Personal health record use and its association with antiretroviral adherence: survey and medical record data from 1871 US veterans infected with HIV.

Patient electronic personal health record (PHR) use has been associated with improved patient outcomes in diabetes and depression care. Little is known about the effect of PHR use on HIV care processes and outcomes. We evaluated whether there was an association between patient PHR use and antiretroviral adherence.

Gaps in monitoring during oral anticoagulation: insights into care transitions, monitoring barriers, and medication nonadherence.

Background: Among patients receiving oral anticoagulation, a gap of > 56 days between international normalized ratio tests suggests loss to follow-up that could lead to poor anticoagulation control and serious adverse events.

Methods: We studied long-term oral anticoagulation care for 56,490 patients aged 65 years and older at 100 sites of care in the Veterans Health Administration. We used the rate of gaps in monitoring per patient-year to predict percentage time in therapeutic range (TTR) at the 100 sites.

Identifying major hemorrhage with automated data: results of the Veterans Affairs study to improve anticoagulation (VARIA).

Introduction: Identifying major bleeding is fundamental to assessing the outcomes of anticoagulation therapy. This drives the need for a credible implementation in automated data for the International Society of Thrombosis and Haemostasis (ISTH) definition of major bleeding.

Materials And Methods: We studied 102,395 patients who received 158,511 person-years of warfarin treatment from the Veterans Health Administration (VA) between 10/1/06-9/30/08.

Pathways to vocational services: factors affecting entry by veterans enrolled in Veterans Health Administration mental health services.

The current study provides naturalistic data documenting the pathways-to-care to vocational services for 155 veterans who were receiving some form of mental health care from the Veterans Health Administration and had a vocational need but were not currently enrolled in vocational services. Of the participants, 94.2% had recognized their vocational need, 80.

Organizational characteristics of high- and low-performing anticoagulation clinics in the Veterans Health Administration.

Objective: Anticoagulation clinics (ACCs) can improve anticoagulation control and prevent adverse events. However, ACCs vary widely in their performance on anticoagulation control. Our objective was to compare the organization and management of top-performing with that of bottom-performing ACCs.

INR targets and site-level anticoagulation control: results from the Veterans AffaiRs Study to Improve Anticoagulation (VARIA).

Background: Not all clinicians target the same International Normalized Ratio (INR) for patients with a guideline-recommended target range of 2-3. A patient's mean INR value suggests the INR that was actually targeted. We hypothesized that sites would vary by mean INR, and that sites of care with mean values nearest to 2.

Methodological issues in using multiple years of the Medicare current beneficiary survey.

Background: The analysis presented in this paper examines the multi-year capacity of the Medicare Current Beneficiary Survey (MCBS).

Methods: We systematically reviewed the literature for methodological approaches in research using multiple years of the MCBS and categorized the studies by study design, use of survey sampling weights, and variance adjustments. We then replicated the approaches in an empirical demonstration using functional status (activities of daily living (ADL) and 2005-2007 MCBS data.

The Medicare policy of payment adjustment for health care-associated infections: perspectives on potential unintended consequences.

In 2008, the Centers for Medicare & Medicaid Services introduced a new policy to adjust payment to hospitals for health care-associated infections (HAIs) not present on admission. Interviews with 36 hospital infection preventionists across the United States explored the perspectives of these key stakeholders on the potential unintended consequences of the current policy. Responses were analyzed using an iterative coding process where themes were developed from the data.

Gender disparities in lipid-lowering therapy among veterans with diabetes.

Purpose: We sought to compare lipid-lowering therapy among female and male veterans with diabetes and hyperlipidemia.

Methods: We conducted a cross-sectional study of veterans serviced by the Veterans Health Administration in 2006 who had both diabetes and hyperlipidemia and compared all female patients to age- and facility-matched males. We compared proportions of patients with any prescription for lipid-lowering therapy in the year and, among those with elevated low-density lipoprotein cholesterol (LDL >100 mg/dL) and no prior treatment, we compared initiation of lipid-lowering therapy.

The business case for quality improvement: oral anticoagulation for atrial fibrillation.

Background: The potential to save money within a short time frame provides a more compelling "business case" for quality improvement than merely demonstrating cost-effectiveness. Our objective was to demonstrate the potential for cost savings from improved control in patients anticoagulated for atrial fibrillation.

Methods And Results: Our population consisted of 67 077 Veterans Health Administration patients anticoagulated for atrial fibrillation between October 1, 2006, and September 30, 2008.

Effects of daily adherence to antihypertensive medication on blood pressure control.

Clinicians are often uncertain about how to manage elevated blood pressure (BP) when a patient reports that he/she has recently missed several doses of antihypertensive medications. While we know that better adherence can improve BP during several months, the magnitude of this relationship in the short term is poorly understood. The authors examined this issue using a group of patients who monitored adherence using a Medication Events Monitoring System (MEMS) cap and had BP measurements in the course of routine clinical practice.

Relevance of current guidelines for organizing an anticoagulation clinic.

Objective: To describe variations in the structure of anticoagulation clinic (ACC) care within the Veterans Health Administration (VA) and to identify structures of care that are associated with better site-level anticoagulation control.

Study Design: Questionnaire correlated with automated clinical data.

Methods: We characterized 90 VA ACCs using a questionnaire administered by the VA Central Office.

Prompt repeat testing after out-of-range INR values: a quality indicator for anticoagulation care.

Background: Improved control of oral anticoagulation reduces adverse events. A program of quality measurement is needed for oral anticoagulation. The interval until the next test after an out-of-range International Normalized Ratio (INR) value (the "follow-up interval") could serve as a process of care measure.

Enhancing self-report assessment of PTSD: development of an item bank.

The authors report results of work to enhance self-report posttraumatic stress disorder (PTSD) assessment by developing an item bank for use in a computer-adapted test. Computer-adapted tests have great potential to decrease the burden of PTSD assessment and outcomes monitoring. The authors conducted a systematic literature review of PTSD instruments, created a database of items, performed qualitative review and readability analysis, and conducted cognitive interviews with veterans diagnosed with PTSD.

Reexamining the recommended follow-up interval after obtaining an in-range international normalized ratio value: results from the Veterans Affairs study to improve anticoagulation.

Background: Patients receiving oral anticoagulation therapy should be tested often enough to optimize control, but excessive testing increases burden and cost. We examined the relationship between follow-up intervals after obtaining an in-range (2.0-3.

Risk-adjusted percent time in therapeutic range as a quality indicator for outpatient oral anticoagulation: results of the Veterans Affairs Study to Improve Anticoagulation (VARIA).

Background: Oral anticoagulation is safer and more effective when patients receive high-quality care. However, there have been no prior efforts to measure quality of oral anticoagulation care or to risk adjust it to ensure credible comparisons. Our objective was to profile site performance in the Veterans Health Administration (VA) using risk-adjusted percent time in therapeutic range (TTR).

Patient characteristics associated with oral anticoagulation control: results of the Veterans AffaiRs Study to Improve Anticoagulation (VARIA).

Background: In patients receiving oral anticoagulation, improved control can reduce adverse outcomes such as stroke and major hemorrhage. However, little is known about patient-level predictors of anticoagulation control.

Objectives: To identify patient-level predictors of oral anticoagulation control in the outpatient setting.

A classification of diabetic foot infections using ICD-9-CM codes: application to a large computerized medical database.

Background: Diabetic foot infections are common, serious, and varied. Diagnostic and treatment strategies are correspondingly diverse. It is unclear how patients are managed in actual practice and how outcomes might be improved.

Veterans Health Administration Transitional work experience vs. job placement in veterans with co-morbid substance use and non-psychotic psychiatric disorders.

Objective: This study seeks to compare the effectiveness of Veterans Health Administration's (VHA) transitional work experience (TWE) services and a minimal but common intervention-job placement (JP) services, for veterans with co-morbid substance and psychiatric disorders.

Methods: We conducted a random clinical trial comparing work outcomes for 89 veterans with co-morbid psychiatric and substance use disorders (SUD) who were randomly assigned to participate in VHA TWE services with those assigned to simple JP services provided by state vocational rehabilitation professionals. Participants were enrolled at the time of application to VHA TWE services and then randomly assigned to the two treatment groups and followed for 12 months.

Epidemiology of subtherapeutic anticoagulation in the United States.

Background: Low international normalized ratio (INR; View Article and Find Full Text PDF

Comparing methods of measuring treatment intensification in hypertension care.

Background: Greater treatment intensification (TI) improves hypertension control. However, we do not know the ideal way to measure TI for research and quality improvement efforts. We compared the ability of different TI measures to predict blood pressure (BP) control.

Anticoagulation for valvular heart disease in community-based practice.

Little is known about patients who receive oral anticoagulation for valvular heart disease (VHD) in community-based practice. It was this study's objective to describe the characteristics, management, and outcomes of patients anticoagulated for VHD, compared to patients anticoagulated for atrial fibrillation (AF). We used a nationally-representative cohort of community-based anticoagulation care in the United States.

Market and beneficiary characteristics associated with enrollment in Medicare managed care plans and fee-for-service.

Background: Risk selection in the Medicare managed care program ("Medicare Advantage") is an important policy concern. Past research has shown that Medicare managed care plans tend to attract healthier beneficiaries and that market characteristics such as managed care penetration may also affect risk selection.

Objectives: To assess whether patient enrollment in Medicare managed care (MMC) or traditional fee-for-service (FFS) Medicare is related to beneficiary and market characteristics and provide a baseline for understanding how changes in Medicare policy affect MMC enrollment over time.

Does opioid therapy affect quality of care for diabetes mellitus?

Objective: To examine whether veterans who received chronic opioid therapy had worse diabetes performance measures than patients who did not receive opioids.

Study Design: Retrospective cohort study.

Methods: We identified all patients with diabetes mellitus receiving care in US Department of Veterans Affairs facilities during 2004.