Veterans Administration Hospital System Research Articles

Facility-Level Percutaneous Coronary Intervention Readmission Rates Are Not Associated With Facility-Level Mortality: Insights From the VA Clinical Assessment, Reporting, and Tracking (CART) Program.

BackgroundThirty‐day readmission after percutaneous coronary intervention (PCI) is common, costly, and linked to poor patient outcomes. Accordingly, facility‐level 30‐day readmission rates have been considered as a potential quality measure. However, it is unknown whether facility‐level 30‐day readmission rates are associated with facility‐level mortality. We sought to determine the effect of 30‐day readmissions after PCI on mortality at both the patient and facility level in the Veterans Administration hospital system.Methods and ResultsWe included all patients who underwent PCI in the Veterans Administration hospital system nationally from October 2007 through August 2012, comparing all‐cause mortality rates between patients with and without 30‐day readmissions following PCI. Patients were then aggregated at the hospital level to evaluate the correlation between hospital‐level readmission rates with hospital‐level 1‐year mortality rates. Among 41 069 patients undergoing PCI at 62 sites, 12.2% were readmitted within 30 days of discharge. Patients with 30‐day readmission had higher risk‐adjusted mortality (hazard ratio 1.53, 95% CI 1.44–1.63, P<0.0001). Facilities varied widely in 30‐day readmission rates (systemwide range of 6.6–19.4%, median 11.8%, interquartile range 10.0–13.2%); however, adjusted facility‐level readmission rates were not correlated with adjusted 1‐year mortality rates.ConclusionsThirty‐day readmissions after PCI are common and are a significant risk factor for mortality for individual patients even after robust statistical adjustment for clinical confounding. However, lack of correlation between readmission and mortality at the facility level suggests that quality improvement based on facility‐level readmission rates will not modify mortality in this high‐risk group.

Social Work in the Veterans Administration Hospital System: Impact of the Work

Social workers in the Veterans Administration (VA) hospital system are faced with numerous challenges to best address the ongoing health and mental health needs of those who serve in the military. Social workers in the VA system serve diverse roles on the multidisciplinary medical teams and mental health services and are integral to the VA hospital environment. Most social workers feel positive about their work and their contributions to the care of the military. Despite positive feelings about their work, social workers are also prone to compassion fatigue and burnout as the work, especially with returning veterans from Afghanistan/Iraq, often extracts a toll. This article details the experience of social workers in the VA hospital system; it describes the impact of the work on the social workers, noting levels of compassion satisfaction, compassion fatigue, and burnout.

Effect of Concomitant Use of Benzodiazepines and Other Drugs on the Risk of Injury in a Veterans Population

Benzodiazepines comprise a class of drugs that when used as monotherapy are generally acknowledged to pose a risk for injury by increasing the likelihood of falls, fall-related injuries, adverse drug events and car accidents. Benzodiazepines may also be used concomitantly with other high risk medications that may further exacerbate the risk of injury. The aim of this study is to examine the occurrence of the concomitant use of benzodiazepines and other drugs and then quantify the indirect effect of these drug combinations on the likelihood of an injury-related health care episode. A multivariate model was specified that included outpatient prescription data and inpatient/outpatient medical utilisation records for 13,745 patients at a Veterans Administration hospital system over a 3-year period (1999-2001). We analysed 1,33,872 outpatient benzodiazepine prescriptions and >1.5 million non-benzodiazepine prescriptions for the study population. Micromedex software was used to identify combinations of benzodiazepines and other drugs that are likely to result in 'major' interactions. We then further restricted our focus to the use of these drug combinations within a 30-day period prior to an injury-related medical event. The adjusted odds ratio on a variable characterising concomitant use of a benzodiazepine and another drug within this period was used to quantify the relative risk of injury. The principal outcome was the estimated risk of an injury-related health care episode within a 30-day period when taking both a benzodiazepine and another drug with a 'major' severity rating as defined by Micromedex. The risk of injury was adjusted for comorbidities, hospital discharges, marital status, age, mean arterial pressure and body mass index, as well as the dose of benzodiazepine (converted to diazepam equivalents) and duration of benzodiazepine treatment. Of the 1,110 unique individuals who experienced an injury, 790 (71.2%) patients had used a benzodiazepine in combination with another drug. Furthermore, only 4.3% (320/7522) of the patients taking benzodiazepines who did not have concomitant drug use experienced an injury. The occurrence of this concomitant use increased the odds of an injury >2-fold in the model. Dose and duration of benzodiazepine use, as well as certain comorbidities, were also associated with an increased risk for injury, whereas being married reduced the risk. This is the first large-scale study to quantify the impact of concomitant use of benzodiazepines and other drugs on the risk of injury in a population of Veterans Administration patients. It demonstrates the utility of expanding the focus of inappropriate medication usage to include analyses that link potentially inappropriate drug use with health care utilisation for injuries.

Proactive Violence Reduction: Successful Quality Assurance

Hospital violence, whether a part of general or psychiatric hospitals, is as endemic as opportunistic infections. Within the Veterans Administration Hospital System, more than 12 000 cases of assault have been reported in a 5-year period. 1 Hospital violence affects the quality of patient care, creates risks for patients and staff, and demoralizes staff. In one study of psychiatrists in Maryland, 48 of 115 respondents had been assaulted. 2 In a survey of psychiatry residents in a West Coast training program, 14 of 31 had been assaulted. 3 In the past, hospital violence frequently was met with administrative and staff denial. Several years ago I inquired about the current assault rate at Veterans Administration hospitals and I was asked whether I wanted the figure generated by incident reports (the lower figure) or that generated by workers' compensation claims (the higher figure). The article by Drummond et al 4 in this

A Sexual Health Workshop for Health Care Professionals

The purpose of the study was to evaluate a three-day workshop in human sexuality for health care professionals using identified and described systematic development and evaluation components. The problem was to determine if the use of a systematic development approach obtains the desired outcomes of an educational experience. The desired outcomes include cognitive gains, attitude shifts toward more openness, and behavioral changes leading to an improvement of the quality ofsexual coun seling and therapy. The main sponsoring agency for the workshop was the Interwest Regional Medical Education Center of the Veterans Administration Hospital system. The 126 participants included physicians, psychologists, social workers, nurses, clergy, and students. The results showed that participants (1) gained significantly on cognitive scores from the pretest to the posttest, (2) shifted toward more open attitudes from pretest to posttest, and (3) incorporated many desired behaviors into their practices 10 to 11 weeks following the workshop.

A model for the development, conduct, and monitoring of multicenter clinical trials in the veterans administration

In the past 20–30 years, increased interest on the part of biostatisticians and medical investigators has been exhibited in clinical trial research. In the mid-1940's, the Veterans Administration Hospital system was recognized as an ideal environment for the conduct of multicenter clinical trials, with the initiation of a study to determine the effectiveness of chemotherapy in the treatment of tuberculosis, in a joint effort with the United States Armed Forces. This research effort later evolved into what is presently known as the Cooperative Studies Program of the Medical Research Service. Within the past seven years, this program has undergone considerable growth and reorganization. This paper describes a system for the review, operation, and conduct of multicenter clinical research in a wide variety of medical specialty areas. In particular, it stresses the importance of core biostatistical coordinating centers where biostatisticians and other key support personnel constitute an integral part of the planning and development, implementation, conduct, and reporting of many cooperative studies in diverse disciplines. The paper also describes the interaction of various review bodies and a check and balance system to promote sound management and opportunity for the exchange of clinical and biostatistical methodology in the cooperative study setting.

The use of ECT within the veterans administration hospital system

Survey data describing present patterns of ECT use within the VA hospital system is presented, with particular focus on ECT technique. Seventy-four percent of the VA psychiatric services possessing an ECT capability responded. The results show that during 1977, most VA hospitals with inpatient psychiatric services (56%) still utilized ECT, with an estimated 3.1% of depressed psychiatric inpatients treated with this modality, versus 0.21% for schizophrenics. As of the summer of 1978, one-third of ECT treatment series were being given with unilateral electrode placement, and there is growing acceptance of ECT equipment that utilizes low-energy brief pulse stimuli and other technical refinements. All respondents reported the use of muscle relaxation and general anesthesia.

The Future of the Veterans Administration Hospital System

The Future of the Veterans Administration Hospital System

Sounding board. The future of the Veterans Administration hospital system: a realistic appraisal.

Eli Ginzberg commented in a previous Sounding Board1 that Physicians are being harangued in many forums on issues related to national health-care delivery. His choice of the word harangue is an apt one to describe the subject addressed by all three contributors to that section, the National Academy of Sciences' study, Health Care for American Veterans,2 with its principal policy recommendation that the Veterans Administration system should ultimately be phased into the general delivery of health services in communities across the nation. Dr. Ginzberg's thesis that the committee of the National Academy of Sciences damaged its case by departing from . . .

The Association of Veterans Administration Surgeons

The Veterans Administration hospital system, founded after World War I, expanded as a result of World War II to become the largest in the United States. In 1945, Dr Paul Magnuson, a pioneering orthopedic surgeon in Chicago, later Chief Medical Director, VA (1948-1951), introduced the affiliation of VA hospitals with medical schools, with overview by "Deans Committees." This concept was designed to provide the caliber of professional staff required to furnish "medical care second to none" (a slogan of Gen Paul Hawley, erstwhile Surgeon Commanding, European theater of operations, World War II). As part of this process, the medical schools were granted residency positions needed to complete the training of the many physicians returning from military service, while the VA established research and educational programs to provide the environment for the residency programs. Magnuson realized that first-class professionals would not work in government hospitals unless their careers were protected from

Three Barriers to Communication

Harold Korolenko is the Personnel Oficer at the Veterans Administration Hospital, Bronx, New York. He has had over 15 years experience as a Personnel Oficer responsible for the direction and implementation of a comprehensive personnel management program in the Veterans Administration Hospital system. While in military service he was a member of the Air Inspector’s Ofice of the Army Air Force Personnel Distribution Command, charged with the responsibility for the inspection of civilian and military personnel ofices. He has an M.A. in Public Administration from New Yolk University and is currently President of the Metropolitan New York Chapter of the Public Personnel Association. This article is based on a talk given by Mr. Korolenko at the 12th Annual Congress of the Association o/ Operating Room Nurses, New York City, February, 1965. by your own working relationships in the operating room. There the issue of life and death is so vivid, so dependent on optimum teamwork, that every member often takes his orders from the demands of the situation rather than from the normal channels of command. “The changing needs of the patient, as they develop in the course of the operation, determine what everybody does. When a surgical team has worked long enough together to have developed true teamwork, each member has such a grasp of the total situation and of his role in it that the needs of the patient give unequivocal orders. A small artery is cut and begins to spurt. In a chain-of-command organization the surgeon would note this and say to the surgical nurse, ‘Give me a hemostat,’ and thus coordinated effort would be achieved. What actually happens is that the bleeder gives a simultaneous command to all three members of the team, all of whom have been watching the progress of the operation with equal attention. I t says to the assistant ‘Get your hand out of the way until this is cantrolled.’ It says to the instrument nurse ‘Get a hemostat ready,’ and it says to the surgeon, ‘Clamp that off .’ This is the highest and most