Terri J. Menke

Geographic Variations in Utilization Rates in Veterans Affairs Hospitals and Clinics

BACKGROUND In the United States, geographic variation in hospital use is common. It is uncertain whether there are similar geographic variations in the health care system of the Department of Veterans Affairs (VA), which differs from the private sector because it predominantly serves men with annual incomes below

Short-term, intermediate-term, and long-term mortality in patients hospitalized for stroke

20,000, has a central system of administration, and uses salaried physicians. Thus, it might be less likely to have geographic variations. METHODS We used VA data bases to obtain information on patients treated for eight diseases (chronic obstructive pulmonary disease, pneumonia, congestive heart failure, angina, diabetes, chronic renal failure, bipolar disorder, and major depression). We analyzed their use of hospital and outpatient services by assessing the risk-adjusted numbers of hospital days (the average number of days a patient spent in the hospital per 12 months of follow-up, regardless of the number of hospital stays), hospital-discharge rates, and clinic-visit rates from 1991 through 1995 for the entire system and within the 22 geographically based health care networks. RESULTS We found substantial geographic variation in hospital use for all eight cohorts of patients and all the years studied. Variations in the numbers of hospital days per person-year among the networks were greatest among patients with chronic obstructive pulmonary disease (ranging from a factor of 2.7 to a factor of 3.1) during a given year and smallest among patients with angina (ranging from a factor of 1.5 to a factor of 2.1). Levels of hospital use were highest in the Northeast and lowest in the West. The variation in the rates of clinic visits for principal medical care among the networks ranged from a factor of approximately 1.6 to a factor of 4.0; variations in the rates were greatest among patients with chronic renal failure and smallest among patients with chronic obstructive pulmonary disease. There was no clear geographic pattern in the rates of outpatient-clinic use. CONCLUSIONS There are significant geographic variations in the use of hospital and outpatient services in the VA health care system. Because VA physicians are unable to increase their income by changing their patterns of practice, our findings suggest that their practice styles are similar to those of other physicians in their geographic regions.

SODA (severity of dyspepsia assessment): A new effective outcome measure for dyspepsia-related health

Cerebrovascular disease is the third leading cause of death and the primary cause of long-term disability in the United States. Although the risk factors for stroke have been well defined, less is known about stroke mortality over varying time periods within the same cohort of patients. The purpose of this study is to define rates of short-term, intermediate-term, and long-term stroke mortality among patients experiencing a first-ever hemorrhagic or ischemic stroke between 1994 and 1998. Patients were identified from the Patient Treatment Files of the Department of Veterans Affairs (VA). We included all patients who were discharged from a VA inpatient facility with a diagnosis of acute stroke. Patients were excluded from the study if they had an admission within the previous 5 years for stroke or hemiplegia. We obtained information on the patients age, gender, and coexisting illnesses. Unadjusted and adjusted 30-day mortality rates were computed using Kaplan-Meier analyses and Cox proportional hazards regression models. The survival-dependent Cox proportional hazards regression models were run for 31-90 days and 91-365 days from the index admission date, for patients who had survived to the start of each of these time periods. Separate models were run for ischemic (n = 34,866 patients) and hemorrhagic (n = 5,442 patients) strokes. Unadjusted 30-day mortality was 8.2 and 20.5% for ischemic and hemorrhagic strokes, respectively. The adjusted 30-day mortality rate was 7.4 and 18.8% for ischemic and hemorrhagic strokes, respectively. For ischemic stroke, age 65 years and older was associated with an increased risk for short-term, intermediate-term, and long-term mortality, while chronic heart failure was associated with an increased risk for short-term and long-term mortality. For hemorrhagic stroke, age 75 years and older, malignancy, and chronic heart failure were associated with increased mortality during all three time periods. Thirty-day mortality is over two times greater following hemorrhagic stroke vs. ischemic stroke. For patients who survive 30 days after an ischemic stroke, the risk factor that remains significantly associated with long-term mortality, which may be improved with appropriate process of care, is chronic heart failure. For patients with a hemorrhagic stroke, variables that remain significantly associated with increased short-term and long-term mortality include malignant neoplasm and chronic heart failure. Information on stroke mortality is important for patients, physicians, and researchers. In addition to stroke treatment, clinicians must be able to provide families of stroke victims with appropriate prognostic information. Further work is needed to assess the impact of actual care patterns, for the above identified risk factors, on stroke prognosis over varying time periods.

Personality disorders in veterans with posttraumatic stress disorder and depression

The aim of this research was to develop and evaluate an instrument for measuring dyspepsia-related health to serve as the primary outcome measure for randomized clinical trials. Building on our previous work we developed SODA (Severity of Dyspepsia Assessment), a multidimensional dyspepsia measure. We evaluated SODA by administering it at enrollment and seven follow-up visits to 98 patients with dyspepsia who were randomized to a 6-week course of omeprazole versus placebo and followed over 1 year. The mean age was 53 years, and six patients (6%) were women. Median Cronbachs alpha reliability estimates over the eight visits for the SODA Pain Intensity, Non-Pain Symptoms, and Satisfaction scales were 0.97, 0.90, and 0.92, respectively. The mean change scores for all three scales discriminated between patients who reported they were improved versus those who were unchanged, providing evidence of validity. The effect sizes for the Pain Intensity (.98) and Satisfaction (.87) scales were large, providing evidence for responsiveness. The effect size for the Non-Pain Symptoms scale was small (.24), indicating lower responsiveness in this study sample. SODA is a new, effective instrument for measuring dyspepsia-related health. SODA is multidimensional and responsive to clinically meaningful change with demonstrated reliability and validity.

A double blind, randomized, placebo-controlled trial of proton pump inhibitor therapy in patients with uninvestigated dyspepsia

Little is known about the frequency of the full-range of personality disorders in outpatients with concurrent posttraumatic stress disorder (PTSD) and depression, a common and oftentimes treatment-resistant combination in clinical practice. In a group therapy outcome study, Axis I and II diagnoses were assessed with the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale to select 115 male combat veterans with PTSD and depressive disorder. Within this sample, 52 (45.2%) had one or more personality disorders—most commonly paranoid (17.4%), obsessive-compulsive (16.5%), avoidant (12.2%), and borderline (8.7%)—and 19 (16.5%) had two or more. Documenting a substantial frequency of personality disorders is a first step in devising appropriate interventions for this treatment-resistant combination of disorders.

Using the national registry of HIV-infected veterans in research: lessons for the development of disease registries.

A double blind, randomized, placebo-controlled trial of proton pump inhibitor therapy in patients with uninvestigated dyspepsia

Rates of health services utilization and survival in patients with heart failure in the Department of Veterans Affairs medical care system.

Disease-specific registries have many important applications in epidemiologic, clinical and health services research. Since 1989 the Department of Veterans Affairs has maintained a national HIV registry. VAs HIV registry is national in scope, it contains longitudinal data and detailed resource utilization and clinical information. To describe the structure, function, and limitations of VAs national HIV registry, and to test its accuracy and completeness. The VAs national HIV registry contains data that are electronically extracted from VAs computerized comprehensive clinical and administrative databases, called Veterans Integrated Health Systems Technology and Architecture (VISTA). We examined the number of AIDS patients and the number of new patients identified to the registry, by year, through December 1996. We verified data elements against information obtained from the medical records at five VA sites. By December 1996, 40,000 HIV-infected patients had been identified to the registry. We encountered missing data and problems with data classification. Missing data occurred for some elements related to the computer programming that creates the registry (e.g., pharmacy files), and for other elements because manual entry is required (e.g., ethnicity). Lack of a standardized data classification system was a problem, especially for the pharmacy and laboratory files. In using VAs national HIV registry we have learned important lessons, which, if taken into account in the future, could lead to the creation of model disease-specific registries.

HOW GOOD ARE US STUDIES OF HIV COSTS OF CARE

The objective of this study was to describe patterns of hospital and clinic use and survival for a large nationwide cohort of patients with heart failure. A retrospective cohort study of patients treated in the Veterans Affairs medical care system was conducted using linked administrative databases as data sources. In 1996, the average heart failure cohort member had 1-2 hospitalizations, 14 inpatient days, 6-7 visits with the primary physician, 15 other visits for consultations or tests, and 1-2 urgent care visits per 12 months. The overall risk-adjusted 5-year survival rate was 36%. Hospital use rates in the cohort fell dramatically between 1992 and 1996. One-year survival rates increased slightly over the period. Patients with heart failure are heavy users of services and have a very poor prognosis. Utilization and outcome data indicate the need for major efforts to assure quality of care and to devise innovative ways of delivering comprehensive services.

Impact of an all-inclusive diagnosis-related group payment system on inpatient utilization

BACKGROUND Valid, timely estimates of the costs of HIV care are needed by health planners and policy makers. OBJECTIVE To perform a methodologic critique of published estimates of resource utilization and costs of HIV care. DATA SOURCES MEDLINE database for 1990-1998. DATA SELECTION Included articles focused on adults with a spectrum of HIV disease in which the authors developed their own resource use and cost data. Thirty one articles met these criteria. DATA EXTRACTION Studies were compared based on: (1) utilization and cost estimates, in 1995 dollars; (2) study period; (3) research design; (4) sampling frame; (5) sample size and patient characteristics; (6) data sources and scope of services; and (7) methods used in the analysis. DATA SYNTHESIS The most recent estimates pertain to the first half of 1995, before the use of protease inhibitor therapy. We found wide variations in the estimates and identified three major sources for this: (1) patient samples that were restricted to subgroups of the national HIV-infected population; (2) utilization data that were limited in scope (e.g., inpatient care only); and (3) invalid methods for estimating annual or lifetime costs, particularly in dealing with decedents. CONCLUSIONS To accurately estimate resource use and costs for HIV care nationwide, a nationally representative probability sample of HIV-infected patients is required. Even in research that is not intended to provide national estimates, the scope of utilization data should be broadened and greater attention to methodologic issues in the analysis of annual and lifetime costs is needed.

Changes in VA Hospital Use 1980-1990

OBJECTIVES Although case-based payment is one of the main reimbursement mechanisms for hospitals, little is known about its effects in the general population. Prior studies have focused on Medicare or on all-payer systems in particular states. This study estimates the effect of a prospective payment system based on diagnosis-related groups (DRGs) nationwide in the Department of Veterans Affairs. METHODS Multiple regression analysis was used to estimate the effect of Department of Veterans Affairss diagnosis-related group system separately for 22 diagnoses. The dependent variables were length of stay, inpatient days per patient, and discharges per patient. Covariates included patient, hospital, and area characteristics. RESULTS Department of Veterans Affairss diagnosis-related group system reduced lengths of stay and inpatient days per patient. The largest impacts were for the psychiatric diagnoses and several surgical procedures. The magnitudes of the effects were generally moderate. Department of Veterans Affairss case-based system had a negligible effect on discharges per patient. CONCLUSIONS Per case reimbursement is a potentially useful tool for improving the efficiency of inpatient care for all types of diagnoses and age groups. The effect may be larger than estimated here because of institutional barriers and caps on financial impact.