244 results on '"Todd H. Wagner"'
Search Results
2. The economics of adaptations to evidence-based practices
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Ramzi G. Salloum, Todd H. Wagner, Amanda M. Midboe, Sarah I. Daniels, Andrew Quanbeck, and David A. Chambers
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Adaptation ,Adaptive ,Economics ,Cost ,Economic evaluation ,Medicine (General) ,R5-920 - Abstract
Abstract Background Evidence-based practices (EBPs) are frequently adapted in response to the dynamic contexts in which they are implemented. Adaptation is defined as the degree to which an EBP is altered to fit the setting or to improve fit to local context and can be planned or unplanned. Although adaptations are common and necessary to maximizing the marginal impact of EBPs, little attention has been given to the economic consequences and how adaptations affect marginal costs. Discussion In assessing the economic consequences of adaptation, one should consider its impact on core components, the planned adaptive periphery, and the unplanned adaptive periphery. Guided by implementation science frameworks, we examine how various economic evaluation approaches accommodate the influence of adaptations and discuss the pros and cons of these approaches. Using the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME), mixed methods can elucidate the economic reasons driving the adaptations. Micro-costing approaches are applied in research that integrates the adaptation of EBPs at the planning stage using innovative, adaptive study designs. In contrast, evaluation of unplanned adaptation is subject to confounding and requires sensitivity analysis to address unobservable measures and other uncertainties. A case study is presented using the RE-AIM framework to illustrate the costing of adaptations. In addition to empirical approaches to evaluating adaptation, simulation modeling approaches can be used to overcome limited follow-up in implementation studies. Conclusions As implementation science evolves to improve our understanding of the mechanisms and implications of adaptations, it is increasingly important to understand the economic implications of such adaptations, in addition to their impact on clinical effectiveness. Therefore, explicit consideration is warranted of how costs can be evaluated as outcomes of adaptations to the delivery of EBPs.
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- 2022
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3. Cost data in implementation science: categories and approaches to costing
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Heather T. Gold, Cara McDermott, Ties Hoomans, and Todd H. Wagner
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Implementation costs ,Intervention costs ,Cost analysis ,Implementation economics ,Medicine (General) ,R5-920 - Abstract
Abstract A lack of cost information has been cited as a barrier to implementation and a limitation of implementation research. This paper explains how implementation researchers might optimize their measurement and inclusion of costs, building on traditional economic evaluations comparing costs and effectiveness of health interventions. The objective of all economic evaluation is to inform decision-making for resource allocation and to measure costs that reflect opportunity costs—the value of resource inputs in their next best alternative use, which generally vary by decision-maker perspective(s) and time horizon(s). Analyses that examine different perspectives or time horizons must consider cost estimation accuracy, because over longer time horizons, all costs are variable; however, with shorter time horizons and narrower perspectives, one must differentiate the fixed and variable costs, with fixed costs generally excluded from the evaluation. This paper defines relevant costs, identifies sources of cost data, and discusses cost relevance to potential decision-makers contemplating or implementing evidence-based interventions. Costs may come from the healthcare sector, informal healthcare sector, patient, participant or caregiver, and other sectors such as housing, criminal justice, social services, and education. Finally, we define and consider the relevance of costs by phase of implementation and time horizon, including pre-implementation and planning, implementation, intervention, downstream, and adaptation, and through replication, sustainment, de-implementation, or spread.
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- 2022
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4. VA’s implementation of universal screening and evaluation for the suicide risk identification program in November 2020 –Implications for Veterans with prior mental health needs
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Kritee Gujral, Nazanin Bahraini, Lisa A. Brenner, James Van Campen, Donna M. Zulman, Samantha Illarmo, and Todd H. Wagner
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Medicine ,Science - Abstract
Importance United States Veterans are at higher risk for suicide than non-Veterans. Veterans in rural areas are at higher risk than their urban counterparts. The coronavirus pandemic intensified risk factors for suicide, especially in rural areas. Objective To examine associations between Veterans Health Administration’s (VA’s) universal suicide risk screening, implemented November 2020, and likelihood of Veterans being screened, and receiving follow-up evaluations, as well as post-screening suicidal behavior among patients who used VA mental health services in 2019. Methods VA’s Suicide Risk Identification Strategy (Risk ID), implemented October 2018, is a national, standardized process for suicide risk screening and evaluation. In November 2020, VA expanded Risk ID, requiring annual universal suicide screening. As such, we are evaluating outcomes of interest before and after the start of the policy among Veterans who had ≥1 VA mental health care visit in 2019 (n = 1,654,180; rural n = 485,592, urban n = 1,168,588). Regression-adjusted outcomes were compared 6 months pre-universal screening and 6, 12 and 13 months post-universal screening implementation. Measures Item-9 on the Patient Health Questionnaire (I-9, VA’s historic suicide screener), Columbia- Suicide Severity Risk Scale (C-SSRS) Screener, VA’s Comprehensive Suicide Risk Evaluation (CSRE), and Suicide Behavior and Overdose Report (SBOR). Results 12 months post-universal screening implementation, 1.3 million Veterans (80% of the study cohort) were screened or evaluated for suicide risk, with 91% the sub-cohort who had at least one mental health visit in the 12 months post-universal screening implementation period were screened or evaluated. At least 20% of the study cohort was screened outside of mental health care settings. Among Veterans with positive screens, 80% received follow-up CSREs. Covariate-adjusted models indicated that an additional 89,160 Veterans were screened per month via the C-SSRS and an additional 30,106 Veterans/month screened via either C-SSRS or I-9 post-universal screening implementation. Compared to their urban counterparts, 7,720 additional rural Veterans/month were screened via the C-SSRS and 9,226 additional rural Veterans/month were screened via either the C-SSRS or I-9. Conclusion VA’s universal screening requirement via VA’s Risk ID program increased screening for suicide risk among Veterans with mental health care needs. A universal approach to screening may be particularly advantageous for rural Veterans, who are typically at higher risk for suicide but have fewer interactions with the health care system, particularly within specialty care settings, due to higher barriers to accessing care. Insights from this program offer valuable insights for health systems nationwide.
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- 2023
5. Atherectomy Overuse: Do Policy Solutions Exist?
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Elizabeth L. George, Todd H. Wagner, and Shipra Arya
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Editorials ,atherectomy ,evidence‐based medicine ,health policy ,overuse ,reimbursement ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Published
- 2022
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6. D101. High Deductible Health Plans Delay Surgical Management of Breast Cancer
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Danielle H. Rochlin, MD, Robyn Rubenstein, MD, Meghana G. Shamsunder, MPH, Arden M. Morris, MD, MPH, Todd H. Wagner, PhD, Evan Matros, MD, MMSc, and Clifford C. Sheckter, MD
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Surgery ,RD1-811 - Published
- 2023
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7. Are EMS bypass policies effective implementation strategies for intravenous alteplase for stroke?
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Alex H. S. Harris, Nicolas B. Barreto, Amber W. Trickey, Sylvia Bereknyei, Tong Meng, Todd H. Wagner, and Prasanthi Govindarajan
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Policy evaluation ,Stroke treatment ,CFIR ,Mixed-methods ,Medicine (General) ,R5-920 - Abstract
Abstract Background Stroke is a leading cause of disability and the fifth leading cause of death in the USA. Intravenous alteplase is a highly effective clot-dissolving stroke treatment that must be given in a hospital setting within a time-sensitive window. To increase the use of intravenous alteplase in stroke patients, many US counties enacted policies mandating emergency medical service (EMS) paramedics to bypass local emergency departments and instead directly transport patients to specially equipped stroke centers. The objective of this mixed-methods study is to evaluate the effectiveness of policy enactment as an implementation strategy, how differences in policy structures and processes impact effectiveness, and to explore how the county, hospital, and policy factors explain variation in implementation and clinical outcomes. This paper provides a detailed description of an Agency for Healthcare Quality and Research (AHRQ)-funded protocol, including the use of the Consolidated Framework for Implementation Research (CFIR) in the qualitative design. Methods/design We will construct the largest-ever national stroke database of Medicare enrollees (~ 1.5 million stroke patients) representing 896 policy counties paired with 1792 non-policy counties, then integrate patient-, hospital-, county-, and state-level covariates from eight different data sources. We will use a difference-in-differences analysis to estimate the overall effect of the policy enactment on intravenous alteplase use (implementation outcome) as well as key patient outcomes. We will also quantitatively examine if variation in the context (urban/rural status) and variation in policy features affect outcomes. Finally, a CFIR-informed multiple case study design will be used to interview informants in 72 stakeholders in 24 counties to identify and validate factors that enable policy effects. Discussion Policies can be potent implementation strategies. However, the effects of EMS bypass policies to increase intravenous alteplase use have not been rigorously evaluated. By learning how context and policy structures impact alteplase implementation, as well as the barriers and facilitators experienced by stakeholders responsible for policy enactment, the results of this study will inform decisions regarding if and how EMS bypass policies should spread to non-policy counties, and if indicated, creation of a “best practices” toolkit.
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- 2020
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8. Estimating the Cost of Surgical Care Purchased in the Community by the Veterans Health Administration
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Todd H. Wagner, Jeanie Lo, Erin Beilstein-Wedel, Megan E. Vanneman, Michael Shwartz, and Amy K. Rosen
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Medicine (General) ,R5-920 - Abstract
Background. Veterans’ access to Veterans Affairs (VA)-purchased community care expanded due to large increases in funding provided in the 2014 Veterans Choice Act. Objectives. To compare costs between VA-delivered care and VA payments for purchased care for two commonly performed surgeries: total knee arthroplasties (TKAs) and cataract surgeries. Research Design. Descriptive statistics and regressions examining costs in VA-delivered and VA-purchased care (fiscal year [FY] 2018 [October 2017 to September 2018]). Subjects. A total of 13,718 TKAs, of which 6,293 (46%) were performed in VA. A total of 91,659 cataract surgeries, of which 65,799 (72%) were performed in VA. Measures. Costs of VA-delivered care based on activity-based cost estimates; costs of VA-purchased care based on approved and paid claims. Results. Ninety-eight percent of VA-delivered TKAs occurred in inpatient hospitals, with an average cost of $28,969 (SD $10,778). The majority (86%) of VA-purchased TKAs were also performed at inpatient hospitals, with an average payment of $13,339 (SD $23,698). VA-delivered cataract surgeries were performed at hospitals as outpatient procedures, with an average cost of $4,301 (SD $2,835). VA-purchased cataract surgeries performed at hospitals averaged $1,585 (SD $629); those performed at ambulatory surgical centers cost an average of $1,346 (SD $463). We also found significantly higher Nosos risk scores for patients who used VA-delivered versus VA-purchased care. Conclusions. Costs of VA-delivered care were higher than payments for VA-purchased care, but this partly reflects legislative caps limiting VA payments to community providers to Medicare amounts. Higher patient risk scores in the VA could indicate that community providers are reluctant to accept high-risk patients because of Medicare reimbursements, or that VA providers prefer to keep the more complex patients in VA.
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- 2021
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9. Risk Communication After Health Care Exposures: An Experimental Vignette Survey With Patients
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A. Rani Elwy, Elizabeth M. Maguire, Thomas H. Gallagher, Steven M. Asch, Janet M. Durfee, Richard A. Martinello, Barbara G. Bokhour, Allen L. Gifford, Thomas J. Taylor, and Todd H. Wagner
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Medicine (General) ,R5-920 - Abstract
Purpose. We investigated how health care systems should communicate with patients about possible exposures to blood-borne pathogens that may have occurred during their care. Our goal was to determine how best to communicate uncertain risk information in a way that would minimize harm to patients, maintain their trust, and encourage patients to seek follow-up treatment. Methods. Participants ( N = 1103) were randomized to receive one of six vignette surveys; 997 (98.4%) responded. All vignettes described the same event, but differed by risk level and recommendations (lower risk v. higher risk) and by communication mode (telephone, letter, social media). We measured participants’ perceived risk of blood-borne infection, trust in the health care system, and shared decision making about next clinical steps. Open-ended questions were analyzed using grounded thematic analysis. Results. When the vignette requested patients to undergo testing and practice certain health behaviors (higher risk), participants’ likelihood of seeking follow-up testing for blood-borne pathogens and their understanding of health issues increased. Perceived trust was unaffected by risk level or communication processes. Qualitative data indicated a desire for telephone communication from providers known to the patient. Limitations. It is not clear whether higher risk language or objective risk levels in vignettes motivated patients’ behavioral intentions. Conclusion. Using higher risk language when disclosing large-scale adverse events increased participants’ willingness to seek follow-up care. Implications. Health care organizations’ disclosures should focus on the next steps to take after health care exposures. This communication should involve helping patients to understand their personal health issues better, make them feel that they know which steps to take following the receipt of this information, and encouraging them to seek follow-up infectious disease testing in order to better take care of themselves.
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- 2021
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10. The Association Between Alpha-1 Adrenergic Receptor Antagonists and In-Hospital Mortality From COVID-19
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Liam Rose, Laura Graham, Allison Koenecke, Michael Powell, Ruoxuan Xiong, Zhu Shen, Brett Mench, Kenneth W. Kinzler, Chetan Bettegowda, Bert Vogelstein, Susan Athey, Joshua T. Vogelstein, Maximilian F. Konig, and Todd H. Wagner
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COVID-19 ,coronavirus disease ,alpha-1-adrenergic receptor antagonist ,infectious disease ,off-label drug use ,Medicine (General) ,R5-920 - Abstract
Effective therapies for coronavirus disease 2019 (COVID-19) are urgently needed, and pre-clinical data suggest alpha-1 adrenergic receptor antagonists (α1-AR antagonists) may be effective in reducing mortality related to hyperinflammation independent of etiology. Using a retrospective cohort design with patients in the Department of Veterans Affairs healthcare system, we use doubly robust regression and matching to estimate the association between baseline use of α1-AR antagonists and likelihood of death due to COVID-19 during hospitalization. Having an active prescription for any α1-AR antagonist (tamsulosin, silodosin, prazosin, terazosin, doxazosin, or alfuzosin) at the time of admission had a significant negative association with in-hospital mortality (relative risk reduction 18%; odds ratio 0.73; 95% CI 0.63–0.85; p ≤ 0.001) and death within 28 days of admission (relative risk reduction 17%; odds ratio 0.74; 95% CI 0.65–0.84; p ≤ 0.001). In a subset of patients on doxazosin specifically, an inhibitor of all three alpha-1 adrenergic receptors, we observed a relative risk reduction for death of 74% (odds ratio 0.23; 95% CI 0.03–0.94; p = 0.028) compared to matched controls not on any α1-AR antagonist at the time of admission. These findings suggest that use of α1-AR antagonists may reduce mortality in COVID-19, supporting the need for randomized, placebo-controlled clinical trials in patients with early symptomatic infection.
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- 2021
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11. Employment benefits and job retention: evidence among patients with colorectal cancer
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Christine M. Veenstra, Paul Abrahamse, Todd H. Wagner, Sarah T. Hawley, Mousumi Banerjee, and Arden M. Morris
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Colorectal neoplasms ,employment ,insurance ,health ,sick leave ,surveys and questionnaires ,Neoplasms. Tumors. Oncology. Including cancer and carcinogens ,RC254-282 - Abstract
Abstract A “health shock,” that is, a large, unanticipated adverse health event, can have long‐term financial implications for patients and their families. Colorectal cancer is the third most commonly diagnosed cancer among men and women and is an example of a specific health shock. We examined whether specific benefits (employer‐based health insurance, paid sick leave, extended sick leave, unpaid time off, disability benefits) are associated with job retention after diagnosis and treatment of colorectal cancer. In 2011–14, we surveyed patients with Stage III colorectal cancer from two representative SEER registries. The final sample was 1301 patients (68% survey response rate). For this study, we excluded 735 respondents who were not employed and 20 with unknown employment status. The final analytic sample included 546 respondents. Job retention in the year following diagnosis was assessed, and multivariable logistic regression was used to evaluate associations between job retention and access to specific employment benefits. Employer‐based health insurance (OR = 2.97; 95% CI = 1.56–6.01; P = 0.003) and paid sick leave (OR = 2.93; 95% CI = 1.23–6.98; P = 0.015) were significantly associated with job retention, after adjusting for sociodemographic, clinical, geographic, and job characteristics.
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- 2018
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12. Evaluating the implementation of a national disclosure policy for large-scale adverse events in an integrated health care system: identification of gaps and successes
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Elizabeth M. Maguire, Barbara G. Bokhour, Todd H. Wagner, Steven M. Asch, Allen L. Gifford, Thomas H. Gallagher, Janet M. Durfee, Richard A. Martinello, and A. Rani Elwy
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Adverse events ,Veterans ,Qualitative ,Communication ,Public aspects of medicine ,RA1-1270 - Abstract
Abstract Background Many healthcare organizations have developed disclosure policies for large-scale adverse events, including the Veterans Health Administration (VA). This study evaluated VA’s national large-scale disclosure policy and identifies gaps and successes in its implementation. Methods Semi-structured qualitative interviews were conducted with leaders, hospital employees, and patients at nine sites to elicit their perceptions of recent large-scale adverse events notifications and the national disclosure policy. Data were coded using the constructs of the Consolidated Framework for Implementation Research (CFIR). Results We conducted 97 interviews. Insights included how to handle the communication of large-scale disclosures through multiple levels of a large healthcare organization and manage ongoing communications about the event with employees. Of the 5 CFIR constructs and 26 sub-constructs assessed, seven were prominent in interviews. Leaders and employees specifically mentioned key problem areas involving 1) networks and communications during disclosure, 2) organizational culture, 3) engagement of external change agents during disclosure, and 4) a need for reflecting on and evaluating the policy implementation and disclosure itself. Patients shared 5) preferences for personal outreach by phone in place of the current use of certified letters. All interviewees discussed 6) issues with execution and 7) costs of the disclosure. Conclusions CFIR analysis reveals key problem areas that need to be addresses during disclosure, including: timely communication patterns throughout the organization, establishing a supportive culture prior to implementation, using patient-approved, effective communications strategies during disclosures; providing follow-up support for employees and patients, and sharing lessons learned.
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- 2016
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13. The Predictive Value of Inflammation-Related Peripheral Blood Measurements in Cancer Staging and Prognosis
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Joanna L. Sylman, Annachiara Mitrugno, Michelle Atallah, Garth W. Tormoen, Joseph J. Shatzel, Samuel Tassi Yunga, Todd H. Wagner, John T. Leppert, Parag Mallick, and Owen J. T. McCarty
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neutrophil-to-lymphocyte ,platelet-to-lymphocyte ,C-reactive protein ,prognosis ,cancer ,longitudinal ,Neoplasms. Tumors. Oncology. Including cancer and carcinogens ,RC254-282 - Abstract
In this review, we discuss the interaction between cancer and markers of inflammation (such as levels of inflammatory cells and proteins) in the circulation, and the potential benefits of routinely monitoring these markers in peripheral blood measurement assays. Next, we discuss the prognostic value and limitations of using inflammatory markers such as neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios and C-reactive protein measurements. Furthermore, the review discusses the benefits of combining multiple types of measurements and longitudinal tracking to improve staging and prognosis prediction of patients with cancer, and the ability of novel in silico frameworks to leverage this high-dimensional data.
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- 2018
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14. The Costs of an Outreach Intervention for Low-Income Women With Abnormal Pap Smears
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Todd H. Wagner, PhD, Linda P. Engelstad, MD, Stephen J. McPhee, MD, and Rena J. Pasick, DrPH
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low-income women ,abnormal pap smears ,outreach intervention ,Public aspects of medicine ,RA1-1270 - Abstract
IntroductionFollow-up among women who have had an abnormal Papanicolaou (Pap) smear is often poor in public hospitals that serve women at increased risk for cervical cancer. This randomized controlled trial evaluated and compared the total cost and cost per follow-up of a tailored outreach intervention plus usual care with the total cost and cost per follow-up of usual care alone.MethodsWomen with an abnormal Pap smear (n = 348) receiving care at Alameda County Medical Center (Alameda County, California) were randomized to intervention or usual care. The intervention used trained community health advisors to complement the clinic’s protocol for usual care. We assessed the costs of the intervention and the cost per follow-up within 6 months of the abnormal Pap smear test result.ResultsThe intervention increased the rate of 6-month follow-up by 29 percentage points, and the incremental cost per follow-up was $959 (2005 dollars). The cost per follow-up varied by the severity of the abnormality. The cost per follow-up for the most severe abnormality (high-grade squamous intraepithelial lesion) was $681, while the cost per follow-up for less severe abnormalities was higher.ConclusionIn a health care system in which many women fail to get follow-up care for an abnormal Pap smear, outreach workers were more effective than usual care (mail or telephone reminders) at increasing follow-up rates. The results suggest that outreach workers should manage their effort based on the degree of abnormality; most effort should be placed on women with the most severe abnormality (high-grade squamous intraepithelial lesion).
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- 2007
15. Use of the Internet for Health Information by the Chronically Ill
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Todd H. Wagner, Laurence C. Baker, M. Kate Bundorf, and Sara Singer
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Internet ,chronic disease ,health information ,Public aspects of medicine ,RA1-1270 - Abstract
Introduction Chronic conditions are among the leading causes of death and disability in the United States. The Internet is a source of health information and advice for individuals with chronic conditions and shows promise for helping individuals manage their conditions and improve their quality of life. Methods We assessed Internet use for health information by people who had one or more of five common chronic conditions. We conducted a national survey of adults aged 21 and older, then analyzed data from 1980 respondents who had Internet access and who reported that they had hypertension, diabetes, cancer, heart problems, and/or depression. Results Adjusted rates for any Internet use for health information ranged from 33.8% (heart problems only) to 52.0% (diabetes only). A sizable minority of respondents particularly individuals with diabetes reported that the Internet helped them to manage their condition themselves, and 7.9% said information on the Internet led them to seek care from a different doctor. Conclusion Use of the Internet for health information by chronically ill patients is moderate. Self-reported effects on choice of treatment or provider are small but noteworthy.
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- 2004
16. Variation in initial and continued use of primary, mental health, and specialty video care among Veterans
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Jacqueline M. Ferguson, Charlie M. Wray, Josephine Jacobs, Liberty Greene, Todd H. Wagner, Michelle C. Odden, Jeremy Freese, James Van Campen, Steven M. Asch, Leonie Heyworth, and Donna M. Zulman
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Health Policy - Abstract
To identify which Veteran populations are routinely accessing video-based care.National, secondary administrative data from electronic health records at the Veterans Health Administration (VHA), 2019-2021.This retrospective cohort analysis identified patient characteristics associated with the odds of using any video care; and then, among those with a previous video visit, the annual rate of video care utilization. Video care use was reported overall and stratified into care type (e.g., primary, mental health, and specialty video care) between March 10, 2020 and February 28, 2021.Veterans active in VA health care (1 outpatient visit between March 11, 2019 and March 10, 2020) were included in this study.Among 5,389,129 Veterans in this evaluation, approximately 27.4% of Veterans had at least one video visit. We found differences in video care utilization by type of video care: 14.7% of Veterans had at least one primary care video visit, 10.6% a mental health video visit, and 5.9% a specialty care video visit. Veterans with a history of housing instability had a higher overall rate of video care driven by their higher usage of video for mental health care compared with Veterans in stable housing. American Indian/Alaska Native Veterans had reduced odds of video visits, yet similar rates of video care when compared to White Veterans. Low-income Veterans had lower odds of using primary video care yet slightly elevated rates of primary video care among those with at least one video visit when compared to Veterans enrolled at VA without special considerations.Variation in video care utilization patterns by type of care identified Veteran populations that might require greater resources and support to initiate and sustain video care use. Our data support service specific outreach to homeless and American Indian/Alaska Native Veterans.
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- 2022
17. Emergency Medicaid programs may be an effective means of providing sustained insurance among trauma patients: A statewide longitudinal analysis
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Lisa M. Knowlton, Linda D. Tran, Katherine Arnow, Amber W. Trickey, Arden M. Morris, David A. Spain, and Todd H. Wagner
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Surgery ,Critical Care and Intensive Care Medicine - Abstract
Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization that offsets costs of care, increases access to postdischarge resources, and provides patients with a path to sustain coverage through Medicaid. Because HPE only lasts up to 60 days, we aimed to determine Medicaid insurance status 6 months after injury among HPE-approved trauma patients and identify factors associated with successful sustainment.Using a customized longitudinal claims data set for HPE-approved patients from the California Department of Health Care Services, we analyzed adults with a primary trauma diagnosis (International Classification of Diseases version 10) who were HPE approved in 2016 and 2017. Our primary outcome was Medicaid sustainment at 6 months. Univariate and multivariate analyses were performed.A total of 9,749 trauma patients with HPE were analyzed; 6,795 (69.7%) sustained Medicaid at 6 months. Compared with patients who did not sustain, those who sustained had higher Injury Severity Score (ISS15: 73.5% vs. 68.7%, p0.001), more frequent surgical intervention (74.8% vs. 64.5%, p0.001), and were more likely to be discharged to postacute services (23.9% vs. 10.4%, p0.001). Medicaid sustainment was high among patients who identified as White (86.7%), Hispanic (86.7%), Black (84.3%), and Asian (83.7%). Medicaid sustainment was low among the 2,505 patients (25.7%) who declined to report race, ethnicity, or preferred language (14.8% sustainment). In adjusted analyses, major injuries (ISS16) (vs. ISS15: adjusted odds ratio [aOR], 1.51; p = 0.02) and surgery (aOR, 1.85; p0.001) were associated with increased likelihood of Medicaid sustainment. Declining to disclose race, ethnicity, or language (aOR, 0.05; p0.001) decreased the likelihood of Medicaid sustainment.Hospital Presumptive Eligibility programs are a promising pathway for securing long-term insurance coverage for trauma patients, particularly among the severely injured who likely require ongoing access to health care services. Patient and provider interviews would help to elucidate barriers for patients who do not sustain.Prognostic and Epidemiological; Level IV.
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- 2022
18. Breaking Down the Barriers Between Health and Social Care Services: Implementing a Social Determinants of Health Network
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Elena Rosenbaum, Jonathan G. Shaw, Todd H. Wagner, Stacie Vilendrer, Marcy Winget, Coretta Killikelly, Lynne Olney, Erica Coletti, Michele Horan, Michele Kelly, and Steven M. Asch
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General Engineering - Published
- 2023
19. Ten-Year Outcomes of Off-Pump vs On-Pump Coronary Artery Bypass Grafting in the Department of Veterans Affairs: A Randomized Clinical Trial
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Jacquelyn A. Quin, Todd H. Wagner, Brack Hattler, Brendan M. Carr, Joseph Collins, G. Hossein Almassi, Frederick L. Grover, and A. Laurie Shroyer
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Surgeons ,Male ,Canada ,Coronary Artery Bypass, Off-Pump ,Coronary Artery Disease ,Middle Aged ,Percutaneous Coronary Intervention ,Treatment Outcome ,Humans ,Surgery ,Female ,Coronary Artery Bypass ,Original Investigation ,Veterans - Abstract
IMPORTANCE: The long-term benefits of off-pump (“beating heart”) vs on-pump coronary artery bypass grafting (CABG) remain controversial. OBJECTIVE: To evaluate the 10-year outcomes and costs of off-pump vs on-pump CABG in the Department of Veterans Affairs (VA) Randomized On/Off Bypass (ROOBY) trial. DESIGN, SETTING, AND PARTICIPANTS: From February 27, 2002, to May 7, 2007, 2203 veterans in the ROOBY trial were randomly assigned to off-pump or on-pump CABG procedures at 18 participating VA medical centers. Per protocol, the veterans were observed for 10 years; the 10-year, post-CABG clinical outcomes and costs were assessed via centralized abstraction of electronic medical records combined with merges to VA and non-VA databases. With the use of an intention-to-treat approach, analyses were performed from May 7, 2017, to December 9, 2021. INTERVENTIONS: On-pump and off-pump CABG procedures. MAIN OUTCOMES AND MEASURES: The 10-year coprimary end points included all-cause death and a composite end point identifying patients who had died or had undergone subsequent revascularization (ie, percutaneous coronary intervention [PCI] or repeated CABG); these 2 end points were measured dichotomously and as time-to-event variables (ie, time to death and time to composite end points). Secondary 10-year end points included PCIs, repeated CABG procedures, changes in cardiac symptoms, and 2018-adjusted VA estimated costs. Changes from baseline to 10 years in post-CABG, clinically relevant cardiac symptoms were evaluated for New York Heart Association functional class, Canadian Cardiovascular Society angina class, and atrial fibrillation. Outcome differences were adjudicated by an end points committee. Given that pre-CABG risks were balanced, the protocol-driven primary and secondary hypotheses directly compared 10-year treatment-related effects. RESULTS: A total of 1104 patients (1097 men [99.4%]; mean [SD] age, 63.0 [8.5] years) were enrolled in the off-pump group, and 1099 patients (1092 men [99.5%]; mean [SD] age, 62.5 [8.5] years) were enrolled in the on-pump group. The 10-year death rates were 34.2% (n = 378) for the off-pump group and 31.1% (n = 342) for the on-pump group (relative risk, 1.05; 95% CI, 0.99-1.11; P = .12). The median time to composite end point for the off-pump group (4.6 years; IQR, 1.4-7.5 years) was approximately 4.3 months shorter than that for the on-pump group (5.0 years; IQR, 1.8-7.9 years; P = .03). No significant 10-year treatment-related differences were documented for any other primary or secondary end points. After the removal of conversions, sensitivity analyses reconfirmed these findings. CONCLUSIONS AND RELEVANCE: No off-pump CABG advantages were found for 10-year death or revascularization end points; the time to composite end point was lower in the off-pump group than in the on-pump group. For veterans, in the absence of on-pump contraindications, a case cannot be made for supplanting the traditional on-pump CABG technique with an off-pump approach. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01924442
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- 2023
20. Alcohol use disorder pharmacotherapy and treatment in primary care (ADaPT-PC) trial: Impact on identified barriers to implementation
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Hildi J. Hagedorn, Jennifer P. Wisdom, Heather Gerould, Erika Pinsker, Randall Brown, Michael Dawes, Eric Dieperink, Donald Hugh Myrick, Elizabeth M. Oliva, Todd H. Wagner, and Alex H. S. Harris
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Alcoholism ,Psychiatry and Mental health ,Primary Health Care ,Humans ,Medicine (miscellaneous) ,Qualitative Research - Published
- 2022
21. Therapeutic and Economic Benefits of Service Dogs Versus Emotional Support Dogs for Veterans With PTSD
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Joan T Richerson, Todd H. Wagner, Thad Abrams, Kelly Skelton, Kousick Biswas, Samantha Illarmo, Frances McSherry, Michael T. Fallon, Austin Frakt, Steven Pizer, Kathryn M. Magruder, Shirley Groer, Patricia A. Dorn, Grant D. Huang, and Eileen M. Stock
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Psychiatry and Mental health - Published
- 2023
22. Timing and Cost of Wound Complications After Colorectal Resection
- Author
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Mary T. Hawn, Todd H. Wagner, Tanmaya D. Sambare, and Laura A. Graham
- Subjects
Male ,medicine.medical_specialty ,Aftercare ,Veterans Health ,Patient Readmission ,Cohort Studies ,Diabetes Complications ,Postoperative Complications ,medicine ,Humans ,Surgical Wound Infection ,Aged ,Colorectal resection ,Gynecology ,business.industry ,Gastroenterology ,Health Care Costs ,General Medicine ,Middle Aged ,Quality Improvement ,Patient Discharge ,Case-Control Studies ,Female ,Laparoscopy ,Colorectal Neoplasms ,business ,Colorectal Surgery - Abstract
BACKGROUND More than 50% of postoperative wound complications occur after discharge. They are the most common postoperative complication and the most common reason for readmission after a surgical procedure. Little is known about the long-term costs of postdischarge wound complications after surgery. OBJECTIVE We sought to understand the differences in costs and characteristics of wound complications identified after hospital discharge for patients undergoing colorectal surgery in comparison with in-hospital complications. DESIGN This is an observational cohort study using Veterans Health Administration Surgical Quality Improvement Program data. SETTING This study was conducted at a Veterans Affairs medical center. SETTING Patients undergoing colorectal resection between October 1, 2007 and September 30, 2014. MAIN OUTCOME MEASURES The primary outcomes measured were adjusted costs of care at discharge, 30 days, and 90 days after surgery. RESULTS Of 20,146 procedures, 11.9% had a wound complication within 30 days of surgery (49.2% index-hospital, 50.8% postdischarge). In comparison with patients with index-hospital complications, patients with postdischarge complications had fewer superficial infections (65.0% vs 72.2%, p < 0.01), more organ/space surgical site infections (14.3% vs 10.1%, p < 0.01), and higher rates of diabetes (29.1% vs 25.0%, p = 0.02), and they were to have had a laparoscopic approach for their surgery (24.7% vs 18.2%, p < 0.01). The average cost including surgery at 30 days was $37,315 (SD = $29,319). Compared with index-hospital wound complications, postdischarge wound complications were $9500 (22%, p < 0.001) less expensive at 30 days and $9736 (15%, p < 0.001) less expensive at 90 days. Patients with an index-hospital wound complication were 40% less likely to require readmission at 30 days, but their readmissions were $12,518 more expensive than readmissions among patients with a newly identified postdischarge wound complication (p < 0.001). LIMITATIONS This study was limited to patient characteristics and costs accrued only within the Veterans Affairs system. CONCLUSIONS Patients with postdischarge wound complications have lower 30- and 90-day postoperative costs than those with wound complications identified during their index hospitalization and almost half were managed as an outpatient. TIEMPO Y COSTO DE LAS COMPLICACIONES LA HERIDA DESPUS DE LA RESECCIN COLORRECTAL ANTECEDENTES:Mas del 50% de complicaciones postoperatorias de la herida ocurren despues del alta. Es la complicacion postoperatoria mas comun y el motivo mas frecuente de reingreso despues del procedimiento quirurgico. Poco se sabe sobre los costos a largo plazo de las complicaciones de la herida despues del alta quirurgica.OBJETIVO:Intentar en comprender las diferencias en los costos y las caracteristicas de las complicaciones de la herida, identificadas despues del alta hospitalaria, en pacientes sometidos a cirugia colorrectal, en comparacion con las complicaciones intrahospitalarias.DISENO:Estudio de cohorte observacional utilizando datos del Programa de Mejora de la Calidad Quirurgica de la Administracion de Salud de Veteranos.ENTORNO CLINICO:Administracion de Veteranos.PACIENTES:Pacientes sometidos a reseccion colorrectal entre el 1/10/2007 y el 30/9/2014.PRINCIPALES MEDIDAS DE VALORACION:Costos de atencion ajustados al alta, 30 dias y 90 dias despues de la cirugia.RESULTADOS:De 20146 procedimientos, el 11,9% tuvo una complicacion de la herida dentro de los 30 dias de la cirugia. (49,2% indice hospitalario, 50,8% despues del alta). En comparacion con los pacientes, del indice de complicaciones hospitalarias, los pacientes con complicaciones posteriores al alta, tuvieron menos infecciones superficiales (65,0% frente a 72,2%, p
- Published
- 2021
23. Commercial Price Variation for Breast Reconstruction in the Era of Price Transparency
- Author
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Danielle H. Rochlin, Nada M. Rizk, Evan Matros, Todd H. Wagner, and Clifford C. Sheckter
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Surgery - Abstract
ImportanceBreast reconstruction is costly, and negotiated commercial rates have been hidden from public view. The Hospital Price Transparency Rule was enacted in 2021 to facilitate market competition and lower health care costs. Breast reconstruction pricing should be analyzed to evaluate for market effectiveness and opportunities to lower the cost of health care.ObjectiveTo evaluate the extent of commercial price variation for breast reconstruction. The secondary objective was to characterize the price of breast reconstruction in relation to market concentration and payer mix.Design, Setting, and ParticipantsThis was a cross-sectional study conducted from January to April 2022 using 2021 pricing data made available after the Hospital Price Transparency Rule. National data were obtained from Turquoise Health, a data service platform that aggregates price disclosures from hospital websites. Participants were included from all hospitals with disclosed pricing data for breast reconstructive procedures, identified by Current Procedural Terminology (CPT) code.Main Outcomes and MeasuresPrice variation was measured via within- and across-hospital ratios. A mixed-effects linear model evaluated commercial rates relative to governmental rates and the Herfindahl-Hirschman Index (health care market concentration) at the facility level. Linear regression was used to evaluate commercial rates as a function of facility characteristics.ResultsA total of 69 834 unique commercial rates were extracted from 978 facilities across 335 metropolitan areas. Commercial rates increased as health care markets became less competitive (coefficient, $4037.52; 95% CI, $700.12 to $7374.92; P = .02; for Herfindahl-Hirschman Index [HHI] 1501-2500, coefficient $3290.21; 95% CI, $878.08 to $5702.34; P = .01; both compared with HHI ≤1500). Commercial rates demonstrated economically insignificant associations with Medicare and Medicaid rates (Medicare coefficient, −$0.05; 95% CI, −$0.14 to $0.03; P = .23; Medicaid coefficient, $0.14; 95% CI, $0.07 to $0.22; P < .001). Safety-net and nonprofit hospitals reported lower commercial rates (coefficient, −$3269.58; 95% CI, −$3815.42 to −$2723.74; P < .001 and coefficient, −$1892.79; −$2519.61 to −$1265.97; P P = .02).Conclusions and RelevanceStudy results suggest that commercial rates for breast reconstruction demonstrated large nationwide variation. Higher commercial rates were associated with less competitive markets and facilities that were large, for-profit, and nonsafety net. Privately insured patients with breast cancer may experience higher premiums and deductibles as US hospital market consolidation and for-profit hospitals continue to grow. Transparency policies should be continued along with actions that facilitate greater health care market competition. There was no evidence that facilities increase commercial rates in response to lower governmental rates.
- Published
- 2022
24. Applying cognitive task analysis to health services research
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Laura A. Graham, Caroline Gray, Todd H. Wagner, Samantha Illarmo, Mary T. Hawn, Sherry M. Wren, James Iannuzzi, and Alex H. S. Harris
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Health Policy - Abstract
Designing practical decision support tools and other health care technology in health services research relies on a clear understanding of the cognitive processes that underlie the use of these tools. Unfortunately, methods to explore cognitive processes are rarely used in health services research. Thus, the objective of this manuscript is to introduce cognitive task analysis (CTA), a family of methods to study cognitive processes involved in completing a task, to a health services research audience. This methods article describes CTA procedures, proposes a framework for their use in health services research studies, and provides an example of its application in a pilot study.Observations and interviews of health care providers involved in discharge planning at six hospitals in the Veterans Health Administration.Qualitative study of discharge planning using CTA.Data were collected from structured observations and semi-structured interviews using the Critical Decision Method and analyzed using thematic analysis.We developed an adaptation of CTA that could be used in a clinical environment to describe clinical decision-making and other cognitive processes. The adapted CTA framework guides the user through four steps: (1) Planning, (2) Environmental Analysis, (3) Knowledge Elicitation, and (4) Analyses and Results. This adapted CTA framework provides an iterative and systematic approach to identifying and describing the knowledge, expertise, thought processes, procedures, actors, goals, and mental strategies that underlie completing a clinical task.A better understanding of the cognitive processes that underly clinical tasks is key to developing health care technology and decision-support tools that will have a meaningful impact on processes of care and patient outcomes. Our adapted framework offers a more rigorous and detailed method for identifying task-related cognitive processes in implementation studies and quality improvement. Our adaptation of this underutilized qualitative research method may be helpful to other researchers and inform future research in health services research.
- Published
- 2022
25. Association of Quality of Care With Where Veterans Choose to Get Knee Replacement Surgery
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Nicholas J. Giori, Erin E. Beilstein-Wedel, Michael Shwartz, Alex H. S. Harris, Megan E. Vanneman, Todd H. Wagner, and Amy K. Rosen
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Cohort Studies ,Male ,Humans ,Female ,General Medicine ,Arthroplasty, Replacement, Knee ,Medicare ,United States ,Aged ,Retrospective Studies ,Veterans - Abstract
ImportanceRecent legislation expanded veterans’ access to Veterans Health Administration (VA)-purchased care. Quality should be considered when choosing where to get total knee arthroplasty (TKA), but currently available quality metrics provide little guidance.ObjectiveTo determine whether an association exists between the proportion of TKAs performed (vs purchased) at each VA facility and the quality of care provided (as measured by short-term complication rates).Design, Setting, and ParticipantsThis 3-year cohort study used VA and community care data (fiscal year 2017 to fiscal year 2019) from the VA’s Corporate Data Warehouse. Complications were defined following the Centers for Medicare and Medicaid Services’ methodology. The setting included 140 VA health care facilities performing or purchasing TKAs. Participants included veterans who had 43 371 primary TKA procedures that were either VA-performed or VA-purchased during the study period.ExposuresOf the 43 371 primary TKA procedures, 18 964 (43.7%) were VA-purchased.Main Outcomes and MeasuresThe primary outcome was risk-standardized short-term complication rates of VA-performed or VA-purchased TKAs. The association between the proportion of TKAs performed at each VA facility and quality of VA-performed and VA-purchased care was examined using a regression model. Subgroups were also identified for facilities that had complication rates above or below the overall mean complication rate and for facilities that performed more or less than half of the facility’s TKAs.ResultsAmong the study sample’s 41 775 veterans who underwent 43 371 TKAs, 38 725 (89.3%) were male, 6406 (14.8%) were Black, 33 211 (76.6%) were White, and 1367 (3.2%) had other race or ethnicity (including American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander); mean (SD) age was 66.9 (8.5) years. VA-performed and VA-purchased TKAs had a mean (SD) raw overall short-term complication rate of 2.97% (0.08%). There was no association between the proportion of TKAs performed in VA facilities and risk-standardized complication rates for VA-performed TKAs, and no association for VA-purchased TKAs.Conclusions and RelevanceIn this cohort study, surgical quality did not have an association with where veterans had TKA, possibly because meaningful comparative data are lacking. Reporting local and community risk-standardized complication rates may inform veterans’ decisions and improve care. Combining these data with the proportion of TKAs performed at each site could facilitate administrative decisions on where resources should be allocated to improve care.
- Published
- 2022
26. Differences Between VHA-Delivered and VHA-Purchased Behavioral Health Care in Service and Patient Characteristics
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Megan E. Vanneman, Amy K. Rosen, Todd H. Wagner, Michael Shwartz, Sarah H. Gordon, Greg Greenberg, Tianyu Zheng, James Cook, Erin Beilstein-Wedel, Tom Greene, and A. Taylor Kelley
- Subjects
Psychiatry and Mental health - Abstract
Federal legislation has expanded Veterans Health Administration (VHA) enrollees' access to VHA-purchased "community care." This study examined differences in the amount and type of behavioral health care delivered in VHA and purchased in the community, along with patient characteristics and area supply and demand factors.This retrospective cross-sectional study examined data for 204,094 VHA enrollees with 448,648 inpatient behavioral health stays and 3,467,010 enrollees with 55,043,607 outpatient behavioral health visits from fiscal years 2016 to 2019. Standardized mean differences (SMDs) were calculated for patient and provider characteristics at the outpatient-visit level for VHA and community care. Linear probability models assessed the association between severity of behavioral health condition and site of care.Twenty percent of inpatient stays were purchased through community care, with severe behavioral health conditions more likely to be treated in VHA inpatient care. In the outpatient setting, community care accounted for 3% of behavioral health care visits, with increasing use over time. For outpatient care, veterans receiving community care were more likely than those receiving VHA care to see clinicians with fewer years of training (SMD=1.06).With a large portion of inpatient behavioral health care occurring in the community and increased use of outpatient behavioral health care with less highly trained community providers, coordination between VHA and the community is essential to provide appropriate inpatient follow-up care and address outpatient needs. This is especially critical given VHA's expertise in providing behavioral health care to veterans and its legislative responsibility to ensure integrated care.
- Published
- 2022
27. Comparing Driving Miles for Department of Veterans Affairs–delivered Versus Department of Veterans Affairs–purchased Cataract Surgery
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Warren B. P. Pettey, Erin Beilstein-Wedel, Michael Shwartz, Megan E. Vanneman, Amy K. Rosen, and Todd H. Wagner
- Subjects
Male ,Automobile Driving ,medicine.medical_treatment ,Eligibility Determination ,Patient Freedom of Choice Laws ,Cataract Extraction ,Health Services Accessibility ,03 medical and health sciences ,0302 clinical medicine ,Humans ,Medicine ,Community Health Services ,030212 general & internal medicine ,Veterans Affairs ,health care economics and organizations ,Veterans ,Aged ,Retrospective Studies ,geographic information systems ,Geography ,business.industry ,030503 health policy & services ,Public Health, Environmental and Occupational Health ,travel burden ,cataract surgery ,Middle Aged ,Cataract surgery ,medicine.disease ,United States ,humanities ,United States Department of Veterans Affairs ,Veterans Health Services ,ComputingMethodologies_DOCUMENTANDTEXTPROCESSING ,access to health care ,Brief Reports ,Female ,Medical emergency ,0305 other medical science ,business - Abstract
Supplemental Digital Content is available in the text., Background: The Veterans Choice Act of 2014 increased the number of Veterans eligible for Department of Veterans Affairs (VA)-purchased care delivered in non-VA community care (CC) facilities. Driving >40 miles from home to a VA facility is a key eligibility criterion for CC. It remains unclear whether this policy change improved geographical access by reducing drive distance for Veterans. Objectives: Describe the driving distance for Veterans receiving cataract surgery in VA and CC facilities, and if they visited the closest-to-home facility or if they drove to farther facilities. Subjects: Veterans who had cataract surgery in federal fiscal year 2015. Measures: We calculated driving miles to the Closest VA and CC facilities that performed cataract surgeries, and to the location where Veterans received care. Results: A total of 61,746 Veterans received 83,875 cataract surgeries. More than 50% of CC surgeries occurred farther than the Closest CC facility providing cataract surgery (median Closest CC facility 8.7 miles vs. Actual CC facility, 19.7 miles). Most (57%) Veterans receiving cataract surgery at a VA facility used the Closest VA facility (median Closest VA facility 28.1 miles vs. Actual VA facility at 31.2 miles). In all, 26.1% of CC procedures occurred in facilities farther away than the Closest VA facility. Conclusions: Although many Veterans drove farther than needed to get cataract surgery in CC, this was not true for obtaining care in the VA. Our findings suggest that there may be additional reasons, besides driving distance, that affect whether Veterans choose CC and, if they do, where they seek CC.
- Published
- 2021
28. County-level Predictors of Growth in Community-based Primary Care Use Among Veterans
- Author
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Sarah S Zahakos, James Cook, Erin Beilstein-Wedel, Megan E. Vanneman, Amy K. Rosen, Sarah H. Gordon, Tianyu Zheng, Todd H. Wagner, and Alan Taylor Kelley
- Subjects
Adult ,Male ,Rural Population ,Urban Population ,provider supply ,Patient Freedom of Choice Laws ,Veterans Health ,Primary care ,community care ,Health Services Accessibility ,03 medical and health sciences ,0302 clinical medicine ,Rurality ,Environmental health ,Health care ,Humans ,Medicine ,Community Health Services ,030212 general & internal medicine ,County level ,Aged ,Veterans ,Community based ,Primary Health Care ,business.industry ,030503 health policy & services ,Health Plan Implementation ,Public Health, Environmental and Occupational Health ,Middle Aged ,Patient Acceptance of Health Care ,United States ,VA-purchased care ,United States Department of Veterans Affairs ,ComputingMethodologies_DOCUMENTANDTEXTPROCESSING ,Community setting ,Female ,Brief Reports ,penetration rates ,Penetration rate ,Rural area ,0305 other medical science ,business - Abstract
Supplemental Digital Content is available in the text., Background: The 2014 Choice Act expanded the Veterans Health Administration’s (VA) capacity to purchase services for VA enrollees from community providers, yet little is known regarding the growth of Veterans’ primary care use in community settings. Objectives: The aim was to measure county-level growth in VA community-based primary care (CBPC) penetration following the Choice Act and to assess whether CBPC penetration increased in rural counties with limited access to VA facilities. Data and Sample: A total of 3132 counties from VA administrative data from 2015 to 2018, Area Health Resources Files, and County Health Rankings. Analysis: We defined the county-level CBPC penetration rate as the proportion of VA-purchased primary care out of all VA-purchased primary care (ie, within and outside VA). We estimated county-level multivariate linear regression models to assess whether rurality and supply of primary care providers and health care facilities were significantly associated with CBPC growth. Results: Nationally, CBPC penetration rates increased from 2.7% in 2015 to 7.3% in 2018. The rurality of the county was associated with a 2–3 percentage point (pp) increase in CBPC penetration growth (P
- Published
- 2021
29. Acquisition of Medicaid at the time of injury: An opportunity for sustainable insurance coverage
- Author
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Linda Diem Tran, David A. Spain, Katherine L. Dickerson, Katherine D. Arnow, Lisa M. Knowlton, Alex H. S. Harris, Arden M. Morris, Joshua D. Jaramillo, Sylvia Bereknyei, Todd H. Wagner, and Amber W. Trickey
- Subjects
Adult ,Male ,medicine.medical_specialty ,Adolescent ,Poison control ,Critical Care and Intensive Care Medicine ,Insurance Coverage ,Young Adult ,Injury Severity Score ,Trauma Centers ,Interquartile range ,Injury prevention ,Risk of mortality ,Humans ,Medicine ,Medicaid ,business.industry ,Patient Protection and Affordable Care Act ,Medical record ,Trauma center ,Middle Aged ,Patient Acceptance of Health Care ,United States ,Hospitalization ,Logistic Models ,Multivariate Analysis ,Emergency medicine ,Wounds and Injuries ,Female ,Surgery ,Health Expenditures ,Emergency Service, Hospital ,business - Abstract
INTRODUCTION Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources, and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher Injury Severity Score (ISS) (ISS >15) would be more likely to be approved for HPE. METHODS We identified Medicaid and uninsured patients aged 18 to 64 years with a primary trauma diagnosis (International Classification of Diseases, Tenth Revision) in a large level I trauma center between 2015 and 2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed. RESULTS Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. Hospital Presumptive Eligibility patients had higher ISS (ISS >15, 14.8% vs. 5.7%; p < 0.001), longer median length of stay (2 days [interquartile range, 0-5 days] vs. 0 [0-1] days, p < 0.001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < 0.001), and discharged to postacute services (11.9% vs. 0.9%, p < 0.001). Patient, hospital, and policy factors contributed to HPE nonapproval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic Whites: aOR, 1.58; p = 0.02) and increasing ISS (p ≤ 0.001) were associated with increased likelihood of HPE approval. CONCLUSION The time of hospitalization due to injury is an underused opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention. LEVEL OF EVIDENCE Economic, level IV.
- Published
- 2021
30. Laboratory‐wide association study of survival with prostate cancer
- Author
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Ericka Sohlberg, Manisha Desai, Chirag J. Patel, Mary K. Goldstein, Glenn M. Chertow, Jaden Yang, Todd H. Wagner, I-Chun Thomas, Kyla N. Velaer, James D. Brooks, Kristopher Kapphahn, and John T. Leppert
- Subjects
Male ,Cancer Research ,medicine.medical_specialty ,Clinical Chemistry Tests ,Blood Sedimentation ,Article ,Leukocyte Count ,03 medical and health sciences ,Prostate cancer ,chemistry.chemical_compound ,0302 clinical medicine ,Cancer Survivors ,Internal medicine ,Natriuretic Peptide, Brain ,Biomarkers, Tumor ,medicine ,Humans ,030212 general & internal medicine ,Serum Albumin ,Aged ,Creatinine ,medicine.diagnostic_test ,Diagnostic Tests, Routine ,business.industry ,Hazard ratio ,Prostatic Neoplasms ,Cancer ,gamma-Glutamyltransferase ,Prostate-Specific Antigen ,Alkaline Phosphatase ,medicine.disease ,Confidence interval ,Clinical trial ,Oncology ,chemistry ,030220 oncology & carcinogenesis ,Erythrocyte sedimentation rate ,Veterans Health Services ,Cohort ,business - Abstract
Background Estimates of overall patient health are essential to inform treatment decisions for patients diagnosed with cancer. The authors applied XWAS methods, herein referred to as "laboratory-wide association study (LWAS)", to evaluate associations between routinely collected laboratory tests and survival in veterans with prostate cancer. Methods The authors identified 133,878 patients who were diagnosed with prostate cancer between 2000 and 2013 in the Veterans Health Administration using any laboratory tests collected within 6 months of diagnosis (3,345,083 results). Using the LWAS framework, the false-discovery rate was used to test the association between multiple laboratory tests and survival, and these results were validated using training, testing, and validation cohorts. Results A total of 31 laboratory tests associated with survival met stringent LWAS criteria. LWAS confirmed markers of prostate cancer biology (prostate-specific antigen: hazard ratio [HR], 1.07 [95% confidence interval (95% CI), 1.06-1.08]; and alkaline phosphatase: HR, 1.22 [95% CI, 1.20-1.24]) as well laboratory tests of general health (eg, serum albumin: HR, 0.78 [95% CI, 0.76-0.80]; and creatinine: HR, 1.05 [95% CI, 1.03-1.07]) and inflammation (leukocyte count: HR, 1.23 [95% CI, 1.98-1.26]; and erythrocyte sedimentation rate: HR, 1.33 [95% CI, 1.09-1.61]). In addition, the authors derived and validated separate models for patients with localized and advanced disease, identifying 28 laboratory markers and 15 laboratory markers, respectively, in each cohort. Conclusions The authors identified routinely collected laboratory data associated with survival for patients with prostate cancer using LWAS methodologies, including markers of prostate cancer biology, overall health, and inflammation. Broadening consideration of determinants of survival beyond those related to cancer itself could help to inform the design of clinical trials and aid in shared decision making. Lay summary This article examined routine laboratory tests associated with survival among veterans with prostate cancer. Using laboratory-wide association studies, the authors identified 31 laboratory tests associated with survival that can be used to inform the design of clinical trials and aid patients in shared decision making.
- Published
- 2020
31. Estimating Costs of an Implementation Intervention
- Author
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Angela So, Jean Yoon, Amy M. Kilbourne, David E. Goodrich, Josephine Jacobs, Wei Yu, and Todd H. Wagner
- Subjects
Cost estimate ,Computer science ,business.industry ,Cost-Benefit Analysis ,030503 health policy & services ,Health Policy ,Statistics as Topic ,Factor price ,Psychological intervention ,Information technology ,03 medical and health sciences ,Intervention (law) ,0302 clinical medicine ,Risk analysis (engineering) ,Scale (social sciences) ,Health care ,Humans ,030212 general & internal medicine ,0305 other medical science ,business ,health care economics and organizations ,Sunk costs ,Implementation Science - Abstract
Health care systems frequently have to decide whether to implement interventions designed to reduce gaps in the quality of care. A lack of information on the cost of these interventions is often cited as a barrier to implementation. In this article, we describe methods for estimating the cost of implementing a complex intervention. We review methods related to the direct measurement of labor, supplies and space, information technology, and research costs. We also discuss several issues that affect cost estimates in implementation studies, including factor prices, fidelity, efficiency and scale of production, distribution, and sunk costs. We examine case studies for stroke and depression, where evidence-based treatments exist and yet gaps in the quality of care remain. Understanding the costs for implementing strategies to reduce these gaps and measuring them consistently will better inform decision makers about an intervention’s likely effect on their budget and the expected costs to implement new interventions.
- Published
- 2020
32. Estimating Downstream Budget Impacts in Implementation Research
- Author
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Todd H. Wagner, Heather T. Gold, and Alex R. Dopp
- Subjects
Budgets ,Quality management ,Cost estimate ,Short run ,business.industry ,Computer science ,030503 health policy & services ,Health Policy ,media_common.quotation_subject ,Time horizon ,Health Care Costs ,Financial management ,03 medical and health sciences ,0302 clinical medicine ,Risk analysis (engineering) ,Health care ,Humans ,Quality (business) ,030212 general & internal medicine ,Implementation research ,0305 other medical science ,business ,Implementation Science ,media_common - Abstract
Health care decision makers often request information showing how a new treatment or intervention will affect their budget (i.e., a budget impact analysis; BIA). In this article, we present key topics for considering how to measure downstream health care costs, a key component of the BIA, when implementing an evidence-based program designed to reduce a quality gap. Tracking health care utilization can be done with administrative or self-reported data, but estimating costs for these utilization data raises 2 issues that are often overlooked in implementation science. The first issue has to do with applicability: are the cost estimates applicable to the health care system that is implementing the quality improvement program? We often use national cost estimates or average payments, without considering whether these cost estimates are appropriate. Second, we need to determine the decision maker’s time horizon to identify the costs that vary in that time horizon. If the BIA takes a short-term time horizon, then we should focus on costs that vary in the short run and exclude costs that are fixed over this time. BIA is an increasingly popular tool for health care decision makers interested in understanding the financial effect of implementing an evidence-based program. Without careful consideration of some key conceptual issues, we run the risk of misleading decision makers when presenting results from implementation studies.
- Published
- 2020
33. Incidence and Prognostic Impact of Incomplete Revascularization Documented by Coronary Angiography 1 Year After Coronary Artery Bypass Grafting
- Author
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Todd H. Wagner, Jacquelyn A. Quin, Muath Bishawi, Robert B. Hawkins, Hossein Almassi, Brack Hattler, Joseph F. Collins, Frederick L. Grover, and Shroyer Al
- Subjects
Male ,Coronary angiography ,medicine.medical_specialty ,Hospitals, Veterans ,medicine.medical_treatment ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,Coronary Angiography ,Revascularization ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,medicine ,Incomplete revascularization ,Humans ,Single-Blind Method ,cardiovascular diseases ,030212 general & internal medicine ,Myocardial infarction ,Coronary Artery Bypass ,medicine.diagnostic_test ,business.industry ,Incidence ,Incidence (epidemiology) ,Middle Aged ,Prognosis ,medicine.disease ,United States ,medicine.anatomical_structure ,Angiography ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business ,Mace ,Artery - Abstract
Complete revascularization (CR) at the time of coronary artery bypass graft (CABG) surgery improves long-term cardiac outcomes. No studies have previously reported angiographically confirmed CR rates post-CABG. This study's aim was to assess the impact upon long-term outcomes of CR versus incomplete revascularization (IR), confirmed by coronary angiography 1 year after CABG. Randomized On/Off Bypass Study patients who returned for protocol-specified 1-year post-CABG coronary angiograms were included. Patients with a widely patent graft supplying the major diseased artery within each diseased coronary territory were considered to have CR. Outcomes were all-cause mortality and major adverse cardiovascular events (MACE; all-cause mortality, nonfatal myocardial infarction, repeat revascularization) over the 4 years after angiography. Of the 1,276 patients, 756 (59%) had CR and 520 (41%) had IR. MACE was 13% CR versus 26% IR, p0.001. This difference was driven by fewer repeat revascularizations (5% CR vs 18% IR; p0.001). There were no differences in mortality (7.1% CR vs 8.1% IR, p = 0.13) or myocardial infarction (4% in both). Adjusted multivariable models confirmed CR was associated with reduced MACE (odds ratio 0.44, 95% confidence interval 0.33 to 0.58, p0.01), but had no impact on mortality. In conclusion, CR confirmed by post-CABG angiography was associated with improved MACE but not mortality. Repeat revascularization of patients with IR, driven by knowledge of the research angiography results, may have ameliorated potential mortality differences.
- Published
- 2020
34. Veterans’ Experiences With Outpatient Care: Comparing The Veterans Affairs System With Community-Based Care
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Amy K. Rosen, Michael Shwartz, Clinton L. Greenstone, Mark Meterko, Megan E. Vanneman, Joseph Francis, and Todd H. Wagner
- Subjects
medicine.medical_specialty ,030503 health policy & services ,Health Policy ,Specialty ,Mental health ,03 medical and health sciences ,0302 clinical medicine ,Quality of life (healthcare) ,Ambulatory care ,Family medicine ,Patient experience ,medicine ,030212 general & internal medicine ,0305 other medical science ,Psychology ,Community-based care ,Veterans Affairs ,Health policy - Abstract
Timely access to outpatient care was a primary driver behind the Department of Veterans Affairs' (VA's) increased purchase of community-based care under the Veterans Access, Choice, and Accountability Act of 2014, known as the Choice Act. To compare veterans' experiences in VA-delivered and community-based outpatient care after implementation of the act, we assessed veterans' scores on four dimensions of experience-access, communication, coordination, and provider rating-for outpatient specialty, primary, and mental health care received during 2016-17. Patient experiences were better for VA than for community care in all respects except access. For specialty care, access scores were better in the community; for primary and mental health care, access scores were similar in the two settings. Although all specialty care scores and the primary care coordination score improved over time, the gaps between settings did not shrink. As purchased care further expands under the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, which replaced the Choice Act in 2019, monitoring of meaningful differences between settings should continue, with the results used to inform both VA purchasing decisions and patients' care choices.
- Published
- 2020
35. Emergency Medicaid Acquisition Through the Affordable Care Act
- Author
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Linda Diem Tran, Todd H. Wagner, and Lisa M. Knowlton
- Subjects
musculoskeletal diseases ,Research design ,congenital, hereditary, and neonatal diseases and abnormalities ,medicine.medical_specialty ,Eligibility Determination ,Logistic regression ,California ,Hospital Medicine ,03 medical and health sciences ,Uncompensated Care ,0302 clinical medicine ,Ambulatory care ,Humans ,Medicine ,Revenue ,030212 general & internal medicine ,Medicaid ,business.industry ,Patient Protection and Affordable Care Act ,030503 health policy & services ,Public Health, Environmental and Occupational Health ,Fixed effects model ,United States ,Difference in differences ,Family medicine ,0305 other medical science ,business - Abstract
BACKGROUND Hospital Presumptive Eligibility (HPE) is a national policy stemming from the Affordable Care Act that allows qualified hospitals, working with state officials, to enroll eligible patients for temporary Medicaid coverage. Although all states are required to operate an HPE program, hospital participation is elective and variable. It is unclear which hospitals choose to participate in HPE and how participation affects hospital utilization and revenue. OBJECTIVE We examined hospital factors associated with HPE participation in the state of California and assessed pre and post changes in hospital revenue and utilization for HPE and non-HPE hospitals. RESEARCH DESIGN We performed a logistic regression to identify hospital attributes associated with HPE participation. We then used a difference in differences methodology with a hospital fixed effect to test whether HPE enrollment was associated with changes in annual revenues by payer source, uncompensated care costs, outpatient visits, and/or discharges. RESULTS Three quarters (76%) of qualified hospitals elected to participate in HPE by the end of 2018. Hospitals with 100 or more beds had over 10 times greater odds of participating in HPE compared with smaller hospitals. Hospitals that did not provide outpatient care were significantly less likely to participate. Among hospitals included in trend analyses, enrollment in HPE was associated with increased annual net patient Medicaid revenue and decreased uncompensated care charges. We predicted that HPE enrollment was associated with an average of 9.7% (95% confidence interval: 3.4%-16.4%) increase in annual net patient Medicaid revenue. As of 2018, ∼33,000 adults and children were enrolled in California's HPE program per month. CONCLUSION Hospital enrollment in the HPE program shifted costs from uncompensated care to Medicaid.
- Published
- 2020
36. Acute pain after breast surgery and reconstruction: A two‐institution study of surgical factors influencing short‐term pain outcomes
- Author
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Amee D. Azad, Catherine Curtin, Amanda Wheeler, Selen Bozkurt, Tina Hernandez-Boussard, and Todd H. Wagner
- Subjects
medicine.medical_specialty ,Younger age ,business.industry ,medicine.medical_treatment ,Breast surgery ,Breast pain ,Chronic pain ,General Medicine ,medicine.disease ,Article ,03 medical and health sciences ,0302 clinical medicine ,Breast cancer ,Oncology ,Quality of life ,030220 oncology & carcinogenesis ,Internal medicine ,medicine ,030211 gastroenterology & hepatology ,Surgery ,medicine.symptom ,business ,Mastectomy ,Acute pain - Abstract
Background and objectives Acute postoperative pain following surgery is known to be associated with chronic pain development and lower quality of life. We sought to analyze the relationship between differing breast cancer excisional procedures, reconstruction, and short-term pain outcomes. Methods Women undergoing breast cancer excisional procedures with or without reconstruction at two systems: an academic hospital (AH) and Veterans Health Administration (VHA) were included. Average pain scores at the time of discharge and at 30-day follow-up were analyzed across demographic and clinical characteristics. Linear mixed effects modeling was used to assess the relationship between patient/clinical characteristics and interval pain scores with a random slope to account for differences in baseline pain. Results Our study included 1402 patients at AH and 1435 at VHA, of which 426 AH and 165 patients with VHA underwent reconstruction. Pain scores improved over time and were found to be highest at discharge. Time at discharge, 30-day follow-up, and preoperative opioid use were the strongest predictors of high pain scores. Younger age and longer length of stay were independently associated with worse pain scores. Conclusions Younger age, preoperative opioid use, and longer length of stay were associated with higher levels of postoperative pain across both sites.
- Published
- 2020
37. Comparing Postoperative Readmission Rates Between Veterans Receiving Total Knee Arthroplasty in the Veterans Health Administration Versus Community Care
- Author
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Amy K. Rosen, Erin E. Beilstein-Wedel, Alex H.S. Harris, Michael Shwartz, Megan E. Vanneman, Todd H. Wagner, and Nicholas J. Giori
- Subjects
Male ,Public Health, Environmental and Occupational Health ,Comorbidity ,Middle Aged ,Patient Readmission ,United States ,United States Department of Veterans Affairs ,Postoperative Complications ,Veterans Health Services ,Humans ,Female ,Arthroplasty, Replacement, Knee ,Aged ,Quality of Health Care ,Retrospective Studies - Abstract
There are growing concerns that Veterans' increased use of Veterans Health Administration (VA)-purchased care in the community may lead to lower quality of care.We compared rates of hospital readmissions following elective total knee arthroplasties (TKAs) that were either performed in VA or purchased by VA through community care (CC) at both the national and facility levels.Three-year cohort study using VA and CC administrative data from the VA's Corporate Data Warehouse (October 1, 2016-September 30, 2019). We obtained Medicare data to capture readmissions that were paid by Medicare. We used the Centers for Medicare and Medicaid Services (CMS) methods to identify unplanned, 30-day, all-cause readmissions. A secondary outcome, TKA-related readmissions, identified readmissions resulting from complications of the index surgery. We ran mixed-effects logistic regression models to compare the risk-adjusted odds of all-cause and TKA-related readmissions between TKAs performed in VA versus CC, adjusting for patients' sociodemographic and clinical characteristics.Nationally, the odds of experiencing an all-cause or TKA-related readmission were significantly lower for TKAs performed in VA versus CC (eg, the odds of experiencing an all-cause readmission in VA were 35% of those in CC. At the facility level, most VA facilities performed similarly to their corresponding CC providers, although there were 3 VA facilities that performed worse than their corresponding CC providers.Given VA's history in providing high-quality surgical care to Veterans, it is important to closely monitor and track whether the shift to CC for surgical care will impact quality in both settings over time.
- Published
- 2022
38. Evaluating the Role of Past Clinical Information on Risk Adjustment
- Author
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Todd H. Wagner, John K Lin, Ciaran S. Phibbs, Peter L. Almenoff, and Juliette Hong
- Subjects
Male ,Diagnostic information ,Predictive capability ,Medicare ,03 medical and health sciences ,risk adjustment ,0302 clinical medicine ,cost ,Clinical information ,Humans ,health economics ,Prospective Studies ,030212 general & internal medicine ,Veterans Affairs ,Data collection ,Actuarial science ,Brief Report ,030503 health policy & services ,Principal (computer security) ,Public Health, Environmental and Occupational Health ,performance measurement ,Health Services ,Patient Acceptance of Health Care ,Risk adjustment ,United States ,United States Department of Veterans Affairs ,ComputingMethodologies_DOCUMENTANDTEXTPROCESSING ,Female ,0305 other medical science ,Psychology ,Models, Econometric - Abstract
Supplemental Digital Content is available in the text., Objective: The objective of this study was to evaluate whether incorporating historical clinical information beyond 1 year improves risk adjustment. Data Sources: Administrative data from the Department of Veterans Affairs and Medicare (for veterans concurrently enrolled in Medicare) for fiscal years (FYs) 2011–2015. Study Design: We regressed total annual costs on Medicare hierarchical condition category indicators and risk scores for FY 2015 in both a concurrent and a prospective model using 5-fold cross-validation. Regressions were repeated incorporating clinical information from FY 2011 to 2015. Model fit was appraised using R2 and mean squared predictive error (MSPE). Data Collection: All veterans affairs users (n=3,254,783) with diagnostic information FY 2011–2015. Principal Findings: In a concurrent model, adding additional years of historical clinical information (FY 2011–2014) did not result in substantive gains in fit (R2 from 0.671 to 0.673) or predictive capability (MSPE from 1956 to 1950). In a prospective model, adding additional years of historical clinical information also did not result in substantive gains in fit (R2 from 0.334 to 0.344) or predictive capability (MSPE from 3988 to 3940). Conclusion: Incorporating historical clinical information yielded no material gain in risk adjustment fit.
- Published
- 2019
39. Improving Prediction of Long-Term Care Utilization Through Patient-Reported Measures: Cross-Sectional Analysis of High-Need U.S. Veterans Affairs Patients
- Author
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Josephine C. Jacobs, Matthew L. Maciejewski, Todd H. Wagner, Courtney H. Van Houtven, Jeanie Lo, Liberty Greene, and Donna M. Zulman
- Subjects
United States Department of Veterans Affairs ,Cross-Sectional Studies ,Health Policy ,Activities of Daily Living ,Humans ,Patient Reported Outcome Measures ,Long-Term Care ,humanities ,health care economics and organizations ,United States ,Veterans - Abstract
This article examines the relative merit of augmenting an electronic health record (EHR)-derived predictive model of institutional long-term care (LTC) use with patient-reported measures not commonly found in EHRs. We used survey and administrative data from 3,478 high-risk Veterans aged ≥65 in the U.S. Department of Veterans Affairs, comparing a model based on a Veterans Health Administration (VA) geriatrics dashboard, a model with additional EHR-derived variables, and a model that added survey-based measures (i.e., activities of daily living [ADL] limitations, social support, and finances). Model performance was assessed via Akaike information criteria, C-statistics, sensitivity, and specificity. Age, a dementia diagnosis, Nosos risk score, social support, and ADL limitations were consistent predictors of institutional LTC use. Survey-based variables significantly improved model performance. Although demographic and clinical characteristics found in many EHRs are predictive of institutional LTC, patient-reported function and partnership status improve identification of patients who may benefit from home- and community-based services.
- Published
- 2021
40. Expansion of the Veterans Health Administration Network and Surgical Outcomes
- Author
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Laura A. Graham, Lena Schoemaker, Liam Rose, Arden M. Morris, Marion Aouad, and Todd H. Wagner
- Subjects
Surgery - Abstract
ImportanceThe US Department of Veterans Affairs (VA) Veterans Choice Program (VCP) expanded health care access to community settings outside the VA for eligible patients. Little is known about the effect of VCP on access to surgery and postoperative outcomes. Since its initiation, care coordination issues, which are often associated with adverse postoperative outcomes, have been reported. Research findings on the association of VCP and postoperative outcomes are limited to only a few select procedures and have been mixed, potentially due to bias from unmeasured confounding.ObjectiveTo investigate the association of the VCP with access to surgery and postoperative outcomes using a nonrandomized controlled regression discontinuity design (RDD) to reduce the impact of unmeasured confounders.Design, Setting, and ParticipantsThis was a nonrandomized RDD study of the Veterans Health Administration (VHA). Participants included veterans enrolled in the VHA who required surgery between October 1, 2014, and June 1, 2019.InterventionsThe VCP, which expanded access to VA-paid community care for eligible veterans living 40 miles or more from their closest VA hospital.Main Outcomes and MeasuresPostoperative emergency department visits, inpatient readmissions, and mortality at 30 and 90 days.ResultsA total of 615 473 unique surgical procedures among 498 427 patients (mean [SD] age, 63.0 [12.9] years; 450 366 male [90.4%]) were identified. Overall, 94 783 procedures (15.4%) were paid by the VHA, and the proportion of VHA-paid procedures varied by procedure type. Patients who underwent VA-paid procedures were more likely to be women (9209 [12.7%] vs men, 38 771 [9.1%]), White race (VA paid, 54 544 [74.4%] vs VA provided, 310 077 [73.0%]), and younger than 65 years (VA paid, 36 054 [49.1%] vs 229 411 [46.0%] VA provided), with a significantly lower comorbidity burden (mean [SD], 1.8 [2.2] vs 2.6 [2.7]). The nonrandomized RDD revealed that VCP was associated with a slight increase of 0.03 in the proportion of VA-paid surgical procedures among eligible veterans (95% CI, 0.01-0.05; P = .01). However, there was no difference in postoperative mortality, readmissions, or emergency department visits.Conclusions and RelevanceExpanded access to health care in the VHA was associated with a shift in the performance of surgical procedures in the private sector but had no measurable association with surgical outcomes. These findings may assuage concerns of worsened patient outcomes resulting from care coordination issues when care is expanded outside of a single health care system, although it remains unclear whether these additional procedures were appropriate or improved patient outcomes.
- Published
- 2022
41. One-Year Costs Associated With the Veterans Affairs National TeleStroke Program
- Author
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Todd H. Wagner, Lena Schoemaker, Elizabeth Gehlert, Richard E. Nelson, Katherine Murphy, Sharyl Martini, Glenn D. Graham, Prasanthi Govindarajan, and Linda S. Williams
- Subjects
Stroke ,Fibrinolytic Agents ,Health Policy ,Tissue Plasminogen Activator ,Public Health, Environmental and Occupational Health ,Costs and Cost Analysis ,Humans ,Emergency Service, Hospital ,Telemedicine ,Veterans - Abstract
Access to timely care is important for patients with stroke, where rapid diagnosis and treatment affect functional status, disability, and mortality. Telestroke programs connect stroke specialists with emergency department staff at facilities without on-site stroke expertise. The objective of this study was to examine healthcare costs for patients with stroke who sought care before and after implementation of the US Department of Veterans Affairs National TeleStroke Program (NTSP).We identified 471 patients who had a stroke and sought care at a telestroke site and compared them to 529 patients with stroke who received stroke care at the same sites before telestroke implementation. We examined patient costs for 12 months before and after stroke, using a linear model with a patient-level fixed effect.NTSP was associated with significantly higher rates of patients receiving guideline concordant care. Compared with control patients, those treated by NTSP were 14.3 percentage points more likely to receive tissue plasminogen activator and 4.3 percentage points more likely to receive a thrombectomy (all P.0001). NTSP was associated with $4821 increased costs for patients with stroke in the first 30 days after the program (2019 dollars). There were no observed savings over 12 months, and the added costs of care were attributable to higher rates of guideline concordant care.Telestroke programs are unlikely to yield short-term savings because optimal stroke care is expensive. Healthcare organizations should expect increases in healthcare costs for patients treated for stroke in the first year after implementing a telestroke program.
- Published
- 2021
42. Risk Communication After Health Care Exposures: An Experimental Vignette Survey With Patients
- Author
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Elizabeth M. Maguire, Steven M. Asch, Thomas J Taylor, Richard A. Martinello, Thomas H. Gallagher, A. Rani Elwy, Barbara G. Bokhour, Janet Durfee, Allen L. Gifford, and Todd H. Wagner
- Subjects
medicine.medical_specialty ,Medicine (General) ,business.industry ,Health Policy ,vignettes ,Public Health, Environmental and Occupational Health ,healthcare exposures ,Qualitative property ,Lower risk ,experimental study ,Risk perception ,Harm ,R5-920 ,risk communication ,Vignette ,Family medicine ,Health care ,medicine ,Social media ,Original Research Article ,veterans ,Thematic analysis ,Psychology ,business - Abstract
Purpose. We investigated how health care systems should communicate with patients about possible exposures to blood-borne pathogens that may have occurred during their care. Our goal was to determine how best to communicate uncertain risk information in a way that would minimize harm to patients, maintain their trust, and encourage patients to seek follow-up treatment. Methods. Participants ( N = 1103) were randomized to receive one of six vignette surveys; 997 (98.4%) responded. All vignettes described the same event, but differed by risk level and recommendations (lower risk v. higher risk) and by communication mode (telephone, letter, social media). We measured participants’ perceived risk of blood-borne infection, trust in the health care system, and shared decision making about next clinical steps. Open-ended questions were analyzed using grounded thematic analysis. Results. When the vignette requested patients to undergo testing and practice certain health behaviors (higher risk), participants’ likelihood of seeking follow-up testing for blood-borne pathogens and their understanding of health issues increased. Perceived trust was unaffected by risk level or communication processes. Qualitative data indicated a desire for telephone communication from providers known to the patient. Limitations. It is not clear whether higher risk language or objective risk levels in vignettes motivated patients’ behavioral intentions. Conclusion. Using higher risk language when disclosing large-scale adverse events increased participants’ willingness to seek follow-up care. Implications. Health care organizations’ disclosures should focus on the next steps to take after health care exposures. This communication should involve helping patients to understand their personal health issues better, make them feel that they know which steps to take following the receipt of this information, and encouraging them to seek follow-up infectious disease testing in order to better take care of themselves.
- Published
- 2021
43. Comparing Complication Rates After Elective Total Knee Arthroplasty Delivered Or Purchased By The VA
- Author
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Alex H S, Harris, Erin E, Beilstein-Wedel, Amy K, Rosen, Michael, Shwartz, Todd H, Wagner, Megan E, Vanneman, and Nicholas J, Giori
- Subjects
United States Department of Veterans Affairs ,Elective Surgical Procedures ,Hospitals, Veterans ,Humans ,Arthroplasty, Replacement, Knee ,United States ,Veterans - Abstract
The Department of Veterans Affairs (VA) both delivers health care in its own facilities and, increasingly, purchases care for veterans in the community. Policy makers, administrators, health care providers, and veterans frequently face decisions about which services should be delivered versus purchased by the VA. Comparisons of quality across settings are essential if veterans are to receive care that is consistently accessible, patient centered, effective, and safe. We compared risk-adjusted major postoperative complication rates for total knee arthroplasties that were delivered in VA facilities versus purchased from community providers. Overall, adjusted complication rates were significantly lower for arthroplasties delivered by the VA compared with those that were purchased. However, hospital-level comparisons revealed five locations where VA-purchased care outperformed VA-delivered care. As the amount of VA-purchased care continues to increase under the Veterans Access, Choice, and Accountability Act of 2014 and the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, these results support VA monitoring of overall and local comparative hospital performance to improve the quality of the care that the VA delivers while ensuring optimal outcomes in VA-purchased care.
- Published
- 2021
44. Long‐term care service mix in the Veterans Health Administration after home care expansion
- Author
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Josephine Jacobs, Courtney Harold Van Houtven, Todd H. Wagner, Ranak B. Trivedi, and Karl A. Lorenz
- Subjects
Gerontology ,Male ,Activities of daily living ,Medicare ,Home and Community‐based Services ,Health Services Accessibility ,03 medical and health sciences ,0302 clinical medicine ,Medicine ,Humans ,030212 general & internal medicine ,Community Health Services ,health care economics and organizations ,Aged ,Retrospective Studies ,Veterans ,Service (business) ,Data collection ,business.industry ,030503 health policy & services ,Health Policy ,Health and Retirement Study ,Mental health ,Home Care Services ,Long-Term Care ,United States ,Long-term care ,United States Department of Veterans Affairs ,Female ,0305 other medical science ,business ,Medicaid ,Administrative Claims, Healthcare ,Cohort study - Abstract
OBJECTIVE: To determine whether the Veterans Health Administration's (VHA) efforts to expand access to home‐ and community‐based services (HCBS) after the 2001 Millennium Act significantly changed Veterans' utilization of institutional, paid home, and unpaid home care relative to a non‐VHA user Medicare population that was not exposed to HCBS expansion efforts. DATA SOURCES: We used linkages between the Health and Retirement Study and VHA administrative data from 1998 until 2012. STUDY DESIGN: We conducted a retrospective‐matched cohort study using coarsened exact matching to ensure balance on observable characteristics for VHA users (n = 943) and nonusers (n = 6106). We used a difference‐in‐differences approach with a person fixed‐effects estimator. DATA COLLECTION/EXTRACTION METHODS: Individuals were eligible for inclusion in the analysis if they were age 65 or older and indicated that they were covered by Medicare insurance in 1998. Individuals were excluded if they were covered by Medicaid insurance at baseline. Individuals were considered exposed to VHA HCBS expansion efforts if they were enrolled in the VHA and used VHA services. PRINCIPAL FINDINGS: Theory predicts that an increase in the public allocation of HCBS will decrease the utilization of its substitutes (e.g., institutional care and unpaid caregiving). We found that after the Millennium Act was passed, there were no observed differences between VHA users and nonusers in the probability of using institutional long‐term care (0.7% points, 95% CI: −0.009, 0.022) or in receiving paid help with activities of daily living (0.06% points, 95% CI: −0.011, 0.0125). VHA users received more hours of unpaid care post‐Millennium Act (1.48, 95% CI: −0.232, 3.187), though this effect was not significant once we introduced controls for mental health. CONCLUSIONS: Our findings indicate that mandating access to HCBS services does not necessarily imply that access to these services will follow suit.
- Published
- 2021
45. In-Stent Restenosis in Saphenous Vein Grafts (from the DIVA Trial)
- Author
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Jayson Liu, Kreton Mavromatis, Robert Edson, Bavana V. Rangan, Lauren Uyeda, Barry F. Uretsky, Hoang Thai, Beverly Ventura, Jose Ortiz, Antony A. Bavry, Kendrick A. Shunk, Todd A. Conner, Steven A. Goldman, Ying Lu, Faisal Latif, Aaron Alsleben, Emmanouil S. Brilakis, David R. Holmes, Ehrin J. Armstrong, Subhash Banerjee, Kodangudi B. Ramanathan, Deepak L. Bhatt, Hani Jneid, Sunil V. Rao, Mei-Chiung Shih, Kul Aggrawal, Santiago Garcia, Edward O. McFalls, Todd H. Wagner, Judit Karacsonyi, and Iosif Xenogiannis
- Subjects
Male ,medicine.medical_specialty ,medicine.medical_treatment ,Vein graft ,Coronary Artery Disease ,Coronary Angiography ,Prosthesis Design ,Coronary Restenosis ,Restenosis ,Risk Factors ,Internal medicine ,Medicine ,Humans ,Saphenous Vein ,Myocardial infarction ,Coronary Artery Bypass ,Aged ,business.industry ,Incidence (epidemiology) ,Age Factors ,Graft Occlusion, Vascular ,Drug-Eluting Stents ,Thrombolysis ,Middle Aged ,medicine.disease ,Diva ,Heart failure ,Cardiology ,Female ,In stent restenosis ,Cardiology and Cardiovascular Medicine ,business - Abstract
Saphenous vein grafts (SVGs) have high rates of in-stent restenosis (ISR). We compared the baseline clinical and angiographic characteristics of patients and lesions that did develop ISR with those who did not develop ISR during a median follow-up of 2.7 years in the DIVA study (NCT01121224). We also examined the ISR types using the Mehran classification. ISR developed in 119 out of the 575 DIVA patients (21%), with similar incidence among patients with drug-eluting stents and bare-metal stents (BMS) (21% vs 21%, p = 0.957). Patients in the ISR group were younger (67 ± 7 vs 69 ± 8 years, p = 0.04) and less likely to have heart failure (27% vs 38%, p = 0.03) and SVG lesions with Thrombolysis In Myocardial Infarction 3 flow before the intervention (77% vs 83%, p0.01), but had a higher number of target SVG lesions (1.33 ± 0.64 vs 1.16 ± 0.42, p0.01), more stents implanted in the target SVG lesions (1.52 ± 0.80 vs 1.31 ± 0.66, p0.01), and longer total stent length (31.37 ± 22.11 vs 25.64 ± 17.42 mm, p = 0.01). The incidence of diffuse ISR was similar in patients who received drug-eluting-stents and BMS (57% vs 54%, p = 0.94), but BMS patients were more likely to develop occlusive restenosis (17% vs 33%, p = 0.05).
- Published
- 2021
46. Costs of Endoscopic vs Open Vein Harvesting for Coronary Artery Bypass Grafting
- Author
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Todd H, Wagner, Brack, Hattler, Eileen M, Stock, Kousick, Biswas, Deepak L, Bhatt, Faisal G, Bakaeen, Kritee, Gujral, and Marco A, Zenati
- Subjects
Adult ,Male ,Tissue and Organ Harvesting ,Humans ,Female ,Saphenous Vein ,Prospective Studies ,General Medicine ,Coronary Artery Bypass ,Medicare ,United States ,Aged - Abstract
Value-based purchasing creates pressure to examine whether newer technologies and care processes, including new surgical techniques, yield any economic advantage.To compare health care costs and utilization between participants randomized to receive endoscopic vein harvesting (EVH) or open vein harvesting (OVH) during a coronary artery bypass grafting (CABG) procedure.This secondary economic analysis was conducted alongside the 16-site Randomized Endo-Vein Graft Prospective (REGROUP) clinical trial funded by the Department of Veterans Affairs (VA) Cooperative Studies Program. Adults scheduled for urgent or elective bypass involving a vein graft were eligible. The first participant was enrolled in September 2013, with most sites completing enrollment by March 2014. The last participant was enrolled in April 2017. A total of 1150 participants were randomized, with 574 participants receiving OVH and 576 receiving EVH. For this secondary analysis, cost and utilization data were extracted through September 30, 2020. Participants were linked to administrative data in the VA Corporate Data Warehouse and activity-based cost data starting with the index procedure.EVH vs OVH, with comparisons based on intention to treat.Discharge costs for the index procedure as well as follow-up costs (including intended and unintended events; mean [SD] follow-up time, 33.0 [19.9] months) were analyzed, with results from different statistical models compared to test for robustness (ie, lack of variation across models). All costs represented care provided or paid by the VA, standardized to 2020 US dollars.Among 1150 participants, the mean (SD) age was 66.4 (6.9) years; most participants (1144 [99.5%] were male. With regard to race and ethnicity, 6 participants (0.5%) self-reported as American Indian or Alaska Native, 10 (0.9%) as Asian or Pacific Islander, 91 (7.9%) as Black, 62 (5.4%) as Hispanic, 974 (84.7%) as non-Hispanic White, and 6 (0.5%) as other race and/or ethnicity; data were missing for 1 participant (0.1%). The unadjusted mean (SD) costs for the index CABG procedure were $76 607 ($43 883) among patients who received EVH and $75 368 ($45 900) among those who received OVH, including facility costs, insurance costs, and physician-related costs (commonly referred to as provider costs in Centers for Medicare and Medicaid and insurance data). No significant differences were found in follow-up costs; per 90-day follow-up period, EVH was associated with a mean (SE) added cost of $302 ($225) per patient. The results were highly robust to the statistical model.In this study, EVH was not associated with a reduction in costs for the index CABG procedure or follow-up care. Therefore, the choice to provide EVH may be based on surgeon and patient preferences.ClinicalTrials.gov Identifier: NCT01850082.
- Published
- 2022
47. The Association Between Alpha-1 Adrenergic Receptor Antagonists and In-Hospital Mortality from COVID-19
- Author
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Liam Rose, Laura Graham, Allison Koenecke, Michael Powell, Ruoxuan Xiong, Zhu Shen, Brett Mench, Kenneth W. Kinzler, Chetan Bettegowda, Bert Vogelstein, Susan Athey, Joshua T. Vogelstein, Maximilian F. Konig, and Todd H. Wagner
- Subjects
Relative risk reduction ,medicine.medical_specialty ,infectious disease ,030204 cardiovascular system & hematology ,Article ,03 medical and health sciences ,Terazosin ,0302 clinical medicine ,Tamsulosin ,Internal medicine ,Doxazosin ,Medicine ,030212 general & internal medicine ,alpha-1-adrenergic receptor antagonist ,Veterans Affairs ,Alfuzosin ,lcsh:R5-920 ,business.industry ,COVID-19 ,Retrospective cohort study ,General Medicine ,Odds ratio ,Brief Research Report ,Silodosin ,off-label drug use ,coronavirus disease ,Cohort ,lcsh:Medicine (General) ,business ,medicine.drug - Abstract
Effective therapies for coronavirus disease 2019 (COVID-19) are urgently needed, and pre-clinical data suggest alpha-1 adrenergic receptor antagonists (α1-AR antagonists) may be effective in reducing mortality related to hyperinflammation independent of etiology. Using a retrospective cohort design with patients in the Department of Veterans Affairs healthcare system, we use doubly robust regression and matching to estimate the association between baseline use of α1-AR antagonists and likelihood of death due to COVID-19 during hospitalization. Having an active prescription for any α1-AR antagonist (tamsulosin, silodosin, prazosin, terazosin, doxazosin, or alfuzosin) at the time of admission had a significant negative association with in-hospital mortality (relative risk reduction 18%; odds ratio 0.73; 95% CI 0.63–0.85; p ≤ 0.001) and death within 28 days of admission (relative risk reduction 17%; odds ratio 0.74; 95% CI 0.65–0.84; p ≤ 0.001). In a subset of patients on doxazosin specifically, an inhibitor of all three alpha-1 adrenergic receptors, we observed a relative risk reduction for death of 74% (odds ratio 0.23; 95% CI 0.03–0.94; p = 0.028) compared to matched controls not on any α1-AR antagonist at the time of admission. These findings suggest that use of α1-AR antagonists may reduce mortality in COVID-19, supporting the need for randomized, placebo-controlled clinical trials in patients with early symptomatic infection.
- Published
- 2020
48. Co-Operative Pain Education and Self-management (COPES) Expanding Treatment for Real-World Access (ExTRA): Pragmatic Trial Protocol
- Author
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Brett Ankawi, John D. Piette, Kristin M. Mattocks, Todd Kawecki, Sarah L. Krein, Todd H. Wagner, Mary A. Driscoll, Alicia A. Heapy, Sara N. Edmond, Jennifer L Murphy, Diana M. Higgins, Kathryn M LaChappelle, Steve Martino, Lynn DeBar, Eugenia Buta, and R. Ross MacLean
- Subjects
Male ,medicine.medical_specialty ,Technology ,Blinding ,Clinical Neurology ,Psychological intervention ,Nonpharmacologic Treatment ,Superiority Trial ,Interactive voice response ,Original Research Articles ,Health care ,Pragmatic Clinical Trials as Topic ,medicine ,Humans ,Veterans Affairs ,Veterans ,Self-management ,Cognitive Behavioral Therapy ,business.industry ,SARS-CoV-2 ,Self-Management ,Chronic pain ,COVID-19 ,General Medicine ,Middle Aged ,medicine.disease ,Telemedicine ,COVID-19 Drug Treatment ,Pragmatic Trial ,Anesthesiology and Pain Medicine ,Chronic Pain ,Interactive Voice Response ,Physical therapy ,Female ,Neurology (clinical) ,business ,AcademicSubjects/MED00010 ,EDITORIALS - Abstract
Background Given access barriers to cognitive behavioral therapy for chronic pain (CBT-CP), this pragmatic superiority trial will determine whether a remotely delivered CBT-CP intervention that addresses these barriers outperforms in-person and other synchronous forms of CBT-CP for veterans with musculoskeletal pain. Design This pragmatic trial compares an asynchronous form of CBT-CP that uses interactive voice response (IVR) to allow patients to participate from their home (IVR CBT-CP) with synchronous CBT-CP delivered by a Department of Veterans Affairs (VA) clinician. Veterans (n=764; 50% male) with chronic musculoskeletal pain throughout nine VA medical centers will participate. The primary outcome is pain interference after treatment (4 months). Secondary outcomes, including pain intensity, depression symptom severity, sleep, self-efficacy, and global impression of change, are also measured after treatment. Where possible, outcomes are collected via electronic health record extraction, with remaining measures collected via IVR calls to maintain blinding. Quantitative and qualitative process evaluation metrics will be collected to evaluate factors related to implementation. A budget impact analysis will be performed. Summary This pragmatic trial compares the outcomes, cost, and implementation of two forms of CBT-CP as delivered in the real-world setting. Findings from the trial can be used to guide future policy and implementation efforts related to these interventions and their use in the health system. If one of the interventions emerges as superior, resources can be directed to this modality. If both treatments are effective, patient preferences and health care system factors will take precedence when making referrals. Implications of COVID-19 on treatment provision and trial outcomes are discussed.
- Published
- 2020
49. Rethinking How We Measure Costs in Implementation Research
- Author
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Todd H. Wagner
- Subjects
Budgets ,Opportunity cost ,Actuarial science ,Cost estimate ,Cost–benefit analysis ,business.industry ,Cost-Benefit Analysis ,010102 general mathematics ,Health Care Costs ,01 natural sciences ,03 medical and health sciences ,0302 clinical medicine ,Intensive care ,Health care ,Internal Medicine ,Medicine ,Humans ,030212 general & internal medicine ,Implementation research ,0101 mathematics ,business ,Fixed cost ,Delivery of Health Care ,Cost database ,Original Research - Abstract
BACKGROUND: Hospitals and other health care delivery organizations are sometimes resistant to implementing evidence‐based programs, citing unknown budgetary implications. OBJECTIVE: In this paper, I discuss challenges when estimating health care costs in implementation research. DESIGN: A case study with intensive care units highlights how including fixed costs can cloud a short‐term analysis. PARTICIPANTS: None. INTERVENTIONS: None. MAIN MEASURES: Health care costs, charges and payments. KEY RESULTS: Cost data should accurately reflect the opportunity costs for the organization(s) providing care. Opportunity costs are defined as the benefits foregone because the resources were not used in the next best alternative. Because there is no database of opportunity costs, cost studies rely on accounting data, charges, or payments as proxies. Unfortunately, these proxies may not reflect the organization’s opportunity costs, especially if the goal is to understand the budgetary impact in the next few years. CONCLUSIONS: Implementation researchers should exclude costs that are fixed in the time period of observation because these assets (e.g., space) cannot be used in the next best alternative. In addition, it is common to use costs from accounting databases where we implicitly assume health care providers are uniformly efficient. If providers are not operating efficiently, especially if there is variation in their efficiency, then this can create further problems. Implementation scientists should be judicious in their use of cost estimates from accounting data, otherwise research results can misguide decision makers.
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- 2020
50. End-of-Life Cost Trajectories in Cancer Patients Treated by Medicare versus the Veterans Health Administration
- Author
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Steven M. Asch, Karl A. Lorenz, Gary Hsin, Derek B. Boothroyd, Manali I. Patel, Todd H. Wagner, Risha Gidwani, Samantha Illarmo, Katherine E. Faricy-Anderson, Jack Needleman, and Kavitha Ramchandran
- Subjects
Male ,medicine.medical_specialty ,Referral ,Total cost ,Hospitals, Veterans ,Medicare ,03 medical and health sciences ,0302 clinical medicine ,Neoplasms ,parasitic diseases ,medicine ,Ambulatory Care ,Humans ,030212 general & internal medicine ,Generalized estimating equation ,health care economics and organizations ,Aged ,Terminal Care ,Inpatient care ,business.industry ,030503 health policy & services ,Drug cost ,Cancer ,Patient Acceptance of Health Care ,medicine.disease ,Veterans health ,Quality Improvement ,United States ,Hospitalization ,United States Department of Veterans Affairs ,Emergency medicine ,Costs and Cost Analysis ,Female ,Geriatrics and Gerontology ,0305 other medical science ,business ,End-of-life care ,Needs Assessment - Abstract
Background/objectives To evaluate differences in end-of-life cost trajectories for cancer patients treated through Medicare versus by the Veterans Health Administration (VA). Design A retrospective analysis of VA and Medicare administrative data from FY 2010 to 2014. We employed three-level generalized estimating equations to evaluate monthly cost trajectories experienced by patients in their last year of life, with patients nested within hospital referral region. Setting Care received at VA facilities or by Medicare-reimbursed providers nationwide. Participants A total of 36,401 patients dying from cancer and dually enrolled in VA and Medicare. Measurements We evaluated trajectories for total, inpatient, outpatient, and drug costs, using the last 12 months of life. Cost trajectories were prioritized as costs are not directly comparable across Medicare and VA. Patients were assigned to be VA-reliant, Medicare-reliant or Mixed-reliant based on their healthcare utilization in the last year of life. Results All three groups experienced significantly different cost trajectories for total costs in the last year of life. Inpatient cost trajectories were significantly different between Medicare-reliant and VA-reliant patients, but did not differ between VA-reliant and Mixed-reliant patients. Outpatient and drug cost trajectories exhibited the inverse pattern: they were significantly different between VA-reliant and Mixed-reliant patients, but not between VA-reliant and Medicare-reliant patients. However, visual examination of cost trajectories revealed similar cost patterns in the last year of life among all three groups; there was a sharp rise in costs as patients approach death, largely due to inpatient care. Conclusion Despite substantially different financial incentives and organization, VA- and Medicare-treated patients exhibit similar patterns of increasing end-of-life costs, largely driven by inpatient costs. Both systems require improvement to ensure quality of end-of-life care is aligned with recommended practice.
- Published
- 2020
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