Shirley Qian

The health status of elderly veteran enrollees in the Veterans Health Administration

Objectives: To examine the health status of elderly veteran enrollees, stratified by age group, and compare with nonveteran populations.

Risk-adjusted mortality as an indicator of outcomes: comparison of the Medicare Advantage Program with the Veterans' Health Administration.

Background:The Medicare Advantage Program (MAP) and the Veterans’ Health Administration (VHA) currently provide many services that benefit the elderly, and a comparative study of their risk-adjusted mortality rates has the potential to provide important information regarding these 2 systems of care. Objective:The objective of this retrospective study was to compare mortality rates between the MAP and the VHA after controlling for case-mix differences. Subjects:This study consisted of 584,294 MAP patients and 420,514 VHA patients. Measures:We used the Death Master File to ascertain the vital status of each study subject over approximately 4 years. We used Cox regression models to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for the MAP compared with VHA patients. Results:The average age for male MAP patients was 73.8 years (±5.6) and for male VHA patients was 74.05 years (±6.3). Unadjusted mortality rates of males for VHA and MAP were 25.7% and 22.8%, respectively, over approximately 4 years (P < 0.0001), respectively. The case-mix of VHA patients, however, was sicker than those from MAP. After adjusting for case-mix, the HR for mortality in the MAP was significantly higher than that in the VHA (HR, 1.404; 95% CI = 1.383–1.426). We obtained similar results when we compared the mortality rates of females for VHA and MAP. Conclusions:After adjusting for their higher prevalence of chronic disease and worse self-reported health, mortality rates were lower for patients cared for in the VHA compared with those in the MAP. Further studies should examine what differences in care structures and processes contribute to lower mortality in the VHA.

Comparison of Health Outcomes for Male Seniors in the Veterans Health Administration and Medicare Advantage Plans

OBJECTIVES To compare the Veterans Health Administration (VHA) with the Medicare Advantage (MA) plans with regard to health outcomes. DATA SOURCES The Medicare Health Outcome Survey, the 1999 Large Health Survey of Veteran Enrollees, and the Ambulatory Care Survey of Healthcare Experiences of Patients (Fiscal Years 2002 and 2003). STUDY DESIGN A retrospective study. EXTRACTION METHODS Men 65+ receiving care in MA (N=198,421) or in VHA (N=360,316). We compared the risk-adjusted probability of being alive with the same or better physical (PCS) and mental (MCS) health at 2-years follow-up. We computed hazard ratio (HR) for 2-year mortality. PRINCIPAL FINDINGS Veterans had a higher adjusted probability of being alive with the same or better PCS compared with MA participants (VHA 69.2 versus MA 63.6 percent, p<.001). VHA patients had a higher adjusted probability than MA patients of being alive with the same or better MCS (76.1 versus 69.6 percent, p<.001). The HRs for mortality in the MA were higher than in the VHA (HR, 1.26 [95 percent CI 1.23-1.29]). CONCLUSIONS Our findings indicate that the VHA has better patient outcomes than the private managed care plans in Medicare. The VHAs performance offers encouragement that the public sector can both finance and provide exemplary health care.

A preference-based measure of health: the VR-6D derived from the veterans RAND 12-Item Health Survey

PurposeThe Veterans RAND 12-Item Health Survey (VR-12) is currently the major endpoint used in the Medicare managed care outcomes measure in the Healthcare Effectiveness Data and Information Set (HEDIS®), referred to as the Health Outcomes Survey (HOS). The purpose of this study is to adapt the Brazier SF-6D utility measure to the VR-12 to generate a single utility index.MethodsWe used the HOS cohorts 2 and 3 for SF-36 data and 9 for VR-12 data. We calculated SF-6D scores from the SF-36 using the algorithms developed by Brazier and colleagues. The values of the Brazier SF-6D were used to estimate utility scores from the VR-12 using a mapping approach based on a 2-stage mapping procedure, named as VR-6D.ResultsThe VR-6D derived from the VR-12 has similar distributional properties as the SF-6D. The change in VR-6D showed significant variations across disease groups with different levels of morbidity and mortality.ConclusionsThis study produced a utility measure for the VR-12 that is comparable to the SF-6D and responsive to change. The VR-6D can be used in evaluations of health care plans and cost-effectiveness analysis to compare the health gains that health care interventions can achieve.

Treatment persistence: a comparison among patients with schizophrenia who were initiated on atypical antipsychotic agents

Background:  Although clinical trials have demonstrated the efficacy of atypical antipsychotic agents in reducing symptoms of schizophrenia, the likelihood of sustaining control of schizophrenic symptoms may depend on treatment persistence.

Adjunctive use of atypical antipsychotics and anticholinergic drugs among patients with schizophrenia

Background:  Treatment of schizophrenia with antipsychotics is often associated with extrapyramidal symptoms (EPS), a disorder involving involuntary muscle movement. Because EPS are often associated with the use of antipsychotics, anticholinergic agents are often indicated.

Evaluation of health services use following the initiation of risperidone long‐acting therapy among schizophrenia patients in the veterans health administration

What is known and Objective:  The introduction of long‐acting injection antipsychotic agents has been associated with better treatment persistence and better subsequent patient outcomes. However, limited empirical data are available on patient outcomes resulting from the initiation of long‐acting injectable antipsychotic agents. In this study, we assessed patterns of health‐care utilization following the initiation of risperidone long‐acting therapy (RLAT), the first and only second generation long‐acting injectable antipsychotic agent, in schizophrenia patients within the Veterans Health Administration.

Monitoring outcomes for the Medicare Advantage program: methods and application of the VR-12 for evaluation of plans.

The Veterans RAND 12-Item Health Survey (VR-12) is one of the major patient-reported outcomes for ranking the Medicare Advantage (MA) plans in the Health Outcomes Survey (HOS). Approaches for scoring physical and mental health are given using contemporary norms and regression estimators. A new metric approach for the VR-12 called the “VR-6D” is presented with case-mix adjustments for monitoring plans that combine utilities and mortality. Results show that the models for ranking health outcomes of the plans are robust and credible. Future directions include the use of utilities for evaluating and ranking of MA plans.

Measurement of Treatment Adherence with Antipsychotic Agents in Patients with Schizophrenia

The importance of medication adherence in sustaining control of schizophrenic symptoms has generated a great deal of interest in comparing levels of treatment adherence with different antipsychotic agents. However, the bulk of the research has yielded results that are often inconsistent. In this prospective, observational study, we assessed the measurement properties of 3 commonly used, pharmacy-based measures of treatment adherence with antipsychotic agents in schizophrenia using data from the Veterans Health Administration during 2000 to 2005. Patients were selected if they were on antipsychotics and diagnosed with schizophrenia (N = 18,425). A gap of ≥30 days (with no filled index medication) was used to define discontinuation of treatment as well as medication “episodes,” or the number of times a patient returned to the same index agent after discontinuation of treatment within a 1-year period. The study found that the 3 existing measures differed in their approaches in measuring treatment adherence, suggesting that studies using these different measures would generate different levels of treatment adherence across antipsychotic agents. Considering the measurement problems associated with each existing approach, we offered a new, medication episode-specific approach, which would provide a fairer comparison of the levels of treatment adherence across different antipsychotic agents.

Estimating utilities for chronic kidney disease, using SF-36 and SF-12-based measures: challenges in a population of veterans with diabetes.

PurposeUsing transformations of existing quality-of-life data to estimate utilities has the potential to efficiently provide investigators with utility information. We used within-method and across-method comparisons and estimated disutilities associated with increasing chronic kidney disease (CKD) severity.MethodsIn an observational cohort of veterans with diabetes (DM) and pre-existing SF-36/SF-12 responses, we used six transformation methods (SF-12 to EQ-5D, SF-36 to HUI2, SF-12 to SF-6D, SF-36 to SF-6D, SF-36 to SF-6D (Bayesian method), and SF-12 to VR-6D) to estimate unadjusted utilities. CKD severity was staged using glomerular filtration rate estimated from serum creatinines, with the modification of diet in renal disease formula. We then used multivariate regression to estimate disutilities specifically associated with CKD severity stage.ResultsOf 67,963 patients, 22,273 patients had recent-onset DM and 45,690 patients had prevalent DM. For the recent-onset group, the adjusted disutility associated with CKD derived from the six transformation methods ranged from 0.0029 to 0.0045 for stage 2; −0.004 to −0.0009 for early stage 3; −0.017 to −0.010 for late stage 3; −0.023 to −0.012 for stage 4; −0.078 to −0.033 for stage 5; and −0.012 to −0.001 for ESRD/dialysis.ConclusionDisutility did not increase monotonically as CKD severity increased. Differences in disutilities estimated using the six different methods were found. Both findings have implications for using such estimates in economic analyses.