Agreement Between HEDIS Performance Assessments in the VA and Medicare Advantage: Is Quality in the Eye of the Beholder?

Medicare Advantage (MA) plans and the Veterans Affairs (VA) health care system assess quality of care using standardized Healthcare Effectiveness Data and Information Set (HEDIS) performance measures. Little is known, however, about the relative accuracy of quality indicators for persons receiving care in more than one health care system. Among Veterans dually enrolled in an MA plan, we examined the agreement between MA and VA HEDIS assessments. Our study tested the hypothesis that private health plans underreport quality of care relative to a fully integrated delivery system utilizing a comprehensive electronic health record. Despite assessing the same individuals using identical measure specifications, reported VA performance was significantly better than reported MA performance for all 12 HEDIS measures. The VAs performance advantage ranged from 9.8% (glycosylated hemoglobin [HbA1c] < 7.0% in diabetes) to 54.7% (blood pressure < 140/90 mm Hg in diabetes). The overall agreement between VA and MA HEDIS assessments ranged from 38.5% to 62.6%. Performance rates derived from VA and MA aggregate data were 1.6% to 14.3% higher than those reported by VA alone. This analysis suggests that neither MA plans nor the VA fully capture quality of care information for dually enrolled persons. However, the VAs system-wide electronic health record may allow for more complete capture of quality information across multiple providers and settings

Letter to Sonora Dodd from Mary Botsford Charlton, May 21, 1915

Letter to Sonora Dodd from Mary Botsford Charlton, Managing Editor, The People\u27s Home Journal, New York.https://digitalcommons.whitworth.edu/fathers-day-correspondence/1029/thumbnail.jp

Exploration of the use of Palladium and Nickel to Catalyze Enolate Cross-coupling and the Enantioselective Mizoroki-Heck Reaction.

Palladium catalysis is a common synthetic tool utilized by organic chemists to create carbon-carbon bonds. We utilized palladium to catalyze the γ-arylation of α, β-unsaturated ketones, and esters. This work expands on palladium-catalyzed α-arylation chemistry and extends it to the vinylogous variation at the γ-position. We report the regioselective synthesis of mono-γ-arylated 7-methoxy-4-methylcoumarin. We also report efforts towards applying our reaction conditions to other α,β-unsaturated ketones and esters to expand the scope of our reaction conditions. In addition, we utilized palladium to catalyze the enantioselective asymmetric intramolecular Mizoroki-Heck reaction to produce potentially bioactive phenanthridinone analogs. We achieve this through the Birch-Heck sequence, a 4-step sequence that includes Birch reduction/alkylation of benzoic acid, acid chloride formation/amide formation, triflation, and then the enantioselective Mizoroki-Heck reaction. In this process, we report N-H and N-Me phenanthridinone analogs\u27 synthesis. A protection/deprotection protocol was found to be the key to accessing phenanthridinone derivatives with N-H. Besides palladium catalysis, we also explored conducting the enantioselective Mizoroki-Heck reaction with nickel. Nickel catalysis is a relatively new research area that has recently demonstrated success with the enantioselective intramolecular Mizoroki-Heck reaction under mild conditions with high yields and ee values. We proposed that we may access a pathway that could increase our enantioselectivity under relatively mild conditions by using nickel. We report efforts to optimize the nickel catalyzed Heck reaction to minimize side products and to improve the yield of the desired 1,3-diene. In the synthesis of phenanthridinone analogs, we have demonstrated that the Birch-Heck sequence is a simple way of synthesizing chiral phenanthridinone derivatives with quaternary centers. In total, three areas of transition metal-catalyzed reactions were explored. This involved cross-coupling between enolates and aryl halides and between aryl halides and alkenes. Strategies for enantioselective synthesis were developed, and potentially bioactive phenanthridinone structures were constructed. Finally, the cross-coupling studies looked at both palladium and, the more cost-effective, nickel in the Mizoroki-Heck reaction

Dual use of VA and Non-VA Hospitals by Veterans with Multiple Hospitalizations

Background: Veterans who are hospitalized in both VA and non-VA hospitals within a short timespan may be at risk for fragmented or conflicting care. To determine the characteristics of these “dual users,” we analyzed administrative hospital discharge data for VA-enrolled veterans of any age in seven states, including any VA or non-VA hospitalizations they had in 2004 – 2007. Method: For VA enrollees in Arizona, Iowa, Louisiana, Florida, South Carolina, Pennsylvania, or New York in 2007, we merged 2004 – 2007 discharge data for all VA hospitalizations and all non-VA hospitalizations listed in state health department or hospital association databases. For patients hospitalized in 2007, we compared those younger or older than 65 years who had one or multiple hospitalizations during the year, split into users of VA hospitals, non-VA hospitals, or both (“ dual users ”), on demographics, priority for VA care, travel times, principal diagnoses, co-morbidities, lengths of stay, and prior (2004 – 2006) hospitalizations, using chi-square analysis or ANOVA. Multiply hospitalized patients were compared with multinomial logistic regressions to predict non-VA and dual use. Payers for non-VA hospitalizations also were compared across groups. Results: Of unique inpatients in 2007, 38% of those 65 or older were hospitalized more than once during the year, as were 32% of younger patients; 3 and 8%, respectively, were dual users. Dual users averaged the most index-year (3.7) and prior (1.5) hospitalizations, split evenly between VA and non-VA. They also had higher rates of admission for circulatory diseases, symptoms/signs/ill-defined conditions, and injury and poisoning, and more admissions for multiple diagnostic categories; among younger patients they had the highest rate of mental disorders admissions. Higher income, non-rural residence, greater time to VA care, lower VA priority, prior non-VA hospitalization, no prior VA hospitalization, and several medical categories predicted greater non-VA use. Among younger patients, however, mental disorders predicted more dual use but less exclusively non-VA use. Dual users’ non-VA admissions were more likely than others’ to be covered by payers other than Medicare or commercial insurance. Conclusions: Younger dual users require more medical and psychiatric treatment, and rely more on government funding sources. Effective care coordination for these inpatients might improve outcomes while reducing taxpayer burden

Patient-Reported Roles, Preferences, and Expectations Regarding Treatment of Stage I Rectal Cancer in the Cancer Care Outcomes Research and Surveillance Consortium

Historically, stage I rectal cancer was treated with total mesorectal excision. However, there has been growing use of local excision, with and without adjuvant therapy to treat these early rectal cancers. Little is known about how patients and providers choose amongst the various treatment approaches

Pharmacy Use by Dual-Eligible Non-Elderly Veterans with Private Healthcare Insurance

The Veterans Health Administration (VHA) is the largest nationally integrated healthcare system in the United States, operating 168 medical centers and more than 1000 community based outpatient clinics. However, many veterans seek care outside the VHA system, particularly when they are also covered by state or federal programs such as Medicare or Medicaid, or have access to private health insurance, often through employment. Concerted efforts have been made to facilitate communication and coordinate care between VHA and private sector healthcare, but concurrent use of these systems adds to an already fragmented U.S health care system

A home-based comprehensive care model in patients with Multiple Sclerosis: A study pre-protocol.

Background Disability is prevalent in individuals with multiple sclerosis (MS), leading to difficulty in care access, significant caregiver burden, immense challenges in self-care and great societal burden. Without highly coordinated, competent and accessible care, individuals living with progressive MS experience psychological distress, poor quality of life, suffer from life-threatening complications, and have frequent but avoidable healthcare utilizations. Unfortunately, current healthcare delivery models present severe limitations in providing easily accessible, patient-centered, coordinated comprehensive care to those with progressive MS. We propose a home-based comprehensive care model (MAHA) to address the unmet needs, challenges, and avoidable complications in individuals with progressive MS with disabling disease. Objective The article aims to describe the study design and methods used to implement and evaluate the proposed intervention. Method The study will use a randomized controlled design to evaluate the feasibility of providing a 24-month, home-based, patient-centered comprehensive care program to improve quality of life, reduce complications and healthcare utilizations overtime (quarterly) for 24 months. A transdisciplinary team led by a MS-Comprehensivist will carry out this project. Fifty MS patients will be randomly assigned to the intervention and usual care program using block randomization procedures. We hypothesize that patients in the intervention group will have fewer complications, higher quality of life, greater satisfaction with care, and reduced healthcare utilization. The proposed project is also expected to be financially sustainable in fee-for-service models but best suited for and gain financial success in valued-based care systems. Discussion This is the first study to examine the feasibility and effectiveness of a home-based comprehensive care management program in MS patients living with progressive disability. If successful, it will have far-reaching implications in research, education and practice in terms of providing high quality but affordable care to population living with severe complex, disabling conditions

Assessing observational studies of medical treatments

BACKGROUND: Previous studies have assessed the validity of the observational study design by comparing results of studies using this design to results from randomized controlled trials. The present study examined design features of observational studies that could have influenced these comparisons. METHODS: To find at least 4 observational studies that evaluated the same treatment, we reviewed meta-analyses comparing observational studies and randomized controlled trials for the assessment of medical treatments. Details critical for interpretation of these studies were abstracted and analyzed qualitatively. RESULTS: Individual articles reviewed included 61 observational studies that assessed 10 treatment comparisons evaluated in two studies comparing randomized controlled trials and observational studies. The majority of studies did not report the following information: details of primary and ancillary treatments, outcome definitions, length of follow-up, inclusion/exclusion criteria, patient characteristics relevant to prognosis or treatment response, or assessment of possible confounding. When information was reported, variations in treatment specifics, outcome definition or confounding were identified as possible causes of differences between observational studies and randomized controlled trials, and of heterogeneity in observational studies. CONCLUSION: Reporting of observational studies of medical treatments was often inadequate to compare study designs or allow other meaningful interpretation of results. All observational studies should report details of treatment, outcome assessment, patient characteristics, and confounding assessment

The Diagnosis and Management of Nonalcoholic Fatty Liver Disease: Practice Guidance from the American Association for the Study of Liver Diseases

This guidance provides a data-supported approach to the diagnostic, therapeutic, and preventive aspects of NAFLD care. A “Guidance” document is different from a “Guideline.” Guidelines are developed by a multidisciplinary panel of experts and rate the quality (level) of the evidence and the strength of each recommendation using the Grading of Recommendations, Assessment Development, and Evaluation (GRADE) system. A guidance document is developed by a panel of experts in the topic, and guidance statements, not recommendations, are put forward to help clinicians understand and implement the most recent evidence

Stop Atherosclerosis in Native Diabetics Study (SANDS): Baseline Characteristics of the Randomized Cohort

Objectives: To present baseline characteristics of American Indians in the Stop Atherosclerosis in Native Diabetics Study (SANDS) and compare them with population-based data from American Indians and other ethnic groups. Design: 499 people with type 2 diabetes ≥ age 40, without known CVD, were recruited for a randomized 3-year trial to evaluate treatment targets for LDL-C (70 vs. 100 mg/dL) and systolic blood pressure (BP) (115 vs. 130 mmHg). Baseline evaluations included physical exam, collection of blood and urine samples, and carotid ultrasound and echocardiographic measures. Results: Mean age was 56 years; 66% were female. Average BMI was 33 kg/m2. Average duration of both hypertension and diabetes was 10 years, average A1c was 8.0 %, and mean LDL-C was 104 mg/dL. Participants in the conventional treatment group had slightly higher systolic BPs than participants in the aggressive treatment group (133 mm Hg vs. 128 mm Hg, p \u3c 0.002). Compared with the population-based cohorts of the Strong Heart Study (SHS), NHANES, and the TRIAD registry, SANDS participants had similar values for lipids, BP, and CRP, as well as degree of obesity, smoking rates, and renal function as indicated by estimated glomerular filtration rate. Conclusions: The baseline characteristics of the SANDS cohort are similar to those of a population-based sample of American Indian diabetic men and women and closely resemble diabetic men and women of other ethnic groups. Results from this study can be used to identify appropriate targets for LDL-C and BP lowering in diabetic American Indians and diabetic patients in other ethnic groups