Organizational factors associated with decreased mortality among Veterans Affairs patients with an ICU stay.

In-hospital mortality rates associated with an ICU stay are high and vary widely among units. This variation may be related to organizational factors such as staffing patterns, ICU structure, and care processes. We aimed to identify organizational factors associated with variation in in-hospital mortality for patients with an ICU stay. This was a retrospective observational cross-sectional study using administrative data from 34 093 patients from 171 ICUs in 119 Veterans Health Administration hospitals. Staffing and patient data came from Veterans Health Administration national databases. ICU characteristics came from a survey in 2004 of ICUs within the Veterans Health Administration. We conducted multilevel multivariable estimation with patient-, unit-, and hospital-level data. The primary outcome was in-hospital mortality. Of 34 093 patients, 2141 (6.3%)died in the hospital. At the patient level, risk of complications and having a medical diagnosis were significantly associated with a higher risk of mortality. At the unit level, having an interface with the electronic medical record was significantly associated with a lower risk of mortality. The finding that electronic medical records integrated with ICU information systems are associated with lower in-hospital mortality adds support to existing evidence on organizational characteristics associated with in-hospital mortality among ICU patients.

Nurse staffing and patient care costs in acute inpatient nursing units.

OBJECTIVE: Studies suggest that a business case for improving nurse staffing can be made to increase registered nurse (RN) skill mix without changing total licensed nursing hours. It is unclear whether a business case for increasing RN skill mix can be justified equally among patients of varying health needs. This study evaluated whether nursing hours per patient day (HPPD) and skill mix are associated with higher inpatient care costs within acute medical/surgical inpatient units using data from the Veterans Health Administration. METHODS: Retrospective cross-sectional study, including 139,360 inpatient admissions to 292 acute medical/surgical units at 125 Veterans Health Administration medical centers between February and June 2003, was conducted. Dependent variables were inpatient costs per admission and costs per patient day. RESULTS: The average costs per surgical and medical admission were $18,624 and $6,636, respectively. Costs per admission were positively associated with total nursing HPPD among medical admissions ($164.49 per additional HPPD, P<0.001), but not among surgical admissions. Total nursing HPPD and RN skill mix were associated with higher costs per hospital day for both medical admissions ($79.02 per additional HPPD and $5.64 per 1% point increase in nursing skill mix, both P<0.001) and surgical admissions ($112.47 per additional HPPD and $13.31 per 1% point increase in nursing skill mix, both P<0.001). Patients experiencing complications or transferring to an intensive care unit had higher inpatient costs than other patients. CONCLUSIONS: The association of nurse staffing level with costs per admission differed for medical versus surgical admissions.

Reliance on Veterans Affairs outpatient care by Medicare-eligible veterans.

OBJECTIVE: To examine longitudinal changes in Medicare-eligible veterans' reliance on the Department of Veterans Affairs (VA) healthcare system for primary and specialty care over 4 years. METHODS: We merged VA administrative and Medicare claims data to examine outpatient use during fiscal years (FY) 2001 to 2004 by 15,520 Medicare-eligible veterans who used VA primary care in FY2000. Reliance on VA outpatient care was defined as the proportion of total (VA/Medicare) visits received in VA for primary or specialty care. RESULTS: Of 869,000 primary and specialty care visits in the study period, 39% occurred within VA and 77% were specialty care. Reliance on VA primary care was substantially higher than specialty care (66% vs. 50% in FY2001; P<0.001). Reliance on VA primary and specialty care decreased over time (57% vs. 31% in FY2004; P<0.001). Significant shifts occurred at both extremes of VA reliance. From FY2001 to FY2004, the proportion of patients in the top decile of reliance on VA primary care decreased from 39% to 31%, whereas the proportion in the bottom decile doubled from 8% to 18%. Similarly, the proportion of patients in the top decile of reliance on VA specialty care decreased from 24% to 13%, whereas the proportion in the bottom decile doubled from 22% to 47%. CONCLUSIONS: Reliance on VA primary and specialty care among VA primary care patients decreased substantially over time, particularly for specialty care. Increasing use of non-VA services may complicate VA's implementation of patient-centered medical home models and performance measurement.

Does medication adherence following a copayment increase differ by disease burden?

OBJECTIVES: To compare changes in medication adherence between patients with high- or low-comorbidity burden after a copayment increase. METHODS: We conducted a retrospective observational study at four Veterans Affairs (VA) medical centers by comparing veterans with hypertension or diabetes required to pay copayments with propensity score-matched veterans exempt from copayments. Disease cohorts were stratified by Diagnostic Cost Group risk score: low- (<1) and high-comorbidity (>1) burden. Medication adherence from February 2001 to December 2003, constructed from VA pharmacy claims data based on the ReComp algorithm, were assessed using generalized estimating equations. RESULTS: Veterans with lower comorbidity were more responsive to a U.S.$5 copayment increase than higher comorbidity veterans. In the lower comorbidity groups, veterans with diabetes had a greater reduction in adherence than veterans with hypertension. Adherence trends were similar for copayment-exempt and nonexempt veterans with higher comorbidity. CONCLUSION: Medication copayment increases are associated with different impacts for low- and high-risk patients. High-risk patients incur greater out-of-pocket costs from continued adherence, while low-risk patients put themselves at increased risk for adverse health events due to greater nonadherence.

Importance of health system context for evaluating utilization patterns across systems.

Measuring health services provided to patients can be difficult when patients see providers across multiple health systems and all visits are rarely captured in a single data source covering all systems where patients receive care. Studies that account for only one system will omit the out-of-system health-care use at the patient level. Combining data across systems and comparing utilization patterns across health systems creates complications for both aggregation and accuracy because data-generating processes (DGPs) tend to vary across systems. We develop a hybrid methodology for aggregation across systems, drawing on the strengths of the DGP in each system, and demonstrate its validity for answering research questions requiring cross-system assessments of health-care utilization. Positive and negative predictive probabilities can be useful to assess the impact of the hybrid methodology. We illustrate these issues comparing public sector (administrative records from the US Department of Veterans Affairs system) and private sector (billing records from the US Medicare system) patient level data to identify primary-care utilization. Understanding the context of a particular health system and its effect on the DGP is important in conducting effective valid evaluations.

Use of outpatient care in Veterans Health Administration and Medicare among veterans receiving primary care in community-based and hospital outpatient clinics.

OBJECTIVE: To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients. DATA SOURCES/STUDY SETTING: VA administrative and Medicare claims data from 2001 to 2004. STUDY DESIGN: Retrospective cohort study of outpatient service use by 8,964 community-based and 6,556 hospital-based VA primary care patients. PRINCIPAL FINDINGS: A significant proportion of VA patients used Medicare-reimbursed primary care (>30 percent) and specialty care (>60 percent), but not mental health care (3-4 percent). Community-based patients had 17 percent fewer VA primary care visits (p<.001), 9 percent more Medicare-reimbursed visits (p<.001), and 6 percent fewer total visits (p<.05) than hospital-based patients. Community-based patients had 22 percent fewer VA specialty care visits (p<.0001) and 21 percent more Medicare-reimbursed specialty care visits (p<.0001) than hospital-based patients, but no difference in total visits (p=.80). CONCLUSIONS: Medicare-eligible VA primary care patients followed over 4 consecutive years used significant primary care and specialty care outside of VA. Community-based patients offset decreased VA use with increased service use paid by Medicare, suggesting that increasing access to VA primary care via community clinics may fragment veteran care in unintended ways. Coordination of care between VA and non-VA providers and health care systems is essential to improve the quality and continuity of care.

Increasing copayments and adherence to diabetes, hypertension, and hyperlipidemic medications.

OBJECTIVE: To examine the impact of a medication copayment increase on adherence to diabetes, hypertension, and hyperlipidemic medications. STUDY DESIGN: Retrospective pre-post observational study. METHODS: This study compared medication adherence at 4 Veterans Affairs medical centers between veterans who were exempt from copayments and propensity-matched veterans who were not exempt. The diabetes sample included 1069 exempt veterans and 1069 nonexempt veterans, the hypertension sample included 3545 exempt veterans and 3545 nonexempt veterans, and the sample of veterans taking statins included 2029 exempt veterans and 2029 nonexempt veterans. The main outcome measure was medication adherence 12 months before and 23 months after the copayment increase. Adherence differences were assessed in a difference-in-difference approach by using generalized estimating equations that controlled for time, copayment exemption, an interaction between time and copayment exemption, and patient demographics, site, and other factors. RESULTS: Adherence to all medications increased in the short term for all veterans, but then declined in the longer term (February-December 2003). The change in adherence between the preperiod and the postperiod was significantly different for exempt and nonexempt veterans in all 3 cohorts, and nonadherence increased over time for veterans required to pay copayments. The impact of the copayment increase was particularly adverse for veterans with diabetes who were required to pay copayments. CONCLUSION: A $5 copayment increase (from $2 to $7) adversely impacted medication adherence for veterans subject to copayments taking oral hypoglycemic agents, antihypertensive medications, or statins.

Line authority for nurse staffing and costs for acute inpatient care.

There is little empirical evidence evaluating the effects of recent, widespread changes in nurse executive roles and nursing management structures on the costs of patient care. This retrospective cross-sectional study examined the relationship between line authority for nurse staffing and patient care costs (total, nursing, and non-nursing cost) using data from 124 Department of Veterans Affairs (VA) medical centers. After controlling for patient, facility, and market characteristics, nursing line authority was significantly associated with lower nursing cost per admission. Our results provide some evidence that a reduction in nursing line authority may adversely impact nursing costs.

Organizational readiness to change assessment (ORCA): development of an instrument based on the Promoting Action on Research in Health Services (PARIHS) framework.

BACKGROUND: The Promoting Action on Research Implementation in Health Services, or PARIHS, framework is a theoretical framework widely promoted as a guide to implement evidence-based clinical practices. However, it has as yet no pool of validated measurement instruments that operationalize the constructs defined in the framework. The present article introduces an Organizational Readiness to Change Assessment instrument (ORCA), organized according to the core elements and sub-elements of the PARIHS framework, and reports on initial validation. METHODS: We conducted scale reliability and factor analyses on cross-sectional, secondary data from three quality improvement projects (n = 80) conducted in the Veterans Health Administration. In each project, identical 77-item ORCA instruments were administered to one or more staff from each facility involved in quality improvement projects. Items were organized into 19 subscales and three primary scales corresponding to the core elements of the PARIHS framework: (1) Strength and extent of evidence for the clinical practice changes represented by the QI program, assessed with four subscales, (2) Quality of the organizational context for the QI program, assessed with six subscales, and (3) Capacity for internal facilitation of the QI program, assessed with nine subscales. RESULTS: Cronbach's alpha for scale reliability were 0.74, 0.85 and 0.95 for the evidence, context and facilitation scales, respectively. The evidence scale and its three constituent subscales failed to meet the conventional threshold of 0.80 for reliability, and three individual items were eliminated from evidence subscales following reliability testing. In exploratory factor analysis, three factors were retained. Seven of the nine facilitation subscales loaded onto the first factor; five of the six context subscales loaded onto the second factor; and the three evidence subscales loaded on the third factor. Two subscales failed to load significantly on any factor. One measured resources in general (from the context scale), and one clinical champion role (from the facilitation scale). CONCLUSION: We find general support for the reliability and factor structure of the ORCA. However, there was poor reliability among measures of evidence, and factor analysis results for measures of general resources and clinical champion role did not conform to the PARIHS framework. Additional validation is needed, including criterion validation.

Measuring nurses' practice environments with the revised nursing work index: evidence from registered nurses in the Veterans Health Administration.

The Revised Nursing Work Index (NWI-R) is a widely used instrument for evaluating registered nurses' (RNs) practice environments. The existence of multiple subscale sets from the NWI-R raises questions about its generalizability. We tested the validity of the one-, three-, and five-subscale sets from the NWI-R and derived a short-form subscale set using a sample of RNs from the Veterans Health Administration (VHA). The prior sets do not have an excellent fit to these data. Results of exploratory factor analyses suggested a four-factor model with Opportunity for Advancement, Collegial Nurse-Physician Relations, Staffing Adequacy, and Nurse Manager Leadership as the most salient and parsimonious solution. Additional research is needed to corroborate these findings in other nurse samples and settings.

Nurse executive and staff nurse perceptions of the effects of reorganization in Veterans Health Administration hospitals.

OBJECTIVE: To examine nurse executive perceptions of effects of service line reorganization on nurse executive roles, nursing staff and patient care, and compare nurse executive responses to staff nurse reports of job satisfaction and quality of care in the same types of Veterans Health Administration facilities. BACKGROUND: Although a growing body of research focuses on the association between nurse staffing structures, nurse satisfaction, and patient outcomes, relatively little attention has been paid to the effects of hospital restructuring on nursing management and nursing staff. METHODS: Data on hospital and nursing service organization and nurse executive perceptions were collected through structured interviews with 125 nurse executives conducted from December 2002 through May 2003. Staff nurse data were derived from a survey of Veterans Health Administration nursing staff conducted from February through June 2003 at the same facilities. RESULTS: Nurse executives in Veterans Health Administration described significant changes in the nurse executive role, and new challenges for managing nursing practice and achieving consistent quality of nursing care. Although nursing management perceived differences in the overall effects of restructuring on nursing staff depending on the type of reorganization, staff nurses reported significant differences in perceived quality of patient care across organization types.

The role of formative evaluation in implementation research and the QUERI experience.

This article describes the importance and role of 4 stages of formative evaluation in our growing understanding of how to implement research findings into practice in order to improve the quality of clinical care. It reviews limitations of traditional approaches to implementation research and presents a rationale for new thinking and use of new methods. Developmental, implementation-focused, progress-focused, and interpretive evaluations are then defined and illustrated with examples from Veterans Health Administration Quality Enhancement Research Initiative projects. This article also provides methodologic details and highlights challenges encountered in actualizing formative evaluation within implementation research.

Nurse staffing and patient outcomes in Veterans Affairs hospitals.

OBJECTIVE: To assess characteristics and perceptions of nurses working in the Veterans Health Administration (VHA), comparing types of nursing personnel, to benchmark to prior studies across healthcare systems. BACKGROUND: Prior studies have shown relationships between positive registered nurse (RN) perceptions of the practice environment and patient outcomes. To date, no study has reported the comparison of RN perceptions of the practice environment in hospital nursing with those of non-RN nursing personnel. This study is the first to offer a more comprehensive look at perceptions of practice environment from the full range of the nursing work force and may shed light on issues such as the relationship of skill mix to nurse and patient outcomes. METHODS: Cross-sectional observational study with a mailed survey administered to all nursing personnel in 125 VA Medical Centers between February and June 2003. RESULTS: Compared with other types of nursing personnel in the VHA, RNs are generally less positive about their practice environments. However, compared with RNs in other countries and particularly with other RNs in the United States (Pennsylvania), VHA RNs are generally more positive about their practice environment and express more job satisfaction. CONCLUSIONS: The nursing work force of the VHA has some unique characteristics. The practice environment for nurses in the VHA is relatively positive, and may indicate that the VHA, as a system, provides an environment that is more like magnet hospitals. This is significant for a public sector hospital system.

The association between clinical integration of care and transfer of veterans with acute coronary syndromes from primary care VHA hospitals.

BACKGROUND: Few studies report on the effect of organizational factors facilitating transfer between primary and tertiary care hospitals either within an integrated health care system or outside it. In this paper, we report on the relationship between degree of clinical integration of cardiology services and transfer rates of acute coronary syndrome (ACS) patients from primary to tertiary hospitals within and outside the Veterans Health Administration (VHA) system. METHODS: Prospective cohort study. Transfer rates were obtained for all patients with ACS diagnoses admitted to 12 primary VHA hospitals between 1998 and 1999. Binary variables measuring clinical integration were constructed for each primary VHA hospital reflecting: presence of on-site VHA cardiologist; referral coordinator at the associated tertiary VHA hospital; and/or referral coordinator at the primary VHA hospital. We assessed the association between the integration variables and overall transfer from primary to tertiary hospitals, using random effects logistic regression, controlling for clustering at two levels and adjusting for patient characteristics. RESULTS: Three of twelve hospitals had a VHA cardiologist on site, six had a referral coordinator at the tertiary VHA hospital, and four had a referral coordinator at the primary hospital. Presence of a VHA staff cardiologist on site and a referral coordinator at the tertiary VHA hospital decreased the likelihood of any transfer (OR 0.45, 95% CI 0.27-0.77, and 0.46, p = 0.002, CI 0.27-0.78). Conversely, having a referral coordinator at the primary VHA hospital increased the likelihood of transfer (OR 6.28, CI 2.92-13.48). CONCLUSIONS: Elements of clinical integration are associated with transfer, an important process in the care of ACS patients. In promoting optimal patient care, clinical integration factors should be considered in addition to patient characteristics.

A qualitative study to identify barriers and facilitators to implementation of pilot interventions in the Veterans Health Administration (VHA) Northwest Network.

OBJECTIVE: To identify barriers and facilitators to implementation of pilot interventions designed to improve measurement and management of low-density lipoprotein cholesterol (LDL-c) levels in coronary heart disease patients using the evidence/context/facilitation model of implementation of evidence-based practice. DESIGN: Theory-based conceptual content analysis of structured interviews conducted between January and April 2001. SETTING: Six medical centers in the United States Veterans Health Administration Northwest Network. PARTICIPANTS: Fifty-one of 64 individuals (physicians, nurses, pharmacists, dieticians, quality managers, and other clinical and nonclinical staff) who participated in planning and/or implementing pilot interventions. MAIN FINDINGS: Barriers to successful implementation related primarily to the intervention process and secondarily to characteristics of the intervention context. Interview responses indicated that planning, including identification of resources and assessment of potential barriers and facilitators, was a critical and universally underutilized step in the intervention process. CONCLUSIONS: Organized team process, documented plans for intervention activities, and ongoing evaluation are essential for sustaining intervention activities. A top priority for facilitating interventions should be the development of educational materials, such as "how to" guides, that teach intervention teams how to anticipate barriers and make plans to address them, as well as identifying and fostering local experts in planning and implementing interventions.

Improving care to patients with ischemic heart disease: experiences in a single network of the Veterans Health Administration.

BACKGROUND: Ischemic heart disease (IHD) is the leading cause of death in the United States. Lowering serum cholesterol levels reduces coronary events and mortality; this effect is most evident in patients with preexisting IHD. AIMS: The primary aim of this article is to describe a set of interventions that were piloted in a single, regional Veterans Integrated Service Network (VISN) to promote secondary prevention among patients with IHD and to explore the effect of those interventions on patient outcomes. METHODS: An observational, before-and-after study of clinical interventions to improve lipid guideline compliance in VISN 20 (the Veterans Administration Northwest Network) was conducted. A total of 2,467 patients with established coronary artery disease from three medical facilities in VISN 20 were included. Each medical facility chose different interventions to lower low-density lipoprotein cholesterol (LDL-c) levels in their patients. One facility chose a paper point-of-care reminder, a second chose a lipid clinic, and a third chose audit/feedback to clinicians in addition to a patient-education component. Data came from a relational database that mirrors the clinical information system at each site. Outcomes included the proportion of patients who had their LDL-c measured, the proportion of patients who had lipid-lowering agents prescribed, and the proportion of patients at LDL-c goal of lower than 100 mg/dL measured before, during, and after the intervention period. RESULTS: Statistically significant improvements were observed within sites after the interventions were implemented. IMPLICATIONS FOR PRACTICE: Interventions that focused on secondary prevention in this high-risk group were moderately successful in changing practice. Tailoring interventions to the needs of a specific site of care is feasible and may add to the likelihood of succeeding. CONCLUSION: Overall, the three facilities improved in lipid measurement and management for patients with coronary artery disease.

Case-mix adjusting performance measures in a veteran population: pharmacy- and diagnosis-based approaches.

OBJECTIVE: To compare the rankings for health care utilization performance measures at the facility level in a Veterans Health Administration (VHA) health care delivery network using pharmacy- and diagnosis-based case-mix adjustment measures. DATA SOURCES/STUDY SETTING: The study included veterans who used inpatient or outpatient services in Veterans Integrated Service Network (VISN) 20 during fiscal year 1998 (October 1997 to September 1998; N = 126,076). Utilization and pharmacy data were extracted from VHA national databases and the VISN 20 data warehouse. STUDY DESIGN: We estimated concurrent regression models using pharmacy or diagnosis information in the base year (FY1998) to predict health service utilization in the same year. Utilization measures included bed days of care for inpatient care and provider visits for outpatient care. PRINCIPAL FINDINGS: Rankings of predicted utilization measures across facilities vary by case-mix adjustment measure. There is greater consistency within the diagnosis-based models than between the diagnosis- and pharmacy-based models. The eight facilities were ranked differently by the diagnosis- and pharmacy-based models. CONCLUSIONS: Choice of case-mix adjustment measure affects rankings of facilities on performance measures, raising concerns about the validity of profiling practices. Differences in rankings may reflect differences in comparability of data capture across facilities between pharmacy and diagnosis data sources, and unstable estimates due to small numbers of patients in a facility.

Construction and characteristics of the RxRisk-V: a VA-adapted pharmacy-based case-mix instrument.

BACKGROUND: Assessment of disease burden is the key to many aspects of health care management. Patient diagnoses are commonly used for case-mix assessment. However, issues pertaining to diagnostic data availability and reliability make pharmacy-based strategies attractive. Our goal was to provide a reliable and valid pharmacy-based case-mix classification system for chronic diseases found in the Veterans Health Administration (VHA) population. OBJECTIVE: To detail the development and category definitions of a VA-adapted version of the RxRisk (formerly the Chronic Disease Score); to describe category prevalence and reliability; to check category criterion validity against ICD-9 diagnoses; and to assess category-specific regression coefficients in concurrent and prospective cost models. RESEARCH DESIGN: Clinical and pharmacological review followed by cohort analysis of diagnostic, pharmacy, and utilization databases. SUBJECTS: 126,075 veteran users of VHA services in Washington, Oregon, Idaho, and Alaska. METHODS: We used Kappa statistics to evaluate RxRisk category reliability and criterion validity, and multivariate regression to estimate concurrent and prospective cost models. RESULTS: The RxRisk-V classified 70.5% of the VHA Northwest Network 1998 users into an average of 2.61 categories. Of the 45 classes, 33 classes had good-excellent 1-year reliability and 25 classes had good-excellent criterion validity against ICD-9 diagnoses. The RxRisk-V accounts for a distinct proportion of the variance in concurrent (R2 = 0.18) and prospective cost (R2 = 0.10) models. CONCLUSIONS: The RxRisk-V provides a reliable and valid method for administrators to describe and understand better chronic disease burden of their treated populations. Tailoring to the VHA permits assessment of disease burden specific to this population.

Predicting costs of care using a pharmacy-based measure risk adjustment in a veteran population.

BACKGROUND: Although most widely used risk adjustment systems use diagnosis data to classify patients, there is growing interest in risk adjustment based on computerized pharmacy data. The Veterans Health Administration (VHA) is an ideal environment in which to test the efficacy of a pharmacy-based approach. OBJECTIVE: To examine the ability of RxRisk-V to predict concurrent and prospective costs of care in VHA and compare the performance of RxRisk-V to a simple age/gender model, the original RxRisk, and two leading diagnosis-based risk adjustment approaches: Adjusted Clinical Groups and Diagnostic Cost Groups/Hierarchical Condition Categories. METHODS: The study population consisted of 161,202 users of VHA services in Washington, Oregon, Idaho, and Alaska during fiscal years (FY) 1996 to 1998. We examined both concurrent and predictive model fit for two sequential 12-month periods (FY 98 and FY 99) with the patient-year as the unit of analysis, using split-half validation. RESULTS: Our results show that the Diagnostic Cost Group /Hierarchical Condition Categories model performs best (R2 = 0.45) among concurrent cost models, followed by ADG (0.31), RxRisk-V (0.20), and age/sex model (0.01). However, prospective cost models other than age/sex showed comparable R2: Diagnostic Cost Group /Hierarchical Condition Categories R2 = 0.15, followed by ADG (0.12), RxRisk-V (0.12), and age/sex (0.01). CONCLUSIONS: RxRisk-V is a clinically relevant, open source risk adjustment system that is easily tailored to fit specific questions, populations, or needs. Although it does not perform better than diagnosis-based measures available on the market, it may provide a reasonable alternative to proprietary systems where accurate computerized pharmacy data are available.