Thad E. Abrams

The Veterans Affairs Shift Change Physician-to-Physician Handoff Project

BACKGROUND Few studies on the safety or efficacy of current patient handoff systems exist, and few standardized electronic medical record (EMR)-based handoff tools are available. An EMR handoff tool was designed to provide a standardized approach to handoff communications and improve on previous handoff methods. METHODS In Phase I, existing handoff methods were analyzed through abstraction of printed handoff sheets and questionnaires of internal medicine residents at Department of Veterans Affairs medical centers (VAMCs). In Phase II, the handoff tool was designed, and the software was tested and revised through user feedback and regular conference calls. Phase III involved postimplementation systematic abstraction of printed handoff sheets and questionnaires of internal medicine residents. Two VAMCs participated in abstraction of printed handoff sheets, with four VAMCs responding to the questionnaires. RESULTS Handoffs were abstracted for 550 patients at baseline and 413 postimplementation. Improvements were found in consistency of information transfer for all handoff content, including code status, floor location, room number, two types of identifying information, typed format, medication, and allergy lists (p = .01). The 63 and 51 questionnaires completed pre- and postimplementation, respectively, showed improvement in perceptions of ease of use, efficiency, and readability (p < .05) and in perceptions of patient safety and quality (p < .01) without causing omission (p < .01) or commission of information (p = .02). DISCUSSION This standardized EMR-based handoff software improved data accuracy and content consistency, was well-received by users, and improved perceptions of handoff-related patient safety, quality, and efficiency. A final version of the software was incorporated into the national EMR software program and made available to all VAMCs.

Acute Exacerbations of Chronic Obstructive Pulmonary Disease and the Effect of Existing Psychiatric Comorbidity on Subsequent Mortality

OBJECTIVES Studies investigating associations between chronic obstructive pulmonary disease (COPD) outcomes and psychiatric comorbidity have yielded mixed findings. We examined a national sample of hospitalized COPD patients to evaluate the impact of three psychiatric conditions on mortality and readmission. METHODS Department of Veterans Affairs (VA) administrative and laboratory data were used to identify 26,591 consecutive patients admitted for COPD during October 2006 to September 2008. Associations between psychiatric comorbidity and both 30-day mortality and readmission were examined using generalized estimating equations and Cox proportional hazards regression, respectively, with adjustments for patient demographics, medical comorbidities, illness severity, and clustering within hospitals. RESULTS Unadjusted 30-day mortality was higher in patients with anxiety (5.3% vs. 3.8% [P < 0.001]) and depression (6.2% vs. 3.8% [<0.001]). In multivariable analyses, adjusted odds of 30-day mortality were higher for patients with depression (OR, 1.53; 95% CI, 1.28-1.82) and anxiety (OR, 1.72; 1.42 -2.10), but not for patients with PTSD (OR, 1.19; 0.92-1.55). Unadjusted 30-day readmission rates also varied by diagnosis; depression and PTSD were associated with lower rates of readmission (10.4% vs. 11.6% [<0.05] and 8.6% vs. 11.6% [<0.001], respectively), whereas anxiety was not (11.3% vs. 11.5% [NS]). However, after covariate adjustment using multivariable models, anxiety and depression (but not PTSD) were associated with increased risk for readmission (HR, 1.22; 1.03 -1.43 and HR, 1.35; 1.18 -1.54, respectively). CONCLUSION Comorbid anxiety and depression may have an adverse impact on COPD hospital prognosis or may be indicative of more severe illness.

Psychiatric Comorbidity and Mortality After Acute Myocardial Infarction

Background—Prior studies of the impact of psychiatric comorbidity on outcomes after acute myocardial infarction (AMI) have frequently relied on inpatient secondary diagnosis codes. This study compared associations between psychiatric comorbidity and AMI outcomes that were derived using secondary diagnosis codes and codes captured from prior outpatient encounters. Methods and Results—Retrospective cohort study analyzing 21 745 patients admitted in 2004 to 2006 to Veterans Health Administration hospitals with AMI using administrative data. Psychiatric comorbidity was identified using (1) secondary inpatient diagnosis codes from the index hospitalization and (2) diagnoses from prior outpatient encounters. Outcomes included 30- and 365-day mortality and the receipt of coronary revascularization within 30 days of admission. Generalized estimating equations and Cox proportional hazards were used to adjust mortality and receipt of revascularization for demographic and clinical variables. Psychiatric disorders were identified in 2285 (10%) patients from inpatient secondary diagnosis codes and 5225 (24%) patients from prior outpatient codes. Patients with psychiatric comorbidity had higher adjusted 30- and 365-day mortality, based on outpatient codes (odds ratios, 1.19 [95% CI, 1.09 to 1.30] and 1.12 [95% CI, 1.03 to 1.22], respectively), but similar mortality based on inpatient codes (odds ratios, 0.89 [95% CI, 0.69 to 1.01] and 0.93 [95% CI, 0.82 to 1.06], respectively). In contrast, patients with psychiatric comorbidity had lower receipt of coronary revascularization based on outpatient codes (hazard ratio, 0.92; [95% CI, 0.85 to 0.99], but similar receipt based on inpatient codes (hazard ratio, 1.00 [95% CI, 0.91 to 1.10]). Conclusions—Inpatient secondary diagnosis codes identified fewer patients with psychiatric comorbidity than prior outpatient codes. Moreover, associations with AMI outcomes differed for the 2 approaches. These findings raise potential concerns about the validity and reliability of psychiatric inpatient secondary diagnosis in estimating the impact of psychiatric comorbidities on AMI outcomes and in developing risk-adjustment models.

Variations in the Associations Between Psychiatric Comorbidity and Hospital Mortality According to the Method of Identifying Psychiatric Diagnoses

SummaryObjectiveLittle is known about associations between psychiatric comorbidity and hospital mortality for acute medical conditions. This study examined if associations varied according to the method of identifying psychiatric comorbidity and agreement between the different methods.Patients/ParticipantsThe sample included 31,218 consecutive admissions to 168 Veterans Affairs facilities in 2004 with a principle diagnosis of congestive heart failure (CHF) or pneumonia. Psychiatric comorbidity was identified by: (1) secondary diagnosis codes from index admission, (2) prior outpatient diagnosis codes, (3) and prior mental health clinic visits. Generalized estimating equations (GEE) adjusted in-hospital mortality for demographics, comorbidity, and severity of illness, as measured by laboratory data.Measurements and Main ResultsRates of psychiatric comorbidities were 9.0% using inpatient diagnosis codes, 27.4% using outpatient diagnosis codes, and 31.0% using mental health visits for CHF and 14.5%, 33.1%, and 34.1%, respectively, for pneumonia. Agreement was highest for outpatient codes and mental health visits (κ = 0.51 for pneumonia and 0.50 for CHF). In GEE analyses, the adjusted odds of death for patients with psychiatric comorbidity were lower when such comorbidity was identified by mental health visits for both pneumonia (odds ratio [OR] = 0.85; P = .009) and CHF (OR = 0.70; P < .001) and by inpatient diagnosis for pneumonia (OR = 0.63; P ≤ .001) but not for CHF (OR = 0.75; P = .128). The odds of death were similar (P > .2) for psychiatric comorbidity as identified by outpatient codes for pneumonia (OR = 1.04) and CHF (OR = 0.93).ConclusionsThe method used to identify psychiatric comorbidities in acute medical populations has a strong influence on the rates of identification and the associations between psychiatric illnesses with hospital mortality.

Aligning clinical practice to PTSD treatment guidelines: medication prescribing by provider type.

OBJECTIVE Veterans with posttraumatic stress disorder (PTSD) are frequently prescribed psychiatric medications that are currently not supported by a guideline developed by the U.S. Department of Veterans Affairs and the U.S. Department of Defense. To better understand this practice, this study examined prescribing frequencies for three classes of psychiatric medications and the proportion of prescribing attributable to various provider types. METHODS This cross-sectional study analyzed fiscal year 2009 electronic pharmacy data from the Veterans Health Administration (VHA) for 356,958 veterans with PTSD who were receiving medications from VHA prescribers. Veterans had at least one VHA encounter with a diagnostic code of PTSD and evidence of continuous medication use. Medications of interest were selective serotonin-norepinephrine reuptake inhibitors (SSRI/SNRIs), second-generation antipsychotic medications, and benzodiazepines. Analyses described the proportion of prescribing attributable to mental health care providers and primary care providers for each medication class. RESULTS In 2009, among all veterans with PTSD who had continuous VA medication use, 65.7% were prescribed SSRI/SNRIs, and 70.2% of this prescribing was attributable to mental health care providers. Second-generation antipsychotics were prescribed for 25.6% of these veterans, and 80.2% of the prescribing was attributable to mental health care providers. Benzodiazepines were prescribed for 37.0% of the sample, and 68.8% of the prescribing was attributable to mental health care providers. CONCLUSIONS The findings indicate that veterans with PTSD were frequently prescribed medications not supported by existing guidelines. Most of these prescriptions were written by mental health care providers. Interventions to align prescribing with PTSD treatment guidelines should emphasize provider type.

The relationship between hearing impairment and depression in older veterans.

ACKNOWLEDGMENTS Financial Disclosure: This work was supported by the Italian Longitudinal Study on Aging (Italian National Research CouncilFCNR-Targeted Project on AgingF Grants 9400419PF40 and 95973PF40) (Dr. Panza, Dr. D’Introno, Dr. Colacicco, Pr. A. Capurso, and Dr. Solfrizzi). Author Contributions: Dr. Panza contributed to concept, interpretation, and manuscript preparation. Dr. C. Capurso, Dr. D’Introno, Dr. Colacicco, Pr. A. Capurso, and Dr. Solfrizzi contributed to interpretation and manuscript preparation. Sponsor’s Role: The funding agencies had no role in design or conduct of the study.

Geographic Isolation and the Risk for Chronic Obstructive Pulmonary Disease-Related Mortality

BACKGROUND Little is known about the possible differences in outcomes between patients with chronic obstructive pulmonary disease (COPD) who live in rural areas and those who live in urban areas of the United States. OBJECTIVE To determine whether COPD-related mortality is higher in persons living in rural areas, and to assess whether hospital characteristics influence any observed associations. DESIGN Retrospective cohort study. SETTING 129 acute care Veterans Affairs hospitals. PATIENTS Hospitalized patients with a COPD exacerbation. MEASUREMENTS Patient rurality (primary exposure); 30-day mortality (primary outcome); and hospital volume and hospital rurality, defined as the mean proportion of hospital admissions coming from rural areas (secondary exposures). RESULTS 18,809 patients (71% of the study population) lived in urban areas, 5671 (21%) in rural areas, and 1919 (7%) in isolated rural areas. Mortality was increased in patients living in isolated rural areas compared with urban areas (5.0% vs. 3.8%; P = 0.002). The increase in mortality associated with living in an isolated rural area persisted after adjustment for patient characteristics and hospital rurality and volume (odds ratio [OR], 1.42 [95% CI, 1.07 to 1.89]; P = 0.016). Adjusted mortality did not seem to be higher in patients living in nonisolated rural areas (OR, 1.09 [CI, 0.90 to 1.32]; P = 0.47). Results were unchanged in analyses assessing the influence of an omitted confounder on estimates. LIMITATIONS The study population was limited to mostly male inpatients who were veterans. Results were based on administrative data. CONCLUSION Patients with COPD living in isolated rural areas of the United States seem to be at greater risk for COPD exacerbation-related mortality than those living in urban areas, independent of hospital rurality and volume. Mortality was not increased for patients living in nonisolated rural areas. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs.

A systematic review of validated methods for identifying pancreatitis using administrative data

To systematically review algorithms identifying cases of pancreatitis in administrative data, with a focus on studies examining algorithm validity.

Mortality and Revascularization Following Admission for Acute Myocardial Infarction: Implication for Rural Veterans

INTRODUCTION Annually, over 3,000 rural veterans are admitted to Veterans Health Administration (VA) hospitals for acute myocardial infarction (AMI), yet no studies of AMI have utilized the VA rural definition. METHODS This retrospective cohort study identified 15,870 patients admitted for AMI to all VA hospitals. Rural residence was identified by either Rural-Urban Commuting Area (RUCA) codes or the VA Urban/Rural/Highly Rural (URH) system. Endpoints of mortality and coronary revascularization were adjusted using administrative laboratory and clinical variables. RESULTS URH codes identified 184 (1%) veterans as highly rural, 6,046 (39%) as rural, and 9,378 (60%) as urban; RUCA codes identified 1,350 (9%) veterans from an isolated town, 3,505 (22%) from a small or large town, and 10,345 (65%) from urban areas. Adjusted mortality analyses demonstrated similar risk of mortality for rural veterans using either URH or RUCA systems. Hazards of revascularization using the URH classification demonstrated no difference for rural (HR, 0.96; 95% CI, 0.94-1.00) and highly rural veterans (HR, 1.13; 0.96-1.31) relative to urban veterans. In contrast, rural (relative to urban) veterans designated by the RUCA system had lower rates of revascularization; this was true for veterans from small or large towns (HR, 0.89; 0.83-0.95) as well as veterans from isolated towns (HR, 0.86; 0.78-0.93). CONCLUSION Rural veterans admitted for AMI care have a similar risk of 30-day mortality but the adjusted hazard for receipt of revascularization for rural veterans was dependent upon the rural classification system utilized. These findings suggest potentially lower rates of revascularization for rural veterans.

Preexisting Comorbid Psychiatric Conditions and Mortality in Nonsurgical Intensive Care Patients

PURPOSE To examine the effects of preexisting comorbid psychiatric conditions on mortality in a large cohort of patients admitted to a nonsurgical intensive care unit. METHODS This retrospective cohort study involved 66,672 consecutive eligible nonsurgical patients admitted to intensive care units in 129 Veterans Health Administration hospitals during 2005 and 2006. Preexisting comorbid psychiatric conditions were identified by using diagnoses from outpatient encounters in the prior year for depression, anxiety, psychosis, bipolar disorders, and posttraumatic stress disorder. Generalized estimating equations were used to adjust the risks of in hospital and 30-day mortality for demographics, comorbid medical conditions, markers of severity, and abnormal findings on laboratory tests at admission. RESULTS Comorbid psychiatric conditions were identified in 28% (n = 18 698) of patients. Patients with preexisting comorbid psychiatric conditions had lower (P < .001) unadjusted in hospital mortality (7.3% vs 8.7%) and 30-day mortality (10.0% vs 12.8%) than did patients without such conditions. After demographics, comorbid medical conditions, and severity were adjusted for, risk of in-hospital mortality among patients with comorbid psychiatric conditions was somewhat higher (odds ratio, 1.07, 95% confidence interval, 1.01-1.14; P = .02), although differences in 30-day mortality (odds ratio, 1.01, 95% confidence interval, 0.94-1.08; P = .70) were no longer significant. CONCLUSION Preexisting comorbid psychiatric conditions are common among intensive care patients, but after comorbid medical conditions and severity were adjusted for, preexisting comorbid psychiatric conditions were not associated with a higher risk of 30-day mortality in a large national cohort of veterans.