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Background The Cancer Center Cessation Initiative (C3I) was launched in 2017 as a part of the NCI Cancer Moonshot program to assist NCI-designated cancer centers in developing tobacco treatment programs for oncology patients. Participating centers have implemented varied evidence-based programs that fit their institutional resources and needs, offering a wide range of services including in-person and telephone-based counseling, point of care, interactive voice response systems, referral to the quitline, text- and web-based services, and medications. Methods We used a mixed methods comparative case study design to evaluate system-level implementation costs across 15 C3I-funded cancer centers that reported for at least one 6-month period between July 2018 and June 2020. We analyzed operating costs by resource category (e.g., personnel, medications) concurrently with transcripts from semi-structured key-informant interviews conducted during site visits. Personnel salary costs were estimated using Bureau of Labor Statistics wage data adjusted for area and occupation, and non-wage benefits. Qualitative findings provided additional information on intangible resources and contextual factors related to implementation costs. Results Median total monthly operating costs across funded centers were $11,045 (range: $5129–$20,751). The largest median operating cost category was personnel ($10,307; range: $4122–$19,794), with the highest personnel costs attributable to the provision of in-person program services. Monthly (non-zero) cost ranges for other categories were medications ($17–$573), materials ($6–$435), training ($96–$516), technology ($171–$2759), and equipment ($10–$620). Median cost-per-participant was $466 (range: $70–$2093) and cost-per-quit was $2688 (range: $330–$9628), with sites offering different combinations of program components, ranging from individually-delivered in-person counseling only to one program that offered all components. Site interviews provided context for understanding variations in program components and their cost implications. Conclusions Among most centers that have progressed in tobacco treatment program implementation, cost-per-quit was modest relative to other prevention interventions. Although select centers have achieved similar average costs by offering program components of various levels of intensity, they have varied widely in program reach and effectiveness. Evaluating implementation costs of such programs alongside reach and effectiveness is necessary to provide decision makers in oncology settings with the important additional information needed to optimize resource allocation when establishing tobacco treatment programs.

Background The majority of stroke survivors return to their homes and need assistance from family caregivers to perform activities of daily living. These increased demands coupled with the lack of preparedness for their new roles lead to a high risk for caregivers developing depressive symptoms and other negative outcomes. Follow-up home support and problem-solving interventions with caregivers are crucial for maintaining stroke survivors in their homes. Problem-solving interventions are effective but are underused in practice because they require large amounts of staff time to implement and are difficult for caregivers logistically. Objective The aim of this study is to test a problem-solving intervention for stroke caregivers that can be delivered over the telephone during the patient’s transitional care period (time when the stroke survivor is discharged to home) followed by 8 asynchronous online sessions. Methods The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 240 caregivers from eight Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a modified problem-solving intervention that uses telephone and web-based support and training with interactive modules, fact sheets, and tools on the previously developed and nationally available Resources and Education for Stroke Caregivers’ Understanding and Empowerment Caregiver website. In the usual care group, no changes are made in the information, discharge planning, or care the patients who have had a stroke normally receive, and caregivers have access to existing VA resources (eg, caregiver support line, self-help materials). The primary outcome is a change in caregiver depressive symptoms at 11 and 19 weeks after baseline data collection. Secondary outcomes include changes in stroke caregivers’ burden, knowledge, positive aspects of caregiving, self-efficacy, perceived stress, health-related quality of life, and satisfaction with care and changes in stroke survivors’ functional abilities and health care use. The team will also determine the budgetary impact, facilitators, barriers, and best practices for implementing the intervention. Throughout all phases of the study, we will collaborate with members of an advisory panel. Results Study enrollment began in June 2015 and is ongoing. The first results are expected to be submitted for publication in 2021. Conclusions This is the first known study to test a transitional care and messaging center intervention combined with technology to decrease caregiver depressive symptoms and to improve the recovery of stroke survivors. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post stroke. Trial Registration ClinicalTrials.gov NCT01600131; https://www.clinicaltrials.gov/ct2/show/NCT01600131 International Registered Report Identifier (IRRID) DERR1-10.2196/21799

BACKGROUND The majority of stroke survivors return to their homes and need assistance from family caregivers to perform activities of daily living. These increased demands coupled with the lack of preparedness for their new roles lead to a high risk for caregivers developing depressive symptoms and other negative outcomes. Follow-up home support and problem-solving interventions with caregivers are crucial for maintaining stroke survivors in their homes. Problem-solving interventions are effective but are underused in practice because they require large amounts of staff time to implement and are difficult for caregivers logistically. OBJECTIVE The aim of this study is to test a problem-solving intervention for stroke caregivers that can be delivered over the telephone during the patient’s transitional care period (time when the stroke survivor is discharged to home) followed by 8 asynchronous online sessions. METHODS The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 240 caregivers from eight Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a modified problem-solving intervention that uses telephone and web-based support and training with interactive modules, fact sheets, and tools on the previously developed and nationally available Resources and Education for Stroke Caregivers’ Understanding and Empowerment Caregiver website. In the usual care group, no changes are made in the information, discharge planning, or care the patients who have had a stroke normally receive, and caregivers have access to existing VA resources (eg, caregiver support line, self-help materials). The primary outcome is a change in caregiver depressive symptoms at 11 and 19 weeks after baseline data collection. Secondary outcomes include changes in stroke caregivers’ burden, knowledge, positive aspects of caregiving, self-efficacy, perceived stress, health-related quality of life, and satisfaction with care and changes in stroke survivors’ functional abilities and health care use. The team will also determine the budgetary impact, facilitators, barriers, and best practices for implementing the intervention. Throughout all phases of the study, we will collaborate with members of an advisory panel. RESULTS Study enrollment began in June 2015 and is ongoing. The first results are expected to be submitted for publication in 2021. CONCLUSIONS This is the first known study to test a transitional care and messaging center intervention combined with technology to decrease caregiver depressive symptoms and to improve the recovery of stroke survivors. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post stroke. CLINICALTRIAL ClinicalTrials.gov NCT01600131; https://www.clinicaltrials.gov/ct2/show/NCT01600131 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/21799

Department of Veterans Affairs (VA) health services researchers often adjust for the differing risk profiles of selected patient populations for a variety of purposes. This paper explains the major...

BACKGROUND Effective poststroke rehabilitation care can speed patient recovery and minimize patient functional disabilities. Veterans affairs (VA) community living centers (CLCs) and VA-contracted community nursing homes (CNHs) are the 2 major sources of institutional long-term care for Veterans with stroke receiving care under VA auspices. OBJECTIVES This study compares rehabilitation therapy and restorative nursing care among Veterans residing in VA CLCs versus those Veterans in VA-contracted CNHs. RESEARCH DESIGN Retrospective observational. SUBJECTS All Veterans diagnosed with stroke, newly admitted to the CLCs or CNHs during the study period who completed at least 2 Minimum Data Set assessments postadmission. MEASURES The outcomes were numbers of days for rehabilitation therapy and restorative nursing care received by the Veterans during their stays in CLCs or CNHs as documented in the Minimum Data Set databases. RESULTS For rehabilitation therapy, the CLC Veterans had lower user rates (75.2% vs. 76.4%, P=0.078) and fewer observed therapy days (4.9 vs. 6.4, P

Examining the impact of Medicaid-managed care home-based and community-based service (HCBS) alternatives to institutional care is critical given the recent rapid expansion of these models nationally.We analyzed the effects of STAR+PLUS, a Texas Medicaid-managed care HCBS waiver program for adults with disabilities on the quality of chronic disease care.We compared quality before and after a mandatory transition of disabled Medicaid enrollees older than 21 years from fee-for-service (FFS) or primary care case management (PCCM) to STAR+PLUS in 28 counties, relative to enrollees in counties remaining in the FFS or PCCM models.Person-level claims and encounter data for 2006-2010 were used to compute adherence to 6 quality measures. With county as the independent sampling unit, we employed a longitudinal linear mixed-model analysis accounting for administrative clustering and geographic and individual factors.Although quality was similar among programs at baseline, STAR+PLUS enrollees experienced large and sustained improvements in use of β-blockers after discharge for heart attack (49% vs. 81% adherence posttransition; P0.01) and appropriate use of systemic corticosteroids and bronchodilators after a chronic obstructive pulmonary disease event (39% vs. 68% adherence posttransition; P0.0001) compared with FFS/PCCM enrollees. No statistically significant effects were identified for quality measures for asthma, diabetes, or cardiovascular disease.In 1 large Medicaid-managed care HCBS program, the quality of chronic disease care linked to acute events improved while that provided during routine encounters appeared unaffected.

Objective To develop a prognostic index using Functional Independence Measure grades and stages that would enable clinicians to determine the likelihood of achieving a level of minimum assistance with physical functioning after a stroke. Grades define varying levels of physical function, and stages define varying levels of cognitive functioning. Design Retrospective cohort study. Setting Veterans Affairs Medical Centers throughout the United States. Participants Veterans with a diagnosis of a new stroke discharged between October 1, 2006, and September 30, 2008, who were below physical grade IV (requiring minimal assistance) at initial rehabilitation assessment. Main Outcome Measure Achievement of physical grade IV or above at final rehabilitation assessment. Results Physical grade IV was reached by 25.8% of participants who were initially below this grade. Seven variables remained independently predictive of physical grade IV after adjustment. These variables were assigned the following points: age, ≤69 years=2, 70-79 years=1, ≥80 years=0; initial physical grade, I=0, II=3, III=4; initial cognitive stage, I or II=0, III=2, IV or V=3, VI or VII=4; absence of renal failure=1; no serious nutritional compromise=3; the type of rehabilitation services received, consultative=0, comprehensive=4; and recovery time between admission and discharge physical grade assessment, 1-2 days=0, 3-7 days=4, and ≥8 days=5. The area under the receiver operating characteristic curve was 0.84 and 0.83 for the point system in the derivation and validation cohorts, respectively. The Hosmer-Lemeshow statistic was not significant ( P = .93) in the derivation cohort, indicating that the regression model demonstrated adequate fit. The proportions of patients recovered to physical grade IV in the first (score ≥9), second (score = 10-12), third (score = 13-15), and fourth (score >15) score quartiles were 2.72%, 11.38%, 28.96%, and 60.34%, respectively. Conclusion By using a simple tool, clinicians can forecast the likelihood of recovery to or above the physical grade IV benchmark by the conclusion of rehabilitation services during the acute stroke hospitalization.

Huanguang Jia,1 Qinglin Pei,1 Charles T Sullivan,1 Diane C Cowper Ripley,1 Samuel S Wu,1 W Bruce Vogel,1 Xinping Wang,1 Douglas E Bidelspach,2 Jennifer L Hale-Gallardo,1 Barbara E Bates3 1Center of Innovation on Disability and Rehabilitation Research, North Florida/South Georgia Veterans Health System, Gainesville, FL, 2Physical Medicine and Rehabilitation Service, Department of Veterans Affairs, Washington, DC, 3Aleda E. Lutz VA Medical Center, Saginaw, MI, USA Introduction: Effective post-acute multidisciplinary rehabilitation therapy improves stroke survivors’ functional recovery and daily living activities. The US Department of Veterans Affairs (VA) places veterans needing post-acute institutional care in private community nursing homes (CNHs). These placements are made under the same rules and regulations across the VA health care system and through individual per diem contracts between local VA facilities and CNHs. However, there is limited information about utilization of these veterans’ health services as well as the geographic variation of the service utilization. Aim: The aims of this study were to determine rehabilitation therapy and restorative nursing care utilization by veterans with stroke in VA-contracted CNHs and to assess risk-adjusted regional variations in the utilization of rehabilitation therapy and restorative nursing care. Methods: This retrospective study included all veterans diagnosed with stroke residing in VA-contracted CNHs between 2006 and 2009. Minimum Dataset (a health status assessment tool for CNH residents) for the study CNHs was linked with veterans’ inpatient and outpatient data within the VA health care system. CNHs were grouped into five VA-defined geographic regions: the North Atlantic, Southeast, Midwest, Continental, and Pacific regions. A two-part model was applied estimating risk-adjusted utilization probability and average weekly utilization days. Two dependent variables were rehabilitation therapy and restorative nursing care utilization by veterans during their CNH stays. Results: The study comprised 6,206 veterans at 2,511 CNHs. Rates for utilization of rehabilitation therapy and restorative nursing care were 75.7% and 30.1%, respectively. Veterans in North Atlantic and Southeast CNHs were significantly (p

Early childhood caries (ECC) is a significant national problem that disproportionately affects low-income children, and its prevalence is increasing (Tomar and Reeves 2009). ECC has significant short- and long-term adverse consequences (Tinanoff and Reisine 2009). ECC is associated with increased risk of future caries (Gray, Marchment, and Anderson 1991; Reisine, Litt, and Tinanoff 1994; O'Sullivan and Tinanoff 1996), missed school days (Gift, Reisine, and Larach 1992; Hollister and Weintraub 1993), hospitalization and emergency room visits (Sheller, Williams, and Lombardi 1997; Griffin et al. 2000), and, in rare cases, death (Casamassimo et al. 2009). These adverse outcomes are avoidable through ECC preventive services (ECCPS). A randomized clinical trial found that fluoride varnish treatment, combined with parent counseling, can reduce caries by up to 50 percent in high-risk children (Weintraub et al. 2006). National guidelines recommend that children have a dental visit by 12 months of age and receive preventive care at regular intervals thereafter (American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health 2008; American Academy of Pediatric Dentistry 2013). The most common recall interval is 6 months. However, the American Academy of Pediatric Dentistry recommends that children at higher caries risk get check-ups, including topical fluoride application, more often (American Academy of Pediatric Dentistry 2013). Medicaid eligibility has been identified as a risk factor for ECC (American Dental Association 2011). Untreated dental caries occurs among 25 percent of children living in poverty compared with 10.5 percent of children living above poverty (Dye, Li, and Thorton-Evans 2012). Comprehensive dental benefits are required in Medicaid and the Children's Health Insurance Program, which cover 35 percent of all U.S. children (DeNavas-Walt, Proctor, and Smith 2012), but only 31 percent of publicly insured children ages 0–5 years receive dental services (Centers for Medicare and Medicaid Services 2012). Although ECC is largely preventable (Savage et al. 2004; Weintraub et al. 2006; Azarpazhooh and Main 2008), it is difficult to reach preschool aged children for caries prevention. Publicly insured, preschool aged children are more likely to receive medical care than dental care (Bouchery 2012a,b). Consequently, 44 state Medicaid programs have implemented policies to reimburse medical primary care providers (M-PCPs), typically including physicians, physician assistants, and advanced registered nurse practitioners, to provide ECCPS. The specific services reimbursed varies across states but may include an examination of the oral cavity, caries risk assessment, anticipatory guidance, topical fluoride application, and referral to a dental home (American Academy of Pediatrics 2013). Despite widespread adoption, there is little scientific evidence on the effects of M-PCP reimbursement on ECCPS receipt, with published studies from only two states. A North Carolina study examined ECCPS receipt subsequent to policy implementation and found steady growth in the number of medical visits that included ECCPS, but it did not use a pre–post study design to evaluate changes in ECCPS receipt (Rozier et al. 2010). Studies of Wisconsin's Medicaid program, which used pre–post designs, found that M-PCP reimbursement was associated with increased claims rates for fluoride varnish treatment with almost one-half of the increase associated with M-PCPs (Okunseri et al. 2009, 2010). This study extends existing research by analyzing the effect of M-PCP reimbursement on ECCPS receipt for Medicaid-enrolled children in Texas and Florida, which are the second and fourth most populous states, respectively, and account for 15 percent of Medicaid-enrolled children nationally (Kaiser Family Foundation 2013; U.S. Census Bureau 2011). These states are among the most diverse with significant representation of African-American and Hispanic populations (Brewer and Suchan 2001), which disproportionately experience low access to dental care (Edelstein and Chinn 2009). In 2008, the Florida and Texas Medicaid programs implemented M-PCP ECCPS reimbursement for children ages 0–4 years. We used secondary data from these programs to test our central hypothesis that M-PCP reimbursement has improved access to ECCPS. Methodologically, we extend existing research by including a control group of children not subject to M-PCP reimbursement and adopting an analytic strategy that allows us to better isolate the treatment effect by controlling for intrinsic differences between the treatment and control groups, secular time trends, and differential time trends between the two groups. In addition to controlling for standard demographic characteristics, we also control for the children's health status and explicitly incorporate enrollment duration into our model.

Objectives To study the degree to which initial physical grades and cognitive stages of independence assessed by physical medicine and rehabilitation (PM&R) staff early after hospitalization for acute stroke relate to the decision to either provide rehabilitation in consultation or admission to a specialized rehabilitation unit (SRU) for comprehensive, high-intensity, multidisciplinary rehabilitation. Design An observational study. Setting Early rehabilitation assessment by PM&R staff during patients' acute hospitalization for stroke in 112 Veterans Affairs facilities. Patients The sample included 8,783 veterans who were assessed by PM&R staff. Methods Shortly after hospital admission, functional status was determined according to 7 physical grades and 7 cognitive stages of increasing independence. Patients' physical grades and cognitive stages ranged at initial PM&R assessment from the lowest and most dependent “I” through intermediate “II, III, IV, V, or VI,” and ended with the highest at total independence “VII.” To assess the statistically independent effects of physical grade and cognitive stage, a multivariable generalized estimating equation was applied to account for within Veterans Affairs facilities correlation and to adjust for demographics, stroke type, comorbidities, clinical events before PM&R assessment, and facility-related factors. Main Outcome Measurements The decision to admit patients to an SRU for comprehensive rehabilitation. Results Only 11.2% of those patients assessed after stroke were admitted to an SRU after the acute management phase. After statistical adjustment, patients at the lowest physical grade (I) of independence had a 9-fold increased odds of admission to an SRU compared with those at the highest combined physical grades VI/VII (adjusted odds ratio 9.15, 95% confidence interval 4.31-19.39). In contrast, patients at intermediate cognitive stages of independence were the most likely to be admitted to an SRU. The presence of an SRU within the treating Veterans Affairs facility was strongly related to admission. Conclusions Patients' physical grades and cognitive stages assessed early after stroke are strong determinants of referral for comprehensive rehabilitation.

Amputation is catastrophic and costly, resulting in loss of mobility and independence with the possibility of expensive treatment or being hospitalized for months. In an era of cost containment, policy makers are concerned with maintaining care quality while limiting expenditures.1 Lower extremity amputation accounts for more than $250 million in direct expenditures each year in healthcare costs in the US.2 Thus, understanding the factors associated with cost is critical to informed decision-making about maximizing service cost-efficiency, benefit, and positive outcomes. The objectives of this study were to identify patient- and facility-level factors associated with total inpatient costs and length of stay (LOS) among veterans who underwent lower extremity amputation in Veterans Affairs Medical Centers (VAMCs) nationwide. Our prior work documents the benefits of rehabilitation services in terms of survival, home discharge, receipt of a prescription for a prosthetic limb, and gains in functional improvement among veterans who underwent lower extremity amputation.3, 4 Andersen's Behavioral Model of Health Service Use5 formed the foundation for this work and was used to conceptualize the factors that determine need and lead to the use of health services measured as patients' total inpatient costs and LOS. Demographic factors were considered predisposing, while diagnostic and other clinical information were seen as driving health services need. We recognized that an understanding of the predisposing and need factors associated with total inpatient costs for these patients, including rehabilitation as an integral component of the overall continuum of care, could helps shed light on the quality implications of ongoing pressures to reduce both total inpatient costs and LOS. We hypothesized that there would be similar predisposing and need factors associated with total inpatient costs and LOS, but there could also be some differences among the factors associated with total inpatient costs and LOS. Limited information is available in the literature regarding the factors associated with total inpatient costs and LOS among veterans who undergo lower extremity amputation. Prior studies have shown that greater comorbidity is related to adverse outcomes such as in-hospital mortality and one-year survival,6-10 and that patients with more severe illnesses oftentimes require hospitalizations for a long period of time.6-8, 11 With respect to patients with lower extremity amputations specifically, information is quite limited. Only one study showed that LOS was associated with patients' payer source, amputation level, and injury characteristics.12 We were unable to find more recent studies on factors associated with total inpatient costs or LOS among veterans who underwent lower extremity amputation.

Veterans hospitalized for hip fracture repair may be discharged to one of several rehabilitation settings, but it is not known what factors influence postsurgical discharge setting. The purpose of the study was to examine the patient, facility, and market factors that influence the choice of postsurgical discharge setting. Using a retrospective cohort design, we linked 11,083 veterans who had hip fracture surgeries in a Department of Veterans Affairs (VA) hospital from 1998 to 2005 as assessed by the VA National Surgical Quality Improvement Program dataset with administrative data. The factors associated with five postdischarge settings were analyzed using multinomial logistic regression. We found that few veterans (0.8%) hospitalized for hip fracture were discharged with home health. Higher proportions of veterans were discharged to a nursing home (15.4%), to outpatient rehabilitation (18.8%), to inpatient rehabilitation (16.9%), or to home (48.2%). Patients were more likely to be discharged to nonhome settings for VA-provided rehabilitation if they had total function dependence, had American Society of Anesthesiologists class 4 or 5, had surgical complications prior to discharge, or lived in counties with lower nursing home bed occupancy rates. Future research should compare postsurgical and longer-term morbidity, mortality, and healthcare utilization across these rehabilitation settings.

Hip fractures in the elderly have high rates of mortality and perioperative complications. Both men and COPD patients have worse mortality and complications but this may be due to more co-morbid disease. We assessed mortality and complications in a large cohort (n = 12,646) of men undergoing hip fracture surgery within the Veteran's Health Affairs (VHA) to define the association of COPD to these outcomes after adjusting for other key factors. We looked for opportunities to improve outcomes for COPD patients.Using the VA Surgical Quality Improvement Program (VASQIP), and administrative databases, we determined COPD status, types of co-morbid conditions and surgical factors, and compared these to outcomes of surgical complications, 30-day and one-year mortality for patients who underwent hip fracture repair during 1998 to 2005.COPD was noted in 47% of the hip fracture patients studied. In 3,261 (26%) cases, the COPD was "severe: (indicated by functional disability, previous hospitalization for exacerbation, chronic drug treatment or record of FEV(1)75% predicted), and in 2,736 (21%) cases it was considered "mild" (any previous outpatient visit or hospitalization with a coded diagnosis of COPD). Severe COPD patients had one year mortality of 40.2% compared to 31.0% in mild COPD and 28.8% in non-COPD subjects. Current smoking, use of general anesthesia and delays to surgery were significant modifiable risk factors identified in adjusted models. Osteoporosis was known pre-fracture in only 3% of subjects.COPD was very common in male veterans with hip fractures and was associated with increased risk of death and complications. Increased use of regional anesthesia and urgent scheduling of hip fracture surgery may improve outcomes for patients with COPD. Osteoporosis was rarely identified preoperatively. Improving diagnosis and treatment of osteoporosis in COPD patients could reduce the incidence of hip fractures.

Studying outcomes after rehabilitation is critical. For persons with trauma-related amputations, Pezzin et al found that inpatient rehabilitation led to better outcomes.1 Unfortunately, outcomes after rehabilitation for persons with lower extremity (LE) amputation for nontraumatic etiologies are under studied with little knowledge about how the types or intensities of rehabilitation influence outcomes. We found that for patients with LE amputation, inpatient rehabilitation compared with no inpatient rehabilitation (regardless of type) during the acute postoperative period was associated with improved 1-year survival and greater likelihood of home discharge from the hospital.2 In this study, we determine if there are incremental benefits of receiving rehabilitation on specialized rehabilitation bed units (SRUs) (specialized) compared with rehabilitation on general medical/ surgical units (generalized) among those who received inpatient rehabilitation during the acute postoperative period. Patients who received generalized rehabilitation may have one to many sessions while hospitalized, therapy may vary from intermittent to regular sessions, and functional restoration is not the primary focus. Conversely, specialized rehabilitation occurs in designated units, which consist of a cluster of beds located in a distinct area in the hospital specifically accredited for rehabilitation services by the Commission on Accreditation of Rehabilitation Facilities (CARF). Restorative therapy typically occurs daily, with rehabilitation the primary focus. To achieve accreditation, SRUs must meet CARF’s explicitly defined standards developed to ensure high quality services. In the Veterans Health Administration (VHA), subacute and acute rehabilitation beds are considered similar, and both were categorized as SRUs if they were CARF accredited for LE amputees. Our objective was to determine the effect of receiving specialized versus generalized rehabilitation after LE amputation on 4 patient outcomes: 1-year survival, discharge home from the hospital, prescription of a prosthetic limb within 1 year post surgery, and improvement in physical functioning at rehabilitation discharge. Type of rehabilitation received can be influenced by patient- and facility-level characteristics and clinical practice variations, which may be associated with outcomes. Conclusions drawn about outcome differences that do not adjust for these factors suffer from selection bias and may be inaccurate. To adjust for selection bias due to measured patient- and facility-level characteristics, we applied propensity score (p score) risk adjustment methods.3 We conducted a sensitivity analysis to determine how the presence of an unmeasured characteristic with a moderately strong effect on the outcome and on the probability of receiving specialized would affect our findings.4,5

State policies and actions are an integral part of our nation's health policy framework. This is particularly obvious in the case of Medicaid, a program for which the states share fiscal obligations and have primary administrative responsibility. Concerns regarding the quality of care provided to enrollees and the financial viability of Medicaid programs in the states are among today's “hot topics” in the health policy arena (The Kaiser Commission on Medicaid and the Uninsured 2006). While the issues are not new, the current conversation may differ from those of previous years because the contemporary political and policy context includes serious consideration of much greater state flexibility in the structuring of Medicaid and the delivery of health care to Medicaid enrollees (Finegold, Wherry, and Schardin 2004; Rowland et al. 2006). At present, a great deal of state interest is focused on moving Medicaid payment systems toward a more intensely managed form of managed care (Bailit, Burgess, and Roddy 2004; Kaye 2005). In considering and pursuing the opportunities deriving from increased flexibility, states frequently begin with overall philosophical preferences and then review past experiences to focus their efforts on Medicaid policy initiatives that are consistent with those preferences and have some demonstrated promise of success. To a significant degree, the observation of prior experience is focused on the outcomes of demonstrations that have been implemented with the authority of a Section 1115 Waiver. While the Deficit Reduction Act of 2005 (DRA) may create new and increased avenues for states to pursue program variation, the historic purpose of waivers has not simply been to change programs, but to test ideas or new approaches to program implementation. Formally, they are “Research and Demonstration Waivers,” explicitly acknowledging the role of observation and research as to the impact of the demonstration. The research part of this function is not always achieved, because that aspect of waiver-based Medicaid program changes typically takes a back seat to program implementation. Furthermore, except for privately funded initiatives such as the State Coverage Initiatives Program (http://www.statecoverage.net) and the State Health Access Data Center (http://www.shadac.umn.edu/), there is no convenient clearinghouse for systematically disseminating demonstration research findings that might prove valuable for subsequent program modifications or to other states as they contemplate policy interventions. Effective July 1, 2006, Florida embarked on a 5-year research and demonstration project that may significantly change its Medicaid program. One element of the Florida reform initiative is the inclusion of provider service networks (PSNs) among the managed care organizations that may be used to organize and deliver care to Medicaid enrollees. The decision to include PSNs in the 2006 reform initiative is explicit in both the enabling legislation (FL Gen. Laws ch. 2005-358 [2005]) and in the state's waiver application. Absent such inclusion, PSNs would not be part of the current reform initiative. The decision to include the PSN option in the current reform initiative derived, in part, from the evaluation research findings from a previous Medicaid demonstration. The purposes of this article are to describe key findings from that prior evaluation and to note the linkages to Florida's current Medicaid Reform initiative.

We examined the cost-effectiveness of a care coordination/home telehealth (CCHT) programme for veterans with diabetes. We conducted a retrospective, pre-post study which compared data for a cohort of veterans ( n=370) before and after the introduction of the CCHT programme for two periods of 12 months. To assess the cost-effectiveness, we converted the patients' health-related quality of life data into Quality Adjusted Life Year (QALY) utility scores and used costs to construct incremental cost-effectiveness ratios (ICERs). The overall mean ICER for the programme at one-year was $60,941, a value within the commonly-cited range of cost-effectiveness of $50,000–100,000. The programme was cost-effective for one-third of the participants. Characteristics that contributed to cost-effectiveness were marital status, location and clinically relevant co-morbidities. By targeting the intervention differently in future work, it may become cost-effective for a greater proportion of patients.

Health-related quality of life (HRQoL) is increasingly used to measure health status. Health profile and preference-based approaches are two types of methods frequently used to measure HRQoL. Health profiles tap multiple dimensions of health. Preference-based approaches quantify the extent to which an individual prefers specific health states using a single index from 0 (death) to 1 (full health). The MOS-HIV Health Survey (Wu et al. 1997) and EQ-5D (The EuroQol Group 1990) are typical health profile and preference-based instruments, respectively. The availability of preference-based HRQoL data is limited because direct assessment is not always feasible. Therefore, researchers have attempted to predict preference-based scores from health profiles, generally using ordinary least squares (OLS) regression (Fryback et al. 1997; Franks et al. 2004). A common phenomenon observed in both health profile and preference-based measures is that the score distribution tends to be skewed to the left. This is called the “ceiling effect.” When data have pronounced ceiling effects, the use of OLS regression violates the statistical requirement for linearity of conditional expectation, leading to inaccurate predictions of preference-based scores and inaccurate identification of predictor variables (Kennedy 1998). Several methods have been proposed to address ceiling effects, such as Tobit models, the censored least absolute deviation (CLAD) approach, two-part models (TPM), and latent class models (LCM) (Greene 2003). The Tobit and CLAD models are preferable to OLS in the presence of a ceiling effect or censored dependent variable. The Tobit model assumes that there is a true unobservable dependent variable that depends linearly on independent variables. The observable dependent variable is defined to be equal to the unobserved variable whenever the true unobserved variable is greater than or equal to the ceiling value. The Tobit model assumes that the error terms are normally distributed with uniform variance (Greene 2003). Unfortunately, evidence suggests that the distribution of utility scores does not follow those assumptions (Austin 2002a). The CLAD approach is based on an assumption that the median will be more robust to ceiling effects than the mean. The coefficients are estimated so as to minimize the sum of the absolute deviations from the regression line (Arabmazar and Schmidt 1981; Johnston 1997). A TPM approach is a more flexible way to address the fact that the HRQoL scores usually have mixed distributions that contain a disproportionate mass of observation at the ceiling and a left-skewed distribution of observations not at the ceiling. The “two parts” model (1) the probability that the dependent variable (e.g., EQ-5D index) can attain the full score and (2) the distribution if the full score is not attained. Both parts are combined in a joint model to predict the dependent variable using the subject's predictors. The LCM is another approach to address data with ceiling effects. This approach is considered by some to be more flexible than the TPM because LCM can handle situations where there are two (or more) classes, with one class being very healthy (i.e., higher utility index) and another group being less healthy (i.e., lower index), as opposed to a TPM which models perfectly healthy (index=1) versus other than perfectly healthy (index

For the Department of Veterans Affairs (VA), traumatic brain injury (TBI) is a significant problem facing active duty military personnel, veterans, their families, and caregivers. The VA has designated TBI treatment as one of its physical medicine and rehabilitation special emphasis programs, thereby providing a comprehensive array of treatment services to those military personnel and veterans with TBI. Timely treatment of TBI is critical in achieving maximal recovery, and being in geographical proximity to a medical center with specialized TBI treatment services is a major determinant of whether such treatment is utilized. We present a mixed integer programming model for locating TBI treatment units in the VA. This model was developed for the VA Rehabilitation Strategic Healthcare Group to assist in locating new TBI treatment units. The optimization model assigns TBI treatment units to existing VA medical centers while minimizing the sum of patient treatment costs, patient lodging and travel costs, and the penalty costs associated with foregone treatment revenue and excess capacity utilization. We demonstrate our model with VA TBI admission data from one of the VA's integrated service networks, and discuss the expected service and cost implications for a range of TBI treatment unit location options.

Our objective was to determine the relationship between receipt of a prescription for a prosthetic limb and three-year mortality post-surgery among veterans with lower extremity amputation. We conducted a retrospective observational study that included 4,578 veterans hospitalized for lower extremity amputation and discharged in Fiscal Years 2003 and 2004. The outcome was time to all-cause mortality from the amputation surgical date up to the 3-year anniversary of the surgical date. There were 1,300 (28.4%) veterans with lower extremity amputations who received a prescription for a prosthetic limb within a year after the surgical amputation. About 46% (n=2086) died within three-years of the surgical anniversary. Among those who received a prescription for a prosthetic limb, only 25.2% died within 3 years of the surgical anniversary. After adjustment, veterans who received a prescription for a prosthetic limb were less likely to die after the surgery than veterans without a prescription with a hazard ratio of 0.68 (95% CI, 0.60-0.77). Findings demonstrated that veterans with lower extremity amputations who received a prescription for a prosthetic limb within a year after the surgical amputation were less likely to die within three years of the surgical amputation after controlling for patient-, treatment-, and facility-level characteristics.

Comprehensive rehabilitation services postacute stroke have been shown efficacious in European trials; however, their effectiveness in everyday practices in the United States is unknown. We compared outcomes of veteran patients provided with comprehensive rehabilitation with those provided with consultative rehabilitation services postacute stroke using propensity scores. Outcomes included change in patients' physical and cognitive independence after rehabilitation, discharge to home as opposed to other settings, and 1-yr posthospital discharge survival. Of the 2,963 patients in the study, 683 (23.1%) received comprehensive rehabilitation while the remaining patients received consultative services. We found, after propensity adjustment, that those who received comprehensive rehabilitation compared with consultative gained on average 12.8 (95% confidence interval [CI]: 9.1 to 16.5) more points of physical independence on a 78-point scale and gained 1.5 (95% CI: 0.8 to 2.2) more points of cognitive independence on a 30-point scale. The likelihoods of discharge to home from the hospital (odds ratio [OR] = 1.61, 95% CI: 1.07 to 2.44) and 1-yr posthospital discharge survival (OR = 1.79, 95% CI: 1.25 to 2.56) were significantly higher among those who received comprehensive rehabilitation. Among patients hospitalized for acute stroke, comprehensive rehabilitation services are associated with greater recovery of physical and cognitive independence, improved home discharge likelihood, and improved 1-yr survival.

To develop a prognostic index for achievement of modified independence (Functional Independence Measure grade VI) after completion of either comprehensive or consultative rehabilitation after stroke.Retrospective cohort study.Veterans Affairs Medical Centers (VAMCs) throughout the United States.Data included 5316 patients with stroke discharged from VAMCs who received rehabilitation services while hospitalized and who were physically dependent at initial assessment. The index was derived with use of 60% of the sample and validated in the remaining 40% of the sample. Points derived from the β coefficients of a multivariable logistic model were added to scores that were associated with the probability of recovery.Recovery to modified independence or above at final rehabilitation assessment, defined as when patients no longer need physical assistance with eating; grooming; dressing the upper and lower body; toileting; sphincter management; bed to chair, toilet, and tub transfers; and walking/wheelchair use and when they require no more than supervision with bathing or climbing stairs.Seven independent predictors were identified through logistic regression in the derivation sample: initial physical grade (I or II = 0 points; III = 2 points; IV = 4 points; V = 5 points), initial cognitive stage (I or II = 0 points; III = 2 points; IV = 3 points, V or VI = 4 points; VII =5 points), type of rehabilitation (consultative = 0 points; comprehensive = 4 points), age (60 years = 3 points; 60-79 years = 2 points; ≥80 years = 0 points), time from initial to final physical grade assessment (1-2 days = 0 points; ≥3 days = 2 points), absence of urinary procedures (3 points), and absence of diabetes with complications (1 point). The following proportions of patients recovered to physical grade VI for the first, second, third, and fourth quartile scores, respectively: 0.59% (score ≤9), 3.87% (score = 9-11), 14.19% (score = 12-15), and 37.38% (score ≥16).Functional recovery to physical grade VI can be predicted on the basis of patients' initial status after a stroke occurs and the type of rehabilitation services to be provided by using a simple scoring system.

The current emphasis on community-based health care makes necessary the implementation and evaluation of nursing practice models that address specific health problems, such as urinary incontinence, of older women living at home in rural communities.

Oral disadvantage can be defined as the avoidance of certain daily activities because of decrements in oral health. These decrements include oral disease and tissue damage, pain, and functional limitation. The Florida Dental Care Study (FDCS) is a longitudinal study of changes in oral health, which included at baseline 873 subjects who had at least 1 tooth, were 45 years old or older, and who participated for an interview and clinical examination. Three objectives of the FDCS are: (1) to describe selected psychometric properties of the measurement of oral disadvantage; (2) to describe oral disadvantage in a diverse sample of dentate adults; and (3) to describe the relationship between disadvantage and other aspects of oral health, such as disease/tissue damage, pain, and functional limitation. The prevalence of oral disadvantage within the previous 6 months, using eight self-reported measures, ranged from 5% to 25%, depending upon the measure. Factor analysis suggested that oral disadvantage is best described as three factors: disadvantage due to (1) oral disease/tissue damage, (2) oral pain, and (3) oral functional limitation. Irregular dental attenders, poor persons, and blacks had the highest prevalence of oral disadvantage. Clinical measures of oral disease/tissue damage, self-reported measures of oral disease/tissue damage, oral pain, and oral functional limitation were strongly associated with the presence of oral disadvantage. In multivariate analyses that accounted for differences in clinical measures of disease/tissue damage, self-reported disease/tissue damage, oral pain, and oral functional limitation, females were more likely to report disadvantage due to disease/tissue damage, and middle-aged persons and irregular dental attenders were more likely to report oral disadvantage due to pain. In these same regressions, differences in disadvantage due to race, poverty status, socioeconomic status, and rural/urban area of residence were not evident. These results have implications regarding the use of oral disadvantage to assess the long-term effectiveness of dental care.

Objective: To determine which patient-, treatment-, and facility-level characteristics were associated with home discharge among patients hospitalized for stroke within the Department of Veterans Affairs. Design: Retrospective observational study. Setting: Veterans Affairs facilities nationwide. Participants: Veterans hospitalized for stroke during fiscal year 2007 to fiscal year 2008 (NZ12,565). Intervention: Not applicable. Main Outcome Measure: Discharge location after hospitalization. Results: There were 10,130 (80.6%) veterans discharged home after hospitalization for acute stroke. Married veterans were more likely than nonmarried veterans to be discharged home (odds ratio [OR]Z1.23; 95% confidence interval [CI]Z1.11e1.35). Compared with veterans admitted to the hospital from home, patients admitted from extended care were less likely to be discharged home (ORZ.04; 95% CIZ.03e.07). Compared with those with occlusion of cerebral arteries, patients with intracerebral hemorrhage (ORZ.61; 95% CIZ.50e.74) or other central nervous system hemorrhage (ORZ.78; 95% CIZ.63e.96) were less likely to be discharged home, whereas patients with occlusion of precerebral arteries (ORZ1.36; 95% CIZ1.07e1.73) were more likely to return home. Evidence of congestive heart failure (ORZ.85; 95% CIZ.76e.95), fluid and electrolyte disorders (ORZ.86;95% CIZ.77e.96),internalorgan procedures and diagnostics (ORZ.87; 95% CIZ.78e.97), and serious nutritionalcompromise (ORZ.49; 95% CIZ.40e.62) during hospitalization remained independently associated with lower odds of home discharge. Longer hospitalizations and receipt of rehabilitation services while hospitalized acutely were negatively associated, whereas treatment on more bed sections and rehabilitation accreditation of the facility were positively associated with home discharge. Region exerted a statistically significant effect on home discharge. Conclusions: We found sociological, clinical, and facility-level factors associated with home discharge after hospitalization for acute stroke. Findings document the importance of considering a broad range of characteristics rather than focusing only on a few specific traits during discharge planning. Archives of Physical Medicine and Rehabilitation 2014;95:1277-82

Background Behavioral symptoms accompanying dementia are associated with increased health care costs, reduced quality of life and daily functioning, heightened family caregiver burden, and nursing home placement. Standard care typically involves pharmacologic agents, but these are, at best, modestly effective, carry serious risks, including mortality, and do not address behavioral symptoms families consider most distressful and which may prompt nursing home placement. Given dementia’s devastating effects and the absence of an imminent cure, the Veterans Administration has supported the development and testing of new approaches to manage challenging behaviors at home. Methods/Design The Tailored Activity Program – Veterans Administration is a Phase III efficacy trial designed to reduce behavioral symptoms in Veterans with dementia living with their caregivers in the community. The study uses a randomized two-group parallel design with 160 diverse Veterans and caregivers. The experimental group receives a transformative patient-centric intervention designed to reduce the burden of behavioral symptoms in Veterans with dementia. An occupational therapist conducts an assessment to identify a Veteran’s preserved capabilities, deficit areas, previous roles, habits, and interests to develop activities tailored to the Veteran. Family caregivers are then trained to incorporate activities into daily care. The attention-control group receives bi-monthly telephone contact where education on topics relevant to dementia is provided to caregivers. Key outcomes include reduced frequency and severity of behavioral symptoms using the 12-item Neuropsychiatric Inventory (primary endpoint), reduced caregiver burden, enhanced skill acquisition, efficacy using activities, and time spent providing care at 4 months; and long-term effects (8 months) on the Veteran’s quality of life and frequency and severity of behavioral symptoms, and caregiver use of activities. The programs’ impact of Veterans Administration cost is also examined. Study precision will be increased through face-to-face research team trainings with procedural manuals and review of audio-taped interviews and intervention sessions. Discussion The Tailored Activity Program – Veterans Administration is designed to improve the quality of life of Veterans with dementia and lessen the burden of care on caregivers. Activities are tailored to reflect the Veteran’s preserved capabilities and interests to enhance active engagement, while not taxing areas of cognition that are most impaired. Trial registration ClinicalTrials.gov, NCT01357564

The 1992 reauthorization of the OlderAmericans Act (OAA) requires the Assistant Secretary on Aging to produce a set of guidelines to aid states in the development of their Intrastate Funding Formula (IFF). The purpose of this investigation was to examine, using two states as case studies, the effects of a preliminary set of guidelines on planning and service areas (PSAs) that vary in the degree to which older adults (60+) in their catchment area live in nonmetropolitan versus metropolitan settings. Dollar amounts allocated to four categories of PSAs were compared with simulations of allocations under three alternative funding strategies. The data from these simulations illustrate that changes in IFF regulations have the potential to cause significant shifts in the distribution of OAA funds. Indeed, given the magnitude of the changes that could occur, there is likely to be considerable controversy within some states as lawmakers and state officials attempt to bnng current IFFs into conformity with new federal regulations.

Most states maintain an Intrastate Funding Formula (IFF) to allocate Older Americans Act funds to planning and service areas within their state. The intention of these formulae is to target resources to those elders in the greatest economic and social need. To achieve this objective, the vast majority of states include measures of age, income, and race in their IFFs. In contrast, the inclusion of a geographic or rural factor is much more controversial. This research was initiated to determine if there was empirical support for the argument that residence influences the need for services after controlling for those factors commonly used by most states in their IFFs. Using data from the Supplement on Aging to the 1984 National Health Interview Survey, the results demonstrate that residing in a nonmetropolitan area increases the likelihood of poor health and the need for services after controlling for age, income, and race. Results also indicate that collectively the four predictor variables account for a very small proportion of the variance in need.

Background Stroke mortality has been found to be much higher among residents in the stroke belt region than in the rest of United States, but it is not known whether differences exist in the quality of stroke care provided in Department of Veterans Affairs medical centers in states inside and outside this region. Objective We compared mortality and inpatient stroke care quality between Veterans Affairs medical centers inside and outside the stroke belt region. Methods Study patients were veterans hospitalized for ischemic stroke at 129 Veterans Affairs medical centers. Inpatient stroke care quality was assessed by 14 quality indicators. Multivariable logistic regression models were fit to examine differences in quality between facilities inside and outside the stroke belt, adjusting for patient characteristics and Veterans Affairs medical centers clustering effect. Results Among the 3909 patients, 28·1% received inpatient ischemic stroke care in 28 stroke belt Veterans Affairs medical centers, and 71·9% obtained care in 101 non-stroke belt Veterans Affairs medical centers. Patients cared for in stroke belt Veterans Affairs medical centers were more likely to be younger, Black, married, have a higher stroke severity, and less likely to be ambulatory pre-stroke. We found no statistically significant differences in short- and long-term post-admission mortality and inpatient care quality indicators between the patients cared for in stroke belt and non-stroke belt Veterans Affairs medical centers after risk adjustment. Conclusions These data suggest that a stroke belt does not exist within the Veterans Affairs health care system in terms of either post-admission mortality or inpatient care quality.

Background Some studies have found that older individuals are not as likely as their younger counterparts to be treated with some guideline-based stroke therapies. We examined whether age-related differences in inpatient quality of care exist among US veterans with ischemic stroke. Methods This was a retrospective study of a national sample of veterans admitted to 129 Veterans Affairs medical centers for ischemic stroke during fiscal year 2007. Inpatient stroke care quality was examined across 14 inpatient processes of care, including dysphagia screening, National Institutes of Health Stroke Scale (NIHSS) score documentation, thrombolysis, deep venous thrombosis prophylaxis, antithrombotic therapy by hospital day 2 and at discharge, early ambulation, fall risk assessment, pressure ulcer risk assessment, rehabilitation needs assessment, atrial fibrillation management, lipid management, smoking cessation counseling, and stroke education. Results Among the 3939 veterans with ischemic stroke, the mean age was 67.8 years (standard deviation, 11.5). The overall performance rate was >70% for 10 of the 14 quality indicators. In unadjusted analyses, older patients were less likely to receive lipid management, smoking cessation, NIHSS documentation, and early ambulation compared with younger patients; conversely, older patients were more likely to receive dysphagia screening and stroke education. After adjusting for demographic, clinical, and hospital level characteristics, the age-related differences in processes of care were less consistent; however, the youngest patients were more likely to receive smoking cessation counseling and the oldest patients were less likely to receive lipid management. Conclusions Risk-adjusted inpatient stroke care quality varies little with age for veterans admitted to a Veterans Affairs medical center for acute ischemic stroke.

Amputation of the lower extremity can be both psychologically and physically traumatic. It can present significant limitations to a person's self-image, self-care, and mobility. Patients must deal with the aftermath, the loss of part or the whole limb. Rehabilitation can help patients learn functional skills assisting in the adjustment to lower extremity amputation. There is a continuum of care that is needed after the surgery, including treatment during the surgical hospitalization and potentially after discharge from the hospital. Rehabilitation is a long difficult process and is an important component that can impact the long-term outcomes of amputees. The goal of rehabilitation during the immediate postoperative period is to return the individual to a lifestyle as functional as possible, and an early emphasis on rehabilitation can focus on preparing the individuals who are candidates for a prosthesis.1 For those patients who are not candidates for prosthetic rehabilitation, the goals may be more modest and may include mobility and activities of daily living independence at the wheelchair level. These patients often remain independent, which highlights the importance of training at the wheelchair level particularly among those who may not be prosthetic candidates.2 The stroke literature has documented the benefits of a standardized multidisciplinary high intensity approach to rehabilitation,3 but it has not been until recently that there is evidence of benefits of inpatient rehabilitation following lower extremity amputation. Dillingham and colleagues applied Medicare claims data to compare inpatient rehabilitation facility (IRF) outcomes to those of other post-acute care settings among dysvacular amputees receiving rehabilitation. After statistically controlling for initial patient characteristics, 1-year survival was significantly increased in those who received IRF care compared to those admitted to nursing homes or directly discharged home, as was the receipt of a prosthesis. Also, the number of non-amputation-related hospital admissions and re-amputations were reduced in patients discharged to IRFs relative to other settings.4 Among trauma-related amputees, typically a comparatively younger population, the number of nights in inpatient rehabilitation correlated with better vocational outcomes, improved role functioning, increased vitality, and decreased pain.1 Our studies among veterans with lower extremity amputations have also shown the benefits of receiving inpatient rehabilitation. In the Department of Veterans Affairs (VA), there are two types of inpatient rehabilitation services. Consultative services occur while patients remain on general medical or surgical bed sections, while specialized rehabilitation occurs on specialized rehabilitation bed units (SRUs). Compared to veterans who had no evidence of inpatient rehabilitation services, patients who received either consultative or specialized rehabilitation were more likely to be discharged home following the surgical amputation and survive to their one year amputation anniversary.5 We further demonstrated that patients who received rehabilitation services on SRUs had incremental benefits over those who received only consultative services. Patients treated on a SRU were more likely to be discharged home following the surgical hospitalization, receive a prescription for a prosthetic limb within one year post amputation, and show improvement in physical functioning at rehabilitation discharge using the Functional Independence Measure (FIM™).6 Those two studies showed benefits of rehabilitation services during the time immediately following the surgical amputation but prior to the surgical hospital discharge date. While conducting these studies, we learned that there is a high variability of the receipt of rehabilitation service, and we are uncertain of the determinants in the variability. Rehabilitation can be offered during a variety of times, in various places, and include a variety of service types. Thus, the Time, Place, and Type (TPT) framework was developed to gain a better understanding of these three inter-connected components as related to alternative patterns or pathways of care.5, 7 The timing of rehabilitation can be prior to the surgical amputation (preoperative), during the time period after the surgical amputation but prior to the surgical hospitalization discharge date (immediate postoperative), or after the surgical discharge date (late). Place can be inpatient, outpatient, nursing home, or home. Type of inpatient rehabilitation can be either consultative services on regular bed sections or specialized services on SRUs. In a subsequent study, we learned that patients who were admitted onto a SRU were more likely to have waited longer to have their first rehabilitation assessment after surgery and had moderate physical and cognitive disabilities during the immediate postoperative time period compared to those with the most or least severe disabilities. Patients who received only consultative rehabilitation during this time period were more likely to have previous amputation complications, paralysis, or renal failure and either very severe or minimal physical and cognitive disabilities.8 The next step would be to determine who and why patients need additional rehabilitation after receiving services during the immediate postoperative time period. This study addresses different elements of the TPT framework focusing on the receipt of inpatient rehabilitation services during both the immediate postoperative and late time periods. The objective of this paper was to determine what patient- and facility-level characteristics drive a late (timing) specialized (type) inpatient (place) rehabilitation episode among those veterans who already received immediate postoperative rehabilitation services, either consultative or specialized. We were unable to find other studies that looked at factors associated with the second inpatient stay in such veterans or non-veterans with lower extremity amputations.

Within the Veterans Health Administration (VHA), the top tier of postacute rehabilitation care is provided in acute rehabilitation bedservice units (ARBUs). The next level of care is provided in subacute rehabilitation bedservice units (SRBUs). We fitted reduced-form and structural models to explain VHA cost differences between ARBUs and SRBUs across time and for the individual cost components. We included sociodemographic variables, time since stroke onset, care facility, and the Functional Independence Measure at admission as explanatory variables. The multivariable results indicate that total index stay costs are lower in ARBUs by almost $6,000 (or approximately 25%) compared with SRBUs. Moreover, the lower costs observed in ARBUs in this study combined with the higher rates of guideline compliance and improved outcomes in ARBUs found in previous work suggest that stroke rehabilitation in an ARBU may be more cost-effective than stroke rehabilitation in an SRBU.

An estimated 500 000 children annually cope with life-limiting conditions expected to lead to premature death, but little is known about their health care expenditures at the end of life. This information is crucial for health planners to propose pediatric palliative care programs. This study aims to estimate predicted health care expenditures for Medicaid-eligible infants and children across several health service categories. Across these categories, infants and children were predicted to spend about US$110 000 and US$62 000 at the end of life, respectively. About 5% of infants and 8% of children incurred hospice expenditures. Results from the multivariate models suggest that black, non-Hispanic children are less likely than white, non-Hispanic children to use hospice care. Baseline expenditure information from this study can be used to develop integrated pediatric palliative care models. Our findings also suggest that many more children could potentially benefit by using hospice care at the end of life.

The State Children's Health Insurance Program (SCHIP) was enacted in 1997 to provide health insurance coverage for uninsured low-income children who do not meet Medicaid eligibility criteria. SCHIP was authorized for 10 years and was up for reauthorization in 2007. Because SCHIP is a capped grant and not an entitlement program, it has a fixed annual funding level and shortfalls were predicted to occur if federal funding was not expanded with the reauthorization. When faced with restricted funding in the past, states adopted different strategies to control the size of their SCHIP caseloads, including adjusting the processes by which families apply for and renew their coverage. The Congressional Budget Office estimated that federal funding would need to be increased by $7.8 billion over the next 5 years (2008–2012) to maintain current programs (Congressional Budget Office 2007). At the time of this writing, President Bush and Congress had reached an impasse over the amount by which SCHIP funding should be expanded, with the President twice vetoing reauthorization bills passed by Congress. As a temporary solution, federal SCHIP funding was extended through March 31, 2009 with the enactment of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (S. 2499). Motivating the national debate over SCHIP reauthorization are concerns about the appropriate income eligibility limit and crowd-out of employer-sponsored insurance. As a result, in addition to funding levels, SCHIP program eligibility is under examination. President Bush has emphasized refocusing “SCHIP on low-income, uninsured children below 200 percent of the Federal poverty level as the program was originally intended” (OMB 2007). In August 2007, the Centers for Medicare and Medicaid Services issued new guidance for providing coverage to children with family income above 250 percent of the federal poverty level (FPL). States must demonstrate that they have enrolled at least 95 percent of eligible children below 200 percent of the FPL in Medicaid or SCHIP and that employer-based coverage of low-income children has not decreased by more than two percentage points during the prior 5 years (CMS 2007). Consequently, states may reconsider how they conduct their eligibility determinations when children are due to renew their coverage. States can meet federal eligibility screening requirements by using existing information from state and federal agencies, thereby allowing families to self-declare income. In 2007, however, only 9 SCHIP programs and 11 Medicaid programs allowed self-declaration of income (Ross, Horn, and Marks 2008). All other states required documentation to verify income. Interviews of SCHIP administrators and descriptive analyses of state administrative data indicate that active redetermination procedures, which require families to submit documents to verify their eligibility, are a significant barrier to enrollee retention (Hill and Lutzky 2003). Retention is important because children who experience interruptions in health insurance coverage are more likely to have worse access to care and greater unmet health care needs (Szilagyi et al. 2000; Olson, Tang, and Newacheck 2005). A comparison of SCHIP renewal policies in four states found marked differences in retention based on the redetermination procedures used. Dick et al. (2002) analyzed SCHIP programs in Florida, Kansas, New York, and Oregon, using data from 2000 and 2001. Florida had a passive renewal process at the time, while the other states had active renewal processes. Under passive renewal, families whose children were in Florida's SCHIP, the Florida Healthy Kids Program (FHKP), received a letter notifying them about renewing their children's coverage. Families were asked to review the income information in the letter and report any changes to the FHKP. They also were asked to report changes in access to employer-sponsored health insurance for their children. Families who did not respond maintained their children's coverage if they continued to pay their premiums. The programs with active renewal processes required families to provide proof of income and complete renewal forms to continue coverage. Dick et al. (2002) found that 33–50 percent of children disenrolled at their first redetermination in the states with active renewal processes; in contrast, they found that 5 percent of children in the FHKP disenrolled at redetermination under the passive renewal process. More recent analyses of SCHIP enrollment patterns have used the renewal month as a control variable when examining the effect of premiums on enrollment and disenrollment behaviors (Kenney et al. 2007; Marton 2007), but none have explored the impact of a change in the renewal process on disenrollment. This study examines the impact of renewal policy changes on the risk of disenrollment in the FHKP. In addition, we examine whether the policy changes had a differential impact on children with different health status levels. We also control for sociodemographic characteristics that may influence parents' decisions to renew their children's coverage. Effective July 1, 2004, the passive renewal process for the FHKP was replaced with active redetermination. The active renewal process requires families to complete a Renewal Request Form annually supplemented with (1) proof of income and (2) information about their access to employer-sponsored family coverage and the cost of such coverage if it is available to them. If families do not provide all of the required documentation, their children are disenrolled from the program. This study extends the analysis by Dick et al. (2002) in three ways. First, we use multivariate survival analysis techniques which allow us to examine multiple factors that may influence children's disenrollment at redetermination. These factors include family income, rural or urban residence, and child age, gender, and health status. This was not possible in the Dick et al. (2002) analyses because of differences in data availability across the states. Second, we take into account program transition, so a child is not considered disenrolled until s/he leaves public health insurance altogether. Finally, we include long-term program enrollees instead of including only children who were newly enrolled during the observation period.

Stineman MG, Kwong PL, Kurichi JE, Prvu-Bettger JA, Vogel WB, Maislin G, Bates BE, Reker DM. The effectiveness of inpatient rehabilitation in the acute postoperative phase of care after transtibial or transfemoral amputation: study of an integrated health care delivery system. Objective To compare outcomes between lower-extremity amputees who receive and do not receive acute postoperative inpatient rehabilitation within a large integrated health care delivery system. Design An observational study using multivariable propensity score risk adjustment to reduce treatment selection bias. Setting Data compiled from 9 administrative databases from Veterans Affairs Medical Centers. Participants A national cohort of veterans (N=2673) who underwent transtibial or transfemoral amputation between October 1, 2002, and September 30, 2004. Interventions Not applicable. Main Outcome Measures One-year cumulative survival, home discharge from the hospital, and prosthetic limb procurement within the first postoperative year. Results After reducing selection bias, patients who received acute postoperative inpatient rehabilitation compared to those with no evidence of inpatient rehabilitation had an increased likelihood of 1-year survival (odds ratio [OR]=1.51; 95% confidence interval [CI], 1.26–1.80) and home discharge (OR=2.58; 95% CI, 2.17–3.06). Prosthetic limb procurement did not differ significantly between groups. Conclusions The receipt of rehabilitation in the acute postoperative inpatient period was associated with a greater likelihood of 1-year survival and home discharge from the hospital. Results support early postoperative inpatient rehabilitation following amputation.

Berlowitz DR, Hoenig H, Cowper DC, Duncan PW, Vogel WB. Impact of comorbidities on stroke rehabilitation outcomes: does the method matter? Objectives To examine the impact of comorbidities in predicting stroke rehabilitation outcomes and to examine differences among 3 commonly used comorbidity measures—the Charlson Index, adjusted clinical groups (ACGs), and diagnosis cost groups (DCGs)—in how well they predict these outcomes. Design Inception cohort of patients followed for 6 months. Setting Department of Veterans Affairs (VA) hospitals. Participants A total of 2402 patients beginning stroke rehabilitation at a VA facility in 2001 and included in the Integrated Stroke Outcomes Database. Interventions Not applicable. Main Outcome Measures Three outcomes were evaluated: 6-month mortality, 6-month rehospitalization, and change in FIM score. Results During 6 months of follow-up, 27.6% of patients were rehospitalized and 8.6% died. The mean FIM score increased an average of 20 points during rehabilitation. Addition of comorbidities to the age and sex models improved their performance in predicting these outcomes based on changes in c statistics for logistic and R 2 values for linear regression models. While ACG and DCG models performed similarly, the best models, based on DCGs, had a c statistic of .74 for 6-month mortality and .63 for 6-month rehospitalization, and an R 2 of .111 for change in FIM score. Conclusions Comorbidities are important predictors of stroke rehabilitation outcomes. How they are classified has important implications for models that may be used in assessing quality of care.

Background and Purpose— Many Veteran Health Administration (VHA) enrollees receive health services outside the VHA system. However, limited information is available about poststroke utilization and mortality by veterans who used multiple sources of health care. This study assessed the likelihood of 12-month poststroke rehospitalization and mortality of veterans who used VHA only versus those who used multiple sources of care. Methods— Our retrospective observational study examined veterans living in Florida and diagnosed with acute stroke. We categorized users into 4 groups: VHA-only, VHA-Medicare, VHA-Medicaid, and VHA-Medicare-Medicaid based on their use of each health care program. Logistic regression models were fitted for 12-month poststroke general rehospitalization, recurrent stroke readmission, and mortality, adjusting for sociodemographic and clinical factors. Results— The sample consisted of 29% VHA-only users, 61% VHA-Medicare users, 3% VHA-Medicaid users, and 7% VHA-Medicare-Medicaid triple users. Compared with the VHA-only users, multiple system users were significantly more likely to be rehospitalized for any cause and for recurrent stroke 12-months postindex. Mortality outcomes depended on when the outcome was measured; at the index admission date, we found no significant difference in mortality across the user groups; at the index discharge date, the VHA-only users was less likely to die within the first 12 months than the users of the 2 dual groups (VHA-Medicare and VHA-Medicaid). Conclusions— Multiple health care source use was common among VHA enrollees with acute stroke in Florida. Multiple system users were more likely to be rehospitalized and the mortality outcomes were dependent on when the outcome was measured.

To assess healthcare use among veterans with diabetes mellitus (DM) enrolled in a Department of Veterans Affairs (VA) Care Coordination Home Telehealth (CCHT) program during 24 months and to contrast this utilization with the service use of a comparison group of veterans with DM not enrolled in the program.Two-year, retrospective, concurrent matched cohort study design.The VA CCHT program included older veterans with type 2 DM at high risk for multiple VA inpatient and outpatient visits. Healthcare utilization (hospitalizations, length of stay, and outpatient visits by type) was assessed at baseline and at 24 months after intervention for the treatment (n = 400) and comparison (n = 400) groups. Propensity scores were used to improve the balance between the treatment and comparison groups. A difference-in-differences approach was used to control for selection bias and for intervening time factors.Two years after enrollment, the treatment group exhibited a statistically significant reduction in the likelihood of all-cause and DM-related hospitalizations. In a subgroup analysis in which we controlled for patients' baseline glycosylated hemoglobin levels, the treatment group had a lower likelihood of having any care coordinator-initiated primary care clinic visits (in which the care coordinator initiated referral to primary care based on health information received from patients' CCHT technology).After controlling for selection bias and for intervening time factors, the VA CCHT program reduced avoidable healthcare services for DM (such as hospitalizations) and reduced care coordinator-initiated primary care clinic visits.

This study examined the effectiveness of a veterans affairs (VA) patient-centered care coordination/home-telehealth (CC/HT) program as an adjunct to treatment for veterans with diabetes. Using an adapted version of the Chronic Care Model, we analyzed the differences in healthcare service use between a cohort of 400 veterans with diabetes who were enrolled in a VA CC/HT program and a matched comparison cohort of 400 veterans with diabetes who received no CC/HT intervention. Propensity scores were used to improve the balance between the treatment and comparison groups. Service use outcomes were assessed at 12 months before and after enrollment. A difference-in-differences approach was used in the multivariate models to assess the treatment effect for patients in the CC/HT programs. Twelve months after enrollment, there was a significant difference between the treatment and comparison groups in terms of need-based primary care visits (newly scheduled visits that enable the veteran to be seen "just in time," where the health status is monitored and met before health deteriorates), increasing in the treatment group and decreasing in the comparison group (P < .01). In a subgroup analysis, where we were able to control for the patients' Hb A1c values, we found that the treatment group had a lower likelihood of having 1 or more hospitalizations than patients in the comparison group. Our findings have implications for management in that the CC/HT program appears to improve the ability of older veterans with diabetes to receive appropriate, timely care, thereby improving the quality of care for them and making more efficient use of VA healthcare resources.

Background and Purpose— Evidence for ethnic disparities in stroke incidence, severity, and mortality has continued to mount in recent years. However, the picture for disparities in acute management and rehabilitation remains more ambiguous. The objective of this report is to summarize current evidence from stroke epidemiology and studies focusing on disparities in stroke care and disability, suggesting courses for action. Methods— A comprehensive search of current literature on ethnic/racial variation in stroke incidence, mortality, and severity, as well as acute and postacute patient care was performed. Results— Recent evidence unambiguously reaffirms a greater burden of disease in stroke, greater mortality, and greater severity of strokes for blacks. Evidence for disparities in acute and postacute care is less conclusive, as is the evidence for disparities among other ethnic groups. Evidence for health disparities in stroke care across settings, regions, and the continuum of care varies considerably. Conclusions— Minority ethnic groups have higher rates or more severe stroke, but variations in prognosis for clinical outcomes other than mortality remain less certain. There is considerable need for more studies that take into account regional ethnic variations in treatment and outcomes, and for better documentation of stroke outcomes among groups in addition to blacks. Dealing with ethnic disparities in stroke will be served by sustained attention to quality improvement in high-impact areas in stroke care, complemented by initiatives that promote cultural competence.

Background Individuals with a strong sense of coherence (SOC), which considers one's ability to respond to stressors by the appropriate use of adaptive coping resources, can avoid breakdown when confronted with stress. This study examined the associations between SOC, perceived burden (caregiver's perception of the effect of caregiving-related stress) and depressive symptoms of informal caregivers (family members and involved friends) of stroke survivors one-month after the stroke. Methods One-hundred and four ethnically diverse veterans who were hospitalized after experiencing an acute stroke and their informal caregivers were enrolled in the study prior to discharge. One-month after being discharged from one of five Veterans Affairs Medical Centers in Florida and Puerto Rico, comprehensive data was collected and analyzed. Results Multiple regression analyses showed that greater SOC was associated with both lower burden (p

This paper addresses the issue of statistical selection bias in multivariate models of functional gain estimated from observational data. Stroke patients from 20 high-volume Veterans Affairs Medical Centers (VAMCs) with acute and subacute inpatient rehabilitation treatment units were observed. Their gains in overall, motor, and cognitive functional status were measured with the use of the Functional Independence Measure (FIM). In estimating multivariate models of FIM gain during rehabilitation using these observational data, we found statistically significant evidence of selection bias, along with considerable differences in inferences between standard multivariate analyses and our selectivity-corrected models. Our results demonstrate the importance of detecting and correcting for statistical selection bias when one uses nonexperimental data to study gains in functional status.

This paper describes how economists view resource allocation decisions in health care markets. The basic economic decisions that must be made in any economic system and the resource allocation decisions in a perfectly competitive market are described. An idealized market can achieve an efficient allocation of resources and is contrasted with a more realistic description of the numerous ways in which health care markets depart from the perfectly competitive ideal. The implications of these departures for health care policy are discussed, along with key controversies concerning reliance upon markets for resource allocation in health care. In particular, the failure of competitive markets to achieve what many consider an equitable distribution of health care is emphasized. The paper concludes with some practical observations on how pharmacists can use the increasing emphasis on economic efficiency to the advantage of their profession.

Health services administration continues to evolve in response to environmental changes in reimbursement, technology, demographics, and health care reform. These changes encourage further integration of business skills in health services, an emphasis which often conflicts with the perspectives of clinicians. The balance between business and clinical perspectives must be developed such that administrators and clinicians foster the survival and growth of their organizations while assuring comprehensive and quality health services to patients and the community. This paper describes education in health services administration, and uses a survey of one program's graduates to assess the usefulness of the current educational model in balancing business and clinical perspectives.

The development of a national program to assure access to prenatal care for all women, regardless of income, is believed to be an effective means of reducing low birthweight and neonatal mortality in the U.S. Yet scarce empirical evidence concerning the effectiveness of large-scale prenatal care programs is available. This paper summarizes an evaluation of a statewide public prenatal care program xohich grew out of the federal Improved Preg- nancy Outcome (IPO) project. Using linked birth and infant death-certificate data, andIPOprogram records from a four-year period (1985-1988), this study compares the neonatal mortality rates of participan ts of Florida s IPO program with those of a matched comparison group. The results indicate an inverse relationship between IPO participation and the risk of neonatal mortality in a low-income population. These findings suggest that large-scale prenatal care programs can be effective in improving birth outcomes.

Backgound Survival implications of achieving different grades of physical independence after lower extremity amputation are unknown. Objectives To identify thresholds of physical independence achievement associated with improved 6-month survival and to identify and compare other risk factors after removing the influence of the grade achieved. Design Data were combined from 8 administrative databases. Grade was measured on the basis of 13 individual self-care and mobility activities measured at inpatient rehabilitation discharge. Setting Ninety-nine US Department of Veterans Affairs Medical Centers. Patients Retrospective longitudinal cohort study of 2616 veterans who underwent lower extremity amputation and subsequent inpatient rehabilitation between October 1, 2002, and September 30, 2004. Main Outcome Measure Cumulative 6-month survival after rehabilitation discharge. Results The 6-month survival rate (95% confidence interval [CI]) for those at grade 1 (total assistance) was 73.5% (70.5%-76.2%). The achievement of grade 2 (maximal assistance) led to the largest incremental improvement in prognosis with survival increasing to 91.1% (95% CI, 85.6%-94.5%). In amputees who remained at grade 1, the 30-day hazards ratio for survival compared with grade 6 (independent) was 43.9 (95% CI, 10.8-278.2), sharply decreasing with time. Whereas metastatic cancer and hemodialysis remained significantly associated with reduced survival (both P ≤ .001), anatomical amputation level was not significant when rehabilitation discharge grade and other diagnostic conditions were considered. Conclusions Even a small improvement to grade 2 in the most severely impaired amputees resulted in better 6-month survival. Health care systems must plan appropriate interdisciplinary treatment strategies for both medical and functional issues after amputation.