Facility-level Variation Research Articles

Abstract 4128599: Facility-level Variation Underlying Low Inferior Vena Cava Filter Retrieval in the United States

Background: Inferior vena cava (IVC) filters are commonly implanted in patients with venous thromboembolism (VTE) who are unable to receive anticoagulation, to protect against clot migration to the heart. With prolonged implantation, IVC filters are associated with complications: device fracture, migration, penetration into adjacent organs and worsened VTE. Two Federal Drug Administration advisories and multi-society guidelines have emphasized the importance of timely retrieval but national retrieval rates remain low (<30%). Aims: To quantify hospital-level variation in IVC filter retrieval , describe time-based retrieval rates and examine factors associated with retrieval. Methods: IVC Filter implantation for all patients >= 18 years was identified in the 2016-2020 inpatient and outpatient 100% limited data set Medicare files using claims codes. Hospital information for the implanting facility was cross-linked from the American Hospital Association and Healthcare Cost Report Information System files, including identifying information, teaching status, census location, operating margin and % uncompensated care. IVC filter retrieval rates and time to retrieval from implantation was calculated. Bayesian hospital profiling methods were used to quantify 1-year retrieval rate for all U.S. facilities, adjusting for patient factors – demographics, diagnostic indications and comorbidities. Results: Among Medicare beneficiaries, there were 140,481 IVC Filter implantations across 2,850 facilities. Excluding patients who died within 90 days of implantation (25.7%), retrieval rates at 3 months, 1 year and anytime were 7.9%, 18.7% and 20.0% respectively. IVC Filter retrieval within 1 year varied significantly at the facility-level, from 0-100% . Focusing on facilities with at least 13 IVC filter implantations each year (top 25%ile volume), 1-year retrieval ranged from 0 to 74.5%. Higher 1-year retrieval was seen among higher implantation volume (12.4% bottom quartile, 20.5% top quartile), teaching (21.1% teaching vs. 16.9% nonteaching) and non-safety net (21.1% low uncompensated care, 15.0% high uncompensated care) hospitals. Retrieval rates did not vary significantly by hospital operating margin or rurality. Conclusion(s): There is low overall IVC filter retrieval in the United States with large underlying facility-level variation. Focused examination of high-performing facilities could yield insights on how to improve device retrieval nationally.

Facility-Level Variation in Nephrology Care among Veterans after Urinary Stone Events

Facility-Level Variation in Nephrology Care among Veterans after Urinary Stone Events

Variation in Urology Care After Urinary Stone Surgery Among Veterans at High-risk for Recurrence

ObjectiveTo determine rates of urology follow-up and implementation of stone prevention measures after stone surgery and to assess variation in care delivery within a large, integrated healthcare system. Materials and MethodsWe used nationwide data from the United States Veterans Health Administration to identify patients who had stone surgery between 2016 and 2018 and who were at higher risk for recurrence. Our cohort included 13,444 Veterans across 90 facilities. We examined the proportion of patients who had a post-operative urology visit or who received a prevention measure (24-hour urine test, serum parathyroid hormone measurement, or prescription of a stone-related medication) within 6 months of stone surgery. We calculated the median odds ratio to quantify facility-level variation in urology care after stone surgery, adjusting for patient- and facility-level characteristics. ResultsWithin 6 months of stone surgery, 94.2% Veterans had a urology visit, yet only 8.8% completed 24-hour urine testing, 8.4% had a parathyroid hormone measurement, and 31.0% were prescribed a stone-related medication. Implementation of prevention measures varied widely across facilities with the median odds ratio ranging between 1.18 for medication prescriptions and 1.77 for 24-hour urine testing. ConclusionsWhile most patients have a urology visit after stone surgery, stone prevention measures were implemented infrequently and inconsistently for patients at higher risk for recurrence, indicating an opportunity for quality improvement.

Facility-Level Variation in Racial Disparities in Anticoagulation for Atrial Fibrillation: The REACH-AF Study.

Oral anticoagulation reduces stroke risk for patients with atrial fibrillation (AF). Prior research demonstrates lower anticoagulant prescribing in Black than in White individuals but few studies have examined racial differences in facility-level anticoagulant prescribing for AF. To assess variation in anticoagulant initiation by race within Veterans Health Administration (VA) facilities. Retrospective cohort study. Black and White patients enrolled in the VA with incident AF from 2020 through 2021. The primary outcome was rate of any anticoagulant initiation (i.e., warfarin or direct oral anticoagulant [DOAC]) or any DOAC therapy within 90days of an AF diagnosis, overall and for Black and White patients at each facility. We also estimated the adjusted Black-White risk difference. In 82 VA facilities serving 26,832 Black and White patients, overall unadjusted rates of any anticoagulant therapy ranged from 56.8 to 87.1% across facilities; the corresponding ranges for Black and White patients were 47.6 to 91.3% and 58.2 to 87.1%, respectively. Overall unadjusted rates of DOAC therapy ranged from 55.1 to 85.5% by facility; ranges for Black and White patients were 42.8 to 86.9% and 56.4 to 85.5%, respectively. The adjusted risk difference between Black and White patients ranged from - 29.9 (95% CI, - 54.9 to - 4.8) to 14.2 (95% CI, - 9.1 to 25.0) across facilities for any anticoagulant therapy and from - 28.8 (95% CI, - 58.3 to 0.8) to 15.0 (95% CI, - 8.0 to 38.1) for DOAC therapy.For any anticoagulant therapy there were 3 facilities where prescribing was statistically higher in White than Black patients; for DOAC therapy there were 5 such facilities. In a national cohort of patients with AF, we observed large facility-level variation and adjusted risk differences in any anticoagulant and DOAC initiation, overall and by race. These findings represent a target for local quality improvement in AF care.

Assessing trends and variability in outpatient dual testing for chronic kidney disease with urine albumin and serum creatinine, 2009–2018: a retrospective cohort study in the Veterans Health Administration System

BackgroundSimultaneous urine testing for albumin (UAlb) and serum creatinine (SCr), that is, ‘dual testing,’ is an accepted quality measure in the management of diabetes. As chronic kidney disease (CKD) is...

Abstract B048: Disparities in treatment course and outcomes in females diagnosed with non-metastatic inflammatory breast cancer

Abstract Background: Inflammatory breast cancer (IBC) is an uncommon, aggressive disease with a poor prognosis. National treatment guidelines recommend neoadjuvant chemotherapy followed by modified radical mastectomy (MRM) and radiation. Disparities in treatment may contribute to survival differences, and few studies have assessed factors contributing to such variation. We aimed to identify demographic and facility differences in treatment and survival among females with non-metastatic IBC. Methods: Secondary analysis of the National Cancer Database (2012-2016) on females diagnosed with non-metastatic IBC was performed. Demographics, treatment, and facility data were collected. Statistical analysis was performed with SAS. Results: A total of 5,438 patients met the inclusion criteria. Receiving surgical intervention was associated with age (p<0.0001), race (p<0.0001), and facility (p=0.03), with increased odds of surgery for younger, white, and comprehensive community cancer program patients. Receiving radiation therapy was associated with age (p <0.0001) and race (p<0.0001), with decreased odds of radiation for older, Black, and Hispanic patients. Receiving chemotherapy was associated with age (p <0.0001), with increased odds of chemotherapy for younger patients. Days from diagnosis to treatment initiation was associated with race (p<0.0001) and facility (p=0.0089), with increased time for Black, Hispanic, and academic facility patients. Survival time was associated with age (p<0.0001), race (p<0.0001), facility (p=0.0002), Charlson-Deyo (CD) score (p<0.0001), and surgery (p<0.0001), with decreased survival for older, Black, non-academic facility, higher CD score, and non-surgery patients. Conclusions: Treatment trends and survival of IBC patients are impacted by sociodemographic and facility-level variation, which, when addressed, may help to improve patient outcomes. Citation Format: Kirsten Lung, Young Sheng, Brandon George, Alliric Willis, Melissa Lazar. Disparities in treatment course and outcomes in females diagnosed with non-metastatic inflammatory breast cancer [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B048.

Uptake of SGLT2i therapy among patients hospitalized with heart failure: Insights from the veterans affairs healthcare system

Abstract Introduction Sodium-glucose cotransporter-2 inhibitors (SGLT2i) improve outcomes among heart failure (HF) patients. However, the uptake of SGLT2i over time remains unknown. Purpose This study describes SGLT2i use in Veteran Affairs (VA) patients hospitalized with HF. Methods We identified a patient cohort of VA patients who were hospitalized with HF (primary HF diagnosis or secondary HF diagnosis with intravenous loop diuretics) from January 2019 to December 2022. Patients without VA medication prescriptions, prior allergy to SGLT2i, advanced chronic kidney disease (CKD), end-stage kidney disease (ESKD), and advanced heart failure therapies were excluded. We identified predictors of SGLT2i use in 2022 and compared the SGLT2i prescription rate to the ARNI prescription rate. The hospital-level variation in SGLT2i prescription was assessed via the median odds ratio. Results From 2019-2022, 70,344 VA patients were hospitalized with HF and eligible for SGLT2i therapy (Table 1). The average age was 72.6 years (SD 10.2); 45.5% had EF ≤40%, 12.3% EF 41%-49%, and 42.3% ≥50%. Among this cohort, 11.6% were prescribed SGLT2is at discharge. SGLT2i prescription rates increased over time (Figure 1) and were higher among patients with HFrEF and those with a primary hospital diagnosis of HF. Among 16,426 patients hospitalized in 2022, SGLT2i prescription was more likely among patients with diabetes mellitus (OR 2.27; 95% CI: 2.09-2.46) and ischemic heart disease (OR 1.13; 95% CI: 1.03-1.25) in multivariable models. Patients with CKD were not more likely to receive SGLT2i therapy (OR 1.07; 95% CI: 0.98-1.16). Patients with increased age (OR 0.77 per 10 years; 95% CI: 0.73-0.80) and lower systolic blood pressure (OR 0.94 per 10mmHg; 95% CI: 0.92-0.96) were less likely to be prescribed SGLT2i. There was substantial facility-level variation of SGLT2i prescription with a median odds ratio (MOR) of 1.81 (1.64-2.03), suggesting a 1.8-fold variation in the likelihood that similar patients at 2 random VA sites were prescribed SGLT2i. Among patients with HFrEF, 30.7% (2,231/7,263) were prescribed an SGLT2i compared with 26.7% (1,937/7,263) patients prescribed ARNI. Conclusion Although utilization of SGLT2i at the time of discharge is overall low in hospitalized VA patients with HF, SGLT2i prescription rates have increased rapidly compared with ARNI. Opportunities exist to reduce variation in SGLT2i prescription rates in eligible patients across hospitals and to emphasize use in patients with CKD and advanced age.

Facility-Level Variation in Care of Veterans with Urinary Stone Disease

Facility-Level Variation in Care of Veterans with Urinary Stone Disease

Racial and Ethnic Disparities and Facility-Level Variation in GLP-1 RA Prescription among US Veterans with CKD.

Racial and Ethnic Disparities and Facility-Level Variation in GLP-1 RA Prescription among US Veterans with CKD.

Utilization Rates of SGLT2 Inhibitors Among Patients With Type 2 Diabetes, Heart Failure, and Atherosclerotic Cardiovascular Disease: Insights From the Department of Veterans Affairs

BackgroundMultiple clinical trials have demonstrated significant cardiovascular benefit with use of sodium-glucose cotransporter-2 (SGLT2) inhibitors in patients with type 2 diabetes (T2DM) and heart failure (HF) irrespective of ejection fraction. There are limited data evaluating real-world prescription and practice patterns of SGLT2 inhibitors. ObjectivesThe authors sought to assess utilization rates and facility-level variation in the use among patients with established atherosclerotic cardiovascular disease (ASCVD), HF, and T2DM using data from the nationwide Veterans Affairs health care system. MethodsThe authors included patients with established ASCVD, HF, and T2DM seen by a primary care provider between January 1, 2020, and December 31, 2020. They assessed the use of SGLT2 inhibitors and the facility-level variation in their use. Facility-level variation was computed using median rate ratios, a measure of likelihood that 2 random facilities differ in use of SGLT2 inhibitors. ResultsAmong 105,799 patients with ASCVD, HF, and T2DM across 130 Veterans Affairs facilities, 14.6% received SGLT2 inhibitors. Patients receiving SGLT2 inhibitors were younger men with higher hemoglobin A1c and estimated glomerular filtration rate and were more likely to have HF with reduced ejection fraction and ischemic heart disease. There was significant facility-level variation of SGLT2 inhibitor use, with an adjusted median rate ratio of 1.55 (95% CI: 1.46-1.64), indicating a 55% residual difference in SGLT2 inhibitor use among similar patients with ASCVD, HF, and T2DM receiving care at 2 random facilities. ConclusionsUtilization rates of SGLT2 inhibitors are low in patients with ASCVD, HF, and T2DM, with high residual facility-level variation. These findings suggest opportunities to optimize SGLT2 inhibitor use to prevent future adverse cardiovascular events.

Hospital admission decisions for older Veterans with community-onset pneumonia: An analysis of 118 U.S. Veterans Affairs Medical Centers.

Age is important for prognosis in community-onset pneumonia, but how it influences admission decisions in the emergency department (ED) is not well characterized. Using clinical data from the electronic health record in a national cohort, we examined pneumonia hospitalization patterns, variation, and relationships with mortality among older versus younger Veterans. In a retrospective cohort of patients ≥ 18 years presenting to EDs with a diagnosis of pneumonia at 118 VA Medical Centers January 1, 2006, to December 31, 2016, we compared observed, predicted, and residual hospitalization risk for Veterans < 70, 70-79, and ≥ 80 years of age using generalized estimating equations and machine learning models with 71 patient factors. We examined facility variation in residual hospitalization across facilities and explored whether facility differences in hospitalization risk correlated with differences in 30-day mortality. Among 297,498 encounters, 165,003 (55%) were for Veterans < 70 years, 61,076 (21%) 70-80, and 71,419 (24%) ≥ 80. Hospitalization rates were 52%, 67%, and 76%, respectively. After other patient factors were adjusting for, age 70-79 had an odds ratio (OR) of 1.39 (95% confidence interval [CI] 1.34-1.44) and ≥ 80 had an OR of 2.1 (95% CI 2.0-2.2) compared to age < 70. There was substantial variation in hospitalization across facilities among Veterans < 70 (<35% hospitalization at the lowest decile of facilities vs. > 66% at the highest decile) that was similar but with higher risk for patients 70-79 years (54% vs. 82%) and ≥ 80 years (59% vs. 85%) and remained after accounting for patient factors, with no consistently positive or negative associations with facility-level 30-day mortality. Older Veterans with community-onset pneumonia experience high risk of hospitalization, with widespread facility variation that has no clear relationship to short-term mortality.

Hospital-level variation in risk-standardized admission rates for emergency care-sensitive conditions among older and younger Veterans.

Research examining emergency department (ED) admission practices within the Department of Veterans Affairs (VA) is limited. This study investigates facility-level variation in risk-standardized admission rates (RSARs) for emergency care-sensitive conditions (ECSCs) among older (≥65 years) and younger (<65 years) Veterans across VA EDs. Veterans presenting to a VA ED for an ECSC between October 1, 2016 and September 30, 2019 were identified and the 10 most common ECSCs established. ECSC-specific RSARs were calculated using hierarchical generalized linear models, adjusting for Veteran and encounter characteristics. The interquartile range ratio (IQR ratio) and coefficient of variation were measures of dispersion for each condition and were stratified by age group. Associations with facility characteristics were also examined in condition-specific multivariable models. The overall cohort included 651,336 ED visits across 110 VA facilities for the 10 most common ECSCs-chronic obstructive pulmonary disease (COPD), heart failure, pneumonia, volume depletion, tachyarrhythmias, acute diabetes mellitus, gastrointestinal (GI) bleeding, asthma, sepsis, and myocardial infarction (MI). After adjusting for case mix, the ECSCs with the greatest variation (IQR ratio, coefficient of variation) in RSARs were asthma (1.43, 32.12), COPD (1.39, 24.64), volume depletion (1.38, 23.67), and acute diabetes mellitus (1.28, 17.52), whereas those with the least variation were MI (1.01, 0.87) and sepsis (1.02, 2.41). Condition-specific RSARs were not qualitatively different between age subgroups. Association with facility characteristics varied across ECSCs and within condition-specific age subgroups. We identified unexplained facility-level variation in RSARs for Veterans presenting with the 10 most common ECSCs to VA EDs. The magnitude of variation did not appear to be qualitatively different between older and younger Veteran subgroups. Variation in RSARs for ECSCs may be an important target for systems-based levers to improve value in VA emergency care.

Predictors, Disparities, and Facility-Level Variation: SGLT2 Inhibitor Prescription Among US Veterans With CKD

Sodium/glucose cotransporter 2 (SGLT2) inhibitors are recommended for type 2 diabetes mellitus (T2DM) in patients with chronic kidney disease (CKD) or atherosclerotic cardiovascular disease (ASCVD). We evaluated factors associated with SGLT2 inhibitor prescription, disparities by race and sex, and facility-level variation in prescription patterns. Retrospective cohort. A national sample of US veterans with comorbid T2DM, CKD, and ASCVD with a primary care visit between January 1 and December 31,2020. Race, sex, and individual Veterans Affairs (VA) location. SGLT2 inhibitor prescription. Multivariable logistic regression assessed associations of race and sex with SGLT2 inhibitor prescription. Facility-level variation in SGLT2i prescription was quantified by median rate ratios (MRR), which express the likelihood that 2 randomly selected facilities differ in their use of SGLT2 inhibitor among similar patients. Of 174,443 patients with CKD, T2DM, and ASCVD, 20,024 (11.5%) were prescribed an SGLT2 inhibitor. Lower odds of SGLT2 inhibitor prescription were seen in Black or African American patients compared with White patients (OR, 0.87 [95% CI, 0.83-0.91]) and among women compared with men (OR, 0.59 [95% CI 0.52-0.67]). The adjusted MRR for SGLT2 inhibitor prescription was 1.58 (95% CI 1.48-1.67) in the total cohort, indicating an unexplained 58% variation in treatment between VA facilities, independent of patient and facility characteristics. Facility-level variation was evaluated among Black or African American patients (MRR, 1.55 [95% CI 1.41-1.68]), White patients (MRR, 1.57 [95% CI 1.47-1.66]), women (MRR, 1.40 [95% CI 1.28-1.51]), and men (MRR, 1.57 [95% CI 1.48-1.67]). Albuminuria was not assessed. Prescription for SGLT2 inhibitors was low among likely eligible patients, with evident disparities by sex and race and between individual VA facilities. Efforts are needed to study and address the reasons for these disparities to improve equitable adoption of these important medications.

Provider- and Facility-Level Variation in Precancerous Cervical Biopsy Diagnoses.

Reproducibility of cervical biopsy diagnoses is low and may vary based on where the diagnostic test is performed and by whom. Our objective was to measure multilevel variation in diagnoses across colposcopists, pathologists, and laboratory facilities. We cross-sectionally examined variation in cervical biopsy diagnoses within the 5 sites of the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR I) consortium within levels defined by colposcopists, pathologists, and laboratory facilities. Patients aged 18 to 65 years with a colposcopy with biopsy performed were included, with diagnoses categorized as normal, cervical intraepithelial neoplasia grade 1 (CIN1), grade 2 (CIN2), and grade 3 (CIN3). Using Markov Chain Monte-Carlo methods, we fit mixed-effects logistic regression models for biopsy diagnoses and presented median odds ratios (MORs), which reflect the variability within each level. Median odds ratios can be interpreted as the average increased odds a patient would have for a given outcome (e.g., CIN2 or CIN3 vs normal or CIN1) when switching to a provider with higher odds of diagnosing that outcome. The MOR is always 1 or greater, and a value of 1 indicates no variation in outcome for that level, with higher values indicating greater variation. A total of 130,110 patients were included who received care across 82 laboratory facilities, 2,620 colposcopists, and 489 pathologists. Substantial variation in biopsy diagnoses was found at each level, with the most occurring between laboratory facilities, followed by pathologists and colposcopists. Substantial variation in biopsy diagnoses of CIN2 or CIN3 (vs normal or CIN1) was present between laboratory facilities (MOR: 1.26; 95% credible interval = 1.19-1.36). Improving consistency in cervical biopsy diagnoses is needed to reduce underdiagnosis, overdiagnosis, and unnecessary treatment resulting from variation in cervical biopsy diagnoses.

Facility level variation in the utilization of neoadjuvant chemotherapy is associated with higher surgical morbidity for patients with advanced stage epithelial ovarian carcinoma

ObjectiveInvestigate outcomes for advanced stage epithelial ovarian cancer (EOC) patients based on facility-level utilization of neoadjuvant chemotherapy (NACT). MethodsStage III-IV EOC patients diagnosed between 2010 and 2016 were identified in the National Cancer Database. Percentage of patients managed with NACT was calculated for facilities, reporting ≥120 patients. Facilities with lowest and highest quartile of NACT rate comprised the low and high-utilizing groups. Clinico-pathological characteristics were collected, and appropriate statistical analysis performed. ResultsHigh- and low-utilizing facilities managed on average 54.1% and 25.4% of patients with NACT respectively. Patients managed at high-utilizing facilities were significantly more likely to be >65 (p = 0.029), have stage IV disease (p < 0.001) and comorbidities (p < 0.001). Patients managed with primary debulking surgery (PDS) at low-utilizing facilities were significantly more likely to be >65, have stage IV disease, and have comorbidities (all, p < 0.001). Patients undergoing PDS at low-utilizing facilities were significantly less likely to achieve complete gross resection (p < 0.001), and were significantly more likely to experience 90-day mortality (p < 0.001), and unplanned 30-day readmission (p < 0.001). After controlling for age, comorbidities, race, insurance status, stage, grade and histology, high-utilizing facilities trended towards better overall survival (OS) (HR: 0.92, 95% CI: 0.85–0.99). Overall, patients undergoing PDS had better OS compared to those who had NACT (median 42 vs 27 months, p < 0.001). ConclusionsDespite treating an EOC population with more advanced disease and comorbidities, high-utilizing facilities have lower surgical morbidity and mortality with no detrimental impact on long-term survival. Careful patient selection to minimize the morbidity and mortality associated with PDS is pivotal.

Predictors and Facility-Level Variation in SGLT2i Prescription Among US Veterans

Predictors and Facility-Level Variation in SGLT2i Prescription Among US Veterans

Association of Prostate-Specific Antigen Screening Rates With Subsequent Metastatic Prostate Cancer Incidence at US Veterans Health Administration Facilities

There is controversy about the benefit of prostate-specific antigen (PSA) screening. Prostate-specific antigen screening rates have decreased since 2008 in the US, and the incidence of metastatic prostate cancer has increased. However, there is no direct epidemiologic evidence of a correlation between population PSA screening rates and subsequent metastatic prostate cancer rates. To assess whether facility-level variation in PSA screening rates is associated with subsequent facility-level metastatic prostate cancer incidence. This retrospective cohort used data for all men aged 40 years or older with an encounter at 128 facilities in the US Veterans Health Administration (VHA) from January 1, 2005, to December 31, 2019. Yearly facility-level PSA screening rates, defined as the proportion of men aged 40 years or older with a PSA test in each year, and long-term nonscreening rates, defined as the proportion of men aged 40 years or older without a PSA test in the prior 3 years, from January 1, 2005, to December 31, 2014. The main outcomes were facility-level yearly counts of incident metastatic prostate cancer diagnoses and age-adjusted yearly metastatic prostate cancer incidence rates (per 100 000 men) 5 years after each PSA screening exposure year. The cohort included 4 678 412 men in 2005 and 5 371 701 men in 2019. Prostate-specific antigen screening rates decreased from 47.2% in 2005 to 37.0% in 2019, and metastatic prostate cancer incidence increased from 5.2 per 100 000 men in 2005 to 7.9 per 100 000 men in 2019. Higher facility-level PSA screening rates were associated with lower metastatic prostate cancer incidence 5 years later (incidence rate ratio [IRR], 0.91 per 10% increase in PSA screening rate; 95% CI, 0.87-0.96; P < .001). Higher long-term nonscreening rates were associated with higher metastatic prostate cancer incidence 5 years later (IRR, 1.11 per 10% increase in long-term nonscreening rate; 95% CI, 1.03-1.19; P = .01). From 2005 to 2019, PSA screening rates decreased in the national VHA system. Facilities with higher PSA screening rates had lower subsequent rates of metastatic prostate cancer. These data may be used to inform shared decision-making about the potential benefits of PSA screening among men who wish to reduce their risk of metastatic prostate cancer.

Specialist Care, Metabolic Testing, and Testing Completeness Among U.S. Veterans with Urinary Stone Disease.

Recent observational studies reporting a lack of benefit from 24-hour urine testing for urinary stone disease (USD) prevention assumed testing included all components recommended from clinical guidelines. We sought to assess the completeness of 24-hour urine testing in the VA population. From the VHA Corporate Data Warehouse (2012-2019), we identified patients with USD (n=198,621) and determined those who saw a urologist and/or nephrologist, and received 24-hour urine testing within 12 months of their index USD encounter. Through Logical Observation Identifiers Names and Codes, we evaluated each collection's completeness, defined as including all of urine volume, calcium, oxalate, citrate, uric acid, and creatinine. We then fit a multilevel logistic regression model with random effects for VHA facility to evaluate factors associated with specialist follow-up, testing, and testing completeness. Specialist follow-up occurred in 54.3% and was stable over time. Testing occurred in 8.4%, declining from 9.3% in 2012 to 7.2% in 2019. Of tests performed, 54.6% were complete (43.7% increasing to 62.7% from 2012-2019). In adjusted analysis, there was high between-facility variation in specialist follow-up (median OR 2.0; 95% CI 1.7-2.0), testing (median OR 2.2, 95% CI 1.9-2.4), and testing completeness (median OR, 6.0, 95% CI 4.5-7.3). Individual facilities contributed 52% (intraclass correlation coefficient, 0.52; 95% CI, 0.44-0.57) towards the observed variation in testing completeness. Approximately 1 in 12 U.S. Veterans with USD receive metabolic testing and half of these tests are complete. Addressing facility level variation in testing completeness may improve USD care.

Development and validation of a new ICD-10-based screening colonoscopy overuse measure in a large integrated healthcare system: a retrospective observational study

BackgroundLow-value use of screening colonoscopy is wasteful and potentially harmful to patients. Decreasing low-value colonoscopy prevents procedural complications, saves patient time and reduces patient discomfort, and can improve access by...

Cohort profile: the South African National Health Laboratory Service (NHLS) National HIV Cohort

PurposeSouth Africa’s National Health Laboratory Service (NHLS) National HIV Cohort was established in 2015 to facilitate monitoring, evaluation and research on South Africa’s National HIV Treatment Programme. In South Africa,...