Evaluating the Role of Past Clinical Information on Risk Adjustment.

Objective: The objective of this study was to evaluate whether incorporating historical clinical information beyond 1 year improves risk adjustment.

Data Sources: Administrative data from the Department of Veterans Affairs and Medicare (for veterans concurrently enrolled in Medicare) for fiscal years (FYs) 2011-2015.

Study Design: We regressed total annual costs on Medicare hierarchical condition category indicators and risk scores for FY 2015 in both a concurrent and a prospective model using 5-fold cross-validation.

Assessment of the Medicare Advantage Risk Adjustment Model for Measuring Veterans Affairs Hospital Performance.

Importance: Policymakers and consumers are eager to compare hospitals on performance metrics, such as surgical complications or unplanned readmissions, measured from administrative data. Fair comparisons depend on risk adjustment algorithms that control for differences in case mix.

Objective: To examine whether the Medicare Advantage risk adjustment system version 21 (V21) adequately risk adjusts performance metrics for Veterans Affairs (VA) hospitals.

Persistence of High Health Care Costs among VA Patients.

Objectives: To examine high-cost patients in VA and factors associated with persistence in high costs over time.

Data Sources: Secondary data for FY2008-2012.

Data Extraction: We obtained VA and Medicare utilization and cost records for VA enrollees and drew a 20 percent random sample (N = 1,028,568).

Case-Mix for Performance Management: A Risk Algorithm Based on ICD-10-CM.

Background: Accurate risk adjustment is the key to a reliable comparison of cost and quality performance among providers and hospitals. However, the existing case-mix algorithms based on age, sex, and diagnoses can only explain up to 50% of the cost variation. More accurate risk adjustment is desired for provider performance assessment and improvement.

PA and NP productivity in the Veterans Health Administration.

This study assessed the 2014 clinical productivity of 5,959 physician assistants (PAs) and nurse practitioners (NPs) in the US Department of Veterans Affairs' Veterans Health Administration (VHA). Total work relative value units divided by the direct clinical full-time equivalent measured annual productivity, and correlated factors were examined using weighted analysis of variance. PAs and NPs in adult primary care roles were more productive than those in other specialties.

Risk Adjustment Tools for Learning Health Systems: A Comparison of DxCG and CMS-HCC V21.

Objective: To compare risk scores computed by DxCG (Verisk) and Centers for Medicare and Medicaid Services (CMS) V21.

Research Design: Analysis of administrative data from the Department of Veterans Affairs (VA) for fiscal years 2010 and 2011.

Study Design: We regressed total annual VA costs on predicted risk scores.

β-Blockade and Operative Mortality in Noncardiac Surgery: Harmful or Helpful?

Importance: The use of perioperative pharmacologic β-blockade in patients at low risk of myocardial ischemic events undergoing noncardiac surgery (NCS) is controversial because of the risk of stroke and hypotension. Published studies have not found a consistent benefit in this cohort.

Objective: To determine the effect of perioperative β-blockade on patients undergoing NCS, particularly those with no risk factors.

Denominator doesn't matter: standardizing healthcare-associated infection rates by bed days or device days.

Objective: To examine the impact on infection rates and hospital rank for catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP) using device days and bed days as the denominator

Design: Retrospective survey from October 2010 to July 2013 SETTING: Veterans Health Administration medical centers providing acute medical and surgical care

Patients: Patients admitted to 120 Veterans Health Administration medical centers reporting healthcare-associated infections

Methods: We examined the importance of using device days and bed days as the denominator between infection rates and hospital rank for CAUTI, CLABSI, and VAP for each medical center. The relationship between device days and bed days as the denominator was assessed using a Pearson correlation, and changes in infection rates and device utilization were evaluated by an analysis of variance.

Results: A total of 7.

Predicting potentially avoidable hospitalizations.

Background: Hospitalizations due to ambulatory care sensitive conditions (ACSCs) are widely accepted as an indicator of primary care access and effectiveness. However, broad early intervention to all patients in a health care system may be deemed infeasible due to limited resources.

Objective: To develop a predictive model to identify high-risk patients for early intervention to reduce ACSC hospitalizations, and to explore the predictive power of different variables.

Impact of patient-level risk adjustment on the findings about nurse staffing and 30-day mortality in veterans affairs acute care hospitals.

Background: Studies about nurse staffing and patient outcomes often lack adequate risk adjustment because of limited access to patient information.

Objective: The aim of this study was to examine the impact of patient-level risk adjustment on the associations of unit-level nurse staffing and 30-day inpatient mortality.

Methods: This retrospective cross-sectional study included 284,097 patients discharged during 2007-2008 from 446 acute care nursing units at 128 Veterans Affairs medical centers.

Degree of Acute Kidney Injury before Dialysis Initiation and Hospital Mortality in Critically Ill Patients.

In a multicenter observational cohort of patients-admitted to intensive care units (ICU), we assessed whether creatinine elevation prior to dialysis initiation in acute kidney injury (AKI-D) further discriminates risk-adjusted mortality. AKI-D was categorized into four groups (Grp) based on creatinine elevation after ICU admission but before dialysis initiation: Grp I  > 0.3 mg/dL to <2-fold increase, Grp II ≥2 times but <3 times increase, Grp III ≥3-fold increase in creatinine, and Grp IV none or <0.

Despite variation in volume, Veterans Affairs hospitals show consistent outcomes among patients with non-postoperative mechanical ventilation.

Objective: To assess the relationship between volume of nonoperative mechanically ventilated patients receiving care in a specific Veterans Health Administration hospital and their mortality.

Design: Retrospective cohort study.

Setting: One-hundred nineteen Veterans Health Administration medical centers.

A hybrid Centers for Medicaid and Medicare service mortality model in 3 diagnoses.

Introduction: Reliance on administrative data sources and a cohort with restricted age range (Medicare 65 y and above) may limit conclusions drawn from public reporting of 30-day mortality rates in 3 diagnoses [acute myocardial infarction (AMI), congestive heart failure (CHF), pneumonia (PNA)] from Center for Medicaid and Medicare Services.

Methods: We categorized patients with diagnostic codes for AMI, CHF, and PNA admitted to 138 Veterans Administration hospitals (2006-2009) into 2 groups (less than 65 y or ALL), then applied 3 different models that predicted 30-day mortality [Center for Medicaid and Medicare Services administrative (ADM), ADM+laboratory data (PLUS), and clinical (CLIN)] to each age/diagnosis group. C statistic (CSTAT) and Hosmer Lemeshow Goodness of Fit measured discrimination and calibration.

Determining population based mortality risk in the Department of Veterans Affairs.

We develop a patient level hierarchical regression model using administrative claims data to assess mortality outcomes for a national VA population. This model, which complements more traditional process driven performance measures, includes demographic variables and disease specific measures of risk classified by Diagnostic Cost Groups (DCGs). Results indicate some ability to discriminate survivors and non-survivors with an area under the Receiver Operating Characteristic Curve (C-statistic) of .

Organizational factors associated with decreased mortality among Veterans Affairs patients with an ICU stay.

In-hospital mortality rates associated with an ICU stay are high and vary widely among units. This variation may be related to organizational factors such as staffing patterns, ICU structure, and care processes. We aimed to identify organizational factors associated with variation in in-hospital mortality for patients with an ICU stay.

Variations in efficiency and the relationship to quality of care in the veterans health system.

There is widespread belief that the US health care system could realize significant improvements in efficiency, savings, and patient outcomes if care were provided in a more integrated and accountable way. We examined efficiency and its relationship to quality of care for medical centers run by the Veterans Health Administration of the Department of Veterans Affairs (VA), a national, vertically integrated health care system that is accountable for a large patient population. After devising a statistical model to indicate efficiency, we found that VA medical centers were highly efficient.

Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement.

Background: Elimination of hospital-acquired infections is an important patient safety goal.

Setting: All 174 medical, cardiac, surgical and mixed Veterans Administration (VA) intensive care units (ICUs).

Intervention: A centralised infrastructure (Inpatient Evaluation Center (IPEC)) supported the practice bundle implementation (handwashing, maximal barriers, chlorhexidinegluconate site disinfection, avoidance of femoral catheterisation and timely removal) to reduce central line-associated bloodstream infections (CLABSI).

Infrastructure for quality transformation: measurement and reporting in veterans administration intensive care units.

BACKGROUND Veterans Health Administration (VA) intensive care units (ICUs) develop an infrastructure for quality improvement using information technology and recruiting leadership. METHODS Setting Participation by the 183 ICUs in the quality improvement program is required. Infrastructure includes measurement (electronic data extraction, analysis), quarterly web-based reporting and implementation support of evidence-based practices.

Declining mortality following acute myocardial infarction in the Department of Veterans Affairs Health Care System.

Background: Mortality from acute myocardial infarction (AMI) is declining worldwide. We sought to determine if mortality in the Veterans Health Administration (VHA) has also been declining.

Methods: We calculated 30-day mortality rates between 2004 and 2006 using data from the VHA External Peer Review Program (EPRP), which entails detailed abstraction of records of all patients with AMI.

Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis.

Objectives: Hyperglycemia during critical illness is common and is associated with increased mortality. Intensive insulin therapy has improved outcomes in some, but not all, intervention trials. It is unclear whether the benefits of treatment differ among specific patient populations.

Incidence and outcomes of acute kidney injury in intensive care units: a Veterans Administration study.

Objectives: : To examine the effect of severity of acute kidney injury or renal recovery on risk-adjusted mortality across different intensive care unit settings. Acute kidney injury in intensive care unit patients is associated with significant mortality.

Design: : Retrospective observational study.

Evidence-based national initiatives to address tobacco use as a public health priority in the Veterans Health Administration.

Historically, the prevalence of smoking and smoking-related illnesses has been higher among veteran patients in the Veterans Health Administration (VHA) in comparison to that of the general population. Although rates of tobacco use have remained high, smoking cessation interventions continued to be greatly underutilized in VHA clinical settings just as they have been nationally. To address tobacco use as a public health priority, VHA has implemented a number of evidence-based national initiatives in recent years.

Veterans Affairs intensive care unit risk adjustment model: validation, updating, recalibration.

Background: A valid metric is critical to measure and report intensive care unit (ICU) outcomes and drive innovation in a national system.

Objectives: To update and validate the Veterans Affairs (VA) ICU severity measure (VA ICU).

Research Design: A validated logistic regression model was applied to two VA hospital data sets: 36,240 consecutive ICU admissions to a stratified random sample of moderate and large hospitals in 1999-2000 (cohort 1) and 81,964 cases from 42 VA Medical Centers in fiscal years 2002-2004 (cohort 2).

Intensive care services in the Veterans Health Administration.

Objective: We describe the national organization and distribution of intensive care services within the Veterans Health Administration (VHA), the largest single integrated health-care system in the United States.

Data Sources: Data come primarily from the 2004 Survey of Intensive Care Units in VHA, an electronically distributed survey of all ICUs in the VHA. Medical directors and nurse managers from all 213 ICUs in the VHA responded to the survey.

Recovery of cell wall-deficient organisms from blood does not distinguish between patients with sarcoidosis and control subjects.

Study Objective: To determine if cell wall-deficient forms (CWDF) of mycobacteria can be grown in culture of blood from subjects with sarcoidosis.

Design: A special multicenter study of sarcoidosis (A Case Control Etiologic Study of Sarcoidosis), supported by the National Heart, Lung, and Blood Institute.

Patients And Control Subjects: PATIENTS AND CONTROL SUBJECTS were recruited at 10 institutions in the United States.