Zhiping Huo

Effect of increased copayments on pharmacy use in the Department of Veterans Affairs

Objectives:In February 2002, the Department of Veterans Affairs (VA) raised medication copayments from

Healthcare Utilization and Costs of Veterans Screened and Assessed for Traumatic Brain Injury

2 to

Comparing VA and private sector healthcare costs for end-stage renal disease.

7 per 30-day supply of medication for certain veteran groups. We examined the impact of the copayment increase on medication acquisition from VA. Methods:This was a retrospective cohort study using data from national VA databases from February 2001 through February 2003. We took a random sample of over 5% of male VA users in 2001. Of 149,107 veterans sampled, 19,504 (13%) had copayments for no drugs, 101,410 (68%) had copayments for some drugs, and 28,193 (19%) had copayments for all drugs. We used multivariable count models to examine changes in the number of 30-day medication supplies after the increase. Results:After the copayment increase, veterans subject to copayments for all drugs received 8% fewer 30-day supplies of medication annually relative to veterans with no copayments (P < 0.001). The effect of the copayment increased as the number of different medications veterans received increased. Among veterans subject to copayments for all drugs, acquisition of lower-cost drugs fell by 36%, higher-cost medications fell by 6%, over-the-counter medications fell by 40%, and prescription-only medications fell by 4% relative to veterans with no drug copayments. Conclusions:The number of medications veterans obtained from VA decreased after the copayment increase. There were relatively larger impacts on veterans with higher medication use and on lower-cost and over-the-counter medications.

Prevalence of Chronic Kidney Disease in Patients with Spinal Cord Injuries/Disorders

Approximately 15% of casualties in the Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) conflicts received mild traumatic brain injury (TBI). To identify Veterans who may benefit from treatment, the Department of Veterans Affairs (VA) implemented a national clinical reminder in 2007 to screen for TBI. Veterans who screen positive are referred for a comprehensive TBI evaluation. We conducted a national retrospective study of OIF/OEF Veterans receiving care at VA facilities between 2007 and 2008. We examined the association of the TBI screen with healthcare costs over a 12 mo period following the initial evaluation. Of the Veterans, 164,438 met inclusion criteria: 31,627 screened positive, 118,545 screened negative, and 14,266 received no TBI screening. Total healthcare costs of Veterans who screened positive, screened negative, or had no TBI screening were

Medication acquisition across systems of care and patient–provider communication among older veterans

9,610,

Predialysis nephrology care and costs in elderly patients initiating dialysis

5,184, and

Validation of erythropoietin use data on Medicare's End-Stage Renal Disease Medical Evidence Report

3,399, respectively (p < 0.001). Understanding these healthcare utilization and cost patterns will assist policymakers to address the ongoing and future healthcare needs of these returning Veterans.

Systolic blood pressure variability and lower extremity amputation in a non-elderly population with diabetes

Background:Healthcare for end-stage renal disease (ESRD) is intensive, expensive, and provided in both the public and private sector. Using a societal perspective, we examined healthcare costs and health outcomes for Department of Veterans Affairs (VA) ESRD patients comparing those who received hemodialysis care at VA versus private sector facilities. Methods:Dialysis patients were recruited from 8 VA medical centers from 2001 through 2003 and followed for 12 months in a prospective cohort study. Patient demographics, clinical characteristics, quality of life, healthcare use, and cost data were collected. Healthcare data included utilization (VA), claims (Medicare), and patient self-report. Costs included VA calculated costs, Medicare dialysis facility reports and reimbursement rates, and patient self-report. Multivariable regression was used to compare costs between patients receiving dialysis at VA versus private sector facilities. Results:The cohort comprised 334 patients: 170 patients in the VA dialysis group and 164 patients in the private sector group. The VA dialysis group had more comorbidities at baseline, outpatient and emergency visits, prescriptions, and longer hospital stays; they also had more conservative anemia management and lower baseline urea reduction ratio (67% vs. 72%; P<0.001), although levels were consistent with guidelines (Kt/V≥1.2). In adjusted analysis, the VA dialysis group had

Veterans' Pharmacy and Health Care Utilization Following Implementation of the Medicare Part D Pharmacy Benefit

36,431 higher costs than those in the private sector dialysis group (P<0.001). Conclusions:Continued research addressing costs and effectiveness of care across public and private sector settings is critical in informing health policy options for patients with complex chronic illnesses such as ESRD.

Survival in patients with Parkinson's disease after deep brain stimulation or medical management

Background and Objectives: Chronic kidney disease (CKD) and spinal cord injury and disorders (SCI/D) are common and costly conditions among Veterans. However, little is known about CKD among adults with SCI/D. Methods: We conducted cross-sectional analyses of Veterans with SCI/D across all VA facilities in 2006. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 and categorized by standard eGFR strata. eGFR was calculated in two ways: (a) the Modification of Diet in Renal Disease (MDRD) equation and (b) the MDRD equation + an empirically derived correction factor for SCI/D (MDRD-SCI/D). Logistic regression models were used to examine the relationship between patient characteristics and CKD. Results: Among 9,333 SCI/D Veterans with an available eGFR, the proportion with CKD was substantially higher based on the MDRD-SCI/D equation (35.2%) than based on the MDRD equation (10.2%). In adjusted analyses, while older age (OR for >65 years = 2.53; 95% CI: 2.21–2.89), female sex (OR 2.18; 95% CI: 1.62–2.92), and a non-traumatic cause for injury (OR 1.39; 95% CI: 1.23–1.57) were associated with an increased odds of CKD, black race (OR 0.64; 95% CI: 0.56–0.72) and a duration of injury of ≥10 years (OR 0.76; 95% CI: 0.67–0.86) were associated with a decreased odds of CKD. Diagnostic codes for CKD and nephrology visits were infrequent for SCI/D Veterans with CKD (27.51 and 6.58%, respectively). Conclusion: Using a recently validated version of the MDRD equation with a correction factor for SCI/D, over 1 in 3 Veterans with SCI/D had CKD, which is more than 3-fold higher than when traditional MDRD estimation is used.