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1.  The Performance of Administrative and Self-Reported Measures for Risk Adjustment of Veterans Affairs Expenditures 
Health Services Research  2005;40(3):887-904.
To evaluate the performance of different prospective risk adjustment models of outpatient, inpatient, and total expenditures of veterans who regularly use Veterans Affairs (VA) primary care.
Data Sources
We utilized administrative, survey and expenditure data on 14,449 VA patients enrolled in a randomized trial that gave providers regular patient health assessments.
Study Design
This cohort study compared five administrative data-based, two self-report risk adjusters, and base year expenditures in prospective models.
Data Extraction Methods
VA outpatient care and nonacute inpatient care expenditures were based on unit expenditures and utilization, while VA expenditures for acute inpatient care were calculated from a Medicare-based inpatient cost function. Risk adjusters for this sample were constructed from diagnosis, medication and self-report data collected during a clinical trial. Model performance was compared using adjusted R2 and predictive ratios.
Principal Findings
In all expenditure models, administrative-based measures performed better than self-reported measures, which performed better than age and gender. The Diagnosis Cost Groups (DCG) model explained total expenditure variation (R2=7.2 percent) better than other models. Prior outpatient expenditures predicted outpatient expenditures best by far (R2=42 percent). Models with multiple measures improved overall prediction, reduced over-prediction of low expenditure quintiles, and reduced under-prediction in the highest quintile of expenditures.
Prediction of VA total expenditures was poor because expenditure variation reflected utilization variation, but not patient severity. Base year expenditures were the best predictor of outpatient expenditures and nearly the best for total expenditures. Models that combined two or more risk adjusters predicted expenditures better than single-measure models, but are more difficult and expensive to apply.
PMCID: PMC1361173  PMID: 15960696
Risk adjustment; health status; expenditures; VA; risk segmentation
2.  Evaluation of a Weight Management Program for Veterans 
To improve the health of overweight and obese veterans, the Department of Veterans Affairs (VA) developed the MOVE! Weight Management Program for Veterans. The aim of this evaluation was to assess its reach and effectiveness.
We extracted data on program involvement, demographics, medical conditions, and outcomes from VA administrative databases in 4 Western states. Eligibility criteria for MOVE! were being younger than 70 years and having a body mass index (BMI, in kg/m2) of at least 30.0, or 25.0 to 29.9 with an obesity-related condition. To evaluate reach, we estimated the percentage of eligible veterans who participated in the program and their representativeness. To evaluate effectiveness, we estimated changes in weight and BMI using multivariable linear regression.
Less than 5% of eligible veterans participated, of whom half had only a single encounter. Likelihood of participation was greater in women, those with a higher BMI, and those with more primary care visits, sleep apnea, or a mental health condition. Likelihood of participation was lower among those who were younger than 55 (vs 55-64), widowed, current smokers, and residing farther from the medical center (≥30 vs <30 miles). At 6- and 12-month follow-up, participants lost an average of 1.3 lb (95% confidence interval [CI], −2.6 to −0.02 lb) and 0.9 lb (95% CI, −2.0 to 0.1 lb) more than nonparticipants, after covariate adjustment. More intensive treatment (≥6 encounters) was associated with greater weight loss at 12 months (−3.7 lb; 95% CI, −5.1 to −2.3 lb).
Few eligible patients participated in the program during the study period, and overall estimates of effectiveness were low.
PMCID: PMC3437789  PMID: 22595323
3.  Wide Clinic-Level Variation in Adherence to Oral Diabetes Medications in the VA 
While there has been extensive research into patient-specific predictors of medication adherence and patient-specific interventions to improve adherence, there has been little examination of variation in clinic-level medication adherence.
We examined the clinic-level variation of oral hypoglycemic agent (OHA) medication adherence among patients with diabetes treated in the Department of Veterans Affairs (VA) primary care clinics. We hypothesized that there would be systematic variation in clinic-level adherence measures, and that adherence within organizationally-affiliated clinics, such as those sharing local management and support, would be more highly correlated than adherence between unaffiliated clinics.
Retrospective cohort study.
VA hospital and VA community-based primary care clinics in the contiguous 48 states.
444,418 patients with diabetes treated with OHAs and seen in 158 hospital-based clinics and 401 affiliated community primary care clinics during fiscal years 2006 and 2007.
Refill-based medication adherence to OHA.
Adjusting for patient characteristics, the proportion of patients adherent to OHAs ranged from 57 % to 81 % across clinics. Adherence between organizationally affiliated clinics was high (Pearson Correlation = 0.82), and adherence between unaffiliated clinics was low (Pearson Correlation = 0.04).
The proportion of patients adherent to OHAs varied widely across VA primary care clinics. Clinic-level adherence was highly correlated to other clinics in the same organizational unit. Further research should identify which factors common to affiliated clinics influence medication adherence.
PMCID: PMC3631064  PMID: 23371383
pharmacoepidemiology; health services research; diabetes; veterans; primary care
4.  Clinical Significance of Postvoid Residual Volume in Older Ambulatory Women 
Journal of the American Geriatrics Society  2011;59(8):10.1111/j.1532-5415.2011.03511.x.
To examine the prevalence, natural history, and clinical significance of elevations in postvoid residual (PVR) volume in ambulatory older women
Prospective cohort study
Group health plan in Washington state
987 ambulatory women aged 55 to 75 years
PVR was measured by bladder ultrasonography at baseline, 1 year, and 2 years. Participants completed questionnaires about urinary symptoms and provided urine samples for microbiologic evaluation.
Of the 987 participants, 79% had a PVR <50 mL, 10% had a PVR of 50–99 mL, 6% had a PVR of 100–199 mL, and 5% had a PVR ≥200 mL at baseline. Of women with a PVR <50, 66% reported at least one urinary symptom at baseline. Of women with a PVR ≥200 mL, 27% reported no significant symptoms at baseline. In adjusted analyses using data from all study visits, women with a PVR ≥100 mL were more likely to report urinating >8 times during the day (OR=1.42, CI=1.07–1.87), and women with a PVR ≥200 mL were more likely to report weekly urgency incontinence (OR=1.50, CI=1.03–2.18), versus those with a PVR <50 mL. Elevated PVR was not associated with increased risk of stress incontinence, nocturnal frequency, or urinary tract infection in adjusted analyses. Forty-six percent of those with a PVR ≥200 mL and 63% of those with a PVR of 100–199 mL at baseline had a PVR <50 mL at 2 years.
Over 10% of ambulatory older women may have a PVR ≥100 mL associated with increased risk of some urinary symptoms, but many with elevated PVR are asymptomatic, and elevations in PVR frequently resolve within 2 years. Symptom-guided management of urinary symptoms may be more appropriate than PVR-guided management in this population.
PMCID: PMC3886558  PMID: 21806559
Postvoid residual; urinary incontinence; urinary tract infection; nocturia
5.  Predicting Mortality and Healthcare Utilization with a Single Question 
Health Services Research  2005;40(4):1234-1246.
We compared single- and multi-item measures of general self-rated health (GSRH) to predict mortality and clinical events a large population of veteran patients.
Data Source/Study Setting
We analyzed prospective cohort data collected from 21,732 patients as part of the Veterans Affairs Ambulatory Care Quality Improvement Project (ACQUIP), a randomized controlled trial investigating quality-of-care interventions.
Study Design
We created an age-adjusted, logistic regression model for each predictor and outcome combination, and estimated the odds of events by response category of the GSRH question and compared the discriminative ability of the predictors by developing receiver operator characteristic curves and comparing the associated area under the curve (AUC)/c-statistic for the single- and multi-item measures.
Data Collection/Extraction Methods
All patients were sent a baseline assessment that included a multi-item measure of general health, the 36-item Medical Outcomes Study Short Form (SF-36), and an inventory of comorbid conditions. We compared the predictive and discriminative ability of the GSRH to the SF-36 physical component score (PCS), the mental component score (MCS), and the Seattle index of comorbidity (SIC). The GSRH is an item included in the SF-36, with the wording: “In general, would you say your health is: Excellent, Very Good, Good, Fair, Poor?”
Principal Findings
The GSRH, PCS, and SIC had comparable AUC for predicting mortality (AUC 0.74, 0.73, and 0.73, respectively); hospitalization (AUC 0.63, 0.64, and 0.60, respectively); and high outpatient use (AUC 0.61, 0.61, and 0.60, respectively). The MCS had statistically poorer discriminatory performance for mortality and hospitalization than any other other predictors (p<.001).
The GSRH response categories can be used to stratify patients with varying risks for adverse outcomes. Patients reporting “poor” health are at significantly greater odds of dying or requiring health care resources compared with their peers. The GSRH, collectable at the point of care, is comparable with longer instruments.
PMCID: PMC1361190  PMID: 16033502
Quality of life; mortality; hospitalization; outpatient; risk assessment
6.  The Future of General Internal Medicine 
The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today's medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep—ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine.
PMCID: PMC1494674  PMID: 14748863
primary care; medical education; physician payment; hospitalist; geriatrics
7.  Multi-Hospital Data Mart for Quality Improvement in Ambulatory Care 
We have used SQL databases, PC based software tools, high volume network printers, and optical scanning technology to build an information system for a clinical trial that tracks the ambulatory care of over 60,000 patients at seven VA hospitals. The system presents patient information to providers at General Internal Medicine (GIM) clinic visits for 26,800 patients assigned to the intervention group.
PMCID: PMC2232204
8.  Relapsing Fever Revisited 
Western Journal of Medicine  1981;134(3):263-264.
PMCID: PMC1272629  PMID: 18748834
9.  Neighborhood Environment and Health Status and Mortality Among Veterans 
The VHA is the largest integrated US health system and is increasingly moving care into the communities where veterans reside. Veterans who utilize the VA for their care have worse health status than the general population. However, there is limited evidence about the association of neighborhood environment and health outcomes among veterans.
The primary aim of this study is to assess the relative contribution of neighborhood environment, health system, and individual characteristics to health status and mortality of veterans.
Information on personal socio-economic indicators, existing medical conditions and health status were obtained from baseline data from a multi-site, randomized trial of primary care patients (n = 15,889). The physical component scale (PCS) and mental component scale (MCS) summarized health status. Census tracts were used as proxies for neighborhoods. A summary score based on census tract data characterized the neighborhood socio-economic environment and walkability. Data were analyzed with multilevel hierarchical models. Analyses of health status were cross-sectional. Mortality analyses were longitudinal as participants were followed for an average of 722.5 days to ascertain vital status.
Neighborhood SES was associated with PCS and MCS scores, controlling for individual socio-economic status, self-reported co-morbid disease, smoking status, and health care access. In the lowest versus highest quartiles of neighborhood SES, adjusted PCS scores were 34.4 vs. 35.4 (p < 0.05) and adjusted MCS scores were 46.2 versus 47.0 (p < 0.05). PCS score was also significantly associated with neighborhood walkability (p < 0.05). Mortality was lower for veterans living in neighborhoods with the highest decile neighborhood SES (HR 0.78, highest vs. lowest decile 95% CI 0.63, 0.97).
Veterans living in lower SES neighborhoods have poorer health status and a higher risk of mortality, independent of individual characteristics and health care access. Neighborhood walkability was associated with higher PCS scores.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1710-0) contains supplementary material, which is available to authorized users.
PMCID: PMC3138994  PMID: 21499826
neighborhood; veterans; health status
10.  Recent hospitalization for Non-coronary events and use of preventive medications for coronary artery disease: An observational cohort study 
High-quality systems have adopted a comprehensive approach to preventive care instead of diagnosis or procedure driven care. The current emphasis on prescribing medications to prevent complications of coronary artery disease (CAD) at discharge following an acute coronary syndrome (ACS) may exclude high-risk patients who are hospitalized with conditions other than ACS.
Among a sample of patients with CAD treated at Veterans Affairs medical centers between January, 2005 and November, 2006, we investigated whether recent non-ACS hospitalization was associated with prescriptions of preventive medications as compared with patients recently hospitalized with ACS.
Of 13,211 patients with CAD, 58% received aspirin, 70% β-blocker, 60% angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB), and 65% lipid-lowering therapy. Twenty-five percent of eligible patients were receiving all four medications. Having been hospitalized for a non-ACS event in the prior 6 months did not substantially affect the adjusted proportion on preventive medications. In contrast, among patients hospitalized for ACS in the prior 6 months, the adjusted proportion prescribed aspirin was 21% higher (p < 0.001), β-blocker was 14% higher (p < 0.001), ACE-I or ARB was 9% higher (p < 0.001), lipid therapy was 12% higher (p < 0.001), and prescribed all four medications was 18% higher (p < 0.001) than among patients hospitalized for ACS more than 2 years earlier.
Being hospitalized for a non-ACS condition did not appear to influence preventive medication use among patients with CAD and represents a missed opportunity to improve patient care. The same protocols employed to improve use of preventive medications in patients discharged for ACS might be extended to CAD patients discharged for other conditions as well.
PMCID: PMC3146403  PMID: 21740591
11.  Use of Administrative Claims Models to Assess 30-Day Mortality among Veterans Health Administration Hospitals 
Medical care  2010;48(7):652-658.
The Centers for Medicare and Medicaid Services publicly-reports hospital-specific risk-standardized, 30-day, all-cause, mortality rates (RSMRs) for all hospitalizations among fee-for-service Medicare beneficiaries for acute myocardial infarction (AMI), heart failure (HF), and pneumonia at non-Federal hospitals.
To examine the performance of the statistical models used by CMS among veterans at least 65 years of age hospitalized for AMI, HF, and pneumonia in Veterans Health Administration (VHA) hospitals.
Research Design
Cross-sectional analysis of VHA administrative claims data between October 1, 2006 and September 30, 2009.
13,046 veterans hospitalized for AMI among 123 VHA hospitals; 26,379 veterans hospitalized for HF among 124 VHA hospitals; and 31,126 veterans hospitalized for pneumonia among 124 VHA hospitals.
Hospital-specific RSMR for AMI, HF, and pneumonia hospitalizations calculated using hierarchical generalized linear models.
Median number of AMI hospitalizations per VHA hospital was 87. Average AMI RSMR was 14.3% (95% Confidence Interval (CI), 13.9%-14.6%) with modest heterogeneity among VHA hospitals (RSMR range: 8.4%-20.3%). The c-statistic for the AMI RSMR statistical model was 0.79. Median number of HF hospitalizations was 188. Average HF RSMR was 10.1% (95% CI, 9.9%-10.4%) with modest heterogeneity (RSMR range: 6.1%-14.9%). The c-statistic for the HF RSMR statistical model was 0.73. Median number of pneumonia hospitalizations was 221.5 Average pneumonia RSMR was 13.0% (95% CI, 12.7%-13.3%) with modest heterogeneity (RSMR range: 9.0%-18.4%). The c-statistic for the pneumonia RSMR statistical model was 0.72.
The statistical models used by CMS to estimate RSMRs for AMI, HF, and pneumonia hospitalizations at non-Federal hospitals demonstrate similar discrimination when applied to VHA hospitals.
PMCID: PMC3020977  PMID: 20548253
12.  Vaginal symptoms in postmenopausal women: self-reported severity, natural history, and risk factors 
Menopause (New York, N.Y.)  2010;17(1):121-126.
This study aimed to examine factors other than estrogen deficiency influencing the development and persistence of vaginal dryness, itching, and painful sexual intercourse after menopause.
We analyzed data from a 2-year, population-based cohort of 1,017 postmenopausal women aged 55 to 75 years. Vaginal symptoms were assessed by interviewer-administered questionnaire, and vaginal swabs were performed to assess vaginal pH and microbial flora at baseline, 12 months, and 24 months. Generalized estimating equations were used to identify characteristics associated with symptoms.
Half of the women (n = 471) reported problematic vaginal dryness, a third (n = 316) reported itching, and 40% of sexually active women (n = 166) reported painful intercourse at baseline. Of women not taking estrogen, half of those reporting baseline symptoms were symptomatic after 24 months. Vaginal dryness was associated with younger age (odds ratio [OR], 0.81; 95% CI, 0.69–0.94, per 5-y increase), nonwhite race (ie, African American, Hispanic, Asian or Pacific Islander, or American Indian [OR, 1.53; 95% CI, 1.04–2.27]), diabetes (OR, 1.51; 95% CI, 1.07–2.12), lower 36-item Short-Form Health Survey physical functioning scores (OR, 0.90; 95% CI, 0.85–0.97, per 10-point increase), lower body mass index (OR, 0.81; 95% CI, 0.71–0.93, per 5 kg/m2 increase), recent sexual activity (OR, 1.14; 95% CI, 1.08–1.21), and vaginal colonization with enterococci (OR, 1.25; 95% CI, 1.04–1.51). Vaginal itching was also associated with lower physical functioning scores (OR, 0.86; 95% CI, 0.80–0.92, per 10-point increase). Risk factors for painful intercourse included younger age (OR, 0.72; 95% CI, 0.56–0.93, per 5-y increase), diabetes (OR, 3.48; 95% CI, 1.93–6.27), lower body mass index (OR, 0.76; 95%CI, 0.61–0.95, per 5 kg/m2 increase), and higher vaginal pH (OR, 1.10; 95% CI, 1.00–1.21, per 0.5 units).
Vaginal symptoms affect a large proportion of postmenopausal women, particularly those with diabetes and those with lower body mass index, but may resolve for up to half of women without estrogen therapy.
PMCID: PMC2806500  PMID: 19574936
Vaginal dryness; Menopause; Vaginal atrophy; Dyspareunia; Sexual dysfunction
13.  Strategies from a Nationwide Health Information Technology Implementation: The VA CART STORY 
Journal of General Internal Medicine  2010;25(Suppl 1):72-76.
The VA Cardiovascular Assessment, Reporting, and Tracking (CART) system is a customized electronic medical record system which provides standardized report generation for cardiac catheterization procedures, serves as a national data repository, and is the centerpiece of a national quality improvement program. Like many health information technology projects, CART implementation did not proceed without some barriers and resistance. We describe the nationwide implementation of CART at the 77 VA hospitals which perform cardiac catheterizations in three phases: (1) strategic collaborations; (2) installation; and (3) adoption. Throughout implementation, success required a careful balance of technical, clinical, and organizational factors. We offer strategies developed through CART implementation which are broadly applicable to technology projects aimed at improving the quality, reliability, and efficiency of health care.
PMCID: PMC2806964  PMID: 20077156
health information technology; implementation; barriers; facilitators; EMR; organizational culture
14.  Performance of Comorbidity, Risk Adjustment, and Functional Status Measures in Expenditure Prediction for Patients With Diabetes  
Diabetes Care  2009;32(1):75-80.
OBJECTIVE—To compare the ability of generic comorbidity and risk adjustment measures, a diabetes-specific measure, and a self-reported functional status measure to explain variation in health care expenditures for individuals with diabetes.
RESEARCH DESIGN AND METHODS—This study included a retrospective cohort of 3,092 diabetic veterans participating in a multisite trial. Two comorbidity measures, four risk adjusters, a functional status measure, a diabetes complication count, and baseline expenditures were constructed from administrative and survey data. Outpatient, inpatient, and total expenditure models were estimated using ordinary least squares regression. Adjusted R2 statistics and predictive ratios were compared across measures to assess overall explanatory power and explanatory power of low- and high-cost subgroups.
RESULTS—Administrative data–based risk adjusters performed better than the comorbidity, functional status, and diabetes-specific measures in all expenditure models. The diagnostic cost groups (DCGs) measure had the greatest predictive power overall and for the low- and high-cost subgroups, while the diabetes-specific measure had the lowest predictive power. A model with DCGs and the diabetes-specific measure modestly improved predictive power.
CONCLUSIONS—Existing generic measures can be useful for diabetes-specific research and policy applications, but more predictive diabetes-specific measures are needed.
PMCID: PMC2606834  PMID: 18945927
15.  Declining mortality following acute myocardial infarction in the Department of Veterans Affairs Health Care System 
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.
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. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files.
Using EPRP data on 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p = .011). Similar declines were found for in-hospital and 90-day mortality.
Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08).
Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals.
PMCID: PMC2746180  PMID: 19719849
16.  A Review of Interventions and System Changes to Improve Time to Reperfusion for ST-Segment Elevation Myocardial Infarction 
Journal of General Internal Medicine  2008;23(8):1246-1256.
Identify and describe interventions to reduce time to reperfusion for patients with ST-segment elevation myocardial infarction (STEMI).
Data Source
Key word searches of five research databases: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Web of Science, and Cochrane Clinical Trials Registry.
We included controlled and uncontrolled studies of interventions to reduce time to reperfusion. One researcher reviewed abstracts and 2 reviewed full text articles. Articles were subsequently abstracted into structured data tables, which included study design, setting, intervention, and outcome variables. We inductively developed intervention categories from the articles. A second researcher reviewed data abstraction for accuracy.
Measurements and Main Results
We identified 666 articles, 42 of which met inclusion criteria. We identified 11 intervention categories and classified them as either process specific (e.g., emergency department administration of thrombolytic therapy, activation of the catheterization laboratory by emergency department personnel) or system level (e.g., continuous quality improvement, critical pathways). A majority of studies (59%) were single-site pre/post design, and nearly half (47%) had sample sizes less than 100 patients. Thirty-two studies (76%) reported significantly lower door to reperfusion times associated with an intervention, 12 (29%) of which met or exceeded guideline recommended times. Relative decreases in times to reperfusion ranged from 15 to 82% for door to needle and 13–64% for door to balloon.
We identified an array of process and system-based quality improvement interventions associated with significant improvements in door to reperfusion time. However, weak study designs and inadequate information about implementation limit the usefulness of this literature.
Electronic supplementary materials
The online version of this article (doi:10.1007/s11606-008-0563-7) contains supplementary material, which is available to authorized users.
PMCID: PMC2517976  PMID: 18459014
cardiac reperfusion; myocardial infarction; systematic review; quality improvement
17.  Sexual Intercourse and Risk of Symptomatic Urinary Tract Infection in Post-Menopausal Women 
Sexual intercourse increases the risk of symptomatic urinary tract infections (UTI) in young women, but its role among post-menopausal women is unclear.
To determine whether recent sexual intercourse, as documented by daily diaries, is associated with an increased risk of symptomatic UTI in post-menopausal women.
A 2-year prospective cohort study conducted from 1998 to 2002.
One thousand and seventeen randomly selected post-menopausal women enrolled at Group Health Cooperative (GHC), a Washington State HMO.
Measurements and Main Results
Women were asked to enter daily diary information on vaginal intercourse, medication use, and genito-urinary symptoms. The outcome of interest, symptomatic UTI, was defined as a positive urine culture ≥105 CFU/mL of a uropathogen and the presence of ≥2 acute urinary symptoms. Nine hundred thirteen women returned diaries and were included in this study. Seventy-eight women experienced 108 symptomatic UTIs, and 361 (40%) reported sexual intercourse in their diaries. There was an increased hazard for UTI 2 calendar days after the reporting of sexual intercourse in the diaries (adjusted hazard ratio [HR], 3.42, 95% CI 1.49–7.80), while there was no evidence for an increased hazard associated with intercourse at other times. When the UTI criterion was relaxed from ≥105 CFU/mL to ≥104 CFU/mL, adding 9 UTI events to the analysis, the HR for UTI 2 days after intercourse changed slightly to 3.26 (95% CI 1.43–7.43).
Our data suggest that, as with younger women, recent sexual intercourse is strongly associated with incident UTI in generally healthy post-menopausal women.
PMCID: PMC2324148  PMID: 18266044
coitus; diaries; postmenopause; urinary tract infections
18.  Cause of death in Washington state veterans hospitalized with acute coronary syndromes in the veterans health administration 
In the United States, relatively little is known about cause of death in individuals who die prior to or after hospital discharge for acute coronary syndromes (ACS). The purpose of this report was to compare baseline patient characteristics according to whether the underlying cause of death was cardiac or non-cardiac.
We linked cause of death information from Washington State death records to the Department of Veterans Affairs (VA) External Peer Review Program ACS registry. From 524 individuals who were hospitalized for ACS in veterans hospitals located in Washington State or Oregon, we identified 136 individuals who according to VA death records died during the years 2003 to 2005. Of these, 117 (86%) were found in Washington State death records. Sociodemographic variables, as well as underlying and secondary causes of death, were obtained from Washington State death records provided by the Washington State Department of Health. Clinical variables, including medical histories, presentation on admission, and in-hospital death were extracted from the VA ACS registry.
Somewhat surprisingly, only 52% of veterans died of cardiac causes when only the underlying cause of death was used. However, when secondary causes of death were added to the definition, the proportion that died of cardiac causes increased to 81%. Patient characteristics were similar in the two groups, although small numbers limited the ability to detect statistically significant differences.
These preliminary findings suggest that it is important to consider secondary causes as well as the underlying one when classifying deaths as cardiac or non-cardiac.
PMCID: PMC2494989  PMID: 18647422
19.  Severe mental illness and mortality of hospitalized ACS patients in the VHA 
Severe mental illness (SMI) has been associated with more medical co-morbidity and less cardiovascular procedure use for older patients with myocardial infarction. However, it is unknown whether SMI is associated with increased long term mortality risk among patients presenting with acute coronary syndromes (ACS). We tested the hypothesis that SMI is associated with higher one-year mortality following ACS hospitalization.
All ACS patients (n = 14,194) presenting to Veterans Health Administration (VHA) hospitals between October 2003 and September 2005 were included. Survival analysis evaluated the association between SMI and one-year all-cause mortality, adjusting for demographics, co-morbidities, in-hospital treatment, and discharge medications.
Overall, 18.4 % of ACS patients had SMI. Patients with SMI were more likely female, younger, Caucasian race, have a history of alcohol abuse, liver disease, dementia, hypertension and more likely to be a current smoker; however, prior cardiac history was similar between the 2 groups. There were no significant differences in cardiac procedure use, including coronary angiogram (38.7% vs. 40.3%, p = 0.14) or coronary revascularization (31.0% vs. 32.3%, p = 0.19), and discharge medications between those with and without SMI. One-year mortality was lower for patients with SMI (15.8% vs. 19.1%, p < 0.001). However, in multivariable analysis, there were no significant differences in mortality (HR 0.91; 95% CI 0.81–1.02) between patients with and without SMI.
Among ACS patients in the VHA, SMI is prevalent, affecting almost 1 in 5 patients. However, patients with SMI were as likely to undergo coronary revascularization and be prescribed evidence-based medications at hospital discharge, and were not at elevated risk of adverse 1-year outcomes compared to patients without SMI.
PMCID: PMC2082028  PMID: 17877804
20.  Toward a VA Women's Health Research Agenda: Setting Evidence-based Priorities to Improve the Health and Health Care of Women Veterans 
Journal of General Internal Medicine  2006;21(Suppl 3):S93-S101.
The expansion of women in the military is reshaping the veteran population, with women now constituting the fastest growing segment of eligible VA health care users. In recognition of the changing demographics and special health care needs of women, the VA Office of Research & Development recently sponsored the first national VA Women's Health Research Agenda-setting conference to map research priorities to the needs of women veterans and position VA as a national leader in Women's Health Research. This paper summarizes the process and outcomes of this effort, outlining VA's research priorities for biomedical, clinical, rehabilitation, and health services research.
PMCID: PMC1513170  PMID: 16637953
women's health; research and development; research priorities; veterans; health care quality; access and evaluation
21.  Moving Implementation Science Forward 
Journal of General Internal Medicine  2006;21(Suppl 2):S65-S66.
PMCID: PMC2557138  PMID: 16637963
22.  The use of percutaneous coronary intervention in black and white veterans with acute myocardial infarction 
It is uncertain whether black white differences in the use of percutaneous coronary intervention (PCI) persist in the era of drug eluting stents. The purpose of this study is to determine if black veterans with acute myocardial infarction (AMI) are less likely to receive PCI than their white counterparts.
This study included 680 black and 3529 white veterans who were admitted to Veterans Health Administration (VHA) medical centers between July 2003 and August 2004. Information for this study was collected as part of the VHA External Peer Review Program for quality monitoring and improvement for a variety of medical conditions and procedures, including AMI. In addition, Department of Veterans Affairs workload files were used to determine PCI utilization after hospital discharge. Standard statistical methods including the Chi-square, 2 sample t-test, and logistic regression with a cluster correction for medical center were used to assess the association between race and the use of PCI ≤ 30 days from admission.
Black patients were younger, more often had diabetes mellitus, renal disease, or dementia and less often had lipid disorders, previous coronary artery bypass surgery, or chronic obstructive pulmonary disease than their white counterparts. Equal proportions of blacks and whites underwent cardiac catheterization ≤ 30 days after admission, but the former were less likely to undergo PCI (32% vs. 40%, p < 0.0001). This difference persisted after multivariate adjustment, although measures of the extent of coronary artery disease were not available.
Given the equivalent use of cardiac catheterization, it is possible that less extensive or minimal coronary artery disease in black patients could account for the observed difference.
PMCID: PMC1560119  PMID: 16923183
23.  Functional Status and Patient Satisfaction 
To determine the extent to which chronic illness and disease severity affect patient satisfaction with their primary care provider in general internal medicine clinics.
Cross-sectional mailed questionnaire study.
Primary care clinics at 7 Veterans Affairs medical centers.
Of 62,487 patients participating in the Ambulatory Care Quality Improvement Project, 35,383 (57%) returned an initial screening questionnaire and were subsequently sent a satisfaction questionnaire. Patients (N=21,689; 61%) who returned the Seattle Outpatient Satisfaction Survey (SOSQ) were included in the final analysis, representing 34% of the original sample.
The organizational score of the SOSQ measures satisfaction with health care services in the internal medicine clinic, and the humanistic scale measures patient satisfaction with the communication skills and humanistic qualities of the primary care physician. For ischemic heart disease (IHD), chronic obstructive pulmonary disease (COPD), and diabetes, patient ability to cope with their disease was more strongly associated with patient satisfaction than disease severity. Among IHD patients, improvement in ability to cope emotionally with their angina was associated with higher SOSQ organizational scores (standardized β=0.18; P<.001) but self-reported physical limitation due to angina was not (β=0.01; P=.65). Similarly, in COPD, improved ability to cope with dyspnea was associated with greater organizational scores (β=0.11; P<.001) but physical function was not (β=−0.03; P=.27). For diabetes, increased education was associated with improved organizational scores (β=0.31; P<.001) but improvement in symptom burden was not (β=0.03; P=.14). Similar results were seen with prediction of SOSQ humanistic scores.
Patient education and ability to cope with chronic conditions are more strongly associated with satisfaction with their primary care provider than disease severity. Further improvements in patient education and self-management may lead to improved satisfaction and quality of care.
PMCID: PMC1490111  PMID: 15963172
patient satisfaction; health services research; quality of care; questionnaire design; linear models
24.  Continuity of Care and Other Determinants of Patient Satisfaction with Primary Care 
The patient-clinician relationship is a central feature of primary care, and recent developments in the delivery of health care have tended to limit continuity of care. The objective of this study was to evaluate the extent to which continuity of care and other factors are related to patient satisfaction.
Cross-sectional, mailed questionnaire study.
Primary care clinics at 7 Veterans Affairs medical centers.
Patients (N=21,689) participating in the Ambulatory Care Quality Improvement Project who returned the baseline Seattle Outpatient Satisfaction Questionnaire (SOSQ).
We evaluated the association between self-reported continuity and satisfaction, after adjusting for characteristics of patients, clinics, and providers. The humanistic scale of the SOSQ measures patient satisfaction with communication skills and humanistic qualities of providers, whereas the organizational scale measures satisfaction with delivery of health care services. The mean adjusted humanistic score for patients who reported always seeing the same provider was 17.3 (95% confidence interval [CI], 15.5 to 19.1) points higher than for those who rarely saw the same provider. Similarly, the mean adjusted organizational score was 16.3 (95% CI, 14.5 to 18.1) points higher for patients who always saw the same provider compared to rarely. Demographic factors, socioeconomic status, health status, clinic site, and patient utilization of services were all associated with both the adjusted humanistic and organizational scores of the SOSQ.
Self-reported continuity of care is strongly associated with higher patient satisfaction. This suggests that improving continuity of care may improve patient satisfaction with providers as well as with their health care organization.
PMCID: PMC1490082  PMID: 15836525
patient satisfaction; health services research; quality of care; questionnaire design; linear models
25.  Adherence to Heart-Healthy Behaviors in a Sample of the U.S. Population 
Preventing Chronic Disease  2005;2(2):A18.
Following national recommendations for physical activity, diet, and nonsmoking can reduce both incident and recurrent coronary heart disease. Prevalence data about combinations of behaviors are lacking. This study describes the prevalence of full adherence to national recommendations for physical activity, fruit and vegetable consumption, and nonsmoking among individuals with and without coronary heart disease and examines characteristics associated with full adherence.
We performed a cross-sectional analysis of data from the 2000 Behavioral Risk Factor Surveillance System, a national population-based survey. We included respondents to the cardiovascular disease module and excluded individuals with poor physical health or activity limitations.
Subjects were most adherent to smoking recommendations (approximately 80%) and less adherent to fruit and vegetable consumption and physical activity (approximately 20% for both). Only 5% of those without coronary heart disease and 7% of those with coronary heart disease were adherent to all three behaviors (P < .01). Among those without a history of coronary heart disease, female sex (odds ratio [OR] 1.47; 95% confidence interval [CI], 1.23–1.76), highest age quintile (OR 1.67; 95% CI, 1.28–2.19), more education (OR 2.48; 95% CI, 1.69–3.64), and more income (OR 1.19; 95% CI, 1.04–1.36) were associated with full adherence. Among those with coronary heart disease, mid-age quintile (OR 3.79; 95% CI, 1.35–10.68), good general health (OR 2.05; 95% CI, 1.07–3.94), and more income (OR 1.51; 95% CI, 1.06–2.16) were associated with full adherence.
These data demonstrate the lack of a heart-healthy lifestyle among a sample of U.S. adults with and without coronary heart disease. Full adherence to combined behaviors is far below adherence to any of the individual behaviors.
PMCID: PMC1327712  PMID: 15888229

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