitoring Project (N = 5436), a national evaluation of VHA mental health services (N = 339,887), and patients receiving detoxification services (N = 23,572). Propensity score–weighted mixed-effects regressions modeled associations between receiving at least 1 week of IOP treatment and patient outcomes, controlling for facility-level performance and a random effect for facility. Results: Propensity score weighting reduced or eliminated observable baseline differences between patient groups. Patients who accessed IOPs versus those who did not reported significantly reduced alcohol- and drug-related symptom severity, with significantly fewer past-month days drinking alcohol (b = 1.83, P < .001) and fewer past-month days intoxicated (b = 1.55, P < .001). Patients who received IOP after detoxification services had higher 6-month utilization of SUD outpatient visits (b = 2.09, P < .001), more subsequent detoxification episodes (b = 0.25, P < .001), and lower odds of 2-year mortality (odds ratio [OR] = 0.68, 95% confidence interval [CI]: 0.61–0.75; P < .001). Conclusions: Receiving at least 1 week of SUD treatment in an IOP was associated with higher follow-up utilization, improved health outcomes, and reduced mortality. These associations lend support to the predictive validity of VHAs IOP quality measure. Future research should focus on measure feasibility and validity outside of VHA, and whether predictive validity is maintained once this quality measure is tied to performance incentives.