Veterans' use of inpatient and outpatient palliative care: The national landscape.

BACKGROUND: Palliative care improves the quality of life for people with life-limiting conditions, which are common among older adults. Despite the Veterans Health Administration (VA) outpatient palliative care expansion, most research has focused on inpatient palliative care. This study aimed to compare veteran characteristics and hospice use for palliative care users across care settings (inpatient vs. outpatient) and dose (number of palliative care encounters). METHODS: This national cohort included veterans with any VA palliative care encounters from 2014 through 2017. We used VA and Medicare administrative data (2010-2017) to describe veteran demographics, socioeconomic status, life-limiting conditions, frailty, and palliative care utilization. Specialty palliative care encounters were identified using clinic stop codes (353, 351) and current procedural terminology codes (99241-99245). RESULTS: Of 120,249 unique veterans with specialty palliative care over 4 years, 67.8% had palliative care only in the inpatient setting (n = 81,523) and 32.2% had at least one palliative care encounter in the outpatient setting (n = 38,726), with or without an inpatient palliative care encounter. Outpatient versus inpatient palliative care users were more likely to have cancer and less likely to have high frailty, but sociodemographic factors including rurality and housing instability were similar. Duration of hospice use was similar between inpatient (median = 37 days; IQR = 11, 112) and outpatient (median = 44 days; IQR = 14, 118) palliative care users, and shorter among those with only one palliative care encounter (median = 18 days; IQR = 5, 64). CONCLUSIONS: This national evaluation provides novel insights into the care setting and dose of VA specialty palliative care for veterans. Among veterans with palliative care use, one-third received at least some palliative care in the outpatient care setting. Differences between veterans with inpatient and outpatient use motivate the need for further research to understand how care settings and number of palliative care encounters impact outcomes for veterans and older adults.

The impact of dual VA-Medicare use on a data-driven clinical management tool for older Veterans with multimorbidity.

BACKGROUND: Healthcare systems are increasingly turning to data-driven approaches, such as clustering techniques, to inform interventions for medically complex older adults. However, patients seeking care in multiple healthcare systems may have missing diagnoses across systems, leading to misclassification of resulting groups. We evaluated the impact of multi-system use on the accuracy and composition of multimorbidity groups among older adults in the Veterans Health Administration (VA). METHODS: Eligible patients were VA primary care users aged ≥65 years and in the top decile of predicted 1-year hospitalization risk in 2018 (n = 558,864). Diagnoses of 26 chronic conditions were coded using a 24-month lookback period and input into latent class analysis (LCA) models. In a random 10% sample (n = 56,008), we compared the resulting model fit, class profiles, and patient assignments from models using only VA system data versus VA with Medicare data. RESULTS: LCA identified six patient comorbidity groups using VA system data. We labeled groups based on diagnoses with higher within-group prevalence relative to the average: Substance Use Disorders (7% of patients), Mental Health (15%), Heart Disease (22%), Diabetes (16%), Tumor (14%), and High Complexity (10%). VA with Medicare data showed improved model fit and assigned more patients with high accuracy. Over 70% of patients assigned to the Substance, Mental Health, High Complexity, and Tumor groups using VA data were assigned to the same group in VA with Medicare data. However, 41.9% of the Heart Disease group and 14.7% of the Diabetes group were reassigned to a new group characterized by multiple cardiometabolic conditions. CONCLUSIONS: The addition of Medicare data to VA data for older high-risk adults improved clustering model accuracy and altered the clinical profiles of groups. Accessing or accounting for multi-system data is key to the success of interventions based on empiric grouping in populations with dual-system use.

Use of high cost care among Veterans with comorbid mental illness and Alzheimer's Disease and related dementias.

INTRODUCTION/OBJECTIVE: Alzheimer's Disease and Other Related Dementias (AD/ADRD) leads to frequent emergency department (ED) and inpatient use. Mental health symptoms among persons with AD/ADRD increases cognitive and functional disabilities and could contribute to these high rates of intensive health care use. The objective of this paper is to assess the relationship of mental illness on 12-month patterns in hospitalization and ED use among Veterans aged 65 and over with a new AD/ADRD diagnosis. METHODS: We used an existing dataset of administrative electronic health record data of Veterans with AD/ADRD from the US Veterans Health Administration linked with Medicare claims data from 2011-2015. We use multivariable logistic regression to examine the association between no pre-existing mental illness, pre-existing mental illness (e.g., major depressive disorder, generalized anxiety disorder, or post-traumatic stress disorder), and pre-existing severe mental illness-or SMI-(e.g., bipolar disorder, major depressive disorder with psychosis, or schizophrenia) and 12- month ED and hospitalization use and readmissions among Veterans who had an initial hospitalization visit. We estimated predicted probabilities, differential effect, and associated 95% confidence intervals. RESULTS: In our sample, 1.4% had SMI and 11% had non-SMI mental illness. The unadjusted percentage with inpatient and ED use was higher among Veterans with SMI (34% and 26%, respectively) and Veterans with non-SMI mental illness (20%, 16%) compared with Veterans without pre-existing mental illness (12%, 9%). Compared to individuals with no pre-existing mental illness, having a pre-existing mental illness (1.27 percentage points, 95% CI: 0.76, 1.78) and a pre-existing SMI (7.17 percentage points, 95% CI: 5.66, 8.69) were both associated with an increased likelihood of ED use. The same pattern was observed for any inpatient use (mental illness 2.18, 95% CI: 1.59, 2.77; SMI 9.91, 95% CI: 8.21, 11.61). Only pre-existing SMI was associated higher hospitalization readmission. DISCUSSION: Pre-existing mental illness increases use of high cost, intensive health care and this association is higher of more severe mental health conditions. We also show that pre-existing mental illness exerts a unique influence, above and beyond other comorbidities, such as diabetes, on ED and inpatient visits. More needs to be done to increase recognition of the unique risks of this combination of health conditions and encourage strategies to address them. Developing, testing, and implementing comprehensive strategies that address the intersection of ADRD and mental illness is promising approach that requires more focused attention.

Effect of Deintensifying Diabetes Medications on Negative Events in Older Veteran Nursing Home Residents.

OBJECTIVE: Guidelines advocate against tight glycemic control in older nursing home (NH) residents with advanced dementia (AD) or limited life expectancy (LLE). We evaluated the effect of deintensifying diabetes medications with regard to all-cause emergency department (ED) visits, hospitalizations, and death in NH residents with LLE/AD and tight glycemic control. RESEARCH DESIGN AND METHODS: We conducted a national retrospective cohort study of 2,082 newly admitted nonhospice veteran NH residents with LLE/AD potentially overtreated for diabetes (HbA1c ≤7.5% and one or more diabetes medications) in fiscal years 2009-2015. Diabetes treatment deintensification (dose decrease or discontinuation of a noninsulin agent or stopping insulin sustained ≥7 days) was identified within 30 days after HbA1c measurement. To adjust for confounding, we used entropy weights to balance covariates between NH residents who deintensified versus continued medications. We used the Aalen-Johansen estimator to calculate the 60-day cumulative incidence and risk ratios (RRs) for ED or hospital visits and deaths. RESULTS: Diabetes medications were deintensified for 27% of residents. In the subsequent 60 days, 28.5% of all residents were transferred to the ED or acute hospital setting for any cause and 3.9% died. After entropy weighting, deintensifying was not associated with 60-day all-cause ED visits or hospitalizations (RR 0.99 [95% CI 0.84, 1.18]) or 60-day mortality (1.52 [0.89, 2.81]). CONCLUSIONS: Among NH residents with LLE/AD who may be inappropriately overtreated with tight glycemic control, deintensification of diabetes medications was not associated with increased risk of 60-day all-cause ED visits, hospitalization, or death.

Palliative Care and Documented Suicide: Association Among Veterans With High Mortality Risk.

CONTEXT: Palliative care consultations (PCCs) are associated with reduced physical and psychological symptoms that are related to suicide risk. Little is known, however, about the association between PCCs and death from suicide among patients at high risk of short-term mortality. OBJECTIVE: To examine the association between the number of PCCs and documentation of suicide in a cohort of Veterans at high risk of short-term mortality, before and after accounting for Veterans' sociodemographic characteristics and clinical conditions. METHODS: An observational cohort study was conducted using linked Veterans Affairs clinical and administrative databases for 580,620 decedents with high risk of one-year mortality. Logistic regression models were used to examine the association between number of PCCs and documentation of suicide. RESULTS: Higher percentages of Veterans who died by suicide were diagnosed with chronic pulmonary disease as well as mental health/substance use conditions compared with Veterans who died from other causes. In adjusted models, one PCC in the 90 days prior to death was significantly associated with a 71% decrease in the odds of suicide (OR = 0.29, 95% CI = 0.23-0.37, P < 0.001) and two or more PCCs were associated with a 78% decrease (OR = 0.22, 95% CI = 0.15-0.33, P < 0.001). Associated "number needed to be exposed" estimates suggest that 421 Veterans in this population would need to receive at least one PCC to prevent one suicide. CONCLUSION: While acknowledging the importance of specialized mental health care in reducing suicide among high-risk patients, interventions delivered in the context of PCCs may also play a role.

Care processes and racial/ethnic differences in family reports of end-of-life care among Veterans: A mediation analysis.

BACKGROUND: Bereaved family members of racial/ethnic minority Veterans are less likely than families of White Veterans to provide favorable overall ratings of end-of-life (EOL) care quality; however, the underlying mechanisms for these differences have not been explored. The objective of this study was to examine whether a set of EOL care process measures mediated the association between Veteran race/ethnicity and bereaved families' overall rating of the quality of EOL care in VA medical centers (VAMCs). METHODS: A retrospective, cross-sectional analysis of linked Bereaved Family Survey (BFS), administrative and clinical data was conducted. The sample included 17,911 Veterans (mean age: 73.7; SD: 11.6) who died on an acute or intensive care unit across 121 VAMCs between October 2010 and September 2015. Mediation analyses were used to assess whether five care processes (potentially burdensome transitions, high-intensity EOL treatment, and the BFS factors of Care and Communication, Emotional and Spiritual Support, and Death Benefits) significantly affected the association between Veteran race/ethnicity and a poor/fair BFS overall rating. RESULTS: Potentially burdensome transitions, high-intensity EOL treatment, and the three BFS factors of Care and Communication, Emotional and Spiritual Support, and Death Benefits did not substantially mediate the relationship between Veteran race/ethnicity and poor/fair overall ratings of quality of EOL care by bereaved family members. CONCLUSIONS: The reasons underlying poorer ratings of quality of EOL care among bereaved family members of racial/ethnic minority Veterans remain largely unexplained. More research on identifying potential mechanisms, including experiences of racism, and the unique EOL care needs of racial and ethnic minority Veterans and their families is warranted.

Caregiver and provider perspectives on dual VA and Medicare Part D medication use in veterans with suspected dementia or cognitive impairment.

PURPOSE: Many older veterans with dementia fill prescriptions through both Veterans Affairs (VA) and Medicare Part D benefits. Dual VA/Part D medication use may have unintended negative consequences in terms of prescribing safety and quality. We aimed to characterize benefits and drawbacks of dual VA/Part D medication use in veterans with dementia or cognitive impairment from the perspectives of caregivers and providers. METHODS: This was a qualitative study based on semistructured telephone interviews of 2 groups: (1) informal caregivers accompanying veterans with suspected dementia or cognitive impairment to visits at a VA Geriatric Evaluation and Management clinic (n = 11) and (2) VA healthcare providers of veterans with dementia who obtained medications via VA and Part D (n = 12). We conducted semistructured telephone interviews with caregivers and providers about benefits and drawbacks of dual VA/Part D medication use. Interview transcripts were subjected to qualitative content analysis to identify key themes. RESULTS: Caregivers and providers both described cost and convenience benefits to dual VA/Part D medication use. Caregivers reported drawbacks including poor communication between VA and non-VA providers and difficulty managing medications from multiple systems. Providers reported potential safety risks including communication barriers, conflicting care decisions, and drug interactions. CONCLUSION: Results of this study allow for understanding of potential policy interventions to better manage dual VA/Part D medication use for older veterans with dementia or cognitive impairment at a time when VA is expanding access to non-VA care.

End-Of-Life Care in the Time of COVID-19: Communication Matters More Than Ever.

CONTEXT: The COVID-19 pandemic resulted in visitation restrictions across most health care settings, necessitating the use of remote communication to facilitate communication among families, patients and health care teams. OBJECTIVE: To examine the impact of remote communication on families' evaluation of end-of-life care during the COVID-19 pandemic. METHODS: Retrospective, cross-sectional, mixed methods study using data from an after-death survey administered from March 17-June 30, 2020. The primary outcome was the next of kin's global assessment of care during the Veteran's last month of life. RESULTS: Data were obtained from the next-of-kin of 328 Veterans who died in an inpatient unit (i.e., acute care, intensive care, nursing home, hospice units) in one of 37 VA medical centers with the highest numbers of COVID-19 cases. The adjusted percentage of bereaved families reporting excellent overall end-of-life care was statistically significantly higher among those reporting Very Effective remote communication compared to those reporting that remote communication was Mostly, Somewhat, or Not at All Effective (69.5% vs. 35.7%). Similar differences were observed in evaluations of remote communication effectiveness with the health care team. Overall, 81.3% of family members who offered positive comments about communication with either the Veteran or the health care team reported excellent overall end-of-life care vs. 28.4% who made negative comments. CONCLUSIONS: Effective remote communication with the patient and the health care team was associated with significantly better ratings of the overall experience of end-of-life care by bereaved family members. Our findings offer timely insights into the importance of remote communication strategies.

Antihypertensive Deprescribing in Older Adult Veterans at End of Life Admitted to Veteran Affairs Nursing Homes.

OBJECTIVES: Geriatric palliative care approaches support deprescribing of antihypertensives in older nursing home (NH) residents with limited life expectancy and/or advanced dementia (LLE/AD) who are intensely treated for hypertension (HTN), but information on real-world deprescribing patterns in this population is limited. We examined the incidence and factors associated with antihypertensive deprescribing. DESIGN: National, retrospective cohort study. SETTING AND PARTICIPANTS: Older Veterans with LLE/AD and HTN admitted to VA NHs in fiscal years 2009-2015 with potential overtreatment of HTN at admission, defined as receiving at least 1 antihypertensive class of medications and mean daily systolic blood pressure (SBP) <120 mm Hg. MEASURES: Deprescribing was defined as subsequent dose reduction or discontinuation of an antihypertensive for ≥7 days. Competing risk models assessed cumulative incidence and factors associated with deprescribing. RESULTS: Within our sample (n = 10,574), cumulative incidence of deprescribing at 30 days was 41%. Veterans with the greatest level of overtreatment (ie, multiple antihypertensives and SBP <100 mm Hg) had an increased likelihood (hazard ratio 1.75, 95% confidence interval 1.59, 1.93) of deprescribing vs those with the lowest level of overtreatment (ie, one antihypertensive and SBP ≥100 to <120 mm Hg). Several markers of poor prognosis (ie, recent weight loss, poor appetite, dehydration, dependence for activities of daily living, pain) and later admission year were associated with increased likelihood of deprescribing, whereas cardiovascular risk factors (ie, diabetes, congestive heart failure, obesity), shortness of breath, and admission source from another NH or home/assisted living setting (vs acute hospital) were associated with decreased likelihood. CONCLUSIONS AND IMPLICATIONS: Real-world deprescribing patterns of antihypertensives among NH residents with HTN and LLE/AD appear to reflect variation in recommendations for HTN treatment intensity and individualization of patient care in a population with potential overtreatment. Factors facilitating deprescribing included treatment intensity and markers of poor prognosis. Comparative effectiveness and safety studies are needed to guide clinical decisions around deprescribing and HTN management.

Evaluation of Low-Value Diagnostic Testing for 4 Common Conditions in the Veterans Health Administration.

Importance: Low-value care is associated with harm among patients and with wasteful health care spending but has not been well characterized in the Veterans Health Administration. Objectives: To characterize the frequency of and variation in low-value diagnostic testing for 4 common conditions at Veterans Affairs medical centers (VAMCs) and to examine the correlation between receipt of low-value testing for each condition. Design, Setting, and Participants: This retrospective cohort study used Veterans Health Administration data from 127 VAMCs from fiscal years 2014 to 2015. Data were analyzed from April 2018 to March 2020. Exposures: Continuous enrollment in Veterans Health Administration during fiscal year 2015. Main Outcomes and Measures: Receipt of low-value testing for low back pain, headache, syncope, and sinusitis. For each condition, sensitive and specific criteria were used to evaluate the overall frequency and range of low-value testing, adjusting for sociodemographic and VAMC characteristics. VAMC-level variation was calculated using median adjusted odds ratios. The Pearson correlation coefficient was used to evaluate the degree of correlation between low-value testing for each condition at the VAMC level. Results: Among 1 022 987 veterans, the mean (SD) age was 60 (16) years, 1 008 336 (92.4%) were male, and 761 485 (69.8%) were non-Hispanic White. A total of 343 024 veterans (31.4%) were diagnosed with low back pain, 79 176 (7.3%) with headache, 23 776 (2.2%) with syncope, and 52 889 (4.8%) with sinusitis. With the sensitive criteria, overall and VAMC-level low-value testing frequency varied substantially across conditions: 4.6% (range, 2.7%-10.1%) for sinusitis, 12.8% (range, 8.6%-22.6%) for headache, 18.2% (range, 10.9%-24.6%) for low back pain, and 20.1% (range, 16.3%-27.7%) for syncope. With the specific criteria, the overall frequency of low-value testing across VAMCs was 2.4% (range, 1.3%-5.1%) for sinusitis, 8.6% (range, 6.2%-14.6%) for headache, 5.6% (range, 3.6%-7.7%) for low back pain, and 13.3% (range, 11.3%-16.8%) for syncope. The median adjusted odds ratio ranged from 1.21 for low back pain to 1.40 for sinusitis. At the VAMC level, low-value testing was most strongly correlated for syncope and headache (ρ = 0.56; P < .001) and low back pain and headache (ρ = 0.48; P < .001). Conclusions and Relevance: In this cohort study, low-value diagnostic testing was common, varied substantially across VAMCs, and was correlated between veterans' receipt of different low-value tests at the VAMC level. The findings suggest a need to address low-value diagnostic testing, even in integrated health systems, with robust utilization management practices.