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Background: Registries that identify people with mild cognitive impairment (MCI) or Alzheimer's dementia (AD) will be critical in targeting interventions to delay disease progression. Optimal methods to identify people for inclusion in such registries remain uncertain. We now compare approaches that rely on International Classification of Diseases (ICD)‐10 codes to the use of natural language processing (NLP) of clinicians' notes. Method: We used data from the Department of Veterans Affairs (VA) considering all Veterans aged 50 or older from the fiscal year 2019. People for the "ICD" cohorts were identified based on at least one code for either AD or MCI. For the "NLP" cohorts, we used electronic clinician notes and previously validated algorithms that search for keywords ("Alz*" or "Mild Cognitive Impairment"), excluding false positive cases identified through text screening such as "family history." The number and overlap of people identified by the ICD‐ and NLP‐based approaches were compared. Result: Overall, 144,942 Veterans documented with either ICD coding or clinical notes using NLP as probable AD patients were identified; 32,498 (22.4%) people were identified by ICD codes and 141,816 (97.8%) people by clinical notes. Only 20.3% of the Veterans were identified by both clinical notes and ICD; 77.5% were identified by clinical notes alone and only 2.2% by ICD alone. In contrast, for the 134,699 Veterans with MCI, 95,324 (70.8%) people were identified by ICD codes and 79,232 (58.8%) people by clinical notes. Veterans identified by both ICD and clinical notes consisted of 29.6% of the sample, compared to 41.2% by ICD and 29.2% by clinical notes. Conclusion: Identification of patients with MCI or AD in electronic clinical notes using NLP is an alternative approach for developing a disease registry to the traditional methodology based on ICD coding in administrative databases. The differences in case identification between NLP‐ and ICD‐based approach may have reflected a clinical practice pattern in making clinical judgments regarding MCI and AD and documenting MCI and AD assessments in clinical notes as opposed to administrative records among the US Veterans. [ABSTRACT FROM AUTHOR]

Background: Information on clinical decision making and disease severity assessments for mild cognitive impairment (MCI) or Alzheimer's dementia (AD) typically only exists in medical notes. In this study, we present the methodology of constructing a database from unstructured electronic health records (EHR), which enables enriched population studies when combined with structured administrative databases. Method: A multidisciplinary team with expertise in neurology, epidemiology, biology, and health informatics designed and created the relational database. The database was established with three tables for patient demographics, neurocognitive and neuropsychiatric test results, and clinical judgment of AD severity. Patient cohorts were identified by searching keywords ("Alz*" or "Mild Cognitive Impairment") from electronic clinical notes and excluding false positives using expert‐designed rules. The most frequently used six neuropsychiatric tests (MMSE, MoCA, SLUMS, Mini‐cog, BNT, BVRT) and their corresponding testing results were extracted in addition to clinicians' judgment on disease severity. The test scores were extracted using a rule‐based natural language processing (NLP) system. Result: A patient cohort with MCI (N = 74,444) or probable AD (N = 141,816) was identified in the VA database for the fiscal year of 2019 (Table 1), with 18,173 patients having both MCI and AD diagnosis among their clinical notes of the year. A total of 1,529,897 neuropsychiatric testing scores were extracted from the patients' clinical notes across all years, with 388,253 MMSE scores, 614,400 MoCA scores, 462,646 SLUMS scores, 18,868 Mini‐cog scores, 45,259 BNT scores, and 471 BVRT scores. A total of 57,879 (77.75%) MCI patients and 82,656 (58.28%) AD patients had at least one test score extracted. A total of 18,939 (13.35%) AD patients had at least one documented severity categorization made by a clinician. Conclusion: We established a database of neuropsychiatric testing scores for patients with MCI or AD based on electronic medical notes from the VA healthcare system, aided by NLP tools. Our approach demonstrated a scalable pipeline to integrate with structured EHR in support of enriched population level analysis in AD. [ABSTRACT FROM AUTHOR]

Background: Cognitive test results from electronic health records (EHRs) are key information for assessing the severity and progression of patients with mild cognitive impairment (MCI) and Alzheimer's' disease (AD). However, such information is often recorded in unstructured clinical notes rather than in an administrative database. We developed and validated a natural language processing (NLP) system to extract cognitive test results from clinical notes in the Veterans Affair (VA) Healthcare System. Method: An NLP system was developed using regular expression‐based rules and Python to extract results for six tests that have been used most frequently in VA: Mini‐Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA), Saint Louis University Mental Status Examination (SLUMS), Mini‐cog, Boston Naming Test (BNT), and Benton Visual Retention Test (BVRT). The system extracted test results from each note in two steps: (1) searched a test name, or variations and abbreviation of the test name and, if successful, (2) searched the quantitative results (e.g., 12/30 for MMSE, 74th percentile for BNT) and/or descriptive results (e.g., "borderline impairment" for BVRT) within 5 words or one sentence before or after the test name. To balance the system performance and speed, we developed 3‐8 extraction rules per test based on a manual review of 30‐50 notes for each test. We further validated NLP performance on 6 held‐out datasets (50‐200 notes/test). We automatically sampled the development and held‐out notes by searching the test name and its variations/abbreviation to increase positive cases, i.e., notes that contained the above test results. Result: The NLP system achieved 0.72‐0.92 predictive positive values (PPV), 0.96‐1.00 recall, and 0.83‐0.95 F1 scores on the validation test sets (Table 1). In addition, it demonstrated a scalable performance (processed 200,000 notes in 7 min), allowing an extraction of millions of notes from ∼1 million patients within hours. Conclusion: Rule‐based NLP can extract cognitive test results with adequate performance and scalable capability for clinical notes from patients with MCI or AD within the VA Healthcare System. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: Chronic kidney disease (CKD) is associated with frailty. Fibroblast growth factor 23 (FGF23) is elevated in CKD and associated with frailty among non‐CKD older adults and individuals with human immunodeficiency virus. Whether FGF23 is associated with frailty and falls in CKD is unknown. DESIGN: Cross‐sectional and longitudinal observational study. SETTING: Systolic Blood Pressure Intervention Trial (SPRINT), a randomized trial evaluating standard (systolic blood pressure [SBP] <140 mm Hg) versus intensive (SBP <120 mm Hg) blood pressure lowering on cardiovascular and cognitive outcomes among older adults without diabetes mellitus. PARTICIPANTS: A total of 2,376 participants with CKD (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2). MEASUREMENTS: The exposure variable was intact FGF23. We used multinomial logistic regression to determine the cross‐sectional association of intact FGF23 with frailty and Cox proportional hazards analysis to determine the longitudinal association with incident falls. Models were adjusted for demographics, comorbidities, randomization group, antihypertensives, eGFR, mineral metabolism markers, and frailty. RESULTS: After adjustment, the odds ratio for prevalent frailty versus non‐frailty per twofold higher FGF23 was 1.34 (95% confidence interval [CI] = 1.01–1.77). FGF23 levels in the highest quartile versus the lowest quartile demonstrated more than a twofold increased fall risk (hazard ratio [HR] = 2.32; 95% CI = 1.26–4.26), and the HR per twofold higher FGF23 was 1.99 (95% CI = 1.48–2.68). CONCLUSION: Among SPRINT participants with CKD, FGF23 was associated with prevalent frailty and falls. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the effect of intensive systolic blood pressure (SBP) control in older adults with hypertension, considering cognitive and physical function. DESIGN: Secondary analysis. SETTING: Systolic Blood Pressure Intervention Trial (SPRINT) PARTICIPANTS: Adults 80 years or older. INTERVENTION: Participants with hypertension but without diabetes (N = 1167) were randomized to an SBP target below 120 mm Hg (intensive treatment) vs a target below 140 mm Hg (standard treatment). MEASUREMENTS: We measured the incidence of cardiovascular disease (CVD), mortality, changes in renal function, mild cognitive impairment (MCI), probable dementia, and serious adverse events. Gait speed was assessed via a 4‐m walk test, and the Montreal Cognitive Assessment (MoCA) was used to quantify baseline cognitive function. RESULTS: Intensive treatment led to significant reductions in cardiovascular events (hazard ratio [HR] =.66; 95% confidence interval [CI] =.49‐.90), mortality (HR =.67; 95% CI =.48‐.93), and MCI (HR =.70; 95% CI =.51‐.96). There was a significant interaction (P <.001) whereby participants with higher baseline scores on the MoCA derived strong benefit from intensive treatment for a composite of CVD and mortality (HR =.40; 95% CI =.28‐.57), with no appreciable benefit in participants with lower scores on the MoCA (HR = 1.33 = 95% CI =.87‐2.03). There was no evidence of heterogeneity of treatment effects with respect to gait speed. Rates of acute kidney injury and declines of at least 30% in estimated glomerular filtration rate were increased in the intensive treatment group with no between‐group differences in the rate of injurious falls. CONCLUSION: In adults aged 80 years or older, intensive SBP control lowers the risk of major cardiovascular events, MCI, and death, with increased risk of changes to kidney function. The cardiovascular and mortality benefits of intensive SBP control may not extend to older adults with lower baseline cognitive function. Trial Registration: Clinicaltrials.gov identifier: NCT01206062. J Am Geriatr Soc 68:496–504, 2020 [ABSTRACT FROM AUTHOR]

OBJECTIVES: Concern about falling is common among older hypertension patients and could impact decisions to intensify blood pressure therapy. Our aim was to determine whether intensive therapy targeting a systolic blood pressure (SBP) of 120 mm Hg is associated with greater changes in concern about falling when compared with standard therapy targeting an SBP of 140 mm Hg. DESIGN: Subsample analysis of participants randomized to either intensive or standard therapy in the Systolic Blood Pressure Intervention Trial (SPRINT). SETTING: Approximately 100 outpatient sites. PARTICIPANTS: A total of 2313 enrollees in SPRINT; participants were all age 50 or older (mean = 69 y) and diagnosed with hypertension. MEASUREMENTS: Concern about falling was described by the shortened version of the Falls Efficacy Scale International as measured at baseline, 6 months, 1 year, and annually thereafter. RESULTS: Concern about falling showed a small but significant increase over time among all hypertension patients. No differences were noted, however, among those randomized to intensive vs standard therapy (P =.95). Among participants younger than 75 years, no increase in concern about falling over time was noted, but among participants aged 75 years and older, the mean falls self‐efficacy score increased by.3 points per year (P <.0001). No differences were observed between the intensive and standard treatment groups when stratified by age (P =.55). CONCLUSION: Intensive blood pressure therapy is not associated with increased concern about falling among older hypertension patients healthy enough to participate in SPRINT. J Am Geriatr Soc 68:614–618, 2020 [ABSTRACT FROM AUTHOR]

Background: There are challenges in studying and monitoring Alzheimer's disease (AD) in large patient populations. Clinicians often have insufficient availability of resources to make the diagnosis (e.g. brain scanning, referral to specialists) and clinical inertia may be tied to the perception that there are no clinical benefits in making the differential diagnosis of this stigmatized disease. Consequently, diagnosis codes specifically for AD are underutilized and prevalence is generally underestimated. Our goal was to improve identification of probable AD in a large patient population with the development and application of a refined search algorithm of computerized clinical notes contained in electronic health records. Method: Our methods were developed using records for all Veteran patients in the national Department of Veterans Affairs Healthcare System (VA) in fiscal years 2010‐2019. Starting with initial searches for "Alzheimer" and related terms in all clinical notes, the algorithm was optimized through an iterative process. Multiple references to "Alz" in notes were evaluated separately and chunks were excluded when the term referred to family history, care facilities, or negative statements, or when it was part of text in assessment instruments or medication indications. The final algorithm was validated through manual reviews of over 2,400 randomly selected patient charts (predictive value positive = 86.3%; kappa = 0.76 among 2‐4 reviewers). Result: When the algorithm was applied to records for the nearly 5 million VA patients over 50 years of age in fiscal year (FY) 2019, we identified 141,816 with probable AD, nearly five times the count based on ICD‐10 codes (30,090). Prevalence, standardized to the 2010 census for age and sex, was 2.70%, with higher prevalence in women (3.26%) than in men (2.06%). Median age of probable AD patients was 75 years. Conclusion: As disease modifying treatments for AD enter the market, there will be more focus on proper diagnosis of AD, particularly early in the disease process, emphasizing the importance of better identification of the disease in patient populations. This method, based on searches of clinical notes, appears to be promising to identify patients with probable AD and study its progression in large patient populations. [ABSTRACT FROM AUTHOR]

Background: Individuals with mild cognitive impairment (MCI), a noticeable decline in cognitive abilities, are at increased risk of developing Alzheimer's disease (AD) or other dementia. Risk factors for dementia, such as obesity, stroke, depression are highly prevalent among U.S. veterans We report on the trends in the prevalence of MCI using clinical notes over the past 5 years in the Veteran Affairs, the largest integrated healthcare system in the U.S. Method: Prevalent cases of MCI were identified from VA clinical notes for all Veterans aged 50 years and older in VA care from fiscal years (FYs) 2015‐19. VA clinical notes are maintained in searchable text integration utility files (TIU) available in the VA Corporate Data Warehouse (CDW). Pharmacy clinical notes were excluded. "Mild cognitive impairment" keyword was searched in clinical notes to identify patients with MCI. We validated the keyword "mild cognitive impairment" in 199 clinical notes. The positive predictive value for this validation was approximately 91%. For each FY, age and sex adjusted rates directly standardized to the 2010 U.S. Census general population were estimated. Result: A total of 308,930 prevalent cases of MCI were identified from VA clinical notes from FYs 2015‐19. Standardized prevalence rates for MCI increased steeply, with prevalence of 0.9% in FY 2015, increasing to 1.31% in FY 2019. Standardized age adjusted MCI prevalence rates also increased sharply for male (0.77% in FY 2015 to 1.10% in FY 2019) and female veterans (1.01% in FY 2015 to 1.50% in FY 2019) with rates higher for females than males for each FY. Conclusion: We observed recent trends of increasing prevalence rates for MCI among veterans identified from VA clinical notes. Considering the increased risk of dementia among individuals with MCI, our study finding of increasing prevalence of MCI among veterans highlights the critical need for effective interventions and treatment to target veterans with MCI. [ABSTRACT FROM AUTHOR]

Background: Alzheimer's disease (AD) typically progresses in three stages: mild, moderate, and severe. Early detection improves patient care related to identification of suitable interventions and end‐of‐life planning. However, AD severity diagnosis is uncommon. The aim of this study is to identify Veterans in various stages of AD using clinical notes in the Veterans Affairs Healthcare System. Method: Notes containing "Alz*" from fiscal year 2019 were identified then screened for information indicating a clinical diagnosis of probable AD. Screened notes with AD severity keywords (mild, moderate, severe, early, late, advanced) within four words of "Alz*" were considered as a severity diagnosis. Notes containing a single AD severity diagnosis were included in the study. Result: 141,816 Veterans with 547,318 notes containing "Alz*" were identified as probable AD cases. Roughly 9% of notes contained at least one severity keyword and 6% of notes contained a single severity keyword. 34,181 notes with a single severity keyword from 14,148 Veterans were included in this study. The cohort comprised of 96% males and 78% identified as White with a mean age of 79. Ten percent of Veterans with an AD note included severity diagnosis. Approximately 19%, 12%, 18%, 20%, 3%, and 28% of severity notes contained mild, moderate, severe, early, late, and advanced, respectively. The mean age for Veterans with a mild, moderate, or severe AD diagnosis increased from 78 to 81. The mean age for early, late, and advanced AD patients increased from 74, 79, and 81, respectively. AD severity diagnosis was found in notes related to primary care (11%), internal medicine (10%), psychiatry (8%), mental health (7%), neurology (6%), geriatric (5%), neuropsychology (1%), and psychology (1%). Conclusion: AD severity diagnosis is uncommon. Identification of patients in various stages of AD will lead to a better understanding of transition from one severity to another and facilitate the coordination of services to improve patient care. Specifically, identification of AD patients in the early stage may identify candidates for novel therapeutics focused on delaying AD progression. [ABSTRACT FROM AUTHOR]

Background: The current standard of practice for assessment of Alzheimer's disease (AD) severity in the Department of Veterans Affairs (VA) Healthcare System is primarily based on clinical examination and cognitive testing. We aimed to assess the consistency between clinician judgements of AD severity compared with that classified by cognitive test scores in the VA system. Method: We identified medical notes for patients with mild, moderate, or severe AD from the VA electronic healthcare records (EHR) database between March 2008 and October 2021, using the natural language processing technology. Mini‐Mental Status Exam (MMSE) and Montreal Cognitive Assessment (MoCA) scores from the corresponding medical notes with physician judgments were classified and used for comparisons of severity levels. A binary variable was coded to indicate concordance or discordance for each paired comparison. Result: We screened clinical notes from 51,809 AD patients and analyzed 8,888 clinical notes that had either an MMSE or MoCA test score from 5,150 AD patients (3.5% female; average age at 78.1±9.4 years). Clinician judgements and test‐score‐based classification of AD severity were concordant in 53.2% of comparisons (weighted Kappa = 0.39, 95% CI:0.38‐0.41, p = 0.009); whereas clinician judgments were less severe in 25.7% and more severe in 21.1% comparisons, relative to the test‐score‐based severity level. Clinician judgments were concordant with 54.1%, 51.8%, and 53.0% cognitive test‐score‐based classifications, of mild, moderate, and severe AD, respectively. Concordance was observed in 55.9% clinician judgments involving internist, 53.0% involving psychiatrist or neurologist, and 51.7% involving psychologist specialties, and in 50.4% involving nurse practitioners. Among discordant severity classifications, clinician judgments tended to be less severe than test scores (Figure). Conclusion: Examination of VA EHR reveals that nearly one half of clinician judgments of AD severity are discordant with severity classification based on the MMSE or MoCA test scores. Discordance is more pronounced in the moderate relative to mild and severe AD categories but does not vary substantially over clinicians' specialty background. Research will aim to find plausible explanations for the variation of concordance vs discordance by further examining the relative contributions of patient, clinician, and system characteristics in the process of AD clinical assessments. [ABSTRACT FROM AUTHOR]

Objective: To determine predictors of serious adverse events (SAEs) involving syncope, hypotension, and falls, with particular attention to age, in the Systolic Blood Pressure Intervention Trial. Design: Randomized clinical trial. Setting: Academic and private practices across the United States (N = 102). Participants: Adults aged 50 and older with a systolic blood pressure (SBP) of 130 to 180 mmHg at high risk of cardiovascular disease events, but without diabetes, history of stroke, symptomatic heart failure or ejection fraction less than 35%, dementia, or standing SBP less than 110 mmHg (N = 9,361). Intervention: Treatment of SBP to a goal of less than 120 mmHg or 140 mmHg. Measurements: Outcomes were SAEs involving syncope, hypotension, and falls. Predictors were treatment assignment, demographic characteristics, comorbidities, baseline measurements, and baseline use of cardiovascular medications. Results: One hundred seventy‐two (1.8%) participants had SAEs involving syncope, 155 (1.6%) hypotension, and 203 (2.2%) falls. Randomization to intensive SBP control was associated with greater risk of an SAE involving hypotension (hazard ratio (HR) = 1.67, 95% confidence interval (CI) = 1.21–2.32, P = .002), and possibly syncope (HR = 1.32, 95% CI = 0.98–1.79, P = .07), but not falls (HR = 0.98, 95% CI = 0.75–1.29, P = .90). Risk of all three outcomes was higher for participants with chronic kidney disease or frailty. Older age was also associated with greater risk of syncope, hypotension, and falls, but there was no age‐by‐treatment interaction for any of the SAE outcomes. Conclusions: Participants randomized to intensive SBP control had greater risk of hypotension and possibly syncope, but not falls. The greater risk of developing these events associated with intensive treatment did not vary according to age. [ABSTRACT FROM AUTHOR]

Objectives To determine the extent of concern about falling in older adults with hypertension, whether lower blood pressure ( BP) and greater use of antihypertensive medications are associated with greater concern about falling, and whether lower BP has a greater effect on concern about falling in older and more functionally impaired individuals. Design Secondary analysis involving cross-sectional study of baseline characteristics of participants enrolled in the Systolic Blood Pressure Intervention Trial ( SPRINT). Setting Approximately 100 outpatient sites. Participants SPRINT enrollees aged 50 and older (mean age 69) diagnosed with hypertension (N = 2,299). Measurements Concern about falling was determined using the shortened version of the Falls Efficacy Scale International as measured at the baseline examination. Results Mild concern about falling was present in 29.3% of participants and moderate to severe concern in 17.9%. Neither low BP (systolic BP<120 mmHg, diastolic BP <70 mmHg) nor orthostatic hypotension was associated with concern about falling ( P > .10). Participants with moderate to severe concern about falling were taking significantly more antihypertensive medications than those with mild or no concern. After adjusting for baseline characteristics, no associations were evident between BP, medications, and concern about falling. Results were similar in older and younger participants; interactions between BP and age and functional status were not significantly associated with concern about falling. Conclusion Although concern about falling is common in older adults with hypertension, it was not found to be associated with low BP or use of more antihypertensive medications in baseline data from SPRINT. [ABSTRACT FROM AUTHOR]

Background: We evaluated healthcare utilization patterns to understand the care pathways for Veterans with Alzheimer's disease (AD) from the Department of Veterans Affairs (VA) healthcare system. Method: VA electronic health records (EHR) were used to extract data from clinical notes and identify patients with AD. The patient cohort was merged with the VA Informatics and Computing Infrastructure (VINCI) administrative database from October 2008–to October 2021 to obtain systematic healthcare utilization records including total inpatient admissions and outpatient visits. A control group was extracted for comparison and matched to the patient cohort using the propensity score on age, sex, and race. A linear mixed‐effects model was used to compare the total outpatient and inpatient utilization, adjusting for patient demographics and comorbidities. Result: We extracted 21,442 AD patients from the EHR clinical notes. A cohort of 85,684 non‐AD and non‐dementia Veterans was constructed as a control group. In the AD vs control groups, the mean age was 82 vs 79 years, 83 vs 84% was White, and 97% were male in both groups. The number of annual outpatient visits 1 year before, and at 1 and 2 years after the first AD diagnosis code was 30, 34 and 27, respectively. The control group maintained 12 annual outpatient visits throughout the three‐year period. The average annual hospital admission rate was 1.8 vs 1.7 in the AD vs control group. The average length of inpatient stay in the year prior to the first AD diagnostic code was 23.1 days, increased to 27.4 days at year 1 after AD diagnosis, and declined back to 20.5 days at year 2, as compared to 13.1, 13.0, and 11.9 days, respectively, in the control group. The mixed‐effects analysis showed significantly higher healthcare utilization trends across VA outpatient and inpatient care settings (p<0.001) in the AD vs control groups, after controlling for age, gender, race, ethnicity, and select comorbidities. Conclusion: Healthcare resource utilization in patients with AD identified from the medical notes is more than doubled that in outpatient care and nearly doubled in inpatient length of stay relative to the matched controls in the VA healthcare system. [ABSTRACT FROM AUTHOR]

Objectives To measure association between self-reported function and an adverse postoperative course and improvement in performance on the American College of Surgeons Universal Risk Calculator ( ACS calculator) with inclusion of self-reported function available through the Veteran Rand-12 based Physical Component Summary ( PCS) and Mental Component Summary ( MCS) scores. Design Cohort analysis. Setting Veteran Affairs health system. Participants Surgeries (n = 3,503) for older male veterans undergoing hip and knee replacement from 2002 to 2009. Measurements Serious complication (per ACS definition), discharge to facility, readmission, and death within 30 days after surgery as a function of PCS and MCS; comparison of prediction of net reclassification index ( NRI) for serious complication using a modified version of the ACS calculator with prediction using the ACS calculator with MCS and PCS added. Results Being in the lowest PCS quartile (vs highest quartile) predicted more than twice the risk of a serious complication (odds ratio ( OR) = 2.27, 95% confidence interval ( CI) = 1.44-3.58), twice the risk of discharge to facility ( OR = 1.97, 95% CI = 1.39-2.79), and almost twice the risk of readmission ( OR = 1.80, 95% CI = 1.37-2.36). The lowest quartile of MCS predicted each outcome, although to a lesser extent than PCS. The enhanced model had a NRI of 29.4% (95% CI = 15.4-43.3%), reflecting that 20.8% of events were appropriately upgraded and 8.6% of nonevents appropriately downgraded. Conclusion Low PCS and MCS predicted an adverse postoperative course and enhanced the ACS calculator. Clinicians evaluating older adults undergoing orthopedic surgery could enhance the accuracy of their assessments by including self-reported functional status. [ABSTRACT FROM AUTHOR]

Objectives To examine facility-level pressure ulcer (PrU) development rates and variations in these rates after a system-wide adoption of culture change in Veterans Health Administration (VHA) nursing homes. Design Four-year retrospective longitudinal design. Setting VHA facilities (N = 109) representing 132 nursing homes known as community living centers (CLCs). Participants VHA nursing home residents. Measurements PrUs were identified using fiscal year (FY) 2008-11 Minimum Data Set (MDS) data. PrU development was defined as a Stage 2 or larger PrU on an MDS assessment with no PrU on the previous assessment. A risk adjustment model was developed using 105,274 MDS observations to predict the likelihood of PrUs (c-statistic = 0.72). A Bayesian hierarchical model that adjusted for differences in the precision of PrU rates from different-size facilities was used to calculate smoothed risk-adjusted (SRA) rates for each facility. The statistical significance of the trend over the 4 years was determined by examining the 95% interval estimate for the slope. Results Over the 4-year period, the beginning of which coincided with the VHA's system-wide adoption of culture change as a performance measure, median SRA facility PrU development rates were fairly consistent at approximately 4%. The range in SRA rates declined over the years, from a 14.8-percentage point spread to 10.1-percentage point spread. Some facilities had significantly improving SRA rates (e.g., declined steadily from 5.5% to 3.9%) and some had significantly worsening SRA rates (e.g., increased steadily from 5.1% to 7.9%). Seven sites had significantly improving rates ( P < .001) that were below the median across all 4 years. Conclusion A system-wide culture change implementation did not affect CLC PrU development rates, but there was significant variation in facility rates, and some facilities had sustained high performance. [ABSTRACT FROM AUTHOR]

Objectives To identify older adults with comorbidities or poor functional status at high risk of postoperative venous thromboembolism ( VTE). Design Retrospective cohort study. Setting Veterans Affairs Medical Center ( VAMC). Participants Older adults who underwent total hip and knee replacement ( THR and TKR) from 2002 to 2009. Measurements Using multivariate logistic regression, the independent effect of cardiopulmonary comorbidities and diabetes on VTE was analyzed. Functional status expressed in a summary physical component score ( PCS) was also analyzed in a subset of individuals in whom information on it was available. Results There were 23,326 THR and TKR surgeries performed at the VAMC during the study period. Individuals with chronic obstructive pulmonary disease ( COPD) had a 25% greater risk of VTE (odds ratio ( OR) = 1.25, 95% confidence interval ( CI) = 1.06-1.48), whereas those with coronary artery disease, congestive heart failure, and cerebrovascular disease did not have a greater risk of VTE. Individuals with diabetes mellitus had a lower risk of VTE ( OR = 0.77, 95% CI = 0.64-0.92). Individuals with low PCS, which were available for 3,169 patients, had a 62% greater risk, although the effect did not reach statistical significance (lowest vs highest quartile OR = 1.62, 95% CI = 0.93-2.80). Conclusion Individuals with COPD had slightly greater risk of VTE, whereas low functional status had a larger effect that did not reach statistical significance. The constraints of administrative data analysis and sample size available for PCS limit conclusions about the role of these comorbidities and functional status. [ABSTRACT FROM AUTHOR]

Objective To demonstrate the value of shrinkage estimators when calculating a composite quality measure as the weighted average of a set of individual quality indicators. Data Sources Rates of 28 quality indicators ( QIs) calculated from the minimum dataset from residents of 112 Veterans Health Administration nursing homes in fiscal years 2005-2008. Study Design We compared composite scores calculated from the 28 QIs using both observed rates and shrunken rates derived from a Bayesian multivariate normal-binomial model. Principal Findings Shrunken-rate composite scores, because they take into account unreliability of estimates from small samples and the correlation among QIs, have more intuitive appeal than observed-rate composite scores. Facilities can be profiled based on more policy-relevant measures than point estimates of composite scores, and interval estimates can be calculated without assuming the QIs are independent. Usually, shrunken-rate composite scores in 1 year are better able to predict the observed total number of QI events or the observed-rate composite scores in the following year than the initial year observed-rate composite scores. Conclusion Shrinkage estimators can be useful when a composite measure is conceptualized as a formative construct. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine the change in use of high-risk medications for the elderly (HRME), as defined by the National Committee on Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) quality measure (HEDIS HRME), by older outpatient veterans over a 3-year period and to identify risk factors for HEDIS HRME exposure overall and for the most commonly used drug classes. DESIGN: Longitudinal retrospective database analysis. SETTING: Outpatient clinics within the Department of Veterans Affairs (VA). PARTICIPANTS: Veterans aged 65 by October 1, 2003, and who received VA care at least once each year until September 30, 2006. MEASUREMENTS: Rates of use of HEDIS HRME overall and according to specific drug classes each year from fiscal year 2004 (FY04) to FY06. RESULTS: In a cohort of 1,567,467, high-risk medication exposure fell from 13.1% to 12.3% between FY04 and FY06 ( P<.001). High-risk antihistamines (e.g., diphenhydramine), opioid analgesics (e.g., propoxyphene), skeletal muscle relaxants (e.g., cyclobenzaprine), psychotropics (e.g., long half-life benzodiazepines), endocrine (e.g., estrogen), and cardiac medications (e.g., short-acting nifedipine) had modest but statistically significant ( P<.001) reductions (range −3.8% to −16.0%); nitrofurantoin demonstrated a statistically significant increase (+36.5%; P<.001). Overall HEDIS HRME exposure was more likely for men, Hispanics, those receiving more medications, those with psychiatric comorbidity, and those without prior geriatric care. Exposure was lower for individuals exempt from copayment. Similar associations were seen between ethnicity, polypharmacy, psychiatric comorbidity, access-to-care factors, and use of individual HEDIS HRME classes. CONCLUSION: HEDIS HRME drug exposure decreased slightly in an integrated healthcare system. Risk factors for exposure were not consistent across drug groups. Future studies should examine whether interventions to further reduce HEDIS HRME use improve health outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify prevalence and risk factors for exposure to drug-disease interactions included in the Healthcare Effectiveness Data and Information Set (HEDIS) Drug-Disease Interaction (Rx-DIS) measure. DESIGN: Cross-sectional retrospective database analysis. SETTING: Outpatient clinics within the Department of Veterans Affairs (VA). PARTICIPANTS: Individuals aged 65 and older who received VA outpatient care between October 1, 2003, and September 30, 2006. MEASUREMENTS: Rx-DIS exposure based on the HEDIS measure was identified in VA patients with dementia, falls, and chronic renal failure using VA pharmacy and administrative databases. Factors associated with Rx-DIS exposure were examined, including demographic, health status, and access-to-care factors, including VA outpatient health services use and copayment status. RESULTS: Of the 305,041 older veterans who met criteria for inclusion, the 1-year prevalence of Rx-DIS exposure was 15.2%; prevalence was 20.2% for dementia, 16.2% for falls, and 8.5% for chronic renal failure. Patients with high disease burden (physical, psychiatric, number of medications) were significantly more likely to have Rx-DIS exposure, regardless of condition. Hispanics and individuals with no copayments were more likely to have Rx-DIS exposure than whites or those with required copayments. There was variation in other predictors based on the type of Rx-DIS. CONCLUSION: The prevalence of Rx-DIS was common in older VA outpatients. Future studies should examine the risk of Rx-DIS exposure on health outcomes using separate analyses for each type of Rx-DIS separately before combining all Rx-DIS into a single measure of exposure. Studies that examine the effectiveness of interventions to reduce Rx-DIS exposure will also be helpful in improving the quality of care for older adults. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine prevalence and resident- and site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants in older Veterans Affairs (VA) Community Living Center (CLC) residents. DESIGN: Longitudinal study. SETTING: One hundred thirty-three VA CLCs. PARTICIPANTS: Three thousand six hundred ninety-two veterans aged 65 and older admitted between January 1, 2004, and June 3, 2005, with long stays (≥90 days). MEASUREMENTS: Prevalence of potential underuse, inappropriate use, and overuse of antidepressants in residents with and without depression (as documented according to International Classification of Diseases, Ninth Revision, Clinical Modification, codes or Depression Rating Scale). RESULTS: Selective serotonin reuptake inhibitors were the most commonly prescribed antidepressant. Of the 877 residents with depression, 25.4% did not receive an antidepressant, suggesting potential underuse. Of residents with depression who received antidepressants, 57.5% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. Of the 2,815 residents who did not have depression, 1,190 (42.3%) were prescribed one or more antidepressants; only 48 (4.0%) of these had a Food and Drug Administration-approved labeled indication, suggesting potential overuse. Overall, only 17.6% of antidepressant use was appropriate (324/1,844). The only consistent resident factor associated with potential underuse and overuse use was taking an antipsychotic without evidence of schizophrenia (underuse: adjusted relative risk ratio (ARRR)=0.56, 95% confidence interval (CI)=0.33-0.94; overuse: adjusted odds ratio=1.52, 95% CI=1.21-1.91). Having moderate to severe pain (ARRR=1.54, 95% CI=1.08-2.20) and the prescribing of an anxiolytic or hypnotic (ARRR=1.33, 95% CI=1.02-1.74) increased the risk of potential inappropriate antidepressant use. CONCLUSION: Potential problems with the use of antidepressants were frequently observed in older U.S. veteran CLC residents. Future studies are needed to examine the true risks and benefits of antidepressant use in CLC and non-VA nursing homes. [ABSTRACT FROM AUTHOR]

Clinicians are often uncertain about how to manage elevated blood pressure (BP) when a patient reports that he/she has recently missed several doses of antihypertensive medications. While we know that better adherence can improve BP during several months, the magnitude of this relationship in the short term is poorly understood. The authors examined this issue using a group of patients who monitored adherence using a Medication Events Monitoring System (MEMS) cap and had BP measurements in the course of routine clinical practice. BP readings were compared following 7 days of excellent adherence (100%) or poor adherence (<60%), omitting BP values following intermediate adherence. Using several different methods, BP following 7 days of excellent adherence was between 12/7 mm Hg and 15/8 mm Hg lower than after 7 days of poor adherence. Clinicians can use this effect size to calibrate their impressions of what the BP might have been with improved adherence. J Clin Hypertens (Greenwich). 2011;13:416-421. ©2011 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

In this article, we study a Bayesian hierarchical model for profiling health-care facilities using approximately sufficient statistics for aggregate facility-level data when the patient-level data sets are very large or unavailable. Starting with a desired patient-level model, we give several approximate models and the corresponding summary statistics necessary to implement the approximations. The key idea is to use sufficient statistics from an approximate model fitted by matching up derivatives of the models' log-likelihood functions. This derivative matching approach leads to an approximation that performs better than the commonly used approximation given in the literature. The performance of several approximation approaches is compared using data on 5 quality indicators from 32 Veterans Administration nursing homes. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives. To compare the Veterans Health Administration (VHA) with the Medicare Advantage (MA) plans with regard to health outcomes. Data Sources. The Medicare Health Outcome Survey, the 1999 Large Health Survey of Veteran Enrollees, and the Ambulatory Care Survey of Healthcare Experiences of Patients (Fiscal Years 2002 and 2003). Study Design. A retrospective study. Extraction Methods. Men 65+ receiving care in MA ( N=198,421) or in VHA ( N=360,316). We compared the risk-adjusted probability of being alive with the same or better physical (PCS) and mental (MCS) health at 2-years follow-up. We computed hazard ratio (HR) for 2-year mortality. Principal Findings. Veterans had a higher adjusted probability of being alive with the same or better PCS compared with MA participants (VHA 69.2 versus MA 63.6 percent, p<.001). VHA patients had a higher adjusted probability than MA patients of being alive with the same or better MCS (76.1 versus 69.6 percent, p<.001). The HRs for mortality in the MA were higher than in the VHA (HR, 1.26 [95 percent CI 1.23–1.29]). Conclusions. Our findings indicate that the VHA has better patient outcomes than the private managed care plans in Medicare. The VHA's performance offers encouragement that the public sector can both finance and provide exemplary health care. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify clinically meaningful potential drug–drug interactions (PDIs) with antiepileptic drugs (AEDs), the AEDs and co-administered drugs commonly associated with AED-PDIs, and characteristics of patients with high likelihood of AED-PDI exposure. DESIGN: Five-year retrospective cohort study of veterans with new-onset epilepsy. SETTING: National Veterans Affairs and Medicare databases. PARTICIPANTS: Veterans aged 66 and older with a new diagnosis of epilepsy between October 1, 1999, and September 30, 2004 (N=9,682). MEASUREMENTS: AED-PDI was restricted to clinically meaningful PDIs identified using prior literature review. AED-PDIs were identified using participants' date of initial AED prescription and overlapping concomitant medications. Logistic regression analysis identified factors associated with AED-PDI, including demographic characteristics, chronic disease states, and diagnostic setting. RESULTS: AED-PDI exposure was found in 45.5% (4,406/9,682); phenytoin, a drug with many PDIs, was the most commonly prescribed AED. Cardiovascular drugs, lipid-lowering medications, and psychotropic agents were the most commonly co-administered AED-PDI medications. Individuals with AED-PDI exposure were more likely to have hypertension (odds ratio (OR)=1.46, 99% confidence interval (CI)=1.24–1.82) and hypercholesterolemia (OR=1.40, 99% CI=1.24–1.57) than those without and to be diagnosed in an emergency or primary care setting than a neurology setting (emergency: OR=1.30, 99% CI=1.08–1.58; primary care: OR=1.29 99% CI=1.12–1.49). CONCLUSION: Exposure to AED-PDI was substantial but less common in patients with epilepsy diagnosed in a neurology setting. Because potential outcomes associated with AED-PDI include stroke and myocardial infarction in a population already at high risk, clinicians should closely monitor blood pressure, coagulation, and lipid measures to minimize adverse effects of AED-PDIs. Interventions to reduce AED-PDIs may improve patient outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify risk factors for new-onset geriatric epilepsy that may trigger clinicians to consider a differential diagnosis of epilepsy at symptom onset. DESIGN: Retrospective cohort study. SETTING: National Veterans Affairs (VA) databases. PARTICIPANTS: Veterans aged 66 and older in fiscal year 2000 (FY00) who received VA care in FY99 and FY00. Individuals with new-onset epilepsy based on a validated algorithm constituted the epilepsy cohort (n=1,843), and individuals without epilepsy constituted the geriatric cohort (n=1,023,376). MEASUREMENTS: Age, sex, and race were derived from VA databases. Clinical conditions associated with new-onset geriatric epilepsy (e.g., cerebrovascular disease, dementia, brain tumor) and stroke risk-factors (e.g., hypertension, diabetes mellitus, cardiovascular disease) were identified using validated International Classification of Diseases, Ninth Revision, Clinical Modification, codes before epilepsy onset (epilepsy cohort) and in FY00 (geriatric cohort). RESULTS: Multivariable logistic regression analysis indicated that patients with cerebrovascular disease (odds ratio (OR)=3.50, 95% confidence interval (CI)=3.13–3.91), cerebrovascular disease and dementia (OR=4.14, 95% CI=3.46–4.96), brain tumor (OR=2.14, 95% CI=1.46–3.13), head injury (OR=2.11, 95% CI=1.41–3.14), and other central nervous system (CNS) conditions (OR=1.57, 95% CI=1.32–1.88) were more likely to experience new-onset epilepsy. Statin prescription (OR=0.64, 95% CI=0.56–0.73), older age (≥85 vs 66–74, OR=0.66, 95% CI=0.50–0.87), obesity (OR=0.74, 95% CI=0.62–0.87), and hypercholesterolemia (OR=0.87, 95% CI=0.76–0.98) were associated with a lower likelihood of epilepsy. CONCLUSION: These data suggest greater epilepsy risk for older individuals with CNS insult and an additive effect of cerebrovascular disease and dementia. The statin finding requires further exploration but points to a possible target for prevention of geriatric epilepsy. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To test the accuracy of a brief cognitive assessment of nursing home (NH) residents and to determine whether facility nurses can reliably perform this assessment. DESIGN: Cross-sectional, independent cognitive screening tests with NH residents. SETTING: Six Department of Veteran Affairs nursing facilities. PARTICIPANTS: Three hundred seventy-four residents from six regionally distributed Veteran Affairs NHs. MEASUREMENTS: Three cognitive assessment instruments: the Brief Interview of Mental Status (BIMS), created for this study; the Minimum Data Set (MDS) 2.0 Cognitive Performance Scale (CPS), and the Modified Mini-Mental State Examination (3MS) as the criterion standard. The 15-point BIMS tests memory and orientation and includes free and cued recall items. Research assistants administered the 3MS and BIMS to all subjects. Facility nurses administered the same BIMS to a subsample. RESULTS: Three hundred seventy-four of 417 (89.7%) residents approached completed the 3MS and research assistant–administered BIMS (BIMS-R); 212 residents also received a facility nurse–administered BIMS (BIMS-N). The BIMS-R was more highly correlated with the 3MS than was the CPS (Pearson correlation coefficient ( r)=0.79 vs 0.62; P<.01 for difference). For the subset who received facility assessments, the BIMS-N was also more highly correlated with the 3MS (Pearson r=0.74 vs 0.65; P<.01 for difference). For any impairment (3MS<78), the area under the receiver operator characteristic curve (AUC) was 0.86 for the BIMS, versus 0.77 for the CPS. For severe impairment (3MS<48) the AUC was 0.94, versus 0.85 for the CPS. CONCLUSION: In this population, a brief cognitive test is a more accurate approach to cognitive assessment than the current observational methods employed using the MDS 2.0. [ABSTRACT FROM AUTHOR]

The authors sought to determine the prescribing practices of clinicians treating veterans with hypertension. A descriptive analysis was performed using a national pharmacy database of patients with a diagnosis of hypertension receiving antihypertensive medication in the fiscal years 2000 to 2006. Angiotensin-converting enzyme inhibitors were the most frequently prescribed antihypertensive class, with utilization increasing from 56.0% in fiscal year 2000 to 63.2% of patients in 2006. Utilization of thiazide-type diuretics increased from 31.9% of patients in fiscal year 2000 to 42.0% in 2006. When patient comorbidities were taken into consideration, 48.1% of patients defined as having uncomplicated hypertension had at least one prescription for a thiazide diuretic in fiscal year 2006. Utilization by monotherapy and combination therapy were also evaluated. The trends in utilization allowed for identification of areas in which a change in prescribing practices may improve blood pressure control and health outcomes in the Veterans Health Administration. [ABSTRACT FROM AUTHOR]

The relative contributions of adherence and treatment intensity to blood pressure (BP) control are not well understood. The authors studied patients with uncontrolled hypertension (N=410) from 3 primary care clinics in the Veterans Affairs (VA) medical system. A questionnaire was used to assess patient adherence to therapy, and VA system pharmacy fills were used to assess the intensity of the antihypertensive regimen. At baseline, an inadequate antihypertensive regimen was implicated as the most probable reason for uncontrolled BP in a majority of patients (72%), while nonadherence could only be implicated in 13%. In multivariate longitudinal analyses, patients who had an increase in their medical treatment during the study had lower final diastolic BP levels compared with the patients who did not (−3.70 mm Hg; P <.05). While patient adherence to therapy plays a role, vigorous clinical management by the clinician is a more important contributor to BP control. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the relationship between blood pressure (BP) and all-cause mortality in subjects aged 80 and older with hypertension. DESIGN: Retrospective cohort study with 5 years of follow-up. SETTING: Ten Veterans AFFAIRS (VA) sites. PARTICIPANTS: Four thousand seventy-one ambulatory patients aged 80 and older with hypertension. MEASUREMENTS: The outcome measure was likelihood of survival during the follow-up period. Vital status was obtained from VA and Social Security files. Variables collected for adjustment in Cox regression models were baseline BP, medications, demographics, diagnoses, and health-related quality of life (HRQoL); HRQoL information was available on 1,289 subjects based on Veterans Health Study Short From-36 (SF-36) questionnaire scores. RESULTS: Subjects with higher BP (up to a systolic BP (SBP) of 139 mmHg and a diastolic BP (DBP) of 89 mmHg) were less likely to die during follow-up than subjects with lower BP. After baseline adjustments, the hazard ratio for a 10-point increase in SBP was 0.82 (95% confidence interval (CI)=0.74–0.91), up to a SBP of 139 mmHg, and for DBP was 0.85 (95% CI=0.78–0.92), up to a DBP of 89 mmHg. There was no significant association between survival and BP levels in subjects with uncontrolled hypertension. CONCLUSION: In a cohort of very old, hypertensive veterans, in subjects with controlled BPs, subjects with lower BP levels had a lower 5-year survival than those with higher BPs. This suggests that clinicians should use caution in their approach to BP lowering in this age group. [ABSTRACT FROM AUTHOR]

Purpose Beta-blockers have many different physiologic effects that could potentially influence the risk of hemorrhagic events in chronic heart failure patients (CHF) on warfarin. We examined how different beta-blockers vary in their associated risk of a hemorrhagic event. Methods We used databases from the Department of Veterans Affairs (VA) that contain information on medications prescribed, diagnoses, and hospitalizations. We identified patients with CHF on warfarin and either metoprolol, carvedilol, atenolol, or no beta-blocker during 1999-2001. We modeled time to first hemorrhagic event using a Cox proportional hazards model, adjusting for age, ethnicity, comorbidities, and other factors. INR levels were examined in a subsample of 3546 patients. Results We identified 66 988 CHF patients on warfarin. Hemorrhagic events occurred in 15.3% of the sample and, in 3.8% of the sample, the hemorrhage was considered severe. Compared to patients on carvedilol, the hazards ratio for a new hemorrhagic event was 1.25 (1.17, 1.34) for no beta-blocker, 1.27 (1.18, 1.38) for atenolol, and 1.38 (1.28, 1.48) for metoprolol. No differences in INR levels were evident among the four groups. Conclusions The risk for a hemorrhagic event among CHF patients on warfarin may be affected by beta-blocker use and varies depending on which beta-blocker is prescribed. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective. To develop an instrument for assessing physician attitudes toward quality incentive programs, and to assess its reliability and validity. Data Sources. Study involved primary data collection. A 40-item paper and pencil survey of primary care physicians in Rochester, New York, and Massachusetts was conducted between May 2004 and December 2004. Seven-hundred and ninety-eight completed questionnaires were received, representing a response rate of 32 percent (798/2,497). Study Design. Based on an extensive review of the literature and discussions with experts in the field, we developed a conceptual framework representing the features of pay-for-performance (P4P) programs hypothesized to affect physician behavior in that context. A draft questionnaire was developed based on that conceptual model and pilot tested in three groups of physicians. The questionnaire was modified based on the physician feedback, and the revised version was distributed to 2,497 primary care physicians affiliated with two of the seven sites participating in Rewarding Results, a national evaluation of quality target and financial incentive programs. Data Collection. Respondents were randomly divided into a derivation and a validation sample. Exploratory factor analysis was applied to the responses of the derivation sample. Those results were used to create scales in the validation sample, and these were then subjected to multitrait analysis (MTA). One scale representing physicians' perception of the impact of P4P on their clinical practice was regressed on the other scales as a test of construct validity. Principal Findings. Seven constructs were identified and demonstrated substantial convergent and discriminant validity in the MTA: awareness and understanding, clinical relevance, cooperation, unintended consequences, control, financial salience, and impact. Internal consistency reliabilities (Cronbach's α coefficients) ranged from 0.50 to 0.80. A statistically significant 25 percent of the variation in perceived impact was accounted for by physician perceptions of the other six characteristics of P4P programs. Conclusions. It is possible to identify and measure the key salient features of P4P programs using a valid and reliable 26-item survey. This instrument may now be used in further studies to better understand the impact of P4P programs on physician behavior. [ABSTRACT FROM AUTHOR]

Objective. To develop a valid quality measure that captures clinical inertia, the failure to initiate or intensify therapy in response to medical need, in diabetes care and to link this process measure with outcomes of glycemic control. Data Sources. Existing databases from 13 Department of Veterans Affairs hospitals between 1997 and 1999. Study Design. Laboratory results, medications, and diagnoses were collected on 23,291 patients with diabetes. We modeled the decision to increase antiglycemic medications at individual visits. We then aggregated all visits for individual patients and calculated a treatment intensity score by comparing the observed number of increases to that expected based on our model. The association between treatment intensity and two measures of glycemic control, change in HbA1c during the observation period, and whether the outcome glycosylated hemoglobin (HbA1c) was greater than 8 percent, was then examined. Principal Findings. Increases in antiglycemic medications occured at only 9.8percent of visits despite 39percent of patients having an initial HbA1c level greater than 8 percent. A clinically credible model predicting increase in therapy was developed with the principal predictor being a recent HbA1c greater than 8 percent. There were considerable differences in the intensity of therapy received by patients. Those patients receiving more intensive therapy had greater improvements in control ( p<.001). Conclusions. Clinical inertia can be measured in diabetes care and this process measure is linked to patient outcomes of glycemic control. This measure may be useful in efforts to improve clinicians management of patients with diabetes. [ABSTRACT FROM AUTHOR]

To identify the extent of inappropriate prescribing using criteria for proper use developed by the Agency for Healthcare Research and Quality (AHRQ) and dose-limitation criteria defined by Beers, as well as to describe duration of use and patient characteristics associated with inappropriate prescribing for older people. Retrospective national Veterans Health Administration (VA) administrative database analysis. VA outpatient facilities during fiscal year 2000 (FY00). Veterans aged 65 and older having at least one VA outpatient visit in FY00 (N=1,265,434). Operational definitions of appropriate use were developed based on recommendations of an expert panel convened by the AHRQ (Zhan criteria). Inappropriate use was identified based on these criteria and inappropriate use of drugs per Beers criteria for dose-limitations in older people. Furthermore, duration of use and patient characteristics associated with inappropriate use were described. After adjusting for diagnoses, dose, and duration, inappropriate prescribing decreased from 33% to 23%. Exposure to inappropriate drugs was prolonged. Pain relievers, benzodiazepines, antidepressants, and musculoskeletal agents constituted 61% of inappropriate prescribing. Whites, patients with psychiatric comorbidities, and patients receiving more medications were most likely to receive inappropriate drugs. Women were more likely to receive Zhan criteria drugs; men were more likely to receive dose-limited drugs For the most part, the Zhan criteria did not explain inappropriate prescribing, which includes problems related to dose and duration of prescriptions. Interventions targeted at prescriptions for pain relievers, benzodiazepines, antidepressants, and musculoskeletal agents may dramatically decrease inappropriate prescribing and improve patient outcomes. [ABSTRACT FROM AUTHOR]

To examine whether quality of care differed for veterans in Department of Veterans Affairs (VA) nursing homes and those on contract in community nursing homes and whether the VA was contracting with nursing homes providing better quality of care than other nursing homes.Observational study using administrative databases from 1997 to 1999.Ten VA and 650 community nursing homes in New York state.Four thousand seven hundred sixty-three veteran and 195,438 nonveteran residents of these nursing homes.Risk-adjusted rates of pressure ulcer development, functional decline, behavioral decline, and mortality.Veterans in VA nursing homes were significantly (P<.05) less likely to develop a pressure ulcer (odds ratio (OR)=0.63) but more likely to experience functional decline (OR=1.6) than veterans in community nursing homes. Residents of community nursing homes with VA contracts were significantly (P<.05) less likely to develop a pressure ulcer (OR=0.91) but more likely to die than residents in noncontract homes. Few nursing homes were consistently among the best or worst performers on all measures; only seven of 650 nursing homes were in the top or bottom decile and 34 in the top or bottom quartile for each measure.Large purchasers and providers of nursing home care such as the VA are unlikely to find information on quality of care useful in making decisions on whether they should“make” or“buy” care. Nursing homes performing well on one quality measure may perform poorly on another, and it is difficult to identify nursing homes that are consistently among the best or worst. Other consumers may encounter similar difficulties when using data on nursing home quality. [ABSTRACT FROM AUTHOR]

To examine the health status of elderly veteran enrollees, stratified by age group, and compare with nonveteran populations. Cross-sectional study. Outpatient. A total of 1,406,049 veteran enrollees were surveyed, and 887,775 returned the questionnaire (63.1%). Of these, 663,729 (74%) were aged 65 and older. Patient demographics, comorbid conditions, and health status, which was assessed using the Veterans 36-item short form (SF-36), a reliable and valid measure of health-related quality of life (HRQoL). Elderly veteran enrollees are a group with poor health status across all scales of the Veterans SF-36. Significant decline in HRQoL was found in patients grouped by increasing age (65–74, 75–84, and ≥85). Of the Veterans SF-36 scales, the role physical and role emotional scales and physical functioning presented the largest decrements by age group. The elderly veteran enrollees had poorer health status than older people enrolled in Medicare managed care, ranging from 0.5 to 1 standard deviations worse. Elderly veteran enrollees have substantial disease burden, as reflected by major impairments across multiple dimensions of HRQoL. These findings bear important implications for use of services, suggesting that the Veterans Health Administration will require considerable resources to provide care for its aging population. [ABSTRACT FROM AUTHOR]

To describe prescribing patterns for older veterans with epilepsy, determine whether disparity exists between these patterns and clinical recommendations, and describe those at greatest risk of receiving potentially inappropriate antiepileptic drugs (AEDs). Retrospective administrative database analysis. All outpatient facilities within the Department of Veterans Affairs (VA). All veterans aged 65 and older who had epilepsy diagnosed before the end of fiscal year 1999 (FY99) and who received AEDs from the VA in FY99 (N=21,435). National VA pharmacy data were used to determine the AED regimen based on the AEDs patients received during the year. Administrative data were used to describe demographic variables and to gauge disease severity and epilepsy onset. Approximately 17% of patients received phenobarbital and 54% phenytoin. Patients classified as having newly diagnosed disease were less likely to receive phenobarbital monotherapy and combination therapy and more likely to receive gabapentin or lamotrigine monotherapy (χ2=288.90, P<.001). Logistic regression analyses indicated that, for all patients, those with more severe disease were less likely to receive phenobarbital monotherapy than other monotherapy and phenobarbital combinations than other combinations. Those who received specialty consultation were less likely to receive phenytoin monotherapy than AED monotherapy, which is consistent with clinical recommendations. Most older veterans received potentially inappropriate AED therapy. Hence, the standard of care for older patients with epilepsy should be reevaluated, although the vast use of phenytoin in this population suggests that change in practice patterns may be difficult. [ABSTRACT FROM AUTHOR]

Objective. To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care. Data Sources/Study Settings. Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database. Study Design. A cross–sectional analysis of the association among the different measures was performed. Data Collection/Extraction Methods. Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk–adjusted rates of pressure ulcer development were calculated from an administrative database. Principal Findings. Nursing homes differed significantly (p<.001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1–point increase in QI score was associated with a 0.83 increase on the 5–point satisfaction scale, p<.001) and were more likely to report adoption of pressure ulcer clinical guidelines (a 1–point increase in QI score was associated with a 28 percent increase in number of staff reporting adoption, p<.001). No significant association was found, though, between QI implementation and either adherence to guideline recommendations as abstracted from records or the rate of pressure ulcer development. Conclusions. Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study aims to assess overall nursing home (NH) implementation of pressure ulcer (PU) prevention guidelines and variation in implementation rates among a geographically diverse sample of NHs. DESIGN: Review of NH medical records. SETTING: A geographically diverse sample of 35 Veterans Health Administration NHs. PARTICIPANTS: A nested random sample of 834 residents free of PU on admission. MEASUREMENTS: Adherence to explicit quality review criteria based on the Agency for Healthcare Research and Quality Practice Guidelines for PU prevention was measured. Medical record review was used to determine overall and facility-specific adherence rates for 15 PU guideline recommendations and for a subset of six key recommendations judged as most critical. RESULTS: Six thousand two hundred eighty-three instances were identified in which one of the 15 guideline recommendations was applicable to a study patient based on a specific indication or resident characteristic in the medical record. NH clinicians adhered to the appropriate recommendation in 41% of these instances. For the six key recommendations, clinicians adhered in 50% of instances. NHs varied significantly in adherence to indicated guideline recommendations, ranging from 29% to 51% overall adherence across all 15 recommendations (P < .001) and from 24% to 75% across the six key recommendations (P < .001). Adherence rates for specific indications also varied, ranging from 94% (skin inspection) to 1% (education of residents or families). Standardized assessment of PU risk was identified as one of the most important and measurable recommendations. Clinicians performed this assessment in only 61% of patients for whom it was indicated. CONCLUSIONS: NHs' overall adherence to PU prevention guidelines is relatively low and is characterized by large variations between homes in adherence to many recommendations. The low level of adherence and high level of variation to many best-care practices for PU... [ABSTRACT FROM AUTHOR]

Objective: To assess the performance of Diagnostic Cost Groups (DCGs) in explaining variation in concurrent utilization for a defined subgroup, patients with substance abuse (SA) disorders, within the Department of Veterans Affairs (VA).Data Sources: A 60 percent random sample of veterans who used health care services during Fiscal Year (FY) 1997 was obtained from VA administrative databases. Patients with SA disorders (13.3 percent) were identified from primary and secondary ICD-9-CM diagnosis codes.Study Design: Concurrent risk adjustment models were fitted and tested using the DCG/HCC model. Three outcome measures were defined: (1) "service days" (the sum of a patient's inpatient and outpatient visit days), (2) mental health/substance abuse (MH/SA) service days, and (3) ambulatory provider encounters. To improve model performance, we ran three DCG/HCC models with additional indicators for patients with SA disorders.Data Collection: To create a single file of veterans who used health care services in FY 1997, we merged records from all VA inpatient and outpatient files.Principal Findings: Adding indicators for patients with mild/moderate SA disorders did not appreciably improve the R-squares for any of the outcome measures. When indicators were added for patients with severe SA who were in the most costly category, the explanatory ability of the models was modestly improved for all three outcomes.Conclusions: Modifying the DCG/HCC model with additional markers for SA modestly improved homogeneity and model prediction. Because considerable variation still remained after modeling, we conclude that health care systems should evaluate "off-the-shelf" risk adjustment systems before applying them to their own populations. [ABSTRACT FROM AUTHOR]

OBJECTIVES: New methods developed to improve the statistical basis of provider profiling may be particularly applicable to nursing homes. We examine the use of Bayesian hierarchical modeling in profiling nursing homes on their rate of pressure ulcer development. DESIGN: Observational study using Minimum Data Set data from 1997 and 1998. SETTING: A for-profit nursing home chain. PARTICIPANTS: Residents of 108 nursing homes who were without a pressure ulcer on an index assessment. MEASUREMENTS: Nursing homes were compared on their performance on risk-adjusted rates of pressure ulcer development calculated using standard statistical techniques and Bayesian hierarchical modeling. RESULTS: Bayesian estimates of nursing home performance differed considerably from rates calculated using standard statistical techniques. The range of risk-adjusted rates among nursing homes was 0% to 14.3% using standard methods and 1.0% to 4.8% using Bayesian analysis. Fifteen nursing homes were designated as outliers based on their z scores, and two were outliers using Bayesian modeling. Only one nursing home had greater than a 50% probability of having a true rate of ulcer development exceeding 4%. CONCLUSIONS: Bayesian hierarchical modeling can be successfully applied to the problem of profiling nursing homes. Results obtained from Bayesian modeling are different from those obtained using standard statistical techniques. The continued evaluation and application of this new methodology in nursing homes may ensure that consumers and providers have the most accurate information regarding performance. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To validate a previously derived risk-adjustment model for pressure ulcer development in a separate sample of nursing home residents and to determine the extent to which use of this model affects judgments of nursing home performance. DESIGN: Retrospective observational study using Minimum Data Set (MDS) data from 1998. SETTING: A large, for-profit, nursing home chain. PARTICIPANTS: Twenty-nine thousand and forty observations were made on 13,457 nursing home residents who were without a pressure ulcer on an index assessment. MEASUREMENTS: We used logistic regression in our validation sample to calculate new coefficients for the 17 previously identified predictors of pressure ulcer development. Coefficients from this new sample were compared with those previously derived. Expected rates of pressure ulcer development were determined for 108 nursing homes. Unadjusted and risk-adjusted rates of pressure ulcer development from these homes were also calculated and outlier identification using these two approaches was compared. RESULTS: Predictors of pressure ulcer development in the derivation sample generally showed similar effects in the validation sample. The model c-statistic was also unchanged at 0.73, but it was not calibrated as well in the validation sample. On applying the model to the nursing homes, expected rates of ulcer development ranged from 1.1% to 3.2% (P < .001). The observed rates ranged from 0% to 12.1% (P < .001). There were 12 outliers using unadjusted rates and 15 using adjusted performance. Ten nursing homes were identified as outliers using both approaches. CONCLUSIONS: Our MDS risk-adjustment model for pressure ulcer development performed well in this new sample. Nursing homes differ significantly in their expected rates of pressure ulcer development. Outlier identification also differs depending on whether unadjusted or risk-adjusted performance is evaluated. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To use the Minimum Data Set (MDS) to derive a risk-adjustment model for pressure ulcer development that may be used in assessing the quality of nursing home care. DESIGN: Perspective observational study using MDS data from 1997. SETTING: A large, for-profit, nursing home chain. PARTICIPANTS: Our unit of analysis was 39,649 observations made on 14,607 nursing home residents who were without a stage 2 or larger pressure ulcer on an index assessment. MEASUREMENTS: Pressure ulcer status was determined at an outcome assessment approximately 90 days after an index assessment. Potential predictors of pressure ulcer development were examined for bivariate associations, contributing to the development of a multivariate logistic regression model. RESULTS: A stage 2 or larger pressure ulcer developed in 2.3% of the observations. Seventeen resident characteristics were found to be associated with pressure ulcer development. These included dependence in mobility and transferring, diabetes mellitus, peripheral vascular disease, urinary incontinence, lower body mass index, and end-stage disease. A risk-adjustment model based on these characteristics was well calibrated and able to discriminate among residents with different levels of risk for ulcer development (model c-statistic = 0.73). CONCLUSION: A clinically credible risk-adjustment model with good performance properties can be developed using the MDS. This model may be useful in profiling nursing homes on their rate of pressure ulcer development. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine the influence of age and comorbidity on intensification of medical therapy for patients with poorly controlled diabetes mellitus (DM). DESIGN: Observational cohort study using data from Department of Veterans Affairs (VA) national databases. SETTING: Thirteen VA medical centers in New England, Florida, and Puerto Rico. PARTICIPANTS: Veterans (N = 5,317) with poorly controlled DM receiving regular medical care MEASUREMENTS: An increase in hypoglycemic medications, or intensification of therapy, was considered present at the visit if a new hypoglycemic medication was started or the dosage of an existing medication was increased. RESULTS: The overall rate of intensification of therapy was 20.8% (1,106/5,317). The rate of intensification was highest in the youngest patients without comorbidity (24.5%) and lowest in the oldest patients with comorbidity (15.7%) (P<.001). CONCLUSION: Rates of intensification at a single clinic visit were quite low in all groups and were lowest in older patients with comorbidity. [ABSTRACT FROM AUTHOR]

An obituary is presented for former physician Gene Stollerman, the former editor of the "Journal of the American Geriatrics Society".

A response by Sarwat I. Chaudry, Dan R. Berlowitz, and John Concato to the letter to the editor about their article "Quality of Care for Older Patients with Diabetes Mellitus with Comorbidity" published within the issue is presented.

Editorial. Comments on two articles on pressure ulcer preventive care in the U.S., published in a 2003 issue of the 'Journal of the American Geriatrics Society.' Need for the medical community to commit to a six-sigma standard of quality improvement; Key processes of care; Difficulties in detecting the performance of routine processes of care; Organization of pressure ulcer care.