Veterans Health Administration Healthcare System Research Articles

Academic Detailing to Improve Opioid Safety: Implementation Lessons from a Qualitative Evaluation

Academic detailing (AD) is a promising intervention to address the growing morbidity and mortality associated with opioids. While AD has been shown to be effective in improving provider prescribing practices across a range of conditions, it is unclear how best to implement AD. The present study was designed to identify key lessons for implementation based on a model AD program in the Veterans Health Administration (VA). Qualitative process evaluation using semistructured interviews. Seven VA health care systems in the Sierra Pacific region. Current and former academic detailers (N = 10) and VA providers with varying exposure to AD (high, low, or no; N = 20). Semistructured interviews were audio-recorded and transcribed. We used a team-based, mixed inductive and deductive approach guided by the Consolidated Framework for Implementation Research. Key lessons identified by academic detailers and providers coalesced around key themes: 1) one-on-one sessions customized to the provider's patient population are most useful; 2) leadership plays a critical role in supporting providers' participation in AD programs; 3) tracking academic detailer and provider performance is important for improving performance for both groups; 4) academic detailers play a key role in motivating provider behavior change and thus training in Motivational Interviewing is highly valuable; and 5) academic detailers noted that networking is important for sharing implementation strategies and resources. Identifying and incorporating these key lessons into the implementation of complex interventions like AD are critical to facilitating uptake of evidence-based interventions addressing the opioid epidemic.

EC-93 - Infection Prevention Workforce Characteristics in the VA: Results of a National Infection Prevention Needs Assessment Survey

Background: In 2017, the Veterans Health Administration (VA) conducted a national needs assessment survey to identify the current state of implementation of healthcare-associated infection (HAI) prevention activities related to preventing emerging and multidrug-resistant organisms (MDROs) in the acute care setting. One section of the survey was dedicated to collecting demographic characteristics of infection prevention (IP) workforce. The purpose of this study is to describe the characteristics of current IPs within the VA healthcare system.

Protocol for a mixed methods study of hospital readmissions: sensemaking in Veterans Health Administration healthcare system in the USA

IntroductionEffective delivery of healthcare in complex systems requires managing interdependencies between professions and organisational units. Reducing 30-day hospital readmissions may be one of the most complex tasks that a healthcare...

Validation of an algorithm to identify heart failure hospitalisations in patients with diabetes within the veterans health administration

ObjectivesWe aimed to validate an algorithm using both primary discharge diagnosis (International Classification of Diseases Ninth Revision (ICD-9)) and diagnosis-related group (DRG) codes to identify hospitalisations due to decompensated heart...

Clinical pharmacist prescribing activities in the Veterans Health Administration.

A comprehensive overview of clinical pharmacist prescribing authority and collaborative drug therapy management activities within the Veterans Health Administration (VHA) is presented. In VHA terminology, "scope of practice" (SOP) denotes authorization to perform as an advanced practice provider, autonomously or collaboratively managing all facets of a patient's disease or condition; VHA clinical pharmacists with an SOP have prescribing authority. National policies outline the broad requirements for conferral of an SOP to VHA clinical pharmacists and processes for SOP development and oversight, as well as the responsibilities of facility and clinical pharmacy leaders to support the role of the clinical pharmacist within the VHA healthcare system. The limits of each pharmacist's SOP are determined at the facility level, with prescribing and other patient care authorities granted according to demonstrated competence. There are approximately 7700 VHA clinical pharmacists, of whom about 3200 (41%) have an active SOP. During fiscal year 2015, VHA clinical pharmacists accounted for more than 5 million patient encounters and 1.9 million prescriptions for chronic disease-targeted medications, generating at least 20% of prescriptions for hepatitis C therapies, hypoglycemic agents, and erythropoiesis-stimulating agents and 69% of prescriptions for anticoagulants systemwide. Clinical pharmacists with an SOP constitute a rapidly expanding workforce within the VHA system, as illustrated by tremendous growth in their numbers since 2010. These individuals play a key role as advanced practice providers, helping to improve access to high-quality chronic disease and medication management for the nation's veterans.

Baseline Variation in Use of VA/DOD Clinical Practice Guideline Recommended Opioid Prescribing Practices Across VA Health Care Systems.

The purpose of this study was to determine baseline adherence to key recommendations from the 2010 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Pain at Veterans Health Administration (VA) facilities. We hoped to understand practice patterns at the time of guideline release to guide quality improvement and implementation efforts. Overall practice patterns were examined at each of the 140 VA Health Care Systems based on quality metrics developed to assess adherence to the VA/DOD Clinical Practice Guideline. Clinical practice varied widely across facilities on measures of use of urine drug screens, substance use disorder treatment for diagnosed substance use disorder patients, and use of rehabilitative treatments. Less variation was observed in measures of sedative coprescription and use of adjunctive pharmacotherapy. Use of guideline recommended practices was generally more frequent for patients prescribed long-acting opioid formulations and those with chronic use. Relative facility-level implementation was correlated across most measures. Overall implementation of guideline recommended practices was lower at less complex facilities and facilities in the Western United States. In 2010, guideline-recommended practices for opioid prescribing were variably used across VA health care systems. Efforts to disseminate practices used at high-performing sites, and increase consistency of use of recommended practices across patients and facilities should be considered to improve pain management and reduce adverse events.

Thirty-day postoperative mortality among individuals with HIV infection receiving antiretroviral therapy and procedure-matched, uninfected comparators.

Antiretroviral therapy (ART) has converted human immunodeficiency virus (HIV) infection into a chronic condition, and patients now undergo a variety of surgical procedures, but current surgical outcomes are inadequately characterized. To compare 30-day postoperative mortality in patients with HIV infection receiving ART with the rates in uninfected individuals. Retrospective analysis of nationwide electronic medical record data from the US Veterans Health Administration Healthcare System, October 1, 1996, to September 30, 2010. Common inpatient surgical procedures were grouped using the Healthcare Cost and Utilization Project Clinical Classification System to match HIV-infected and uninfected patients in a 1:2 ratio. Data on 1641 patients with HIV infection receiving combination ART who were undergoing inpatient surgery were compared with data on 3282 procedure-matched, uninfected comparators. Poisson regression models of 30-day postoperative mortality were adjusted for procedure year, age, Charlson Comorbidity Index score, hemoglobin level, albumin level, HIV infection, CD4 cell count, and HIV-1 RNA level. All-cause 30-day postoperative mortality. The most common procedures in both groups were cholecystectomy (10.5%), hip arthroplasty (10.5%), spine surgery (9.8%), herniorrhaphy (7.4%), and coronary artery bypass grafting (7.0%). In patients with HIV infection, CD4 cell distributions were 80.0% with 200/μL or more, 16.3% with 50/μL to 199/μL, and 3.7% with less than 50/μL; 74.1% of patients with HIV infection had undetectable HIV-1 RNA. Human immunodeficiency virus infection was associated with higher 30-day postoperative mortality compared with the mortality in uninfected patients (3.4% [56 patients]) vs 1.6% [53]); incidence rate ratio [IRR], 2.11; 95% CI, 1.41-3.17; P < .001). CD4 cell count was inversely associated with mortality, but HIV-1 RNA provided no additional information. After adjustment, patients with HIV infection had increased mortality compared with uninfected patients at all CD4 cell count strata (≥500/μL: IRR, 1.92; 95% CI, 1.02-3.60; P = .04; 200-499/μL: IRR, 1.89; 95% CI, 1.20-2.98; P = .01; 50-199/μL: IRR, 2.66; 95% CI, 1.29-5.47; P = .01; and <50/μL: IRR, 6.21; 95% CI, 3.55-10.85; P < .001). Hypoalbuminemia (IRR, 4.35; 95% CI, 2.78-6.81; P < .001) and age in decades (IRR, 1.47; 95% CI, 1.23-1.76; P < .001) were also strongly associated with mortality. Current postoperative mortality rates among individuals with HIV infection who are receiving ART are low and are influenced as much by hypoalbuminemia and age as by CD4 cell status. Human immunodeficiency virus infection and CD4 cell count are only 2 of many factors associated with surgical outcomes that should be incorporated into surgical decision making.

A partnered research initiative to accelerate implementation of comprehensive care for women veterans: the VA women's health CREATE.

A partnered research initiative to accelerate implementation of comprehensive care for women veterans: the VA women's health CREATE.

Readying the workforce: evaluation of VHA's comprehensive women's health primary care provider initiative.

Veterans Health Administration (VHA) primary care providers (PCPs) often see few women, making it challenging to maintain proficiency in women's health (WH). Therefore, VHA in 2010 established Designated WH Providers, who would maintain proficiency in comprehensive WH care and be preferentially assigned women patients. To evaluate early implementation of this national policy. At each VHA health care system (N=140), the Women Veterans Program Manager completed a Fiscal Year 2012 workforce capacity assessment (response rate, 100%), representing the first time the national Designated WH Provider workforce had been identified. Assessment data were linked to administrative data. Of all VHA PCPs, 23% were Designated WH Providers; 100% of health care systems and 83% of community clinics had at least 1 Designated WH Provider. On average, women veterans comprised 19% (SD=27%) of the patients Designated WH Providers saw in primary care, versus 5% (SD=7%) for Other PCPs (P<0.001). For women veterans using primary care (N=313,033), new patients were less likely to see a Designated WH Provider than established women veteran patients (52% vs. 64%; P<0.001). VHA has achieved its goal of a Designated WH Provider in every health care system, and is approaching its goal of a Designated WH Provider at every hospital/community clinic. Designated WH Providers see more women than do Other PCPs. However, as the volume of women patients remains low for many providers, attention to alternative approaches to maintaining proficiency may prove necessary, and barriers to assigning new women patients to Designated WH Providers merit attention.

Surgical compared with nonsurgical management of fractures in male veterans with chronic spinal cord injury.

Retrospective review of a clinical database. To examine treatment modalities of incident appendicular fractures in men with chronic SCI and mortality outcomes by treatment modality. United States Veterans Health Administration Healthcare System. This was an observational study of 1979 incident fractures that occurred over 6 years among 12 162 male veterans with traumatic SCI of at least 2 years duration from the Veterans Health Administration (VA) Spinal Cord Dysfunction Registry. Treatment modalities were classified as surgical or nonsurgical treatment. Mortality outcomes at 1 year following the incident fracture were determined by treatment modality. A total of 1281 male veterans with 1979 incident fractures met inclusion criteria for the study. These fractures included 345 (17.4%) upper-extremity fractures and 1634 (82.6%) lower-extremity fractures. A minority of patients (9.4%) were treated with surgery. Amputations and disarticulations accounted for 19.7% of all surgeries (1.3% of all fractures), and the majority of these were done more than 6 weeks following the incident fracture. There were no significant differences in mortality among men with fractures treated surgically compared with those treated nonsurgically. Currently, the majority of appendicular fractures in male patients with chronic SCI are managed nonsurgically within the VA health-care system. There is no difference in mortality by type of treatment.

Trends in prevalent and incident opioid receipt: an observational study in Veterans Health Administration 2004-2012.

Improved understanding of temporal and regional trends may support safe and effective prescribing of opioids. We describe national, regional, and facility-level trends and variations in opioid receipt between fiscal years (FY) 2004 and 2012. Observational cohort study using Veterans Health Administration (VHA) administrative databases. All patients receiving primary care within 137 VHA healthcare systems during a given study year and receiving medications from VHA one year before and during a given study year. Prevalent and incident opioid receipt during each year of the study period. The overall prevalence of opioid receipt increased from 18.9% of all veteran outpatients in FY2004 to 33.4% in FY2012, a 76.7% relative increase. In FY2012, women had higher rates of prevalent opioid receipt than men (42.4% vs. 32.9%), and the youngest veterans (18-34 years) had higher prevalent opioid receipt compared to the oldest veterans (≥ 80 years) (47.6% vs. 17.9%). All regions in the United States saw increased rates of prevalent opioid receipt during this time period. Prevalence rates varied widely by facility: in FY2012, the lowest-prescribing facility had a rate of 13.5%, and the highest of 50.8%. Annual incident opioid receipt increased from 8.8% in FY2004 to 10.2% in FY2011, with a decline to 9.8% in FY2012. Incident prescribing increased at some facilities and decreased at others. Facilities with high prevalent prescribing tended to have flat or decreasing incident prescribing rates during the study time frame. Rates of opioid receipt increased throughout the study time frame, with wide variation in prevalent and incident rates across geographical region, sex, and age groups. Prevalence and incidence rates reflect distinct prescribing practices. Areas with the highest prevalence tended to have lower increases in incident opioid receipt over the study period. This likely reflects facility-level variations in prescribing practices as well as baseline rates of prevalent use. Future work assessing opioid prescribing should employ methodologies to account for and interpret both prevalent and incident opioid receipt.

Mental illness and intensification of diabetes medications: an observational cohort study.

BackgroundMental health condition (MHC) comorbidity is associated with lower intensity care in multiple clinical scenarios. However, little is known about the effect of MHC upon clinicians’ decisions about intensifying antiglycemic medications in diabetic patients with poor glycemic control. We examined whether delay in intensification of antiglycemic medications in response to an elevated Hemoglobin A1c (HbA1c) value is longer for patients with MHC than for those without MHC, and whether any such effect varies by specific MHC type.MethodsIn this observational study of diabetic Veterans Health Administration (VA) patients on oral antiglycemics with poor glycemic control (HbA1c ≥8) (N =52,526) identified from national VA databases, we applied Cox regression analysis to examine time to intensification of antiglycemics after an elevated HbA1c value in 2003–2004, by MHC status.ResultsThose with MHC were no less likely to receive intensification: adjusted Hazard Ratio [95% CI] 0.99 [0.96-1.03], 1.13 [1.04-1.23], and 1.12 [1.07-1.18] at 0–14, 15–30 and 31–180 days, respectively. However, patients with substance use disorders were less likely than those without substance use disorders to receive intensification in the first two weeks following a high HbA1c, adjusted Hazard Ratio 0.89 [0.81-0.97], controlling for sex, age, medical comorbidity, other specific MHCs, and index HbA1c value.ConclusionsFor most MHCs, diabetic patients with MHC in the VA health care system do not appear to receive less aggressive antiglycemic management. However, the subgroup with substance use disorders does appear to have excess likelihood of non-intensification; interventions targeting this high risk subgroup merit attention.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6963-14-458) contains supplementary material, which is available to authorized users.

National prevalence of traumatic brain injury, posttraumatic stress disorder, and pain diagnoses in OIF/OEF/OND Veterans from 2009 to 2011

Improvements in protective body armor technology in the past decade, combined with advances in emergency and intensive care medicine, have saved countless lives from battlefield [1-4]. Survivors of military conflicts often present with a constellation of injuries, recently described as by the Veterans Health Administration (VHA) [5]. While traumatic brain (TBI) has been coined as the signature injury in this generation of combat returnees, other concomitant physical and psychological impairments also require long-term follow-up and care [6-8]. The 2009 study by Lew et al. systematically reviewed 340 Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) Veterans seen at a VHA Polytrauma Network Site (PNS) from 2007 to 2008, and the data revealed that TBI, posttraumatic stress disorder (PTSD), and pain were reported in 66.8, 68.2, and 81.5 percent of Veterans, respectively [9]. Since these three conditions (TBI, PTSD, and pain) tend to occur in combination (42.1%), as opposed to existing in isolation (5.3%, 2.9%, and 10.3%, respectively), their co-occurrence has been referred as the clinical [9]. Given its complexity, an interdisciplinary team approach to diagnosis and treatment has been recommended for patients with this clinical triad [9-10]. Note, however, that this previous study [9] involved only those OIF/OEF Veterans who had (1) sought care within the VHA healthcare system, (2) completed the TBI screening questionnaire at the VHA, (3) answered yes to all four screening questions, (4) agreed to undergo further evaluation, and (5) then completed a comprehensive evaluation at a local VHA PNS (Figure). This issue of the Journal of Rehabilitation Research and Development includes a landmark article that truly defines the national prevalence of TBI, PTSD, and pain in Veterans from the OIF/OEF/Operation New Dawn (OND) conflicts, encompassing data from 2009 to 2011. Specifically, Cifu et al. [11] conducted a comprehensive investigation that systematically collected and analyzed data from 613,391Veterans who received any healthcare in the VHA from the beginning of 2009 to the end of 2011. Utilizing data from the entire population of OIF/OEF/OND Veterans seen for this three year period, Cifu et al.'s study revealed the actual prevalence of TBI, PTSD, and pain in this new generation of Veterans. Data from 613,391Veterans were captured at the initial stage of entry into the system, when they sought care with the VHA as either outpatients or inpatients, and then at subsequent visits during that three year period. Pooled data from all three years (2009-2011) revealed that only 6.0 percent of this population had the full polytrauma triad expression (TBI, PTSD, and pain). This current percentage (6.0%) is low when compared with the 42.1 percent from Lew et al.'s previous study [9], which was from a more selective sample since it assessed the local prevalence of the polytrauma triad in Veterans who had not only sought care with the VHA but also completed the TBI screening questionnaire at the VHA, answered yes to all four screening questions, agreed to undergo further evaluation, and completed a comprehensive evaluation at a VHA PNS. Comparisons of the overall and isolated occurrence rates of TBI, PTSD, and pain between the two studies are summarized in Tables 1 and 2, respectively. The drastic contrast in the TBI rates between the two studies was likely because the sample evaluated in the former study had already screened positive for TBI but not for PTSD or pain. [FIGURE OMITTED] Moreover, Cifu et al.'s results also revealed that Among those with a TBI diagnosis, the majority also had a mental health disorder, with approximately half having both PTSD and pain. While the absolute number of Veterans increased by over 40 percent from 2009 to 2011, the proportion of Veterans diagnosed with TBI and the high rate of comorbid PTSD and pain in this population has remained relatively stable [11]. …

Suicide Prevention for Veterans and Active Duty Personnel

A considerable body of research has identified correlates of suicide at the genetic, neurologic, psychological, social, and cultural levels. Among risk characteristics identified in existing studies, current or former military service has emerged as a topic of considerable scientific and public interest. Of those who die from suicide, veterans and active duty military personnel represent a select group with considerable heterogeneity in individual characteristics and life histories. Such heterogeneity in individuallevel characteristics and precipitating events carries with it the potential to obfuscate relationships between individual risk factors, experiences uniquely associated with military service, and social and cultural factors. Despite these challenges, results from existing studies suggest that history of military service is an element worthy of consideration in efforts to address the complex and multifaceted nature of intentional self-harm. Given the intricate etiology of suicide and limitations of current data systems, it is not surprising that uncertainty surrounds the exact nature of the relationships between history of military service and suicide.1 Moreover, the unique experiences of different military cohorts may play a key role as major contextual factors given the diverse range of exposures experienced by different cohorts.

Suicide Mortality Among Patients Treated by the Veterans Health Administration From 2000 to 2007

We sought to examine rates of suicide among individuals receiving health care services in Veterans Health Administration (VHA) facilities over an 8-year period. We included annual cohorts of all individuals who received VHA health care services from fiscal year (FY) 2000 through FY 2007 (October 1, 1999-September 30, 2007; N = 8,855,655). Vital status and cause of death were obtained from the National Death Index. Suicide was more common among VHA patients than members of the general US population. The overall rates of suicide among VHA patients decreased slightly but significantly from 2000 to 2007 (P < .001). Male veterans between the ages of 30 and 64 years were at the highest risk of suicide. VHA health care system patients are at elevated risk for suicide and are appropriate for suicide reduction services, although the rate of suicide has decreased in recent years for this group. Comprehensive approaches to suicide prevention in the VHA focus not only on recent returnees from Iraq and Afghanistan but also on middle-aged and older Veterans.

Male-to-Female Transgender Veterans and VA Health Care Utilization

ABSTRACT This study examined rates of military veteran status in an American male-to-female transgender community sample (n = 141). Thirty percent were veterans (n = 43), a rate that is triple the proportion of veteran status noted in the general population (10.1%). Among the veteran subsample, we examined health care utilization, including Veterans Health Administration (VA), health, and barriers to care. Use of VA services was higher among transgender veterans (transvets) than published rates of VA use in the general population of veterans (annual 6.2% to 15.8%), with 16.3% of all transvets seeking some VA care in the past 6- months. The most common physical health problems treated at the VA in the past year were high cholesterol, blood pressure, and vision problems. Irrespective of VA use, the majority of transvets reported getting routine health care (88.4%), and their physical health ratings were commensurate with population norms. Mental health services (e.g., depression, posttraumatic stress disorder, and gender identity counseling) were also utilized (9.3% VA, 25.6% non-VA) at levels consistent with the relatively low mental health functioning scores in this sample (SF-12 = 32.6, SD = 8.3). Barriers to care were endorsed more for medical than mental health treatment. In particular, transvets were concerned about medical providers’ reactions to their gender identity or sexual orientation. Given elevated rates of transvets in this community sample and reported barriers to care, culturally sensitive treatment is a priority for transvets in both VA and non-VA health care systems.

Primary care–mental health integration and treatment retention among Iraq and Afghanistan war veterans.

Despite the high prevalence of posttraumatic stress disorder (PTSD) and medical comorbidity among veterans from Iraq/Afghanistan (OEF/OIF), keeping these patients engaged in health care is challenging. Primary Care-Mental Health Integration (PC-MHI), an initiative in the Veterans Health Administration (VA), sought to improve access to mental health care from within primary care. This study examined the lag between first PC-MHI visit and next mental/medical care visit, if any, and the relationship of PC-MHI with short-term (subsequent year) and long-term (4 years later) use of VA. We identified 2,470 OEF/OIF veterans receiving care during fiscal year 2006 (FY06) in a regional VA health care system. Unconditional survival analysis modeled time to next mental/medical visit and logistic regression modeled short- and long-term care as a function of PC-MHI, demographics, and clinical covariates. Of 181 patients in the PC-MHI program, 60%/18% returned for mental/medical care within 1 month, and 82%/74% within 1 year. Sixty-one percent (1,503) were still using the VA in FY09. Short-term mental care was related to prior-year PC-MHI. Consistent correlates of short- and long-term mental/medical care included physical comorbidity and Priority 1 status. Most patients attended mental health appointments subsequent to PC-MHI, and PC-MHI was correlated with mental health treatment retention in adjusted models for our cohort. Need for treatment, notably VA Priority 1 status and physical comorbidity, were the primary correlates of care-seeking. Developing innovative approaches to engaging new veterans in care remains imperative as multiple options will be necessary to meet the needs of these complex patients.

Use of Outpatient Care in Veterans Health Administration and Medicare among Veterans Receiving Primary Care in Community‐Based and Hospital Outpatient Clinics

To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients. VA administrative and Medicare claims data from 2001 to 2004. Retrospective cohort study of outpatient service use by 8,964 community-based and 6,556 hospital-based VA primary care patients. A significant proportion of VA patients used Medicare-reimbursed primary care (>30 percent) and specialty care (>60 percent), but not mental health care (3-4 percent). Community-based patients had 17 percent fewer VA primary care visits (p<.001), 9 percent more Medicare-reimbursed visits (p<.001), and 6 percent fewer total visits (p<.05) than hospital-based patients. Community-based patients had 22 percent fewer VA specialty care visits (p<.0001) and 21 percent more Medicare-reimbursed specialty care visits (p<.0001) than hospital-based patients, but no difference in total visits (p=.80). Medicare-eligible VA primary care patients followed over 4 consecutive years used significant primary care and specialty care outside of VA. Community-based patients offset decreased VA use with increased service use paid by Medicare, suggesting that increasing access to VA primary care via community clinics may fragment veteran care in unintended ways. Coordination of care between VA and non-VA providers and health care systems is essential to improve the quality and continuity of care.

End‐of‐life care for older cancer patients in the Veterans Health Administration versus the private sector

Treatment of older cancer patients at the end of life has become increasingly aggressive, despite the absence of evidence for better outcomes. We compared aggressiveness of end-of-life care of older metastatic cancer patients treated in the Veterans Health Administration (VHA) and those under fee-for-service Medicare arrangements. Using propensity score methods, we matched 2913 male veterans who were diagnosed with stage IV lung or colorectal cancer in 2001-2002 and died before 2006 with 2913 similar men enrolled in fee-for-service Medicare living in Surveillance, Epidemiology, and End Result (SEER) areas. We assessed chemotherapy within 14 days of death, intensive care unit (ICU) admissions within 30 days of death, and >1 emergency room visit within 30 days of death. Among matched cohorts, men treated in the VHA were less likely than men in the private sector to receive chemotherapy within 14 days of death (4.6% vs 7.5%, P<.001), be admitted to an ICU within 30 days of death (12.5% vs 19.7%, P<.001), or have >1 emergency room visit within 30 days of death (13.1 vs 14.7, P=.09). Older men with metastatic lung or colorectal cancer treated in the VHA healthcare system received less aggressive end-of-life care than similar men in fee-for-service Medicare. This may result from the absence of financial incentives for more intensive care in the VHA or because this integrated delivery system is better structured to limit potentially overly aggressive care. Additional studies are needed to assess whether men undergoing less aggressive end-of-life care also experience better outcomes.

Using geographic information system tools to improve access to MS specialty care in Veterans Health Administration

Access to appropriate and timely healthcare is critical to the overall health and well-being of patients with chronic diseases. In this study, we used geographic information system (GIS) tools to map Veterans Health Administration (VHA) patients with multiple sclerosis (MS) and their access to MS specialty care. We created six travel-time bands around VHA facilities with MS specialty care and calculated the number of VHA patients with MS who resided in each time band and the number of patients who lived more than 2 hours from the nearest specialty clinic in fiscal year 2007. We demonstrate the utility of using GIS tools in decision-making by providing three examples of how patients' access to care is affected when additional specialty clinics are added. The mapping technique used in this study provides a powerful and valuable tool for policy and planning personnel who are evaluating how to address underserved populations and areas within the VHA healthcare system.