To examine facility-level pressure ulcer development rates and variations in these rates after a system-wide adoption of culture change in Veterans Health Administration (VHA) nursing homes.
4-year retrospective longitudinal design.
109 VHA facilities representing 132 nursing homes, known as Community Living Centers (CLCs).
Pressure ulcers were identified using FY08-11 Minimum Data Set (MDS) data. Pressure ulcer development was defined as a stage 2 or larger pressure ulcer on an MDS assessment with no pressure ulcer on the previous assessment. A risk adjustment model was developed using 105,274 MDS observations to predict the likelihood of pressure ulcers (c statistic = 0.72). A Bayesian hierarchical model that adjusted for differences in the precision of pressure ulcer rates from differently sized facilities was used to calculate smoothed risk-adjusted (SRA) rates for each facility. The statistical significance of the trend over the 4 years was determined by examining the 95% interval estimate for the slope.
Over the 4 year period, the beginning of which coincided with the VHA’s system-wide adoption of culture change as a performance measure, median SRA facility pressure ulcer development rates were fairly consistent at approximately 4%. The range in SRA rates declined from 14.8% to 10.1%. Some facilities had significantly improving SRA rates (e.g., declined steadily from 5.5% to 3.9%) and some had significantly worsening SRA rates (e.g., increased steadily from 5.1% to 7.9%). Seven sites had significantly improving rates (p<.001) that were below the median across all 4 years.
CLC pressure ulcer development rates were unaffected by a system-wide culture change implementation. There was, however, significant variation in facility rates and some facilities exhibited sustained high performance.
pressure ulcer; nursing homes; culture change; veterans health
Identify clinically-meaningful potential drug-drug interactions with antiepileptic drugs (AED-PDI), the AEDs and co-administered drugs commonly associated with AED-PDI, and characteristics of patients with increased likelihood of AED-PDI exposure.
Five-year retrospective cohort study of veterans with new-onset epilepsy.
National VA and Medicare databases.
Veterans age 66 years and older with a new diagnosis of epilepsy between October 1, 1999-September 30, 2004 (N=9,682).
We restricted AED-PDI to clinically-meaningful potential drug interactions identified by prior literature review. AED-PDI were identified using participants' date of initial AED prescription and overlapping concomitant medications. Logistic regression analysis identified factors associated with AED-PDI including demographic characteristics, chronic disease states and diagnostic setting.
AED-PDI exposure was found in 45.5% (4,406/9,682); phenytoin, a drug with many potential drug interactions, was the most commonly prescribed AED. Cardiovascular drugs, lipid-lowering medications and psychotropic agents were the most commonly co-administered AED-PDI medications. Individuals at higher likelihood of AED-PDI exposure had 1) hypertension (OR=1.46, 99% CI 1.24-1.82), 2) hypercholesterolemia (OR=1.40, 99% CI 1.24-1.57) and 3) were diagnosed in emergency or primary care vs. Neurology settings (emergency OR: 1.30 99% CI=1.08-1.58; primary care OR: 1.29 99% CI 1.12-1.49).
Exposure to AED-PDI was substantial, but less common in epilepsy patients diagnosed in a neurology setting. Because potential outcomes associated with AED-PDI include stroke and myocardial infarction in a population already at elevated risk, clinicians should closely monitor blood pressure, coagulation, and lipid measures to minimize adverse effects of AED-PDI. Interventions to reduce AED-PDI may improve patient outcomes.
drug-drug interaction; epilepsy; geriatrics; antiepileptic drugs
Patients with mental health conditions (MHCs) experience poor anticoagulation control when using warfarin, but we have limited knowledge of the association between specific mental illness and warfarin treatment outcomes.
To examine the relationship between the severity of MHCs and outcomes of anticoagulation therapy.
Retrospective cohort analysis.
We studied 103,897 patients on warfarin for 6 or more months cared for by the Veterans Health Administration during fiscal years 2007–2008. We identified 28,216 patients with MHCs using ICD-9 codes: anxiety disorders, bipolar disorder, depression, post-traumatic stress disorder, schizophrenia, and other psychotic disorders.
Outcomes included anticoagulation control, as measured by percent time in the therapeutic range (TTR), as well as major hemorrhage. Predictors included different categories of MHC, Global Assessment of Functioning (GAF) scores, and psychiatric hospitalizations.
Patients with bipolar disorder, depression, and other psychotic disorders experienced TTR decreases of 2.63 %, 2.26 %, and 2.92 %, respectively (p < 0.001), after controlling for covariates. Patients with psychotic disorders other than schizophrenia experienced increased hemorrhage after controlling for covariates [hazard ratio (HR) 1.24, p = 0.03]. Having any MHC was associated with a slightly increased hazard for hemorrhage (HR 1.19, p < 0.001) after controlling for covariates.
Patients with specific MHCs (bipolar disorder, depression, and other psychotic disorders) experienced slightly worse anticoagulation control. Patients with any MHC had a slightly increased hazard for major hemorrhage, but the magnitude of this difference is unlikely to be clinically significant. Overall, our results suggest that appropriately selected patients with MHCs can safely receive therapy with warfarin.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-014-2784-2) contains supplementary material, which is available to authorized users.
anticoagulation; mental health; veterans; warfarin therapy; psychiatric conditions
To develop a valid quality measure that captures clinical inertia, the failure to initiate or intensify therapy in response to medical need, in diabetes care and to link this process measure with outcomes of glycemic control.
Existing databases from 13 Department of Veterans Affairs hospitals between 1997 and 1999.
Laboratory results, medications, and diagnoses were collected on 23,291 patients with diabetes. We modeled the decision to increase antiglycemic medications at individual visits. We then aggregated all visits for individual patients and calculated a treatment intensity score by comparing the observed number of increases to that expected based on our model. The association between treatment intensity and two measures of glycemic control, change in HbA1c during the observation period, and whether the outcome glycosylated hemoglobin (HbA1c) was greater than 8 percent, was then examined.
Increases in antiglycemic medications occured at only 9.8percent of visits despite 39percent of patients having an initial HbA1c level greater than 8 percent. A clinically credible model predicting increase in therapy was developed with the principal predictor being a recent HbA1c greater than 8 percent. There were considerable differences in the intensity of therapy received by patients. Those patients receiving more intensive therapy had greater improvements in control (p<.001).
Clinical inertia can be measured in diabetes care and this process measure is linked to patient outcomes of glycemic control. This measure may be useful in efforts to improve clinicians management of patients with diabetes.
Diabetes mellitus; outcomes assessment; quality of health care
High-risk medication exposure in the elderly is common and associated with increased mortality, hospitalizations, and emergency department (ED) visits. Skeletal muscle relaxants and antihistamines are high-risk medications commonly prescribed in elderly patients. The objective of this study was to determine the association between skeletal muscle relaxants or antihistamines and mortality, hospitalizations, and emergency department visits.
This study used a new-user, retrospective cohort design using national Veteran Affairs (VA) data from 128 hospitals. Veterans ≥65 years of age on October 1, 2005 who received VA inpatient/outpatient care at least once in each of fiscal year (FY) 2005 and FY 2006 were included. Exposure to skeletal muscle relaxants and antihistamines was defined by the National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set measures for high-risk medications in the elderly. Primary outcomes identified within one year of exposure were death, ED visit, or hospitalization; ED visits or hospitalizations due to falls and fracture were also assessed. Propensity score matching (1 to 1 match) was used to balance covariates between exposed patients and non-exposed patients.
In this cohort of 1,807,404 patients 55,566 patients were included in the propensity-matched cohort for skeletal muscle relaxants and 60,058 patients were included in the propensity-matched cohort for anti-histamines. Mortality was lower in skeletal muscle relaxants-exposed patients (adjusted odds ratio [AOR] 0.87, 95% CI 0.81-0.94), but risk of emergency care (AOR 2.25, 95% CI 2.16-2.33) and hospitalization (AOR 1.56, 95% CI 1.48-1.65) was higher for patients prescribed skeletal muscle relaxants. Similar findings were observed for emergency and hospital care for falls or fractures. Mortality (AOR 1.93, 95% CI 1.82-2.04), ED visits (AOR 2.35, 95% CI 2.27-2.43), and hospitalizations (AOR 2.21, 95% CI 2.11-2.32) were higher in the antihistamine-exposed group, with similar findings for falls and fractures outcomes.
Skeletal muscle relaxants and antihistamines are associated with an increased risk of ED visits and hospitalizations in elderly patients. Antihistamines were also associated with an increased risk of death, further validating the classification of these drug classes as “high risk”.
Aged; Antihistamines; Skeletal muscle relaxant; Adverse drug events; Healthcare effectiveness data and information set; Mortality; Hospitalizations; Emergency service
Identify prevalence and risk factors for drug-disease interactions included in the Healthcare Effectiveness Data and Information Set Drug-Disease Interaction (HEDIS Rx-DIS) Measure.
Cross-sectional retrospective database analysis.
Outpatient clinics within the Department of Veterans Affairs (VA).
Individuals 65 years and older who received VA outpatient care October 1, 2003 to September 30, 2006.
We identified drug-disease interactions in 2006 defined by the HEDIS Rx-DIS criteria among VA patients with dementia, falls, and chronic renal failure using VA pharmacy and administrative databases. We examined factors associated with HEDIS Rx-DIS exposure including demographic, health status, and access to care factors including VA outpatient health services use and co-payment status.
Of the 305,041 older veterans who met criteria for inclusion, the one-year prevalence of HEDIS Rx-DIS exposure was 15.2%; prevalence was 20.2% for dementia, 16.2% for falls and 8.5% for chronic renal failure. Patients with high disease burden (physical, psychiatric, number of medications) were significantly more likely to have HEDIS Rx-DIS exposure, regardless of condition. Hispanics and individuals with no copayments were more likely to have Rx-DIS exposure than whites or those with required copayments. There was variation on other predictors based on the type of Rx-DIS.
The prevalence of Rx-DIS was common in older VA outpatients. Future studies should examine the risk of Rx-DIS exposure on health outcomes using separate analyses for each type of Rx-DIS separately before combining all Rx-DIS into a single measure of exposure. Studies that examine the effectiveness of interventions to reduce Rx-DIS exposure will also be helpful in improving the quality of care for older patients.
Drug disease interaction; HEDIS measures; Potentially Inappropriate Prescribing; aged; pharmacoepidemiology
To examine the change in use of “High Risk Medications for the Elderly,” as defined by the National Committee on Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) quality measure (HEDIS HRME), by older outpatient veterans over a three year time period. We also sought to identify risk factors for HEDIS HRME exposure overall, and among the most commonly used drug classes.
Longitudinal retrospective database analysis.
Outpatient clinics within the Department of Veterans Affairs (VA).
Veterans aged 65 by October 1, 2003 and who received VA care at least once each year until September 30, 2006.
Rates of use of HEDIS HRME overall and by specific drug classes each year FY04-06.
In our cohort of 1,567,467, high risk medication exposure was reduced from 13.1% to 12.3% between FY04-06 (p<0.01). High risk antihistamines (e.g., diphenhydramine), opioid analgesics (e.g., propoxyphene), skeletal muscle relaxants (e.g., cyclobenzaprine), psychotropics (e.g., long half-life benzodiazepines), endocrine (e.g., estrogen), and cardiac medications (e.g., short-acting nifedipine) had modest but statistically significant (p<0.01) reductions (range -3.8% to -16.0%); nitrofurantoin demonstrated a statistically significant increase (+36.5%; p<0.01). Overall HEDIS HRME exposure was more likely for men, Hispanics, those receiving more medications, psychiatric comorbidity, and those without prior geriatric care. Exposure was lower for individuals exempt from copayment. Similar associations were seen between ethnicity, polypharmacy, psychiatric comorbidity, access to care factors and use of individual HEDIS HRME classes.
HEDIS HRME drug exposure decreased slightly in an integrated health care system. Risk factors for exposure were not consistent across drug groups.Future studies should examine whether interventions to further reduce HEDIS HRME use results in an improvement in health outcomes.
Inappropriate prescribing; quality of care; aged; pharmacoepidemiology
Mental health condition (MHC) comorbidity is associated with lower intensity care in multiple clinical scenarios. However, little is known about the effect of MHC upon clinicians’ decisions about intensifying antiglycemic medications in diabetic patients with poor glycemic control. We examined whether delay in intensification of antiglycemic medications in response to an elevated Hemoglobin A1c (HbA1c) value is longer for patients with MHC than for those without MHC, and whether any such effect varies by specific MHC type.
In this observational study of diabetic Veterans Health Administration (VA) patients on oral antiglycemics with poor glycemic control (HbA1c ≥8) (N =52,526) identified from national VA databases, we applied Cox regression analysis to examine time to intensification of antiglycemics after an elevated HbA1c value in 2003–2004, by MHC status.
Those with MHC were no less likely to receive intensification: adjusted Hazard Ratio [95% CI] 0.99 [0.96-1.03], 1.13 [1.04-1.23], and 1.12 [1.07-1.18] at 0–14, 15–30 and 31–180 days, respectively. However, patients with substance use disorders were less likely than those without substance use disorders to receive intensification in the first two weeks following a high HbA1c, adjusted Hazard Ratio 0.89 [0.81-0.97], controlling for sex, age, medical comorbidity, other specific MHCs, and index HbA1c value.
For most MHCs, diabetic patients with MHC in the VA health care system do not appear to receive less aggressive antiglycemic management. However, the subgroup with substance use disorders does appear to have excess likelihood of non-intensification; interventions targeting this high risk subgroup merit attention.
Electronic supplementary material
The online version of this article (doi:10.1186/1472-6963-14-458) contains supplementary material, which is available to authorized users.
Psychiatric diagnosis; Diabetes mellitus/therapy; Health care delivery; Hypoglycemic agents/therapeutic use; Veterans; Health services research
Warfarin is effective in preventing thromboembolic events, but concerns exist regarding its use in patients with substance abuse.
Identify which patients with substance abuse who receive warfarin are at risk for poor outcomes.
Retrospective cohort study. Diagnostic codes, lab values, and other factors were examined to identify risk of adverse outcomes.
Veterans AffaiRs Study to Improve Anticoagulation (VARIA) database of 103,897 patients receiving warfarin across 100 sites.
Outcomes included percent time in therapeutic range (TTR), a measure of anticoagulation control, and major hemorrhagic events by ICD-9 codes.
Nonusers had a higher mean TTR (62 %) than those abusing alcohol (53 %), drugs (50 %), or both (44 %, p < 0.001). Among alcohol abusers, an increasing ratio of the serum hepatic transaminases aspartate aminotransferase/alanine aminotransferase (AST:ALT) correlated with inferior anticoagulation control; normal AST:ALT ≤ 1.5 predicted relatively modest decline in TTR (54 %, p < 0.001), while elevated ratios (AST:ALT 1.50–2.0 and > 2.0) predicted progressively poorer anticoagulation control (49 % and 44 %, p < 0.001 compared to nonusers). Age-adjusted hazard ratio for major hemorrhage was 1.93 in drug and 1.37 in alcohol abuse (p < 0.001 compared to nonusers), and remained significant after also controlling for anticoagulation control and other bleeding risk factors (1.69 p < 0.001 and 1.22 p = 0.003). Among alcohol abusers, elevated AST:ALT >2.0 corresponded to more than three times the hemorrhages (HR 3.02, p < 0.001 compared to nonusers), while a normal ratio AST:ALT ≤ 1.5 predicted a rate similar to nonusers (HR 1.19, p < 0.05).
Anticoagulation control is particularly poor in patients with substance abuse. Major hemorrhages are more common in both alcohol and drug users. Among alcohol abusers, the ratio of AST/ALT holds promise for identifying those at highest risk for adverse events.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-013-2453-x) contains supplementary material, which is available to authorized users.
anticoagulation; alcohol abuse; drug abuse
The potential to save money within a short time frame provides a more compelling “business case” for quality improvement (QI) than merely demonstrating cost-effectiveness. Our objective was to demonstrate the potential for cost savings from improved control in patients anticoagulated for atrial fibrillation (AF).
Methods and Results
Our population consisted of 67,077 real Veterans Health Administration (VA) patients anticoagulated for AF between 10/1/2006-9/30/2008. We simulated the number of adverse events, and their associated costs and utilities, both before and after various degrees of improvement in percent time in therapeutic range (TTR). The simulation had a two-year time horizon and costs were calculated from the perspective of the payer. In the base-case analysis, improving TTR by 5% prevented 1,114 adverse events, including 662 deaths; it gained 863 QALYs and saved $15.9 million compared to the status quo, not accounting for the cost of the QI program. Improving TTR by 10% prevented 2,087 events, gained 1,606 QALYs, and saved $29.7 million. In sensitivity analyses, costs were most sensitive to the estimated risk of stroke and the expected stroke reduction from improved TTR. Utilities were most sensitive to the estimated risk of death and the expected mortality benefit from improved TTR.
A QI program to improve anticoagulation control would likely be cost-saving for the payer, even if it were only modestly effective in improving control, and even without considering the value of improved health. This study demonstrates how to make a business case for a QI initiative.
anticoagulants; atrial fibrillation; patient simulation; quality improvement
To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care.
Data Sources/Study Settings
Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database.
A cross-sectional analysis of the association among the different measures was performed.
Data Collection/Extraction Methods
Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk-adjusted rates of pressure ulcer development were calculated from an administrative database.
Nursing homes differed significantly (p<.001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1-point increase in QI score was associated with a 0.83 increase on the 5-point satisfaction scale, p<.001) and were more likely to report adoption of pressure ulcer clinical guidelines (a 1-point increase in QI score was associated with a 28 percent increase in number of staff reporting adoption, p<.001). No significant association was found, though, between QI implementation and either adherence to guideline recommendations as abstracted from records or the rate of pressure ulcer development.
Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain.
Quality improvement; quality of care; nursing homes; decubitus ulcers
To assess the performance of Diagnostic Cost Groups (DCGs) in explaining variation in concurrent utilization for a defined subgroup, patients with substance abuse (SA) disorders, within the Department of Veterans Affairs (VA).
A 60 percent random sample of veterans who used health care services during Fiscal Year (FY) 1997 was obtained from VA administrative databases. Patients with SA disorders (13.3 percent) were identified from primary and secondary ICD-9-CM diagnosis codes.
Concurrent risk adjustment models were fitted and tested using the DCG/HCC model. Three outcome measures were defined: (1) “service days” (the sum of a patient's inpatient and outpatient visit days), (2) mental health/substance abuse (MH/SA) service days, and (3) ambulatory provider encounters. To improve model performance, we ran three DCG/HCC models with additional indicators for patients with SA disorders.
To create a single file of veterans who used health care services in FY 1997, we merged records from all VA inpatient and outpatient files.
Adding indicators for patients with mild/moderate SA disorders did not appreciably improve the R-squares for any of the outcome measures. When indicators were added for patients with severe SA who were in the most costly category, the explanatory ability of the models was modestly improved for all three outcomes.
Modifying the DCG/HCC model with additional markers for SA modestly improved homogeneity and model prediction. Because considerable variation still remained after modeling, we conclude that health care systems should evaluate “off-the-shelf” risk adjustment systems before applying them to their own populations.
Risk adjustment; case-mix; substance abuse; capitation payments
Clinical validation studies of the Healthcare Effectiveness Data and Information Set (HEDIS®) measures of inappropriate prescribing in the elderly are limited.
The objective of this study was to examine associations of new exposure to High Risk Medication in Elderly (HRME) and drug-disease interaction (Rx-DIS) with mortality, hospital admission, and emergency care.
A retrospective database study was conducted examining new use of HRME and Rx-DIS in fiscal year 2006 (Oct 2005-Sep 2006; FY06), with index date being date of first HRME/Rx-DIS exposure, or first day of FY07 if no HRME/Rx-DIS exposure. Outcomes were assessed one year after index date. The participants are veterans who were ≥65 years old in FY06and received Veterans Health Administration (VA) care in FY05-06. A history of falls/hip fracture, chronic renal failure, and/or dementia per diagnosis codes defined the Rx-DIS subsample. The variables included a number of new unique HRME drug exposures and new unique Rx-DIS drug exposure (0, 1, >1) in FY06, and outcomes (i.e., 1-year mortality, hospital admission, and emergency care) up to one year after exposure. Descriptive statistics summarized variables for the overall HRME cohort and the Rx-DIS subset. Multivariable statistical analyses using Generalized Estimating Equations (GEE) models with a logit link accounted for nesting of patients within facilities. For these latter analyses, we controlled for demographic characteristics, chronic disease states, and indicators of disease burden the previous year (e.g., number of prescriptions, emergency/hospital care).
Among the 1,807,404 veterans who met inclusion criteria, 5.2% had new HRME exposure. Of the 256,388 in the Rx-DIS cohort, 3.6% had new Rx-DIS exposure. Multivariable analyses found that HRME was significantly associated with mortality (1: adjusted odds ratio [AOR]=1.62, 95% CI 1.56-1.68; >1: AOR=1.80; 95% CI 1.45-2.23), hospital admission (1: AOR=2.31, 95% CI 2.22-2.40; >1: AOR=3.44, 95% CI 3.06-3.87) and emergency care (1: AOR=2.59, 95% CI 2.49-2.70; >1: AOR=4.18, 95% CI 3.71-4.71). Rx-DIS exposure was significantly associated with mortality (1: AOR=1.60, 95% CI 1.51-1.71; >1: AOR=2.00; 95% CI 1.38-2.91), hospital admission for one exposure (1: AOR=1.12, 95% CI 1.03-1.27; >1: AOR=1.18; 95% CI 0.71-1.95) and emergency care for two or more exposures (1: AOR=1.06; 95% CI 0.97-1.15; >1: AOR=2.0; 95% CI 1.35-3.10.
Analyses support the link between HRME/Rx-DIS exposure and clinically significant outcomes in older Veterans. Now is the time to begin incorporating input from both patients who receive these medications and providers who prescribe to develop approaches to reduce exposure to these agents.
To examine prevalence and patient/site level factors associated with potential underuse, overuse and inappropriate use of antidepressants in older Veterans Affairs (VA) Community Living Center (CLC) patients.
133 VA CLCs.
3,692 veterans 65 years or older admitted between 1/1/04-6/3/05 with long stays (90+days).
Prevalence of potential underuse, inappropriate use and overuse of antidepressants in patients with and without depression (as documented by International Classification of Diseases-9 Clinical Modification codes or Depression Rating Scale).
Selective serotonin reuptake inhibitors were the most commonly prescribed antidepressant. Of the 877 patients with depression, 25.4% did not receive an antidepressant suggesting potential underuse. Among depressed patients who received antidepressants, 43.1% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. Of the 2,815 patients who did not have depression, 1190 (42.3%) were prescribed one or more antidepressants; of these only 48 of 1190 (4.0%) had a FDA-approved labeled indication-suggesting potential overuse. Overall only 17.6% of antidepressant use was appropriate (324/1844). The only consistent patient factor associated with potential underuse and overuse use was taking an antipsychotic without evidence of schizophrenia (underuse-adjusted relative risk ratio [ARRR] 0.56, 95% confidence interval [CI] 0.33-0.94; overuse-Adjusted Odds Ratio 1.52, 95% CI 1.21-1.91). Both having moderate/severe pain (ARRR 1.54, 95% CI 1.08-2.20) and the prescribing of an anxiolytic/hypnotic (ARR 1.33, 95% CI 1.02-1.74) increased the risk of potential inappropriate antidepressant use.
Potential problems with the use of antidepressants were frequently observed in older US veteran CLC patients. Future studies are needed to examine the true risks and benefits of antidepressant use in CLC and non-VA nursing homes.
aged; nursing homes; depression; pharmacoepidemiology
While developed for managing individuals with atrial fibrillation, risk stratification schemes for stroke, such as CHADS2, may be useful in population-based studies, including those assessing process of care. We investigated how certain decisions in identifying diagnoses from administrative data affect the apparent prevalence of CHADS2-associated diagnoses and distribution of scores. Two sets of ICD-9 codes (more restrictive/ more inclusive) were defined for each CHADS2-associated diagnosis. For stroke/transient ischemic attack (TIA), the more restrictive set was applied to only inpatient data. We varied the number of years (1-3) in searching for relevant codes, and, except for stroke/TIA, the number of instances (1 vs. 2) that diagnoses were required to appear. The impact of choices on apparent disease prevalence varied by type of choice and condition, but was often substantial. Choices resulting in substantial changes in prevalence also tended to be associated with more substantial effects on the distribution of CHADS2 scores.
Stroke; atrial fibrillation; risk stratification; CHADS2; ICD-9-CM codes
Disparities in blood pressure (BP) control may be a function of disparities in treatment intensification (TI).
To examine racial differences in TI, understand modifiable factors that may mediate this relationship, and explore the relative effects of TI and race on blood pressure.
Prospective cohort study.
Participants were 819 black and white patients with hypertension from an urban, safety-net hospital
We sequentially explored the effects of patient race, sociodemographic and clinical characteristics, beliefs about BP/medications, perceptions of provider/discrimination, sodium intake, medication adherence, and provider counseling on TI, performing a series of random effects analyses. To assess the effects of race and TI on BP, we performed linear regressions, using systolic BP (SBP) as the outcome.
Unadjusted analyses and those including sociodemographic and clinical characteristics revealed that black patients had less TI than whites (−0.31 vs.−0.24, p < 0.001), but adjustment for patient beliefs and experiences eliminated the effects of race (β =−0.02, p = 0.5). Increased patient concerns about BP medications were related to lower TI, as was more provider counseling (β =−0.06, p = 0.02 and β = −0.01, p = 0.001, respectively). In the unadjusted analysis, black race was a significant predictor of SBP (134 mm/Hg for blacks vs. 131 mm/Hg for whites, p = 0.009), but when both race and TI were included in the model, TI was a significant predictor of SBP (final SBP 2.0 mm/Hg lower for each additional therapy increase per 10 visits, p < 0.001), while race was not (Blacks 1.6 mm/Hg higher than whites, p = 0.17).
Improved patient–provider communication targeted towards addressing patient concerns about medications may have the potential to reduce racial disparities in TI and ultimately, BP control.
disparities; treatment intensification; hypertension
We examined the quality of adult epilepsy care using the Quality Indicators in Epilepsy Treatment (QUIET) measure, and variations in quality based on the source of epilepsy care.
We identified 311 individuals with epilepsy diagnosis between 2004 and 2007 in a tertiary medical center in New England. We abstracted medical charts to identify the extent to which participants received quality indicator (QI) concordant care for individual QI's and the proportion of recommended care processes completed for different aspects of epilepsy care over a two year period. Finally, we compared the proportion of recommended care processes completed for those receiving care only in primary care, neurology clinics, or care shared between primary care and neurology providers.
The mean proportion of concordant care by indicator was 55.6 (standard deviation = 31.5). Of the 1985 possible care processes, 877 (44.2%) were performed; care specific to women had the lowest concordance (37% vs. 42% [first seizure evaluation], 44% [initial epilepsy treatment], 45% [chronic care]). Individuals receiving shared care had more aspects of QI concordant care performed than did those receiving neurology care for initial treatment (53% vs. 43%; X2 = 9.0; p = 0.01) and chronic epilepsy care (55% vs. 42%; X2 = 30.2; p < 0.001).
Similar to most other chronic diseases, less than half of recommended care processes were performed. Further investigation is needed to understand whether a shared-care model enhances quality of care, and if so, how it leads to improvements in quality.
More intensive management can improve control blood pressure (BP) in hypertensive patients. However, many would posit that treatment intensification (TI) is not beneficial in the face of suboptimal adherence. We investigated whether the effect of TI upon BP varies by adherence. We enrolled 819 patients with hypertension, managed in primary care at an academically-affiliated inner-city hospital. We used the following formula to characterize TI: (visits with a medication change - visits with elevated BP)/total visits. Adherence was characterized using electronic monitoring devices (“MEMS caps”). Patients who returned their MEMS caps (671) were divided into quartiles of adherence, while patients who did not return their MEMS caps (148) had “missing” adherence. We examined the relationship between TI and the final systolic blood pressure (SBP), controlling for patient-level covariates. In the entire sample, each additional therapy increase per 10 visits predicted a 2.0 mm/Hg decrease in final SBP (p < 0.001). After stratifying by adherence, in the “best” adherence quartile each therapy increase predicted a 2.1 mm/Hg decrease in final SBP, followed by 1.8 for the “next-best” adherence quartile, 2.3 in the third quartile, and 2.4 in the “worst” adherence quartile. The effect size for patients with “missing” adherence was 1.6 mm/Hg. The differences between the group with “best” adherence and the other 4 groups were not statistically significant. In this observational study, treatment intensification was associated with similar BP improvement regardless of the patient’s level of adherence. A randomized trial could further examine optimal management of patients with suboptimal adherence.
Hypertension; adherence; medication therapy management; quality of care; ambulatory care
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.
Methods and Results
We enrolled 819 hypertensive outpatients from an academic, urban hospital. Each patient was assigned 3 scores to characterize TI. The any/none score divides patients into those who had any therapy increases during the study vs. none. The Norm-Based Method (NBM) models the chance of a medication increase at each visit, then scores each patient based on whether they received more or fewer medication increases than predicted. The Standard-Based Method (SBM) is similar to NBM, but expects a medication increase whenever the BP is uncontrolled. We compared the ability of these scores to predict the final systolic blood pressure (SBP). The any/none score showed a paradoxical result: any therapy increase was associated with SBP 4.6 mm/Hg higher than no increase (p < 0.001). The NBM score did not predict SBP in a linear fashion (p = 0.18); further investigation revealed a U-shaped relationship between NBM score and SBP. However, the SBM score was a strong linear predictor of SBP (2.1 mm/Hg lower for each additional therapy increase per ten visits, p < 0.001). Similarly, SBM predicted dichotomized BP control, as measured by SBP < 140 mm/Hg (OR 1.30, p < 0.001).
Our results suggest that SBM is the preferred measure of treatment intensity for hypertension care.
Hypertension; chronic disease; research methodology; quality of care; ambulatory care
The term “clinical inertia” is used to describe the failure to manage a chronic condition aggressively enough to bring it under control. The underlying mechanisms for clinical inertia remain poorly understood.
To describe one potential mechanism for clinical inertia, seen through the lens of clinician responses to a computerized hypertension reminder.
A total of 509 hypertensive patients from 2 primary care clinics in urban Veterans Health Administration (VA) Medical Centers. All patients had elevated blood pressure (BP) values that triggered a computerized reminder. Given a set of possible responses to the reminder, clinicians asserted at least once for each patient that medication adjustments were unnecessary because the BP was “usually well controlled”.
Using recent BP values from the electronic medical record, we assessed the accuracy of this assertion.
In most instances (57%), recent BP values were not well controlled, with the systolic BP (56%) much more likely to be elevated than the diastolic BP (13%). Eighteen percent of recent systolic BP values were 160 mmHg or greater.
When clinicians asserted that the BP was “usually well controlled”, objective evidence frequently suggested otherwise. This observation provides insight into one potential mechanism underlying clinical inertia.
hypertension; ambulatory care; informatics; quality of care; chronic disease
African Americans have higher rates of hypertension and worse blood pressure (BP) control than Whites, and poorer medication adherence may contribute to this phenomenon. We explored associations among patients’ race, self-reported experiences with clinicians, attitudes and beliefs about hypertension, and ultimately, medication adherence, among a sample with no racial disparities in BP control, to determine what lessons we could learn from patients and providers in this setting.
We recruited 793 White and African-American (58%) patients previously diagnosed with hypertension from 3 VA medical centers to participate in survey assessments of each of the above dimensions, subsequent to a primary care clinic visit.
African-American patients’ providers were significantly more active in advising and counseling about hypertension care and medication adherence. African-American patients indicated greater knowledge or heightened awareness of the importance of controlling their BP, but there were no race differences on a summary adherence measure. In multivariate models modeling medication adherence, race was not significant, but having been told to split one’s pills, believing one’s BP continues to be high, and having one’s provider discuss things to do to make it easier to take BP medications were each significantly associated with worse adherence, whereas having more confidence in one’s ability to take BP medications as prescribed was associated with better adherence (all p’s ≤ .02).
When both physicians and patients take BP management seriously, disparities in BP adherence and control may be reduced.
physician–patient relations; patient compliance; attitude to health
Poor adherence to antihypertensives has been shown to be a significant factor in poor blood pressure (BP) control. Providers' communication with patients about their medication-taking behavior may be central to improving adherence.
The goal of this study was to characterize the ways in which providers ask patients about medication taking.
Clinical encounters between primary care providers and hypertensive patients were audiotaped at 3 Department of Veterans' Affairs medical centers.
Primary care providers (n =9) and African-American and Caucasian patients (n =38) who were diagnosed with hypertension (HTN).
Transcribed audiotapes of clinical encounters were coded by 2 investigators using qualitative analysis based on sociolinguistic techniques to identify ways of asking about medication taking. Electronic medical records were reviewed after the visit to determine the BP measurement for the day of the taped encounter.
Four different aspects of asking about medication were identified: structure, temporality, style and content. Open-ended questions generated the most discussion, while closed-ended declarative statements led to the least discussion. Collaborative style and use of lay language were also seen to facilitate discussions. In 39% of encounters, providers did not ask about medication taking. Among patients with uncontrolled HTN, providers did not ask about medications 33% of the time.
Providers often do not ask about medication-taking behavior, and may not use the most effective communication strategies when they do. Focusing on the ways in which providers ask about patients' adherence to medications may improve BP control.
hypertension; medication adherence; provider-patient communication