HERC: Featured News
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On-pump yields better outcomes 5 years after the procedure compared to off-pump.

November 16, 2018

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Risk adjustment is one way of adjusting for inherent differences in patients' underlying clinical needs.

November 15, 2018

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Interested in Using Choice Data in Research?

November 14, 2018

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What is Cost-Effectiveness Analysis?

November 13, 2018

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Return on Investment Assessment: When, Why, and How to Use It

May 7, 2018

Join HERC on May 16, 2018 for the cyberseminar “Return on Investment Assessment: When, Why, and How to Use It.” Return on investment assessments compare the cost offsets of an intervention to the investment required to implement the intervention. In this webinar, Melanie Whittington, PhD, a health economic methodologist from the Seattle-Denver Center of Innovation for Veteran-Centered and Value Driven Care, will explain when a return on investment assessment could be done within VA why it should be done to inform sustainability and resource use. Participants will learn how to conduct and interpret a return on investment assessment.

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Using the Managerial Cost Accounting 4-Character National Code (CHAR4) File for Program Evaluation

May 1, 2018

The MCA CHAR4 is a National Data Extract cost file produced by the MCA office. The CHAR4 file reports costs of outpatient encounters for specific clinics or types of clinics using a 4-Character National Code.

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Using Choice Data in Research

February 14, 2018

HERC has launched new series of cyberseminars, “HERC Q&A,” which have an emphasis on audience discussion and practical application. The first HERC Q&A, led by HSR&D Investigators Amy Rosen, Megan Vanneman, and Todd Wagner, focused on using Choice data in research, which is a growing area of interest for those evaluating non-VA care provided through the 2014 Veterans’ Choice Program. Investigations into the Choice data are still in the early stages; the purpose of this cyberseminar was to provide a starting point for understanding how to work with these data. The Q&A opened with a brief discussion of available Choice data sources, followed by a question and answer session with participants.

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How Do I Evaluate the Uncertainty of an Incremental Cost-Effectiveness Ratio?

February 7, 2018

HERC economists explain one method for determining whether an intervention yields sufficient value to justify its cost.

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Cost Effectiveness Analysis Course Happening Now

February 1, 2018

The HERC Cost-Effectiveness Analysis course is happening now! This introductory course covers cost-effectiveness and budget impact analyses using VA data. The lectures are held on Wednesdays, with each hourly session beginning at 11:00am Pacific or 2:00pm Eastern time. The 12-session course concludes on April 25. The full list of courses is available on the HERC website. To register for courses, please visit the HSR&D website.

February 28, 2018 Estimating Transition Probabilities for a Model
March 7, 2018 Medical Decision Making and Decision Analysis
March 14, 2018 Evidence Synthesis to Derive Model Transition Probabilities (Part I - Systematic Literature Review)
March 28, 2018 Evidence Synthesis to Derive Model Transition Probabilities (Part II - Quantitative Pooling)
April 4, 2018 Sensitivity Analyses
April 11, 2018 Budget Impact Analysis
April 25, 2018 How can cost-effectiveness analysis be made more relevant to U.S. health care?
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HERC Discharge Data for FY 2016 Now Available

November 7, 2017

HERC Discharge data for Fiscal Year 2016 are now available at VINCI.

The Managerial Cost Accounting System (MCA) maintains National Data Extracts (NDE) that track cost and utilization for care provided by the U.S. Department of Veterans Affairs (VA) medical centers. The MCA Discharge (DISCH) NDE provides the discharge bed section (DBEDSECT), but does not have detailed information on other inpatient treating specialties (i.e. categories of care) during an inpatient stay. HERC created a new dataset that is identical to the DISCH with the addition of fields containing cost and length of stay subtotals for each inpatient category of care (e.g., acute medicine, psychiatry, nursing home, etc.).

The updated guidebook, which describes how HERC created the Discharge dataset, is available on the HERC website.

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How can I identify a patient's primary care provider?

November 1, 2017

HERC economists discuss one method for identifying a patient’s primary care provider using Corporate Data Warehouse (CDW) data.

 

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FY16 HERC Outpatient Average Cost Data Now Available

July 13, 2017

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Learn more about resources and tools for conducting economic analyses for implementation projects

May 3, 2017

To continue to provide economics support to the QUERI programs, HERC has created an “Economics of Implementation & QUERI” web page. The page includes resources and tools for conducting economic analyses for implementation projects.

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Join us on 4/19/17 for a presentation by Gillian Sanders-Schmidler

March 17, 2017

Join us on Wednesday, April 19, 2017 at 11:00am Pacific/2:00pm Eastern for a presentation by Gillian Sanders-Schmidler, PhD on the recommendations of the Second Panel on Cost-Effectiveness in Health and Medicine. Dr. Sanders-Schmidler will discuss major changes to the recommendations including the perspectices of the reference case and the use of an impact inventory table. Register for the seminar at http://www.hsrd.research.va.gov/cyberseminars/catalog-upcoming-series.cfm?seriessort=hmcs.

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Medicare Wage Index for VA Facilities Updated

February 8, 2017

HERC has combined data from the Centers for Medicare and Medicaid Services (CMS) and the VHA Support Services Center (VSSC) to create a Medicare wage index for VA facilities. The guidebook and accompanying Excel have been updated through 2017.

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New Technical Report 33: Comparing the Measurement of Chronic Conditions in ICD-9-CM and ICD-10-CM in VA Patients, FY2014-FY2016

December 14, 2016

We developed ICD-9-CM and ICD-10-CM definitions for 34 different chronic conditions, and we compared the prevalence rates of these chronic conditions from federal fiscal year (FY) 2014 to FY2016 in a large sample of VA patients in order to measure the changes before and after transition to ICD-10-CM.

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Major changes were made to guidelines on how U.S. cost-effectiveness studies should be conducted and reported

December 8, 2016

Major changes were made to guidelines on how U.S. cost-effectiveness studies should be conducted and reported. The new guidelines were released December 7 in a day-long meeting at the National Academy of Sciences in Washington DC. The panel that developed the guidelines presented their recommendations and took questions from health economists from industry, government and academia. The new guidelines updated recommendations originally released 20 years ago. A full report from the meeting is available from HERC.

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Updated Recommendations for Cost Effectiveness Analysis

November 10, 2016

After three and a half years of deliberation, U.S. experts have released new recommendations on how cost-effectiveness research should be conducted. The recommendations are the focus of a December 7, 2016 meeting to be held at the National Academy of Sciences that will be broadcast over the Internet. To register to attend the webinar, go to http://tinyurl.com/cea-in-person. The recommendations published in JAMA may be found at http://jamanetwork.com/journals/jama/fullarticle/2552214.

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New Technical Report #32: Costing Methods Used in VA Research, 1980-2012

October 13, 2016

The Health Economics Resource Center (HERC) of the U.S. Department of Veterans Affairs (VA) reviewed peer-reviewed publications to determine the methods and data sources used in studies of VA health care costs between 1980 and 2012. The review identified the number of published papers that used four principal methods of costing available to VA researchers and examined how practices differed in the last five years of the research that was reviewed. The review generated a bibliography of publications that used each of the four methods. The goal of this review was to identify priorities for HERC strategic planning.

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New Technical Report #31: Updating mental health/SUD codes for ICD-10

August 24, 2016

PsyCMS was designed using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes from all Veterans who used VA healthcare services during the federal fiscal year 1999 (FY99). On October 1, 2015, all United States healthcare systems were requried to begin using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). This report describes the methods HERC used to update PsyCMS with ICD-10-CM codes.

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New HIV CD4 testing guidelines could reduce unnecessary testing and costs

May 10, 2016

This study analyzed CD4 and viral load tests for patients receiving HIV care from VA during 2009-2013. The authors found that reduced CD4 monitoring of HIV-infected patients would result in modest cost savings and likely reduce patient anxiety, with little or no impact on the quality of care.

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HERC develops SAS code to flag and adjust outliers in MCA PHA NDE

May 9, 2016

HERC has developed SAS code to flag and adjust outlier observations in the Managerial Cost Accounting Pharmacy National Data Extract (the MCA PHA NDE). The PHA file contains prescription-level records which include detailed cost information on each prescription filled, both inpatient and outpatient.

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Patient factors account for large variation in annual VA costs of heart failure patients

April 13, 2016

This study of VA utilization and cost records for all patients with a diagnosis of heart failure in FY2010 found that mean annual VA costs were $30,719 with more than one-half of their costs from inpatient care. Patients at younger ages, of Hispanic or black race/ethnicity, diagnosed with comorbid drug use disorders, or who died during the year had the highest costs. There was variation in mean adjusted costs by facility ranging from $15,000 to $48,000. In adjusted analyses, patient factors alone explained more of the variation in health care costs compared with the facility where the patient was treated.

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HERC's cost-effectiveness analysis course is ongoing through 4/13/16

March 7, 2015

Interested researchers can still register for any or all of the remaining cost-effectiveness analysis course sessions. This introductory course, hosted by HERC, covers cost-effectiveness and budget impact analyses and VA economic data sources. Cost-effectiveness analysis is a method to determine if interventions provide sufficient health benefit to justify their cost. Budget impact analyses comple-ment cost-effectiveness analyses, providing decision makers with information on the effect of adopting cost-effective interventions. This HERC course will provide an overview these and other types of deci-sion analysis and how to conduct these analyses with VA data.

The course is designed for researchers who would like an introduction to methods of cost-effectiveness analysis and budget impact analysis as applied to health services and medicine. The course takes place through conference calls with web-based slide presentations.

Please visit the HERC CEA webpage to register.

A workgroup of HSR&D investigators is talking with VA leadership about improving the safety and efficiency of VA care by reducing use of low-value services.

November 16, 2015

A workgroup of HSR&D investigators is talking with VA leadership about improving the safety and efficiency of VA care by reducing use of low-value services.  

"There are hundreds of targets for action," said workgroup leader Paul Barnett, of the Health Economics Resource Center, "it is a question of deciding who needs to participate and where to begin." In addition to the services identified by the Choosing Wisely initiative, lists of unneeded services have been developed by the Institute for Healthcare Improvement, the National Quality Forum, and the Institute on Clinical Excellence. Workgroup members include David Au, Christian Helfrich, and Adam Rose from the new HSR&D QUERI center on de-implementation, and Eve Kerr, Director of the HSR&D Center in Ann Arbor, Michigan. These HSR&D investigators are involved in one or more studies designed to de-implement unnecessary or harmful care.  

The workgroup wants to hear from VA operations groups interested in addressing poor safety and high cost that result from low-value services. Its goal is to identify potential VA operations customers for this work, to consider how to obtain patient and clinician input, and to identify high priority areas for action.

For more information contact Paul Barnett at HERC (paul.barnett@va.gov).

Fee Basis Data: A Guide for Researchers now available

November 10, 2015

The Fee Basis Data Guidebook is intended to help researchers understand and use the National Fee Basis files, which come in both SQL and SAS formats. This update describes for the first time the SQL Fee Basis files. The guidebook provides information about the characteristics of the data, such as contents and missingness, in both SAS and SQL. It compares the data available in the two formats, highlights important variables, and discusses certain data limitations. View the guidebook at http://www.herc.research.va.gov/include/page.asp?id=guidebook-fee-basis.

HERC's FY 14 cost data now available

September 1, 2015

The Fiscal Year 2014 Outpatient Average Cost data and Person Level Cost data are now available through the VHA Data Portal (Intranet only: http://vaww.vhadataportal.med.va.gov). Navigate to Data Sources > HERC Average Cost data to request access.

HERC presented at this year's HSR&D/QUERI National Conference in Philadelphia, PA

August 31, 2015

Todd Wagner, Risha Gidwani, and Ciaran Phibbs were among some of HERC's staff who presented at this year's VA Health Services Research and Development Service (HSR&D) and Quality Enhancement Research Initiative (QUERI) National Conference. Presentations included "PTSD and Antepartum Complications: Increased Risk of Gestational Diabetes and Preeclampsia" and "Overuse of Lumbar Spine MRI in VA: A National Analysis", among others. See our August 2015 Bulletin for full details.

Risk scores for VA cost analyses technical report now available

February 5, 2015

HERC worked with the Office of Productivity, Efficiency and Staffing (OPES) to design and implement a new risk adjustment system for cost data. The new technical report provides a description of the input files and the SAS programs used to calculate the V21 and Nosos risk scores. View the report at http://www.herc.research.va.gov/include/page.asp?id=technical-report-risk-adjustment.

HERC's econometrics course series begins March 2015

January 6, 2015

There are many powerful econometric techniques available to applied researchers who wish to answer questions outside of randomized clinical trials. This course is intended to provide an introduction to econometric methods used to analyze data in health services research. Topics will include: the linear regression model; research design; propensity scores; the instrumental variable model; nonlinear regression models; binary, count, and categorical dependent variables; and cost as the dependent variable. The lectures are held on Wednesdays, with each hourly session beginning at 11:00am Pacific or 2:00pm Eastern time.

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MCA (formerly DSS) cost data and NDEs are no longer available on Austin. They now reside within CDW.

June 18, 2014

VA's Managerial Cost Accounting (MCA) System (formerly Decision Support System or DSS) cost data and NDEs are no longer available on Austin as SAS datasets. They now reside within CDW as SQL tables. Data elements are the same, but some variable names are different. MCA has a crosswalk on their webpage to translate old variable names to new variable names. Researchers with VA network access can visit the MCAO Intranet site by copying and pasting the following URL into their browser: http://vaww.dss.med.va.gov/.

ISPOR released new budget impact guidelines in 2014

December 19, 2013

The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Task Force on Good Research Practices released updated guidelines for conducting budget impact analyses, replacing the guidelines originally released in 2007. To educate the VA community about the updated budget impact analysis guidelines, Josephine Mauskopf, PhD, MHA, the co-chair of the ISPOR task force on budget impact analysis, presented in the HERC Health Economics Cyber Seminar series on January 15, 2014 at 11:00am PT (2:00pm ET).

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Urban Institute researchers shared estimates of new coverage options for uninsured Veterans

December 18, 2013

On November 21, 2013 Urban Institute researchers Jennifer Haley and Genevieve Kenney, Ph.D. hosted a special HERC cyber seminar on the new insurance coverage options available to uninsured Veterans and their family members under the Affordable Care Act (ACA). They shared findings from their recent report on the estimated number of currently uninsured Veterans who can gain new Medicaid coverage due to provisions in ACA.

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Use of newer antiretroviral agents can be cost-effective for patients with advanced HIV

December 18, 2013

A modeling study using data from the VA CSP OPTIMA trial and from published randomized trials found that substituting newer antiretroviral (ART) drugs increased expected survival by 3.9 years in advanced HIV disease. The incremental cost-effectiveness ratio of newer, compared with conventional ART, was $75,556/quality-adjusted life year gained. These findings suggest that newer ART drugs should be used in carefully selected patients for whom less expensive options are inferior.

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The July 2013 issue of Medical Decision Making focuses on evidence synthesis

December 18, 2013

The July 2013 edition of Medical Decision Making focuses on evidence synthesis for decision making. Article topics include network meta-analysis and Bayesian approaches to evidence synthesis. Many of the articles in this edition are authored by well-known UK researchers in this field from the University of Bristol and the University of Leicester and are based on Technical Support Documents they prepared for the National Institute for Health and Clinical Excellence (NICE) Decision Support Unit. HERC recommends these articles for anyone interested in evidence synthesis for stand-alone purposes or for deriving inputs for use in a cost-effectiveness model.

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HERC joins Healthcare Value and Results Subcommittee

May 24, 2013

Paul Barnett and Todd Wagner, HERC’s Director and Associate Director, were invited to participate in the Healthcare Value and Results Subcommittee as advisory board members. Managed by the VHA National Leadership Council Healthcare Quality and Value Committee, the Subcommittee is tasked with implementing and measuring value-driven care to improve health outcomes and experiences for Veterans in a patient-driven and cost-effective manner. Goals include 1) developing a VA-centric prototype for delivery of value-driven care; 2) developing means to evaluate healthcare value and outcome achievement; and 3) fostering internal and external analyses and benchmarking to reduce internal variation and promote improvement, transparency, and accountability.

Mental health diagnoses and medication use impact potentially avoidable hospitalizations

May 16, 2013

A 2-year longitudinal analysis of 18,526 primary care patients in VA found that prior diagnoses for depression and drug use disorders and lower medication use were independent risk factors for ambulatory care-sensitive condition (ACSC)-related hospitalizations. ACSCs include hypertension, diabetes, pulmonary disease, congestive heart failure, and other chronic illnesses. These findings suggest that patients with mental health conditions in primary care require additional support beyond standard primary care visits.

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PSSG Enrollee File, a geographic dataset, was released

May 16, 2013

The Planning Systems Support Group (PSSG) Enrollee File is a geographic dataset that presents the most current study of veterans’ health care access, travel, and demand for health services. This guidebook proceeds as follows: 1)Introduction; 2) Access, which describes where to access to the Enrollee File; 3) Data Sources, which describes each of the files used to create the Enrollee File and the methods used to develop the urban/rural/highly rural classification; and 4) Variables, which provides a table of variables within the Enrollee File and a brief description of each variable.

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Researchers explore RN perceptions of off-shift nursing care

May 16, 2013

A qualitative study exploring registered nurses' perceptions of off-shift (e.g. nights and weekends) nursing care and quality resulted in six themes: (1) collaboration among self-reliant night nurses; (2) completing tasks; (3) taking a breather on weekend day shift; (4) new nurse requirement to work at night; (5) mixture of registered nurse personnel; and (6) night nurse perception of under-appreciation. These findings support the importance of sufficient resources as well as communication between night and day nurses.

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Labor cost dataset and guidebook now available

November 28, 2012

HERC has updated its dataset and guide to estimating VHA labor costs for FY2000 to FY2011. VHA labor cost estimates are needed for economic evaluations of innovative services. The analyst who needs to determine the time spent by different types of staff can turn to this source to find the cost of that effort.

There are two labor cost sources at VA: the Financial Management System (FMS) and the DSS Account Level Budgeter (ALB). Both sources report labor cost by job category, or budget object code,and generally provide similar hourly costs. The updated labor cost dataset provides the annual labor cost estimates by job category from both.

The companion guide provides information on the datasources, methods used to create the dataset,and recommendations about using each datasource.

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What determines successful implementation of inpatient information technology systems?

November 28, 2012

A qualitative analysis identified factors that lead to successful implementation of hospital-based IT systems in the VA: stable and supportive leadership, a gradual approach, adequate resources, and plans for responding to setbacks in IT implementation.

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Patients diagnosed with depression and drug use disorders at greater risk for potentially avoidable hospitalizations

November 28, 2012

An observational study of primary care patients found that those diagnosed with depression and drug use disorders had greater risk for potentially avoidable hospitalizations. These findings suggest that mental health conditions require focused attention if the full benefits of new primary care models are to be achieved.

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Researchers propose new framework to identify patients with neck and back pain

May 22, 2012

Given significant variation in reports of incidence, prevalence, and morbidity associated with neck and back pain problems, HERC researchers recently reviewed existing methods for identifying patients with these problems in administrative data. Using a snowball-sampling approach, which searched various databases including Web of Knowledge and PubMed, Sinnott et al. reviewed 170 articles and ultimately identified 7 distinct methods for identifying neck and back pain.

The authors evaluated the difference in these 7 algorithms by using VA administrative data to identify 2.77 million unique neck and back pain patients (FY2002-FY2009). They demonstrated that adding new selection methods, in addition to the previous algorithm(s), resulted in additional unique individuals. For example, using the Cherkin (Spine, 1992) list alone, Sinnott et al identified over 2 million unique individuals with back problems; when adding the HCUP back category codes, the researchers identified more than 33,000 additional individuals. The authors also categorized each case by spinal segment involved.

The authors suggest an update to the most commonly used algorithm and advise that a new framework be based on international standards, among other recommendations.

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Female veterans shape trends in rates and costs in VA

May 22, 2012

Investigators analyzed all inpatient, outpatient, and pharmacy utilization and cost files in fiscal years 2000 and 2008 for women Veterans. Findings showed 266,978 female veterans received VA care in 2008, up from 156,305 in 2000. The largest increase occurred among women aged 45 to 64 years old. The rate of women treated for specific conditions increased substantially for many gender-specific and psychiatric conditions, e.g. pregnancy (133%), diagnosed posttraumatic stress disorder (106%), and diagnosed depression (41%). Mean costs of care increased from $4,962 per woman in 2000 to $6,570 per woman in 2008. Psychiatric conditions accounted for more than one quarter of population health care costs in 2008. Gender-specific conditions and musculoskeletal diseases accounted for a rising share of population costs and rose to 8.2% and 8.7% of population costs in 2008, respectively.

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Poor quality of life associated with high risk of death in patients with acute kidney injury

May 22, 2012

Joyce et al. analyzed health-related quality of life (HRQoL) data collected from a randomized trial that compared more- with less-intensive renal replacement therapy in patients with acute kidney injury (AKI). They used Cox proportional hazards models to assess whether 60-day HRQoL, as measured by the Health Utilities Index, predicted mortality 1 year after AKI while controlling for possible confounders.

Of 1124 AKI patients enrolled at baseline, 439 (39%) patients were alive at day 60 and had evaluable HRQoL data. Low HRQoL at day 60, adjusted for traditional clinical variables, was associated with higher mortality at 1 year. Older age, very high comorbidity scores, and longer length of initial hospital stay were also associated with increased hazard of death. Low HRQoL attribute scores, including ambulation, emotion, cognition, and pain scores, were also independently associated with mortality.

The researchers concluded that measuring HRQoL could be useful in identifying patients at high risk for death after AKI.

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Researchers profile new women veterans in VHA

February 16, 2012

Investigators looked at women veterans who used VHA outpatient services for fiscal years 2003 through 2009, with "new" patients in a given year identified as having had no outpatient use within the prior 3 years. Of 287,447 women veteran VHA outpatients in 2009, 40,000 (14%) were new to VHA in that year and over half had joined VHA since 2003. Nearly two thirds of these new patients were younger than 45, and 43% carried a service-connected disability status. Most new patients (88%) received primary care services in 2008, and 40% used mental health services. Repeated use of mental health services (at least three visits per year) nearly doubled among new patients (from 11% in 2003 to 20% in 2008). In every year studied, researchers found a high rate of VHA retention among new patients. The influx of new women veterans seeking VHA services in recent years, combined with their high rate of retention within VHA, contribute to the marked increase in numbers of women veterans using VHA.

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Patients seeking VA care up by 40%; drives growth in chronic condition spending

February 15, 2012

The number of patients who sought VA care grew by 40% between 2000 and 2008, driving most of the growth in chronic condition spending. A large increase in the prevalence of renal failure led the rise in spending among all chronic conditions. Recent veterans’ high risk for mental health problems, as evidenced by prevalence and spending, are likely to contribute to higher spending for mental health problems in the future. Although some conditions, including arthritis and spinal injury had higher treatment costs over time, costs to treat diabetes, COPD, heart conditions, renal failure, and stroke were lower during this time period and may have helped to slow spending. The VA continued to expand its outpatient care capacity during the time period with community-based outpatient clinics, so better access to outpatient care may have shifted costs away from hospital care.

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Characterizing the cost of HIV care including combination antiretroviral treatment (ART)

February 15, 2012

Randomly sampled HIV positive patients seen between 2002 and 2006 incurred a mean of $17,484 in annual VHA healthcare cost (in 2006 dollars) which is consistent with recent reviews. Outpatient pharmacy accounted for 62.8% of the costs of patients highly adherent with antiretroviral (ART) therapy, 32.2% of the cost of those with lower adherence, and 6.2% of the cost of those not receiving ART. Compared with patients not receiving ART, high adherence was associated with lower hospital cost, but no greater total cost. Individuals with a low CD4 count (<50 cells/mm3) incurred 1.9 times the cost of patients with counts >500. Most patients had medical, psychiatric, or substance abuse comorbidities. These conditions were associated with greater cost.

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Injectable no better than oral antipsychotics in time to hospitalization or quality of life

June 17, 2011

In VA patients with schizophrenia or schizoaffective disorder, long-acting injectable risperidone was no more effective than oral antipsychotics in keeping patients out of the hospital. The rates of hospitalization were 39% (injectable) versus 45% (oral) which was not significant and could have occurred by chance alone (hazard ratio 0.87, 95%; confidence interval 0.63 to 1.20). Quality of life scores, as measured by the Quality of Well-Being Scale, found similar, not significant results for the injectable and oral medications (0.67 versus 0.66, P=0.63).

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Study finds no difference in patency, costs, or quality of life between arterial and saphenous vein grafts

June 17, 2011

Among VA patients undergoing first-time elective coronary artery bypass grafting (CABG), there was no difference in 1-year patency for those who had radial artery grafts compared with those who received saphenous vein grafts. Moreover, there was no significant difference in mean cost ($47,560 versus $49,390, P=.51) between saphenous and radial artery graft patients, and no significant differences in quality of life scores (Health Utilities Index) at 12 months (0.67 saphenous versus 0.64 radial artery, P=.23). Differences in patency, cost, and quality of life may have occurred by chance alone. VA has funded a 5-year follow-up of these patients.

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Nurse staffing affects patient outcomes and length of stay, but less than previous estimates

June 17, 2011

Increasing nursing hours per patient day by one hour reduced length of stay by 1-3%. A 10% reduction in the use of nursing aides reduced length of stay by 12% and a 10% reduction in contract nurses reduced length of stay by over 20%. A one year increase in average unit tenure (i.e. a reduction in turnover) reduced length of stay by over 2%. These effects were smaller in intensive care units (ICUs) than in other acute care units. A one hour increase in nursing hours per patient day was associated with 1% reductions in mortality and nursing-sensitive patient safety indicators. There were large effects on the estimates when the fixed effects were removed; for example the effect of nurse staffing levels on length of stay quadrupled and the effect of contract nurses reversed. Using unit-level, monthly, panel data and fixed-effects models yields smaller estimated effects of nurse staffing on length of stay than models using cross-sectional data and/or more aggregated data.

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Home monitoring of INR equal but not superior to clinic testing

December 17, 2010

Warfarin anticoagulation reduces thromboembolic complications in patients with atrial fibrillation or mechanical heart valves, but effective management is complex, and the international normalized ratio (INR) is often outside the target range. As compared with venous plasma testing, point-of-care INR measuring devices allow greater testing frequency and patient involvement and may improve clinical outcomes.

We randomly assigned 2922 patients who were taking warfarin because of mechanical heart valves or atrial fibrillation and who were competent in the use of point-of-care INR devices to either weekly self-testing at home or monthly high-quality testing in a clinic. The primary end point was the time to a first major event (stroke, major bleeding episode, or death).

The patients were followed for 2.0 to 4.75 years, for a total of 8730 patient-years of follow-up. The time to the first primary event was not significantly longer in the self-testing group than in the clinic-testing group (hazard ratio, 0.88; 95% confidence interval, 0.75 to 1.04; P=0.14). The two groups had similar rates of clinical outcomes except that the self-testing group reported more minor bleeding episodes. Over the entire follow-up period, the self-testing group had a small but significant improvement in the percentage of time during which the INR was within the target range (absolute difference between groups, 3.8 percentage points; P<0.001). At 2 years of follow-up, the self-testing group also had a small but significant improvement in patient satisfaction with anticoagulation therapy (P=0.002) and quality of life (P<0.001).

As compared with monthly high-quality clinic testing, weekly self-testing did not delay the time to a first stroke, major bleeding episode, or death to the extent suggested by prior studies. These results do not support the superiority of self-testing over clinic testing in reducing the risk of stroke, major bleeding episode, and death among patients taking warfarin therapy. (Funded by the Department of Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT00032591.)

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Free Care for Veterans with MST Does Not Result in Major Income Loss to VA

December 7, 2010

Since 2002 there have been no co-payments for VA healthcare related to military sexual trauma (MST), defined by VA as sexual assault or harassment that took place during military service. Congress eliminated the co-payment for care related to MST in order to reduce the financial barrier to treatment; however, eliminating co-payments reduces income for the VA healthcare system. The potential loss may be substantial because more than 70,000 Veterans who use VA healthcare had screened positive for MST by FY2006. This retrospective study estimated the loss in outpatient co-payment revenue for VA due to the mandate for free care related to MST. Investigators analyzed VA data for all Veterans who received VA healthcare and screened positive for MST from FY06 through FY08. The number of Veterans with outpatient encounters related to MST rose from approximately 44,000 in FY06 to 57,000 in FY08. Women had the majority of these encounters.

Findings show that about 95% of Veterans who received outpatient care for military sexual trauma would have had no co-payment, even in the absence of a free-care mandate. The estimated co-payment revenue foregone by the free-care mandate for MST was modest, totaling about $418,000 in FY06, $517,000 in FY07, and $455,000 in FY08. These totals represented only .04-.05% of first-party co-payment revenues for outpatient care. These results suggest that VA can continue to provide free care for patients who have experienced military sexual trauma without major income loss.

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VA Significantly Increased Prescriptions for Smoking Cessation Medications

December 7, 2010

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Evaluating robots for improving outcomes in stroke patients

April 15, 2010

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How to estimate average annual and hourly wages for VHA employees

March 19, 2010

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The cost of US health care - a systematic review

March 19, 2010

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New findings on the quality of life of patients with advanced HIV

March 19, 2010

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Examining the cost of treating solitary pulmonary nodules managed by PET

March 19, 2010

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Could changes in FDA labeling improve comparative effectiveness?

March 19, 2010

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