Xinhua S. Ren

Differences in Health-Related Quality of Life in Rural and Urban Veterans

OBJECTIVES We sought to determine whether disparities in health-related quality of life exist between veterans who live in rural settings and their suburban or urban counterparts. METHODS We determined health-related quality-of-life scores (physical and mental health component summaries) for 767109 veterans who had used Veterans Health Administration services within the past 3 years. We used rural/urban commuting area codes to categorize veterans into rural, suburban, or urban residence. RESULTS Health-related quality-of-life scores were significantly lower for veterans who lived in rural settings than for those who lived in suburban or urban settings. Rural veterans had significantly more physical health comorbidities, but fewer mental health comorbidities, than their suburban and urban counterparts. Rural-urban disparities persisted in all survey subscales, across regional delivery networks, and after we controlled for sociodemographic factors. CONCLUSIONS When compared with their urban and suburban counterparts, veterans who live in a rural setting have worse health-related quality-of-life scores. Policymakers, within and outside the Veterans Health Administration, should anticipate greater health care demands from rural populations.

Improving the response choices on the veterans SF-36 health survey role functioning scales: results from the Veterans Health Study.

Abstract:Role functioning and its limitations due to ones health is an important aspect of health-related quality of life (HRQoL). The Medical Outcomes Study (MOS) SF-36 includes 2 role functioning scales: role limitations due to physical health problems (RP) or emotional problems (RE). Although they capture important concepts of HRQoL, these 2 scales have some limitations in their measurement properties. Using dichotomized sets of response choices, the scales are limited in their distributional properties (eg, higher standard deviation than other SF-36 scales) and ability to discriminate between clinically relevant groups. In this study, we ascertain the improvements to these 2 scales using 5-point ordinal response choices for each of the scale items. Two thousand one hundred sixty-two patients from the Veterans Health Study (VHS), an observational study of health outcomes in patients receiving ambulatory care, completed a health status questionnaire and a medical history. The health questionnaire included (1) the MOS SF-36, in which the RP and RE items used dichotomized yes/no responses; and (2) a set of modified RP and RE items that used 5-response choices for each of the items, ranging from “no, none of the time” to “yes, all of the time.” We compared the original and modified RP and RE scales using internal consistency reliability and factor analysis. We tested item convergent and discriminant validity using multitrait scaling, and scale discriminant validity using ordinary least squares regression. Results indicate that the modifications to the original RP and RE scales accomplish important gains in the distributional properties of the scales. The floor and ceiling effects of the 2 scales have been reduced and the reliability of the RP scale has increased (0.87–0.95). Factor analysis and multitrait scaling tests indicate that the modified items have the same interpretation as the original items. Tests of discriminant validity indicate that the modified RP and RE scales have greater explanatory power for measures of disease burden, depression, and disease severity. The modified SF-36 role scales are clearly superior to the original versions. The modifications have increased the explained variability, suggesting greater explanatory power and more information obtained by the role functioning measures. The modified RP and RE are capturing a wider spectrum of disease severity, in part due to the lowering of the floor and raising of the ceiling of the scales. Additional work needs to test these improvements in other populations and to expand the analysis to track the responsiveness of the modified scales to clinically and socially important changes over time.

Social support, social selection and self-assessed health status : results from the veterans health study in the United States

This study provided a comprehensive assessment of the association between social support and health using longitudinal data from the Veterans Health Study. Unlike previous studies which examined the relationship between one single domain of social support with either mental or physical health, the present study assessed the effects of three different domains of social support on multiple measures of health. The findings of the study indicated that social support tended to mediate the deleterious effects of non-military traumatic events; whereas the adverse consequences of traumatic events experienced in the military were not affected by social support, suggesting that stressors associated with combat had a long lasting effect on the health status of veterans. The study results revealed that compared with those with better health, respondents with poor health were more likely to have lower levels of social support, suggesting that poor health might be a barrier to a persons ability to participate and/or maintain social relationships. The study also showed that different types of social support had varying beneficial effects on different measures of health. While perceived support had a strong effect on all the measures of health (except alcoholism) included in the study, living arrangement had a significant effect on post-traumatic stress disorder or physical health and participation in group activities had a strong effect only on physical functioning. The results of the study highlight the need for future research to determine whether particular types of social support affect various aspects of health differently. This simultaneous focus on multiple support functions and health outcomes is important because it provides insight into the mechanisms linking social support to health.

Patient-reported measures of health: The Veterans Health Study.

Abstract:The goal of the Veterans Health Study (VHS) was to extend the work of the Medical Outcomes Study (MOS) into the VA, by developing methodology for monitoring patient-based outcomes of care for use in ambulatory outpatient care. The principal objective of the VHS was developing valid and reliable measures to assess general health-related quality of life (HRQoL) and identifying the presence of selected health conditions, their severity, and their impact on HRQoL. In this article, we provide an overview of the historical context, framework, objectives, and applications of the VHS for the purpose of assessing the health outcomes of veteran patients. The VHS is a prospective observational study that has followed 2425 VA patients for up to 2 years. The patients were sampled from users of the Veterans Affairs (VA) ambulatory care system in the Boston area. The health conditions selected were hypertension, diabetes, chronic lung disease, osteoarthritis of the knee, chronic low-back pain, and alcohol-related problems. These conditions were chosen because they are both prevalent in the VA and have measurable impacts on HRQoL. One of the cornerstones of the VHS was the development of the Veterans SF-36, modified from the MOS SF-36 for use in veteran ambulatory populations. Other key accomplishments included the development of patient-based disease-specific measures of health and the establishment of methods and logistics for comprehensive health outcomes research in large health care systems such as the VA, using these patient-based measures. Selected measures developed in the VHS, eg, the Veterans SF-36, have been integrated into the VA outcomes measurement system. The scope of the VHS is unique; it resulted in the development of a broad range of patient-focused process and outcome measures, as well as methodologies for assessing large numbers of patients, that have been widely used in the VA outpatient health care system for monitoring health outcomes across the nation.

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.

Applications of methodologies of the Veterans Health Study in the VA healthcare system: conclusions and summary.

The Veterans Health Study (VHS) had as its overarching goal the development, testing, and application of patient-centered assessments for monitoring patient outcomes in ambulatory care in large integrated care systems such as the Department of Veterans Affairs (VA). Unlike other previous studies, the VHS has capitalized on rich administrative databases restricted to the VA and linked to patient-centered outcomes. The VHS has developed a comprehensive set of general and disease-specific measures for use by systems of care for ambulatory patients. Chief among these assessments is the Veterans SF-36 Health Survey for measuring health-related quality of life in veteran ambulatory populations. The Veterans SF-36 Health Survey provides the cornerstone for this study and historically has been extensively disseminated and used in the VA with close to 2 million administrations nationally as part of its quality management system. National surveys administered by the VA since 1996 using the Veterans SF-36 Health Survey indicate important regional differences with implications for varying resource needs. Based upon the rich foundation provided by the VHS methodology, the VA has implemented some of these approaches as part of its quality monitoring system and can serve as a model for other large integrated systems of care.

Risk-adjusted mortality rates as a potential outcome indicator for outpatient quality assessments

Objective. The quality of outpatient medical care is increasingly recognized as having an important impact on mortality. We examined whether a clinically credible risk adjustment methodology can be developed for outpatient quality assessments. Research Design. This study used data from the 1998 National Survey of Ambulatory Care Patients, a prospective monitoring system of outcomes of patients receiving ambulatory care in the Veterans Affairs (VA) integrated service networks. Subjects. Thirty-one thousand eight hundred twenty-three patients were followed for 18 months. Measures. The main study outcome measures were observed and risk-adjusted mortality rates. Results. Of the 31,823 patients, 1559 (5%) died during the 18-months of follow-up. Observed mortality rates across the 22 VA integrated service networks varied significantly from 3.3% to 6.7% (P <0.001). Age, gender, comorbidities (Charlson Index), physical health, and mental health were significant predictors of dying. The resulting risk-adjusted mortality model performed well in cross-validated tests of discrimination (c-statistic = 0.768; 95% CI, 0.749–0.788) and calibration. Analysis of variance confirmed that the 22 integrated service networks differed in their average level of expected risk (P <0.001). Risk-adjusted rates and ranks of the networks differed considerably from unadjusted ratings. Conclusions. Risk-adjusted mortality rates may be a useful outcome measure for assessing quality of outpatient care. We have developed a clinically credible risk adjustment model with good performance properties using sociodemographics, diagnoses, and functional status data. The resulting risk adjustment model altered assessments of the performance of the integrated service networks when compared with the unadjusted mortality rates.

Identifying patient and physician characteristics that affect compliance with antihypertensive medications

Background: Compliance with antihypertensive medications is essential to the clinical management of hypertension. Poor compliance with antihypertensive medications has often been associated with treatment failure and disease progression.

Racial differences in health-related beliefs, attitudes, and experiences of VA cardiac patients: Scale development and application

Objectives. To determine whether there are racial differences in patients’ health-related attitudes, beliefs, and experiences regarding invasive cardiac procedures, and to develop psychometrically and conceptually valid scales and single items to assess these dimensions. Methods. A survey was designed and administered to 854 white and black patients with ischemic heart disease at five VA medical centers. Patients were queried about the domains proposed to be important to treatment decision making by the Health Decision Model: sociodemographic characteristics, social interactions, health care experiences, patient preferences for care, knowledge about diseases and potential treatments, and health beliefs. Using multitrait analysis, the psychometric properties of scales assessing these domains were examined. It was then assessed whether there were racial differences in scale or individual item scores using &khgr;2 and t test analyses. Results. The analyses yielded eight psychometrically valid scales: disease severity, patient evaluation of physician’s interpersonal style, patient evaluations of VA care, satisfaction with treatment decision making, perceived urgency of catheterization, vulnerability to catheterization, bodily impact of catheterization, and attitudes toward religion. There were only racial differences on mean scores for the latter scale. Individual item analyses indicated that black patients were less likely to have been encouraged by friends or family to have cardiac catheterization, and had less personal or familial experiences with this or other surgical procedures. In contrast to expectations, white patients were more likely to be skeptical of medical care. Conclusions. The multiple dimensions of white and black patients’ health-related attitudes, beliefs, and experiences were examined, and few differences were found. These results suggest that racial differences in patients’ attitudes, beliefs, and experiences are not a likely source of racial disparities in cardiac care. Future research will examine the association of beliefs, attitudes and experiences with actual use of invasive cardiac procedures.

The development, validation, and testing of a health outcomes burn questionnaire for infants and children 5 years of age and younger: American Burn Association/Shriners Hospitals for Children.

The 12-member American Burn Association/Shriners Hospitals for Children Outcomes Task Force was charged with developing a health outcomes questionnaire for use in children 5 years of age and younger that was clinically based and valid. A 55-item form was tested using a cross-sectional design on the basis of a range of 184 infants and children between 0 and 5 years of age at 8 burn centers, nationally. A total of 131 subjects completed a follow-up health outcomes questionnaire 6 months after the baseline assessment. A comparison group of 285 normal nonburn children was also obtained. Internal consistency reliability of the scales ranged from 0.74 to 0.94. Tests of clinical validity were significant in the hypothesized direction for the majority of scales for length of hospital stay, duration since the burn, percent of body surface area burned, overall clinician assessment of severity of burn injury, and number of comorbidities. The criterion validity of the instrument was supported using the Child Developmental Inventories for Burn Children in early childhood and preschool stages of development comparing normal vs abnormal children. The instrument was sensitive to changes over time following a clinical course observed by physicians in practice. The Health Outcomes Burn Questionnaire for Infants and Children 5 years of age and younger is a clinically based reliable and valid assessment tool that is sensitive to change over time for assessing burn outcomes in this age group.