National Veterans Health Administration Databases Research Articles

Perinatal mental health and pregnancy-associated mortality: opportunities for change.

Perinatal mental health conditions have been associated with adverse pregnancy outcomes, including maternal death. This quality improvement project analyzed pregnancy-associated death among veterans with mental health conditions in order to identify opportunities to improve healthcare and reduce maternal deaths. Pregnancy-associated deaths among veterans using Veterans Health Administration (VHA) maternity care benefits between fiscal year 2011 and 2020 were identified from national VHA databases. Deaths among individuals with active mental health conditions underwent individual chart review using a standardized abstraction template adapted from the Centers for Disease Control and Prevention (CDC). Thirty-two pregnancy-associated deaths were identified among 39,720 paid deliveries with 81% (n = 26) occurring among individuals with an active perinatal mental health condition. In the perinatal mental health cohort, most deaths (n = 16, 62%) occurred in the late postpartum period and 42% (n = 11) were due to suicide, homicide, or overdose. Opportunities to improve care included addressing (1) racial disparities, (2) mental health effects of perinatal loss, (3) late postpartum vulnerability, (4) lack of psychotropic medication continuity, (5) mental health conditions in intimate partners, (6) child custody loss, (7) lack of patient education or stigmatizing patient education, and (8) missed opportunities for addressing reproductive health concerns in mental health contexts. Pregnancy-associated deaths related to active perinatal mental health conditions can be reduced. Mental healthcare clinicians, clinical teams, and healthcare systems have opportunities to improve care for individuals with perinatal mental health conditions.

Improving the Maternity Care Safety Net: Establishing Maternal Mortality Surveillance for Non-Obstetric Providers and Institutions.

The siloed nature of maternity care has been noted as a system-level factor negatively impacting maternal outcomes. Veterans Health Administration (VA) provides multi-specialty healthcare before, during, and after pregnancy but purchases obstetric care from community providers. VA providers may be unaware of perinatal complications, while community-based maternity care providers may be unaware of upstream factors affecting the pregnancy. To optimize maternal outcomes, the VA has initiated a system-level surveillance and review process designed to improve non-obstetric care for veterans experiencing a pregnancy. This quality improvement project aimed to describe the VA-based maternal mortality review process and to report maternal mortality (pregnancy-related death up to 42 days postpartum) and pregnancy-associated mortality (death from any cause up to 1 year postpartum) among veterans who use VA maternity care benefits. Pregnancies and pregnancy-associated deaths between fiscal year (FY) 2011-2020 were identified from national VA databases. All deaths underwent individual chart review and abstraction that focused on multi-specialty care received at the VA in the year prior to pregnancy until the time of death. Thirty-two pregnancy-associated deaths were confirmed among 39,720 pregnancies (PAMR = 80.6 per 100,000 live births). Fifty percent of deaths occurred among individuals who had experienced adverse social determinants of health. Mental health conditions affected 81%. Half (n = 16, 50%) of all deaths occurred in the late postpartum period (43-365 days postpartum) after maternity care had ended. More than half of these late postpartum deaths (n = 9, 56.2%) were related to suicide, homicide, or overdose. Integration of care delivered during the perinatal period (pregnancy through postpartum) from primary, mental health, emergency, and specialty care providers may be enhanced through a system-based approach to pregnancy-associated death surveillance and review. This quality improvement project has implications for all healthcare settings where coordination between obstetric and non-obstetric providers is needed.

Risk of Prostate Cancer in US Veterans With Rheumatoid Arthritis.

Patients with rheumatoid arthritis (RA) have an increased risk of select cancers, including lymphoma and lung cancer. Whether RA influences prostate cancer risk is uncertain. We aimed to determine the risk of prostate cancer in patients with RA compared to patients without RA in the Veterans Health Administration (VA). We performed a matched (up to 1:5) cohort study of male patients with and without RA in the VA from 2000 to 2018. RA status, as well as covariates, were obtained from national VA databases. Prostate cancer was identified through linked VA cancer databases and the National Death Index. Multivariable Cox models compared prostate cancer risk between patients with RA and patients without RA, including models that accounted for retention in the VA system. We included 56,514 veterans with RA and 227,284 veterans without RA. During 2,337,104 patient-years of follow-up, 6,550 prostate cancers occurred. Prostate cancer incidence (per 1,000 patient-years) was 3.50 (95% confidence interval [95% CI] 3.32-3.69) in patients with RA and 2.66 (95% CI 2.58-2.73) in patients without RA. After accounting for confounders and censoring for attrition of VA health care, RA was modestly associated with a higher prostate cancer risk (adjusted HR [HRadj ] 1.12 [95% CI 1.04-1.20]). There was no association between RA and prostate cancer mortality (HRadj 0.92 [95% CI 0.73-1.16]). RA was associated with a modestly increased risk of prostate cancer, but not prostate cancer mortality, after accounting for relevant confounders and several potential sources of bias. However, even minimal unmeasured confounding could explain these findings.

1499. Incidence of Community Acquired Pneumonia by Age and Comorbid Conditions in the Veterans Health Administration (VHA)

BackgroundCommunity acquired pneumonia (CAP) remains a major cause of morbidity and mortality. Risk factors for CAP are often grouped as moderate- (e.g., diabetes mellitus, chronic liver, lung, or heart disease) and high-risk (e.g., immunosuppressive) conditions, which in turn influences preventative strategies, notably pneumococcal vaccination. Here, we use the national VHA databases to assess the risk of CAP among adults, expanding on previous work by using administrative data to assess the incidence of CAP among people with > 1 moderate risk conditionMethodsWe used the national VHA databases merged with claims summaries from the Centers for Medicare and Medicaid Services (CMS) to identify patients receiving clinical care in the VHA without clinical Medicare claims in 2016-2017. Within this population, we identified CAP cases defined by the presence of a diagnostic code for pneumonia, chest X-ray, and antibiotics as well as the absence of healthcare exposure or antibiotics in prior 90 days. We determined the total patient years at risk and calculated incidence rates by age group and by moderate- and high-risk comorbid conditions.ResultsWe identified 37,348 CAP cases in 7.9 million person-years at risk and observed similar annual rates in 2016 and 2017 (468.9 and 472.2 cases/100,000 person-years, respectively). The prevalence of high-risk conditions and incidence of CAP increased with age whereas the prevalence of >1 moderate-risk condition peaked for ages 50-64 and 65-74 years (Table). The incidence of CAP among those with > 1 moderate-risk condition exceeded that of patients with high-risk conditions across all age strata (Figure).Table Figure ConclusionAge-adjusted analysis revealed that the greatest burden of CAP occurs in patients with > 1 moderate-risk condition, even compared to those with a high-risk condition. Our analysis of CAP based on national VHA data suggest that additional preventative health measures directed at individuals older than 50 years with > 1 moderate-risk condition may help to reduce the burden of CAP and limit its morbidity and mortality.Disclosures Robin Jump, MD, PhD, Accelerate (Grant/Research Support)Merck (Grant/Research Support)Pfizer (Grant/Research Support, Advisor or Review Panel member)Roche (Advisor or Review Panel member) Federico Perez, MD, MS, Accelerate (Research Grant or Support)Merck (Research Grant or Support)Pfizer (Research Grant or Support)

The Quality of Peer-Reviewed Publications on Surgery for Early Stage Lung Cancer Within the Veterans Health Administration

The peer-reviewed literature is often referenced to generalize outcomes for lung cancer surgeries performed within the Veterans Health Administration (VHA) and include assessments following resection of early stage non-small-cell lung cancer (NSCLC). We sought to determine the reliability of these reports that are publicly available. A systematic review was undertaken to identify PubMed indexed articles that report postoperative outcomes following surgical resections for stage I NSCLC within the VHA. Only studies that reported American Joint Committee on Cancer staging were included. Eleven studies spanning 49 years (1966-2015) met the inclusion criteria. Two reported findings from national VHA databases while 9 reported outcomes from single institutions. Reporting of outcomes and prognostic factors varied widely between studies and were frequently omitted. This made it difficult to evaluate prognostic factors that may be associated with a wide range of 30- and 90-day perioperative mortality (0-3.8% and 0-6.4%), 3- and 5-year cause-specific survival (72-92% and 32-84%), and 3- and 5- year overall survival (47-85.7% and 24-74%). The quality of peer-reviewed literature that reports outcomes following thoracic surgery for stage I NSCLC in the VHA is inconsistent and precludes accurate assessments for generalizations about the quality of care in this healthcare system. Efforts to develop a dedicated outcome tracking and registry system can provide more meaningful evidence to identify areas for improvement for this often-curable malignancy.

Determining Best Practices for Management of Bacteriuria in Spinal Cord Injury: Protocol for a Mixed-Methods Study.

BackgroundBacteriuria, either asymptomatic (ASB) or symptomatic, urinary tract infection (UTI), is common in persons with spinal cord injury (SCI). Current Veterans Health Administration (VHA) guidelines recommend a screening urinalysis and urine culture for every veteran with SCI during annual evaluation, even when asymptomatic, which is contrary to other national guidelines. Our preliminary data suggest that a positive urine culture (even without signs or symptoms of infection) drives antibiotic use.ObjectiveThrough a series of innovative studies utilizing mixed methods, administrative databases, and focus groups, we will gain further knowledge about the attitudes driving current urine testing practices during the annual exam, as well as quantitative data on the clinical outcomes of these practices.MethodsAim 1 will identify patient, provider, and facility factors driving bacteriuria testing and subsequent antibiotic use after the SCI annual evaluation through qualitative interviews and quantitative surveys. Aim 2 will use national VHA databases to identify the predictors of urine testing and subsequent antibiotic use during the annual examination and compare the clinical outcomes of those who received antibiotics with those who did not. Aim 3 will use the information gathered from the previous 2 aims to develop the Test Smart, Treat Smart intervention, a combination of patient and provider education and resources that will help stakeholders have informed conversations about urine testing and antibiotic use; feasibility will be tested at a single site.ResultsThis protocol received institutional review board and VHA Research and Development approval in July 2017, and Veterans Affairs Health Services Research and Development funding started on November 2017. As of submission of this manuscript, 10/15 (67%) of the target goal of provider interviews were complete, and 77/100 (77%) of the goal of surveys. With regard to patients, 5/15 (33%) of the target goal of interviews were complete, and 20/100 (20%) of the target goal of surveys had been completed. Preliminary analyses are ongoing; the study team plans to present these results in April 2019. Database analyses for aim 2 will begin in January 2019.ConclusionsThe negative consequences of antibiotic overuse and antibiotic resistance are well-documented and have national and even global implications. This study will develop an intervention aimed to educate stakeholders on evidence-based management of ASB and UTI and guide antibiotic stewardship in this high-risk population. The next step will be to refine the intervention and test its feasibility and effectiveness at multiple sites as well as reform policy for management of this common but burdensome condition.International Registered Report Identifier (IRRID)DERR1-10.2196/12272

Reduced Cardiovascular Disease Incidence With a National Lifestyle Change Program.

Lifestyle change programs implemented within healthcare systems could reach many Americans, but their impact on cardiovascular disease (CVD) remains unclear. The MOVE! program is the largest lifestyle change program implemented in a healthcare setting in the U.S. This study aimed to determine whether MOVE! participation was associated with reduced CVD incidence. This retrospective cohort study, analyzed in 2013-2015, used national Veterans Health Administration databases to identify MOVE! participants and eligible non-participants for comparison (2005-2012). Patients eligible for MOVE!-obese or overweight with a weight-related health condition, and no baseline CVD-were examined (N=1,463,003). Of these, 169,248 (12%) were MOVE! Patients were 92% male, 76% white, with mean age 52 years and BMI of 32. The main outcome was incidence of CVD (ICD-9 and procedure codes for coronary artery disease, cerebrovascular disease, peripheral vascular disease, and heart failure). Adjusting for age, race, sex, BMI, statin use, and baseline comorbidities, over a mean 4.9 years of follow-up, MOVE! participation was associated with lower incidence of total CVD (hazard ratio [HR]=0.83, 95% CI=0.80, 0.86); coronary artery disease (HR=0.81, 95% CI=0.77, 0.86); cerebrovascular disease (HR=0.87, 95% CI=0.82, 0.92); peripheral vascular disease (HR=0.89, 95% CI=0.83, 0.94); and heart failure (HR=0.78, 95% CI=0.74, 0.83). The association between MOVE! participation and CVD incidence remained significant when examined across categories of race/ethnicity, BMI, diabetes, hypertension, smoking status, and statin use. Although participation was limited, MOVE! was associated with reduced CVD incidence in a nationwide healthcare setting.

Temporal trends in new exposure to antiepileptic drug monotherapy and suicide-related behavior

Because some recent studies suggest increased risk for suicide-related behavior (SRB; ideation, attempts) among those receiving antiepileptic drugs (AEDs), we examined the temporal relationship between new AED exposure and SRB in a cohort of older veterans. We used national Veterans Health Administration databases to identify veterans aged ≥65 years who received a new AED prescription in 2004-2006. All instances of SRB were identified using ICD-9-CM codes 1 year before and after the AED exposure (index) date. We also identified comorbid conditions and medication associated with SRB in prior research. We used generalized estimating equations with a logit link to examine the association between new AED exposure and SRB during 30-day intervals during the year before and after the index date, controlling for potential confounders. In this cohort of 90,263 older veterans, the likelihood of SRB the month prior to AED exposure was significantly higher than in other time periods even after adjusting for potential confounders. Although there were 87 SRB events (74 individuals) the year before and 106 SRB events (92 individuals) after, approximately 22% (n = 16) of those also had SRB before the index date. Moreover, the rate of SRB after AED start was gradually reduced over time. The temporal pattern of AED exposure and SRB suggests that, in clinical practice, the peak in SRB is prior to exposure. While speculative, the rate of gradual reduction in SRB thereafter suggests that symptoms may prompt AED prescription.

What Drives Frequent Emergency Department Use in an Integrated Health System? National Data From the Veterans Health Administration

There is widespread concern about patients with frequent emergency department (ED) use. We identify sociodemographic and clinical factors most strongly associated with frequent ED use within the Veterans Health Administration (VHA) nationally. We conducted a cross-sectional analysis of national VHA databases (N=5,531,379) in 2010. The primary outcome measure was the number of VHA ED visits categorized into 6 frequency levels. In 2010, 4,600,667 (83.2%) VHA patients had no ED visit, whereas 493,391 (8.9%) had 1 visit, 356,258 (6.4%) had 2 to 4 visits, 70,741 (1.3%) had 5 to 10 visits, 9,705 (0.2%) had 11 to 25 visits, and 617 (0.01%) had greater than 25 visits. Increasing ED use frequency was associated with homelessness, medical diagnoses, substance abuse and psychiatric diagnoses, receipt of psychotropic and opioid prescriptions, and more frequent use of outpatient medical and mental health services. In multivariable analyses, factors most strongly associated with all levels of ED use were schizophrenia (odds ratio [OR] range 1.44 [95% confidence interval {CI} 1.41 to 1.47] to 6.86 [95% CI 5.55 to 8.48] across categories of increasing ED use), homelessness (OR range 1.41 [95% CI 1.38 to 1.43] to 6.60 [95% CI 5.36 to 8.12]), opioid prescriptions filled (OR range 2.09 [95% CI 2.07 to 2.10] to 5.08 [95% CI 4.16 to 6.19]), and heart failure (OR range 1.64 [95% CI 1.63 to 1.66] to 3.53 [95% CI 2.64 to 4.72]). Frequent ED use occurs even in a coordinated health care system that provides ready access to outpatient care. Frequent ED users are characterized by traits that represent high levels of psychosocial and medical needs. The correlates we identified for frequent ED use were consistent across multiple distinct levels of ED use.

Cataract Surgery Among Veterans 65 Years of Age and Older: Analysis of National Veterans Health Administration Databases

The authors examine the rates of cataract surgery as a crude measure of appropriateness of care among veterans 65 years of age and older who use Veterans Health Administration (VHA). Data were obtained from the national VHA data sets for fiscal years 2000 through 2007, using International Classification of Diseases codes and the American Medical Association's Current Procedural Terminology codes. Cataract surgery was expressed as procedures per 10 000 veteran beneficiaries per fiscal year. The annual incidence of cataract surgery increased marginally over the study period with an average annual incidence of 105.8 surgeries per 10 000 beneficiaries. Institutional rates of VHA surgery differ substantially from those of Medicare beneficiaries, which are approximately 5.5-fold greater. Although direct comparison must be interpreted cautiously, the difference is too great to be explained by demographic factors or secular trends in surgery. Additional research is required to elucidate factors that influence the rate of cataract surgery in the VHA.

CENTRAL SEROUS CHORIORETINOPATHY AND PHOSPHODIESTERASE-5 INHIBITORS

The purpose of this study was to determine if there is an increased risk of central serous chorioretinopathy (CSC) associated with prescription exposure to phosphodiesterase-5 (PDE-5) inhibitors. A case-control study linking 2 National Veterans Health Administration databases (clinical and pharmacy) for fiscal years 2004 to 2005. The likelihood of past exposure to PDE-5 inhibitors among newly diagnosed patients with CSC, identified through International Classification of Diseases, 9th Edition, Clinical Modification codes, was compared with 2 age-matched control groups after excluding subjects with risk factors for CSC. Among 577 men, aged 59 years and younger with newly diagnosed CSC during the study year, 111 were prescribed a PDE-5 inhibitor (19.2%). The proportions of age-matched controls prescribed a PDE-5 inhibitor in the 2 groups were 18.5% and 21.5%. The odds ratio of exposure was 1.05 (95% confidence limit: 0.74-1.22) and 0.87 (95% confidence limit: 0.68-1.12). Patients with CSC had no increase in prescription exposure to PDE-5 inhibitors than did age-matched control subjects. Although the findings in this study do not support an association between CSC and PDE-5 inhibitors, postmarketing surveillance methods for drug-related side effects have acknowledged limitations.

National Veterans Health Administration Hospitalizations for Syncope Compared to Acute Myocardial Infarction, Fracture, or Pneumonia in Community‐Dwelling Elders: Outpatient Medication and Comorbidity Profiles

The authors used 2 national Veterans Health Administration databases to identify outpatient medications and all 30 Elixhauser comorbidities for 2579 unique patients, age 65+ years, hospitalized for syncope in fiscal year 2004. For comparison, we identified other elderly patients hospitalized with acute myocardial infarction (N = 4491), fracture (N = 2797), or pneumonia (N = 9473). The categories of medications included drugs that affect the cardiovascular, central nervous, or the muscular skeletal system. The most notable differences between syncope compared to acute myocardial infarction patients occurred in central nervous system drugs in anticonvulsants/barbiturates, antidepressants, antihistamine/antinauseants, antipsychotics, and cholinesterase inhibitors (P < .0018). Comparing syncope patients with fracture patients, the central nervous medication profile was similar, but the cardiovascular medication profile differed (P < .0018); their hypertension comorbidities also differed (60.45% vs 46.34%); (P < .0016). These findings indicate significant potential associations that warrant further study. Studies linking national outpatient medications to hospitalizations for specific conditions can foster the development of more proactive pharmacovigilance systems.