Outcomes of Care for Ischemic Heart Disease and Chronic Heart Failure in the Veterans Health Administration.

Importance: The Department of Veterans Affairs (VA) operates a nationwide system of hospitals and hospital-affiliated clinics, providing health care to more than 2 million veterans with cardiovascular disease. While data permitting hospital comparisons of the outcomes of acute cardiovascular care (eg, myocardial infarction) are publicly available, little is known about variation across VA medical centers (VAMCs) in outcomes of care for populations of patients with chronic, high-risk cardiovascular conditions. Objective: To determine whether there are substantial differences in cardiovascular outcomes across VAMCs. Design, Setting, and Participants: Retrospective cohort study comprising 138 VA hospitals and each hospital's affiliated outpatient clinics. Patients were identified who received VA inpatient or outpatient care between 2010 and 2014. Separate cohorts were constructed for patients diagnosed as having either ischemic heart disease (IHD) or chronic heart failure (CHF). The data were analyzed between June 24, 2015, and November 21, 2017. Exposures: Hierarchical linear models with VAMC-level random effects were estimated to compare risk-standardized mortality rates for IHD and for CHF across 138 VAMCs. Mortality estimates were risk standardized using a wide array of patient-level covariates derived from both VA and Medicare health care encounters. Main Outcomes and Measures: All-cause mortality. Results: The cohorts comprised 930 079 veterans with IHD and 348 015 veterans with CHF; both cohorts had a mean age of 77 years and were predominantly white (IHD, n = 822 665 [89%] and CHF, n = 287 871 [83%]) and male (IHD, n = 916 684 [99%] and CHF n = 341 352 [98%]). The VA-wide crude annual mortality rate was 7.4% for IHD and 14.5% for CHF. For IHD, VAMCs' risk-standardized mortality varied from 5.5% (95% CI, 5.2%-5.7%) to 9.4% (95% CI, 9.0%-9.9%) (P < .001 for the difference). For CHF, VAMCs' risk-standardized mortality varied from 11.1% (95% CI, 10.3%-12.1%) to 18.9% (95% CI, 18.3%-19.5%) (P < .001 for the difference). Twenty-nine VAMCs had IHD mortality rates that significantly exceeded the national mean, while 35 VAMCs had CHF mortality rates that significantly exceeded the national mean. Veterans Affairs medical centers' mortality rates among their IHD and CHF populations were not associated with 30-day mortality rates for myocardial infarction (R2 = 0.01; P = .35) and weakly associated with hospitalized heart failure 30-day mortality (R2 = 0.16; P < .001) and the VA's star rating system (R2 = 0.06; P = .005). Conclusions and Relevance: Risk-standardized mortality rates for IHD and CHF varied widely across the VA health system, and this variation was not well explained by differences in demographics or comorbidities. This variation may signal substantial differences in the quality of cardiovascular care between VAMCs.

Race, Rehabilitation, and 30-Day Readmission After Elective Total Knee Arthroplasty.

INTRODUCTION: To examine racial variations in access to postacute care (PAC) and rehabilitation (Rehab) services following elective total knee arthroplasty and whether where patients go after surgery for PAC/Rehab is associated with 30-day readmission to acute care facility. MATERIALS AND METHODS: Sample consisted of 129 522 patients discharged from 169 hospitals in the State of Pennsylvania between fiscal years 2008 and 2012. We used multinomial regression models to assess the relationship between patient race and discharge destination after surgery, for patients aged 18 to 64 years and for those aged 65 and older. We used multivariable (MV) regression and propensity score (PS) approaches to examine the relationship between patient discharge destination after surgery for PAC/Rehab and 30-day readmission, controlling for key individual- and facility-level factors. RESULTS: Lower proportions of younger patients compared to those older than 65 were discharged to inpatient rehabilitation facilities (IRFs; 5.8% vs 12.6%, respectively) and skilled nursing facilities (SNFs; 15.2% vs 32.7%, respectively) compared to home-based Rehab (self-care; 23.3% vs 14.2%, respectively). Compared to whites, African American patients had significantly higher odds of discharge to IRF (age < 65, odds ratio = 2.04; age ≥ 65, odds ratio = 1.64) and to SNF (age < 65, odds ratio = 2.86; age ≥ 65, odds ratio = 2.19) and discharge to home care in patients younger than 65 years (odds ratio = 1.31). The odds of 30-day readmission among patients discharged to an IRF (MV odds ratio = 7.76; PS odds ratio = 8.34) and SNF (MV odds ratio = 2.01; PS odds ratio = 1.83) were significantly higher in comparison to patients discharged home with self-care. CONCLUSION: African American patients with knee replacement are more likely to be discharged to inpatient Rehab settings following surgery. Inpatient Rehab is significantly associated with 30-day readmission to acute care facility.

Comparative effectiveness of high-dose versus standard-dose influenza vaccination in community-dwelling veterans.

BACKGROUND: Influenza is a significant cause of morbidity and mortality in older adults. High-dose (HD) trivalent inactivated vaccine has increased immunogenicity in older adults compared with standard-dose (SD) vaccine. We assessed the relative effectiveness of HD influenza vaccination (vs SD influenza vaccination). METHODS: We conducted a retrospective cohort study among patients who receive primary care at Veteran Health Administration (VHA) medical centers, and who received influenza vaccine in the 2010-2011 influenza season. The primary outcome was hospitalization for influenza or pneumonia. We also conducted an analysis in subgroups defined by age. RESULTS: We evaluated 25 714 patients who received HD vaccine and 139 511 who received SD vaccine in 23 VHA medical centers. The rate of hospitalization for influenza or pneumonia was 0.3% in both groups in the influenza season. After accounting for patient characteristics in propensity-adjusted analyses, the risk of hospitalization for influenza or pneumonia was not significantly lower among patients receiving HD vaccine vs those receiving SD vaccine (risk ratio, 0.98; 95% confidence interval, .68-1.40). In the subgroup of patients ≥85 years of age, receiving HD (compared with SD) vaccine was associated with lower rates of hospitalization for influenza or pneumonia. CONCLUSIONS: HD vaccine was not found to be more effective than SD vaccine in protecting against hospitalization for influenza or pneumonia; however, we found a protective effect in the oldest subgroup of patients. Additional studies are needed to evaluate the effectiveness of HD vaccine.

Family involvement at the end-of-life and receipt of quality care.

CONTEXT: Most patients will lose decision-making capacity at the end of life. Little is known about the quality of care received by patients who have family involved in their care. OBJECTIVES: To evaluate differences in the receipt of quality end-of-life care for patients who died with and without family involvement. METHODS: We retrospectively reviewed the charts of 34,290 decedents from 146 acute and long-term care Veterans Affairs facilities between 2010 and 2011. Outcomes included: (1) palliative care consult, (2) chaplain visit, and 3) death in an inpatient hospice or palliative care unit. We also assessed "do not resuscitate" (DNR) orders. Family involvement was defined as documented discussions with the health care team in the last month of life. We used logistic regression adjusted for demographics, comorbidity, and clustered by facility. For chaplain visit, hospice or palliative care unit death, and DNR, we additionally adjusted for palliative care consults. RESULTS: Mean (SD) age was 74 (±12) years, 98% were men, and 19% were nonwhite. Most decedents (94.2%) had involved family. Veterans with involved family were more likely to have had a palliative care consult, adjusted odds ratio (AOR) 4.31 (95% CI 3.90-4.76); a chaplain visit, AOR 1.18 (95% CI 1.07-1.31); and a DNR order, AOR 4.59 (95% CI 4.08-5.16) but not more likely to die in a hospice or palliative care unit. CONCLUSION: Family involvement at the end of life is associated with receipt of palliative care consultation and a chaplain visit and a higher likelihood of a DNR order. Clinicians should support early advance care planning for vulnerable patients who may lack family or friends.

A nationwide study comparing end-of-life care for men and women veterans.

BACKGROUND: The quality of end-of-life (EOL) care at Veterans Affairs Medical Centers (VAMC) has improved. To date, however, the quality and outcomes of end-of-life care delivered to women veterans have not been examined. OBJECTIVE: The goal of this study was to evaluate gender differences in the quality of EOL care received by patients in VAMCs nationwide. DESIGN: The study was conducted via retrospective medical chart review and telephone survey with next of kin of recently deceased inpatients. SETTING/SUBJECTS: The chart review included records for all patients who died in acute and long-term care units in 145 VAMCs nationwide (n=36,618). For the survey, the documented next of kin were invited to respond on behalf of the deceased veteran; a total of 25,638 next of kin completed the survey. MEASUREMENTS: Chart review measures included five indicators of optimal end-of-life care. Bereaved family survey items included one global and nine specific items (e.g., bereavement care, pain management) describing care in the last month of life. RESULTS: Receipt of optimal end-of-life care did not differ significantly between women and men with respect to frequency of discussion of treatment goals with a family member, receipt of palliative consult, bereavement contact, and chaplain contact with a family member. Family members of women were more likely than those of men to report that the overall care provided to the veteran had been "excellent" (adjusted proportions: 63% versus 56%; odds ratio (OR)=1.33; 95% confidence interval (CI) 1.10-1.61; p=0.003). CONCLUSIONS: In this nationwide study of all inpatient deaths in VAMCs, women received comparable and on some metrics better quality EOL care than that received by male patients.

Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized trial.

BACKGROUND: Compared with white persons, African Americans have a greater incidence of diabetes, decreased control, and higher rates of microvascular complications. A peer mentorship model could be a scalable approach to improving control in this population and reducing disparities in diabetic outcomes. OBJECTIVE: To determine whether peer mentors or financial incentives are superior to usual care in helping African American veterans decrease their hemoglobin A(1c) (HbA(1c)) levels. DESIGN: A 6-month randomized, controlled trial. (ClinicalTrials.gov registration number: NCT01125956) SETTING: Philadelphia Veterans Affairs Medical Center. PATIENTS: African American veterans aged 50 to 70 years with persistently poor diabetes control. INTERVENTION: 118 patients were randomly assigned to 1 of 3 groups: usual care, a peer mentoring group, and a financial incentives group. Usual care patients were notified of their starting HbA(1c) level and recommended goals for HbA(1c). Those in the peer mentoring group were assigned a mentor who formerly had poor glycemic control but now had good control (HbA(1c) level ≤7.5%). The mentor was asked to talk with the patient at least once per week. Peer mentors were matched by race, sex, and age. Patients in the financial incentive group could earn $100 by decreasing their HbA(1c) level by 1% and $200 by decreasing it by 2% or to an HbA(1c) level of 6.5%. MEASUREMENTS: Change in HbA(1c) level at 6 months. RESULTS: Mentors and mentees talked the most in the first month (mean calls, 4; range, 0 to 30), but calls decreased to a mean of 2 calls (range, 0 to 10) by the sixth month. Levels of HbA(1c) decreased from 9.9% to 9.8% in the control group, from 9.8% to 8.7% in the peer mentor group, and from 9.5% to 9.1% in the financial incentive group. Mean change in HbA(1c) level from baseline to 6 months relative to control was -1.07% (95% CI, -1.84% to -0.31%) in the peer mentor group and -0.45% (CI, -1.23% to 0.32%) in the financial incentive group. LIMITATION: The study included only veterans and lasted only 6 months. CONCLUSION: Peer mentorship improved glucose control in a cohort of African American veterans with diabetes. PRIMARY FUNDING SOURCE: National Institute on Aging Roybal Center.

Effectiveness of guideline-recommended cardiac drugs for reducing mortality in the elderly medicare heart failure population: a retrospective, survey-weighted, cohort analysis.

BACKGROUND: Heart failure (HF) management guidelines recommend that most patients with HF receive an ACE inhibitor or an angiotensin II type 1 receptor antagonist (angiotensin receptor blocker [ARB]) and a ß-blocker (ß-adrenoceptor antagonist), collectively referred to as 'cardiac drugs', based on results from randomized controlled trials showing that these drugs reduce mortality. However, the results of randomized controlled trials may not be generalizable to the population most likely (i.e. the elderly) to receive these drugs in clinical practice. OBJECTIVE: To determine the effectiveness of cardiac drugs for reducing mortality in the elderly Medicare HF population. STUDY DESIGN: Retrospective, survey-weighted, cohort analysis of the 2002 Medicare Current Beneficiary Survey Cost and Use files. PARTICIPANTS: 12 697 beneficiaries, of whom 1062 had a diagnosis of HF and 577 were eligible to receive cardiac drugs. MEASUREMENTS: Association between mortality and cardiac drugs, adjusted for sociodemographics, co-morbidity and propensity to receive cardiac drugs. RESULTS: The mortality rate among the 577 eligible beneficiaries with HF was 9.7%. The mortality rate for those receiving an ACE inhibitor or ARB alone, a ß-blocker alone, or both an ACE inhibitor or ARB and a ß-blocker, was 6.1%, 5.9% and 5.3%, respectively; in the absence of any of the three cardiac drugs, the mortality rate was 20.0% (p < 0.0001). In multivariable analyses, mortality rates remained significantly lower for beneficiaries receiving an ACE inhibitor or ARB alone (odds ratio [OR] 0.24; 95% CI 0.11, 0.50), a ß-blocker alone (OR 0.17; 95% CI 0.07, 0.41), or both an ACE inhibitor or ARB and a ß-blocker (OR 0.24; 95% CI 0.10, 0.55) compared with patients who did not receive any of the three cardiac drugs. CONCLUSIONS: Use of guideline-recommended cardiac drugs is associated with reduced mortality in the elderly Medicare HF population. Providing evidence of the benefit of cardiac drugs among the elderly with HF will become increasingly important as the size of the Medicare population grows.