Abstract 4358111: Variability of Outpatient Cardiology Clinician Performance Metric Achievement in the Veteran Affairs Health System

Post-Traumatic Stress Disorder and Heart Failure in Men Within the Veteran Affairs Health System

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. To determine whether there are substantial differences in cardiovascular outcomes across VAMCs. 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. 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. All-cause mortality. 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). 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.

Missed and delayed cancer diagnoses worsen patient outcomes. Overlooking cancer-related diagnostic signals may result in advanced-stage presentations. To develop and implement a digital quality measure of the proportion of advanced-stage cancer diagnoses in the US and assess the rate of missed diagnostic opportunities. This cohort study used electronic health records and a cancer registry of patients with cancer diagnosed from 2016 to 2020 at 2 integrated health care systems, Department of Veterans Affairs (VA) health system and Geisinger Health System. Patients with incident colorectal cancer (CRC) or non-small cell lung cancer, with at least 1 primary care visit in the 2 years before cancer diagnosis, were included. A random sample of 100 advanced-stage cases per cancer type and health system was manually reviewed using a 2-year look-back period. Data were analyzed from January 27 to June 9, 2025. The primary outcome was a digital quality measure for advanced stage cancer and a descriptive analysis (by health system and cancer type) of the rate of missed opportunities in diagnosis, dates of investigation initiation and completion, and factors associated with missed opportunities. There were 37 691 patients from the VA health system and 2914 patients from Geisinger with lung cancer, and there were 14 674 patients from the VA health system and 627 patients from Geisinger with CRC. For lung cancer, the advanced stage comprised 45.9% at the VA health system and 58.3% at Geisinger. Advanced CRC stage was 33.2% at the VA health system and 36.2% at Geisinger. Notably, 58.9% (95% CI, 48.6%-68.5%) of patients from the VA health system and 77.8% (95% CI, 68.6%-84.8%) of patients from Geisinger with advanced-stage lung cancer had missed opportunities in diagnosis. For CRC, 66.3% (95% CI, 56.3%-75.0%) of patients at the VA health system and 69.7% (95% CI, 60.0%-77.9%) of patients at Geisinger had missed opportunities. Patients with missed opportunities had notable delays in diagnosis (eg, the median time from diagnostic signal to workup completion ranged from 1 to 20 months). Lack of screening was associated with 6.1% to 16.7% of late-stage cancers across health systems and cancer types. For lung cancer, missed opportunities were associated with problems in patient-clinician encounters and performing and interpreting diagnostic tests. For CRC, missed opportunities were primarily associated with patient-related factors and problems performing and interpreting diagnostic tests. This study found high rates of missed diagnostic opportunities among patients with advanced-stage cancer. By using advanced stage as a digital quality measure, health systems, payers, and other stakeholders can better identify care gaps and track initiatives to reduce preventable delays in cancer diagnosis.

Initiation of Assertive Community Treatment Among Veterans With Serious Mental Illness: Client and Program Factors

Association between Age and Early Mortality Risk after Implantable Cardioverter Defibrillator Implantation within The Veteran Affairs Health System

Understanding the dynamics between ethnicity and health care: Another role for health services research in chronic disease management.

Implantable cardioverter-defibrillator (ICD) therapy reduces mortality in patients with heart failure and current guidelines advise implantation of ICDs in patients with a life expectancy of >1year. We examined trends in all-cause mortality in patients who underwent primary or secondary prevention ICD placement in the Veterans Affairs (VA) Health System. US veterans receiving a new ICD placement for primary or secondary prevention of sudden cardiac death between January 2007 and January 2015, who had heart failure with reduced ejection fraction (HFrEF) were included in the analysis. We assessed all-cause mortality 1 year post-ICD implantation. ICD implantation and HFrEF diagnosis were established with associated ICD-9 codes. The VA death registry was utilized to identify mortality rates following ICD placement. Results were subsequently age-stratified. There were 17 901 veterans with HFrEF with ICD placement nationwide. There was no statistically significant difference in 1-year mortality from 2007 (13.1%) to 2014 (13.4%, P> 0.05). There was a significant increase in 1-year mortality in patients in the oldest age quartile (81.6 years, 32.3% mortality) compared to the youngest quartile (55.5 years, 7% mortality). The finding of diverging clinical outcomes extended to the 30-day but also 8-year mark. Our data suggest there is a high 1-year mortality in aging HFrEF patients undergoing primary and secondary prevention ICD placement. This highlights the importance of developing better predictive models for mortality in our ICD eligible patient population.

Introduction: Veterans Affairs (VA) facilities evaluate cardiology clinicians using three performance measures for outpatient care: anticoagulation for atrial fibrillation or atrial flutter (AF) with elevated stroke risk, statin therapy for coronary artery disease (CAD), and renin-angiotensin-aldosterone system (RAAS) inhibition for heart failure (HF). We sought to assess these metrics and their differences by clinician characteristics using VA health record data. Methods: We assessed AF, CAD, and HF performance measures for cardiology clinicians with at least 50 annual outpatient encounters from 2017-2023 in VA. A clinician-patient relationship was defined as ≥2 encounters within 1 year or ≥3 encounters within 3 years. Performance measure achievement was calculated separately for each clinician as well as an overall average. If more than one encounter occurred per year for a clinician-patient dyad, one was chosen at random for evaluation. Clinician performance distributions were represented as histograms, and differences in unadjusted performance by clinician training status and gender were assessed using Welch two sample t-tests. Results: Of 456,071 unique cardiology encounters, 179,476 included AF with elevated stroke risk, 313,603 included CAD, and 225,476 included HF with EF ≤40%. There were 1,046 cardiology providers including 53% physicians and 52% women. Overall mean performance measure achievement was 87.7%. Mean performance scores for AF, CAD, and HF were 86.3%, 94.2%, and 78.9% respectively, and distributions are shown in the Figure. There was a modest difference in unadjusted overall performance between physicians and non-physician providers (88.0 vs. 87.2%, p = 0.005) and no difference between female and male clinicians (87.5% vs. 87.8%, p = 0.4) Conclusion: There was high achievement of three established VA outpatient cardiology performance measures with minimal differences by clinician training or gender. This may represent a ceiling effect. However, significant variation remained at the clinician level, indicating potential opportunities for quality improvement even for these well-established treatments.

Discussing goals of care and advance care planning is beneficial, yet how to best integrate goals of care communication into clinical care remains unclear. To develop and determine the feasibility of a structured goals of care communication guide for nurses and social workers. Developmental study with providers in an academic and Veterans Affairs (VA) health system (n = 42) and subsequent pilot testing with patients with chronic obstructive pulmonary disease or heart failure (n = 15) and informal caregivers (n = 4) in a VA health system. During pilot testing, the communication guide was administered, followed by semistructured, open-ended questions about the content and process of communication. Changes to the guide were made iteratively, and subsequent piloting occurred until no additional changes emerged. Provider and patient feedback to the communication guide. Iterative input resulted in the goals of care communication guide. The guide included questions to elicit patient understanding of and attitudes toward the future of illness, clarify values and goals, identify end-of-life preferences, and agree on a follow-up plan. Revisions to guide content and phrasing continued during development and pilot testing. In pilot testing, patients validated the importance of the topic; none said the goals of care discussion should not be conducted. Patients and informal caregivers liked the final guide length (∼30 minutes), felt it flowed well, and was clear. In this developmental and pilot study, a structured goals of care communication guide was iteratively designed, implemented by nurses and social workers, and was feasible based on administration time and acceptability by patients and providers.

Unlike convenience, cost, and quality, camaraderie with other similar patients has not been reported as a prominent patient consideration when choosing a health care system or practitioner. As the Veterans Affairs (VA) Health System expands choice of practitioners for its enrollees, it is important to identify ways to promote veteran camaraderie in community care settings. To determine whether camaraderie with other veterans is important to veterans using the VA Health System. In 2019, a web-based survey was administered to veterans who reported using VA health care. The survey included questions about cultural factors, such as camaraderie, practitioners' understanding of veterans, trust of VA caregivers, and a scenario-based question to ascertain whether veterans would choose VA or private health care if cost and distance were equivalent. Data analysis was performed from November 2024 to January 2025. Using the VA health care system. The primary outcome was the importance of camaraderie in selecting a health care system or practitioner, measured as the percentage of veterans who reported positive ratings on relevant survey items. In this survey study of 652 veterans, the majority were male (486 veterans [74.54%]). Respondents were categorized into 3 age groups: 18 to 34 years (246 veterans [37.73%]), 35 to 64 years (320 veterans [49.08%]), and 65 years and older (86 veterans [13.19%]). In total, 52.41% of respondents rated camaraderie and being around other veterans as important; this increased to 75.88% among veterans aged 18 to 34 years and to 65.35% for those aged 35 to 64 years. For those aged 65 years and older, only 35.75% felt it was important. When asked whether they would choose VA or a private sector health system if cost and travel distance were equal, 69.00% of respondents indicated they would choose VA. The risk-adjusted model demonstrated those who valued being around veterans at VA were 2.24 times more likely (95% CI, 1.81-2.77) to choose VA. In this survey study of 652 veterans, camaraderie was important to most of these VA Health System users, especially younger veterans. As VA provides more choice of practitioners to its enrollees, it will be important to consider ways to preserve veterans' ability to affiliate with other veterans in community care settings, especially for younger veterans who are often challenged in transitioning from military service to civilian life.

Background Herpes zoster (HZ) is characterized by a painful dermatomal rash and is associated with increased healthcare costs. Research quantifying work productivity loss and activity impairment associated with HZ is limited and outdated. This study aimed to describe severity of HZ related pain, health related quality of life, activity impairment, and work productivity among employed adults diagnosed with HZ in the Department of Veterans Affairs (VA) Health System. Methods This cross-sectional study utilized a self-reported survey among adults in the VA health system. Eligibility was assessed biweekly from electronic health record data, and adults with an incident International Classification of Diseases, 10th Revision (ICD-10) HZ diagnosis were invited to complete an online survey. Respondents were indexed on their HZ diagnosis and included if aged 18-70 years, reported working for pay at index, and had 6 months of baseline continuous enrollment. Respondents were excluded if they had a baseline HZ vaccine, did not complete the survey within 30 days after index, or reported not having HZ or experiencing a rash &amp;gt; 14 days prior to index. Questions used to assess outcomes were based on validated survey instruments (Table 1). Work productivity was described among respondents employed at survey completion. Data were collected from 05/04/2021 to 07/07/2022. Descriptive statistics were used to summarize survey responses. Results Among 231 respondents completing the survey, mean (standard deviation [SD]) age was 49 (10) years and 79% were male. Overall, 70% reported experiencing pain in the last 7 days. Mean (SD) [minimum, maximum] “average-pain” severity and EQ-5D-3L scores were 4.0 (2.8) [0, 10] and 0.69 (0.22) [-0.04, 1.00], respectively. Mean (SD) activity impairment was 42% (33%). Mean (SD) absenteeism, presenteeism, and overall work impairment were 17% (27%), 35% (30%), and 43% (35%) out of 202, 192, and 202 respondents, respectively. Conclusion Burden associated with HZ is substantial, with a significant proportion experiencing pain, activity impairment, and work productivity loss. These results provide updated context on the impact of HZ in this population of employed adults in the VA health system. Funding: GlaxoSmithKline Biologicals SA (GSK study identifiers: 208907/HO-16-16967). Disclosures Shaloo Gupta, MS; ORCID: 0000-0002-2535-2892, Cerner Enviza: Salary|GSK: Funding to employer to conduct and support this study Nai-Chung N. Chang, PhD; ORCID: 0000-0002-4541-8967, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Kantar Health: Grant/Research Support|Myriad Genetic Laboratories, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Nikita Stempniewicz, MSc, GSK: Salary|GSK: Ownership Interest Chenchu Bhavani K. Tirupati, MS, MBA, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Kantar Health: Grant/Research Support|Myriad Genetic Laboratories, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Gregorio Coronado, MBA, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Kantar Health: Grant/Research Support|Myriad Genetic Laboratories, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Julie A. Lynch, PhD, RN, MBA; ORCID: 0000-0003-0108-2127, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Cosmina Hogea, PhD; ORCID: 0000-0002-0686-2395, Gilead Sciences: Ownership Interest|GSK: Salary at the time of the submitted work|GSK: Ownership Interest Emily Mulvihill, MBA; ORCID: 0000-0002-1430-8837, Cerner Enviza: Salary|GSK: Funding to employer to conduct and support this study Scott L. DuVall, PhD, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support

Diabetes mellitus performance measures in individuals with limited life expectancy.

Frequency of Statin Use in Patients With Low-Density Lipoprotein Cholesterol ≥190 mg/dl from the Veterans Affairs Health System

Older adults with bipolar disorder are at increased risk of developing dementia. The literature suggests lithium treatment may reduce the incidence of dementia. This study sought to inform clinical practice in the Veterans Affairs (VA) health system by estimating the effect of past year lithium receipt on dementia incidence among Veterans with bipolar disorder. Divalproex receipt was used as a comparison. Using VA medical records, 121,094 Veterans aged 50 and older with a diagnosis of bipolar disorder but no dementia diagnosis were identified in fiscal years 2005-2019. Follow-up continued until dementia diagnosis, 36 months from the index date, death, or the end of fiscal year 2020, whichever came first. 4347 (3.6%) were diagnosed with dementia during follow-up. Time-varying indicators of receipt of lithium and divalproex in the prior 365 days were calculated for each day, categorized as 301-365, 61-300, 1-60, or 0 days of receipt. Unadjusted Cox proportional hazards regression analyses indicated reduced dementia incidence with 301-365 (HR=0.86, 95% Confidence Interval [95%CI] 0.75-0.99) and 61-300 (HR=0.75, 95%CI 0.65-0.87) days of lithium receipt, compared to 0 days. For divalproex, 301-365 (HR=1.34, 95%CI 1.23-1.47) and 61-300 (HR=1.13, 95%CI 1.03-1.23) days of receipt were each associated with increased dementia incidence. Lithium effects were not statistically significant after adjusting for age, sex, race, ethnicity, medical comorbidities, and antidepressant, antipsychotic, and anxiolytic medication receipt. Divalproex effects remained statistically significant. Past year divalproex, but not lithium, receipt was significantly associated with dementia incidence among VA patients with bipolar disorder when adjusting for demographics and medical comorbidities.

This paper reports on residential mobility among patients treated in the Veterans Affairs (VA) health system. We examine mobility in relation to patients' psychiatric disorders, and we assess the impact of mobility on health system geographic accessibility and continuity of care following inpatient discharge. Subjects included 534,002 patients with schizophrenia, bipolar disorder, depression, or with none of these conditions, who received VA services in both FY 01 and FY 02. We report the frequency and predictors of residential moves; we examine distance moved and changes in the proximity of VA providers; and we evaluate associations with timely receipt of outpatient care following inpatient discharges. Approximately 25% of patients with bipolar disorder, 20% with schizophrenia, 16% with depression, and 9% of patients without these conditions completed a residential move in FY 2002. When relocating, patients with schizophrenia and bipolar disorder were more likely to move closer to providers, suggesting greater sensitivity to accessibility barriers.