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Matchar D.B.,Duke University | Matchar D.B.,National University of Singapore | Jacobson A.,Loma Linda University | Dolor R.,Duke University | And 11 more authors.
New England Journal of Medicine | Year: 2010

BACKGROUND: Warfarin anticoagulation reduces thromboembolic complications in patients with atrial fibrillation or mechanical heart valves, but effective management is complex, and the international normalized ratio (INR) is often outside the target range. As compared with venous plasma testing, point-of-care INR measuring devices allow greater testing frequency and patient involvement and may improve clinical outcomes. METHODS: We randomly assigned 2922 patients who were taking warfarin because of mechanical heart valves or atrial fibrillation and who were competent in the use of point-ofcare INR devices to either weekly self-testing at home or monthly high-quality testing in a clinic. The primary end point was the time to a first major event (stroke, major bleeding episode, or death). RESULTS: The patients were followed for 2.0 to 4.75 years, for a total of 8730 patient-years of follow-up. The time to the first primary event was not significantly longer in the self-testing group than in the clinic-testing group (hazard ratio, 0.88; 95% confidence interval, 0.75 to 1.04; P = 0.14). The two groups had similar rates of clinical outcomes except that the self-testing group reported more minor bleeding episodes. Over the entire follow-up period, the self-testing group had a small but significant improvement in the percentage of time during which the INR was within the target range (absolute difference between groups, 3.8 percentage points; P<0.001). At 2 years of follow-up, the self-testing group also had a small but significant improvement in patient satisfaction with anticoagulation therapy (P = 0.002) and quality of life (P<0.001). CONCLUSIONS: As compared with monthly high-quality clinic testing, weekly self-testing did not delay the time to a first stroke, major bleeding episode, or death to the extent suggested by prior studies. These results do not support the superiority of self-testing over clinic testing in reducing the risk of stroke, major bleeding episode, and death among patients taking warfarin therapy. (Funded by the Department of Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT00032591.). Copyright © 2010 Massachusetts Medical Society.


Nair V.S.,Stanford University | Barnett P.G.,Stanford University | Barnett P.G.,Health Economics Resource Center | Ananth L.,Health Economics Resource Center | And 2 more authors.
Chest | Year: 2010

Objective: Our objective was to examine the association between 18F-fluorodeoxyglucose (FDG) uptake on PET scan and prognosis in patients with surgically treated, clinical stage IA non-small cell lung cancer (NSCLC). Methods: We reviewed data collection forms and Veterans Affairs administrative records of 75 patients with surgically treated, stage IA NSCLC who were enrolled in a prospective study of PET imaging from 1999 to 2001. We used Cox proportional hazards analysis to examine the association between FDG uptake and survival 4 years following enrollment. Results: Most patients were men (97%), and the mean age was 68±9 years. Almost half of the patients (44%) had adenocarcinoma, and 35% underwent a sublobar resection. The mean maximum standardized uptake value (SUV max) was 4.9±2.5 in survivors and 7.1±3.9 in nonsurvivors (P = .045). Before and after adjustment for age, tumor size, histology, and type of resection, the hazard of death was significantly higher in patients with squamous cell histology (adjusted hazard ratio [HR], 4.54; 95% CI, 1.09-18.9) and those with higher degrees of FDG uptake (adjusted HR, 1.21 per 1 unit increment; 95% CI, 1.01-1.45). At a threshold value of 5 for SUV max, 34 of 39 patients (87%) with low FDG uptake survived, compared with only 24 of 36 patients (67%) with high FDG uptake (P 5.04). Visual assessment of FDG uptake was not associated with an increased hazard of death (HR 0.66; 95% CI, 0.19-2.29). Conclusions: High FDG uptake as measured by SUV max identifies individuals with clinical stage IA NSCLC who are at increased risk of death following surgery. Such high-risk patients may be good candidates for participation in future trials of adjuvant therapy. © 2010 American College of Chest Physicians.


Barnett P.G.,Health Economics Resource Center | Barnett P.G.,Stanford University | Ananth L.,Health Economics Resource Center | Gould M.K.,VA Palo Alto Health Care System | Gould M.K.,Stanford University
Chest | Year: 2010

Background: No prior study to our knowledge has observed the cost of managing solitary pulmonary nodules of patient groups defined by PET scan results. Methods: We combined study and administrative data over 2 years of follow-up. Results: Of 375 individuals with a definitive diagnosis, 54.4% had a malignant nodule and 62.1% had positive PET scan results. Mortality risk was 5.0 times higher (CI, 3.1-8.2) and cost was greater ($50,233 vs $22,461, P < .0001) among patients with malignant nodule. Mortality risk was 4.1 times higher (CI, 2.4-7.0) and cost was greater ($47,823 vs $20,744, P < .0001) among patients with a positive PET scan result. Among patients with a malignant nodule, 4.9% had a false-negative PET scan, but cost and survival were not different from true positives. Among patients with a benign nodule, 22.8% had a false-positive PET scan. These patients had greater cost ($33,783 vs $19,115, P < .01), more surgeries and biopsies, and 3.8 times the mortality risk (CI, 1.6-9.2) of true negatives. Just over one-half (54.5%) of individuals with positive PET scans received surgery. Most individuals with negative PET scans (85.2%) were managed by watchful waiting. They incurred fewer costs than patients with negative PET scans who were managed more aggressively ($19,378 vs $28,611, P < .01). Conclusions: Management of solitary pulmonary nodules is expensive, especially if the nodule is malignant or if the PET scan result is false positive. Among patients with malignant nodules, 2-year survival is poor. Compared with true-positive PET scan results, false-negative results are not associated with lower costs or better outcomes. © 2010 American College of Chest Physicians.


Gidwani R.,Health Economics Resource Center | Gidwani R.,Center for Innovation to Implementation | Gidwani R.,Stanford University | Bhattacharya J.,Stanford University
Journal of General Internal Medicine | Year: 2015

BACKGROUND: In October 2008, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursing hospitals for the marginal cost of treating certain preventable hospital-acquired conditions.OBJECTIVE: This study evaluates whether CMS’s refusal to pay for hospital-acquired pulmonary embolism (PE) or deep vein thrombosis (DVT) resulted in a lower incidence of these conditions.DESIGN: We employ difference-in-differences modeling using 2007–2009 data from the Nationwide Inpatient Sample, an all-payer database of inpatient discharges in the U.S. Discharges between 1 January 2007 and 30 September 2008 were considered “before payment reform;” discharges between 1 October 2008 and 31 December 2009 were considered “after payment reform.” Hierarchical regression models were fit to account for clustering of observations within hospitals.PARTICIPANTS: The “before payment reform” and “after payment reform” incidences of PE or DVT among 65–69-year-old Medicare recipients were compared with three different control groups of: a) 60–64-year-old non-Medicare patients; b) 65–69-year-old non-Medicare patients; and c) 65–69-year-old privately insured patients. Hospital reimbursements for the control groups were not affected by payment reform.INTERVENTION: CMS payment reform for hospital-based reimbursement of patients with hip and knee replacement surgeries.MAIN MEASURES: The outcome was the incidence proportion of hip and knee replacement surgery admissions that developed pulmonary embolism or deep vein thrombosis.KEY RESULTS: At baseline, pulmonary embolism or deep vein thrombosis were present in 0.81 % of all hip or knee replacement surgeries for Medicare patients aged 65–69 years old. CMS payment reform resulted in a 35 % lower incidence of hospital-acquired pulmonary embolism or deep vein thrombosis in these patients (p = 0.015). Results were robust to sensitivity analyses.CONCLUSION: CMS’s refusal to pay for hospital-acquired conditions resulted in a lower incidence of hospital-acquired pulmonary embolism or deep vein thrombosis after hip or knee replacement surgery. Payment reform had the desired direction of effect. © 2014, Society of General Internal Medicine.


Yoon J.,Health Economics Resource Center | Zulman D.,Center for Healthcare Evaluation | Zulman D.,Stanford University | Scott J.Y.,Health Economics Resource Center | And 2 more authors.
Medical Care | Year: 2014

Background: Multimorbidity (the presence of multiple chronic conditions) is associated with high levels of healthcare utilization and associated costs. We investigated the association between number of chronic conditions and costs of care for nonelderly and elderly Veterans Affairs (VA) patients, and estimated mean VA healthcare costs for the most prevalent and most costly combinations of 3 conditions (triads). Methods: We identified a cohort of 5,233,994 patients who received care within the VA system in fiscal year 2010. We estimated the costs of VA care for each patient using established methods and aggregated costs for inpatient care, outpatient care, prescription drugs, and contract care. Using ICD-9 diagnosis fields from all inpatient and outpatient records, we determined the prevalence of 28 chronic conditions and all condition triads. We then compared the condition-cost gradient, most prevalent triads, and most costly triads among nonelderly (below 65 y) and elderly (65 y and above) patients. Results: Almost one third of nonelderly and slightly more than a third of elderly VA patients had ≥3 conditions, but these patients accounted for 65% and 67% of total VA healthcare costs, respectively. The most common triad of chronic conditions for both nonelderly and elderly patients was diabetes, hyperlipidemia, and hypertension (24% and 29%, respectively). Conditions that were present in the most costly triads included spinal cord injury, heart failure, renal failure, ischemic heart disease, peripheral vascular disease, stroke, and depression. Although patients with the most costly triads had average costs that were 3 times higher than average costs among patients with ≥3 conditions, the prevalence of these costly triads was extremely low (0.1%-0.4%). Conclusions: Patients with multiple chronic conditions account for a disproportionate share of VA healthcare expenditures. Interventions that aim to optimize care and contain costs for multimorbid patients need to incorporate strategies specific to the most prevalent and the most costly combinations of conditions. © 2014 by Lippincott Williams & Wilkins.


Zulman D.M.,Center for Health Care Evaluation | Nazi K.M.,Stratton Medical Center | Turvey C.L.,University of Iowa | Wagner T.H.,Health Economics Resource Center | And 2 more authors.
Annals of Internal Medicine | Year: 2011

Background: Electronic personal health record (PHR) systems are proliferating but largely have not realized their potential for enhancing communication among patients and their network of care providers. Objective: To explore preferences about sharing electronic health information among users of the U.S. Department of Veterans Affairs (VA) PHR system, My HealtheVet. Design: Web-based survey of a convenience sample. Setting: My HealtheVet Web site from 7 July through 4 October 2010. Participants: 18 471 users of My HealtheVet. Measurements: Interest in shared PHR access and preferences about who would receive access, the information that would be shared, and the activities that users would delegate. Results: Survey respondents were predominantly men (92%) and aged 50 to 64 years (51%) or 65 years or older (39%); approximately 39% reported poor or fair health status. Almost 4 of 5 respondents (79%) were interested in sharing access to their PHR with someone outside of their health system (62% with a spouse or partner, 23% with a child, 15% with another family member, and 25% with a non-VA health care provider). Among those who selected a family member other than a spouse or partner, 47% lived apart from the specified person. Preferences about degree of access varied on the basis of the type of information being shared, the type of activity being performed, and the respondent's relationship with the selected person. Limitations: The survey completion rate was 40.8%. Results might not be generalizable to all My HealtheVet users. Conclusion: In a large survey of PHR users in the VA system, most respondents were interested in sharing access to their electronic health information with caregivers and non-VA providers. Existing and evolving PHR systems should explore secure mechanisms for shared PHR access to improve information exchange among patients and the multiple persons involved in their health care. Primary Funding Source: Veterans Health Administration and The Robert Wood Johnson Foundation Clinical Scholars Program.


Smith M.W.,Health Economics Resource Center
Tobacco control | Year: 2010

Since 2002 the US Veterans Affairs (VA) healthcare system has initiated national policies and programmes to reduce smoking among its patients and to increase evidence-based treatment for smoking. To document changes in dispensing rates of cessation-related medications in VA from 2004 to 2008. Retrospective analysis of VA administrative data. Prescription fills for nicotine replacement therapy (NRT), and for bupropion among NRT users, each grew more than 60% in four years. The increase stemmed primarily from treating more people rather than from filling more prescriptions per person. The results provide strong support for the efficacy of these policies and illustrate how healthcare systems can successfully employ multiple strategies to increase evidence-based smoking-cessation treatment.


Sinnott P.L.,Health Economics Resource Center | Siroka A.M.,Health Economics Resource Center | Shane A.C.,Health Economics Resource Center | Trafton J.A.,Program Evaluation and Resource Center | Wagner T.H.,Health Economics Resource Center
Spine | Year: 2012

STUDY DESIGN.: We reviewed existing methods for identifying patients with neck and back pain in administrative data. We compared these methods using data from the Department of Veterans Affairs. OBJECTIVE.: To answer the following questions: (1) what diagnosis codes should be used to identify patients with neck pain and back pain in administrative data; (2) because the majority of complaints are characterized as nonspecific or mechanical, what diagnosis codes should be used to identify patients with nonspecific or mechanical problems in administrative data; and (3) what procedure and surgical codes should be used to identify patients who have undergone a surgical procedure on the neck or back. SUMMARY OF BACKGROUND DATA.: Musculoskeletal neck and back pain are pervasive problems, associated with chronic pain, disability, and high rates of health care utilization. Administrative data have been widely used in formative research, which has largely relied on the original work of Volinn, Cherkin, Deyo, and Einstadter and the Back Pain Patient Outcomes Assessment Team first published in 1992. Significant variation in reports of incidence, prevalence, and morbidity associated with these problems may be due to nonstandard or conflicting methods to define study cohorts. METHODS.: A literature review produced 7 methods for identifying neck and back pain in administrative data. These code lists were used to search Veterans Health Administration data for patients with back and neck problems, and to further categorize each case by spinal segment involved, as nonspecific/mechanical and as surgical or not. RESULTS.: There is considerable overlap in most algorithms. However, gaps persist. CONCLUSION.: Gaps are evident in existing methods and a new framework to identify patients with neck pain and back pain in administrative data is proposed. Copyright © 2012 Lippincott Williams &Wilkins.


Wagner T.H.,Health Economics Resource Center | Sinnott P.,Health Economics Resource Center | Siroka A.M.,Health Economics Resource Center
Psychiatric Services | Year: 2011

Objective: This study analyzed spending for treatment of mental health and substance use disorders in the Department of Veterans Affairs (VA) in fiscal years (FYs) 2000 through 2007. Methods: VA spending as reported in the VA Decision Support System was linked to patient utilization data as reported in the Patient Treatment Files, the National Patient Care Database, and the VA Fee Basis files. All care and costs from FY 2000 to FY 2007 were analyzed. Results: Over the study period the number of veterans treated at the VA increased from 3.7 million to over 5.1 million (an average increase of 4.9% per year), and costs increased .7% per person per year. For mental health and substance use disorder treatment, the volume of inpatient care decreased markedly, residential care increased, and spending decreased on average 2% per year (from $668 in FY 2000 to $578 per person in FY 2007). FY 2007 saw large increases in mental health spending, bucking the trend from FY 2000 through FY 2006. Conclusions: VA's continued emphasis on outpatient and residential care was evident through 2007. This trend in spending might be unimpressive if VA were enrolling healthier Veterans, but the opposite seems to be true: over this time period the prevalence of most chronic conditions, including depression and posttraumatic stress disorder, increased. VA spending on mental health care grew rapidly in 2007, and given current military activities, this trend is likely to increase.


Rosenheck R.A.,Research Education and Clinical Center | Rosenheck R.A.,Yale University | Krystal J.H.,Research Education and Clinical Center | Krystal J.H.,Yale University | And 7 more authors.
New England Journal of Medicine | Year: 2011

BACKGROUND: Long-acting injectable risperidone, a second-generation antipsychotic agent, may improve adherence to treatment and outcomes in schizophrenia, but it has not been tested in a long-term randomized trial involving patients with unstable disease. METHODS: We randomly assigned patients in the Veterans Affairs (VA) system who had schizophrenia or schizoaffective disorder and who had been hospitalized within the previous 2 years or were at imminent risk for hospitalization to 25 to 50 mg of long-acting injectable risperidone every two weeks or to a psychiatrist's choice of an oral antipsychotic. All patients were followed for up to 2 years. The primary end point was hospitalization in a VA or non-VA psychiatric hospital. Symptoms, quality of life, and functioning were assessed in blinded videoconference interviews. RESULTS: Of 369 participants, 40% were hospitalized at randomization, 55% were hospitalized within the previous 2 years, and 5% were at risk for hospitalization. The rate of hospitalization after randomization was not significantly lower among patients who received long-acting injectable risperidone than among those who received oral antipsychotics (39% after 10.8 months vs. 45% after 11.3 months; hazard ratio, 0.87; 95% confidence interval, 0.63 to 1.20). Psychiatric symptoms, quality of life, scores on the Personal and Social Performance scale of global functioning, and neurologic side effects were not significantly improved with long-acting injectable risperidone as compared with control treatments. Patients who received long-acting injectable risperidone reported more adverse events at the injection site and more extrapyramidal symptoms. CONCLUSIONS: Long-acting injectable risperidone was not superior to a psychiatrist's choice of oral treatment in patients with schizophrenia and schizoaffective disorder who were hospitalized or at high risk for hospitalization, and it was associated with more local injection-site and extrapyramidal adverse effects. (Supported by the VA Cooperative Studies Program and Ortho-McNeil Janssen Scientific Affairs; ClinicalTrials.gov number, NCT00132314.) Copyright © 2011 Massachusetts Medical Society.

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