non-VA Sites Research Articles

Differences in VA and Non-VA Pulmonary Nodules: All Evaluations Are not Created Equal

BackgroundIndeterminate pulmonary nodules present a common challenge for clinicians who must recommend surveillance or intervention based on an assessed risk of malignancy. Patients and MethodsIn this cohort study, patients presenting for indeterminate pulmonary nodule evaluation were enrolled at sites participating in the Colorado SPORE in Lung Cancer. They were followed prospectively and included for analysis if they had a definitive malignant diagnosis, benign diagnosis, or radiographic resolution or stability of their nodule for > 2 years. ResultsPatients evaluated at the Veterans Affairs (VA) and non-VA sites were equally as likely to have a malignant diagnosis (48%). The VA cohort represented a higher-risk group than the non-VA cohort regarding smoking history and chronic obstructive pulmonary disease (COPD). There were more squamous cell carcinoma diagnoses among VA malignant nodules (25% vs. 10%) and a later stage at diagnosis among VA patients. Discrimination and calibration of risk calculators produced estimates that were wide-ranging and different when comparing between risk score calculators as well as between VA/non-VA cohorts. Application of current American College of Chest Physicians guidelines to our groups could have resulted in inappropriate resection of 12% of benign nodules. ConclusionComparison of VA with non-VA patients shows important differences in underlying risk, histology of malignant nodules, and stage at diagnosis. This study highlights the challenge in applying risk calculators to a clinical setting, as the model discrimination and calibration were variable between calculators and between our higher-risk VA and lower-risk non-VA groups.Microabstract: Risk stratification and management of indeterminate pulmonary nodules (IPNs) is a common clinical problem. In this prospective cohort study of 282 patients with IPNs from Veterans Affairs (VA) and non-VA sites, we found differences in patient and nodule characteristics, histology and diagnostic stage, and risk calculator performance. Our findings highlight challenges and shortcomings of current IPN management guidelines and tools.

What matters to psychology trainees when making decisions about internship and postdoctoral training sites: Differences between racial/ethnic minority and White VA trainees.

It is projected that by 2045, racial/ethnic minorities in the U.S. will become the majority. Unfortunately, the numbers of racial/ethnic minority psychologists have not kept up with population trends. This discrepancy poses challenges for many psychology training sites, including the Department of Veterans Affairs (VA). There is a lack of data on what factors are important for psychology applicants, including racial/ethnic minority trainees when they are considering internship and postdoctoral training sites. This quality improvement project surveyed 237 VA psychology trainees (59% psychology interns, 32.5% psychology postdoctoral fellows, 69.6% White, 9.3% multiracial, 6.8% Asian American or Pacific Islander, 5.1% Black/African American, 4.2% Latinx American, 0.8% Native American, 0.8% Middle Eastern) to study what factors are important when considering training sites. Results indicated that overall, racial/ethnic minority and White trainees endorsed similar primary factors when considering training programs. Site related factors (e.g., perceived workload, training opportunities) and future work related factors (e.g., ease of licensure, obtaining a first job) were top considerations regardless of race/ethnicity. The groups diverged in secondary factors with racial/ethnic minorities desiring infusion of diversity in training more than White applicants and White applicants considering quality of life factors such as extracurricular opportunities and convenience of daily living more important than racial/ethnic minority applicants. Qualitative data indicated applicants perceived VA training sites to be more welcoming and offer more opportunities for learning about diversity than non-VA sites. Recommendations for recruiting psychology trainees in general, and then specifically for racial/ethnic minority applicants are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Differences in complications, cardiovascular risk factor, and diabetes management among participants enrolled at veterans affairs (VA) and non-VA medical centers in the glycemia reduction approaches in diabetes: A comparative effectiveness study (GRADE)

AimsWe evaluated differences in participants with type 2 diabetes (T2DM) enrolled in the GRADE study at VA vs non-VA sites, focusing on cardiovascular risk factors and rates of diabetes care target achievements. MethodsWe compared baseline characteristics between participants at VA (n = 1216) and non-VA (n = 3831) sites, stratifying analyses by cardiovascular disease (CVD) history. ResultsVA and non-VA participants had similar diabetes duration (4.0 years), HbA1c (7.5%), and BMI (34 kg/m2); however, VA participants had more individuals ≥ 65 years (37.3% vs 19.8%, p < 0.001), men (90.0% vs 55.2%, p < 0.001), hypertension (75.8% vs 63.6%, p < 0.001), hyperlipidemia (76.6% vs 64.6%, p < 0.001), current smokers (19.0% vs 12.1%, p < 0.001), nephropathy (20.4% vs 17.0%, p < 0.05), albuminuria (18.4% vs 15.1%, p < 0.05), and CVD (10.4% vs 5.2%, p < 0.001). In those without CVD, more VA participants were treated with lipid (70.8% vs 59.5%, p < 0.001) and blood pressure (74.9% vs 65.4%, p < 0.001) lowering medications, and had LDL-C < 70 mg/dl (32.9% vs 24.2%, p < 0.05). Among those with CVD, more VA participants had BP < 140/90 (80.2% vs 70.1%, p < 0.05) after adjusting for demographics. ConclusionGRADE participants at VA sites had more T2DM complications, greater CVD risk and were more likely to be treated with medications to reduce it, leading to more LDL-C at goal than non-VA participants, highlighting differences in diabetes populations and care.

Barriers and facilitators to providing primary care-based weight management services in a patient centered medical home for Veterans: a qualitative study.

BackgroundObesity is highly prevalent among Veterans. In the United States, the Veterans Health Administration (VHA) offers a comprehensive weight management program called MOVE!. Yet, fewer than 10 % of eligible patients ever attend one MOVE! visit. The VHA has a patient-centered medical home (PCMH) model of primary care (PC) called Patient-Aligned Care Teams (PACT) at all Veterans Affairs (VA) Medical Centers. PACT teamlets conduct obesity screening, weight management counseling, and refer to MOVE!. As part of a needs assessment to improve delivery of weight management services, the purpose of this study was to assess PACT teamlet and MOVE! staff: 1) current attitudes and perceptions regarding obesity care; 2) obesity-related counseling practices 3) experiences with the MOVE! program; and 4) targets for interventions to improve implementation of obesity care in the PC setting.MethodsWe recruited 25 PACT teamlet members from a single VA study site—11 PC physicians, 5 registered nurses, 5 licensed practical nurses, 1 clerical assistant, and 3 MOVE! staff (2 dietitians, 1 psychologist)—for individual interviews using a combination of convenience and snowball sampling. Audio recorded interviews were professionally transcribed and iteratively coded by two independent reviewers. The analytic process was guided by discourse analysis in order to discover how the participants perceived and provided weight management care and what specific attitudes affected their practices, all as bounded within the organization.ResultsEmerging themes included: 1) role perceptions, 2) anticipated outcomes of weight management counseling and programs, and 3) communication and information dissemination. Perceived role among PCPs was influenced by training, whereas personal experience with their own weight management impacted role perception among LPNs/RNs. Attitudes about whether or not they could impact patients’ weight outcomes via counseling or referral to MOVE! varied. System-level communication about VHA priorities through electronic health records and time allocation influenced teams to prioritize referral to MOVE! over weight management counseling.ConclusionWe found a diversity of attitudes, and practices within PACT, and identified factors that can enhance the MOVE! program and inform interventions to improve weight management within primary care. Although findings are site-specific, many are supported in the literature and applicable to other VA and non-VA sites with PCMH models of care.

Effect of PCI on Long-Term Survival in Patients with Stable Ischemic Heart Disease

BackgroundPercutaneous coronary intervention (PCI) relieves angina in patients with stable ischemic heart disease, but clinical trials have not shown that it improves survival. Between June 1999 and January 2004, we randomly assigned 2287 patients with stable ischemic heart disease to an initial management strategy of optimal medical therapy alone (medical-therapy group) or optimal medical therapy plus PCI (PCI group) and did not find a significant difference in the rate of survival during a median follow-up of 4.6 years. We now report the rate of survival among the patients who were followed for up to 15 years.MethodsWe obtained permission from the patients at the Department of Veterans Affairs (VA) sites and some non-VA sites in the United States to use their Social Security numbers to track their survival after the original trial period ended. We searched the VA national Corporate Data Warehouse and the National Death Index for survival information and the dates of death from any cause. We calculated survival according to the Kaplan–Meier method and used a Cox proportional-hazards model to adjust for significant between-group differences in baseline characteristics.ResultsExtended survival information was available for 1211 patients (53% of the original population). The median duration of follow-up for all patients was 6.2 years (range, 0 to 15); the median duration of follow-up for patients at the sites that permitted survival tracking was 11.9 years (range, 0 to 15). A total of 561 deaths (180 during the follow-up period in the original trial and 381 during the extended follow-up period) occurred: 284 deaths (25%) in the PCI group and 277 (24%) in the medical-therapy group (adjusted hazard ratio, 1.03; 95% confidence interval, 0.83 to 1.21; P=0.76).ConclusionsDuring an extended-follow-up of up to 15 years, we did not find a difference in survival between an initial strategy of PCI plus medical therapy and medical therapy alone in patients with stable ischemic heart disease. (Funded by the VA Cooperative Studies Program and others; COURAGE ClinicalTrials.gov number, NCT00007657.)

Predictors of Stage of Adoption for Colorectal Cancer Screening Among African American Primary Care Patients

Compared with other racial groups, African Americans have the highest colorectal cancer (CRC) incidence and mortality rates coupled with lower screening rates. Our study examined the predictors of stage of adoption for fecal occult blood testing (FOBT) and colonoscopy among African American primary care patients who were nonadherent to published screening guidelines. Baseline data (N = 815) in a randomized clinical trial were analyzed. Participants were categorized into precontemplation, contemplation, and preparation stages for FOBT and colonoscopy. Predictor variables were demographics, clinical variables, CRC health beliefs and knowledge, and social support. Hierarchical modeling was to identify significant predictors of stage of adoption. Older, male, Veterans Affairs participants and those with higher perceived self-efficacy, family/friend encouragement, and a provider recommendation had higher odds of being at a more advanced stage of adoption for FOBT. Patients with a history of cancer and higher perceived barriers had higher odds of being at an earlier stage of adoption for FOBT. Predictors of more advanced stage of adoption for colonoscopy included higher perceived benefits, higher perceived self-efficacy, family/friend encouragement, and a provider recommendation for colonoscopy. Higher income (>30 000 vs <15 000) was predictive of earlier stage of adoption for colonoscopy. Enhancing self-efficacy, encouragement from family and friends, and provider recommendations are important components of interventions to promote CRC screening. Nurses can use knowledge of the characteristics associated with stage of adoption to educate and motivate their African American primary care patients to complete CRC screening tests.

Quality care process in the VA: a synopsis and comment on "Comparison of the quality of medical care in veterans affairs and non-veterans affairs settings".

The fourth column on Evidence-Based Behavioral Medicine presents a synopsis of the systematic review by Trivedi et al. (2011) comparing the quality of medical care in veterans affairs (VA) and non-VA settings. Thirty-six studies were included in the synthesis. Each article was given a grade of A, B, or C based on the six elements of high-quality studies. Most studies assessing adherence to recommended processes of care showed that the VA performed better that non-VA sites. Similar rates were found for both groups in studies that assessed risk-adjusted mortality. This implies that a greater adherence to evidence-based processes (e.g., preventive care, medication prescription, and referral) did not result in decreased morbidity and mortality. It is established that engaging in evidence-based practices and processes improves short-term intermediate endpoints (e.g., patient satisfaction). Future research is needed to test whether short-term benefits of evidence-based care processes connect to mortality outcomes.

Medical Student Psychiatry Examination Performance at VA and Non-VA Clerkship Sites

The authors examined the effects of medical student assignment to U.S. Department of Veterans Affairs (VA) Medical Center inpatient and outpatient psychiatry clerkship sites versus other university and community sites on the performance outcome measure of National Board of Medical Examiners (NBME) subject examination scores. NBME psychiatry scores were compared for stratified random samples of 70 students each for inpatient and outpatient VA and non-VA sites, controlling for baseline clinical knowledge as reflected by second year Human Behavior course scores. No significant differences were demonstrated in NBME scores between VA and non-VA sites for either inpatient or outpatient programs. Assessed students rotating through several VA clinical sites were as well prepared for NBME subject examinations as those assigned to other sites. Additional measures of educational outcome for VA sites are recommended to assess and enhance clinical education provided by the VA and to strengthen collaboration with university-based medical student teaching programs.

The Influence of Integration on the Expenditures and Costs of Mental Health and Substance Use Care: Results from the randomized PRISM-E Study.

We compared the healthcare costs associated with an integrated care model to an enhanced referral model for the treatment of depression, anxiety, and at-risk drinking from the randomized Primary Care Research in Substance Abuse and Mental Health for the Elderly study. We examined total healthcare costs and cost components, separately for Veteran's Affairs and non-VA participants. No differences in total health expenditures were detected between study arms. No differences in behavioral health expenditures were detected for non-VA sites, but the VA integrated arm had slightly higher ($38; p<0.05) behavioral health costs. Differences in other types of services use were detected.

Important Aspects of End-of-Life Care Among Veterans: Implications for Measurement and Quality Improvement

To identify aspects of end-of-life care in the U.S. Department of Veterans Affairs (VA) health care system that are not assessed by existing survey instruments and to identify issues that may be unique to veterans, telephone interviews using open-ended questions were conducted with family members of veterans who had received care from a VA facility in the last month of life. Responses were compared to validated end-of-life care assessment instruments in common use. The study took place in four VA medical centers and one family member per patient was invited to participate, selected from medical records using predefined eligibility criteria. These family members were asked to describe positive and negative aspects of the care the veteran received in the last month of life. Interview questions elicited perceptions of care both at VA sites and at non-VA sites. Family reports were coded and compared with items in five existing prospective and retrospective instruments that assess the quality of care that patients receive near the end of life. Interviews were completed with 66 family members and revealed 384 codes describing both positive and negative aspects of care during the last month of life. Almost half of these codes were not represented in any of the five reference instruments ( n = 174; 45%). These codes, some of which are unique to the veteran population, were grouped into eight categories: information about VA benefits ( n = 36; 55%), inpatient care ( n = 36; 55%), access to care ( n = 33; 50%), transitions in care ( n = 32; 48%), care that the veteran received at the time of death ( n = 31; 47%), home care ( n = 26; 40%), health care facilities ( n = 12; 18%), and mistakes and complications ( n = 18; 27%). Although most of the reference instruments assessed some aspect of these categories, they did not fully capture the experiences described by our respondents. These data suggest that many aspects of veterans' end-of-life care that are important to their families are not assessed by existing survey instruments. VA efforts to evaluate end-of-life care for veterans should not only measure common aspects of care (e.g., pain management), but also examine performance in areas that are more specific to the veteran population.

Ethnic Differences in Blood Pressure Control Among Men at Veterans Affairs Clinics and Other Health Care Sites

Differential access to health care may contribute to lower blood pressure (BP) control rates to under 140/90 mm Hg in African American compared with white hypertensive patients, especially men (26.5% vs 36.5% of all hypertensive patients in the National Health and Nutrition Examination Survey 1999-2000). The Department of Veterans Affairs (VA) system, which provides access to health care and medications across ethnic and economic boundaries, may reduce disparities in BP control. To test this hypothesis, BP treatment and control groups were compared between African American (VA, n = 4379; non-VA, n = 2754) and white (VA, n = 7987; non-VA, n = 4980) hypertensive men. In both groups, whites were older than African Americans (P<.05), had lower BP (P<.001), and had BP controlled to below 140/90 mm Hg more often on their last visit (P<.01). Blood pressure control to below 140/90 mm Hg was comparable among white hypertensive men at VA (55.6%) and non-VA (54.2%) settings (P = .12). In contrast, BP control was higher among African American hypertensive men at VA (49.4%) compared with non-VA (44.0%) settings (P<.01), even after controlling for age, numerous comorbid conditions, and rural-urban classification. African American hypertensive men received a comparable number of prescriptions for BP medications at VA sites (P = .18) and more prescriptions at non-VA sites than did whites (P<.001). African Americans had more visits in the previous year at VA sites (P<.001) and fewer visits at non-VA sites (P<.001) compared with whites. The ethnic disparity in BP control between African Americans and whites was approximately 40% less at VA than at non-VA health care sites (6.2% vs 10.2%; P<.01). Ensuring access to health care could constitute one constructive component of a national initiative to reduce ethnic disparities in BP control and cardiovascular risk.

Availability of comprehensive women’s health care through Department of Veterans Affairs Medical Center

Despite increased numbers of women veterans, little is known about health services delivery to women across the Department of Veterans Affairs (VA). To assess VA availability of women’s health services, we surveyed the senior clinician at each VA site serving 400 or more women veterans. We found that virtually all sites have developed arrangements, either directly or through off-site contracts, to ensure availability of comprehensive women’s health care. On-site care, however, is routinely available only for basic services. Future work should evaluate cost and quality trade-offs between using non-VA sites to increase specialized service availability and using VA sites to enhance continuity of care.