Class of 2006 Abstract / Objectives: To assess predictors of systolic blood pressure control in the Southern Arizona Veterans Affairs Health Care System. Methods: 6185 patients were followed over a 2 year period and predictors of blood pressure control were examined using univariate and multivariate analyses. Primary independent variables assessed were age, gender, race, antihypertensive medication class, and comorbidities. The primary dependent variable was systolic blood pressure. Results: Sixty percent of patients studied had controlled hypertension. Significant predictors of better blood pressure control were the presence of coronary artery disease, use of loop diuretics, not using miscellaneous antihypertensive agents, lower age, and not of Hispanic descent or not an African-American. Conclusions: Frequency of systolic blood pressure control was found to be higher than previously reported. In contrast, age, sex, and race were significant predictors of control as reported elsewhere. Lastly, coronary artery disease, loop diuretics, and miscellaneous antihypertensive agents were found to be the only other significant predictors of systolic blood pressure control. These results suggest that there is largely no difference between the major antihypertensive medications class with respect to blood pressure control.

Healthcare costs have risen from 13.8% in 2000 to 17.9% in 2009 (Gordon, Leiman, Deland, & Pardes, 2014). Poor transitional care has been identified as a cause of the high healthcare costs (Naylor et al., 2013; Obama, 2013). In 2009, the Department of Veterans Health Administration (VHA) implemented a national reform of outpatient care to create Patient-Aligned Care Teams (PACTs) with a goal to improve transitional care and reintegration into outpatient care through registered nurse case managers conducting discharge telephone follow-up calls. However, discharge telephone follow-up calls have not been explored within the VHA. This study explored the relationships among discharge telephone follow-up calls, selected Veteran characteristics including the length of index hospital stay, and 30-day all cause hospital readmissions between fiscal years 2011 and 2013. Hospital readmissions were explored in parallel time periods to the timing of the discharge telephone follow-up calls. Study data were collected retrospectively from VHA inpatient and outpatient records. Descriptive statistics, measures of central tendency, bivariate statistics, and logistic regression were used to analyze the data. The study found 124,069 Veterans were discharged from the VHA from 2011 to 2013. Of those discharges, 15,954 (12.86%) were readmitted to the hospital within 30 days and 35.06% of the readmissions occurred within the first seven days after discharge. Discharge telephone follow-up calls increased from 312 in 2011 to 26,549 in 2013. Increasing Veteran age, number of comorbidities, length of index hospital stay, and being identified as frequently hospitalized in the previous year were significantly related to hospital readmissions at each of the hospital readmission time frames (within two days, between three and seven days, and between eight and thirty days after hospital discharge). This study identified a relationship between discharge telephone follow-up calls and the parallel hospital readmission time period. However, only discharge telephone follow-up calls within two days were found to decrease the likelihood of hospital readmissions and only hospital readmissions within two days after discharge (OR=0.595). The relationships between discharge telephone follow-up calls and hospital readmissions potentially explains previously mixed results and suggests two potential explanations. One, discharge telephone follow-up calls have a limited relationship to hospital readmissions and a short duration of protective effects preventing hospital readmissions. The second explanation is self-selection bias confounds the relationship between discharge telephone follow-up calls and hospital readmissions. Both explanations suggest future research and clinical practice should focus on exploring bundled transitional care interventions as a method to reduce hospital readmissions.

Health outcomes fulfill a number of roles in the health sector. Economists, clinicians, researchers and managers use health outcomes in a range of different contexts for distinct purposes. New management approaches that use contracts as the basis for health service accountability have attempted to take health outcomes from their clinical role into a management setting. In particular, the purchasers and managers of some health services expect that service providers should demonstrate that they improve the health outcomes of their patients to justify their on-going funding. However, a number of organisations have experienced barriers to the application of the outcomes approach to health service management and there has been no systematic evaluation of the approach. Nor has there been an investigation into why purchasing organisations have difficulty introducing health outcomes into purchasing contracts. The result is that managers and purchasers continue to assign resources to the pursuit of health outcomes as an accountability tool. This thesis addresses two research questions around the use of health outcomes in community and allied health service accountability. The first is the barriers to the application of health outcomes to health services accountability. The second question examines the conditions that must be met before health outcomes can be used as an accountability tool in purchasing contracts for allied health. The research questions are addressed through the analysis of case studies that explore systematically the approach taken by two organisations, the Department of Veterans� Affairs and ACT Community Care, in their attempts to identify health outcomes that could be used in purchasing contracts for community and allied health services. The case study analysis uses a health services research approach that draws on multidisciplinary techniques including epidemiology, health services management and anthropology. The thesis describes the accountability interactions within the purchaser-provider model. Accountability is not a uniform construct. It consists of many domains, levels and interactions. In health service delivery, there are a number of different actors and a wide range of interactions for which they are accountable. Two important interactions are identified: professional accountability, which describes the accountability of the health service professional to their patient; and contractual accountability, which is the obligation of the health service provider (or providing organisation) to the purchaser through their contractual agreement. I conclude that health outcomes are not an appropriate domain of contractual accountability but they are an important component of professional accountability and I discuss the implications of these finding for theory and practice.

Thesis (Ph.D.)--University of Florida, 2004. / Typescript. Title from title page of source document. Document formatted into pages; contains 182 pages. Includes Vita. Includes bibliographical references.

Background: Increasing numbers of women veterans (WV) present an organizational challenge to a healthcare system that primarily serves men. WV use reproductive services traditionally not provided by the Veterans Health Administration (VHA). Objective: Examine the association of organizational factors and adoption of comprehensive women’s health (WH) care in the VHA. Study Design: Cross-sectional secondary analysis of the 2007 VHA Survey of Women’s Veterans Health Programs and Practices. Methods: Dependent measures were (a) model of women’s health care: separate women’s health clinic (WHC), designated women’s health provider within primary care (DWHP), both (WHC/DWHP), or neither and (b) availability of five basic WH services: cervical cancer screening and evaluation and management of: vaginitis, menstrual disorders, contraception and menopause. Exposure variables were organizational factors drawn from an adaptation of the Greenhalgh model of diffusion of innovations including structural factors, measures of absorptive capacity and system readiness for innovation. Results: Compared to sites with DWHP or neither, WHC and WHC/DWHP were more likely at facilities with: a gynecology clinic, an academic affiliation, a WH representative on high impact committee, and a greater number of WV. Academic affiliation and high impact committee remained significant in multivariable analysis. All five basic WH services were more likely to be offered at sites with WHC or WHC/DWHP, remaining significant after adjusting for organizational factors. Conclusion: Facilities that adopt WHC are associated with greater absorptive capacity (academic affiliation and WH representation on high-impact committees) and are more likely to deliver basic WH services. Separate WHCs may promote more comprehensive care for WV.

Background: Hepatitis C virus is currently the most common chronic blood borne pathogen in the United States, with only half of those infected aware of their condition. The cost for treatment is higher with Harvoni® (ledipasvir/sofosbuvir) than Viekira Pak® (ombitasvir/paritaprevir/ritonavir and dasabuvir). With finite resources available to treat patients, it is important to understand which clinical factors may influence treatment selection decisions. Methods: The study is a 12-month medical record review within the Veterans Affairs (VA) system to evaluate significant relationships between selected clinical and sociodemographic factors and HCV treatment selection with either Harvoni® or Viekira Pak®. Clinical and demographic information was collected as well a presence of interacting medications, contraindication to components of the treatment regimen, and the treatment regimen indicated and selected. Results: In total, 25,717 patients were extracted from the database and were compared by the use of frequency charts and logistic regression analysis with results reflective of the nationally reported numbers. There was a statistically significant difference in the prescribing pattern between the VA Northern California Health System (station 612) and the other stations nationally with Viekira Pak® prescribed more often in that station. Station 612 utilized an electronic decision tree (otherwise known as a ‘quick order’) during the medication ordering process. In a comparison between station 612 and the other stations within the VA a notable difference in the impact of drug-drug interactions on the prescribing patterns was found within station 612. Conclusion: Many methods can be used to ensure optimal treatment for HCV infections. In station 612 the use of a decision tree may have assisted in avoidance of potentially modifiable factors which enabled for a higher utilization of the less expensive treatment option, Viekira Pak®, for HCV infections, thereby potentially allowing for more Veterans to be treated with finite resources.

Introduction: Many Veterans with PTSD struggle with symptoms of social dysfunction, including isolation [1] and physical violence [2]. Current Veterans Affairs (VA) treatments effectively decrease posttraumatic stress symptoms (PTSS) [3, 4, 5, 6], but do not directly target social dysfunction. In the current study, we investigate deficits in two potential mechanisms: trust and social responsiveness. We propose to use the iterated Trust Game [7, 8]– an economic exchange task that operationalizes trust and social responsiveness– to investigate differences due to PTSS severity. We will also investigate changes after treatment using the Trust Game in a dataset of Veterans undergoing residential treatment for PTSD at a VA Medical Center. We hypothesize that those with greater PTSS severity will show deficits in trust or social responsiveness, and these deficits will assuage with PTSS improvement after treatment. Methods: We analyze a cross-sectional dataset of combat-exposed Veterans (n = 153) and a dataset undergoing residential treatment for PTSD (n = 36). PTSS are measured using the PTSD CheckList (PCL). Each Veteran plays a ten-round variant of the iterated Trust Game. Each round involves exchange between the Veteran (or “investor”) who is endowed $20 each round, and a “trustee”, in whom the investor may entrust any portion of the $20. The investment is tripled before being sent to the trustee, and the trustee may return any proportion. Trust is operationalized as investment, and social responsiveness is operationalized as the ability of the trustee’s changes in response to the investor—“trustee reciprocity”—to predict changes in the investor’s next round investment. We investigate the two potential mechanisms in the cross-sectional dataset. To determine the relationship between trust and PTSS, we regress investment onto PCL. To investigate the relationship between social responsiveness and PTSS, we regress round change in investment onto the interaction of PCL and trustee reciprocity. We next investigate the impact of treatment in the residential treatment dataset. To determine the impact of PTSS improvement on trust, we regress change in investment onto PCL score change (posttreatment–pretreatment). To determine the impact of treatment-related change on social responsiveness, we regress round change in investment onto the interaction of change in PCL (posttreatment–pretreatment), visit, and trustee reciprocity. Results: In the cross-sectional dataset, higher PTSS correlates with decrease in trust, operationalized as investment (β1 = −0.002, p = 0.003, n = 153). Increase in trustee reciprocity correlates with increase in round change in investment (β1 = −0.25, p < 0.001, n = 153), indicating Veterans were socially responsive. There was no PTSS-related variation in social responsive- ness (0 < β3 < 0.001,p = 0.5,n = 153). In the residential treatment dataset, less PTSS improvement correlated with decrease in trust after treatment (β1 = −0.006, p = 0.015, n = 36). Veterans were socially responsive (β1 = 0.39,p < 0.001,n = 36), with a decrease in responsiveness at posttreatment (β5 = −0.29,p = 0.001, n = 36) and a greater decrease posttreatment in those with less improvement in PTSS (β7 = −0.01, p = 0.02, n = 36). Conclusions: In the cross-sectional dataset, trust decreased with higher PTSS, while social responsiveness did not change with PTSS severity. This suggests that Veterans with more severe PTSS show deficits in trust, but not social responsiveness, and supports deficit trust as a mechanism for the social dysfunction observed in Veterans with PTSD. In the residential treatment dataset, both trust and social responsiveness decreased with less improvement in PTSS after treatment. This suggests that Veterans whose PTSS do not improve with treatment experience further decline in mechanisms of social functioning after discharge. In the absence of a control group, it is hard to determine whether this decline is due to symptom-related order effect, or unsuccessful treatment itself. These findings suggest decreased trust, but not social responsiveness, is a mechanism of social dysfunction observed in PTSD. Further investigation into mechanisms of social dysfunction and treatment-related change in Veterans with PTSD, the iatrogenic effects described, and the way these effects can be minimized is also necessary. These findings lend support to treatments that directly target social dysfunction in the context of treatment-resistant post- traumatic stress disorder. / National Institute of Health, 1I01RX000120, NIH-I01 2009-2010, 2013-2014, NIH-I01 2018-2019 National Institute of Health, 5I01RX002354, NIH-I01 2018-2019, 2020-2021 / Master of Science

No description available.

The Polytrauma/TBI Rehabilitation Center (PRC) of the Veterans Affairs Hospital (VAH) treats patients with Traumatic Brain Injury (TBI). These patients have major motor and cognitive disabilities. Most of the patients stay in the hospital for many months without major improvements. This suggests that patients, family and the VAH could benefit if healthcare provider had a way to better assess or "predict" patients' progression. The individual progress of patients over time is assessed using a pre-defined multi-component performance measure Functional Independence Measures (FIM) at admission and discharge, and a semi-quantitative documentation parameter Clinical Pathway (CP) at weekly intervals. This work uses already de-identified and transformed data to explore developing a clinical outcome predictive model for patients with TBI, as early as possible. The clinical outcome is measured as percentage of recovery using CP scores. The results of this research will allow healthcare providers to improve the current resource management (e.g. staff, equipment, space) through setting goals for each patient, as well as to provide the family more accurate and timely information about the status and needs of the patient.

Combat veterans often return from war with psychological as well as physical injuries. Armed service members who are bodily injured routinely go to hospitals for treatment, first at military hospitals and later in the U.S. Department of Veterans Affairs (VA) system. But those with psychological injuries like post-traumatic stress disorder (PTSD) often go years, if not a lifetime, without treatment, in large part because the VA denies their claims with dubious justification. Veterans’ service organizations like the Veterans of Foreign Wars (VFW), the American Legion, and others, as well as state and county governments, have knowledgeable service officers whose job is to help guide veterans through the VA system and through the many appeals that are often needed to get treatment and an adequate disability rating that could result in monetary payments. This report tells the story of one VFW post in Burnet, Texas, its veterans, their families, and how their success in getting treatment for PTSD has positively affected their lives. It has also enabled them, as they recover, to help other veterans seek treatment and win compensatory disability ratings too. The report focuses on one Vietnam veteran, who four decades after his discharge from the Army came to be treated for PTSD. / text