Steven M. Wright

Positive Predictive Value of the Diagnosis of Acute Myocardial Infarction in an Administrative Database

OBJECTIVE: To determine the positive predictive value of ICD-9-CM coding of acute myocardial infarction and cardiac procedures.METHODS: Using chart-abstracted data as the standard, we examined administrative data from the Veterans Health Administration for a national random sample of 5,151 discharges.MAIN RESULTS: The positive predictive value of acute myocardial infarction coding in the primary position was 96.9%. The sensitivity and specificity of coding were, respectively, 96% and 99% for catheterization, 95.7% and 100% for coronary artery bypass graft surgery, and 90.3% and 99.7% for percutaneous transluminal coronary angioplasty.CONCLUSIONS: The positive predictive value of acute myocardial infarction and related procedure coding is comparable to or better than previously reported observations of administrative databases.

Impact of race on cardiac care and outcomes in veterans with acute myocardial infarction.

Objectives. The goal of this study was to assess racial differences in process of care and outcome for acute myocardial infarction in the VA health care system. Design. Retrospective cohort study using clinical data. Setting. Eighty-one acute care VA hospitals. Patients. Four thousand seven hundred sixty veterans discharged with a confirmed diagnosis of acute myocardial infarction. The analysis was restricted to 606 black and 4005 white patients. Main Outcome Measures. Comparison of use of guideline-based medications, invasive cardiac procedures, and all-cause mortality at 30 days, 1 year, and 3 years. Results. Black patients were equally likely to receive &bgr;-blockers, more likely than white patients to receive aspirin (86.8% vs. 82.0%;P <0.05), and marginally more likely to receive angiotensin converting enzyme inhibitors (55.7% vs. 49.6%;P = 0.07) at the time of discharge. In contrast, black patients were less likely than white patients to receive thrombolytic therapy at the time of arrival (32.4% vs. 48.2%;P <0.01). There was no significant difference in refusal of angiography or percutaneous transluminal coronary angioplasty between black patients and white patients, or in crude rates of either of these procedures. There was also no difference overall in the percentage of patients who refused coronary artery bypass graft surgery. However, black patients were less likely than white patients to undergo bypass surgery (6.9% vs. 12.5% by 90 days;P <0.001). Black patients remained less likely to undergo bypass surgery even when high-risk specific coronary anatomy subgroups were examined. There was no difference in mortality in the two groups. Conclusions. In this integrated health care system, no significant racial disparities in use of noninterventional therapies, diagnostic coronary angiography, or short- or long-term mortality was found. Disparities in use of thrombolytic therapy and coronary artery bypass surgery existed, however, even after accounting for differences in clinical indications for treatment and patient refusals. Further work should assess the role of the medical interaction and physician behavior in racial disparities in use of health care.

Patient Satisfaction of Female and Male Users of Veterans Health Administration Services

AbstractOBJECTIVE: To compare patient satisfaction of male and female users of Veterans Health Administration (VHA) services. DESIGN: Cross-sectional study based on secondary analysis of data from VHA’s Survey of Healthcare Experiences of Patients (SHEP). PATIENTS: National random sample of 107,995 outpatients and 112,817 inpatients in FY2004. MEASURES: Patient’s ratings of overall quality (OQ) and unique dimensions of satisfaction. Sociodemographic and health-related patient attributes. ANALYSIS: Bivariate unadjusted analyses of the association between gender and other patient attributes and the outcomes of OQ and dimensions of satisfaction were conducted followed by multivariate analyses for each outcome, adjusting for demographic and health variables. RESULTS: Significant differences between female and male reporting of satisfaction were found in the unadjusted analyses with males showing greater levels of satisfaction than females (P<.05). These differences disappeared or became smaller for both outpatient and inpatient services, after adjusting for covariates. For 6 of the inpatient dimensions (Transitions, Physical Comfort, Involvement Family and Friends, Courtesy, Coordination, and Access) males had higher satisfaction than females after statistical adjustment. CONCLUSIONS: After adjustment for patient attributes, female VHA outpatients report similar OQ with VHA services as male patients. The fact that some inpatient dimensions of satisfaction continued to show effects favoring males even after adjustment suggests areas for continued focus in improving health care quality. Covariate adjustment is essential for evaluating satisfaction with health care services. Breaking down overall satisfaction into independent aspects of services is useful. The SHEP survey has provided a useful tool for evaluating and improving satisfaction among its VHA veteran users.

Despite Improved Quality Of Care In The Veterans Affairs Health System, Racial Disparity Persists For Important Clinical Outcomes

Both government and private health care systems have engaged in efforts to improve quality, but the effect of these initiatives on racial and ethnic disparities has not been well studied. In the decade following an organizational transformation, the Veterans Affairs (VA) health care system achieved substantial improvements in quality of care with minimal racial disparities for most process-of-care measures, such as rates of cholesterol screenings. However, in our study we observed a striking disconnect between high levels of performance on widely used process measures and modest levels of improvement in clinical outcomes, such as control of blood pressure, blood glucose, and cholesterol levels. We also observed a gap in clinical outcomes of as much as nine percentage points between African American veterans and white veterans. Almost all of the disparity in outcomes in the VA was explained by within-facility disparity, which suggests that VA medical centers need to measure and address racial gaps in care for their patient populations. Moreover, because cardiovascular disease and diabetes are major contributors to racial disparities in life expectancy, the findings of this study and others underscore the urgency of focused efforts to improve intermediate outcomes among African Americans in the VA and other settings.

INCREASING USE OF MEDICARE SERVICES BY VETERANS WITH ACUTE MYOCARDIAL INFARCTION

OBJECTIVES Some of the nations 26 million veterans have two government-financed health care entitlements: Medicare and the Department of Veterans Affairs (VA). The aims of this investigation were to examine trends where Medicare-eligible VA users are initially hospitalized for acute myocardial infarction (AMI) and then to assess rates of cardiac procedure use and mortality for veterans initially admitted to each system of care. METHODS We used VA and HCFA national databases to identify VA users (age range, > or = 65 years) who were initially admitted to a VAMC or Medicare financed hospital (Medicare hospital) with a primary diagnosis of AMI between January 1, 1992, and December 31, 1995, (n = 47,598). We examined the use of cardiac procedures (cardiac catheterization [CC], coronary artery bypass surgery [CABG], and coronary angioplasty [CA] and mortality (30-day and 1-year) by the type of initial admitting hospital within each system of care. RESULTS Almost 70% of VA users hospitalized for AMI were initially admitted to Medicare hospitals versus VAMCs between 1992 (64%) and 1995 (72%). After adjusting for patient characteristics in logistic models, VA users initially hospitalized in Medicare hospitals were significantly more likely to undergo cardiac procedures than were VA users hospitalized in VAMCs. Differences in the odds of receiving a procedure were most significant when comparing Medicare hospitals with on-site cardiac technology to VA hospitals without on-site cardiac technology (CC: OR 4.34, 95% CI 3.98-4.73; CABG: OR 2.16, 95% CI 1.92-2.43; CA: OR 4.56, 95% CI 3.98-5.25). We found no significant differences in 30-day and 1-year adjusted mortality rates between VA users initially admitted to VAMCs or Medicare hospitals. CONCLUSIONS Medicare-eligible VA users are increasingly hospitalized in Medicare hospitals for AMI. VA users cared for in Medicare hospitals receive more cardiac procedures but have the same survival as VA users cared for in VAMCs. These findings have policy implications for access, quality, and costs in both systems of care.

Integration of Women Veterans into VA Quality Improvement Research Efforts: What Researchers Need to Know

The Department of Veterans Affairs (VA) and other federal agencies require funded researchers to include women in their studies. Historically, many researchers have indicated they will include women in proportion to their VA representation or pointed to their numerical minority as justification for exclusion. However, women’s participation in the military—currently 14% of active military—is rapidly changing veteran demographics, with women among the fastest growing segments of new VA users. These changes will require researchers to meet the challenge of finding ways to adequately represent women veterans for meaningful analysis. We describe women veterans’ health and health-care use, note how VA care is organized to meet their needs, report gender differences in quality, highlight national plans for women veterans’ quality improvement, and discuss VA women’s health research. We then discuss challenges and potential solutions for increasing representation of women veterans in VA research, including steps for implementation research.

Examining Quality Issues in Alcohol Misuse Screening

SUMMARY The Veterans Health Administration (VHA) has successfully implemented evidence-based alcohol misuse screening with the AUDIT-C. The purpose of this study was to evaluate clinical alcohol screening during the first year after implementation. Using medical record review and mailed patient surveys collected during 2004 by VHA Office of Quality and Performance, this study analyzed concordance of screening results among patients with AUDIT-Cs in both data sources. Among 1,637 patients with AUDIT-C from both sources within 90 days, the medical record screening prevalence rate of alcohol misuse, 24.6% (95% CI: 22.5% to 26.7%), was significantly lower than the survey rate, 33.4% (31.1% to 35.7%). Of 8,312 patients identified as nondrinkers in medical records, 24% reported past year alcohol use and 5% screened positive for alcohol misuse on surveys. Lower rates of alcohol use and misuse documented in medical records compared to mailed surveys suggest further investigation and standardization of clinical screening are necessary.

Utilization of VA and Medicare services by Medicare-eligible veterans: the impact of additional access points in a rural setting.

EXECUTIVE SUMMARY The Veterans Health Administration (VA) has recently established community‐based outpatient clinics (CBOCs) to improve access to primary care. In our study we sought to understand the relationship between the degree to which older, Medicare‐eligible veterans use CBOCs and their utilization of health services through both the VA and Medicare. We wanted to limit our analysis to a largely rural setting in which patients have greater healthcare needs and where we expected to find that the availability of CBOCs significantly improved access to VA healthcare. Therefore, we identified 47,209 patients who lived in the largely rural states of northern New England and were enrolled in the VA in 1997, 1998, and 1999. We used a merged VA/Medicare dataset to determine utilization in the VA and the private sector and to categorize patients into three segments: those who used only CBOCs for VA primary care, those who used only VA medical centers for VA primary care, and those who used both. For all three groups, we found that VA patients obtained an increasing amount of their care in the private sector, which was funded by Medicare. VA patients who obtained all of their VA primary care services through CBOCs relied on the private sector for most of their specialty and inpatient care needs. Our findings suggest that, in this rural New England setting, improved access to VA care through CBOCs appears to provide complementary, not substitutive, services. Analyses of the efficiency of adding access points to healthcare systems should be conducted, with particular emphasis on examining the possibilities of encroachment, worsened coordination of care, and potential health services overuse.

Veterans Health Administration patients' use of the private sector for coronary revascularization in New York: opportunities to improve outcomes by directing care to high-performance hospitals.

Objective:We sought to quantify Veterans Health Administration (VA) patients’ utilization of coronary revascularization in the private sector and to assess the potential impact of directing this care to high-performance hospitals. Methods:Using VA and New York State administrative and clinical databases, we conducted a retrospective cohort study examining residents of New York State who were enrolled in the VA and underwent either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in 1999 or 2000 (n = 6562) in either the VA or the private sector. We first calculated the proportion of revascularizations obtained in the VA and the private sector. We then identified the private sector hospitals in which these men obtained revascularizations and determined potential changes in mortality and travel burden associated with directing private sector care to high performance hospitals. Results:VA patients in New York were much more likely to undergo revascularization in the private sector than in VA hospitals: 83% of CABGs (2341/2829) and 87% of PCIs (4054/4665) were obtained in the private sector. Private sector utilization was distributed evenly across high- and low-mortality hospitals. Directing private-sector CABG surgery to high-performance hospitals could have reduced expected mortality by 24% (from 2.3% to 1.7%) and would only increase median travel time from 21 to 30 minutes. The benefit of redirecting PCI care is minimal. Conclusions:For high-mortality procedures that veterans frequently obtain in the private sector, like CABG, directing care to high-performance hospitals may be an effective way to improve outcomes for veterans.

Comparing performance of multinomial logistic regression and discriminant analysis for monitoring access to care for acute myocardial infarction.

One way to monitor patient access to emergent health care services is to use patient characteristics to predict arrival time at the hospital after onset of symptoms. This predicted arrival time can then be compared with actual arrival time to allow monitoring of access to services. Predicted arrival time could also be used to estimate potential effects of changes in health care service availability, such as closure of an emergency department or an acute care hospital. Our goal was to determine the best statistical method for prediction of arrival intervals for patients with acute myocardial infarction (AMI) symptoms. We compared the performance of multinomial logistic regression (MLR) and discriminant analysis (DA) models. Models for MLR and DA were developed using a dataset of 3,566 male veterans hospitalized with AMI in 81 VA Medical Centers in 1994-1995 throughout the United States. The dataset was randomly divided into a training set (n = 1,846) and a test set (n = 1,720). Arrival times were grouped into three intervals on the basis of treatment considerations: <6 hours, 6-12 hours, and >12 hours. One model for MLR and two models for DA were developed using the training dataset. One DA model had equal prior probabilities, and one DA model had proportional prior probabilities. Predictive performance of the models was compared using the test (n = 1,720) dataset. Using the test dataset, the proportions of patients in the three arrival time groups were 60.9% for <6 hours, 10.3% for 6-12 hours, and 28.8% for >12 hours after symptom onset. Whereas the overall predictive performance by MLR and DA with proportional priors was higher, the DA models with equal priors performed much better in the smaller groups. Correct classifications were 62.6% by MLR, 62.4% by DA using proportional prior probabilities, and 48.1% using equal prior probabilities of the groups. The misclassifications by MLR for the three groups were 9.5%, 100.0%, 74.2% for each time interval, respectively. Misclassifications by DA models were 9.8%, 100.0%, and 74.4% for the model with proportional priors and 47.6%, 79.5%, and 51.0% for the model with equal priors. The choice of MLR or DA with proportional priors, or DA with equal priors for monitoring time intervals of predicted hospital arrival time for a population should depend on the consequences of misclassification errors.