Impact of discontinuing disease-modifying therapies on health care utilization among midlife patients with multiple sclerosis in the United States.

Background: Multiple sclerosis (MS) is a lifelong progressive neurological disease treated primarily with disease-modifying therapies (DMTs). Disease activity tends to decline as patients age. Midlife represents a crossroads where the risks of DMT may outweigh the benefits, prompting providers to consider DMT discontinuation to reduce treatment burden.

Initiation and Persistence of Antipsychotic Medications at Hospital Discharge Among Community-Dwelling Veterans With Dementia.

Objectives: Adults with dementia are frequently prescribed antipsychotic medications despite concerns that risks outweigh benefits. Understanding conditions where antipsychotics are initially prescribed, such as hospitalization, may offer insights into reducing inappropriate use.

Design, Setting, Participants: Retrospective cohort study of community-dwelling veterans with dementia aged ≥68 with VA hospitalizations in 2014, using Veterans Health Administration (VA) and Medicare data.

Veterans' use of inpatient and outpatient palliative care: The national landscape.

Background: Palliative care improves the quality of life for people with life-limiting conditions, which are common among older adults. Despite the Veterans Health Administration (VA) outpatient palliative care expansion, most research has focused on inpatient palliative care. This study aimed to compare veteran characteristics and hospice use for palliative care users across care settings (inpatient vs.

The impact of dual VA-Medicare use on a data-driven clinical management tool for older Veterans with multimorbidity.

Background: Healthcare systems are increasingly turning to data-driven approaches, such as clustering techniques, to inform interventions for medically complex older adults. However, patients seeking care in multiple healthcare systems may have missing diagnoses across systems, leading to misclassification of resulting groups. We evaluated the impact of multi-system use on the accuracy and composition of multimorbidity groups among older adults in the Veterans Health Administration (VA).

Use of high cost care among Veterans with comorbid mental illness and Alzheimer's Disease and related dementias.

Introduction/objective: Alzheimer's Disease and Other Related Dementias (AD/ADRD) leads to frequent emergency department (ED) and inpatient use. Mental health symptoms among persons with AD/ADRD increases cognitive and functional disabilities and could contribute to these high rates of intensive health care use. The objective of this paper is to assess the relationship of mental illness on 12-month patterns in hospitalization and ED use among Veterans aged 65 and over with a new AD/ADRD diagnosis.

Effect of Deintensifying Diabetes Medications on Negative Events in Older Veteran Nursing Home Residents.

Objective: Guidelines advocate against tight glycemic control in older nursing home (NH) residents with advanced dementia (AD) or limited life expectancy (LLE). We evaluated the effect of deintensifying diabetes medications with regard to all-cause emergency department (ED) visits, hospitalizations, and death in NH residents with LLE/AD and tight glycemic control.

Research Design And Methods: We conducted a national retrospective cohort study of 2,082 newly admitted nonhospice veteran NH residents with LLE/AD potentially overtreated for diabetes (HbA1c ≤7.

Care processes and racial/ethnic differences in family reports of end-of-life care among Veterans: A mediation analysis.

Background: Bereaved family members of racial/ethnic minority Veterans are less likely than families of White Veterans to provide favorable overall ratings of end-of-life (EOL) care quality; however, the underlying mechanisms for these differences have not been explored. The objective of this study was to examine whether a set of EOL care process measures mediated the association between Veteran race/ethnicity and bereaved families' overall rating of the quality of EOL care in VA medical centers (VAMCs).

Methods: A retrospective, cross-sectional analysis of linked Bereaved Family Survey (BFS), administrative and clinical data was conducted.

Caregiver and provider perspectives on dual VA and Medicare Part D medication use in veterans with suspected dementia or cognitive impairment.

Purpose: Many older veterans with dementia fill prescriptions through both Veterans Affairs (VA) and Medicare Part D benefits. Dual VA/Part D medication use may have unintended negative consequences in terms of prescribing safety and quality. We aimed to characterize benefits and drawbacks of dual VA/Part D medication use in veterans with dementia or cognitive impairment from the perspectives of caregivers and providers.

Identifying sociodemographic profiles of veterans at risk for high-dose opioid prescribing using classification and regression trees.

Objective: To identify sociodemographic profiles of patients prescribed high-dose opioids.

Design: Cross-sectional cohort study.

Setting/patients: Veterans dually-enrolled in Veterans Health Administration and Medicare Part D, with ≥1 opioid pre-scription in 2012.

End-Of-Life Care in the Time of COVID-19: Communication Matters More Than Ever.

Context: The COVID-19 pandemic resulted in visitation restrictions across most health care settings, necessitating the use of remote communication to facilitate communication among families, patients and health care teams.

Objective: To examine the impact of remote communication on families' evaluation of end-of-life care during the COVID-19 pandemic.

Methods: Retrospective, cross-sectional, mixed methods study using data from an after-death survey administered from March 17-June 30, 2020.

Evaluation of Low-Value Diagnostic Testing for 4 Common Conditions in the Veterans Health Administration.

Importance: Low-value care is associated with harm among patients and with wasteful health care spending but has not been well characterized in the Veterans Health Administration.

Objectives: To characterize the frequency of and variation in low-value diagnostic testing for 4 common conditions at Veterans Affairs medical centers (VAMCs) and to examine the correlation between receipt of low-value testing for each condition.

Design, Setting, And Participants: This retrospective cohort study used Veterans Health Administration data from 127 VAMCs from fiscal years 2014 to 2015.

Discontinuation of Statins in Veterans Admitted to Nursing Homes near the End of Life.

Background/objectives: Geriatric guidelines recommend against statin use in older adults with limited life expectancy (LLE) or advanced dementia (AD). This study examined resident and facility factors predicting statin discontinuation after nursing home (NH) admission in veterans with LLE/AD taking statins for secondary prevention.

Design: Retrospective cohort study of Veterans Affairs (VA) bar code medication administration records, Minimum Data Set (MDS) assessments, and utilization records linked to Medicare claims.

Antihypertensive Deprescribing in Older Adult Veterans at End of Life Admitted to Veteran Affairs Nursing Homes.

Objectives: Geriatric palliative care approaches support deprescribing of antihypertensives in older nursing home (NH) residents with limited life expectancy and/or advanced dementia (LLE/AD) who are intensely treated for hypertension (HTN), but information on real-world deprescribing patterns in this population is limited. We examined the incidence and factors associated with antihypertensive deprescribing.

Design: National, retrospective cohort study.

Deintensification of Diabetes Medications among Veterans at the End of Life in VA Nursing Homes.

Objectives: Many older adults with limited life expectancy and/or advanced dementia (LLE/AD) are potentially overtreated for diabetes and may benefit from deintensification. Our aim was to examine the incidence and predictors of diabetes medication deintensification in older Veterans with LLE/AD who were potentially overtreated at admission to Veterans Affairs (VA) nursing homes (community living centers [CLCs]).

Design: Retrospective cohort study using linked VA and Medicare clinical/administrative data and Minimum Data Set assessments.

Impact of deprescribing AChEIs on aggressive behaviors and antipsychotic prescribing.

Introduction: We evaluated the impact of deprescribing acetylcholinesterase inhibitors (AChEIs) on aggressive behaviors and incident antipsychotic use in nursing home (NH) residents with severe dementia.

Methods: We conducted a retrospective study of Medicare claims, Part D, Minimum Data Set for NH residents aged 65+ with severe dementia receiving AChEIs in 2016. Aggressive behaviors were measured using the aggressive behavior scale (ABS; n = 30,788).

Incidence and Predictors of Aspirin Discontinuation in Older Adult Veteran Nursing Home Residents at End of Life.

Objectives: Continuation of aspirin for secondary prevention in persons with limited life expectancy (LLE) is controversial. We sought to determine the incidence and predictors of aspirin discontinuation in veterans with LLE and/or advanced dementia (LLE/AD) who were taking aspirin for secondary prevention at nursing home admission, stratified by whether their limited prognosis (LP) was explicitly documented at admission.

Design: Retrospective cohort study using linked Veterans Affairs (VA) and Medicare clinical/administrative data and Minimum Data Set resident assessments.

Risk for Health Events After Deprescribing Acetylcholinesterase Inhibitors in Nursing Home Residents With Severe Dementia.

Background/objective: Reevaluation of the appropriateness of acetylcholinesterase inhibitors (AChEIs) is recommended in older adults with severe dementia, given the lack of strong evidence to support their continued effectiveness and risk for medication-induced adverse events. We sought to evaluate the impact of deprescribing AChEIs on risk of all-cause events (hospitalizations, emergency department visits, and mortality) and serious falls or fractures in older nursing home (NH) residents with severe dementia.

Design: Analysis of 2015 to 2016 data from Medicare claims, Part D prescriptions, Minimum Data Set (MDS) version 3.

Association Between Dual Use of Department of Veterans Affairs and Medicare Part D Drug Benefits and Potentially Unsafe Prescribing.

This observational study evaluates the association of dual prescribing for Veterans Affairs and Medicare Part D benefits with unsafe prescription exposure in a national cohort of older veterans.

Low-Value Prostate Cancer Screening Among Older Men Within the Veterans Health Administration.

Background/objectives: Prostate-specific antigen (PSA) screening can be of low value in older adults. Our objective was to quantify the prevalence and variation of low-value PSA screening across the Veterans Health Administration (VA), which has instituted programs to reduce low-value care.

Design: Retrospective cohort.

Factors Associated With Deprescribing Acetylcholinesterase Inhibitors in Older Nursing Home Residents With Severe Dementia.

Background/objective: Uncertainty regarding benefits and risks associated with acetylcholinesterase inhibitors (AChEIs) in severe dementia means providers do not know if and when to deprescribe. We sought to identify which patient-, provider-, and system-level characteristics are associated with AChEI discontinuation.

Design: Analysis of 2015 to 2016 data from Medicare claims, Part D prescriptions, Minimum Data Set (MDS), version 3.

Use of a medication-based risk adjustment index to predict mortality among veterans dually-enrolled in VA and medicare.

Background: There is systemic undercoding of medical comorbidities within administrative claims in the Department of Veterans Affairs (VA). This leads to bias when applying claims-based risk adjustment indices to compare outcomes between VA and non-VA settings. Our objective was to compare the accuracy of a medication-based risk adjustment index (RxRisk-VM) to diagnostic claims-based indices for predicting mortality.

Identifying Optimal Factor Scores on the Bereaved Family Survey: Implications for Practice and Policy.

Context: The Bereaved Family Survey (BFS) is used to evaluate the quality of end-of-life (EOL) care in Veterans Affairs inpatient settings. The BFS consists of a global Performance Measure (BFS-PM) and three factors that relate to specific aspects of EOL care.

Objective: The purpose of this study was to identify empirically based target scores on each BFS factor that are most strongly related to a rating of "excellent" on the BFS-PM.

Economic and objective burden of caregiving on informal caregivers of patients with systemic vasculitis.

Introduction: Systemic vasculitis (SV) is associated with substantial economic impact to patients and the healthcare system but little is known about the burden of SV on informal caregivers. We evaluated the objective caregiving burden experienced by informal caregivers of patients with SV.

Methods: We surveyed adult patients and their informal caregivers on the physical, emotional, social and economic impacts of SV.