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Background: Congress, veterans' groups, and the press have expressed concerns that access to care and quality of care in Department of Veterans Affairs (VA) settings are inferior to access and quality in non-VA settings.Objective: To assess quality of outpatient and inpatient care in VA at the national level and facility level and to compare performance between VA and non-VA settings using recent performance measure data.Main Measures: We assessed Patient Safety Indicators (PSIs), 30-day risk-standardized mortality and readmission measures, and ORYX measures for inpatient safety and effectiveness; Healthcare Effectiveness Data and Information Set (HEDIS®) measures for outpatient effectiveness; and Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS) and Survey of Healthcare Experiences of Patients (SHEP) survey measures for inpatient patient-centeredness. For inpatient care, we used propensity score matching to identify a subset of non-VA hospitals that were comparable to VA hospitals.Key Results: VA hospitals performed on average the same as or significantly better than non-VA hospitals on all six measures of inpatient safety, all three inpatient mortality measures, and 12 inpatient effectiveness measures, but significantly worse than non-VA hospitals on three readmission measures and two effectiveness measures. The performance of VA facilities was significantly better than commercial HMOs and Medicaid HMOs for all 16 outpatient effectiveness measures and for Medicare HMOs, it was significantly better for 14 measures and did not differ for two measures. High variation across VA facilities in the performance of some quality measures was observed, although variation was even greater among non-VA facilities.Conclusions: The VA system performed similarly or better than the non-VA system on most of the nationally recognized measures of inpatient and outpatient care quality, but high variation across VA facilities indicates a need for targeted quality improvement. [ABSTRACT FROM AUTHOR]

Measures of medication adherence have become common parameters with which disease management (DM) programs are being evaluated, leading to the question of how this concept should be measured in the particular context of a DM intervention. We hypothesize that DM improves adherence to prescriptions more than the rate with which prescriptions are being filled. We used health plan claims data to construct 13 common measures of medication adherence for five chronic conditions. The measures were operationalized in three different ways: the Prescription Fill Rate (PFR), which requires only one prescription; the Medication Possession Ratio (MPR), which requires a supply that covers at least 80% of the year; and the Length of Gap (LOG), which requires no gap greater than 30 days between prescriptions. We compared results from a baseline year to results during the first year of a DM program. Changes in adherence were quite small in the first year of the intervention, with no changes greater than six percentage points. In the intervention year, three measures showed a significant increase based on all three operational definitions, but two measures paradoxically decreased based on the PFR. For both, the MPR and the LOG suggested either no change or significant improvement. None of the MPR and LOG measures pointed toward significantly lower compliance in the intervention year. Different ways to operationalize the concept of medication adherence can lead to fundamentally different conclusions. While more complex, MPR- and LOG-based measures could be more appropriate for DM evaluation. Our initial results, however, need to be confirmed by data covering longer term follow-up. (Disease Management 2007;10:91–100) [ABSTRACT FROM AUTHOR]

Abstract: U sing data from the National Health Interview Survey and the RAND Health Insurance Experiment, we estimated the external costs (costs borne by others) of a sedentary life-style. External costs stem from additional payments received by sedentary individuals from collectively financed programs such as health insurance, sick-leave coverage, disability insurance, and group life insurance. Those with sedentary life-styles incur higher medical costs, but their life expectancy at age 20 is 10 months less so they collect less public and private pensions. The pension costs come late in life, as do some of the medical costs, and so the estimate of the external cost is sensitive to the discount rate used. At a 5 percent rate of discount, the lifetime subsidy from others to those with a sedentary life style is $1,900. Our estimate of the subsidy is also sensitive to the assumed effect of exercise on mortality. The subsidy is a rationale for public support of recreational facilities such as parks and swimming pools and employer support of programs to increase exercise. (Am J Public Health 1989; 79:975-981.) [ABSTRACT FROM AUTHOR]