Class of 2005 Abstract / Objectives: The purpose of the study was to evaluate if rosiglitazone was being used in full compliance with the SAVA consensus criteria for appropriate use of thiazolinediones. Methods: A retrospective chart review was performed on 50 SAVA patients selected at random from a list of patients that were on rosiglitazone treatment as of March 15, 2005. Results: The percent of patients who met all of the criteria set forth by the SAVA when initiating therapy was 44%. Rosiglitazone treatment should not have been started in 28 out of the 50 patients. Once initiated on rosiglitazone, patients’ follow-up ALT was only obtained in 16% of patients. Once rosiglitazone has been prescribed for 3 months, HbA1c should decrease. Twenty percent of the patients showed an increase in HbA1c from baseline and were continued on the medication despite the criteria. Implications: Once therapy was initiated, the majority of patients studied failed to meet the SAVA guidelines for the appropriate use of rosiglitazone. In addition, a majority failed to follow the aspects of the guideline regarding initiation of rosiglitazone therapy.

Objectives: Research shows transgender individuals experience pronounced health disparities compared with their nontransgender peers. Yet, there remains insufficient research about health differences within transgender populations. This study seeks to fill this gap by exploring how current urban/rural status is associated with lifetime diagnosis of mood disorder, alcohol dependence disorder, illicit drug abuse disorder, tobacco use, posttraumatic stress disorder, human immunodeficiency virus, and suicidal ideation or attempt among veterans with transgender-related diagnoses. Methods: This study used a retrospective review of The Department of Veterans Affairs (VA) administrative data for transgender patients who received VA care from 1997 through 2014. Transgender patients were defined as individuals that had a lifetime diagnosis of any of 4 International Classification of Diseases-9 diagnosis codes associated with transgender status. Independent multivariable logistic regression models were used to explore associations of rural status with medical conditions. Results: Veterans with transgender-related diagnoses residing in small/isolated rural towns had increased odds of tobacco use disorder (adjusted odds ratio=1.39; 95% confidence intervals, 1.09-1.78) and posttraumatic stress disorder (adjusted odds ratio=1.33; 95% confidence intervals, 1.03-1.71) compared with their urban transgender peers. Urban/rural status was not significantly associated with other medical conditions of interest. Conclusions: This study contributes the first empirical investigations of how place of residence is associated with medical diagnoses among veterans with transgender-related diagnoses. The importance of place as a determinant of health is increasingly clear, but for veterans with transgender-related diagnoses this line of research is currently limited. The addition of self-reported sex identity data within VA electronic health records is one way to advance this line of research.

Small business failure rates equate to 30% within 2 years and 50% after 5 years. The purpose of this multiple case study was to explore the strategies that veteran-owned small businesses used to sustain a business beyond 5 years in central Florida. Using a purposeful sampling technique, 13 central Florida veteran small business owners consented to interviews about their operating processes. Analysis of the veteran-owner managerial practices revealed common nodes and themes regarding small business longevity factors. Based on constant comparison coding, 4 small business themes emerged: business operating practices, market research, business adversities, and external small business assistance avenues. The experiences of veteran small business owners emulated the general systems theory and the triple-loop learning theory in identifying, organizing, and initiating process changes for small business operational permanence. This study has social change implications for aspiring veteran small business owners: Successful veteran entrepreneurship can promote positive social values, stakeholder satisfaction, and employment opportunities by exploring small business operating strategies, conducting market analysis, overcoming adversities, and petitioning external small business veteran programs.

Class of 2017 Abstract / Objectives: The first aim is to assess efficacy of aspirin versus enoxaparin in preventing a venous thromboembolism (VTE) after a total knee arthroplasty (TKA) or total hip arthroplasty (THA) within 30 days after discharge. The second aim is to assess the safety of aspirin versus enoxaparin in preventing major bleeding events after a TKA or THA within 30 days after discharge. Methods: This study was a retrospective cohort study with data obtained from an online Veterans Affairs (VA) hospital database. For analysis, the primary outcome was assessed with a Chi-Square test, and the secondary outcome was reported with descriptive statistics.Results: Results: Demographics for 374 patients (TKA, n = 275; THA, n = 99): 90% male, average age of 65, average body mass index (BMI) of 32, 26% smokers, 72% had a history of hypertension, and 60% had a history of dyslipidemia. VTE events 30 days post-operatively: enoxaparin (n = 2), enoxaparin/aspirin (n = 1), and aspirin (n = 2) (P-value = 0.78). Safety events (major bleeding events): enoxaparin (n = 42), enoxaparin/aspirin (n = 7), and aspirin (n = 4). Conclusions: There was no significant difference between the treatment groups for VTE rate 30 days post- operation. The enoxaparin treatment group had the greatest number of safety events compared to the other groups.

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.