The History and Applications of the Veterans RAND 12-Item Health Survey (VR-12).

There has been an increasing emphasis on placing patients at the center of clinical care and health care research and, in particular, assessing outcomes and experiences from the patient's perspective. One of the most widely used patient-reported outcome instruments is the Veterans RAND 12-item Health Survey (VR-12). This article reviews the VR-12 development and its applications over the last 2 decades, including research and potential uses in clinical care.

Health Status in Adults With Chronic Conditions: Intervention Strategies for Improving Patient-Reported Outcomes.

This literature review analyzes 418 articles from 2 periods (2000-2010 and 2011-2017) to provide interpretative guidelines for the change in physical (PCS) and mental component summaries (MCS) of well-established patient-reported measures (MOS SF-36 V1, HOS SF-12, VR-36, and VR-12). The magnitude of the intervention effects was calculated using baseline and follow-up data. Results were similar across the 2 periods, although the effects of social and behavioral interventions are less consistent and are smaller for PCS. Both single interventions and multicomponent interventions met the moderate to large effect size criterion for PCS and MCS.

Guideline-recommended medications: variation across Medicare Advantage plans and associated mortality.

OBJECTIVES: To evaluate variation in the prescription of guideline-recommended medications across Medicare Advantage (MA) plans and to determine whether such variation is associated with increased mortality. METHODS: Observational study of 111,667 patients aged 65 years or older receiving care in 203 MA plans. We linked data from the Medicare Health Outcomes (HOS) Survey cohort 9 (April 2006-May 2008) with the Medicare Part D prescription benefit files (January 1, 2006-December 31, 2007) to examine variation in treatment across MA plans and its association with differences in observed (O)/expected (E) mortality ratio for 5 high-volume chronic conditions: diabetes, coronary artery disease (CAD), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD)/asthma, and depression. RESULTS: Analysis of variance confirmed that the 203 MA plans differed significantly in their use of guideline-recommended treatment (P≤0.02). Those MA plans with higher use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (r=-0.40; P<0.0001) and beta-blockers (r=-0.27; P<0.0001) in patients with CHF were significantly associated with lower O/E mortality ratios. Those MA plans with higher use of multiple guideline-recommended medications were significantly associated with lower O/E mortality ratios in CHF (r=-0.45; P<0.0001) and diabetes (r=-0.14; P<0.042). There were no significant associations between the variation in performance indicators and mortality ratios in patients with CAD and COPD/asthma. Those MA plans with higher use of antidepressant medications had significantly higher O/E mortality ratios (r=0.28, P<0.0001). CONCLUSIONS: There was wide variation across MA plans in the prescription of guideline-recommended medications that had a measurable relationship to the mortality of elderly patients with CHF and diabetes. These findings can serve to both motivate and target quality improvement programs.

Monitoring outcomes for the Medicare Advantage program: methods and application of the VR-12 for evaluation of plans.

The Veterans RAND 12-Item Health Survey (VR-12) is one of the major patient-reported outcomes for ranking the Medicare Advantage (MA) plans in the Health Outcomes Survey (HOS). Approaches for scoring physical and mental health are given using contemporary norms and regression estimators. A new metric approach for the VR-12 called the "VR-6D" is presented with case-mix adjustments for monitoring plans that combine utilities and mortality. Results show that the models for ranking health outcomes of the plans are robust and credible. Future directions include the use of utilities for evaluating and ranking of MA plans.

A preference-based measure of health: the VR-6D derived from the veterans RAND 12-Item Health Survey.

PURPOSE: The Veterans RAND 12-Item Health Survey (VR-12) is currently the major endpoint used in the Medicare managed care outcomes measure in the Healthcare Effectiveness Data and Information Set (HEDIS(®)), referred to as the Health Outcomes Survey (HOS). The purpose of this study is to adapt the Brazier SF-6D utility measure to the VR-12 to generate a single utility index. METHODS: We used the HOS cohorts 2 and 3 for SF-36 data and 9 for VR-12 data. We calculated SF-6D scores from the SF-36 using the algorithms developed by Brazier and colleagues. The values of the Brazier SF-6D were used to estimate utility scores from the VR-12 using a mapping approach based on a 2-stage mapping procedure, named as VR-6D. RESULTS: The VR-6D derived from the VR-12 has similar distributional properties as the SF-6D. The change in VR-6D showed significant variations across disease groups with different levels of morbidity and mortality. CONCLUSIONS: This study produced a utility measure for the VR-12 that is comparable to the SF-6D and responsive to change. The VR-6D can be used in evaluations of health care plans and cost-effectiveness analysis to compare the health gains that health care interventions can achieve.

Comparison of health outcomes for male seniors in the Veterans Health Administration and Medicare Advantage plans.

OBJECTIVES: To compare the Veterans Health Administration (VHA) with the Medicare Advantage (MA) plans with regard to health outcomes. DATA SOURCES: The Medicare Health Outcome Survey, the 1999 Large Health Survey of Veteran Enrollees, and the Ambulatory Care Survey of Healthcare Experiences of Patients (Fiscal Years 2002 and 2003). STUDY DESIGN: A retrospective study. EXTRACTION METHODS: Men 65+ receiving care in MA (N=198,421) or in VHA (N=360,316). We compared the risk-adjusted probability of being alive with the same or better physical (PCS) and mental (MCS) health at 2-years follow-up. We computed hazard ratio (HR) for 2-year mortality. PRINCIPAL FINDINGS: Veterans had a higher adjusted probability of being alive with the same or better PCS compared with MA participants (VHA 69.2 versus MA 63.6 percent, p<.001). VHA patients had a higher adjusted probability than MA patients of being alive with the same or better MCS (76.1 versus 69.6 percent, p<.001). The HRs for mortality in the MA were higher than in the VHA (HR, 1.26 [95 percent CI 1.23-1.29]). CONCLUSIONS: Our findings indicate that the VHA has better patient outcomes than the private managed care plans in Medicare. The VHA's performance offers encouragement that the public sector can both finance and provide exemplary health care.

Deriving SF-12v2 physical and mental health summary scores: a comparison of different scoring algorithms.

PURPOSE: Summary scores for the SF-12, version 2 (SF-12v2) health status measure are based on scoring coefficients derived for version 1 of the SF-36, despite changes in item wording and response scales and despite the fact that SF-12 scales only contain a subset of SF-36 items. This study derives new summary scores based directly on SF-12v2 data from a recent U.S. sample and compares the new summary scores to the standard ones. Due to controversy regarding methods for developing scoring coefficients for the summary score, we compare summary scores produced by different methods. METHODS: We analyzed nationally representative U.S. data, which provided 53,399 observations for the SF-12v2 in 2003-2005. In addition to the standard SF-12V2 scoring algorithm, summary scores were generated using exploratory factor analysis (EFA), principal components analysis (PCA), and confirmatory factor analysis (CFA), with orthogonal and oblique rotation. We examined correlations among different summary scores, their associations with demographic and clinical variables, and the consistency between changes in scale scores and in summary scores over time. RESULTS: The 8 scale means in the current data were similar to the 1998 SF-12v2 means, with the exception of the vitality scale. Correlations among the scales based on SF-12v2 data differed slightly from correlations derived from scales based on the SF-36 data. Correlations among summary scores derived using different methods were high (≥0.84). However, changes in summary scores derived using orthogonal rotation of components or factors were not consistent with changes in sub-scales, whereas changes in summary scores derived using oblique rotation were more consistent with patterns of change in sub-scales. CONCLUSIONS: Although the basic structure of the SF-12 is stable, summary scores derived from oblique rotation are preferable and more consistent with changes in individual scales. On empirical and conceptual grounds, we suggest using summary scores based on oblique CFA.

Differences in risk-adjusted mortality between medicaid-eligible patients enrolled in medicare advantage plans and those enrolled in the veterans health administration.

BACKGROUND: We compared risk-adjusted mortality rates between Medicaid-eligible patients in the Medicare Advantage plans ("MA dual enrollees") and Medicaid-eligible patients in the Veterans Health Administration ("VHA dual enrollees"). METHODS: We used the Death Master File to ascertain the vital status of 1912 MA and 2361 VHA dual enrollees. We used Cox regression models to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS: The 3-year mortality rates of VHA and MA dual enrollees were 15.8% and 19.0%, respectively. The adjusted HR of mortality in the MA dual enrollees was significantly higher than in the VHA dual enrollees (HR, 1.260 [95% CI, 1.044-1.520]). This was also the case for elderly patients and those from racial/ethnic minority groups. CONCLUSIONS: The VHA had better health outcomes than did MA plans. The VHA's performance is reassuring, given its emphasis on equal access to healthcare in an environment that is less dependent on patient financial considerations.

Updated U.S. population standard for the Veterans RAND 12-item Health Survey (VR-12).

PURPOSE: The purpose of this project was to develop an updated U.S. population standard for the Veterans RAND 12-item Health Survey (VR-12). METHODS: We used a well-defined and nationally representative sample of the U.S. population from 52,425 responses to the Medical Expenditure Panel Survey (MEPS) collected between 2000 and 2002. We applied modified regression estimates to update the non-proprietary 1990 scoring algorithms. We applied the updated standard to the Medicare Health Outcomes Survey (HOS) to compute the VR-12 physical (PCS((MEPS standard))) and mental (MCS((MEPS standard))) component summaries based on the MEPS. We compared these scores to PCS and MCS based on the 1990 U.S. population standard. RESULTS: Using the updated U.S. population standard, the average VR-12 PCS((MEPS standard)) and MCS((MEPS standard)) scores in the Medicare HOS were 39.82 (standard deviation [SD] = 12.2) and 50.08 (SD = 11.4), respectively. For the same Medicare HOS, the average PCS and MCS scores based on the 1990 standard were 1.40 points higher and 0.99 points lower in comparison to VR-12 PCS and MCS, respectively. CONCLUSIONS: Changes in the U.S. population between 1990 and today make the old standard obsolete for the VR-12, so the updated standard developed here is widely available to serve as such a contemporary standard for future applications for health-related quality of life (HRQoL) assessments.

Change in health status and mortality as indicators of outcomes: comparison between the Medicare Advantage Program and the Veterans Health Administration.

BACKGROUND: Comparing health outcomes with adequate methodology is central to performance assessments of health care systems. We compared the Medicare Advantage Program (MAP) and the Veterans Health Administration (VHA) with regard to changes in health status and mortality. METHODS: We used the Death-Master-File for vital status and the Short-Form 36 to determine physical (PCS) and mental (MCS) health at baseline and at 2 years. We compared the probability of being alive with the same or better (than would be expected by chance) PCS (or MCS) at 2 years and mortality, while adjusting for case-mix. Given the geographic variations in MAP enrollment, we did a regional sub-analysis. RESULTS: There were no significant differences in the probability of being alive with the same or better PCS except for the South (VHA 65.8% vs. MAP 62.5%, P = .0014). VHA patients had a slightly higher probability than MAP patients of being alive with the same or better MCS (71.8% vs. 70.1%, P = .002) but no significant regional variations. The hazard ratios for mortality in the MAP were higher than in the VHA across all regions. CONCLUSION: With the use of appropriate methodology, we found small differences in 2-year health outcomes that favor the VHA.

A Patient-based severity measure of chronic lung disease: evaluating functional health and predicting health services use.

Prior research has consistently shown that among patients with chronic lung disease (CLD), health-related quality of life (HRQOL) is tied more to respiratory symptoms than to physiologic measures. However, traditional methods to quantify the severity of CLD have been restricted to physiologic measures (eg, FEV1, FVC, etc) that are often poor predictors of HRQOL and utilization of health services. Using a patient-based measure of symptom severity for CLD developed in the Veterans Health Study (VHS), this article evaluated the impact of the severity of CLD on patients' self-reported HRQOL and future use of health services. We used data from the VHS, a prospective study of patients receiving ambulatory care services in 4 Veterans Affairs outpatient clinics in the greater Boston area. Three hundred fifty-two (14.5%) patients were identified as having CLD through self-report of having a physician's diagnosis of chronic bronchitis, emphysema, or asthma, and either using inhaled medications or having a productive cough for most days for 3 months. Ordinary least-square regressions were used to ascertain the effects of CLD severity on functional health and health services use. Compared with peak expiratory flow rate, which explained only 10% and 2%, respectively, of the variance in the SF-36 physical component summary (PCS) and in future doctor visits, the symptom severity explained 19% and 19%, respectively, of the variance in PCS and future doctor visits, after adjusting for age, education, and household income. The symptom severity measure is a strong predictor of future functional health (at 12 months of the VHS baseline) and health services use (within 6 months following the baseline). The study findings indicate that our measure of CLD severity is an efficient and easy-to-use approach that can be readily administered in ambulatory setting. It can be used as a case-mix adjustment in evaluating health outcomes and in predicting future utilization of health services.

Risk-adjusted mortality as an indicator of outcomes: comparison of the Medicare Advantage Program with the Veterans' Health Administration.

BACKGROUND: The Medicare Advantage Program (MAP) and the Veterans' Health Administration (VHA) currently provide many services that benefit the elderly, and a comparative study of their risk-adjusted mortality rates has the potential to provide important information regarding these 2 systems of care. OBJECTIVE: The objective of this retrospective study was to compare mortality rates between the MAP and the VHA after controlling for case-mix differences. SUBJECTS: This study consisted of 584,294 MAP patients and 420,514 VHA patients. MEASURES: We used the Death Master File to ascertain the vital status of each study subject over approximately 4 years. We used Cox regression models to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for the MAP compared with VHA patients. RESULTS: The average age for male MAP patients was 73.8 years (+/- 5.6) and for male VHA patients was 74.05 years (+/- 6.3). Unadjusted mortality rates of males for VHA and MAP were 25.7% and 22.8%, respectively, over approximately 4 years (P < 0.0001), respectively. The case-mix of VHA patients, however, was sicker than those from MAP. After adjusting for case-mix, the HR for mortality in the MAP was significantly higher than that in the VHA (HR, 1.404; 95% CI = 1.383-1.426). We obtained similar results when we compared the mortality rates of females for VHA and MAP. CONCLUSIONS: After adjusting for their higher prevalence of chronic disease and worse self-reported health, mortality rates were lower for patients cared for in the VHA compared with those in the MAP. Further studies should examine what differences in care structures and processes contribute to lower mortality in the VHA.

Use of risk-adjusted change in health status to assess the performance of integrated service networks in the Veterans Health Administration.

OBJECTIVE: Health outcome assessments have become an expectation of regulatory and accreditation agencies. We examined whether a clinically credible risk adjustment methodology for the outcome of change in health status can be developed for performance assessment of integrated service networks. STUDY DESIGN: Longitudinal study. SETTING: Outpatient. STUDY PARTICIPANTS: Thirty-one thousand eight hundred and twenty-three patients from 22 Veterans Health Administration (VHA) integrated service networks were followed for 18 months. MAIN MEASURE: The physical (PCS) and mental (MCS) component scales from the Veterans Rand 36-items Health Survey (VR-36) and mortality. The outcomes were decline in PCS (decline in PCS scores greater than -6.5 points or death) and MCS (decline in MCS scores greater than -7.9 points). RESULTS: Four thousand three hundred and twenty-eight (13.6%) patients showed a decline in PCS scores greater than -6.5 points, 4322 (13.5%) had a decline in MCS scores by more than -7.9 points, and 1737 died (5.5%). Multivariate logistic regression models were used to adjust for case-mix. The models performed reasonably well in cross-validated tests of discrimination (c-statistics = 0.72 and 0.68 for decline in PCS and MCS, respectively) and calibration. The resulting risk-adjusted rates of decline in PCS and MCS and ranks of the networks differed considerably from unadjusted ratings. CONCLUSION: It is feasible to develop clinically credible risk adjustment models for the outcomes of decline in PCS and MCS. Without adequate controls for case-mix, we could not determine whether poor patient outcomes reflect poor performance, sicker patients, or other factors. This methodology can help to measure and report the performance of health care systems.

Comprehensive health status assessment of centenarians: results from the 1999 large health survey of veteran enrollees.

BACKGROUND: Information on the health status of centenarians provides a means for understanding the health care needs of this growing population. Therefore, we examined the health status of a national cohort of centenarian veteran enrollees. METHODS: Ninety-three centenarian veteran enrollees returned a complete health history questionnaire, which included questions about sociodemographic information, age-associated conditions, health behaviors, health-related quality of life as measured by the Veterans SF-36, and change in health status. RESULTS: Centenarian veteran enrollees are a group with major impairment across multiple dimensions of health-related quality of life despite having a relatively low prevalence of diseases. They had considerable physical limitations as reflected by their physical health summary scores (26.2 +/- 8.3). However, their mental health was comparatively good (mental health summary score 44.1 +/- 12.5). Compared to younger elderly veterans (ages 85-99), centenarians had a lower prevalence of hypertension, angina or myocardial infarction, diabetes, and chronic low back pain (p <.05). Centenarians had significantly worse physical functioning, role physical, vitality, and social functioning scores than did younger elderly veterans. The two groups did not differ in their general health, bodily pain, role emotional, and mental health scores. Centenarians did not perceive much decline in their physical or mental health during the preceding year. CONCLUSIONS: Centenarian veteran enrollees are a group with a low number of age-associated diseases and good mental health despite substantial physical limitations. These results support future studies of services directed toward improvement of function as opposed to those focused solely on the treatment of diseases.

Comorbidity assessments based on patient report: results from the Veterans Health Study.

The objective of the study was to develop a self-reported measure of patients' comorbid illnesses that could be readily administered in ambulatory care settings and that would improve assessment of their health-related quality of life and utilization of health services. Data were analyzed from the Veterans Health Study, an observational study of health outcomes in patients receiving Veterans Administration (VA) ambulatory care. Patients who received ambulatory care services in 4 VA outpatient clinics in the greater Boston area between August 1993 and March 1996 were eligible for inclusion. Among the 4137 patients recruited, 2425 participated in the Veterans Health Study, representing a response rate of 59%. Participants were mailed a health-related quality of life questionnaire, the Medical Outcomes Study Short Form Health Survey (SF-36). They were also scheduled for an in-person interview at which time they completed a medical history questionnaire. We developed a comorbidity index (CI) that included 30 self-reported medical conditions (physical CI) and 6 self-reported mental conditions (mental CI). The physical CI and the mental CI were significantly associated with all SF-36 scales and explained 24% and 36%, respectively, of the variance in the physical component summary and the mental component summary of the SF-36. Both indexes were also significant predictors of future outpatient visits and mortality. The CI is an independent predictor of health status, outpatient visits, and mortality. Its use appears to be a practical approach to case-mix adjustment to account for differences in comorbid illnesses in observational studies of the quality of healthcare. It can be administered to large patient populations at relatively low cost. This method may be particularly valuable for clinicians and researchers interested in population-based studies, case-mix adjustment, and clinical trials.

The health status of elderly veteran enrollees in the Veterans Health Administration.

OBJECTIVES: To examine the health status of elderly veteran enrollees, stratified by age group, and compare with nonveteran populations. DESIGN: Cross-sectional study. SETTING: Outpatient. PARTICIPANTS: A total of 1,406,049 veteran enrollees were surveyed, and 887,775 returned the questionnaire (63.1%). Of these, 663,729 (74%) were aged 65 and older. MEASUREMENTS: Patient demographics, comorbid conditions, and health status, which was assessed using the Veterans 36-item short form (SF-36), a reliable and valid measure of health-related quality of life (HRQoL). RESULTS: Elderly veteran enrollees are a group with poor health status across all scales of the Veterans SF-36. Significant decline in HRQoL was found in patients grouped by increasing age (65-74, 75-84, and > or =85). Of the Veterans SF-36 scales, the role physical and role emotional scales and physical functioning presented the largest decrements by age group. The elderly veteran enrollees had poorer health status than older people enrolled in Medicare managed care, ranging from 0.5 to 1 standard deviations worse. CONCLUSION: Elderly veteran enrollees have substantial disease burden, as reflected by major impairments across multiple dimensions of HRQoL. These findings bear important implications for use of services, suggesting that the Veterans Health Administration will require considerable resources to provide care for its aging population.

No racial differences in mortality found among Veterans Health Administration out-patients.

OBJECTIVE: Health care delivery systems that offer equal access to ambulatory care may hold promise for preventing and correcting racial disparities that exist in our health care system as a whole. We examined whether racial differences in mortality rates exist among patients receiving outpatient care within the Veterans Health Administration. STUDY DESIGN AND SETTING: This study used data from the 1998 National Survey of Ambulatory Care Patients, a prospective monitoring system of patient outcomes. We used an outpatient care system in the Veterans Health Administration. We followed 25,172 Whites and 3,517 African-Americans for 48 months. The main study outcome measures were unadjusted and adjusted mortality rates over a 48-month period. RESULTS: African-Americans had significantly lower unadjusted 48-month mortality rates than Whites (33 vs. 40 deaths per 1,000 person-year, hazard ratio, 0.84; 95% confidence interval [CI], 0.75-0.95). After risk adjustment, the mortality rates became similar for African-Americans and Whites (hazard ratio, 0.99; 95% CI, 0.89-1.09). These findings were consistent across all time points evaluated during the 48-month follow-up. CONCLUSIONS: The lack of racial differences in mortality in patients receiving ambulatory care in the Veterans Health Administration is reassuring, given the emphasis on equal access within this health care system. This warrants further research to determine whether efforts to improve access in other settings have the potential to reduce racial disparities in health care.

Risk-adjusted mortality rates as a potential outcome indicator for outpatient quality assessments.

OBJECTIVE: The quality of outpatient medical care is increasingly recognized as having an important impact on mortality. We examined whether a clinically credible risk adjustment methodology can be developed for outpatient quality assessments. RESEARCH DESIGN: This study used data from the 1998 National Survey of Ambulatory Care Patients, a prospective monitoring system of outcomes of patients receiving ambulatory care in the Veterans Affairs (VA) integrated service networks. SUBJECTS: Thirty-one thousand eight hundred twenty-three patients were followed for 18 months. MEASURES: The main study outcome measures were observed and risk-adjusted mortality rates. RESULTS: Of the 31,823 patients, 1559 (5%) died during the 18-months of follow-up. Observed mortality rates across the 22 VA integrated service networks varied significantly from 3.3% to 6.7% (P <0.001). Age, gender, comorbidities (Charlson Index), physical health, and mental health were significant predictors of dying. The resulting risk-adjusted mortality model performed well in cross-validated tests of discrimination (c-statistic = 0.768; 95% CI, 0.749-0.788) and calibration. Analysis of variance confirmed that the 22 integrated service networks differed in their average level of expected risk (P <0.001). Risk-adjusted rates and ranks of the networks differed considerably from unadjusted ratings. CONCLUSIONS: Risk-adjusted mortality rates may be a useful outcome measure for assessing quality of outpatient care. We have developed a clinically credible risk adjustment model with good performance properties using sociodemographics, diagnoses, and functional status data. The resulting risk adjustment model altered assessments of the performance of the integrated service networks when compared with the unadjusted mortality rates.