Patient-reported quality of supportive care among patients with colorectal cancer in the Veterans Affairs Health Care System.
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ABSTRACT:
SUBMITTER: van Ryn M
PROVIDER: S-EPMC3940539 | biostudies-other | 2014 Mar
REPOSITORIES: biostudies-other
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Project description:ImportancePostcolonoscopy colorectal cancer (PCCRC) refers to colorectal cancer (CRC) diagnosed after a colonoscopy in which no cancer was found and is reflective of colonoscopy quality at the individual and system levels. Colonoscopy is widely performed in the Veterans Affairs (VA) health care system, but the prevalence of PCCRC and its associated mortality are unknown.ObjectiveTo examine PCCRC prevalence and its all-cause mortality (ACM) and CRC-specific mortality (CSM) within the VA health care system.Design, setting, and participantsThis retrospective cohort study used VA-Medicare administrative data to identify 29 877 veterans aged 50 to 85 years with newly diagnosed CRC between January 1, 2003, and December 31, 2013. Patients whose colonoscopy occurred less than 6 months before CRC diagnosis with no other colonoscopy within the previous 36 months were categorized as having detected CRC (DCRC). Those who had a colonoscopy that did not detect CRC between 6 and 36 months before CRC diagnosis were categorized as having postcolonoscopy CRC (PCCRC-3y). A third group included patients with CRC and no colonoscopy within the prior 36 months. The final analysis of the data was performed in September 2022.ExposuresPrior receipt of colonoscopy.Main outcomes and measuresCox proportional hazards regression (with censoring, last follow-up December 31, 2018) analyses were conducted to compare PCCRC-3y and DCRC for 5-year ACM and CSM after CRC diagnosis.ResultsOf 29 877 patients with CRC (median [IQR] age, 67 [60-75] years; 29 353 [98%] male; 5284 [18%] Black, 23 971 [80%] White, and 622 [2%] other), 1785 (6%) were classified as having PCCRC-3y and 21 811 (73%) as having DCRC. The 5-year ACM rates were 46% vs 42% for patients with PCCRC-3y vs patients with DCRC. The 5-year CSM rates were 26% vs 25% for patients with PCCRC-3y vs patients with DCRC. In multivariable Cox proportional hazards regression analysis, there was no significant difference in ACM and CSM between patients with PCCRC-3y (adjusted hazard ratio [aHR], 1.04; 95% CI, 0.98-1.11; P = .18) and patients with DCRC (aHR, 1.04; 95% CI, 0.95-1.13; P = .42). However, compared with patients with DCRC, patients with no prior colonoscopy had significantly higher ACM (aHR, 1.76; 95% CI, 1.70-1.82; P < .001) and CSM (aHR, 2.22; 95% CI, 2.12-2.32; P < .001). Compared with patients with DCRC, patients with PCCRC-3y had significantly lower odds of having undergone colonoscopy performed by a gastroenterologist (odds ratio, 0.48; 95% CI, 0.43-0.53; P < .001).Conclusions and relevanceThis study found that PCCRC-3y constituted 6% of CRCs in the VA system, which is similar to other settings. Compared with patients with CRC detected by colonoscopy, those with PCCRC-3y have comparable ACM and CSM.
| S-EPMC10080371 | biostudies-literature
Project description:BackgroundGender differences in inpatient quality of care are well known. However, whether men and women receive equivalent ambulatory care is less well understood.ObjectiveTo study gender differences in quality of care for patients receiving primary care in the Veterans Affairs (VA) Health Care System.DesignCross-sectional samples of VA enrollees during fiscal years 1999 to 2000.ParticipantsSamples of 6,442 to 86,405 men and women treated at VA facilities for whom at least 1 of 9 quality measures was available.MeasurementsAppropriate general preventive services (pneumococcal vaccination, influenza vaccination, colorectal cancer screening), and specific services for diabetes (annual hemoglobin A1c [HbA1c] testing, good glycemic control, annual diabetic eye exam), hypertension (good blood pressure control), or prior myocardial infarction (use of beta-blockers or aspirin).ResultsIn adjusted analyses, there were no substantial gender differences in rates of appropriate care. For women compared with men, the adjusted relative risk for appropriate care ranged from 0.96 for blood pressure control (95% confidence interval: 0.93 to 0.99; P=.02) to 1.05 for HbA1c< or =8.0% (95% confidence interval: 1.03 to 1.07; P<.01). Analyses stratified by age demonstrated equivalent care between men and women in 9 of the 14 subgroups evaluated.ConclusionsIn this large national health care system that predominantly serves men, the quality of ambulatory care is equivalent for women and men on numerous measures.
| S-EPMC1490181 | biostudies-literature
Project description:Vaccine hesitancy undermines the control of the COVID-19 pandemic and has been observed in health care workers. As part of a quality improvement effort, we aimed to describe reasons for vaccine acceptance and hesitancy among employees in the Veteran Affairs Portland Health Care System (VAPORHCS). We administered an open-ended and web-based survey to all VAPORHCS employees in July 2021. Data were analyzed using a rapid usability framework, whereby qualitative data were synthesized into thematic categories to inform decision making. Among the 1157 employees who completed the survey, 88% reported that they had received the vaccine and 12% reported that they did not receive the vaccine. Over half (54%) of vaccinated respondents reported having initial hesitancy to the COVID-19 vaccine but overcame their hesitancy by deciding that the vaccine's benefits outweighed its risks. Reasons for COVID-19 vaccine acceptance were: 1) individual and community health; 2) protect vulnerable and unvaccinated family members; 3) promote patient and workplace safety; 4) scientific evidence. Reasons for COVID-19 vaccine hesitancy among unvaccinated employees were: 1) concerns with safety and risk profile of vaccine; 2) mistrust in vaccine development; 3) personal choice; 4) openness to future vaccination. These results provide information for tailored vaccine messaging efforts as well as emphasizes the need for trust-building between employees and health care organizations.
| S-EPMC8783525 | biostudies-literature
Project description:Data are needed from outpatient settings to better inform antimicrobial stewardship. In this study, a random sample of outpatient antibiotic prescriptions by primary care providers (PCPs) at our health care system was reviewed and compared to consensus guidelines. Over 12 months, 3,880 acute antibiotic prescriptions were written by 76 PCPs caring for 40,734 patients (median panel, 600 patients; range, 33 to 1,547). PCPs ordered a median of 84 antibiotic prescriptions per 1,000 patients per year. Azithromycin (25.8%), amoxicillin-clavulanate (13.3%), doxycycline (12.4%), amoxicillin (11%), fluoroquinolones (11%), and trimethoprim-sulfamethoxazole (10.6%) were prescribed most commonly. Medical records corresponding to 300 prescriptions from 59 PCPs were analyzed in depth. The most common indications for these prescriptions were acute respiratory tract infection (28.3%), urinary tract infection (23%), skin and soft tissue infection (15.7%), and chronic obstructive pulmonary disease (COPD) exacerbation (6.3%). In 5.7% of cases, no reason for the prescription was listed. No antibiotic was indicated in 49.7% of cases. In 12.3% of cases, an antibiotic was indicated, but the prescribed agent was guideline discordant. In another 14% of cases, a guideline-concordant antibiotic was given for a guideline-discordant duration. Therefore, 76% of reviewed prescriptions were inappropriate. Ciprofloxacin and azithromycin were most likely to be prescribed inappropriately. A non-face-to-face encounter prompted 34% of prescriptions. The condition for which an antibiotic was prescribed was not listed in primary or secondary diagnosis codes in 54.5% of clinic visits. In conclusion, there is an enormous opportunity to reduce inappropriate outpatient antibiotic prescriptions.
| S-EPMC6105840 | biostudies-other
Project description:ImportanceUntreated primary hyperparathyroidism impairs quality of life and incurs substantial costs. Parathyroidectomy is a low-risk, high-success, definitive intervention.ObjectivesTo determine the appropriateness of diagnostic evaluation for primary hyperparathyroidism in patients with hypercalcemia and the use of parathyroidectomy for the treatment of primary hyperparathyroidism across the Veterans Affairs (VA) health care system.Design, setting, and participantsA retrospective cohort study of veterans with hypercalcemia and primary hyperparathyroidism was conducted from January 1, 2000, through September 30, 2015, using the VA Corporate Data Warehouse, a national electronic health record-based repository. The study included 371 370 veterans with chronic hypercalcemia and 47 158 veterans with biochemical evidence of primary hyperparathyroidism diagnosed by hypercalcemia, elevated serum parathyroid hormone levels, and near-normal serum creatinine levels. Statistical analysis was performed from April 21, 2017, to April 10, 2019.Main outcomes and measuresThe proportion of veterans with hypercalcemia who have parathyroid hormone levels evaluated, the proportion of veterans with hyperparathyroidism who are treated surgically, and the factors associated with parathyroidectomy using generalized linear latent and mixed model regression.ResultsOf 371 370 patients with chronic hypercalcemia, 86 887 (23.4%) received further testing with parathyroid hormone level. Of 47 158 patients meeting diagnostic criteria for primary hyperparathyroidism (42 737 men [90.6%] and 4421 women [9.4%]; mean [SD] age, 67.3 [11.8] years), 6048 (12.8%) underwent parathyroidectomy. Of 5793 patients with primary hyperparathyroidism presenting with a serum calcium level more than 1 mg/dL above the upper limit of normal, 1501 (25.9%) underwent parathyroidectomy. There was a decreasing trend in the use of parathyroidectomy over time. Factors positively associated with parathyroidectomy were nephrolithiasis (odds ratio [OR], 2.23; 95% CI, 1.90-2.61) and non-Hispanic white race/ethnicity (OR, 1.31; 95% CI, 1.17-1.46), while age (OR, 0.95; 95% CI, 0.95-0.96), Elixhauser Comorbidity Index score (OR, 0.76; 95% CI, 0.72-0.80), decreased estimated glomerular filtration rate (OR, 0.52; 95% CI, 0.45-0.60), and diagnosis of osteoporosis (OR, 0.65; 95% CI, 0.52-0.80) were inversely related to surgery.Conclusions and relevanceFrom this study's findings, parathyroid hormone level is infrequently tested in patients with hypercalcemia, suggesting underdiagnosis of primary hyperparathyroidism. Patients meeting diagnostic criteria for primary hyperparathyroidism are undertreated with recommended parathyroidectomy. Similar gaps have previously been observed in non-VA care of primary hyperparathyroidism, suggesting the need for a systematic evaluation of barriers to diagnosis and treatment that informs intervention design.
| S-EPMC6632180 | biostudies-literature
Project description:Timely access to outpatient care was a primary driver behind the Department of Veterans Affairs' (VA's) increased purchase of community-based care under the Veterans Access, Choice, and Accountability Act of 2014, known as the Choice Act. To compare veterans' experiences in VA-delivered and community-based outpatient care after implementation of the act, we assessed veterans' scores on four dimensions of experience-access, communication, coordination, and provider rating-for outpatient specialty, primary, and mental health care received during 2016-17. Patient experiences were better for VA than for community care in all respects except access. For specialty care, access scores were better in the community; for primary and mental health care, access scores were similar in the two settings. Although all specialty care scores and the primary care coordination score improved over time, the gaps between settings did not shrink. As purchased care further expands under the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, which replaced the Choice Act in 2019, monitoring of meaningful differences between settings should continue, with the results used to inform both VA purchasing decisions and patients' care choices.
| S-EPMC10031805 | biostudies-literature
Project description:ObjectiveThe aim of this retrospective study was to evaluate the oral health-related quality of life (oHRQoL) and patient-reported outcome measures (PROMs) after 10 years of supportive periodontal care (SPC).Material and methodsPatients were re-examined 120±12 months after active periodontal therapy. Dental and periodontal status and oHRQoL by completing Oral Health Impact Profile-G49 (OHIP-G49) and PROMs by marking a visual analogue scale (VAS) for self-perceived esthetics (VASe), chewing function (VASc), and hygiene ability (VASh) were assessed. Patient- and tooth-related factors (age, insurance status, number of SPC, compliance, change of therapist, smoking, tooth loss, need for surgery or antibiotic intake, bleeding on probing (BOP), periodontal inflamed surface area) influencing oHRQoL and PROMs were evaluated.ResultsOne hundred eight periodontally compromised patients (59 female, mean age 65.4±10.7 years) lost 135 teeth during 10 years of SPC. At re-examination, 1.8% of all sites showed PPD ≥6mm. The mean OHIP-G49 sum score was 17.6±18.5, and VAS resulted in 76.0±22.5 (VASe), 86.3±16.3 (VASc), and 79.8±15.8 (VASh). Linear regression analyses identified a positive correlation with oHRQoL and/or PROMs for private insurance status (OHIP-G49, p=0.015, R2=0.204; VASc, p=0.005, R2=0.084; VASh, p=0.012, R2=0.222) and compliance to SPC (VASe, p=0.032; R2=0.204), as well as a negative correlation for active smoking (VASc, p=0.012, R2=0.084), increased BOP (VASh, p=0.029, R2=0.222) at the start of SPC, and number of lost molars (VASh, p=0.008, R2=0.222).ConclusionIt is realistic to obtain satisfactory oHRQoL and PROM values in most of the patients after 10 years of SPC. The identified factors may help to predict patient satisfaction in the long-term course of therapy.Clinical relevanceSystematic therapy of periodontally compromised patients provides values for oHRQoL and PROMs in a favorable range 10 years after therapy. This should encourage dentists to implement SPC in their daily routine.Clinical trial numberNCT03048045.
| S-EPMC10264521 | biostudies-literature
Project description:Although women will account for almost 11% of veterans by 2040, we know little about their health and functioning, particularly compared to men.To compare women and men veterans' health-related quality of life (HRQOL) and VA health care utilization and to see if previously described associations between HRQOL, subsequent VA health care utilization, and mortality in male veterans would generalize to women veterans.Prospective cohort study of all veterans who received medical care from an Upper Midwest Veterans Affairs facility between 10/1/96 and 3/31/98 and returned a mailed questionnaire.Women's effective survey response rate was 52% (n = 1,500); men's, 58% (n = 35,000). In the following year, 9% of women and 12% of men had at least one hospitalization. One percent of women and 3% of men died in the post-survey year. After adjustment, women's HRQOL was higher than men's; for every 10-point decrement in overall physical or mental functioning, women and men had similarly increased risk/odds of subsequently dying, being hospitalized at a VA facility, or making a VA outpatient stop. Among younger women and women who received VA care outside of the Twin City metro area, poorer overall mental or physical health functioning was associated with fewer primary care stops; among their male counterparts, it was associated with more primary care stops.Compared to men, women veterans receiving VA health care in the upper Midwest catchment area had better HRQOL and used fewer health services. Although VA health care utilization was similar across gender after adjusting for HRQOL, poorer mental or physical health was associated with fewer primary care stops for selected subgroups of women.
| S-EPMC2219767 | biostudies-other
Project description:Importance:Current guidelines recommend statin therapy for millions of US residents for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). It is unclear whether traditional prediction models that do not account for current widespread statin use are sufficient for risk assessment. Objectives:To examine the performance of the Pooled Cohort Equations (PCE) for 5-year ASCVD risk estimation in a contemporary cohort and to test the hypothesis that inclusion of statin therapy improves model performance. Design, Setting, and Participants:This cohort study included adult patients in the Veterans Affairs health care system without baseline ASCVD. Using national electronic health record data, 3 Cox proportional hazards models were developed to estimate 5-year ASCVD risk, as follows: the variables and published ? coefficients from the PCE (model 1), the PCE variables with cohort-derived ? coefficients (model 2), and model 2 plus baseline statin use (model 3). Data were collected from January 2002 to December 2012 and analyzed from June 2016 to March 2020. Exposures:Traditional ASCVD risk factors from the PCE plus baseline statin use. Main Outcomes and Measures:Incident ASCVD and ASCVD mortality. Results:Of 1?672?336 patients in the cohort (mean [SD] baseline age 58.0 [13.8] years, 1?575?163 [94.2%] men, 1?383?993 [82.8%] white), 312?155 (18.7%) were receiving statin therapy at baseline. During 5 years of follow-up, 66?605 (4.0%) experienced an ASCVD event, and 31?878 (1.9%) experienced ASCVD death. Compared with the original PCE, the cohort-derived model did not improve model discrimination in any of the 4 age-sex strata but did improve model calibration. The PCE overestimated ASCVD risk compared with the cohort-derived model; 211?237 of 1?136?161 white men (18.6%), 29?634 of 218?463 black men (13.6%), 1741 of 44?399 white women (3.9%), and 836 of 16?034 black women (5.2%) would be potentially eligible for statin therapy under the PCE but not the cohort-derived model. When added to the cohort-derived model, baseline statin therapy was associated with a 7% (95% CI, 5%-9%) lower relative risk of ASCVD and a 25% (95% CI, 23%-28%) lower relative risk for ASCVD death. Conclusions and Relevance:In this study, lower than expected rates of incident ASCVD events in a contemporary national cohort were observed. The PCE overestimated ASCVD risk, and more than 15% of patients would be potentially eligible for statin therapy based on the PCE but not on a cohort-derived model. In the statin era, health care professionals and systems should base ASCVD risk assessment on models calibrated to their patient populations.
| S-EPMC7361654 | biostudies-literature
Project description:BackgroundAn investigational drug service (IDS) has a foundational role in ensuring the safe and efficient management of investigational drugs. The objective of this assessment is to determine economic value of an IDS within a Veterans Affairs health care system.MethodsThis assessment was a single-center retrospective record review. Study protocols managed by the IDS over a 2-year period were evaluated for cost avoidance, revenue, and waived revenue. Cost avoidance was defined as the cost savings generated when a research subject received sponsor-provided treatment in place of a therapy that would have been otherwise funded by the institution. Revenue from fees charged to investigators and waived revenue based on the standardized IDS fee schedule were also totaled. The total economic value to the institution accounted for the personnel costs of the IDS.ResultsTwenty-three investigational study protocols managed by the IDS resulted in economic outcomes. The total cost avoidance during the two-year period was $482,627.33. The total revenue and waived revenue associated with the IDS was $16,822 and $54,200, respectively. Oncology protocols had the highest contribution to the outcomes of cost avoidance and revenue and mental health protocols had the highest contribution for waived revenue. The overall economic value of the IDS to the institution was $393,649.33.ConclusionsOver a two-year period, the IDS demonstrated a substantial economic value that was largely driven by cost avoidance. Revenue generation from fees charged to investigators and cost savings to the investigator through waived revenue also contributed economic benefits to the institution.
| S-EPMC6461586 | biostudies-literature