Drug Overdose and Suicide Among Veteran Enrollees in the VHA: Comparison Among Local, Regional, and National Data
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ABSTRACT:
SUBMITTER: Ahonle Z
PROVIDER: S-EPMC7535957 | biostudies-literature | 2020 Sep
REPOSITORIES: biostudies-literature
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Project description:BackgroundAlthough pay-for-performance (P4P) strategies have been used by the Veterans Health Administration (VHA) for over a decade, the long-term benefits of P4P are unclear. The use of P4P is further complicated by the increased use of non-VHA healthcare providers as part of the Veterans Choice Program. We conducted a systematic review and key informant interviews to better understand the effectiveness and potential unintended consequences of P4P, as well as the implementation factors and design features important in both VHA and non-VHA/community settings.MethodsWe searched PubMed, PsycINFO, and CINAHL through March 2017 and reviewed reference lists. We included trials and observational studies of P4P targeting Veteran health. Two investigators abstracted data and assessed study quality. We interviewed VHA stakeholders to gain further insight.ResultsThe literature search yielded 1031 titles and abstracts, of which 30 studies met pre-specified inclusion criteria. Twenty-five examined P4P in VHA settings and 5 in community settings. There was no strong evidence supporting the effectiveness of P4P in VHA settings. Interviews with 17 key informants were consistent with studies that identified the potential for overtreatment associated with performance metrics in the VHA. Key informants' views on P4P in community settings included the need to develop relationships with providers and health systems with records of strong performance, to improve coordination by targeting documentation and data sharing processes, and to troubleshoot the limited impact of P4P among practices where Veterans make up a small fraction of the patient population.DiscussionThe evidence to support the effectiveness of P4P on Veteran health is limited. Key informants recognize the potential for unintended consequences, such as overtreatment in VHA settings, and suggest that implementation of P4P in the community focus on relationship building and target areas such as documentation and coordination of care.
| S-EPMC6025676 | biostudies-literature
Project description:BackgroundTo determine differences in the incidence and risks of suicide attempt (SA) and suicidal drug overdose (SDO) between chronic obstructive pulmonary disease (COPD) patients with and without comorbid depression by using data from Taiwan's National Health Insurance Research Database.MethodsWe analyzed the data of patients aged ?20 years who had received a COPD diagnosis between 2000 and 2012. These COPD patients were divided into those with and without depression, and they were compared against a cohort from the general population. We calculated adjusted hazard ratios and the corresponding 95% confidence intervals for SA and SDO in the three cohorts after adjustment for age, sex, and comorbidities.ResultsUntil the end of 2012, 5.81% of patients with COPD developed depression. The incidence of SA and SDO in COPD patients with and without depression was 29.7 and 4.69 per 10,000 person-years and 71.2 and 20.9 per 10,000 person-years, respectively. COPD patients with depression had 13.6- and 10.0-fold higher risks of SA and SDO, respectively, than did controls. Particularly, an increased risk of SA caused by the enhancement effects of depression on COPD was noted in patients aged less than 50 years.ConclusionSA and SDO risks are extremely high in Taiwanese COPD patients with depression. Our findings suggest that clinicians should be aware that for COPD patients with comorbid depression, prescribing a large amount of medications may be associated with SA risk through SDO.
| S-EPMC7174688 | biostudies-literature
Project description:BackgroundJustice-involved Veterans experience notable risk for psychosocial stressors (e.g., homelessness) and psychiatric multimorbidity, which can result in complex clinical presentations. However, research examining how such factors coalesce to impact risk for suicide remains limited.MethodsWe conducted a latent class analysis of 180,454 Veterans accessing Veterans Health Administration (VHA) justice-related services from 2005 to 2018.ResultsA four-model class membership solution was identified. Among these classes, risk for suicide was highest among Veterans with greater psychiatric burden, with risk most notable among those with high VA service use. Veterans seeking healthcare primarily focused on substance use disorders or with low psychiatric burden and service use had a lower risk for suicide.ConclusionsPsychiatric multimorbidity is salient as it relates to suicide among Veterans accessing VHA justice-related services. Further evaluation of existing VHA services for this population and methods of augmenting and enhancing care for justice-involved Veterans with histories of co-occurring psychiatric conditions may be beneficial in facilitating suicide prevention efforts.
| S-EPMC10080851 | biostudies-literature
Project description:Patients living with headache diseases often have difficulty accessing evidence-based care. Authors conducted a qualitative research study with 20 patients receiving headache care at seven Headache Centers of Excellence within the Veterans Health Administration to examine their experiences navigating headache care. This study employed thematic qualitative analysis and conducted cross-case comparisons. Several key findings emerged. 1) Most patients saw multiple healthcare providers over numerous years before reaching a headache specialist to manage chronic headaches. 2) Receipt of high-quality and comprehensive headache specialty care was associated with high satisfaction. 3) Patients with headache diseases reported oftentimes they experienced an arduous journey across multiple healthcare systems and between several healthcare providers before receiving evidence-based headache treatment that they found acceptable. Results demonstrate that most patients were satisfied with their current specialty headache care in the Veterans Health Administration. Authors discuss implications for future studies and highlight ways to improve patient satisfaction and timely access to appropriate headache care.
| S-EPMC9880564 | biostudies-literature
Project description:ObjectiveTo evaluate veteran patient and provider perceptions and preferences on complementary and integrative medicine (CIM) for headache management.BackgroundThe Veterans Health Administration (VHA) has spearheaded a Whole Health system of care focusing on CIM-based care for veteran patients. Less is known about patients' and providers' CIM perceptions and preferences for chronic headache management.MethodsWe conducted semi-structured interviews with 20 veteran patients diagnosed with headache and 43 clinical providers, across 12 VHA Headache Centers of Excellence (HCoE), from January 2019 to March 2020. We conducted thematic and case comparative analyses.ResultsVeteran patients and VHA clinical providers viewed CIM favorably for the treatment of chronic headache. Specific barriers to CIM approaches included: (1) A lack of personnel specialized in specific CIM approaches for timely access, and (2) variation in patient perceptions and responses to CIM treatment efficacy for headache management.ConclusionVeteran patients and VHA clinical providers in this study viewed CIM favorably as a safe addition to mainstream headache treatments. Advantages to CIM include favorable adverse effect profiles and patient autonomy over the treatment. By adding more CIM providers and resources throughout the VHA, CIM modalities may be recommended more routinely in the management of veterans with headache.
| S-EPMC8790919 | biostudies-literature
Project description:Background:The epidemic of drug overdose deaths in the United States has led to an increase in organ donors. Objective:To characterize donors who died of overdose and to analyze outcomes among transplant recipients. Design:Prospective observational cohort study. Setting:Scientific Registry of Transplant Recipients, 1 January 2000 to 1 September 2017. Participants:138 565 deceased donors; 337 934 transplant recipients at 297 transplant centers. Measurements:The primary exposure was donor mechanism of death (overdose-death donor [ODD], trauma-death donor [TDD], or medical-death donor [MDD]). Patient and graft survival and organ discard (organ recovered but not transplanted) were compared using propensity score-weighted standardized risk differences (sRDs). Results:A total of 7313 ODDs and 19 897 ODD transplants (10 347 kidneys, 5707 livers, 2471 hearts, and 1372 lungs) were identified. Overdose-death donors accounted for 1.1% of donors in 2000 and 13.4% in 2017. They were more likely to be white (85.1%), aged 21 to 40 years (66.3%), infected with hepatitis C virus (HCV) (18.3%), and increased-infectious risk donors (IRDs) (56.4%). Standardized 5-year patient survival was similar for ODD organ recipients compared with TDD organ recipients (sRDs ranged from 3.1% lower to 3.9% higher survival) and MDD organ recipients (sRDs ranged from 2.1% to 5.2% higher survival). Standardized 5-year graft survival was similar between ODD and TDD grafts (minimal difference for kidneys and lungs, marginally lower [sRD, -3.2%] for livers, and marginally higher [sRD, 1.9%] for hearts). Kidney discard was higher for ODDs than TDDs (sRD, 5.2%) or MDDs (sRD, 1.5%); standardization for HCV and IRD status attenuated this difference. Limitation:Inability to distinguish between opioid and nonopioid overdoses. Conclusion:In the United States, transplantation with ODD organs has increased dramatically, with noninferior outcomes in transplant recipients. Concerns about IRD behaviors and hepatitis C among donors lead to excess discard that should be minimized given the current organ shortage. Primary Funding Source:National Institutes of Health.
| S-EPMC6205229 | biostudies-literature
Project description:The incidence of hospital-presenting self-harm peaks among young people, who most often engage in intentional drug overdose (IDO). The risk of self-harm repetition is high among young people and switching methods between self-harm episodes is common. However, little is known about their patterns of repetition and switching following IDO. This study aimed to investigate repeat self-harm and method-switching following hospital-presenting IDO among young people. Data from the National Self-Harm Registry Ireland on hospital-presenting self-harm by individuals aged 10-24 years during 2009-2018 were examined. Cox proportional hazards regression models with associated hazard ratios (HRs), survival curves and Poisson regression models with risk ratios (RRs), were used to examine risk factors for repetition and method-switching. During 2009-2018, 16,800 young people presented following IDO. Within 12 months, 2136 young people repeated self-harm. Factors associated with repetition included being male (HR = 1.13, 95% CI: 1.03-1.24), aged 10-17 years (HR = 1.29, 95% CI: 1.18-1.41), consuming ≥ 50 tablets (HR = 1.27, 95% CI: 1.07-1.49) and taking benzodiazepines (HR = 1.67, 95% CI: 1.40-1.98) or antidepressants (HR = 1.36, 95% CI: 1.18-1.56). The cumulative risk for switching method was 2.4% (95% CI: 2.2-2.7). Method-switching was most likely to occur for males (RR = 1.36; 95% CI: 1.09-1.69) and for those who took illegal drugs (RR = 1.63; 95% CI: 1.19-2.25). Young males are at increased risk of repeat self-harm and method-switching following IDO and the type and quantity of drugs taken are further indicators of risk. Interventions targeting IDO among young people are needed that ensure that mental health assessments are undertaken and which address access to drugs.
| S-EPMC7504369 | biostudies-literature
Project description:BackgroundPredicting when and where pathogens will emerge is difficult, yet, as shown by the recent Ebola and Zika epidemics, effective and timely responses are key. It is therefore crucial to transition from reactive to proactive responses for these pathogens. To better identify priorities for outbreak mitigation and prevention, we developed a cohesive framework combining disparate methods and data sources, and assessed subnational pandemic potential for four viral haemorrhagic fevers in Africa, Crimean-Congo haemorrhagic fever, Ebola virus disease, Lassa fever, and Marburg virus disease.MethodsIn this multistage analysis, we quantified three stages underlying the potential of widespread viral haemorrhagic fever epidemics. Environmental suitability maps were used to define stage 1, index-case potential, which assesses populations at risk of infection due to spillover from zoonotic hosts or vectors, identifying where index cases could present. Stage 2, outbreak potential, iterates upon an existing framework, the Index for Risk Management, to measure potential for secondary spread in people within specific communities. For stage 3, epidemic potential, we combined local and international scale connectivity assessments with stage 2 to evaluate possible spread of local outbreaks nationally, regionally, and internationally.FindingsWe found epidemic potential to vary within Africa, with regions where viral haemorrhagic fever outbreaks have previously occurred (eg, western Africa) and areas currently considered non-endemic (eg, Cameroon and Ethiopia) both ranking highly. Tracking transitions between stages showed how an index case can escalate into a widespread epidemic in the absence of intervention (eg, Nigeria and Guinea). Our analysis showed Chad, Somalia, and South Sudan to be highly susceptible to any outbreak at subnational levels.InterpretationOur analysis provides a unified assessment of potential epidemic trajectories, with the aim of allowing national and international agencies to pre-emptively evaluate needs and target resources. Within each country, our framework identifies at-risk subnational locations in which to improve surveillance, diagnostic capabilities, and health systems in parallel with the design of policies for optimal responses at each stage. In conjunction with pandemic preparedness activities, assessments such as ours can identify regions where needs and provisions do not align, and thus should be targeted for future strengthening and support.FundingPaul G Allen Family Foundation, Bill & Melinda Gates Foundation, Wellcome Trust, UK Department for International Development.
| S-EPMC5735217 | biostudies-literature
Project description:Intensity-duration-frequency (IDF) analyses of rainfall extremes provide critical information to mitigate, manage, and adapt to urban flooding. The accuracy and uncertainty of IDF analyses depend on the availability of historical rainfall records, which are more accessible at daily resolution and, quite often, are very sparse in developing countries. In this work, we quantify performances of different IDF models as a function of the number of available high-resolution (N τ ) and daily (N 24h) rain gauges. For this aim, we apply a cross-validation framework that is based on Monte Carlo bootstrapping experiments on records of 223 high-resolution gauges in central Arizona. We test five IDF models based on (two) local, (one) regional, and (two) scaling frequency analyses of annual rainfall maxima from 30-min to 24-h durations with the generalized extreme value (GEV) distribution. All models exhibit similar performances in simulating observed quantiles associated with return periods up to 30 years. When N τ >10, local and regional models have the best accuracy; bias correcting the GEV shape parameter for record length is recommended to estimate quantiles for large return periods. The uncertainty of all models, evaluated via Monte Carlo experiments, is very large when N τ ≤ 5; however, if N 24h ≥ 10 additional daily gauges are available, the uncertainty is greatly reduced and accuracy is increased by applying simple scaling models, which infer estimates on subdaily rainfall statistics from information at daily scale. For all models, performances depend on the ability to capture the elevation control on their parameters. Although our work is site specific, its results provide insights to conduct future IDF analyses, especially in regions with sparse data.
| S-EPMC8216225 | biostudies-literature
Project description:BackgroundThe overdose crisis continues across Canada which calls for novel harm reduction strategies. Previous research indicates that a majority of eHealth solutions are cost-effective however current literature on the cost-benefit of eHealth for harm reduction is sparse. The National Overdose Response Service (NORS) is a Canada-wide telephone-based harm reduction service. Service users can call the phone number and connect to a peer who can virtually monitor the substance use session and dispatch appropriate interventions in the case of overdose.Objectives of the research/projectWe aim to assess the cost-benefit of NORS by comparing the estimated cost-savings from prevented overdose mortality to the operating costs of the program, alongside healthcare costs associated with its operation.MethodsData around systems costs and operational costs were gathered for our calculations. Our primary outcome was cost-benefit ratios, derived from estimates and models of mortality rates in current literature and value of life lost. We presented our main results across a range of values for costs and the probability of death following an unwitnessed overdose. These values were utilized to calculate cost-benefit ratios and value per dollar spent on service provision by NORS over the length of the program's operation (December 2020-2022).ResultsOver the total funded lifespan of the program, and using a Monte Carlo estimate, the benefit-to-cost ratio of the NORS program was 8.59 (1.53-15.28) per dollar spent, depending on estimated mortality rates following unwitnessed overdose and program operation costs. Further, we conservatively estimate that early community-based naloxone intervention results in healthcare system savings of $4470.82 per overdose response.ConclusionsWe found the NORS program to have a positive benefit-to-cost ratio when the probability of death following an unwitnessed overdose was greater than 5%. NORS and potentially other virtual overdose monitoring services have the potential to be cost-effective solutions for managing the drug poisoning crisis.
| S-EPMC10548617 | biostudies-literature