Veterans Affairs Health Research Articles

Outcomes of Pharmacy-Led Hepatitis C Direct-Acting Antiviral Utilization Management at a Veterans Affairs Medical Center.

The Veterans Affairs Health (VA) Administration has reported hepatitis C virus (HCV) infection rates among veterans to be twice that of the general U.S population. New HCV direct-acting antiviral (DAA) treatment options offer superior sustained virologic response (SVR) rates, improved side-effect profiles, and shortened treatment courses; yet, these new HCV DAAs are expensive, and utilization management strategies are needed to optimize use and improve clinical outcomes. A VA medical center uses pharmacist-led HCV DAA utilization management strategies that includes clinical guidance, optimizing operational flow, budget tracking and forecasting, and patient outcomes tracking. To assess the economic and clinical outcomes of pharmacy-led HCV DAA utilization management in a VA medical center. This was a single-center, retrospective cohort study. Patient electronic health records and the hepatitis C DAA outcomes tracking database were reviewed at a VA medical center. Patients with an HCV DAA prior authorization drug request and therapy initiated between October 1, 2014, and September 30, 2015, were included. The primary endpoint was the ratio of drug spend to cure rate calculated as the total dollars spent to the number of patients achieving SVR at least 12 weeks from end of treatment. Secondary endpoints included economic, clinical, and safety outcomes. A total of 372 patients were included in the study. The overall cost ratio of total drug spend to cure rate was $40,135.22. The overall cure rate was 94.1%, with no discontinuations due to treatment failure. The ratio of drug spend to cure rate was $41,907.35 and $38,430.77 in cirrhotic and noncirrhotic patients, respectively, and $39,481.62 and $39,178.74 in treatment-experienced and naive patients, respectively. Ten patients discontinued therapy because of the adverse effects of anemia, nausea, vomiting, and anxiety. The medication possession ratio was 98.7% (± 0.13) for all patients included in the study. This study suggests that pharmacist-led HCV DAA utilization management is an important factor in costs and cure rates. Utilization management strategies are valuable to help adequately manage patients with chronic hepatitis C (CHC) and may allow practitioners to maximize available funding for CHC, while maintaining high efficacy and safety. No outside funding supported this research. The authors have no conflicts of interest to report. Study concept and design were contributed primarily by Britt, along with Hashem, Brown, and Yang. Yang took the lead in data collection, along with Britt, and data interpretation was performed by all the authors. The manuscript was written and revised by Yang, Britt, Brown, and Hashem.

Abstract 008: Statin Use and Its Facility Level Variation in Patients With Peripheral Artery Disease: Insights From the Department of Veterans Affairs

Background: The 2013 ACC/AHA cholesterol guideline recommends high-intensity statin therapy in patients 75 years or younger and moderate-intensity statin therapy in patients > 75 years with atherosclerotic cardiovascular disease including those with peripheral artery disease (PAD). Statin prescribing patterns and their facility-level variation in patients with PAD are unknown. Methods: We examined the frequency and facility-level variation in the use of any and correct intensity of statins in patients with known PAD receiving primary care in 130 facilities across the Veterans Affairs (VA) health care system with or without concomitant ischemic heart disease (IHD) or ischemic cerebrovascular disease (ICVD). We calculated the median rate ratios (MRR) adjusted for patient demographic factors to assess the magnitude of facility-level variation in statin prescribing patterns for comparable patients. Results: Among 194,151 patients with PAD, 88,905 (45.8%) had PAD without IHD (with or without ICVD) and 70,404 (36.3%) had PAD without IHD or ICVD. Rates of statin use in the entire PAD cohort, patients with PAD without IHD and PAD alone were 79.0%, 69.1% and 66.3%, respectively. Median facility-level rates of statin use were 78.9% (IQR 75.9-81.5), 69.2% (65.4-72.6) and 66.4% (62.6-70.1), respectively. Correct intensity statins were prescribed among 40.9% for the entire PAD cohort, 28.9% of those with PAD without IHD, and 26.4% of those with PAD alone. Median facility-level rate of correct statin intensity use in all PAD patients was 40.1% (36.4-44.2), 27.8% (24.1-32.4) for patients with PAD without IHD and 25.3% (10.8-29.7) in patients with PAD alone. Calculated MRRs reflected a 20-22% variation among two facilities in treating identical PAD patients with statin therapy and a 24-28% variation in treating identical patients with correct statin intensity (Table). Conclusions: The use of statin and especially correct statin intensity is suboptimal in PAD patients, especially in PAD patients without concomitant IHD or ICVD. There is a significant facility-level variation in the receipt of guideline directed statin therapy in PAD patients. Interventions are needed to improve guideline directed moderate to high-intensity statin use and to reduce variation in care in this high-risk group.

Abstract 093: Use of Echocardiography Following an Elevated B-Type Natriuretic Peptide Level

Background: Echocardiography (echo) is recommended for those with an elevated B-type natriuretic peptide (BNP) value and no prior diagnosis of heart failure. We sought to examine the rate of echo use following a BNP value over 100 pg/ml. Methods: We identified patients in the Veterans Affairs (VA) Health Care System with no prior echocardiography within the past five years, no diagnosis of heart failure within the past 2 years, and a BNP value of ≥100 pg/ml. We examined the use of echo during the six months following identification of an elevated BNP value. Multivariable predictors of echo use were evaluated as well, including demographics, prior medical diagnoses, lab values, and institutional teaching status. Results: Among 20,143 patients identified, 6,205 (31%) had an echo during the next 6 months. Among VA hospitals with at least 20 included patients, use of echo ranged from 8.6% to 66% (Figure 1). Patients undergoing echo were younger (mean age 71±12 vs. 74±12, p<0.0001), had higher BNP values (mean value 571±1,524 vs 378±1,127, p<0.0001) and more likely to be of white race (76% vs. 74%, p<0.0001). In multivariate analysis, independent predictors of six-month echo use were age (odds ratio 0.78, 95% CI 0.76-0.80 per 10 year increase), female gender (0.79, 0.66-0.94 vs. male), race (black 0.87, 0.79-0.95 vs. white) and academic affiliation (Council of Teaching Hospital Member (COTH) 2.11, 1.87-2.38, academic but not COTH 1.74, 1.54-1.96 vs. non-academic). Conclusion: Following an elevated BNP value, an echocardiogram was ordered in only 31% with a wide range across different VA medical centers. Gender and racial disparities were present.

Abstract 195: Statin Use and Its Facility Level Variation in Patients With Ischemic Cerebrovascular Disease: Insights From the Department of Veterans Affairs

Background: The 2013 ACC/AHA cholesterol guideline recommends high-intensity statin therapy in patients 75 or younger and moderate-intensity statins in patients > 75 years with atherosclerotic cardiovascular disease including those with ischemic cerebrovascular disease (ICVD). Statin prescribing patterns and their facility-level variation in patients with ICVD are unknown. Methods: We examined the frequency and facility-level variation in the use of any and correct intensity statins in patients with ICVD (ischemic stroke or carotid arterial disease) who received primary care in 130 facilities across the Veterans Affairs (VA) health care system with or without concomitant ischemic heart disease (IHD) or peripheral artery disease (PAD). We then calculated median rate ratios (MRR) adjusted for patient demographic factors to assess the magnitude of facility-level variation in statin prescribing patterns for comparable patients. Results: Among 339,771 ICVD patients, 182,231 (53.6%) had ICVD without IHD (with or without PAD) and 163,730 (48.2%) had ICVD without IHD or PAD. Rates of statin use in the entire ICVD group, patients with ICVD without IHD, and ICVD alone were 78.1%, 70.9% and 69.9%, respectively. Median facility-level rates of any statin use were 78.1% (IQR 75.5-80.7), 70.7% (67.9-73.8) and 69.9% (66.9-73.1), respectively. Correct intensity statins were prescribed among 40.2% of the entire ICVD group, 30.5% with ICVD without IHD, and 29.6% with ICVD alone. Median facility-level rate of correct statin use in all ICVD patients was 39.1% (35.8-43.9), 29.9% (26.0-34.6) for patients with ICVD without IHD and 29.0% (25.4-33.7) in those with ICVD alone.Calculated MRRs reflect approximately 22% variation among two facilities treating two identical ICVD patients with statin therapy and a 27-28% variation in identical ICVD patients for correct statin intensity (Table). Conclusions: The use of statin and especially guideline-recommended statin intensity is suboptimal in ICVD patients, especially patients without concomitant IHD or PAD. There is significant facility-level variation in receipt of guideline directed statin therapy in ICVD patients. Interventions are needed to improve guideline directed moderate to high-intensity statin use and reduce variation in care in this high risk group.

Mortality in Patients Admitted for Concurrent COPD Exacerbation and Pneumonia

ABSTRACTIt is unclear whether concurrent pneumonia and chronic obstructive pulmonary disease (COPD) have a higher mortality than either condition alone. Further, it is unknown how this interaction changes over time. We explored the effect of pneumonia and COPD on inpatient, 30-day and overall mortality. We used a Veterans Health Affairs database to compare patients who were hospitalized for a COPD exacerbation without pneumonia (AECOPD), patients hospitalized for pneumonia without COPD (PNA) and patients hospitalized for pneumonia who had a concurrent diagnosis of COPD (PCOPD). We studied records of 15,065 patients with the following primary discharge diagnoses: (a) AECOPD cohort (7,154 individuals); (b) PNA cohort (4,433 individuals); and (c) PCOPD (3,478 individuals), comparing inpatient, 30-day and overall mortality in the three study cohorts. We observed a stepwise increase in inpatient mortality for AECOPD, PNA and PCOPD (4.8%, 9.5% and 13.2%, respectively). These differences persisted at 30 days post-discharge (AECOPD = 6.7%, PNA = 12.4% and PCOPD = 14.6%; p < 0.0001), but not throughout the study period (median follow-up: 37 months). With time, the death rate rose disproportionally in patients who had been admitted for AECOPD (AECOPD = 64.5%; PNA = 57.4% and PCOPD 66.2%; p < 0.001). In multivariate analysis, PCOPD predicted the greatest inpatient mortality (p < 0.001). The data showed a progression in inpatient and 30-day mortality from AECOPD to PNA to PCOPD. Pneumonia and COPD differentially affected inpatient, 30-day and overall mortality with pneumonia affecting predominantly inpatient and 30-day mortality while COPD affecting the overall mortality.

The use of natural language processing on narrative medication schedules to compute average weekly dose.

Medications with non-standard dosing and unstandardized units of measurement make the estimation of prescribed dose difficult from pharmacy dispensing data. A natural language processing tool named the SIG extractor was developed to identify and extract elements from narrative medication instructions to compute average weekly doses (AWDs) for disease-modifying antirheumatic drugs. The goal of this paper is to evaluate the performance of the SIG extractor. This agreement study utilized Veterans Health Affairs pharmacy data from 2008 to 2012. The SIG extractor was designed to extract key elements from narrative medication schedules (SIGs) for 17 select medications to calculate AWD, and these medications were categorized by generic name and route of administration. The SIG extractor was evaluated against an annotator-derived reference standard for accuracy, which is the fraction of AWDs accurately computed. The overall accuracy was 89% [95% confidence interval (CI) 88%, 90%]. The accuracy was ≥85% for all medications and route combinations, except for cyclophosphamide (oral) and cyclosporine (oral), which were 79% (95%CI 72%, 85%) and 66% (95%CI 58%, 73%), respectively. The SIG extractor performed well on the majority of medications, indicating that AWD calculated by the SIG extractor can be used to improve estimation of AWD when dispensed quantity or days' supply is questionable or improbable. The working model for annotating SIGs and the SIG extractor are generalized and can easily be applied to other medications. Copyright © 2016 John Wiley & Sons, Ltd.

Medicare-VHA dual use is associated with poorer chronic wound healing.

Veterans who use Veterans Health Affairs (VHA) have the option of enrolling in and obtaining care from other non-VA sources. Dual system use may improve care by increasing options or it may result in poorer outcomes because of fragmented care. Our objective was to assess whether dual system use of VHA and Medicare for wound care was associated with chronic wound healing. We conducted a retrospective cohort study of 227 Medicare-enrolled VHA users in the Pacific Northwest who had an incident, chronic lower limb wound between October 1, 2006 and September 30, 2007 identified through VHA chart review. All wounds were followed until resolution or for up to one year. Dual system wound care was identified through Medicare claims during follow-up. We used a proportional hazards model to compare wound healing among VHA-exclusive and dual wound care users, using a time-varying measure of dual use and treating amputation and death as competing risks. About 18.1% of subjects were classified as dual wound care users during follow-up. After adjustment using propensity scores, dual use was associated with a significantly lower hazard of wound healing compared to VHA-exclusive use (HR = 0.63, 95%CI: 0.39-0.99, p = 0.047). Hazards for the competing risks, amputation (HR = 4.23, 95% CI: 1.61-11.15, p = 0.003) and death (HR = 3.08, 95%CI: 1.11-8.56, p = 0.031), were significantly higher for dual users compared to VHA-exclusive users. Results were similar in inverse probability of treatment weighted analyses and in sensitivity analyses that excluded veterans enrolled in a Medicare managed care plan and that used a revised wound resolution date based on Medicare claims data, but were not always statistically significant. Overall, dual wound care use was associated with substantially poorer wound healing compared to VHA-exclusive wound care use. VHA may need to design programs or policies that support and improve care coordination for veterans needing chronic wound care.

Performance of a Natural Language Processing (NLP) Tool to Extract Pulmonary Function Test (PFT) Reports from Structured and Semistructured Veteran Affairs (VA) Data.

Introduction/Objective:Pulmonary function tests (PFTs) are objective estimates of lung function, but are not reliably stored within the Veteran Health Affairs data systems as structured data. The aim of this study was to validate the natural language processing (NLP) tool we developed—which extracts spirometric values and responses to bronchodilator administration—against expert review, and to estimate the number of additional spirometric tests identified beyond the structured data.Methods:All patients at seven Veteran Affairs Medical Centers with a diagnostic code for asthma Jan 1, 2006–Dec 31, 2012 were included. Evidence of spirometry with a bronchodilator challenge (BDC) was extracted from structured data as well as clinical documents. NLP’s performance was compared against a human reference standard using a random sample of 1,001 documents.Results:In the validation set NLP demonstrated a precision of 98.9 percent (95 percent confidence intervals (CI): 93.9 percent, 99.7 percent), recall of 97.8 percent (95 percent CI: 92.2 percent, 99.7 percent), and an F-measure of 98.3 percent for the forced vital capacity pre- and post pairs and precision of 100 percent (95 percent CI: 96.6 percent, 100 percent), recall of 100 percent (95 percent CI: 96.6 percent, 100 percent), and an F-measure of 100 percent for the forced expiratory volume in one second pre- and post pairs for bronchodilator administration. Application of the NLP increased the proportion identified with complete bronchodilator challenge by 25 percent.Discussion/Conclusion:This technology can improve identification of PFTs for epidemiologic research. Caution must be taken in assuming that a single domain of clinical data can completely capture the scope of a disease, treatment, or clinical test.

Transforming veterans health care through academic-practice partnerships

The Veterans Health Affairs Office of Academic Affiliations (OAA) has invested in the creation of academic-practice partnerships to transform the care of veterans and their families. This article details how a long-standing relationship between the University of Alabama at Birmingham School of Nursing and the Birmingham Veterans Affairs Medical Center grew into such a partnership. The three programs that now exist within the Birmingham Veterans Affairs Nursing Academic Partnership (VANAP) umbrella are described, including an undergraduate VA nurse scholars program that has sustained beyond OAA funding, a VANAP graduate education program for psychiatric mental health nurse practitioners (NPs), and a Mental Health NP Residency. Key features of the programs are noted as are outcomes and lessons learned for building mutual goals and a sustainable academic-practice partnership. With the recent passage of the Veterans Choice Program, the importance of educating all nurses about veterans and veterans' health is stressed.

Does Co-Occurring Traumatic Brain Injury Affect VHA Outpatient Health Service Utilization and Associated Costs Among Veterans With Posttraumatic Stress Disorder? An Examination Based on VHA Administrative Data.

To examine whether a traumatic brain injury (TBI) diagnosis was associated with increased outpatient service utilization and associated costs among Iraq and Afghanistan (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]/Operation New Dawn [OND]) War veterans with posttraumatic stress disorder (PTSD) who used Veterans Health Affairs (VHA) care in a 1-year period. N/A. OEF/OIF/OND veterans with a diagnosis of PTSD and/or TBI who utilized VHA services during fiscal year 2012 (N = 164 644). Observational study using VHA administrative data. Outpatient VHA utilization (total and by category of care) and associated costs (total and by VA Health Economic Resource Center cost category). Veterans in the comorbid PTSD/TBI group had significantly more total outpatient appointment than veterans with PTSD but no TBI. This pattern held for all categories of care except orthopedics. The comorbid TBI/PTSD group ($5769) incurred greater median outpatient healthcare costs than the PTSD ($3168) or TBI-alone ($2815) group. Co-occurring TBI increases the already high level of healthcare utilization by veterans with PTSD, suggesting that OEF/OIF/OND veterans with comorbid PTSD/TBI have complex and wide-ranging healthcare needs.

IMPACT OF STAKEHOLDER-DRIVEN INSTITUTIONAL CHANGES ON HEART FAILURE OUTCOMES

Heart failure (HF) accounts for >1 million hospitalizations in the US annually and is the number one admission diagnosis for Veterans treated within the Veterans Affairs (VA) Health Care System. Interventions for improving HF outcomes have been examined but generalizing strategies between hospitals

Female Veterans Who Died by Suicide: Qualitative Analysis of Medical Records

ABSTRACTThe suicide rate among female veterans increased 40% between 2000 and 2010, yet very little research has examined the unique psychosocial and health needs of veteran women at high risk for suicide. We describe female veterans’ psychosocial experiences, primary health concerns, and health care received prior to suicide to identify areas for future efforts to improve care and reduce suicide in this population. We conducted a qualitative analysis of the Veterans Affairs (VA) health care records of 27 female veterans, drawn from 11 states, during the six months prior to suicide. The women were mostly White, non-Hispanic, and not married, with an average age of 44 (range 26 to 67). We identified several common experiences: non-military-related trauma, lack of supportive relationships, substance use disorders, and prescription of multiple sedatives. We also observed that communication between patients and clinicians may have been insufficient, resulting in undetected or unmet needs. The findings call for additional research to better understand the frequency and impact of these experiences for women veterans and suggest that enhancing patient-centered and trauma-sensitive care, as well as improving outreach and continuity in care, may reduce instances of unmet needs.

Abstract 12737: Sex and Race/Ethnic Disparities in the Use of High Potency Statins for Patients With Atherosclerotic Cardiovascular Disease

Background: The November 2013 AHA/ACC prevention guidelines recommend the use of a fixed dose high potency statin (HPS) for patients with established atherosclerotic cardiovascular disease (ASCVD), irrespective of low-density lipoprotein cholesterol levels. We sought to determine how these guidelines are being adopted at the Veterans Affairs (VA) Health System and identify treatment gaps in patient groups. Methods: We examined administrative data from the VA 6 months prior to the index dates of 4/1/2013 and 4/1/2014 to identify patients with at least one outpatient visit for a diagnosis of established ASCVD, defined as coronary heart disease, cerebrovascular disease, or peripheral arterial disease. Statin use was assessed 6 months following the index date, and HPS was defined as atorvastatin 40mg or 80mg, rosuvasatin 20mg or 40mg, and simvastatin 80mg. Patient and facility-level predictors of statin use for secondary prevention were analyzed using multivariate logistic regressions. Results: Our study sample included 507,072 and 489,754 eligible adults with established ASCVD, in 4/1/2013 and 4/1/2014, respectively. The sample consisted of approximately 190,035 (2%) women and 200,461 (19%) non-white patients. HPS use was lowest in Hispanics and Native Americans, though all groups showed an increase over time (Figure 1). After adjustment for clinical and facility characteristics, there was a 40% increase in the use of HPS during the study period [OR=1.4; 95%CI (1.39-1.42)]. However, the racial differences shown in Figure 1 persisted and women were less likely to receive HPS than men (Odds Ratios [OR]=0.85; 95% CI 0.83-0.87). Conclusion: HPS use has increased following release of the ACC/AHA prevention guideline in the VA, though racial and gender disparities persist. Our findings highlight the continued need for targeted efforts to increase HPS use for women and certain minority groups.

System Safety in Healthcare

Electronic health records (EHR) are critical to precision medicine. They provide greater patient access to medical history data and are available quickly. But there are many inherent risks in using these records.&#x0D; According to a new study, even in long-standing EHR systems such as the one used by the Department of Veterans Affairs (VA) health care system, many significant EHR-related safety concerns remain. In a study of investigations of EHR-related safety violations launched through the VA’s Informatics Patient Safety office (IPS) from 2009 to 2013, researchers looked at 100 closed cases at 55 VA facilities. Of those cases, 74 involved unsafe technology, and 25 involved unsafe use of technology, which the researchers of the study wrote “most commonly involved the dimensions of people, clinical content, workflow and communication, and human interface.” A majority of cases (70 percent) involved both unsafe technology and unsafe use.

Evaluation of a Health Coaching Course for Providers and Staff in Veterans Health Affairs Medical Facilities.

The purpose of this study was to determine whether a health coaching (HC) course for providers and staff in Veterans Health Affairs medical facilities resulted in increased attitudes toward, intentions to use, and actual use of HC. A Whole Health Coaching Course was developed and implemented in national sites in 2014. A pre-post intervention group only design was used to assess changes in HC outcomes, including use of HC skills. There were large pre- to posttest increases in preparedness and self-efficacy that were sustained at follow-up. Initial small increases in attitudes toward patient-centered care and intentions to use HC skills were not sustained at follow-up. There was a medium-sized increase in actual use of HC skills between pre-test and follow-up. Findings suggest that participation in the HC course is an effective means for providers and staff to increase preparedness, self-efficacy, and actual use of health coaching skills.

Utilizing the ECHO Model in the Veterans Health Affairs System: Guidelines for Setup, Operations and Preliminary Findings

Background: In 2011, the Veterans Health Administration (VHA) consulted with the Project ECHO (Extension for Community Healthcare Outcomes) team at the University of New Mexico, Albuquerque, to reproduce their successful model within the VHA. Methods: The VHA launched SCAN-ECHO (Specialty Care Access Network-Extension for Community Healthcare Outcomes), a multisite videoconferencing system to conduct live clinical consultations between specialists at a VHA Medical Center (hospital) and primary care providers stationed at satellite VHA CBOCs (Community-Based Outpatient Clinic). Results: Analysis of the first three years rendered a mean attendee satisfaction of 89.53% and a consultation satisfaction score of 88.10%. About half of the SCAN-ECHO consultations resulted in patients receiving their treatment from their local primary care providers; the remaining half were referred to the VHA Medical Center when the treatment involved equipment or services not available at the CBOCs (e.g., MRI, surgery). Conclusion: This paper details the setup, operation logistics and preliminary findings, suggesting that SCAN-ECHO is a viable model for providing quality specialty clinical consultation service, prompter access to care, reduced commutes and continuing education. Additionally, the use of a secured Internet-based videoconferencing system that supports connectivity to multiple (mobile) devices could expand the utilization of this service.

Local Area Unemployment and the Demand for Inpatient Care Among Veterans Affairs Enrollees.

Prior research examining the relationship between economic conditions and health service demand has focused primarily on outpatient use. This study examines whether local area unemployment, as an indicator of economic conditions, was associated with use of inpatient care, which is theoretically less subject to discretionary use. Using a random sample of 131,603 patients dually enrolled in the Veterans Affairs (VA) Health System and fee-for-service Medicare, we measured VA, Medicare, and total (VA and Medicare) hospitalizations. Overall, local unemployment was not associated with VA, Medicare, or total hospitalization probability. Among low-income veterans exempt from VA copayments, higher local unemployment was moderately associated with a lower probability of hospitalization through Medicare. For veterans subject to VA copayments, higher local unemployment was moderately associated with a higher likelihood of VA hospitalization. These results suggest inpatient use is less sensitive to the economy, although worse economic conditions slightly affected inpatient demand for select veterans.

U.S. Veterans Increase CAM Utilization upon Completion of a Pain Education Program

Pain is one of the most common reasons U.S. Veterans consult with their general medicine practitioners and is one of the most prevalent symptoms reported by returning Veterans [1]. In fact, almost half of patients within the Department of Veteran Affairs (VA) health care settings experience pain on a regular basis [2]. Furthermore, Veterans with chronic, non-cancer pain are often more complex in their presentation due to difficulties returning to civilian life and the influence of their past military service on their pain [3]. Past studies have shown that the pain suffered by Veterans is significantly worse than that of the general public [4]. Complementary therapies are typically used in conjunction with conventional medicine, while alternative modalities are used in place of orthodox treatments. About half of U.S. complementary and alternative medicine (CAM) users utilize these treatments for pain [5]. Thus there is a growing demand for CAM by Veterans seeking its benefits. The perception of Veterans is that the current U.S. medical care system is lacking in “holism,” which is a cornerstone in chronic pain management [6]. The average rate of CAM consumption among U.S. Veterans is approximately 30-50% [6,7]. Past research has indicated that Veterans with chronic, noncancer pain have reported that chiropractic care was the least preferred, while massage therapy was the most favored CAM modality [8]. Despite the discernment that U.S. Veterans are active consumers of CAM [8,9], they are still lower than the general population [10]. In addition, more than 75% of Veteran non-users report they would utilize these treatment options if made available [8]. Thus, Veterans may not be fully aware of the CAM options currently available to them in the current U.S. VA health care system [11].

Improving Veterans’ Mobility in Small Urban and Rural Areas

The need for veterans’ transportation is growing rapidly because of the increasing number of older veterans as well as the many injured servicemen and -women returning from Iraq and Afghanistan. Thirty percent of veterans live in rural areas that often present transportation challenges. Many veterans in rural areas must travel extremely long distances to receive medical care, and veterans living in rural areas are reported to be in poorer health than veterans living in urban areas. The objective of this study was to identify veterans with mobility needs living in rural Minnesota, Montana, and North Dakota and to quantify the cost of feasible transportation options for meeting veterans’ mobility needs. This study included a survey of veterans and a simulation of their health care transportation costs. Online and paper surveys were distributed to veterans throughout Minnesota, Montana, and North Dakota. More than 80% of respondents classified themselves as disabled with nearly three-fourths of these indicating that their veteran disability rating was greater than 30%. The most common disability reported by survey respondents was having a mobility impairment, followed by hearing impairment and mental health issues. When a coordination effort between U.S. Department of Veterans Affairs (VA) health care centers and rural public transit agencies was simulated with @Risk risk analysis software, results varied by state and region because of varying operating costs and fare recovery rates. Overall, most simulations indicated that a coordination effort between VA health care centers and rural public transit agencies would be feasible if estimated ridership levels could be attained.

Abstract 13013: The Impact of Prolonged Clopidogrel Beyond 12 Months After Coronary Stenting in Patients with Acute Coronary Syndromes

Introduction: Clopidogrel up to 12 months after an acute coronary syndrome (ACS) lowers the risk of major adverse coronary events. Guidelines recommend clopidogrel for 12 months after coronary intervention (PCI) with bare-metal (BMS) or drug-eluting (DES) stents. The value of prolonging clopidogrel beyond 12 months in PCI patients with ACS is unknown. Hypothesis: We hypothesize that prolonged clopidogrel differentially reduces adverse events in patients receiving DES compared with those receiving BMS for an ACS. Methods: We linked all PCIs in the national Veterans Affairs (VA) health system from 2002-2006 with the VA pharmacy database. VA and non-VA clinical outcomes were identified by ICD9 codes from the VA and CMS/Medicare databases. All patients who were event free at 12 months were followed for death, myocardial infarction (MI), and recurrent target vessel revascularization (TVR). The hazard ratio for prolonged clopidogrel use (more than 12 months) versus clopidogrel for less than or equal to 12 months was assessed for each outcome within each stent type, using Cox proportional hazards models. Multivariable models and propensity models were also used to adjust for confounding related to the propensity for prolonged clopidogrel treatment. Results: After exclusions, 28,507 patients had PCI and were event free at 12 months. Of these, 18,279 (64%) had an ACS at their index PCI including 9,336 (51%) who received a DES and 8,447 (46%) who received prolonged clopidogrel. Events occurring up to 4 years after PCI in these ACS patients included 1358 deaths, 1885 death or MIs, and 1335 TVRs. Prolonged clopidogrel was associated with lower risk of death (interaction p=0.04) and death or MI (interaction p=0.001) only in patients receiving DES (Table). Similar results were seen in multivariable and propensity models. Conclusions: Prolonging clopidogrel more than 12 months after PCI for ACS may lower the risk of death or MI in patients receiving DES but not in patients receiving BMS.