Adherence to Surveillance Guidelines in Nondysplastic Barrett’s Esophagus

Introduction: Surveillance patterns in Barrett's esophagus (BE) are not well characterized. Guidelines published between 2002 and 2008 recommended surveillance esophagogastroduodenoscopy (sEGD) at 3-year intervals for nondysplastic BE (NDBE). We assessed guideline adherence in incident NDBE in a Veterans Affairs (VA)-based study. Methods: At a single VA center, we identified incident cases of biopsy-confirmed NDBE between January, 2006 and December, 2008. We excluded patients aged 76 years and above and those who developed BE-associated dysplasia or cancer during follow-up. All sEGDs through October, 2014 were documented. Our primary criteria classified cases as guideline adherent if a sEGD was performed within 6 months of each expected 3-year surveillance interval; in cases with >=2 sEGDs, 1 sEGD >6 months, and <=1 year outside an interval was allowed if the average interval was between 2.5 and 3.5 years. Comorbidity, primary care encounters, presence of long-segment BE (LSBE), endoscopist recommendations, and Charlson comorbidity index (CCI) were assessed. Results: We identified 110 patients (96.4% male, 93.6% white) with mean age 58.9+/-8.5 years at index EGD. Median follow-up was 6.7 years (range, 3.7 to 8.6). Thirty-three (30.0%) cases were guideline adherent; 77 (70.0%) cases were nonadherent, including 52 (47.3%) with irregular surveillance and 25 (22.7%) with no surveillance. Forty cases (14 adherent) had 1 sEGD, 36 (18 adherent) had 2, 8 (1 adherent) had 3, and 1 nonadherent case had 4. Adherent cases were significantly older (61.5 vs. 57.9 y, P=0.04), and tended to have more LSBE (33.3% vs. 20.8%, P=0.16). There were no differences between adherent and nonadherent cases in annual primary care encounters (72.7% vs. 66.2%, P=0.66), CCI>=4 (15.2% vs. 15.6%, P=0.95), biopsy-positive sEGDs (75.8% vs. 76.6%, P=0.92), and any recommendation for subsequent surveillance (81.8% vs. 77.9%, P=0.65). A logistic regression model using age, CCI, and LSBE showed an independent association between adherence and older age (P=0.03). Conclusions: In a single-center VA cohort, sEGD of NDBE was mostly nonadherent to guidelines. Adherent cases were older at baseline with a trend toward more LSBE. A larger study is needed to identify medical and social factors associated with adherence or nonadherence to surveillance

Lessons and Outcomes of Mobile Acute Care for Elders Consultation in a Veterans Affairs Medical Center

OBJECTIVE Describe the implementation and effects of Mobile Acute Care for Elders (MACE) consultation at a Veterans Affairs Medical Center (VAMC). DESIGN Retrospective cohort analysis. INTERVENTION Veterans aged 65 or older who were admitted to the medicine service between October 1, 2012, and September 30, 2014, were screened for geriatric syndromes via review of medical records within 48 hours of admission. If the screen was positive, the MACE team offered the admitting team a same‐day consultation involving comprehensive geriatric assessment and ongoing collaboration with the admitting team and supportive services to implement patient‐centric recommendations for geriatric syndromes. RESULTS Veterans seen by MACE (n = 421) were compared with those with positive screens but without consultation (n = 372). The two groups did not significantly differ in age, comorbidity, sex, or race. All outcomes (30‐day readmission, 30‐day mortality, readmission costs) were in the expected direction for patients receiving MACE but did not reach statistical significance. Patients receiving MACE had lower odds of 30‐day readmission (11.9% vs 14.8%; odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.54‐1.25; p = .360) and 30‐day mortality (5.5% vs 8.6%; OR = 0.64; CI = 0.36‐1.12; p = .115), and they had lower 30‐day readmission costs (MACE $15,502; CI =$12,242‐$19,631; comparison =$18,335; CI = $14,641‐$22,962; p = .316) than those who did not receive MACE after adjusting for age and Charlson Comorbidity Index. CONCLUSION Our MACE consultation model for older veterans with geriatric syndromes leverages the limited supply of clinicians with expertise in geriatrics. Although not statistically significant in this study of 793 subjects, MACE patients had lower odds of 30‐day readmission and mortality, and lower readmission costs

The Relationship Between Race, Patient Activation, and Working Alliance: Implications for Patient Engagement in Mental Health Care

This study explored the relationship between race and two key aspects of patient engagement—patient activation and working alliance—among a sample of African-American and White veterans (N = 152) seeking medication management for mental health conditions. After adjusting for demographics, race was significantly associated with patient activation, working alliance, and medication adherence scores. Patient activation was also associated with working alliance. These results provide support for the consideration of race and ethnicity in facilitating patient engagement and patient activation in mental healthcare. Minority patients may benefit from targeted efforts to improve their active engagement in mental healthcare

Comparison of Risk Factor Control in the Year After Discharge for Ischemic Stroke Versus Acute Myocardial Infarction

BACKGROUND AND PURPOSE: The Veterans Health Administration has engaged in quality improvement to improve vascular risk factor control. We sought to examine blood pressure (<140/90 mm Hg), lipid (LDL [low-density lipoprotein] cholesterol <100 mg/dL), and glycemic control (hemoglobin A1c <9%), in the year post-hospitalization for acute ischemic stroke or acute myocardial infarction (AMI). METHODS: We identified patients who were hospitalized (fiscal year 2011) with ischemic stroke, AMI, congestive heart failure, transient ischemic attack, or pneumonia/chronic obstructive pulmonary disease. The primary analysis compared risk factor control after incident ischemic stroke versus AMI. Facilities were included if they cared for ≥25 ischemic stroke and ≥25 AMI patients. A generalized linear mixed model including patient- and facility-level covariates compared risk factor control across diagnoses. RESULTS: Forty thousand two hundred thirty patients were hospitalized (n=75 facilities): 2127 with incident ischemic stroke and 4169 with incident AMI. Fewer stroke patients achieved blood pressure control than AMI patients (64%; 95% confidence interval, 0.62-0.67 versus 77%; 95% confidence interval, 0.75-0.78; P<0.0001). After adjusting for patient and facility covariates, the odds of blood pressure control were still higher for AMI than ischemic stroke patients (odds ratio, 1.39; 95% confidence interval, 1.21-1.51). There were no statistical differences for AMI versus stroke patients in hyperlipidemia (P=0.534). Among patients with diabetes mellitus, the odds of glycemic control were lower for AMI than ischemic stroke patients (odds ratio, 0.72; 95% confidence interval, 0.54-0.96). CONCLUSIONS: Given that hypertension control is a cornerstone of stroke prevention, interventions to improve poststroke hypertension management are neede

Indiana Physician Re-Licensure 2009 Survey Report

Since 1997, licenses were renewed by mail and a paper questionnaire was included with the physician license renewal form. Beginning in 2003, Indiana Professional Licensing Agency (IPLA) began on-line license renewals. Since then, all Indiana physicians who renewed their license on-line were asked to complete an online survey instrument. This report summarizes the responses to the 2009 Indiana Physician Survey and compares them to the results of prior physician surveys reported in the Indiana Physician Survey Databook and the Indiana Physician Re-Licensure Survey reports

Validation of Stroke Meaningful Use Measures in a National Electronic Health Record System

BACKGROUND: The Meaningful Use (MU) program has increased the national emphasis on electronic measurement of hospital quality. OBJECTIVE: To evaluate stroke MU and one VHA stroke electronic clinical quality measure (eCQM) in national VHA data and determine sources of error in using centralized electronic health record (EHR) data. DESIGN: Our study is a retrospective cross-sectional study of stroke quality measure eCQMs vs. chart review in a national EHR. We developed local SQL algorithms to generate the eCQMs, then modified them to run on VHA Central Data Warehouse (CDW) data. eCQM results were generated from CDW data in 2130 ischemic stroke admissions in 11 VHA hospitals. Local and CDW results were compared to chart review. MAIN MEASURES: We calculated the raw proportion of matching cases, sensitivity/specificity, and positive/negative predictive values (PPV/NPV) for the numerators and denominators of each eCQM. To assess overall agreement for each eCQM, we calculated a weighted kappa and prevalence-adjusted bias-adjusted kappa statistic for a three-level outcome: ineligible, eligible-passed, or eligible-failed. KEY RESULTS: In five eCQMs, the proportion of matched cases between CDW and chart ranged from 95.4 %-99.7 % (denominators) and 87.7 %-97.9 % (numerators). PPVs tended to be higher (range 96.8 %-100 % in CDW) with NPVs less stable and lower. Prevalence-adjusted bias-adjusted kappas for overall agreement ranged from 0.73-0.95. Common errors included difficulty in identifying: (1) mechanical VTE prophylaxis devices, (2) hospice and other specific discharge disposition, and (3) contraindications to receiving care processes. CONCLUSIONS: Stroke MU indicators can be relatively accurately generated from existing EHR systems (nearly 90 % match to chart review), but accuracy decreases slightly in central compared to local data sources. To improve stroke MU measure accuracy, EHRs should include standardized data elements for devices, discharge disposition (including hospice and comfort care status), and recording contraindications

Indiana Registered Nurse 2007 Re-Licensure Survey Report

The registered nurse re-licensure survey is implemented through a collaboration of the Indiana State Department of Health (ISDH) and the Indiana Professional Licensing Agency (IPLA). This report summarizes the responses to the 2007 Indian a registered nurse re-licensure survey and compares them to the results of the prior registered nurse re-licensure surveys reported in the Indiana Registered Nurse Survey Databook, 1997 and 2001 and the 2005 Indiana Registered Nurse Re-Licensure Survey Report

Indiana Registered Nurse 2009 Re-Licensure Survey Report

The registered nurse re-licensure survey is implemented through a collaboration of the Indiana State Department of Health (ISDH) and the Indiana Professional Licensing Agency (IPLA). This report summarizes the responses to the 2009 Indian a registered nurse re-licensure survey and compares them to the results of the prior registered nurse re-licensure surveys reported in the Indiana Registered Nurse Survey Databook and the Indiana Registered Nurse Re-Licensure Survey Reports

Association Between Antithrombotic Medication Use After Bioprosthetic Aortic Valve Replacement and Outcomes in the Veterans Health Administration System

IMPORTANCE: The recommendations about antithrombotic medication use after bioprosthetic aortic valve replacement (bAVR) vary. OBJECTIVES: To describe the post-bAVR antithrombotic medication practice across the Veterans Health Administration (VHA) and to assess the association between antithrombotic strategies and post-bAVR outcomes. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study. Multivariable modeling with propensity scores was conducted to adjust for differences in patient characteristics across the 3 most common antithrombotic medication strategies (aspirin plus warfarin sodium, aspirin only, and dual antiplatelets). Text mining of notes was used to identify the patients with bAVR (fiscal years 2005-2015). MAIN OUTCOMES AND MEASURES: This study used VHA and non-VHA outpatient pharmacy data and text notes to classify the following antithrombotic medications prescribed within 1 week after discharge from the bAVR hospitalization: aspirin plus warfarin, aspirin only, dual antiplatelets, no antithrombotics, other only, and warfarin only. The 90-day outcomes included all-cause mortality, thromboembolism risk, and bleeding events. Outcomes were identified using primary diagnosis codes from emergency department visits or hospital admissions. RESULTS: The cohort included 9060 veterans with bAVR at 47 facilities (mean [SD] age, 69.3 [8.8] years; 98.6% male). The number of bAVR procedures per year increased from 610 in fiscal year 2005 to 1072 in fiscal year 2015. The most commonly prescribed antithrombotic strategy was aspirin only (4240 [46.8%]), followed by aspirin plus warfarin (1638 [18.1%]), no antithrombotics (1451 [16.0%]), dual antiplatelets (1010 [11.1%]), warfarin only (439 [4.8%]), and other only (282 [3.1%]). Facility variation in antithrombotic prescription patterns was observed. During the 90-day post-bAVR period, adverse events were uncommon, including all-cause mortality in 127 (1.4%), thromboembolism risk in 142 (1.6%), and bleeding events in 149 (1.6%). No differences in 90-day mortality or thromboembolism were identified across the 3 antithrombotic medication groups in either the unadjusted or adjusted models. Patients receiving the combination of aspirin plus warfarin had higher odds of bleeding than patients receiving aspirin only in the unadjusted analysis (odds ratio, 2.58; 95% CI, 1.71-3.89) and after full risk adjustment (adjusted odds ratio, 1.92; 95% CI, 1.17-3.14). CONCLUSIONS AND RELEVANCE: These data demonstrate that bAVR procedures are increasingly being performed in VHA facilities and that aspirin only was the most commonly used antithrombotic medication strategy after bAVR. The risk-adjusted results suggest that the combination of aspirin plus warfarin does not improve either all-cause mortality or thromboembolism risk but increases the risk of bleeding events compared with aspirin only