**1999 HSR&D Annual Meeting**

# ABSTRACT BOOK

## Table of Contents

### 

### Listing of Conference Presentations by Session

Plenary
Presentations..................................................................
2

Concurrent Paper Sessions

Session A
...................................................................... 2

Session B
...................................................................... 3

Session C
...................................................................... 3

Session D
...................................................................... 4

Workshops......................................................................
4

Session E
...................................................................... 4

Session F
...................................................................... 5

Session G
...................................................................... 6

Session H
...................................................................... 6

> Workshops
> .................................................................... 7
>
> Posters
> .........................................................................
> 8
>
> Session I
> ......................................................................
> 12

Session J
......................................................................
12

Session K
..................................................................... 14

Session L
..................................................................... 14

Workshops
................................................................... 15

Complete Listing of Abstracts Submitted\* by Title
............................ 16

Abstracts\*
.............................................................................
23

Author Index
.........................................................................
193

\*This document includes all of the submitted abstracts that were rated
as acceptable methodologically. Many of these submitted abstracts would
have made excellent presentations had meeting time and space permitted.
These abstracts are included here as a useful reference for VA managers,
researchers and other individuals who have expressed an interest in
identifying individuals with particular research expertise.

#### **1999 HSR&D Annual Meeting**

**Plenary Presentations, Concurrent Papers, Workshops and Poster**

######### Listed by Session

**Plenary Paper Session:** Thursday, February 25, 1999 9:25AM-10:25AM

Presenter Abstract \# Title

Berlowitz 1 Are we Improving the Quality of Nursing Home Care: The Case
of Pressure Ulcers?

Fihn 2 Variations in Condition-Specific Health Status Among VA General
Internal Medicine Clinics

Wilkins 3 Patient Preferences in PSA Screening: The Impact of Shared
Decision-Making Videos

Yano 4 Effectiveness of VA Primary Care Firm Systems:

Preliminary Findings

####### Concurrent Paper Sessions

**Session A:** Thursday, February 25, 1999 10:40AM-12:00PM

##### **General Mental Health Access**

Presenter Abstract \# Title

Hankin 5 Do Patients with Mental Disorders "Unnecessarily" Use more
Medical Services? Policy Implications for Mental Health Capitation

Hoff 6 A Comparison of VA to Public Sector Mental Health Patients: the
Connecticut Outcomes Study

Leslie 7 Comparing Quality of Mental Health Care in Public Sector and
Privately Insured Populations: First Efforts and Methodological
Challenges

Leslie 8 Comparing Reimbursement Models for VA Mental Health Services

Rosenheck 9 Impact of Primary Care Satellite Clinics on Access to
General Health Care Services and Mental Health Services

**Session B:** Thursday, February 25, 1999 10:40AM-12:00PM

###### HIV/Hepatitis C

Presenter Abstract \# Title

Bennett 10 Corticosteroid Utilization and Outcomes in HIV Associated
Pneumocystis Carinii Pneumonia: Three-fold Higher Mortality among
Severely Ill Patients when Corticosteroids given by CEC Guidelines

Bozzette 11 Use of Centralized VA Data Registry to Assess Quality of HIV
Care

Muir 12 The Prevalence of Hepatitis C in a Sample of Severely Mentally
Ill Veterans

Dawson 13 Management of Hepatitis C at the VA Puget Sound Health Care
System

Roselle 14 Hepatitis C Virus Infection and Addiction Disorders in
Department of Veterans Affairs Facilities Nationwide

**Session C:** Thursday, February 25, 1999 10:40AM-12:00PM

##### **Quality Databases**

Presenter Abstract \# Title

Geraci 15 Mortality after Cardiac Bypass Surgery: Prediction from
Administrative versus Clinical Data

Gordon 16 The Houston Approach to Optimal Risk-Adjustment Using
Administrative Data

Johnson 17 A Markov Model of Severity of Illness States and Hospital
Mortality

Johnson 18 Hospital Profiles of Mortality from Cardiac Bypass Surgery:
Effect of Definition of Outcome Based on Administrative versus Clinical
Data

Szeto 19 Accuracy of Computer Identified Diagnoses in a VA General
Medicine Clinic

**Session D:** Thursday, February 25, 1999 10:40AM-12:00PM

####### Prostate 

Presenter Abstract \# Title

Kim 20 Prostate Cancer Quality of Life and Outcomes Research among
Patients with Low Socioeconomic Status: An Overview of the VA Cancer of
the Prostate Outcomes Study (VA CaPOS)

Yano 21 Prevalence of Lower Urinary Tract Symptoms and Associated
Resource Utilization among VA Primary Care Patients

Wilt 22 Relative Effectiveness of Androgen Suppressive Therapies for
Advanced Prostate Cancer

Zemencuk 23 Men's Beliefs about the Benefits of and Professional
Recommendations for PSA Screening

Saint 24 Preventing Urinary Tract Infection using Urinary Catheters
Coated with Silver Alloy: a Cost-Effectiveness Analysis

**Workshops** Thursday, February 25, 1999 10:40am-12:00pm

Presenter Abstract \# Title

Bradham 25 HSR&D Development Center Workshop

Ibrahim 26 Internet-Based Education for Epidemiology

Reiber 27 Using National VA Data in Health Services and Epidemiologic
Research

**Session E:** Thursday, February 25, 1999 3:45pm-5:30pm

###### Health-Related Quality of Life: Patient Centered Measures

Presenter Abstract \# Title

Burman 28 Continuity of Care as a Determinant of Patient Satisfaction.
Results from the ACQUIP Study.

Burman 29 Patient Satisfaction Among Veterans Varies by Disease
Condition but not by Symptom Burden. Results from the ACQUIP Study.

**Session E:** (continued) Thursday, February 25, 1999 3:45pm-5:30pm

###### Health-Related Quality of Life: Patient Centered Measures

Presenter Abstract \# Title

Gralnek 30 A Disease-Targeted Measure of Health-Related Quality of Life
(HRQOL) for Patients with Chronic Liver Disease: The LDQOL 1.0.

McDonell 31 Measuring the Job Satisfaction of Providers in VA Primary
Care: the Seattle Provider Satisfaction Questionnaire (SPSQ)

Selim 32 Patient Characteristics and Patterns of use of Lumbar Spine
Radiographs: Results from the Veterans Health Study.

Starks 33 Positive Effects of a Workbook-centered Advance Care Planning
Intervention.

Peck 34 Measuring Patient Expectations: Does the Measurement Instrument
Affect the Number of Expectations Elicited and Patient Satisfaction?

**Session F:** Thursday, February 25, 1999 3:45pm-5:30pm

####### Special Populations

Presenter Abstract \# Title

Dubbert 35 Barriers to Walking for Exercise in Elderly Primary Care
Patients.

Dubbert 36 Validity of Physical Activity Recall in Urban and Rural
Elderly Men.

Evans 37 Multidisciplinary Rehabilitation versus Medical Care use of
Meta-Analysis to Determine the Clinical Effectiveness of Physical
Medicine.

Ibrahim 38 Racial Variation in Congestive Heart Failure Mortality among
the Elderly.

Kiefe 39 African American Veterans with Coronary Artery Disease Report
Worse Health and Less Satisfaction with Care than Whites: Results from
the ACQUIP Survey.

Collins 40 Racial Variation in Mortality Following Elective Surgery for
Vascular Disease

**Session F:** (continued) Thursday, February 25, 1999 3:45pm-5:30pm

####### General Health Services Research

Presenter Abstract \# Title

Morton 41 Antimicrobial Prophylaxis for Urinary Tract Infection in
Persons with Spinal Cord Dysfunction.

**Session G:** Thursday, February 25, 1999 3:45pm-5:30pm

####### General Health Services Research

Presenter Abstract \# Title

Baldwin 42 Predictors of Outcomes in Patients with Type 2 Diabetes
Mellitus

Sipler 43 Variations in Institutional Review Board (IRB) Approvals for
Allowing Third Party Medical Record Reviews of HIV-infected Individuals
without Patient Consent. The Multicity PCP Quality of Care Study.

Garvey 44 Tailoring Smoking Cessation Treatments Based on Nicotine
Dependence Level and Depression Status of Patients.

Sherman 45 The Effectiveness of Bupropion vs. Bupropion Plus Nicotine
Patch in a Smoking Cessation Clinic.

Whited 46 Reliability and Accuracy of Dermatologists' Digital Image
Consultations.

Wright 47 Use of VA Services by Medicare HMO Enrollees.

Wright 48 Validating Ascertainment of Mortality Using Multiple
Administrative Data.

**Session H:** Thursday, February 25, 1999 3:45pm-5:30pm

####### Access/Use of Health Care

Presenter Abstract \# Title

Borowsky 49 Veterans' Preferences for Transfer of Primary Care to
Community Based Outpatient Clinics (CBOC): Association with Health
Status, Satisfaction with VA Care, and Prior use of VA Care.

**Session H:** (continued) Thursday, February 25, 1999 3:45pm-5:30pm

####### Access/Use of Health Care

Presenter Abstract \# Title

Byrne 50 Effect of Facility-Level Characteristics on Primary Care
Enrollment and Bed-days of Care.

Dresselhaus 51 Determinants of House Staff Time Use in the Inpatient

Setting

Gifford 52 Effects of Race, Income, and Psychological Well-being on HIV
Patient Decisions about Emergency Department (ED) Use.

Lam 53 Cost-effectiveness of the Primary Care Provider Program at the
West Los Angeles VAMC.

Thompson 54 The Impact of Involving LPNs in Colorectal Cancer Screening

Washington 55 A Standardized Method for Assessing Urgency Among Walk-in
VA Patients.

######## Workshops Thursday, February 25, 1999 3:45pm-5:30pm

Presenter Abstract \# Title

Barnett 56 Determining the Cost of VA Health Care

Hendricks 57 Using VHA Administrative Data to Measure Performance:
Methodological Issues of HEDIS

Rosen 58 Implementing Ambulatory Care Case-Mix Measures in the VA: From
Theory to Practice

**Posters** Thursday, February 25, 1999 5:30pm-8:00pm

Presenter Abstract \# Title

Bauer 59 Are Clinical Practice Guidelines Implemented in Clinical
Practice?

Bauer 60 VA Cooperative Study #430: "Reducing the Efficacy-Effectiveness
Gap in Bipolar Disorder"

Bittner 61 Consistent Satisfaction Measured by American Board of
Internal Medicine Patient Satisfaction Questionnaire Following Initial
Evaluation of inpatients by VA Medical Center Interns.

Bosworth 62 The Effect of Depression on Change in Stroke Patients'
Physical and Mental Health.

Chaney 63 Implementing Depression Screening in Primary Care: An
Effective Strategy?

Chapko 64 Coronary Artery Stent Outcomes in Department of Veterans
Affairs Medical Centers.

Cronkite 65 Symptom-Based Predictors of a Ten-Year Course of Treated
Depression.

Czarnowski 66 Family Satisfaction with VA Hospice Care.

Druss 67 Mental Health Services Delivery in the Department of Veterans
Affairs: Treatment in Psychiatric, Primary Care, and Specialty Medical
Settings.

Dubbert 68 Provider Advice and Walking for Exercise in Elderly Primary
Care, and Specialty Medical Setting.

Evans 69 Evaluating Screening Criteria for Adverse Outcomes in Medical
Patients

Gaehde 70 A Pilot Study: Telecare in the Management of Diabetes.

**Posters** (continued) Thursday, February 25, 1999 5:30pm-8:00pm

Presenter Abstract \# Title

Good 71 Assessing VA's National Formulary Policy by Physician Survey.

Harada 72 Does Military Status Influence Use of VA Ambulatory Care?

Hasenberg 73 How Primary Care Providers Treat Depression: Attitudes,
Skills, Barriers and Personal Experience.

Hechtel 74 The Use of Ambulatory Care Sensitive Hospitalization as a
Qualitative Indicator of Primary Care.

Humphreys 75 Treatment can Enhance the Effectiveness of Substance Abuse
Self-Help Groups.

Jones 76 Do Oral Health-Related Quality of Life Measures Relate to use
of Dental Care?

Kazis 77 Health Outcomes of Veterans using SF-36V: 1998 National Survey
of Ambulatory Care Patients.

Keane 78 Multi-Site Research: Overcoming Hurdles.

King 79 Toward Gender-Aware VA Health Care: Staff Ideology, Sensitivity,
and Knowledge.

Kressin 80 Is Depression Associated with Oral Health-Related Quality of
Life?

Kubal 81 An Overview of the Decision Support System.

Lee 82 Establishing Clinical Equivalence: An Example from a Study of
Self-care Center versus Full-care Hemodialysis.

Lee 83 Evaluating the Effect of Primary Care Clinic Visits on Survival
for Hospitalization.

Lee 84 The Economic Impact of Automated Primary Screening for Cervical
Cancer: Use of a Markov Chain Model.

Lohr 85 Patient-Centered Alternative to Psychiatric Hospitalization.

**Posters** (continued) Thursday, February 25, 1999 5:30pm-8:00pm

Presenter Abstract \# Title

Loveland 86 VA Utilization by Level of Diagnostic Cost Group (DCG)
Predicted Risk.

Maciejewski 87 Mortality and Days of Survival for Medicare Beneficiaries
in the Fee-for-Service and HMO Systems.

Mares 88 Recidivism among Veterans with Schizophrenia Living in Board
and Care: An Outcome Evaluation of the Community Residential Care
Program.

Meier 89 Patterns of Medical Treatment for Congestive Heart Failure
(CHF) in a Veteran Population.

Menke 90 Comparison of Health Care Use and Outcomes for HIV-Infected
Patients in VA versus Non-VA Settings.

Menke 91 Developing Algorithms to Define Episodes of Care.

Mittman 92 Designing Guidelines for Successful Dissemination and
Implementation: The California Guidelines for Alzheimer's Disease
Management.

Penrod 93 Health and Functional Status Differences between Veterans
Admitted to State Veterans Homes Compared to Community Nursing Homes.

Piette 94 Access to Care among Adults with Diabetes in VA and County
Clinics.

Pietz 95 Ambulatory Care Groups and SF-36 Mental and Physical Component
Summary Scores.

Pogach 96 Development of a Case Mix Adjustment Model for Hemoglobin Alo.

Pyne 97 Extending the use of the Self-Administered Quality of Well-Being
Scale to Patients with Depression.

**Posters** (continued) Thursday, February 25, 1999 5:30pm-8:00pm

Presenter Abstract \# Title

Ren 98 The Relationship Between Functional Status and Satisfaction of
Care Among Patients Served by the Veterans Health Administration.

Render 99 VISN 10 Automated ICU Severity Adjustment Tool: SISVISTA

Rosansky 100 Psychogeriatric Interventions Saves Inpatient Costs:
Preliminary Findings.

Souchek 101 One-Year Mortality Rates for all Users of the VA Medical
Care System.

Steele 102 Accelerometer Activity Monitoring in a Sedentary Population:
Methodology, Clinical Utility, Validity

Steinhauser 103 Defining the Attributes of the Quality of Dying:
Perspectives of Patients, Families and Health Care Providers.

VanDeusen Lukas 104 Integrating VA Medical Centers.

Weaver 105 Characteristics and Outcomes of Women Undergoing
Hysterectomies in VA Facilities.

Whooley 106 Depression, Falls, and Risk of Fracture in Older Women.

Wu 107 Comparing Approaches to Predict Decline in Functional Status in
the VA Long-Term Care Population.

Zalenski 108 ACI-TIPI Intervention in the Triage of Urgest Care Patients
with Chest Pain

**Pre-Post-Doctoral Poster Session** Thursday, February 25, 1999
5:30pm-8:00pm

Presenter Abstract \# Title

Bokhour 109 Improving the Quality of Interdisciplinary Team Meetings:
The use of In-Depth Qualitative Research to Understand Team Processes.

Chun 110 Gender Differences in Addiction Severity, Health Status, and
Psychosocial Functioning in Veterans with Substance Use Disorders.

Cotton 111 Seeking Care in the VA: What Differentiates Level of VA use
for Women Veterans?

Curran 112 Depression Post-Alcohol Treatment and Drinking Outcomes;
Implications for Clinical Intervention and Research Design.

Fink 113 Efficacy and Safety of Medical Interventions for Male Erectile
Dysfunction: A Systematic Review.

Gardner 114 The Effect of Electrical Stimulation on Chronic Wound
Healing: A Meta-Analysis.

Kemppainen 115 Predictors of Quality of Life in AIDS Patients.

Licht 116 Variations and Conflicts in Clinical Practice Guideline
Recommendations: Sources and Implications.

Miller 117 A Population-Based Survey of Tuberculosis Symptoms: Insight
into the Utility of Symptom-Based Screening for Active Disease.

Rosen 118 Consistency of Self-Administered ASI Composites with the
Interview ASI.

**Session I:** Friday, February 26, 1999 8:00am-9:30am

####### General Epidemiology

Presenter Abstract \# Title

Branch 119 Rediscovering the Patient's Role in Receiving Health
Promotion Services.

**Session I:** Friday, February 26, 1999 8:00am-9:30am

####### General Epidemiology

Presenter Abstract \# Title

Fink 120 The Accuracy of Physical Examination to Detect Abdominal Aortic
Aneurysm.

MacLean 121 The Risk of Gastrointestinal Complications from Nonsteroidal
Anti-inflammatory Drugs: a Meta-Analysis.

Nachtigall 122 Depression, Self-Care, and Glycemic Control in Patients
with Diabetes Mellitus.

Provenzale 123 Colorectal Cancer: Risk Factors for Advanced Disease --
Comparison of Stage at Diagnosis with SEER Cancer Statistics.

Reiber 124 Epidemiology Education Preferences of VA Administrators,
Clinicians and Researchers.

**Session J:** Friday, February 26, 1999 8:00am-9:30am

####### Quality

Presenter Abstract \# Title

Murdoch 125 Impact of a Low-cost Intervention on the Cholesterol
Awareness of Older Veterans Enrolled in an Ambulatory Care Clinic.

Luck 126 Measuring the Validity of Chart Abstraction: Should we use it
as a Quality Improvement Tool?

McDonell 127 Validation of a Computerized Adaptation of the Charlson
Index using the SF-36 Among VA Outpatients.

Niakan 128 Appropriateness of Quinidine use at a Veterans Affairs
Medical Center.

Sales 129 Testing the Performance of VHA's 1997 Ambulatory Care Survey
Instrument

Young 130 Patient-Level and Facility-Level Factors Affecting Patient
Satisfaction Ratings of VA Care.

**Session K:** Friday, February 26, 1999 8:00am-9:30am

####### Health Services Research/Cost

Presenter Abstract \# Title

Chang 131 Comparing Facilities on Functional Status Decline: A
Hierarchical Bayes Linear Modeling Approach.

Hughes 132 Cost Effectiveness of Team Managed Home Based Primary Care.

Hynes 133 Cost Effectiveness of a Primary Care Intervention: Results
from a VA Cooperative Study.

Meier 134 Cost Savings Associated with Limited Academic Detailing to
Promote Hypertension (HTN) Clinical Practice Guidelines.

Phillips 135 The Impact of Per-Episode Payment for Medicare Home Health
Care on the Use of Non-Medicare Services: A Randomized Control Trial.

Saint 136 Cost-effectiveness of Antiseptic-impregnated Central Venous
Catheters in the Critically Ill.

**Session L:** Friday, February 26, 1999 8:00am-9:30am

####### Mental Health

Presenter Abstract \# Title

Covinsky 137 Depressive Symptoms and Three-Year Mortality in
Hospitalized Elders.

Lenert 138 Conflicts in Values for Health Outcomes in Schizophrenia.

Linn 139 Evaluating the Effectiveness of Telemedicine for Enhancing
Compliance in the Treatment of Schizophrenia.

Mansell 140 Validity of a Alcohol Severity Measure in Ambulatory
Patients with Alcohol Disorders.

Owen 141 Guideline-Concordant Antipsychotic Dose and Outcomes of Routine
Care for Schizophrenia.

**Session L:** (continued) Friday, February 26, 1999 8:00am-9:30am

####### Mental Health

Presenter Abstract \# Title

Murdoch 142 Gender Differences in VA Disability Benefits for PTSD after
Controlling for Combat Exposure.

**Workshops** Friday, February 26, 1999 8:00am-9:30am

Presenter Abstract \# Title

Captain 143 Using Focus Group Methodology in the VA System.

Lee 144 Evaluating Health Care Organizational Change: Benefits and
Limitations of Hierarchical and Structural Equation Modeling.

Pugh 145 VA National Guidelines, Strategies for Implementation, Local
Modifications, and Ways to Quantitatively Assess Guideline Impact.

Complete Listing of Abstracts Submitted

Listed Alphabetically by Title

This listing includes all of the submitted abstracts that were rated as
acceptable methodologically. Many of these submitted abstracts would
have made excellent presentations had meeting time and space permitted.
Abstracts NOT presented at the meeting are indicated with an asterisk.

**[Abstract Title]{.underline} [Abstract \#]{.underline}**

A Comparison of VA to Public Sector Mental Health Patients: the
Connecticut 6

Outcomes Study

A Disease-Targeted Measure of Health-Related Quality of Life (HRQOL) for
Patients 30

with Chronic Liver Disease: The LDQOL 1.0

A Markov Model of Severity of Illness States and Hospital Mortality 17

A Pilot Study: Telecare in the Management of Diabetes 70

A Population-based Survey of Tuberculosis Symptoms: Insight into the
Utility of 117

Symptom-based Screening for Active Disease

A Standardized Method for Assessing Urgency Among Walk-in VA Patients 55

\*Accelerometer Activity Monitoring in a Sedentary Population:
Methodology, Clinical 102

Utility, Validity

Access to Care Among Adults with Diabetes in VA and County Clinics 94

Accuracy of Computer Identified Diagnoses in a VA General Medicine
Clinic 19

ACI-TIPI Intervention in the Triage of Urgest Care Patients with Chest
Pain 108

African American Veterans with Coronary Artery Disease Report Worse
Health and Less 39

Satisfaction with Care than Whites: Results Form the ACQUIP Survey

Ambulatory Care Groups and SF-36 Mental and Physical Component Summary
Scores 95

\*Ambulatory Care Sensitive Hospitalizations for Veterans in Rural
Nebraska 146

An Overview of the Decision Support System 81

Antimicrobial Prophylaxis for Urinary Tract Infection in Persons with
Spinal Cord 41

Dysfunction

Appropriateness of Quinidine use at a Veterans Affairs Medical Center
128

Are Clinical Practice Guidelines Implemented in Clinical Practice? 59

\*Are U.S. Veterans Still the Forerunners of Retirement Migration 147

Are we Improving the Quality of Nursing Home Care: the Case of Pressure
Ulcers 1

Assessing VA's National Formulary Policy by Physician Survey 71

\*Barriers to Adherence to Highly Active Antiretroviral Therapy as
Expressed by 148

People Living with HIV/AIDS

Barriers to Walking for Exercise in Elderly Primary Care Patients 35

\*Cancer Related Fatigue: Traversing the Edge 149

Characteristics and Outcomes of Women Undergoing Hysterectomies in VA
Facilities 105

Colorectal Cancer: Risk Factors for Advanced Disease Comparison of Stage
at 123

Diagnosis with SEER Cancer Statistics

Comparing Approaches to Predict Decline in Functional Status in the VA
Long-Term 107

Care Population

Comparing Facilities on Functional Status Decline: A Hierarchical Bayes
Linear 131

Modeling Approach

Comparing Quality of Mental Health Care in Public Sector and Privately
Insured 7

Populations: First Efforts and Methodological Challenges

Comparing Reimbursement Models for VA Mental Health Services 8

**Abstract \#**

Comparison of Health Care Use and Outcomes for HIV-Infected Patients in
VA versus 90

Non-VA Settings

Conflicts in Values for Health Outcomes in Schizophrenia 138

Consistency of Self-Administered ASI Composites with the Interview ASI
118

Consistent Satisfaction Measured by American Board of Internal Medicine
Patient 61

Satisfaction Questionnaire Following Initial Evaluation of Inpatients by
VA

Medical Center Interns

Continuity of Care as a Determinant of Patient Satisfaction. Results
from the ACQUIP Study 28

Coronary Artery Stent Outcomes in Department of Veterans Affairs Medical
Centers 64

Corticosteroid Utilization and Outcomes in HIV Associated Pneumocystis
Carinii 10

Pneumonia: Three-fold Higher Mortality among Severely Ill Pateints when

Corticosteriods Given by CEC Guidelines

Cost Effectiveness of a Primary Care Intervention: Results from a VA
Cooperative Study 133\
Cost Effectiveness of Team Managed Home Based Primary Care 132

Cost-effectiveness of Antiseptic-impregnated Central Venous Catheters in
the Critically Ill 136

Cost-effectiveness of the Primary Care Provider Program at the West Los
Angeles VAMC 53

Cost Savings Associated with Limited Academic Detailing to Promote
Hypertension 134

(HTN) Clinical Practice Guidelines

\*Creating an Operational Definition of Degree of Clinical Integration
150

\*Current Smoking Among Veterans and Nonveterans Age 70 and Older:
Results from 151

the Survey of Asset and Health Dynamics Among the Oldest-Old (AHEAD)

\*Decision Support and Quality Assessment of Chronic Hypertension Care
Based on 152

a Computerized System for Implementing Clinical Practice Guidelines

Defining the Attributes of the Quality of Dying: Perspectives of
Patients, Families 103

and Health Care Providers

Depression, Falls, and Risk of Fracture in Older Women 106

Depression, Self-Care and Glycemic Control in Patients with Diabetes
Mellitus 122

Depression Post-Alcohol Treatment and Drinking Outcomes: Implications
for Clinical 112

Intervention and Research Design

Depressive Symptoms and Three-Year Mortality in Hospitalized Elders 137

Designing Guidelines for Successful Dissemination and Implementation:
The California 92

Determinants of House Staff Time Use in the Inpatient Setting 51

Determining the Cost of VA Health Care 56

Developing Algorithms to Define Episodes of Care 91

Development of a Case Mix Adjustment Model for Hemoglobin Alo 96

\*Development of a Longitudinal Database for Monitoring Quality of Care
Provided to 153

Patients with Spinal Cord Dysfunction Receiving Long Team Care Under

VHA Auspices

\*Diabetes Quality Improvement Project Initial Measure Set: can we
Measure the 154

Measures?

Do Oral Health-Related Quality of Life Measures Relate to use of Dental
Care? 76

Do Patients with Mental Disorders "Unnecessarily" Use more Medical
Services? Policy 5

Implications for Mental Health Capitation

\*Do Women VA Patients with a History of Military-Related Sexual Assault
155

Participate in Cancer Screening?

Does Military Status Influence Use of VA Ambulatory Care? 72

Effect of Facility-Level Characteristics on Primary Care Enrollment and
Bed-days of Care 50

Effectiveness of VA Primary Care Firm Systems: Preliminary Findings 4

> **Abstract \#**

Effects of Race, Income, and Psychological Well-being on HIV Patient
Decisions 52

about Emergency Department (ED) Use

Efficacy and Safety of Medical Interventions for Male Erectile
Dysfunction: a 113

Systematic Review

Epidemiology Education Preferences of VA Administrators, Clinicians and
Researchers 124

Establishing Clinical Equivalence: An Example from a Study of Self-care
Center versus 82

Full-care Hemodialysis

Evaluating Health Care Organizational Change: Benefits and Limitations
of 144

Hierarchical and Structural Equation Modeling

Evaluating Screening Criteria for Adverse Outcomes in Medical Patients
69

Evaluating the Effect of Primary Care Clinic Visits on Survival for
Hospitalization 83

Evaluating the Effectiveness of Telemedicine for Enhancing Compliance in
the Treatment 139

of Schizophrenia

Extending the use of the Self-Administered Quality of Well-Being Scale
to Patients 97

with Depression

\*Factors Predicting Completion of DCHV Program 156

Family Satisfaction with VA Hospice Care 66

Gender Differences in Addiction Severity, Health Status, and
Psychosocial Functioning 110

in Veterans with Substance Use Disorders

Gender Differences in VA Disability Benefits for PTSD after Controlling
for 142

Combat Exposure

Guideline-Concordant Antipsychotic Dose and Outcomes of Routine Care for
Schizophrenia 141

Health and Functional Status Differences Between Veterans Admitted to
State Veterans 93

Homes Compared to Community Nursing Homes

Health Outcomes of Veterans using SF-36V: 1998 National Survey of
Ambulatory 77

Care Patients

Hepatitis C Virus Infection and Addiction Disorders in Department of
Veterans Affairs 14

Facilities Nationwide

\*HIV Risk Behavior and Patterns of HIV Testing among a Probability
Sample of 157

Homeless Women

Hospital Profiles of Mortality from Cardiac Bypass Surgery: Effect of
Definition of 18

Outcome Based on Administrative versus Clinical Data

How Primary Care Providers Treat Depression: Attitudes, Skills, Barriers
and 73

Personal Experience

HSR&D Development Center Workshop 25

\*Identifying Informal Caregivers of Elderly Veterans with Dementia
using Multiple 158

VA Databases: Process, Results and Implications

\*Identifying the "Active Ingredients" of Substance Abuse Treatment:
using Structural 159

Equation Modeling to Test Mediation Hypotheses

Impact of a Low-cost Intervention on the Cholesterol Awareness of Older
Veterans 125

Enrolled in an Ambulatory Care Clinic

\*Impact of Post-operative Complications on Hospital Patient Care Costs
for Coronary 160

Artery Bypass Surgery

Impact of Primary Care Satellite Clinics on Access to General Health
Care Services 9

and Mental Health Services

\*Implementation and Evaluation of Telemedicine to Improve Health Care
161

\*Implementation of a Telehealth Nurse Consultation Wound Clinic 162

\*Implementation of Primary Care Principles in VISN 20 163

Implementing Ambulatory Care Case-Mix Measures in the VA: From Theory to
Practice 58

Implementing Depression Screening in Primary Care: An Effective
Strategy? 63

Abstract \#

Improving the Quality of Interdisciplinary Team Meetings: The use of
In-Depth 109

Qualitative Research to Understand Team Processes

\*Integrating Primary Care into Mental Health Services: an Assessment of
Feasibility 164

and Barriers to Implementation

Integrating VA Medical Centers 104

Internet-Based Education for Epidemiology 26

Is Depression Associated with Oral Health-Related Quality of Life? 80

\*Lung Volume Reduction Surgery for Emphysema: Initial Results from the
Veterans 165

Affairs Puget Sound Health Care System -- Seattle

Management of Hepatitis C at the VA Puget Sound Health Care System 13

Measuring Patient Expectations: Does the Measurement Instrument Affect
the Number 34

of Expectations Elicited and Patient Satisfaction?

\*Measuring Self-Efficacy for an HIV Disease Management Intervention 166

Measuring the Job Satisfaction of Providers in VA Primary Care: the
Seattle Provider 31

Satisfaction Questionnaire (SPSQ)

Measuring the Validity of Chart Abstraction: Should we use it as a
Quality 126

Improvement Tool?

Men's Beliefs about the Benefits of and Professional Recommendations for
PSA Screening 23

Mental Health Services Delivery in the Department of Veterans Affairs:
Treatment in 67

Psychiatric, Primary Care, and Specialty Medical Settings

\*Methodological Issues in Meta-Synthesis of Qualitative Research 167

\*Michigan Diabetes Outreach Networks (MDONs): a Public Health Approach
to 168

Improve Diabetes Care and Outcomes

\*Modification of Self-Monitoring of Blood Glucose (SMBG) Testing
Frequency in 169

Stable Type II Diabetics on Oral Agents or Diet Therapy

Mortality after Cardiac Bypass Surgery: Prediction from Administrative
versus Clinical Data 15

Mortality and Days of Survival for Medicare Beneficiaries in the
Fee-for-Service and 87

HMO Systems

Multidisciplinary Rehabilitation Versus Medical Care Use of
Meta-Analysis to Determine 37

the Clinical Effectiveness of Physical Medicine

Multi-Site Research: Overcoming Hurdles 78

\*National Patient Care Database: Uses for Outcomes Research 170

\*Non-equivalent Control Group Study using Soap and Towel Consumption
Measurements 171

to Detect a Transient Increase in Handwashing Associated with Simple
Feedback

in an Adult Intensive Care Unit

One-year Mortality Rates for all Users of the VA Medical Care System 101

Patient Characteristics and Patterns of use of Lumbar Spine Radiographs:
Results from 32

the Veterans Health Study

\*Patient Factors Associated with Poor Quality Medication Management for
Schizophrenia 172

\*Patient Preferences for Recovery of Activities after Hip Fracture 173

Patient Preferences in PSA Screening: The Impact of Shared
Decision-making Videos 3

\*Patient Satisfaction Among Veterans varies by Disease Condition but
not by Symptom 29

Burden. Results from the ACQUIP Study

\*Patient Satisfaction, Quality of Life, and Reasons for Seeking Care in
Veterans Affairs 174

Medical Centers among Lower Socioeconomic Status Men with Prostate
Cancer

Patient-Centered Alternative to Psychiatric Hospitalization 85

Patient-Level and Facility-Level Factors Affecting Patient Satisfaction
Ratings of VA Care 130

Patterns of Medical Treatment for Congestive Heart Failure (CHF) in a
Veteran Population 89

\*Pilot Study of the Effectiveness of Telepsychiatry Treatment in the
Upper Mid-west 175

> Abstract \#

Positive Effects of a Workbook-centered Advance Care Planning
Intervention 33

Predictors of Outcomes in Patients with Type 2 Diabetes Mellitus 42

Predictors of Quality of Life in AIDS Patients 115

Prevalence of Lower Urinary Tract Symptoms and Associated Resource
Utilization among 21

VA Primary Care Patients

Preventing Urinary Tract Infection using Urinary Catheters Coated with
Silver Alloy: 24

a Cost-Effectiveness Analysis

\*Primary Care Delivery in VHA Satellite Outpatient Clinics (1993-96)
176

\*Private and Public Sectors Purchase of Behavioral Healthcare Benefits:
a 177

Comparison of Quality Based Behavioral Healthcare Purchases in the

VA and in the Private Sector

Prostate Cancer Quality of Life and Outcomes Research among Patients
with Low 20

Socioeconomic Status: An Overview of the VA Cancer of the Prostate
Outcomes

Study (VA CaPOS )

Provider Advice and Walking for Exercise in Elderly Primary Care, and
Speciality 68

Medical Setting

Psychogeriatric Interventions Saves Inpatient Costs: Preliminary
Findings 100

Racial Variation in Congestive Heart Failure Mortality among the Elderly
38

Racial Variation in Mortality Following Elective Surgery for Vascular
Disease 40

Recidivism among Veterans with Schizophrenia Living in Board and Care:
an Outcome 88

Evaluation of the Community Residential Care Program

Rediscovering the Patient's Role in Receiving Health Promotion Services
119

\*Reducing Inpatient Length of Stay in the PRIME Multidisciplinary
Education Program 178

\*Rehabilitation Issues of Concern to Women with Spinal Cord Injuries
179

Relative Effectiveness of Androgen Suppressive Therapies for Advanced
Prostate Cancer 22

Reliability and Accuracy of Dermatologists' Digital Image Consultations
46

Seeking Care in the VA: What Differentiates Level of VA use for Women
Veterans? 111

\*Sharing Lessons Learned: Improving Healthcare Cost, Quality and
Outcomes 180

\*Simulation Modeling of Access to the ICU 181

Symptom-Based Predictors of a Ten-Year Course of Treated Depression 65

Tailoring Smoking Cessation Treatments Based on Nicotine Dependence
Level and 44

Depression Status of Patients

Testing the Performance of VHA's 1997 Ambulatory Care Survey Instrument
129

The Accuracy of Physical Examination to Detect Abdominal Aortic Aneurysm
120

\*The Care Guide (Care Aided and Refined wit GUIDElines) Program. A
Guideline- 182

based Conceptual Model for Continuous Quality Improvement in the

21^st^ Century

The Economic Impact of Automated Primary Screening for Cervical Cancer:
Use of 84

a Markov Chain Model

The Effect of Depression on Change in Stroke Patients' Physical and
Mental Health 62

The Effect of Electrical Stimulation on Chronic Wound Healing: A
Meta-analysis 114

The Effectiveness of Bupropion vs. Bupropion Plus Nicotine Patch in a
Smoking 45

Cessation Clinic

The Houston Approach to Optimal Risk-Adjustment Using Administrative
Data 16

The Impact of Involving LPNs in Colorectal Cancer Screening 54

The Impact of Per-Episode Payment for Medicare Home Health Care on the
Use of 135

Non-Medicare Services: A Randomized Control Trial

The Prevalence of Hepatitis C in a Sample of Severely Mentally Ill
Veterans 12

> Abstract \#

\*The Prevalence of Veterans Meeting Selection Criteria for Lung Volume
Reduction 183

Surgery

\*The Psychodynamics of Traumatic Memories 184

The Relationship Between Functional Status and Satisfaction of Care
Among 98

Patients Served by the Veterans Health Administration

The Risk of Gastrointestinal Complications from Nonsteroidal
Anti-inflammatory 121

Drugs: a Meta-Analysis

\*The Simulation of Medical Work using Information-Processing Theory:
185

Anticipating Outcomes by Understanding the Process of Medical Care

The Use of Ambulatory Care Sensitive Hospitalization as a Qualitative
Indicator 74

of Primary Care

\*The Use of Risk-Adjusted Mortality Rates to Monitor Performance in the
Department 186

of Veterans Affairs

Toward Gender-Aware VA Health Care: Staff Ideology, Sensitivity, and
Knowledge 79

Treatment can Enhance the Effectiveness of Substance Abuse Self-help
Groups 75

\*Trends in Primary Care and Subspecialty Residents in Network 7
Compared to VHA 187

Use of Centralized VA Data Registry to Assess Quality of HIV Care 11

\*Use of Geographic Information Systems to Assess the Effect of Travel
Distance on 188

Utilization of Specialized SCI Services

Use of VA Services by Medicare HMO Enrollees 47

\*Using Clinical Vignettes to Compare Quality in Disparate Health Care
Systems 189

Using Focus Group Methodology in the VA System 143

Using National VA Data in Health Services and Epidemiologic Research 27

\*Using Patients' Perspectives to Develop an Intervention to Improve
Outpatient-Clinician 190

Communication

Using VHA Administrative Data to Measure Performance: Methodological
Issues of HEIDS 57

VA Cooperative Study #430: "Reducing the Efficacy-Effectiveness Gap in
Bipolar Disorder" 60

VA National Guidelines, Strategies for Implementation, Local
Modifications, and Ways to 145

Quantitatively Assess Guideline Impact

\*VA Participation in a Statewide Nursing Quality Indicator Database
Project 191

VA Utilization by Level of Diagnostic Cost Group (DCG) Predicted Risk 86

Validating Ascertainment of Mortality using Multiple Administrative Data
Sources 48

Validation of a Computerized Adaptation of the Charlson Index using the
SF-36 Among 127

VA Outpatients

Validity of a Alcohol Severity Measure in Ambulatory Patients with
Alcohol Disorders 140

Validity of Physical Activity Recall in Urban and Rural Elderly Men 36

\*Variation in Discharge Destination of VA Ischemic Stroke Patients 192

Variations and Conflicts in Clinical Practice Guideline Recommendations:
Sources and 116

Implications

Variations in Condition-Specific Health Status Among VA General Internal
2

Medicine Clinics

Variations in Institutional Review Board (IRB) Approvals for Allowing
Third Party 43

Medical Record Reviews of HIV-infected Individuals without Patient
Consent.

The Multicity PCP Quality of Care Study

Veterans' Preferences for Transfer of Primary Care to Community Based
Outpatient 49

Clinics (CBOC): Association with Health Status, Satisfaction with VA
Care, and

Prior Use of VA Care

VISN 10 Automated ICU Severity Adjustment Tool: SISVISTA 99

\*Women Undergoing Mastectomies in VA Facilities: Characteristics and
Outcomes 193

Submitted Abstracts

# 1. Are We Improving the Quality of Nursing Home Care: The Case of Pressure Ulcers?

## DR Berlowitz, MD, MPH. HSR&D Field Program CHQOER, Bedford, MA. HQ, Bezerra, GH Brandeis, JJ Anderson

**Objectives:** Despite recent initiatives to improve nursing home care,
widespread concerns regarding nursing home quality persist and it is
unknown whether care is improving. Large databases describing nursing
home residents are now becoming available. We use two such databases to
determine whether risk-adjusted rates of pressure ulcer development have
changed over time in two large, national providers of nursing home care,
the VA and a private, for profit chain.

**Methods:** We used the Patient Assessment File (PAF) to study VA
nursing homes from 1990 through 1997, and the Minimum Data Set (MDS) to
study the private nursing home chain from 1991 to 1995. Information from
after 1995 was unavailable due to the switch to version 2 of the MDS.
Rates of pressure ulcer development were calculated for successive
six-month periods by determining the proportion of initially ulcer-free
residents having a stage 2 or larger pressure ulcer on subsequent
assessments. Rates were risk-adjusted for patient characteristics using
previously developed models specific to each setting. The proportion of
new ulcers that were deep (stages 3 or 4) were also calculated for each
period.

**Results:** We examined risk-adjusted rates of pressure ulcer
development based on 274,919 observations of VA nursing home residents,
and 144,379 observations of residents from the private chain. Between
1990 and 1995, rates of pressure ulcer development declined by over 25%
in both systems (p\<0.05). Additionally, the proportion of new ulcers
that were deep declined in the private chain from 30% to 22% (p\<0.01).
Beginning in 1996, though, VA risk-adjusted rates of ulcer development
increased to levels similar to those in 1990. The proportion of new
ulcers that were deep also increased from 40% before 1996, to 45%
afterwards (p=0.01).

**Conclusions:** Significant improvements have occurred in the quality
of nursing home care between 1990 and 1995. Further studies are required
to understand why these improvements were not sustained in the VA.

**Impact:** These results demonstrate how large databases may be used to
monitor the quality of nursing home care over time. Despite concerns
over nursing home quality, our results are reassuring in that
improvements have occurred. However, pressure ulcer preventive care in
the VA should be reexamined.

**HSR&D Funded:** IIR 95-031

2\. Variations in Condition-Specific Health Status Among VA General
Internal Medicine Clinics

[Stephan Fihn, MD, MPH, and Mary McDonell, MS]{.underline}. Northwest
Center for Outcomes Research in Older Adults, Seattle, WA.

**Objectives:** Recent efforts to improve quality of care and
productivity have involved measurements of patients' general health
status to adjust for case-mix and assess outcomes. Measures of health
status, such as the SF-36, however, may be too general to identify
important differences in health and function among patients with
specific medical conditions. We compared variability in general and
condition-specific measures of health status among patients from a
geographically diverse sample of VA primary care clinics.

**Methods:** As part of the Ambulatory Care Quality Improvement Project,
we surveyed 38,642 active, eligible patients in 7 VA General Internal
Medicine Clinics. Baseline data collected on respondents included an
inventory of active medical conditions, including a depression screen
(MHI5), and a demographic survey. Respondents were then mailed the SF-36
and condition-specific health status measures for any of six target
conditions reported. Measures included the Seattle Angina Questionnaire
(SAQ) and the Seattle Obstructive Lung Disease Questionnaire (SOLQ).
Patients with a positive MHI-5 were mailed the SCL-20, a measure of
depression.

**Results:** Sixty-six percent of patients responded to the baseline
inventory. The mean age was 64 years, and 96% were male. Of the 24,287
patients who were mailed follow-up SF-36 and condition-specific surveys,
15,007 (62%) responded. Statistically and clinically significant
differences among sites were observed on all SF-36 scales including
Physical Function (range 38.9 to 58.6), General Health (36.1 to 54.4),
Vitality (33.8 to 50.5); Bodily Pain (44.7 to 61.3). Significant but
smaller variation was observed on scales of social and mental health.
The relative differences among sites were consistent across scales and
approximated a full standard deviation comparing the highest and lowest
sites. Of 9004 patients who reported angina on the initial
questionnaire, 5697 (63%) returned the SAQ. Highly significant
differences among sites were also observed for scores on all SAQ scales
including Anginal Frequency (69.4 to 80.5), Anginal Stability (50.6 to
64.4) and Physical Function (43.5 to 55.6). Of 5553 patients who
reported COPD, 3302 (59%) returned the SOLQ. Again, highly significant
differences among sites were present for all scales including Coping
(59.8 to 70.7), Emotional function (51.1 to 65.5) and Physical Function
(51.8 to 61.6).

**Conclusions:** Although potentially limited by response bias, these
results suggest there are clinically important differences among primary
care patients in different geographic locations with regard to both
general and condition-specific health status for chronic stable angina
and COPD.

**Impact:** Differences in health status among primary care patients in
different locations must be taken into account when comparing outcomes
and quality of care. These results indicate that substantially more
research is required to understand and address these differences.

**HSR&D Funded:** SDR 96-002

**3. Patient Preferences in PSA Screening: The Impact of Shared
Decision-Making Videos**

## EG Wilkins, MD, JC Lowery, MHSA, PhD, and JB Hamill, MPH. VA Center for Practice Management and Outcomes Research, Ann Arbor, MI.

**Objectives:** VHA has recognized the need for a more patient-oriented
approach to the delivery of healthcare, including sharing responsibility
for medical decisions between providers and patients. Previous research
has shown that shared decision-making (SDM) may result in a variety of
benefits, including improvements in patient satisfaction and clinical
outcomes. SDM programs have involved the use of educational materials,
primarily videotapes, to encourage patients to actively participate in
their healthcare. Although initial assessments of these approaches have
been encouraging, randomized clinical trials (RCTs) are lacking for most
SDM interventions. Our study used an RCT design to assess the impact of
a standardized video program for patients considering Prostate Specific
Antigen (PSA) screening.

**Methods:** Male patients eligible for PSA testing were recruited from
five VA outpatient clinics and randomized to either SDM video or
non-video groups. Prior to meeting with their primary care provider,
those in the SDM group viewed a PSA video from the Foundation for Shared
Medical Decision-Making. The control group received information
(verbally and in writing) traditionally used by the participating
centers for PSA test candidates. Following the provider meeting,
patients in both groups were administered written questionnaires
ascertaining their decisions to undergo or decline PSA testing.
Consisting largely of previously validated instruments, the surveys also
evaluated patients\' overall satisfaction with care; knowledge about PSA
testing; decision-making and information-seeking preferences; and
decisional conflict. Comparisons of categorical variables between the
two groups were performed using chi-square analysis, while continuous
variables were analyzed using t-tests.

**Results:** A total of 91 patients were randomized to either SDM (n=43)
or control (n=48) groups. While no significant differences between the
two groups were noted in age, race, or marital status, the control group
reported a significantly higher educational level than the SDM group
(p=0.04). Fewer SDM patients chose to undergo testing (59.5%) compared
with controls (80.4%) (p=0.099). SDM patients were more satisfied with
both the information received (p=0.08) and their levels of input into
the testing decision (p=0.07). Furthermore, the SDM group demonstrated
significantly greater knowledge about PSA testing compared to the
control patients (p=0.0001). Both groups expressed a strong desire for
information; but SDM patients expressed significantly greater
preferences for active participation in the PSA decision (p=0.0075).
Finally, in spite of assuming larger roles in medical decision-making,
SDM patients did not report significantly higher levels of anxiety or
uncertainty surrounding their decisions.

**Conclusions:** VA patients want information to help them make
decisions about their healthcare. Implementation of a video-based SDM
protocol for patients considering PSA screening appears to result in
significantly greater knowledge and preferences for active
decision-making roles. These findings contradict reports by Ende and
others (1989) who found that older, less educated patients prefer less
information and participatory roles.

**Impact:** Our findings have important implications for designing and
implementing patient-centered care in VHA. Patients want and need
information to help them make decisions about their healthcare. SDM
videos offer a means of conveying the results of outcomes research in a
way that patients can understand and use to make decisions consistent
with their preferences and values.

# 4. Effectiveness of VA Primary Care Firm Systems: Preliminary Findings

[Elizabeth Yano, PhD, Mingming Wang, MPH, Lisa Rubenstein, MD,
MSPH.]{.underline} Center for the Study of Healthcare Provider Behavior,
Sepulveda, CA.

**Objectives:** As a healthcare delivery model, firm systems have been
associated with improved prevention, continuity and coordination. By
1996, many VA facilities had launched firm \"like\" primary care
delivery models, with little information about the relative
effectiveness of the variations being used. We assessed the relative
performance of VA firm systems in contrast with non-firms in terms of
preventive and chronic disease care and patients\' satisfaction with
continuity and coordination.

**Methods:** In 1996, a national VA expert panel operationally defined a
VA firm system through a modified Delphi process that examined the
relative importance and contribution to the suggested effects of firms
of each of 30 proposed features. Survey items based on these features
were incorporated into a 50-item organizational survey, pilot tested and
fielded in June 1996 among all VAMCs nationwide. A VAMC was classified
as having a firm system if they had 1+ interdisciplinary primary care
teams with patients indefinitely assigned to a primary care provider who
was responsible for care from clinic-to-ward. We used these survey
results (100% response rate) to evaluate the performance associated with
VA firm systems using baseline chart-based data from the VHA External
Peer Review Program and 1996 VHA National Customer Feedback Center
patient satisfaction data. We compared performance associated with firms
vs. non-firms and among alternate firm system specifications using the
Kruskal-Wallis test.

**Results:** Overall, 35 (21.9%) VAMCs had firm systems. Compared to
non-firms, VA firms served fewer patients (p\<.05), but achieved higher
proportions of patients who reported having a primary care provider
(76.4% vs. 71.3%, p\<.05). Preventive practices were higher in firms vs.
non-firms (Prevention Index .79 vs. .74, p\<.05), with specific benefits
in alcohol counseling and colon-cancer screening (p\<.05). The Chronic
Disease Index scores were also higher among firms (.87 vs. .82, p\<.05),
with higher performance of sensation exams and foot pulse checks among
diabetics, and exercise counseling among hypertensives and obese
patients (each p\<.05). On average, patients reported slightly fewer
problems with continuity (.24+/-.12 vs. .28+/-.10, p=.08). VA firms were
more likely to have specialty referral and notification policies
(p\<.01). The subset of firms with randomized patients and providers and
the larger set of firms without inpatient-outpatient continuity had few
performance benefits in contrast.

**Conclusions:** VA healthcare facilities adopting firm systems as their
primary care delivery model have higher proportions of patients who
report having a primary care provider, provide more preventive care, and
higher quality of care for selected chronic conditions. Patients were
only marginally more satisfied with their continuity of care. More
research is needed to understand the key ingredients of effective
delivery models to support the continued growth and development of VA
primary care delivery systems, including the adoption of managed care
practices, especially as they relate to interdisciplinary teams of
providers.

**Impact:** This work will support the planning and design of VA primary
care delivery systems that are associated with higher facility
performance.

**HSR&D Funded:** MPC 97-012

**5. Do Patients with Mental Disorders \"Unnecessarily\" Use More
Medical Services? Policy Implications for Mental Health Capitation**

[CS Hankin, PhD, A Spiro III,PhD, and D Miller.]{.underline} Bedford VA
Medical Center, Bedford, MA. [D Mansell,MD, MPH.]{.underline} Assistant
Professor, Birmingham, AL [LE Kazis, ScD]{.underline}, Bedford VA
Medical Center, Bedford, MA.

**Objectives:** It is commonly believed that patients with mental
disorders \"unnecessarily\" use high rates of medical services; the
objective of the present study was to explore this assumption. We
examined patterns of medical services use among VA ambulatory care
patients who screened positive for depressive, alcohol-related, or
posttraumatic stress (PTSD) disorders. We hypothesized that even with
adjustment for age and medical disease comorbidity, patients who
screened positive for targeted mental disorders would have higher rates
of medical services use that those who did not screen positive.

**Methods:** Baseline data were obtained from the Veterans Health Study,
a longitudinal investigation of the health of 2,425 Boston-area, male VA
ambulatory care patients. Screening measures were CES-D for depression,
CAGE for alcohol-related disorder, and PCL-C for PTSD. Prior medical
services use (number of inpatient stays in the prior 12 months, and
emergency room visits, outpatient visits, or telephone contact with
medical personnel in the prior 3 months) was assessed by self-report.
The Disease Burden Index (DBI; Kazis et. al., 1998) was used to adjust
for medical comorbidity. We compared unadjusted means between groups
using t-tests. We then used general linear modeling to compare means,
adjusting for age and DBI.

**Results:** In unadjusted analyses, patients screening positive for
depression reported significantly more inpatient stays (1.86 vs. 1.53),
outpatient visits (4.80 vs. 3.15), and telephone contacts (2.53 vs.
1.83); following adjustment for age and medical comorbidity, only the
significant difference in number of inpatient stays (1.78 vs. 1.58)
remained. Prior to adjustment, patients screening positive for
alcohol-related disorder reported significantly more inpatient stays
(2.16 vs. 1.57), fewer emergency room visits (1.20 vs. 2.12), outpatient
visits (3.36 vs. 3.78), and telephone contacts (2.05 vs. 2.15); however,
with adjustment, differences in number of inpatient stays (2.02 vs.
1.58) and outpatient visits (2.56 vs. 3.85) remained significant, but
differences in number of emergency room visits and telephone contacts no
longer met statistical significance. Prior to adjustment, patients
screening positive for PTSD reported significantly more inpatient stays
(1.82 vs. 1.59), emergency room visits (2.47 vs. 1.66), outpatient
visits (4.76 vs. 3.46), and telephone contact (2.88 vs.1.88); following
adjustment, differences in medical services use were no longer
significant.

**Conclusions:** Although unadjusted analyses of medical services use
revealed clear effects of the screening presence of mental disorders on
most outcomes, after adjusting for age and medical comorbidity, many of
these effects no longer met statistical significance.

**Impact:** Our findings have particular relevance for private sector
managed care organizations, where restrictions on mental health benefits
(\"capitation\") serve to reduce adverse selection of patient with
mental disorders who are assumed to be poor risk because they
\"unnecessarily\" use high rates of medical services. Our findings do
not support the notion of such a discrete or direct relationship between
mental disorders and medical services use. Results suggest that
capitation strategies which are based upon the presumed relationship
between mental disorders and medical services use should reconsider the
important contributions of age, comorbid medical disorders, and specific
mental disorder diagnoses.

**HSR&D Funded:** SDR 91-006

**6. A Comparison of VA to Public Sector Mental Health Patients: the
Connecticut Outcomes Study**

[Rani Hoff, PhD, Robert Rosenheck, MD, M Sernyak, J Steiner, S
Atkins]{.underline}. VA Connecticut Healthcare System, West Haven, CT.

**Objectives:** This paper presents results from a study comparing
mental health service delivery to seriously mentally ill patients at
three institutions: a VA hospital and two local community mental health
centers operated by the State Mental Health Agency (SMHA). The objective
was to compare mental health care delivered in VA to those services
delivered to a socio-demographically similar population in community
mental health centers.

**Methods:** A random sample of 600 patients with serious mental illness
were taken from the three institutions (200 at each) and interviewed
about their clinical status, service use, satisfaction with services,
and needs and barriers to care.

**Results:** VA patients were older, less likely to be non-white, had
higher incomes both from entitlements and other sources, had fewer
problems with housing, and were more satisfied with their housing. They
also received significantly more medical care, particularly outpatient
medical care, than did SMHA patients, even after controlling for age and
medical conditions. There were no differences in the severity of mental
health symptoms or use of inpatient mental health care across the three
sites. However, VA was less community oriented in its outpatient mental
health care: VA patients were less likely to have received case
management and rehabilitation services, were more likely to be receiving
individual therapy and medication management from a psychiatrist, and
were less likely to be taking atypical antipsychotics. These differences
persisted after controlling for severity of symptoms, age, race, marital
status, income, and education.

**Conclusions:** We conclude that the integrated medical system in VA
affords veterans better access to needed medical services; that the VA
in Connecticut has successfully moved away from a focus on inpatient
mental health care; but that VA has not made a complete transition to
community oriented mental health care.

**Impact:** The impact of this research highlights the advantages of an
integrated medical system in ensuring veterans\' access to all types of
health care. However, it also indicates that mental health treatment in
VA has not been completely translated to a community-oriented model.

**HSR&D Funded:** PPR 94-002

7\. Comparing Quality of Mental Health Care in Public Sector and
Privately Insured Populations: First Efforts and Methodological
Challenges

## Douglas Leslie, PhD and Robert Roseheck, MD. VA Connecticut Healthcare System, West Haven, CT.

**Objectives:** Comparing quality of care between large health care
systems is methodologically difficult, but is an important challenge to
health care system management. This study demonstrates methods for
measuring quality of mental health care and compares a sample of VA and
privately insured patients using these measures.

**Methods:** Using discharge abstracts, we identified individuals
receiving inpatient mental health care in VA during the first six months
of each fiscal year 1993 to 1995. A similar cohort of privately insured
individuals was identified using MEDSTAT\'s MarketScan database. These
individuals were tracked for six months following discharge and length
of stay, readmission rates, and access to outpatient services were
calculated. Means of these variables, adjusted for patient
characteristics, were compared over time and between the two
populations.

**Results:** The private sector outperformed VA with respect to most of
the quality measures, although these differences were modest in
magnitude and are likely explained by the fact that VA patients are
generally more severely ill and far more socially disadvantaged.
However, readmission rates increased considerably over time in the
private sector, whereas they declined among VA patients. The outpatient
measures improved in both systems, with VA improving more on the number
of outpatient visits after discharge and the private sector improving
more with respect to the number of days to the first outpatient visit
after discharge. VA outperformed the private sector with respect to the
continuity of care measure in each year. Quality measures varied by
diagnosis, with VA performing better relative to the private sector in
treating patients diagnosed with substance abuse and mental health
disorders not elsewhere classified, but performing relatively worse in
treating patients belonging to the depression diagnostic groups.
Unfortunately, variables describing income, disability and homelessness
were not available to adjust for major differences between patients
treated in the two systems.

**Conclusions:** Although the private sector outperformed VA to a modest
degree with respect to these quality measures (with the exception of
continuity of care), VA improved markedly over time compared to the
private sector, especially with respect to the inpatient quality
measures, and treats a more troubled population for which adjustment was
not possible.As these systems continue to adopt strategies to reduce the
costs of care and as government systems are increasingly compared to
their private sector counterparts, methods for comparing and evaluating
the quality of care delivered become increasingly important, although
methodological challenges, as illustrated here, are substantial.

**Statements:** This study provides a benchmark for quality of mental
health care in VA as efforts are made to reduce costs. Although
similarities in these quality measures between VA and the private sector
are impressive (especially given the fact that VA treats a more severely
ill population), this study shows that there is room for improvement.

# 8. Comparing Reimbursement Models for VA Mental Health Services

## Douglas Leslie, PhD, Robert Rosenheck, MD, Rani Hoff, WD White. VA Connecticut Healthcare System, West Haven, CT.

**Objectives:** VA funding mechanisms have historically relied on
previous utilization as a basis for distributing funds, and have been
criticized as rewarding inefficient provision of care. In response to
such criticisms, there is a desire to base these funding mechanisms
entirely on patient characteristics. This study explores the impact of
using various reimbursement models based on two patient classification
schemes - a functional assessment measure (the GAF) and clinical
diagnosis - to distribute funds for VA mental health care across VISNs.

**Methods:** We identify a cross-sectional sample of veterans treated in
specialty mental health clinics during a two-week period in fiscal year
(FY) 1991. Data from the Patient Treatment File, Outpatient Care File,
and the Cost Distribution Report were combined to calculate total
utilization and costs for this sample during FY 1991. We then simulate
hypothetical reimbursement amounts for these patients based on five
different reimbursement models: 1) reimbursement based on average total
cost per capita (average cost), 2) reimbursement based on average total
cost by GAF score (GAF-based), 3) reimbursement based on average total
cost by diagnosis (diagnosis-based), 4) outpatient care reimbursed based
on average overall outpatient costs and inpatient care reimbursed based
on average inpatient costs by GAF score (GAF-based inpatient), and 5)
outpatient care reimbursed based on average overall outpatient costs and
inpatient care reimbursed based on average inpatient costs by diagnosis
(diagnosis-based inpatient). Total simulated reimbursement by VISN for
each of these models was then compared to actual resource utilization.

**Results:** The distribution of funds nationally across VISNs changes
substantially as a result of our reimbursement models compared to actual
expenditures. The percentage of total VA expenditures redistributed
across VISNs as a result of our models ranges from 6.86% for the
diagnosis-based reimbursement model to 8.29% for the simple average cost
reimbursement model. However, using functional or diagnostic measures
resulted in only small changes from simple average cost capitation. The
effects on individual VISNs were substantial and consistent across
reimbursement models, with some VISNs experiencing an increase in
funding of over 30% and others experiencing a decrease of almost 22% in
some simulations.

**Conclusions:** Reimbursement mechanisms based on functional measures
could have a substantial impact on funding patterns compared to current
regimes, although they make only minor changes compared to a simple
average cost capitation rate. Ideally, one would like to base the
distribution of funds on the inherent costs of treating patients in the
VA system. Our use of GAF scores and diagnoses is a step in the right
direction, but these measures are probably imperfect bases for
classification and predicting costs because they are based on clinician
judgement and are vulnerable to rater bias.

**Impact:** These preliminary analyses demonstrate the application of
simple, readily available clinical classification schemes to reimbursing
VA mental health care. Further analyses are underway to elucidate the
strengths and weaknesses of this approach.

**9. Impact of Primary Care Satellite Clinics on Access to General
Health Care Services and Mental Health Services**

[Robert Rosenheck, MD.]{.underline} VA Connecticut Healthcare System,
West Haven, CT.

**Objectives:** This study sought to determine whether the establishment
of community-based primary care clinics (CBOCs) facilitate access to
general health care and/or mental health care services, in both the
general population and among people with disabling mental illness.

**Methods:** From the last quarter of FY 1995 through the third quarter
of FY 1997, the Department of Veterans Affairs established thirty-four
new community-based primary care clinics in underserved areas. Data were
obtained from the 1990 Census on the number of veterans residing in each
US county. Data were also obtained from VA\'s computerized workload data
bases (the Patient Treatment File and the Outpatient Care File) on the
number of veterans residing in each US County who used VA health and
mental health services In FY 1995, before the clinics were established
and FY 1997 and used to determine the proportion of veterans in each
county who used VA health and mental health services. Analysis of
Covariance was used to compare changes from FY 1995 - FY 1997 in use of
VA services in counties in which new primary care clinics were located
and in other US counties, adjusting for potentially confounding factors
such age distribution, race and gender composition, and income
distribution.

**Results:** Counties in which new clinics were established in late
1995-6 showed an increase in the proportion of veterans who used general
VA health care services that was almost twice as large as that observed
in comparison counties (2.3% vs 1.3%; F=4.94; df=1,3117; p=.03).
However, introduction of these clinics was not associated with greater
use of specialty VA mental health services in the general veteran
population; or of either general health care services or mental health
services among veterans who received VA compensation for psychiatric
disorders. Interaction analysis showed that CBOCs had their greatest
impact on VA service use in counties with larger proportions of low
income veterans (beta = 0.006; F=2.11; df=1,3019; p=.03) and had less of
an impact in counties with a high proportion of hispanics (beta=-.35;
F=2.20; df=1,3019; p=.02).

**Conclusions:** Community-base primary care clinics successfully
improve access to general health care services but do not improve access
to specialty mental health care for either the general population or for
people with serious mental illness.

**Impact:** In part as a result of this study, the Under Secretary\'s
Special Committee on Treatment of Seriously Mentally Ill Veterans
recommended that specialty mental health staff be included in planning
of future CBOCs and the Undersecretary has approved the recommendation.

**HSR&D Funded**: PPR 94-002

10\. Corticosteroid Utilization and Outcomes in HIV Associated
Pneumocystis Carinii Pneumonia: Three-fold Higher Mortality among
Severely Ill Patients when Corticosteroids given by CDC Guidelines

## Charles Bennett, MD, PhD and TC,Ilraith. Chicago VA Hospital, Chicago, IL.

**Objectives:** Experience with the management of Pneumocystis carinii
pneumonia (PCP) exploded with the onset of the AIDS epidemic. Anecdotal
reports of improved outcome when steroids were used as adjuncts to
appropriate anti-microbial therapy led to controlled trials
demonstrating their efficacy.\[Bozette S, NEJM\] The CDC created
guidelines supporting adjunctive therapy with corticosteroids. PCP
management during 1995 to 1997 was evaluated for variations in guideline
adherence and outcomes.

**Methods:** Chart reviews from 7 states, 74 hospitals (66 non-VA and 8
VA), and 1,660 empirically diagnosed or confirmed PCP cases.

**Results:** 735 (44.2%) met CDC guidelines for adjunctive steroids (Aa
oxygen gradient \> 35 mm Hg or p02 \< 70 mm Hg) and 606 (82.4%) received
steroids as directed by the guidelines (w/in 3 days of anti-PCP
medications). Higher rates of appropriate steroid use were associated
with African-American race/ethnicity (84%) versus white (81%) or
Hispanics (73%) (p=0.02), younger age (p=0.002), or receiving care in
Chicago or Seattle (90%) vs NY, Miami, or LA (71%) (p=0.001). Among
severely ill patients with Aa oxygen gradient \> 53 mm Hg, 73% were
confirmed PCP cases and 82% received corticosteroids per the CDC
guidelines. Among these patients, mortality rates were three-fold higher
for those who DID receive steroids (18% vs 6%, p=0.02). Similar findings
were noted for severely ill persons with confirmed PCP (17% vs 6%). In
addition, receiving PCP prophylaxis was associated with higher mortality
rates (30% vs 16%, p=.001).

**Conclusions:** Adherence to CDC guidelines for adjunctive
corticosteroid use varied according to city and patient
sociodemographics. More importantly, improved outcomes seen in
randomized controlled trials were not realized in practice. Among
severely ill PCP patients, mortality was three-fold higher when
corticosteroids were given according to CDC guidelines. Our findings
suggest that the utility of adjunctive corticosteroids in severe PCP
needs to be revisited.

**Impact:** There was a three-fold higher mortality among severely ill
patients with associated Pneumocystis carinii pneumonia when
corticosteroids were given by CDC guidelines.

# 11. Use of Centralized VA Data Registry to Assess Quality of HIV Care

[Samuel Bozzette, MD, PhD and the HIV-QUERI Executive
Committee]{.underline}. Center for the Study of Healthcare Provider
Behavior, San Diego, CA.

**Objectives:** To demonstrate the feasibility of extracting Quality of
Care data from the comprehensive longitudinal VA Immunology (HIV) Case
Registry (ICR) by assessing the use of newer "highly active"
antiretroviral therapies among the HIV-infected under VHA care.

**Methods:** The HIV-QUERI Coordinating Center was provided with copies
of the ICR. We identified unique patients and constructed ratios of the
number of patients and of total outpatient visits and hospital
discharges, and prescriptions for protease inhibitors or non-nucleoside
reverse transcriptase inhibitors (PI-NNRTI). We compared these values
with national data on the population of adults under care from the HIV
Cost and Service Utilization Study (HCSUS).

**Results:** Approximately 11,000 unique HIV-infected patients were seen
at VA facilities each quarter from the 1st quarter of 1996 (1Q96), when
PI-NNRTIs were licensed, to the 4th quarter of 1997 (4Q97). Outpatient
visits/100 patients fluctuated from 769 in 1Q96 to 715 in 4Q96 to 851 in
4Q97. However, discharges/100 patients declined monotonically from 30 in
1Q96 to 24 in 4Q96 to 18 in 4Q97. The patterns of use accompanied the
rapid adoption of PI-NNRTI therapy in the VA as the percentage of unique
patients having at least one prescription written for a PI-NNRTI reached
62% by 4Q96 and 71% by 4Q97. The former compares favorably with
estimates that 52 to 61% of all HIV-infected adults under care in the US
received the newer drugs in 12/96.

**Conclusions:** Newer antiretroviral therapies were adopted by VHA
providers and patients at least as quickly as by the general population.
Increasing use of these agents was accompanied by a dramatic decline in
inpatient but not outpatient care.

**Impact:** Initial comparisons suggest that access of VHA patients to
newer HIV therapies is similar to that of other American adults, and
that use of these therapies is associated with a reduction in inpatient
stays. The VA ICR database contains important information on care for
HIV. Improving the validity and accessibility of this database is a high
priority for the HIV-QUERI.

**HSR&D Funded:** HIV 98-000

# 12. The Prevalence of Hepatitis C in a Sample of Severely Mentally Ill Veterans

##### Andrew Muir, MD and M Butterfield,. Duke University Medical Center, Durham, NC. KG Meador, Hayden Bosworth, PhD. Durham VA Medical Center, Durham, NC. K Stechuchak, and R Frothingham.

**Objectives:** There is a pressing need to study Hepatitis C prevalence
and risks in veterans including those with severe mental illness. The
goal of this study is to establish a prevalence estimate of Hepatitis C
in severely mentally ill veterans.

**Methods:** From March 1 1998- October 15, 1998 consecutive patients
admitted to the Durham VAMC inpatient psychiatric unit with a severe
mental illness (SMI) diagnosis were serotested for Hepatitis C. SMI
diagnoses were defined as meeting Diagnostic and Statistical Manuel of
Mental Disorders fourth edition, (DSM-IV) criteria for schizophrenia,
schizoaffective disorder, bipolar disorder, or posttraumatic stress
disorder (PTSD).

**Results:** 146 SMI veterans were serotested during the study period.
Among these patients, 92.5% were male, 58.9% were African-American. The
overall proportion of hepatitis C in this sample of severely mentally
ill patients was 17.8% (26 of 146). There was a trend for SMI
African-Americans to have significantly higher prevalence rates of
Hepatitis C than for SMI Caucasians (24.42% vs. 9.62%). Among those who
tested positive for Hepatitis C, 42.3% were diagnosed with
schizophrenia, 3.9% with schizoaffective disorder, 7.7% with bipolar
disorder, and 46.2% with PTSD.

**Conclusion:** SMI patients have substantially higher levels of
Hepatitis C than what has been reported in community samples. There is a
significant trend for SMI African-American patients to have higher
Hepatitis C prevalence rates than Caucasian persons with SMI. Positive
Hepatitis C was most prevalent among veterans suffering from
schizophrenia or PTSD.

**Implications:** Hepatitis C is a potential epidemic among veterans,
including those with severe mental illnesses. Veterans with severe
mental illness who are infected with Hepatitis C may increasingly rely
on the VA health system for care with substantial cost implications.
Further studies are necessary to determine potential Hepatitis C risk
factors for SMI persons who are particularly vulnerable to Hepatitis C.
Racial differences in Hepatitis C among SMI veterans may exist and
warrant further exploration. Increased risk behaviors (intravenous drug
and alcohol use) and increased social/contextual risks (community
violence poverty, and trauma) have been associated with race/ethnicity
and may impact on Hepatitis C and associated risks. Research directed
toward understanding Hepatitis C prevalence, transmission, risks, and
progression in severely mentally ill veterans is essential.

**CSP Funded:** EPP 97-022 "HIV Seroprevalence and Risks in Veterans
with Severe Mental Illness

**13. Management [of Hepatitis C at the VA Puget Sound Health Care
System]{.underline}**

[Therese Dawson, BMED.]{.underline} VA Puget Sound Health Care System
Seattle, WA.

**Objectives:** Hepatitis C virus (HCV) infection is emerging as a major
health concern in the veteran population. Reports suggest up to 85% of
those infected will develop chronic hepatitis and 20% of these will
develop cirrhosis. While the prevalence in the VA patient population is
estimated to be 10 times that of the general community there appears to
be no uniform approach to the management of HCV. Although recent
guidelines may help clarify HCV treatment several factors may impede
their implementation. The aims of this study were to review the
management of patients diagnosed with HCV at the VA Puget Sound Health
Care System (VAPSHCS) in 1996 and identify factors influencing this
management.

**Methods:** A retrospective, systematic analysis was made of medical,
pathology and pharmacy records of all patients diagnosed with HCV in
1996 at the VAPSHCS. Patients were followed through to May, 1998. Data
collected included demographics; diagnostic tests for HCV; history of
drug and alcohol abuse; history of HIV, HAV and HBV (testing and
status); frequency and results of liver function tests; the presence of
concomitant liver disease; HCV notation in discharge summaries; hospital
attendances; Gastroenterology referrals; liver biopsies and alpha
interferon treatment. Descriptive statistics were performed where
appropriate.

**Results:** One hundred and twenty seven patients were diagnosed with
HCV in 1996, 125 males and 2 females (mean age 46 years). Four died
during the study, 3 from liver disease. Infection with HCV was detected
by ELISA in 119 (94%) and confirmed by PCR in 15 (12%), (RIBA not
available). Eight patients (6%) had only PCR results recorded. A history
of intravenous and alcohol abuse was recorded in 89 (70%) and 68 (53%),
respectively. Thirty-nine patients were tested for HIV (2 positive), 93
for HAV IgM (all negative) and 110 for HBV (70 previous exposure, 3
chronic disease). Liver function tests were performed at HCV diagnosis
in 121 patients (95%) of which 63 (52%) were abnormal. Of these, 42/121
(33%) had no subsequent LFTs. Hepatic cirrhosis was recorded in 10 (13%)
and hepatocellular carcinoma in 2. Of 149 admissions among 84 patients
HCV was recorded in 98 (66%) of their discharge summaries. Twenty-seven
patients (21%) have been referred to Gastroenterology and 11 have
undergone liver biopsy. Treatment with alpha interferon was commenced in
9 patients.

**Conclusions:** This review provides an insight into current
managementpractices of HCV in our veteran population. Although it is
limited by the accuracy and completeness of records and data extraction
some conclusions may be drawn. The diagnosis and management of HCV
infection at the VAPSHCS lacks uniformity and direction with only 12% of
patients receiving confirmatory PCRs. Even once diagnosed, 5% of
patients did not have LFTs performed and despite a high incidence of
abnormality, a further 33% have not had LFTs repeated. Few patients are
referred to Gastroenterology and fewer receive alpha interferon
treatment. That HCV has a low profile among health care providers is
demonstrated by its lack of inclusion in the discharge summaries of 34%
of patients.

**Impact:** Hepatitis C infection is over represented in the veteran
population. Despite its associated morbidity and mortality HCV appears
to have a low profile at the VAPSHCS. Although new treatment guidelines
have been proposed it is unlikely that these will have significant
impact on patient care if an active program for raising the profile of
HCV and organizing and centrally implementing them is not established.

**14. Hepatitis C Virus Infection and Addiction Disorders in Department
of Veterans Affairs Facilities Nationwide**

##### Gary Roselle, MD, and Marta RENDER, MD. VA Medical Center, Cincinnati, OH. SM Kralovic, LH Danko, and LA Simbart.

**Objectives:** An association exists between Hepatitis C Virus (HCV)
infection and addiction disorders (AD), such as illicit injection drug
use, inhalation of cocaine, and alcohol ingestion. Alcohol use is of
special importance since data suggest an accelerated progression to
cirrhosis, and perhaps, hepatocellular carcinoma. This investigation was
designed to quantify the extent of comorbidities of documented AD in
persons testing positive for HCV antibody (HCVAb).

**Methods:** The DVA has implemented a national automated electronic
surveillance tool (Emerging Pathogens Initiative \[EPI\]) to extract
information from VHA local facility computer systems. The EPI program
first identifies persons with a laboratory test positive for HCVAb. Once
identified, data are automatically extracted, including demographics
such as age, gender, era served, race/ethnicity, and ICD-9-CM coded
diagnoses for inpatients. At the Austin Automation Center data are
converted to SAS format for analysis by the Infectious Diseases Program
Office. Each patient was only counted once, even if the HCVAb test was
positive on multiple occasions. AD for inpatients were defined by
ICD-9-CM codes and included: Alcohol Only, Cocaine Only, Tobacco Only,
Other Drugs Only (including barbiturates, amphetamines, narcotics,
etc.), and combinations of these diagnoses. Data were collected from
9/97 - 7/98 (11 months). Statistical analysis used the chi-square test.

**Results:** Over 11-months, 22,676 persons were identified with a
positive test for HCVAb. Mean age was 48.51 (+9.03 SD); 2,021 (8.9%)
were noted as homeless; 21,811 (96.5%) were male. 15,981 (70.5%) were
outpatients, 6,695 (29.5%) were inpatients; 41% were identified as
White, 28.6% Black, and 6.6% Hispanic; 2.6% of inpatients with HCVAb
died. 54.2% of inpatients with HCVAb had an ICD-9-CM code for an
alcohol-related diagnosis. Any cocaine and any other drug ICD-9-CM
diagnoses were seen in 30.5% and 35% of patients who had HCVAb,
respectively. 27.9% of persons who were HCVAb positive had no documented
AD. HIV infection was seen in 3.7% of inpatients with HCVAb. 81.6% of
HCVAb positive persons were from the Vietnam or post-Vietnam era.

**Conclusions:** 54.2% of inpatients with a positive test for HCVAb had
an ICD-9-CM diagnosis related to intemperate use of alcohol, a substance
associated with greater severity of HCV-related liver disease. The AD
seen in approximately 72% of the patients are often associated with risk
behavior for transmission, such as sharing equipment for illicit
injection drug use or inhalation of cocaine, and sexual risk behavior.
AD in patients with HCV infection will be challenging to provision of
the continuum of care; treatment regimen will require complex drug
combinations with the need for close follow-up, presenting major
obstacles to mitigation of disease.

**Impact:** The VHA has identified a large population of HCVAb positive
persons, creating an inevitable patient care (\>22,000 patients to date)
and financial (up to 750 million dollars) burden. AD were common,
including intemperate alcohol use. Intervention strategies must include
VHA data driven targeted screening of risk populations (IL 10-98-013),
providing treatment and education for those currently infected, and,
most importantly, emphasize prevention of risk behavior that leads to
transmission.

**HSR&D Funded:** DEV 97-032

**15. Mortality after Cardiac Bypass Surgery: Prediction from
Administrative versus Clinical Data**

##### Jane Geraci, MD, MPH, Howard Gordon, MD, ML Johnson, Nancy Petersen, PhD, L Shroyer, Nelda Wray, MD, MPH. Houston Center for Quality of Care and utilization Studies, Houston, TX.

**Objectives:** To determine whether the administrative data contained
in the VA Patient Treatment File (PTF) can adjust for patient severity
and identify hospital mortality outliers identical to severity
adjustment and outlier identification using clinical data from a primary
data collection, the Continuous Improvement in Cardiac Surgery Program
(CICSP).

**Methods:** We developed logistic regression models to predict
operative mortality following cardiac bypass surgery (BYPASS) in 15,288
veterans who underwent bypass from 10/93-3/96. Two models were
developed: one from PTF data and one from the CICSP data.
Observed-to-expected (O/E) ratios for operative mortality in each of 43
hospitals performing BYPASS were calculated, and hospitals were
identified as outliers if the 90% confidence interval for their O/E
ratios did not include 1.0. Hospital outlier status was compared for the
O/E ratios calculated from each of the 2 logistic models. Because the
PTF model and CICSP models did not identify the same hospitals as
outliers, clinical variables from the CICSP data set were added, in
stepwise fashion (entry criterion pú0.1), to the PTF model to determine
whether it could be \"enriched\" to equal the CICSP model in outlier
assignment. Both the PTF and the CICSP models were developed on 2/3 of
the study population and validated on the remaining 1/3.

**Results:** The PTF and CICSP models had comparable predictive power (c
statistics=0.767 and 0.760, respectively). The PTF model identified 3 of
6 CICSP high outliers and 1 of 4 CICSP low outliers, plus 2 unique high
and 3 unique low outliers. Two additional CICSP variables added to the
PTF model resulted in identification of 4 of 6 high and 2 of 4 low
outlier hospitals; addition of other CICSP variables increased the PTF
modelÆs predictive power (final c statistic=0.811) but did not further
improve outlier identification.

**Conclusions:** PTF data have predictive power for BYPASS operative
mortality. Addition of a few clinical variables improved the PTF modelÆs
hospital outlier assignment, but differences between the PTF and the
CICSP model in this performance remained.

**Impact:** Administrative data have an ability to predict operative
death following BYPASS that is comparable in predictive power to that of
clinical data. The comparable predictive power yet unique hospital
outlier identification suggests that the PTF model and CICSP model
adjust for different things. The addition of a small number of clinical
variables not currently available in the PTF improved its ability to
detect hospital outliers, as measured against the CICSP data.

**HSR&D Funded:** 95-005

### 16. The Houston Approach to Optimal Risk-Adjustment Using Administrative Data

#####  Howard Gordon, MD, Jane Geraci, MD, MPH, ML Johnson, Nancy Petersen, PhD, L Shroyer, and Nelda Wray. Houston Center for Quality of Care and Utilization Studies, Houston, TX.

**Objectives:** To develop a comprehensive risk adjustment that takes
full advantage of the data available in an administrative database.

**Methods:** We analyzed 15,288 veterans who underwent cardiac bypass
surgery (BYPASS) in the Department of Veterans Affairs (VA) between
10/93-3/96, using data from the Patient Treatment File (PTF), the
administrative data base on inpatient hospitalizations maintained by the
VA. Data included death within 30 days of BYPASS, age, date of surgery
(weekend versus other), ancillary procedure performance before or on the
day of surgery (coronary angioplasty or intraortic balloon pump (IABP)),
and the ICD-9-CM principal and up to 9 comorbid diagnosis codes.
Diagnoses identified as possible complications of BYPASS were not used
for risk-adjustment. The frequency of post-operative death for principal
and comorbid diagnoses was ascertained in a developmental set of FY92-93
BYPASS cases. Principal diagnoses that occurred in 30 or more cases were
coded individually. Less frequent principal diagnoses were grouped
together into a \"rare principal\" variable. Comorbid diagnoses were
ranked in five groups by risk of death, for codes occurring in at least
30 cases. Less frequent comorbid diagnoses were grouped together into a
\"rare\" group. Patients without any comorbid diagnosis codes were
placed into another group. Stepwise logistic regression was used to
choose important independent predictors of death within 30 day of
BYPASS. In addition, we explored whether a count of comorbid conditions
had independent predictive power, and whether a count within each of the
comorbidity groups was predictive. The model was developed on 2/3 of the
study sample and validated on the remaining 1/3. Data are presented from
the full study sample.

**Results:** Eight independent predictors of postoperative death were
identified: age, weekend surgery, angioplasty on the day of surgery,
IABP before or on the day of surgery, and 4 variables representing
principal or comorbid diagnoses. Two principal diagnosis codes were
protective against operative death: angina pectoris (413) and \"other
forms of chronic ischemic heart disease\" (414). A count of the
comorbidities within the group having the lowest mortality rate in the
developmental set also was protective. Having any comorbidity from the
rare group increased the risk of postoperative death. The model c
statistic=0.767, Hosmer-Lemeshow goodness-of-fit statistic=4.4 (p=0.82).

**Conclusions:** Administrative data have moderate ability to predict
operative death following BYPASS. Even in a homogenous group of patients
undergoing the same surgical procedure the principal medical diagnosis
influenced the risk of death, and should be handled separately from
comorbid conditions. Some comorbid conditions were more influential than
others in predicting death, illustrating that a unit-weighting of them
does not accurately reflect their risk.

**Impact:** Administrative data have moderate ability to predict
operative death following BYPASS. Even in a homogenous group of patients
undergoing the same surgical procedure the principal medical diagnosis
influenced the risk of death, and should be handled separately from
comorbid conditions. Some comorbid conditions were more influential than
others in predicting death, illustrating that a unit-weighting of them
does not accurately reflect their risk.

**HSR&D Funded:** 95-005

# 17. A Markov Model of Severity of Illness States and Hospital Mortality

##### ML Johnson, W Chan, DH Kuykendall, and Carol Ashton, MD, MPH. Houston Center for Quality of Care and Utilization Studies, Houston, TX.

**Objectives:** To model the course of hospitalization from admission to
discharge or death using a Markov model of illness severity states
derived from laboratory data.

**Methods:** Laboratory data was collected using the Health Summary
component of VISTA for 476 consecutive patients admitted with
non-psychiatric principal diagnoses to the general medicine section of
the Houston VAMC. Laboratory test results were scored to create APACHE-L
severity of illness measures for each day of the hospital stay that
laboratory tests were conducted. Patients were classified into Low,
Medium, or High severity states based on the APACHE-L scores. A Markov
chain is proposed to model the transition of patients between severity
states over the course of the hospital stay, until reaching states of
discharge or hospital death, defined as death in the hospital or within
30 days of discharge. A total of 12 possible transitions can occur from
day to day: from Low to Medium (LM), Low to High (LH), Low to Discharge
(Ldisch), or Low to Dead (Ldead); and similarly four each from Medium
and High. A split sample technique was employed to validate predictions
of transition rates between severity states, and from severity states to
discharge or death.

**Results:** In the development sample, 44.5% of patients were admitted
in severity state Low (106/238), 46.2% in Medium (110/238) and 9.2% in
High (22/238). The overall hospital mortality rate was 9.2% (22/238),
with a 3.8% mortality rate occurring in patients admitted in Low state
(4/106), 9.1% in Medium (10/110) and 36.4% in High (8/22). Median
waiting times were 4 days in a Low state, 2 days in Medium and 1 day in
High. Example transition rates were: Ldisch 8.7%, meaning patients in a
Low state had a 8.7% probability of discharge the next day; Hdead 6.25%,
meaning patients who ever reach a High severity state faced a 6.25%
chance of dying before the next day. Rates were applied to the
validation sample and accurate predictions were found, including: 149.55
expected discharges from Low state with 149 observed; 9.6 expected Hdead
transitions, 6 observed; and 5.8 Ldead transitions, 6 observed.
Stationary transition probabilities obtained from the limiting
probability distribution were 6.1% deaths from Low state, 9.0% Medium
and 21.6% High for an entire course of hospitalization.

**Conclusions:** A Markov model can be constructed from laboratory data
to accurately predict transitions between severity of illness states and
from severity states to discharge or death. Waiting times indicate
relatively quick departure from High and Medium severity states, but
relatively long stays in a Low severity state before being discharged,
with risk of becoming more ill or even dying.

**Impact:** Further research is needed to explore methods to use results
of Markov modeling as quality of care indicators. In addition to
hospital mortality rates, performance could be monitored on rates of
improvement or worsening during the course of hospitalization. To
improve quality of patient care, a computerized system could track
severity states of patients daily to provide a synthesis of laboratory
data and risk of mortality to physicians.

**18. Hospital Profiles of Mortality from Cardiac Bypass Surgery: Effect
of Definition of Outcome based on Administrative versus Clinical Data**

##### ML Johnson, JM Geraci, NP Wray, HS Gordon, MJ Petersen, AL Shroyer. Houston Center for Quality of Care and Utilization Studies, Houston, TX.

##### 

**Objectives:** To determine whether using a definition of
post-operative mortality based on administrative data from the Patient
Treatment File (PTF) affects identification of hospital mortality
outliers derived from a model of post-operative mortality based on
clinical data from a primary data collection the Continuous Improvement
in Cardiac Surgery Program (CICSP).

**Methods:** A sample of 15,288 patients from the CICSP data collection
who underwent cardiac bypass surgery from 10/93 to 3/96 were studied.
The CICSP defined post-operative mortality as any death occurring within
30 days of the operation, or any post-surgical death attributable to
surgical complication by medical peer review. Post-operative death was
defined using administrative data as any death occurring within 30 days
of surgery. Agreement of the outcome variables defined by administrative
data versus clinical data was assessed. A logistic regression model was
constructed to predict the dependent variable, operative mortality, as
defined by CICSP, using the CICSP clinical data as independent variables
in a backward stepwise selection (Model 1). Observed-to-expected (O/E)
ratios for operative mortality in each of 43 hospitals performing bypass
were calculated, and hospitals were identified as outliers if the 90%
confidence interval for their O/E ratios did not include 1.0. A second
logistic model was constructed using the same independent variables from
Model 1, but substituting the dependent variable with post-operative
mortality as defined by the PTF to determine the unique effect of the
definition of outcome on hospital profiles (Model 2).= Hospital outlier
status was compared for the O/E ratios calculated from each of the 2
logistic models.

**Results:** CICSP classified 557 patients as post-operative deaths, and
the PTF classified 498 as post-operative deaths. Sensitivity of the PTF
definition to the CICSP was 89.4% and specificity was 100%. Model 1
identified 6 hospitals as high outliers and 4 hospitals as low outliers.
Model 2 identified 5 high outliers, 3 of which were original outliers,
and 3 low outliers, 2 of which were outliers originally.

**Conclusions:** Agreement of classifications of post-operative death
was very high between administrative data and clinical data. However,
using the definition of death from administrative data resulted in 10.6%
fewer patients classified as a post-operative mortality, due to the
inability of the administrative data to capture post-30 day deaths
attributed to the surgery by medical review. This discrepancy in the
definition of death further resulted in different hospitals being
identified as outliers than originally derived from clinical data alone.

**Impact:** Further research to examine the sensitivity of hospital
profiles to changes in outcome definition is needed to determine best
use of both administrative and clinical data. The PTF is a highly
accurate source of identifying post-operative death from cardiac bypass
surgery overall; however, the administrative database does not contain
the clinical information to identify which post-30 day deaths are due to
surgical complications. Hospital profiles developed from clinical or
administrative models may differ because of differences in the
definition of outcome even when the independent variables are identical.

**HSR&D Funded:** IIR 95-005

**19. Accuracy of Computer Identified Diagnoses in a VA General Medicine
Clinic**

## Herbert Szeto, MD, MPH and Mary Goldstein, MD. VA Palo Alto, Palo Alto, CA.

**Objectives:** Many existing and proposed critiques of medical care
rely on DHCP diagnoses. Whereas the accuracy of VA inpatient diagnoses
in VISTA/DHCP versus charts have been well studied, little is known
about the accuracy of outpatient diagnoses. This study sought to examine
the accuracy of diagnoses for hypertension-relevant disorders recorded
in DHCP when compared to the outpatient medical record.

**Methods:** We undertook a cross-sectional chart review to assess the
accuracy of common medical diagnoses that may affect the choice of
anti-hypertensive therapy. Eight clinical conditions, asthma/COPD ,
atrial fibrillation, BPH, congestive heart failure, coronary artery
disease, diabetes mellitus, gastroesphogeal reflux disease (GERD),
hyperlipidemia, and hypertension were assessed in the general medical
clinic at VA Palo Alto. Charts of patients scheduled to one of the
half-day clinics of 16 residents, 5 nurse practitioners (NPs) and 5
attending physicians (MDs) were reviewed for the week of May 18-22,
1998. A half-day clinic schedule was chosen by convenience for MDs and
NPs who had more than one general medicine clinic that week. Clinic
charts of 137 of the 148 scheduled established patients were available
for review. A diagnosis was considered to be present if it was listed
either in the past medical history or as part of the problem list for
any past note in the clinic record. A list of diagnoses for each patient
was then obtained through DHCP and compared to diagnoses listed in the
chart.

**Results:** The prevalence of the conditions varied from 5.1% for CHF
to 51.1% for hypertension. Using the outpatient record as the gold
standard, the sensitivity/specificity of DHCP for the conditions are as
follows: asthma/COPD (.43/.96), atrial fibrillation (.89/.97), BPH
(.3/.95), congestive heart failure (.57/.97), coronary artery disease
(.57/.98), diabetes mellitus (.77/.95), GERD (.58/.97), hyperlipidemia
(.73/.88), and hypertension (.74/.79). The specificity of DHCP was
generally greater than .95, but was as low as .79 for hypertension. The
positive predictive value for a diagnosis listed in DHCP varied from .50
for BPH to .89 for CAD. One of the limitations of this study is that
patients were chosen through scheduled appointments with specific
providers. As is typical of university affiliated VA clinics, our
clinics are staffed by resident and staff physicians. Since resident
physicians have clinic scheduled only once a week, the sample was
disproportionately shifted toward patients cared for by residents.
Moreover, the patient population may be biased toward patients with a
greater number of medical problems, who seek medical attention more
frequently. Coding of diagnoses for these patients may be less complete
since providers are less likely to list secondary diagnoses related to
any one visit.

**Conclusions:** This pilot study suggests that significant
discrepancies may exist between clinic records and the DHCP system.
Diagnoses were often omitted from DHCP, and some diagnoses present in
DHCP were not present in the clinic record.

**Impact:** As we move into an era where electronic clinical databases
may be used to assess quality, risk adjust, or as a basis for automated
treatment recommendations, careful attention must be paid to the
accuracy of such data.

**20. Prostate Cancer Quality of Life and Outcomes Research among
Patients with Low Socioeconomic** **Status: An Overview of the VA Cancer
of the Prostate Outcomes Study (VA CaPOS)**

## Simon Kim, MPH. Chicago, VA Hospital. SJ Knight, E Moran, CN Robertson, and JE Smith. Charles Bennett, MD, PhD. Chicago VA Hospital, Chicago, IL.

**Objectives:** Outcomes assessment for prostate cancer are important,
because of debates over the benefits and costs of alternate treatments
and outcomes. Because of a lack of evidence of survival benefits with
specific therapies, quality of life (QOL) evaluations have taken on
increased importance. QOL is rarely assessed among racial/ethnic
minorities and men of lower socioeconomic status, who make up a
disproportionately large part of the prostate cancer burden. We have
initiated the first multi-center QOL outcomes study of lower
socioeconomic status men, the VA Cancer of the Prostate Outcomes Study
(VA CaPOS).

**Methods:** VA CaPOS QOL information is collected from prostate cancer
patients, spouses, and physicians at six VA medical centers. Because of
low rates of literacy, interviewers assess QOL, involvement in care, and
the relative importance of likely outcomes following alternative
treatments. Spouses provide proxy ratings of patient QOL. Physicians
provide information on patients' performance status and the patients'
perceived preferences for alternate outcomes. Medical records and
electronic databases are reviewed for sociodemographic characteristics
and relevant clinical characteristics.

**Results:** Currently, 601 men with prostate cancer are included in the
VA CaPOS, over half of whom are African American. The mean time since
diagnosis was 1.4 month for newly diagnosed patients and over 4 years
for the rest. QOL responses were most favorable for newly diagnosed,
intermediate for stable metastatic disease, and poorest for progressive
metastatic disease patients, most of whom had been followed for several
years. Spouse emotional well-being assessments were significantly worse
than those of individual patients. While patients were not able to
provide reliable estimates of their own preferences for future QOL
states, they were able to respond reliably to questions phrased as a
comparison of the preferences of two hypothetical patients. While
African American prostate cancer patients were more likely to have
advanced stage disease at the time of diagnosis, after adjustment for
differences in health literacy, race was no longer a significant
predictor of having advanced prostate cancer.

**Conclusions:** The VA CaPOS provides useful information on health
status, QOL, and low literacy for VA prostate cancer patients. Our
results indicate that valid and reliable assessments in low literacy
populations are feasible, but that long-term evaluations are needed to
detect clinically meaningful information on QOL as the disease
progresses. Alternative sources of QOL information, such as spouses,
provided results that had poor concordance for emotional and social
functioning, but were generally valid for other dimensions of health.
The reliability of patient ratings of future QOL states was increased
when questions were based on two hypothetical friends rather than
consideration by the patients themselves of two potential, but
different, future health states. Observational database efforts are
potential sources of important information for lower socioeconomic
status patients who are faced with difficult therapeutic decisions,
limited financial resources, and concerns over both quantity and quality
of life outcomes with alternative therapies.

**Impact:** VA CaPOS provides useful information on health status, QOL,
and low literacy for VA prostate cancer patients. It also provides
useful information about spouse proxy ratings of patient QOL.

21\. Prevalence of Lower Urinary Tract Symptoms and Associated Resource
Utilization among VA Primary Care Patients

## Elizabeth Yano, PhD, MSPH. VA Greater Los Angeles Healthcare System, Sepulveda, CA. AB Lanto. Timothy Wilt, MD, MPH. VA Medical Center, Minneapolis, MN. Lisa Rubenstein, MD MSPH. VA Greater Los Angeles Healthcare System, Sepulveda, CA.

**Objectives:** In 1997, nearly 750,000 male veterans had outpatient
diagnoses of benign and malignant prostate disease, yet little is known
about their presenting symptoms in primary care or associated resource
utilization, information that would be useful in the design of programs
to systematically screen and treat them. We assessed the prevalence of
lower urinary tract symptoms consistent with the presentation of
prostate disease among VA primary care patients and assessed their VA
healthcare utilization.

**Methods:** These data were drawn from a longitudinal cohort of
randomly sampled male veterans in no acute distress who were visiting
the Primary Ambulatory Care and Education (PACE) Center from March-June
1993. Using the Survey of Health and Medical Care designed for the
evaluation of PACE, a primary care firm system, we conducted a telephone
survey of 1,849 veterans with 3+ primary care visits regarding their
health status and symptoms. Lower urinary symptoms (e.g., nocturia) were
queried using items developed by a national panel of academic
urologists. Cutpoints were selected to identify the most clinically
meaningful symptom burden. Survey data were linked with VA
administrative data to evaluate general medicine and subspecialty
outpatient visits (particularly urology), and admission rates during the
following year. We used logistic regression to evaluate the predictors
of symptom burden among primary care patients.

**Results:** For specific symptoms, 24.4% of men reported
sometimes-to-frequently having urinary urgency (11.2% frequently), 12.1%
reported sometimes-to-often having problems urinating in the previous
month (4.0% often), and 24.1% reported urinating 1+ times/hour (4.4% \>2
times/hour). Nearly half of those surveyed (47.5%) reported that they
urinated 2+ times/night (22.2% with 3+ trips), while over half
(56.2%)reported moderate-to-slow streams (11.2% slow and strained).
Taking the most severe category for each symptom, we found that 32.9%
had 1+ clinically meaningful lower urinary tract symptoms (21.0% with 1,
6.7% with two symptoms). As clinically expected, hypertensives were 53%
more likely to report 1+ symptoms (1.53, 95%CI 1.18-1.98), diabetics
were 75% more likely (1.75, 95%CI 1.32-2.31), and men reporting
shortness-of-breath at rest (1.80, 95%CI 1.28-2.52) or on exertion
(2.03, 95%CI 1.49-2.77) were more likely to report 1+ lower urinary
tract symptoms (p\<.0001). Adjusting for these comorbid conditions, men
with 1+ symptoms had significantly more general medicine (p\<.01) and
urology visits (p\<.00001) in the following year compared to men without
urinary symptoms. The more symptoms reported, the higher the general
medicine (p\<.005), subspecialty (p\<.0001) and urology (p\<.0001) visit
rates, as well as medical-and-surgical admission rates (p\<.0001).

**Conclusions:** Male primary care patients have a significant lower
urinary tract symptom burden consistent with underlying prostate disease
that is associated with significantly higher utilization of VA
healthcare resources. Clinical guidelines and pathways that address the
optimal role of primary care practitioners and urologists in a
coordinated system of care are needed.

**Impact:** VHA has identified prostate disease as a high impact target
condition for QUERI. These analyses are helpful in quantifying the needs
of veterans and in assessing how to manage patients in primary and
specialty care.

# 22. Relative Effectiveness of Androgen Suppressive Therapies for Advanced Prostate Cancer 

[Timothy Wilt, MD, MPH.]{.underline} VA Medical Center, Minneapolis, MN.
[N Aronson, J Seidenfeld, D Samson, V Hasselblad, and P
Albertsen.]{.underline} [Charles Bennett, MD,]{.underline} Chicago, IL.
[PhD Alan Garber, MD. PhD.]{.underline} Center for Health Care
Evaluation, Palo Alto, CA.

**Objectives:** To determine the relative effectiveness of alternative
strategies for androgen suppression as treatment of advanced prostate
cancer.

**Methods:** We conducted a systematic review of the evidence from
randomized controlled trials Options included monotherapy with surgical
or medical orchiectomy (diethlystibesterol, \[DES\], luteinizing
hormone-releasing hormone \[LHRH\] agonist, or antiandrogens) or
combination therapy with additional suppression of adrenal androgens
(Combined Androgen Blockade) \[CAB\]. Three issues were addressed: (1)
the relative effectiveness of monotherapy (orchiectomy, DES, LHRH
agonists, and antiandrogens); (2) the effectiveness of CAB compared to
monotherapy; (3) the effectiveness of immediate androgen suppression for
PSA rise compared to androgen suppression deferred until clinical
progression. Outcomes included overall, cancer-specific, and
progression-free survival; time to treatment failure; adverse effects
and quality of life.

**Results:** There are wide differences in costs of androgen
suppression: annual costs were DES = \$109; LHRH agonists = \$5,000;
antiandrogens = \$3500; CAB = \$8500; surgical orchiectomy per operation
= \$3000. Survival after treatment with an LHRH agonist is equivalent to
survival after orchiectomy or DES (Hazard ratio \[HR\] = 1.11; 95% CI=
0.89,1.39). The available LHRH agonists are equally effective regarding
survival and no LHRH agonist is superior to others when considering
adverse effects. Survival may be lower with use of a nonsteroidal
antiandrogen (hazard ratio relative to orchiectomy = 1.22; 95% CI =
0.97, 1.54). There is no statistically significant difference in
survival at 2 years between patients treated with CAB or monotherapy (HR
= 0.97; 95% CI=0.87,1.09). Meta-analysis of the limited data available
show a statistically significant difference in survival at 5 years that
favors CAB but this is of questionable clinical significance (HR = 0.91;
95% CI = 0.85,0.99). Data suggest that monotherapy has fewer adverse
events and results in improved quality life. More men randomized to CAB
(10%) withdrew from therapy due to adverse events than men randomized to
monotherapy (4%). There is no evidence from randomized trials to compare
early androgen suppression initiated upon PSA rise to androgen
suppression deferred until clinical progression. There was a significant
difference in 5-year overall survival in favor of androgen suppression
initiated at the time of radiation compared to radiation alone followed
by androgen suppression initiated at clinical progression (HR = 0.63;
95% CI = 0.48, 0.83; NNT at 5 years = 12).

**Conclusions:** Androgen suppression with orchiectomy or DES provides
equivalent survival at lower cost than LHRH agonist, antiandrogens or
CAB. Adverse events and quality of life favored monotherapy.

**Impact:** Androgen suppression for advanced prostate cancer with
orchiectomy or DES provides equivalent survival and quality of life
compared to LHRH agonists, antiandrogens or CAB. Treatment with
orchiectomy or DES would result in considerable cost savings. Despite
widespread practice of initiating androgen suppression for rising PSA
levels in the absence of clinical signs or symptoms there is no evidence
from randomized trials comparing this strategy to androgen suppression
deferred until clinical evidence of disease progression. Patients who
undergo immediate treatment will have a longer duration of therapy in
which they experience the adverse effects and increased costs of
androgen suppression.

**23. Men\'s Beliefs about the Benefits of and Professional
Recommendations for PSA Screening**

## Judith Zemencuk MA, and Rodney Hayward MD. Center for Practice Management and Outcomes Research, Ann Arbor, MI. SJ Katz

**Objectives:** Despite the many uncertainties surrounding screening for
prostate cancer, few published studies have examined men\'s beliefs
about the pros and cons of prostate-specific antigen (PSA) testing. This
study assesses and describes the beliefs men hold with regard to the
benefits of, controversies about, and professional recommendations for
screening for prostate cancer by PSA testing.

**Methods:** Using a self-administered questionnaire developed to
measure men\'s knowledge and understanding regarding PSA testing, we
collected data from a sample of men seeking care at a VA medical center
general medicine outpatient clinic or at one of two primary care sites
of its university affiliate. Of 390 consecutive men, 45 years or older,
at the VA medical center site, 270 (69%) consented to participate and
returned completed questionnaires. At its university affiliate sites,
119 of the 162 (73%) eligible patients completed questionnaires.

**Results:** Over 42% of all men reported that they had had a PSA test,
while 16% were unsure. Nearly 77%, however, indicated a desire for PSA
testing within the next year or two, including 75% of men 70 years and
older (for whom the test is not generally recommended even by screening
advocates). In general, most men believed regular PSA testing to be
highly beneficial. For example, over 80% of all men thought that medical
studies have shown that regular PSA testing can reduce a man\'s chance
of dying from prostate cancer by 50% or more. Most men were unaware of
the uncertainties surrounding the use of PSA as a screening test. For
example, although nearly half of men reported reading or hearing reports
about PSA testing, nearly two-thirds were unsure as to whether there was
a controversy among medical professionals concerning when and how often
a man should get regular PSA testing. Beliefs regarding recommendations
for PSA screening for men their age were inconsistent. For example,
while 62% of all men thought that the medical profession in general
recommends that men their age get regular PSA testing, 46% were unsure
as to whether their own physician endorsed a similar recommendation.
There were no significant differences in responses at the VA vs. non-VA
clinics.

**Conclusions:** Most men were uncertain as to whether screening for
prostate cancer by PSA testing is controversial, while a majority
believed that PSA testing is recommended by the medical profession in
general. A substantial proportion of men were uncertain as to whether
their own physician recommended PSA testing. Still, a large majority
believed PSA testing to be substantially beneficial and wanted PSA
screening.

**Impact:** Uncertainties concerning the benefits of screening for
prostate cancer using prostate-specific antigen (PSA) have led many to
suggest that men be involved in the decision to screen. Indeed, the VA
has mandated documentation of PSA counseling. Our study\'s findings
indicate that men may not have sufficient information to make an
informed decision regarding screening for prostate cancer by PSA testing
and highlight the need to improve men\'s knowledge and understanding of
this screening test.

**24. Preventing Urinary Tract Infection using Urinary Catheters Coated
with Silver Alloy: A Cost-Effectiveness Analysis**

## Sanjay Saint, MD, MPH. Center for Practice Management and Outcomes Research, Ann Arbor, MI. DL Veenstra, SD Sullivan, C Chenoweth, and AM Fendrick.

**Objectives:** Up to 25% of hospitalized patients have a urinary
catheter placed at some time during their stay. The overall incidence of
nosocomial urinary tract infection (UTI) among patients with an
indwelling catheter is about 5% per day. UTIs account for up to 40% of
nosocomial infections, with bacteremia complicating nosocomial UTI in
about 4% of cases. A recent meta-analysis indicated that silver alloy
urinary catheters were efficacious in preventing UTI compared with
standard urinary catheters; however, providers must decide whether the
efficacy of such catheters is worth the extra cost of approximately \$5
per catheter. We performed an analysis to determine the incremental cost
and the incremental incidence of catheter-related UTI, bacteremia, and
death associated with the use of silver alloy urinary catheters versus
standard urinary catheters.

**Methods:** The decision analytic model, performed from the healthcare
payer=92s perspective, was based on patients admitted to acute care
hospitals on general medical, surgical and urological services requiring
indwelling urethral catheterization between three and six days. Three
interventions were compared: 1) universal silver alloy catheter use; 2)
silver alloy catheter use only in those at high risk for
catheter-related UTI, defined as patients not on systemic
antimicrobials; and 3) standard (non-coated) urinary catheter use in all
patients. Outcome estimates were derived from several quantitative
syntheses of published reports. Cost estimates were based on University
of Michigan Health System costs and literature review. Sensitivity
analyses were performed and included scenarios in which estimates were
set to favor either the universal use of silver catheters or the
universal use of standard catheters.

**Results:** In the base-case analysis, the strategy of universal silver
catheter use resulted in an expected cost savings of almost \$6 per
catheter compared with universal standard catheter use and a 45%
relative decrease in the incidence of symptomatic UTI, bacteremia, and
death. The strategy of targeted silver catheter use resulted in cost
savings of \$3.75 per catheter used compared to universal standard
catheter use and an expected 20% relative decrease in symptomatic UTI,
bacteremia, and death. Sensitivity analyses across the reasonable range
of outcome and cost estimates did not dramatically alter these findings.

**Conclusions:** The results of our analysis indicate that strategies
using either universal silver catheters or targeted silver catheters in
patients requiring urinary catheterization between three and six days
are cost-saving compared to standard catheters and should reduce the
incidence of symptomatic UTI, bacteremia, and death. The appropriate use
of silver catheters in patients requiring catheterization for less than
three days or more than six days remains unclear.

**Impact:** The universal use of silver alloy-coated urinary catheters
in patients requiring catheterization between three and six days should
be strongly considered. The base-case analysis suggests that for
approximately every 1000 silver-alloy catheters used, an average of
\$6500 will be saved overall, and 9.7 cases of symptomatic UTI, 1.7
cases of bacteremia and .2 deaths will be avoided.

**25. HSR&D Development Center Workshop**

[Douglas D. Bradham, DrPH]{.underline}. HSR&D Developmental Center,
Capital VISN (5), Baltimore, MD.

**Purpose:** To provide an open discussion (from the trenches) of key
issues facing these Centers as they mature into HSR&D infrastructure for
their VISNs.

**Objective A:** To encourage interchange among the current (10) HSR&D
Developmental Centers by discussing their approaches to several key
issues including:

a\) Attracting a critical mass of clinician investigators.

b\) Training and mentoring these investigators toward successful LOIs
and IIRs.

c\) Hiring talented staff in critical areas of:

i\) VA Database extraction and programming.

ii\) Biostatistics and methodologists.

iii\) Health economists.

iv\) Others?

d\) Acquiring and holding on to space!

e\) Maintaining linkage with R&D and VISN-level operational concerns.

f\) Gaining VISN-level financial support.

**Objective B:** To improve the next round of HSR&D Developmental Center
applications by discussing the current Centers\' approaches to issues
including:

i\) Critical items in the proposals.

ii\) Critical items in the organizational phase.

iii\) Critical items in the implementation phase.

iv\) Other critical items for success.

**Approach:** Each topic will be examined by the 10 directors along
characteristics of:

a\) What works and why?

b\) What does not work?

c\) Who is helpful and why?

**Activities:** Each Developmental Center Director will be asked to
participate. Modifications in the issues listed above will be generated.
Prior to the Annual Meeting, each Director will be asked to lead a
posting of ideas for group contributions for a particular topic. The
posting of ideas will be recorded and a summary report will be
assembled. That report will be made available for the attendees and for
HSR&D Headquarters staff for use in encouraging new applicant\'s
success.

**Audience:** Current and future of applicants for developmental center
funding.

**Audience Familiarity:** Individuals who are considering application
for Developmental Center funding should attend.

**26. Internet-Based Education for Epidemiology**

[Michel A. Ibrahim, MD,]{.underline} University of North Carolina at
Chapel Hill, Chapel Hill, NC .

**Abstract:** This workshop is intended to demonstrate the utility of
Internet-based courses in basic and continuing education of
epidemiology. As an illustration, one module for an outbreak
investigation will showcase the technology and demonstrate the
interactive and stimulating nature of this mode of learning. A module is
a self-contained unit of study that requires advanced readings and
consists of an audio tutorial and a review of a case study with a set of
questions and answers. An entire course consists of several related
modules. You need not to bring anything with you to benefit from this
demonstration. However, if you want to have a hands-on experience by
actual participation you should bring a laptop with Windows95, Intel
Pentium, floppy drive, 16Mb of RAM, 16-bit sound card with headphones,
Netscape Navigator version 3.x or 4.x, RealAudio Player and CD-Rom
drive. You may download Netscape from http://home.netscape.com/ and
RealAudio Player from http://www.real.com - both these programs are free
and are needed for the demonstration. No Internet link is necessary
during the demonstration. In order to be able to use the technology
effectively to complete an actual module or an entire course, the
\"student\" must have the skills and understanding of Internet jargon,
Internet navigation, discussion forums, listservs, and other related
topics.

**Target:** The target audience includes The Veterans Administration
clinicians, researchers and administrators. The educational offerings
would vary in terms of the nature of topics covered as well as the
degree of complexity of content from the introductory to the advanced,
depending on the particular audience.

**27. Using National VA Data in health Services and Epidemiologic
Research**

[Reiber, Gayle, PhD, MPH, and Jennifer MAYFIELD, MD, MPH.]{.underline}
VA Puget Sound Health Care System, Seattle, WA. [Charles
Maynard.]{.underline} [Michael Chapko, PhD]{.underline}, VA Puget Sound
Health Care System, Seattle, WA.

**Objective:** To describe and illustrate basic considerations and
strategies for use of national VA data in health services and
epidemiologic research.

**Activities:** In this workshop, participants will have an opportunity
to follow the steps involved in procuring data from national VA
databases. Two clinical examples will provide participants with an
overview of the process and specific methods used to obtain the data.
The first example is ô what was the prevalence of esophageal cancer in
the VA from 1993-1997 and what was the survival experience of these
patients? Ö The second example is ô how many lower limb bypass and
amputation procedures were performed in VA hospitals between 1992 and
1996? Participants will receive information on administrative and human
subjects clearance, database considerations, downloading strategies,
sample programs for data extraction, and file linkage and data quality
considerations.

**Target:** Health services researchers with no prior experience using
national VA databases.

**28. Continuity of Care as a Determinant of Patient Satisfaction.
Results from the ACQUIP Study**

## Marcia Burman, MD, Mary McDonell, MS, and Stephan Fihn, MD, MPH. VA Puget Sound Health Care System, Seattle, WA.

**Objectives:** Patient satisfaction has been positively associated with
improved patient compliance and improved clinical outcomes and
negatively associated with malpractice claims. Factors that have been
found to be related to patient satisfaction include sociodemographic
factors, payment source, both patient and physician rated health status
and utilization measures. We examined relationship between continuity of
care and patient satisfaction.

**Methods:** We surveyed 38,642 General Internal Medicine Clinic (GIMC)
patients followed at 7 VAs. Data gathered included demographics, active
medical problems and satisfaction with care using the Seattle Outpatient
Satisfaction Questionnaire (SOSQ) which measures satisfaction with
humanistic and organization aspects of care. Patients who reported
angina, COPD, diabetes or hypertension also received condition-specific
questionnaires (e.g. the Seattle Angina Questionnaire and the Seattle
Obstructive Lung Disease Questionnaire) which include measures of
condition-specific satisfaction. All scales were scored from 0 (worst)
to 100 (best). Patients were also asked to rate their continuity of
care.

**Results:** 14,865 patients responded with 11,711 reporting one or more
of the following disease conditions: angina (n=5544), COPD (n=3189),
diabetes (n=3249) or hypertension (n=8059). The percent of patients
reporting seeing the same provider "always", "most of the time",
"sometimes", and "rarely or never" were 38, 39, 14 and 6 respectively.
There was no difference in the distribution of continuity scores between
the disease conditions. Mean scores on both the SOSQ humanistic scale
and condition-specific scales were strongly related to perceived
continuity of care with satisfaction scores ranging from 86.7 to 61.4
among veterans who reported "always" seeing the same provider.
Satisfaction scores among veterans who reported "rarely or never" seeing
the same provider ranged from 69.5 to 41.9 (p\<.001). These findings
persisted after adjusting for age, education, race, income, VA facility,
and length of time receiving care at the VA and SF-36 scores.

**Conclusions:** Continuity with the same provider is highly related to
Patients' general and condition-specific satisfaction.

**Impact:** Since higher patient satisfaction has been associated with
improved outcomes in chronic disease and improved medical compliance
efforts to improve patient satisfaction might be reasonable
interventions for improving outcomes. Further studies are needed to
evaluate the contribution of various components of continuity of care
(for example convenience, access, ease of negotiating the system, etc)
to patient satisfaction.

**HSR&D Funded:** SDR 96-002

**29. Patient Satisfaction Among Veterans Varies by Disease Condition
but not by Symptom Burden. Results from the ACQUIP Study.**

# [Marcia Burman, MD, Mary McDonell, MS and Stephan Fihn, MD, MPH.]{.underline} VA Puget Sound Health Care System, Seattle, WA.

**Objectives:** We examined the variation of patient satisfaction among
veterans with angina, COPD, diabetes and hypertension. We also examined
the relationship between satisfaction and measures of symptom severity
and symptom burden.

**Methods:** We performed a cross-sectional survey of 38,642 General
Internal Medicine Clinic patients followed at 7 VAs. Survey information
included demographics and an inventory of active medical conditions
including angina, COPD, diabetes and hypertension. Patients reporting
any of these conditions were sent follow-up surveys including the
Medical Outcomes Study SF-36 and the Seattle Outpatient Satisfaction
Questionnaire (SOSQ) which measures satisfaction with humanistic and
organization aspects of care. As appropriate, patients also received
condition-specific questionnaires (e.g. the Seattle Angina Questionnaire
and the Seattle Obstructive Lung Disease Questionnaire) which include
measures of symptom severity and symptom burden. All scales were scored
from 0 (worst) to 100 (best).

**Results:** 14, 865 patients responded to both the SOSQ and the SF-36
questionnaires. 11,711 veterans reported one or more of the following
disease conditions: angina (n=5544), COPD (n=3189), diabetes (n=3211) or
hypertension (n=8059). The overall SOSQ humanistic satisfaction score
was 72.7. Mean condition-specific satisfaction scores ranged from 56.6
in patients with COPD to 83.3 in patients with angina (p\<.001). Symptom
severity and symptom burden were modestly correlated with satisfaction
in patients with heart disease (r=.28 for angina frequency) but not in
patients with the other three conditions (r range from .04 to .21).
These findings persisted after adjustment for age, income, education,
race and site.

**Conclusions:** Patient satisfaction varies significantly by medical
condition. However, there is little or no correlation between several
measures of symptom burden and either general satisfaction (as measured
by the SOSQ Humanistic score) or condition-specific satisfaction.

**Impact:** While patient satisfaction has been associated with improved
outcomes in chronic disease and improved medical compliance, it appears
that there is not a straightforward correlation with symptom burden.
Further studies examining the differential impact of non-symptom related
factors on patient satisfaction may lead to novel approaches to
improving patient satisfaction and perhaps outcomes in different disease
conditions.

**HSR&D Funded:** SDR 96-002

**30. A Disease-Targeted Measure of Health-Related Quality of Life
(HRQOL) for Patients with Chronic Liver Disease the LDQOL 1.0.**

## Ian Gralnek,MD, MSHS. West Los Angeles VA Medical Center, Los Angeles, CA. RD Hays, HR Rosen, EB Keeffee, DM Jensen, and P Martin.

**Objectives:** The development and validation of a patient-centered
HRQOL outcomes measure is timely and needed for individuals with chronic
liver disease. Disease-targeted measures can capture small, yet
clinically meaningful changes in patients\' health status due to an
intervention or disease progression that a generic instrument may fail
to detect. Therefore, the objective of this study is to evaluate the
psychometric properties (reliability and validity) of a newly developed
disease-targeted HRQOL instrument (the LDQOL 1.0) for individuals with
chronic liver disease.

**Methods:** Disease-targeted items in the LDQOL 1.0 were developed from
focus groups of patients with chronic liver disease awaiting liver
transplantation, expert hepatology panel input, and an extensive review
of the literature. Cognitive interviews were conducted to detect
potential problems with instrument design or wording of items. The HRQOL
instrument was then constructed consisting of 36 generic items (SF-36)
supplemented with 77 disease-targeted items. A multicenter,
cross-sectional field test was conducted.

**Results:** 221 consecutive ambulatory adult patients being evaluated
for liver transplantation participated in this field test (64.1% male;
median age = 51 years (range 23-78 years); 68.9% white, 6.8%
Asian/Pacific Islander, 3.9% frican-American, 1.9% Native American,
18.5% other or multiracial). The LDQOL 1.0 is a self-report measure that
includes 21 multi-item scales (number of items): physical functioning
(10), role limitations-physical (4), pain (2), liver disease-related
symptoms (19), emotional well-being (7), role imitations-emotional (3),
energy (4), cognitive function (6), memory (4), concentration 3),
hopelessness (7), loneliness (6), stigma of liver disease (8), social
function (2), quality of social interaction (5), sexual function (3),
sleep 6), general health perceptions (7), health distress (4), effects
of liver disease 9), and impact of liver disease (4). Internal
consistency reliabilities (Cronbach\'s alpha) ranged from 0.67 to 0.95
(median=0.86); 20/21 reliability estimates were excellent, alpha \>=
0.70. All 21 scales were significantly (p\<0.05) associated with
self-reported severity of symptoms and 4 scales with duration of liver
disease (better HRQOL related to less severity and shorter duration of
liver disease). Role limitations-physical was most strongly related to
severity of symptoms (p\<0.01); sleep was most strongly associated with
duration of disease (p\<0.05). Worse physical functioning (p\<0.01),
worse sexual functioning among males (p\<0.01), role
limitations-physical (p\<0.01), more liver disease-related symptoms
(p\<0.05), and greater negative effects of liver disease (p\<0.05) were
all significantly associated with higher Child-Pugh class.

**Conclusions:** This multicenter study demonstrates the high degree of
reliability and construct validity of the LDQOL 1.0 for individuals with
chronic liver disease. This HRQOL outcomes instrument is able to measure
significant impairment of daily functioning not detected by more
traditional clinician-rated methods (e.g., Child-Pugh classification).
The LDQOL 1.0 is now ready for implementation into prospective,
longitudinal studies.

**Impact:** 1. The LDQOL 1.0 will allow for a better understanding of
HRQOL in patients with chronic liver disease. 2. The LDQOL 1.0 fits well
with the VHA\'s initiative to build a system of data collection that
will integrate both generic and disease-targeted functional status
instruments into a routine process of HRQOL data collection. 3. HRQOL
data collection in chronic liver disease will allow for case mix
comparisons, evaluation of changes in patient functional status over
time and its potential relationship to processes of care, and generation
of patient summary information for the clinician in their care of
patients with chronic liver disease. 4. The LDQOL 1.0 may provide
important information on resource utilization within the VA health care
system such as response to therapeutic interventions (e.g., therapies
for chronic viral hepatitis and liver transplantation).

**31. Measuring the Job Satisfaction of Providers in VA Primary Care:
the Seattle Provider Satisfaction Questionnaire (SPSQ)**

## Mary McDonell, MS. VA Puget Sound Health Care System, Seattle, WA. J Marshall. Stephan Fihn, MD, MPH. VA Puget Sound Health Care System, Seattle, WA. KE Kilpatrick, and DS Lessler.

**Objectives:** Determining the satisfaction of health care providers is
critical given continual changes in organization and expectations that
often dramatically affect providers and influence their perceptions
about their ability to deliver high quality care. We developed and
validated a survey to measure multiple dimensions of job satisfaction
among VA primary care providers.

**Methods:** Open-ended interviews designed to elicit provider
perceptions of organizational characteristics that contributed to work
satisfaction were conducted with 20 providers from a large group
practice and VAPSHCS. Interviews and published questionnaires were used
to generate a prototype 78-item questionnaire. As part of the Ambulatory
Care Quality Improvement Project (ACQUIP) pilot study, the survey was
tested among 236 general internists at 8 facilities (VA and non-VA) and
condensed to 50 items. The 50-item questionnaire has now been
administered to 220 providers at 7 ACQUIP sites and 792 providers at 56
VA facilities participating in the PRIME program. We performed
exploratory (EFA) and confirmatory factor analyses (CFA) to analyze
dimensionality of the SPSQ. Convergent and discriminate validity of the
SPSQ were assessed using CFA as an approximation of the
multitrait-multimethod approach. ANOVA and linear regression were used
to examine subscale and global satisfaction scores and to adjust for
demographic characteristics. Scales were scored from 0 (least satisfied)
to 100 (most satisfied).

**Results:** The sample of 1012 providers was comprised of physicians
(69%), nurse practitioners (NPs) (22%) and physician assistants (PAs)
(9%). 49% were female. Ages ranged from 20-65 years; 40% were between 36
and 45. 77% were Caucasian, 12% Asian, and 4% African American. 44% had
been at their jobs for \>5 years. Six dimensions (subscales) emerged
from factor analysis and all demonstrated high internal consistency:
clinical staff communication (Cronbach\'s alpha=.86); relationships with
specialists (.89); hassle-free work environment (.89); patient
characteristics (.77); philosophy of practice (.84); and colleagues
(.84). The CFA also demonstrated both convergent and discriminant
validity (p\<.001). Mean scores for all scales were low: staff
communication (38.6); specialists (41.5); assle-free (37.7); patient
characteristics (49.3); philosophy (66.4); and colleagues (58.4).
Subscale and global satisfaction scores did not differ significantly
according to gender, age, ethnicity, time on the job or provider type
(resident, staff MD, PA, NP). Comparing different VA facilities, there
were significant differences for all scales that were most dramatic
(i.e., \>25 points) for philosophy and colleagues. When the six domains
were entered into a regression model predicting global satisfaction, the
philosophy domain (belief in organization\'s philosophy and ability to
practice according to personal standards) accounted for 57% of the
variance (p \< .001). Clinic organization and clinical staff
communication were also significantly related to overall satisfaction
(p\< .001).

**Conclusions:** The SPSQ is a reliable, valid measure of multiple
domains of provider satisfaction. The extent to which a provider\'s
practice standards and philosophy are aligned with the organizations is
a key determinant of overall satisfaction.

**Impact:** The SPSQ is potentially useful for monitoring outcomes and
evaluating changes in clinic organization.

**HSR&D Funded:** SDR 96-002

32\. Patient Characteristics and Patterns of use of Lumbar Spine
Radiographs: Results from the Veterans Health Study

## Alfredo Selim,, MD, MPH. Boston VA Medical Center, Boston, MA. G Fincke. X Ren, PhD. Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA. A Lee, and C Skinner. Lewis Kazis, ScD. Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA.

**Objectives:** Understanding patient factors that affect patterns of
use of lumbar spine films is essential for clinicians, hospital
administrators, and managers in order to adopt the best and most
effective practice of x-ray utilization. Very little is known about
patient factors that affect patterns of x-ray use such as no use and
repeat lumbar spine films. In this study, we examined a number of
patient characteristics in groups of low back pain patients as defined
by their pattern of x-ray use after 12 months of prospective follow-up.

**Methods:** We analyzed longitudinal data from the Veterans Health
Study, an observational study of patients receiving ambulatory care.
Five hundred and seventy four patients with LBP were identified through
self-report of ever having had LBP that began more than three months ago
and a health care visit for LBP in the past year. Four hundred and one
of these patients were available for follow-up 12 months after the
initial study visit. Participants were mailed a health-related quality
of life questionnaire (HRQoL), and had an interview that included a LBP
questionnaire and a straight leg raising test. We defined four groups
based on the patterns of use of lumbar spine films (new, repeat, no
repeat, and no use of lumbar spine films. We compared these groups in
terms of sociodemographics, comorbid conditions, low back pain
intensity, radiating leg pain, straight leg raising, HRQoL, and low back
disability. We examined predictors of repeat lumbar spine radiographs
during the 12 months of prospective follow-up and no use of lumbar spine
films.

**Results:** Patients with new lumbar spine films showed worse physical
impairment and psychological distress than the other groups. Compared to
other groups, patients with no lumbar spine films reported minor
physical impairment. Patients with repeat lumbar spine films showed
evidence of psychological distress which can not be explained by the
small differences in physical health between these patients and those
who had no have repeat films. Using regression models, straight leg
raising, radiating leg pain, and mental health were found to be
independent predictors of repeat use of lumbar spine radiographs
(c-statistic of 0.73). We found that low back pain intensity, vitality,
and mental health were independent predictors of no use of lumbar spine
films (c-statistic of 0.72).

**Conclusions:** This study found that the use of lumbar spine film is
strongly influenced by patient characteristics. Given the physical and
emotional toll that low back pain takes on these patients, our data
illustrated that physicians rely primarily on the degree of physical
impairment to request initial roentgenographic evaluations. Physicians
appear to give the benefit of the doubt to patient in psychological
distress in considering repeat lumbar spine films. However for many of
these patients, education is needed instead of lumbar spinal films.

**Impact:** Careful consideration of both physical and psychological
characteristics of patients with LBP is essential when evaluating and
comparing use of lumbar spine films.

**HSR&D Funded:** SDR 91-006

**33. Positive Effects of a Workbook-centered Advance Care Planning
Intervention**

## Helene Starks, MPH. VA Puget Sound Health Care System, Seattle, WA. RA Pearlman. KC Cain, and G Cole.

**Objectives:** We evaluated the effectiveness of a comprehensive
advance care planning (ACP) intervention in clinical practice by
measuring whether it increased ACP discussions, and completion and
documentation of advance directives.

**Methods:** In this randomized controlled trial, the intervention group
received an ACP workbook (Your Life, Your Choices), social work
counseling, and cues to primary care providers to discuss ACP with their
patients. The control group received the VA brochure on advance
directives. Twenty-two primary care providers were recruited from the
Puget Sound VA. For each provider, 14 patients were randomized to the
control or intervention groups. Eligibility criteria included having a
primary care provider whom the patient had seen at least once, age \>55
with at least one chronic condition, and no advance directive in the
medical record. The intervention was structured around an existing
appointment with the primary care provider.

**Results:** Thirty-five percent of subjects that were approached for
the study agreed to participate. At enrollment these patients generally
endorsed the importance of ACP and were ready to engage in it.
Preliminary data are available for 113 patients (49 and 64 patients were
in the intervention and control arms, respectively. This imbalance is
due to delays in obtaining outcomes data in some intervention subjects
and not due to subject drop-out.). The intervention patients
demonstrated greater ACP activities than the control patients. They
self-reported having more ACP discussions with their primary care
providers (65% versus 41%), written instructional directives (67% versus
45%), and appointments of durable power of attorney for health care (63%
versus 41%) (all comparisons, p\<0.05). The intervention patients also
self-reported that the directives were in their VA medical records more
often: written instructional directives (49% versus 19%) and
appointments of durable power of attorney (49% versus 17%) (both
comparisons, p\<0.01). Electronic flags of advance directives in the
medical records of intervention patients demonstrated greater than
three-fold improvements in documentation: 40% versus 11% for written
instructional directives, 33% versus 10% for durable power appointments
(both comparisons, p\<0.01).

**Conclusions:** A multifaceted intervention centered around a
newly-created ACP workbook promoted discussions about this topic with
primary care providers and resulted in a substantial increase in the
documentation of directives in the medical records. The control patients
exhibited more ACP-related activities than the general population. This
is not unexpected, given that most patients who truly are unprepared for
or unwilling to think about ACP will not consent to participate in such
a study. Our finding of a large treatment effect among our relatively
receptive sample (representing about one-third of those eligible)
suggests that being willing to consider ACP is not enough: a
multi-faceted intervention aimed at educating, motivating and
facilitating the process can increase ACP activity substantially.

**Impact:** These preliminary results suggest that utilizing the
workbook, entitled Your Life, Your Choices, social workers and clinician
cues can increase ACP discussions and completion of directives. These
are desirable outcomes that suggest that this multifaceted intervention
should be implemented at other VA medical centers.

**HSR&D Funded:** IIR 96-047

34\. Measuring Patient Expectations: Does the Measurement Instrument
Affect the Number of Expectations Elicited and Patient Satisfaction?

[Bob Peck, MS.]{.underline} Durham VA Medical Center, Durham, NC. [DA
Asch, MD, MBA.]{.underline} Leonard Davis Institute of Health Economics,
Philadelphia, PA. [SD Goold, and D Roter.]{.underline} [Peter Ubel,
MD.]{.underline} Philadelphia VA Medical Center. [James Tulsky,
MD.]{.underline} Durham VA Medical Center, Durham, NC.

**Objectives:** Fulfillment of patient expectations can be used as an
indicator of quality of care, and may influence health care utilization
and costs. Previous research has shown that the number of expectations
fulfilled is positively associated with medical visit satisfaction.
However, research also suggests that how expectations are measured may
create expectations for care. We conducted this study to examine the
relationship between the type of instrument used to measure patients\'
expectations, the method of eliciting expectations, and patient
satisfaction. In particular, we sought to determine whether instruments
that elicit different numbers of expectations create bias by yielding
different patient satisfaction.

**Methods:** We randomly assigned patients in a single VA outpatient
clinic to one of three methods of expectation assessment. One group
received a questionnaire that asked only about 3 specific expectations
for care: tests, referrals, and new medications. A second group received
a questionnaire that asked about the same three expectations; however,
they were nested within a longer list of expectations. The third group
received no pre-visit measure of expectations. All patients were
interviewed after the clinic visit to assess whether expectations were
met and to assess satisfaction with the visit using the ABIM and Ware
Visit Specific Questionnaire (VSQ).

**Results:** 409 consecutive patients in the outpatient clinics were
approached to participate. 291 (71%) patients completed both the pre-
and post-visit interviews. The remaining 118 patients either refused
(20%), did not complete the post-visit interview (8%), or failed the
enrollment criteria (1%). The mean patient age was 60, 99% were male,
69% were white and, on average, the patients had completed 12 years of
education. The treatment groups did not differ significantly by any
demographic variables. The type of instrument used to measure
expectations for care was significantly related to the number of
expectations reported. The group receiving the specific questionnaire
reported an average of 0.74 expectations for tests, referrals, and new
medications. The group receiving the nested questionnaire reported an
average of 1.65 expectations for the same items (p\<0.001). Despite the
differences in expectations elicited, reported satisfaction did not
differ among the groups. The mean ABIM satisfaction scores for the three
groups (specific, nested, control) were 13.86, 13.83, 14.42 respectively
(p=.660). The mean Ware VSQ scores for the three groups were 16.09,
16.57, 16.42 (p=.897).

**Conclusions:** The type of instrument used to measure patient
expectations affects key outcome variables. A questionnaire with more
expectations to choose from generates more expectations than a
questionnaire with fewer expectations. Different measurement
instruments, however, do not affect patient satisfaction.

**Impact:** Investigators studying patient expectations must contend
with an \"instrument\" effect when measuring the number of expectations.
However, they need not worry that the instrument will affect patient
satisfaction with the medical encounter.

**HSR&D Funded:** MCV 97-011

# 35. Barriers to Walking for Exercise in Elderly Primary Care Patients

## Patricia Dubbert, PhD. GU "Sonny" Montgomery VA Medical Center, Jackson, MS. DE Bilbrew, KM Cooper, and ER Meydrech.

**Objectives:** Walking is a good exercise recommendation for many older
patients, but not all are able or willing to adopt a regular walking
habit. Interventions to increase physical activity in older patients at
risk for increased disability require understanding of potential
barriers to regular activity. The purpose of this study was to identify
barriers to unsupervised walking for exercise as viewed from two
perspectives: the health care provider and the patient.

**Methods:** Participants were patients being screened for the Seniors
Telephone Exercise Primary Care Study (STEPS), which is designed to test
the effectiveness of nurse telephone counseling to increase walking for
exercise. To determine the relative frequency of medical exclusion
barriers identified by health care providers, medical records of 658
veterans aged 60-80 and enrolled in VA primary care clinics were
selected randomly on the day of clinic visits and reviewed by a nurse
researcher. Conditions which would exclude the patient from counseling
for an unsupervised walking program ere recorded. Subsequently, patients
who passed the medical record prescreen and attended a research clinic
visit completed an instrument listing 18 potential barriers to exercise.
Patients indicated the degree to which they agreed or disagreed with
each potential barrier. Responses were ranked within patients and
analysis of variance used to identify the most highly ranked barriers.

**Results:** 217 (33%) of the 658 medical records reviewed by the
research nurse over a period of several months revealed one or more
medical exclusions for nurse counseling for unsupervised walking. The
most frequent were: severe cardiovascular disease (41%), severe
orthopedic problem/joint disease (21%), and severe pulmonary disease
(15%).. Ratings by patients of the potential barriers revealed 8 were
most endorsed. Ranked in order these were: 1) no good place to exercise;
2) exercise makes me tired; 3) too much exercise could be bad for my
heart; 4) exercise makes me hurt more; 5) exercise is hard work for me;
6) family members don\'t encourage exercise; 7) too much exercise could
make me sick; 8) persons close to me don\'t encourage exercise. Rankings
of barriers were not associated with age, ethnicity, or urban vs. rural
home location.

**Conclusions:** The STEPS program was designed to provide nurse
counseling for physical activity for patients with chronic medical
conditions, but we found that one-third of elderly primary care patients
had to be excluded from consideration due to health barriers to
unsupervised exercise or inability to walk. Among eligible patients who
attended a screening visit, health concerns were highly ranked as
perceived barriers to exercise

**Implications:** Although the majority of elderly primary care patients
could be eligible for nurse counseling for home-based exercise, a
substantial minority (1/3 in our sample) could not be referred for a
walking program. Future prevention efforts need to include consideration
of appropriate physical activity designed to maintain functional status
and the psychosocial benefits of activity for those who cannot engage in
a walking program. Effective methods of addressing patientsÆ perceived
barriers, including concerns about health risks of exercise, are needed
to optimize prevention counseling for those patients who can walk for
exercise.

**HSR&D Funded:** NRI 95-022

# 36. Validity of Physical Activity Recall in Urban and Rural Elderly Men

## Patricia Dubbert, PhD. GU "Sonny" Montgomery VA Medical Center, Jackson, MS. KE Kerr, DE Bilbrew, KA Kirchner, EF Meydrech, B Shaw.

**Objectives:** To evaluate the impact of low levels of physical
activity (PA) on health and the effects of interventions to increase PA,
investigators must often rely on self-report measures such as the 7 day
physical activity recall (PAR). The reliability and validity of this
measure has not been established in older and rural populations. The
purpose of the study was to evaluate the temporal stability and the
validity of PAR in elderly urban and rural dwelling elderly men.

**Methods:** 142 men, average age 68.7 (S.D. 4.6) years, 27% minority,
54% rural, 46% \< HS education, who were being screened for the Seniors
Telephone Exercise Primary Care Study (STEPS) completed the PAR; a
subset of 97 of these subsequently completed a submaximal treadmill
test. 138 completed a second PAR 2 to 4 weeks after the first. PARs were
administered and scored by trained interviewers using standardized
protocols. Energy expenditure (EE) was estimated for several intensity
levels of PA. Temporal stability was estimated with Pearson correlations
of EE at different intensities of PA across the 2 occasions. Validity
coefficients were the Pearson correlations of estimated EE with
cardiorespiratory fitness as measured by the submaximal treadmill
performance (METs).

**Results:** Most participants reported little or no hard intensity PA.
Temporal stability was 0.45 (P\<.01) for total weekly EE; 0.44 (P\<.01)
for moderate PA; and 0.65 (P\<.01) for light-moderate PA; comparing
favorably with results of previous studies with young, healthy, active

samples. In urban participants, total EE (0.33, P\<.03), hard PA (0.36,
P=.02), and moderate PA (0.31, P=.04) were each significantly correlated
with treadmill performance with validity coefficients similar to those
observed in previous research with younger samples. In rural
participants, however, only estimated EE for light-moderate PA was
significantly correlated with treadmill performance (0.29, P=.03). Total
EE estimates and submaximal treadmill performance were similar for both
groups. Validity coefficients were improved by coding specifically for
both light-moderate and moderate PA.

**Conclusions:** Stability of moderate and light-moderate PA was similar
in urban and rural dwelling elderly men and stability of moderate and
light-moderate PA recall in both groups was similar to results from
previous research. In our sample, the performance of the PAR against
treadmill fitness as a validation standard was better in urban men. It
may be more difficult to accurately estimate duration and intensity (and
EE) of the variety of PA described by rural men.

**Impact:** Measurement of the effectiveness of preventive counseling to
promote healthful PA requires measures which are reliable and valid in
the diverse populations served. Failure to accurately assess the health
behaviors of elderly and rural dwelling populations will make it

difficult to evaluate effectiveness of interventions to decrease health
risks. Future research should examine differences in types of PA which
could account for the findings as well as evaluate the accuracy of EE
estimates by using motion sensor and other approaches for measuring PA
which do not depend.

37\. Multidisciplinary Rehabilitation Versus Medical Care use of
Meta-Analysis to Determine the Clinical Effectiveness of Physical
Medicine

## Ron Evans, MSW. VA Puget Sound Health Care System, Seattle, WA.

**Objectives:** Research studies in physical medicine have not
demonstrated the effectiveness of inpatient rehabilitation services,
primarily due to differences in methodological approaches which have led
to inconsistent findings. To address this problem, research studies
comparing the clinical effects of rehabilitation with medical care were
evaluated for 3 uniformly available outcomes: survival, functional
ability, and discharge location. Published trials were obtained from
citations in Medline and Nursing and Allied Health Abstracts covering
the period from 1974 to 1995 using the descriptors: rehabilitation,
physical medicine, activities of daily living, and functional ability.

**Methods:** We used meta-analysis of completed clinical trials to test
the hypotheses that rehabilitation results in better health care
outcomes. To be included studies had to prospectively evaluate a
multidisciplinary program of physical rehabilitation by comparing
outcomes with a control group and report results in a manner that
allowed quantitative analysis of uniformly available variables: e.g.,
mortality, function, and residence. Eleven studies met this rather
stringent criteria.

**Results:** Results indicated that rehabilitation services are
significantly associated with better rates of short term survival (86%
versus 81%, Chi-square=7.30, p \< 0.01) and improved function during
hospital stay (Fisher Combined Test, Chi-square=67.12, p \< 0.01), but
significance was not observed at one year. Also, rehabilitation patients
returned home and remained there more frequently than controls (Odds
ratio=2.08, Chi-square=40.15, p\< 0.001).

**Conclusions:** We concluded that patients who participate in
rehabilitation: 1\] function better at hospital discharge, 2\] have a
better chance of short term survival, and 3\] return home more
frequently than non-participants. Contrarily, long term survival and
function were unaffected by the relatively short term treatment \[3-5
weeks\].

**Impact:** The sustaining benefit of returning home may justify
provision of inpatient rehabilitation. However, the lack of other long
term benefits suggests that services may need to be continued at home or
in subacute care settings to optimize their effectiveness. Future
clinical research might include social and behavioral outcomes so that
results of rehabilitation research can be applied to clinical settings
and can more accurately reflect psychosocial objectives.

**HSR&D Funded:** IIR 94-125

# 38. Racial Variation in Congestive Heart Failure Mortality among the Elderly

[Said Ibrahim, MD.]{.underline} University Hospitals of Cleveland and
Cleveland VA Medical Center, Cleveland, OH. [EF Cook]{.underline} [C.
Kent Kwoh, MD and Gary Rosenthal, MD.]{.underline} Cleveland VA Medical
Center. [DW Baker.]{.underline}

**Objectives:** Prior studies have suggested a significant difference
between blacks and whites in in-hospital mortality from congestive heart
failure (CHF). Whether this difference is sustained in the long-term and
what clinical factors account for this difference remain unclear. The
objective of this study was to compare risk-adjusted,
post-hospitalization short-term and long-term mortality from congestive
heart failure in elderly black and white patients. This is a 2-year
follow-up of a cohort for whom an in-hospital mortality was reported in
a published study in 1996.

**Methods:** The study sample consists of 12,991 patients with the
principal discharge diagnosis of congestive heart failure (CHF)
following an admission to one of 30 hospitals in Northeast Ohio between
1991 and 1993. All patients were Medicare enrollees 65 years of age or
older.

**Data Collection:** This data comes from the Cleveland Health Quality
Choice Program (CHQC). The reliability of data collection for CHQC has
been confirmed in prior studies. The database includes information on
demographics, comorbid conditions, laboratory test results and detailed
clinical information abstracted from patients\' hospital records.
Analysis: Crude and adjusted 30-day and 2-year survival curves were
compared for black and white patients using Kaplan-Meier method.
Multivariate analysis was performed using Cox Proportional Hazard models
to determine adjusted hazard ratios for the relationship between race
and 30-day, 90-day and 2-year mortality. Important clinical variables
such as age, gender, comorbid medical conditions, ejection fraction,
albumin level, creatinine level and serum sodium level were included in
the models.

**Results:** Black and white patients in this cohort were comparable
with respect to age, and gender. Blacks were more likely to have
hypertension ( blacks 47%, whites 31% ), and less likely to have
Ischemic Heart Disease (blacks 30%, whites 58%). Other comorbidities
were comparable. In the one third of the cohort who had ejection
fraction recorded, blacks were just as likely to have left ventricular
systolic dysfunction compared with whites. During the first 30 days,
blacks showed better survival compared to whites (adjusted hazard ratio
0.7 95% CI 0.60-0.83). However, over time the survival advantage for
blacks diminished, although it remained significant. During the first 90
days the adjusted hazard ratio for blacks was 0.80 (95% CI 0.60-0.90),
and during the first 2 years it was 0.90 (95% CI 0.83-0.97).

**Conclusions:** This study is one of the first to compare short term
and long-term CHF mortality between blacks and whites. Although in the
short-term elderly blacks have lower mortality, in the long-term their
mortality approaches that of whites. However, because the majority of
patients did not have left ventricular ejection fraction measured,
further studies are necessary to understand whether racial differences
in survival are explained by differences in left ventricular function.

**Impact:** This study adds to our understanding of the racial
variations in outcomes of chronic medical conditions. As the minority
patient population in the VA health system increases, understanding
racial variations in outcomes will help us devise approaches that will
reduce black and white disparities in health outcomes.

**39. African American Veterans with Coronary Artery Disease** **Report
Worse Health and Less Satisfaction with Care than Whites: Results from
the ACQUIP Survey**

## Catarina Kiefe, Mary McDonell, MS, Donald Martin, PhD, and Stephan Fihn, MD, MPH. VA Puget Sound Health Care System, Seattle, WA.

**Objectives:** Racial differences in management of coronary artery
disease (CAD) are well known but poorly understood. Several studies
document less intense management of African Americans (AA) compared to
Whites, even within the Department of Veteran Affairs (DVA). We examined
AA vs. White differences in self-reported health status and satisfaction
among veterans with CAD.

**Methods:** Cross-sectional analysis of surveys mailed to 38,642
General Internal Medicine Clinic patients at 7 VAs. Survey information
included socioeconomic factors and a checklist of medical conditions,
including CAD. Patients reporting CAD received follow-up surveys
including: the Seattle Angina Questionnaire (SAQ); the Seattle
Outpatient Satisfaction Questionnaire (SOSQ) which measures satisfaction
with humanistic and organizational aspects of care; and the Medical
Outcomes Study SF36. All scales were scored from 0 (worst) to 100
(best).

**Results:** 66% of patients responded to the baseline surveys; 4,204
(16.4%) classified themselves as AA, and 15,391 (63.5%) as White. AAs
compared to Whites were younger (58.9 vs. 62.8 years, p \< .001), less
likely to use non -VA health care (27.9% vs. 37.2%, p \< .001) or to be
married (44.8% vs. 59.2%, p \< .001); more likely to have income below
\$10,000 (39.9% vs. 24.8%, p \< .001), to smoke (33.6% vs. 25.6%, p \<
.001), and to screen positive for drinking problems (39.2% vs. 30.4%, p
\< .001). AAs were also more likely to report diabetes (25.8% vs. 20.2%,
p \< .001) and hypertension (65.4% vs. 52.0%, p \< .001), but less
likely to report CAD (26.6% vs. 37.9%, p \< .001). CAD was reported by
9,287 patients (36%); 1,118 AAs, 5,836 Whites and 4,642 other. The
differences between Whites and AAs reported above were also present in
CAD patients. Among CAD patients, 61.3% returned the SAQ, SOSQ, and
SF36. AAs scored lower than Whites on the Exertional Capacity (48.6 vs.
52.4, p=.003) , Disease Perception (58.8 vs. 64.1, p\<.001) and
Satisfaction (77.1 vs. 84.4, p\<.001) domains of the SAQ (p \< .01), but
did not differ on Angina Frequency and Stability. AAs were also less
satisfied than Whites with humanistic (65.6 vs. 74.3, p \< .001) and
organizational (58.7 vs. 64.2, p \< .001) aspects of care. AAs scored
higher than Whites on the Vitality scale of SF36 (40.9 vs. 35.2, p \<
.001) and lower on Emotional Function (50 vs. 54.7, p \< .001); AAs
tended to score lower on the other SF36 scales but differences were not
significant at p\<0.01. Differences persisted after adjustment for age,
income, education, and marital status.

**Conclusions:** Compared to Whites, AAs in this DVA sample had poorer
socioeconomic circumstances. Among those with CAD, there were no racial
differences in overall health or severity of angina symptoms. Yet, even
after adjustment for socioeconomic factors, AAs had worse scores on
exertional capacity, disease perception, and satisfaction, both general
and related to their CAD.

**Impact:** Racial differences in health status and satisfaction
parallel differences in treatment observed in other studies.
Longitudinal analyses should explore potential causal relationships
between these different instances of racial differences.

**HSR&D Funded:** SDR 96-002

# 40. Racial Variation in Mortality Following Elective Surgery for Vascular Disease

[Tracie Collins, MD, MPH, Howard Gordon, MD.]{.underline} Houston VA
Medical Center, Houston, TX. [M Johnson.]{.underline} [Jennifer Daley,
MD.]{.underline} Brockton, MA. [W Henderson, and SF Khuri.]{.underline}

**Objectives:** Racial variation in mortality for common medical
interventions such as elective surgery has not been well investigated.
The purpose of this study is to assess differences in 30-day
postoperative mortality between whites and blacks after elective surgery
for vascular disease.

**Methods:** Data from the National VA Surgical Quality Improvement
Program were used. A prospective, multicenter observational study of
risk adjusted surgical outcomes after major surgery. Race was defined as
black, not of Hispanic origin or white, not of Hispanic origin as
identified by the physician, physician assistant, or clinical nurse
specialist. Cases involving other races were excluded. The following
elective surgeries were evaluated: abdominal aortic aneurysm repair
(AAA; n=1401;94.2% white and 5.8% black), and lower extremity
revascularization surgery (LEVS;n=2773;81.7% white and 18.3% black), and
lower extremity amputations (AMP;n=2336;70.7% white and 29.3% black).
The outcome of interest was all cause mortality within 30 days of the
index surgery. For each surgery, the independent relationship of race
and mortality was examined with multivariable logistic regression
models. Models were adjusted for co-existing illnesses and markers of
baseline health that were univariately significantly associated with
30-day mortality and/or clinically relevant.

**Results:** The overall 30-day mortality was 4.0% for AAA, 2.1% for
LEVS, and 7.0% for AMP. The 30-day unadjusted mortality rate in black
compared to white patients was higher (9.5 vs. 3.5%;p=.013) for AAA, and
was similar for other vascular disease related surgeries (1.7 vs.
2.2,p=.517, LEVS;8.0 vs. 6.6%,p=.253,AMP). The multivariable odds ratio
for mortality in blacks compared with white patients undergoing AAA was
2.6 (95% CI 1.11-6.05) after adjusting for age, hypertension, dyspnea,
creatinine \>= 1.2, history of cerebrovascular accident, diabetes, and
ASA-class.

**Conclusions:** For black patients who undergo elective AAA, there is a
higher rate of both unadjusted and adjusted mortality compared to white
patients. Following LEVS and AMP, there were no statistically
significant increased risks of mortality among blacks. The increased
risk of mortality following AAA could not be accounted for by
co-morbidities. Further research is needed to address issues of access
to care, unmeasured risk factors specific to African Americans, and/or
process of care, which could account for the increased 30-day mortality
following elective AAA.

**Impact:** Understanding the factors related to increased 30-day
mortality for a minority population following an elective medical
intervention can help to improve health care within the Veterans
Administration.

**HSR&D Funded:** NSQIP

**41. Antimicrobial Prophylaxis for Urinary Tract Infection in Persons
with Spinal Cord Dysfunction**

## Sally Morton, PhD. Rand Statistics Group, Santa Monica, CA. Paul Shekelle, MD. West Los Angeles VA Medical Center, Los Angeles, CA. JL Adams. Charles Bennett, MD, PhD. Chicago VA Medical Center, Chicago, IL. B Dobkin and BG Vickrey.

**Objectives:** Recurrent urinary tract infections (UTIs) occur
frequently in persons with neurogenic bladders due to spinal cord
dysfunction, resulting in increased morbidity and cost. To assess the
potential benefits and possible harms of antimicrobial prophylaxis to
prevent recurrent UTI, we conducted a meta-analysis of controlled
trials.

**Methods:** MEDLINE and EMBASE were searched from 1966 and 1974
respectively to January 1998, and CINAHL was searched from 1982 to July
1998 using a broad and inclusive strategy with no language restriction.
Additional articles were identified by experts and via a hand-search of
reference lists. All controlled trials of prophylaxis of UTI that
included bacteriuria or UTI as an outcome were included; two reviewers
were used. Nineteen trials were identified. Two reviewers abstracted
data. Studies were graded according to the quality criteria of Jadad and
Schulz. Effect sizes of differences in weekly infection rates (treatment
minus control) were pooled using a random effects model. Specific
subgroup analyses (asymptomatic versus symptomatic infections; acute
versus non-acute patients; high quality, defined as a Jadad score
greater than or equal to three, versus low quality) were identified a
priori. Sensitivity analyses were also conducted.

**Results:** Antimicrobial prophylaxis is associated with a reduction in
asymptomatic bacteriuria among patients in the acute phase (less than 90
days) following spinal cord injury. The difference in weekly infection
rates was equal to -0.27 (95% confidence interval of -0.40 to -0.15; p
\< 0.05). This means that one patient would require 3.7 weeks of
treatment on average to prevent one infection. For non-acute patients
the reduction in asymptomatic infections was -0.06 (95% confidence
interval of -0.12 to 0.00; p = 0.06). However, antimicrobial prophylaxis
did not significantly decrease symptomatic infections among any
patients. For acute patients, the difference was -0.03 (95% confidence
interval of -0.08 to 0.02; p \> 0.05), while for non-acute patients, the
difference was -0.04 (95% confidence interval of -0.11 to 0.04; p \>
0.05). The study quality subgroup analyses showed no differences from
the overall pooled results. In addition, antimicrobial prophylaxis
resulted in a two-fold increase in the proportion of
antimicrobial-resistant bacteria.

**Conclusion**s**:** The regular use of antimicrobial prophylaxis for
reducing symptomatic infections in most patients with neurogenic bladder
due spinal cord dysfunction cannot be supported.

**Impact:** Routine antimicrobial prophylaxis should not be given to
patients with neurogenic bladder due to spinal cord dysfunction. Future
research to identify subgroups of patients who might benefit from
antimicrobial prophylaxis is needed. Such research should focus on
randomized controlled trials that employ rigorous methods; have adequate
statistical power; define the study population and outcomes carefully;
measure cost and quality-of-life outcomes; and measure potential harms,
particularly the development of antimicrobial resistant organisms.

**42. Predictors of Outcomes in Patients with Type 2 Diabetes Mellitus**

## Virginia Baldwin, PhD, RPL. Portland VA Medical Center, Portland, OR. SK Joos and DH Hicham

**Objectives:** Quality improvement programs for the management of
diabetes mellitus (DM) often emphasize the importance of regularly
assessing hemoglobin A1c (HgA1c) and maintaining good glycemic control,
but there is only limited evidence that HgA1c accurately predicts
outcomes for patients with type 2 DM. The purpose of this study was to
investigate the relationships among HgA1c, severity of disease, and
outcome measures for a group of patients with type 2 DM.

**Methods:** In 1994-96, 212 veterans with confirmed type 2 DM were
enrolled in the study and followed for an average of 3.2 years. Patients
were recruited during regularly scheduled visits to a general medicine
clinic at the Portland VAMC. Upon study entry, subjects completed the
Diabetes Severity Index (DSI) Questionnaire, the SF-36, the GHAA
Consumer Satisfaction Survey, and a series of demographic questions. In
September 1998, information on death from all causes, medication use,
and HgA1c lab values was downloaded from VISTA. A DSI score, composed of
five subscales (Visual, Renal, Vascular, Neurological, and Metabolic),
SF-36 scores, and satisfaction scores were calculated for each patient.
Based on mean HgA1c values, patients were classified as well-controlled
(WC) (HgA1c\<=7.0), moderately controlled (MC) (HgA1c\>7.0 and \<9.0),
or poorly controlled (PC) (HgA1c\>=9.0).

**Results:** The patients\' mean age was 64.4 years, and 95% were male.
Forty-two (19.8%) died during the follow-up period. Sixteen percent of
patients were classified as WC, 59% as MC, and 25% as PC. WC patients
had significantly shorter duration of DM than did MC or PC patients (5.7
vs. 10.2 and 10.7 years, respectively) and tended to be treated with
oral diabetic agents (40%) or diet alone (50%). PC patients more often
were treated with oral medications (64%) and/or insulin (68%). Mean
HgA1c values were not significantly associated with death, any of the
eight SF-36 subscales, any of the seven GHAA patient satisfaction
measures, or any of the DSI disease severity subscales with the
exception of the metabolic subscale, which consists primarily of
glycemic control variables. Several DSI measures of disease severity
were significantly associated with patient functional status (SF-36) and
satisfaction. The overall DSI score and the neurological and vascular
subscales were significantly and negatively associated with all eight
SF-36 subscales (Spearman\'s rho \[r\] ranged -0.20 to -0.40) and nearly
all of the seven patient satisfaction subscales (r -0.15 to -0.22) , and
positively associated with death (p\<0.05). However, the metabolic
subscale was not associated with any satisfaction or functional status
measures, or death.

**Conclusions:** HgA1c measures were poorly associated with severity of
disease and patient outcomes, such as functional status, satisfaction
with care, and mortality. Other measures of diabetes severity were much
more strongly associated with outcomes for these patients with type 2
DM.

**Impact:** In these older type 2 diabetic patients with relatively low
functional status, glycemic control as measured by HgA1c appears to be
unrelated to patient outcomes. However, a multidimensional measure of
severity of diabetes does predict outcomes. Quality improvement efforts
for type 2 DM should focus more attention on clinical factors other than
glycemic control.

**43. Variations in Institutional Review Board (IRB) Approvals for
Allowing Third Party Medical Record Reviews of HIV-infected Individuals
without Patient Consent. The Multicity PCP Quality of Care Study**.

[Alison Sipler, BA.]{.underline} Chicago VA Medical Center, Chicago, IL

**Objectives:** Evaluation of medical care depends on record reviews and
Institutional Review Board (IRB) approval. There is increasing concern
about medical record confidentiality, especially among HIV-infected
individuals. We evaluated variations in IRB decisions for access to
medical records of HIV-infected individuals as part of a multi-city
study of quality of HIV care.

**Methods:** The research setting was a random sample of VA and non-VA
hospitals in New York, Miami, Chicago, Los Angeles, Raleigh-Durham,
Seattle, and Arizona in 1990 (n=109) and 1997 (n=84). IRB decisions were
evaluated in response to a single protocol requesting permission for
third party reviewers to abstract medical record information for
patients with HIV-related Pneumocystis carinii pneumonia (PCP) without
written consent.

**Results:** In New York, IRB approval rates increased from 74% in 1990
to 100% in 1997. In Chicago, Los Angeles, and Miami, IRB approval rates
in 1990 were high (80%, 89%, and 92%), but decreased by 18% to 47% in
1997. In Seattle, Raleigh-Durham, and Arizona and in all 14 VA hospitals
in the study, IRB acceptance rates were 100% in both time periods. Over
half of the IRBs expedited approval. Of 67 IRBs that received requests
for collaboration in both periods, 70% approved the project twice, 24%
approved the study in 1990 and rejected the study in 1997, and 6%
rejected the study in 1990 and approved the study in 1997.

**Conclusions:** Despite assurances of confidentiality, IRB decisions
varied markedly for permission for the same study protocol. While
legislation that addresses confidentiality of medical record information
is currently being proposed, proposals that require written consent
before medical information could be disclosed to third party researchers
would virtually end the ability to conduct large scale health services
and epidemiologic research studies.

**Impact**: Concerns over medical privacy for persons with HIV-infection
are widespread. Inappropriate disclosure of confidential medical
information by medical researchers or providers, similar to that which
has already occurred with electronic data bases, can affect the
employability, insurability, and social situation of large numbers of
individuals. Despite legislative progress in the area for HIV-infected
individuals and in IRB practices in the first two decades of the AIDS
epidemic, more uniformity is needed to assure patient, physician, and
hospital confidentialty and to enable large scale health services and
epidemiologic research studies to be continued.

**44. Tailoring Smoking Cessation Treatments Based on Nicotine
Dependence Level and Depression Status of Patients**

## Arthur Garvey, PhD. Harvard School of Dental Medicine, Bedford, MA. Pantel Vokonas, MD. Boston VA Medical Center, Boston, MA.

**Objectives:** Cigarette smoking is highly prevalent in the VA patient
population. In an attempt to improve the delivery of smoking cessation
interventions for Veteran patients, we conducted a study with a 1-year
follow-up period which involved delivery of different degrees of
nicotine replacement for low- and high-dependence smokers, and for
smokers who were depressed or nondepressed.

**Methods:** The Fagerstrom Tolerance Questionnaire was used to classify
subjects by level of dependence, and the Center for Epidemiological
Studies Depression Scale (CES-D) was used to assess depression status.
Subjects were randomly assigned to placebo, 2 mg, or 4 mg nicotine gum
treatment. We collected both objective and self-reported indices of
withdrawal, and we also collected saliva samples which were assessed for
cotinine content by radioimmunoassay procedures so that we could
determine the percent of nicotine replacement achieved by each subject.
Survival analyses, logistic regression analysis, and repeated measures
analysis of variance were used to assess significance.

**Results:** Major differences in outcomes were found for patients with
different characteristics. Highly- dependent smokers had significantly
better success rates at 1-year post-cessation with the 4 mg gum, while
low-dependence smokers were benefited equally by either the 2 mg or 4 mg
gum. Either dose resulted in significantly better outcomes than did
placebo gum. Depressed smokers given placebo gum had exceptionally high
relapse rates (94%), but depressed smokers given nicotine gum (either 2
mg or 4 mg) had significantly better outcomes (30% abstinent at 3-months
post-cessation). A higher proportion of nicotine replacement was also
significantly related to better cessation rates, and significantly
reduced objective signs of withdrawal such as heart rate decline and
weight gain.

**Conclusions:** Our findings strongly suggest that smoking cessation
outcomes will be significantly improved if treatment is tailored, or
individualized based on specific patient characteristics. Highly-
dependent smokers need greater nicotine replacement, while those low on
dependence can succeed using a lower dose of nicotine. Depressed
smokers, a major sub-population among VA patients, must receive greater
nicotine replacement if they are to quit smoking successfully.

**Impact:** Results from our study clearly demonstrate that the \"one
size fits all\" model of smoking cessation treatment simply will not
succeed in helping smokers quit successfully. Smoking cessation
interventions need to be tailored to smokers based on at least two
critical dimensions: (a) their nicotine dependence level, and (b) their
depression status. Highly dependent patients must receive a higher dose
of nicotine replacement, and depressed smokers clearly need nicotine
replacement therapy if they are to be helped to stop smoking.

**45. The Effectiveness of Bupropion vs. Bupropion plus Nicotine Patch
in a Smoking Cessation Clinic.**

## Scott Sherman, MD, MPH. VA Greater Los Angeles Healthcare System, Sepulveda, CA. S Takayesu, P West, and A Chapman.

**Objectives:** Several research trials have examined the efficacy of
bupropion. While efficacy studies such as these are helpful, they
unfortunately often do not translate into effectiveness in actual
clinical practice. We examined the effectiveness of bupropion vs.
bupropion plus nicotine patch in the routine practice of a smoking
cessation clinic.

**Methods:** The Sepulveda VA Smoking Cessation Clinic was established
in 1992 and has consistently received approximately 60 referrals/month.
Patients attend seven visits over two months and receive individual
counseling in a group setting from both a health educator and a clinical
pharmacist. Compliance is assessed by carbon monoxide meter at each
visit, and patients with repeated high readings are dropped from the
clinic. Since April, 1998, we have randomly assigned all new patients to
either bupropion or bupropion plus nicotine patch (\"combined
therapy\"). Patients were assigned to only nicotine patches if they had
a history of seizures or refused bupropion. We assessed how patients
were doing at each visit and whether or not they were tolerating their
therapy. We also determined the percent of patients who successfully
completed the two-month program. No extra resources or funding were
used, so that we were comparing these two regimens in routine practice.
We calculated approximate direct costs of the medication and counseling
for each regimen.

**Results:** During the first four months, 231 patients were referred,
of whom 140 (61%) attended at least one session. 62 patients were
assigned to bupropion, 54 to combined therapy, and 22 to nicotine
patches. Two patients chose not to use any pharmacologic therapy. Side
effects were noted in 21 people taking bupropion (34%), 14 people taking
combined therapy (26%), and 3 people taking nicotine patches (14%). 18%
of patients started on bupropion were switched to another regimen (10 to
nicotine patches, 1 to combined therapy), compared to 15% of patients
started on combined therapy (6 to nicotine patches, 2 to bupropion), and
0% of patients started on nicotine patches. The rate of successfully
completing the two-month program (by initial treatment assignment) was
as follows: bupropion 13/62 (21%), combined therapy 21/54 (39%), and
nicotine patch 5/22 (23%). The cost of medication and counseling for one
complete two-month course was \$190 for bupropion and \$310 for combined
therapy. Factoring in the unsuccessful patients, the cost/successful
completer was approximately \$447 for bupropion and \$513 for combined
therapy.

**Conclusions:** We conclude that in routine practice, patients taking
combined therapy tolerate it as well (when measured by side effects or
treatment switching) as patients taking bupropion. The success rate
appears to be higher in patients initially assigned to combined therapy,
making the cost/successful completer just slightly higher for combined
therapy.

**Impact:** These data are helpful in determining what regimen to use
within a smoking cessation clinic, especially since there are so few
trials of combination therapy. We are continuing to accrue approximately
40 patients/month, which will allow us to more precisely compare these
two regimens. We do not yet have data on long-term abstinence to
determine whether the relapse rate differs by initial treatment
assignment.

**46. Reliability and Accuracy of Dermatologists' Digital Image
Consultations**

[John Whited MD, MHS.]{.underline} Center for Health Services Research
in Primary Care, Durham, NC. [DL Simel, RP Hall, ME Foy, and KM
Stechuchak.]{.underline} [Ronnie Horner PhD]{.underline}, Center for
Health Services Research in Primary Care, Durham, NC

**Objectives:** Teledermatology, using digital imaging technology, is a
potentially important alternative means of dermatologic health care
delivery. While teledermatology consultations are technically feasible,
they have not been critically evaluated against traditional clinic-based
consultations comparing diagnostic and management outcomes. Our study
asked the question, how reliable and accurate are dermatologists'
diagnoses and treatment plans generated from digital image consultations
when compared to clinic-based consultations?

**Methods:** Patients with skin lesions being referred for a diagnostic
question to the dermatology consult service from ambulatory care clinics
at the Durham VAMC were included in the study. Each patient underwent a
standardized history assessment and digital imaging of the referred
condition. Two dermatologists independently evaluated the patients in a
traditional clinic setting. Three different dermatologists independently
reviewed the standardized histories and digital images. Examiners were
asked to provide a single most likely diagnosis and differential
diagnoses and suggest a management plan (medications, diagnostic
testing, and therapeutic interventions). We compared diagnostic
reliability, management plan reliability, and diagnostic accuracy
between clinic-based examiners and digital image examiners.

**Results:** One-hundred sixty-eight lesions found on 129 patients were
included in the study. A comparable level of diagnostic reliability was
found among the different examiners. The simple proportion agreement
between the clinic-based examiner pair for their single most likely
diagnosis was 0.54 (95% CI 0.46-0.61), and was 0.92 (95% CI 0.88-0.96)
when both the single most likely and differential diagnoses were
considered. Only one pairing that compared the reliability of
clinic-based examiners' diagnoses with digital image examiners'
diagnoses (in the category that included single most likely and
differential diagnoses) resulted in a lower level of agreement (0.79,
95% CI 0.72-0.85) than that found between the two clinic-based
examiners. Additionally, the diagnoses offered by different digital
image examiners were equally reliable with each other and did not differ
from the diagnostic reliability of the clinic-based examiner pair.
Recommendations for medical therapy were also found to be reliable.
Therapeutic recommendations were less reliable than diagnoses and
medical therapy recommendations, and diagnostic testing decisions were
unreliable. Accuracy of the single most likely diagnosis did not differ
among the five examiners (p = 0.21).

**Conclusions:** Compared to traditional clinic-based consultations,
dermatologic consultations that use digital imaging technology provide
reliable diagnostic outcomes. Management recommendations were not as
reliable which may reflect, in view of diagnostic reliability, the
different practice settings of the dermatologist examiners. Our study
also suggests that diagnostic accuracy does not differ by consult
modality.

**Impact:** This study may have a considerable impact on the future of
teledermatology and telemedicine health care delivery and research in
the VA. With the knowledge that digital imaging results in reliable and
accurate diagnostic outcomes in dermatology, the clinical utility of
digital imaging as a consult modality can be justified. This essential
information allows for further investigations into the health services
implications of functioning telemedicine consult systems.

**HSR&D Funded:** 95-045

# 47. Use of VA Services by Medicare HMO Enrollees

[Steven Wright PhD.]{.underline} VA Medical Center, West Roxbury, MA.
[ES Fisher, R Lamkin, C Cagan, D Hults]{.underline}.

**Objectives:** It is well established that HMO plans receive capitated
payments intended for the comprehensive care of Medicare enrollees at
the same time those enrollees receive care from other federal providers
such as the VA. Regional studies in Florida and California have found
that a high proportion of Medicare-eligible VA patients were enrolled in
Medicare HMOs at the same time they received VA care. The objective of
this study was to determine time trends and patterns of health care
utilization by all veteran patients of the VA according to their
enrollment status in Medicare HMOs.

**Methods:** HCFA Medicare enrollment files were linked with a
denominator file Of all veterans who used the VA for inpatient or
outpatient services between 1992 and 1996. We identified VA patients 65
and older who were eligible for Medicare during this period. Enrollment
in Medicare risk-contract HMOs was then determined using the monthly
enrollment indicator on the Medicare enrollment files. The proportion of
Medicare-eligible patients who were enrolled in Medicare HMOs were
calculated for each year. We used VA PTF and OPC administrative files to
determine VA resource use and the national CDR (Cost Distribution
Report) to calculate costs for patients who enrolled in HMOs throughout
FY1996.

**Results:** The proportion of VA patients who were in Medicare HMOs
increased from 3.5% in 1992 to 10.2% in 1996. In FY 96, there were
56,776 VA patients over 65 who were enrolled in Medicare HMOs throughout
the year and an additional 32,415 who enrolled at some point during the
year. In several states, the proportion of Medicare-eligible VA patients
enrolled in Medicare HMOs exceeds 20%; in other states the rates of
enrollment doubled between 1994 and 1996. In FY 96 rates of outpatient
visits were similar between HMO enrollees compared to HMO non-enrollees
(10.8 vs 10.6 per capita). Hospitalization rates in the VA were lower
for HMO enrollees compared to non-enrollees (150 vs 310 per 1,000). For
VA patients covered by HMOs throughout FY 96, the total costs to the VA
for their care was approximately \$177 million.

**Conclusions:** There was rapid national growth in Medicare HMO
enrollment by VA patients between 1992 and 1996. There was also marked
geographic variation In patterns of HMO enrollment by states. VA
patients enrolled in HMOs receive a substantial amount of VA care at
significant cost to the federal government.

**Impact:** Rates of HMO enrollment in the general Medicare Population
have continued to increase suggesting that the rates for VA patients
have continued to increase. These patients will likely also continue to
use VA care under the current federal system. These trends have
implications for the coordination, continuity, and cost of care to VA
patients. Further research will be required to determine why veterans
enrolled in Medicare HMOs continue to seek care in the VA.

# 48. Validating Ascertainment of Mortality Using Multiple Administrative Data Sources

[Steven Wright, PhD. VA Medical Center, West Roxbury, MA.]{.underline} R
Lamkin, LA Petersen

## **Objectives:** The VA conducts research on cardiovascular disease using large administrative databases. Ascertainment of veteran deaths is accomplished using the Beneficiary Identification and Record Locator Sub-system(BIRLS), the national VA index of all deaths. In-hospital deaths are also coded in the PTF, the national VA inpatient utilization database. The objective is to examine the validity of BIRLS for Health Services Research. 

**Methods:** We created a cohort of 43,514 veterans age 65 hospitalized
with AMI in the VA or under Medicare financing from 1992-95. Site of
initial hospitalization classified veterans as VA index or Medicare
index. We compared 30 day and 1 year mortality rates using BIRLS and/or
PTF files against mortality rates obtained from combining BIRLS, PTF and
HCFA Medicare Denominator Files (all source, gold standard). We examined
sensitivity and specificity of the BIRLS and PTF stratified by index
hospitalization and patient characteristics.

**Results:** Sensitivity of BIRLS for VA index cases was 93% for 30 day
Mortality and 92% for 1 year mortality. Sensitivity of BIRLS for
Medicare index cases was 79% for 30 day mortality and 81% for 1 year
mortality. Sensitivity in the VA index group improved to 98% for 30 day
mortality and 95% for 1 year mortality when both BIRLS and PTF were
used. Specificity of BIRLS was 100% for both groups. A greater
percentage of Medicare index cases coded as dead from all sources but
alive in BIRLS were from the western region of the country (22 vs 16%).
There were no differences in the sensitivity of BIRLS by age or race.

**Conclusions:** Sensitivity of BIRLS data in ascertaining death is not
equivalent among all VA patients. Sensitivity of BIRLS was lower for
patients hospitalized with AMI in Medicare-financed hospitals compared
to patients hospitalized with AMI in VA hospitals.

**Impact:** BIRLS death status is obtained directly from funeral home
directors. Differences in the reporting of deaths for our index groups
raises concern about the validity of BIRLS for different patient
subsets. We encourage researchers to use multiple sources for
ascertaining mortality in veterans.

**49. Veterans\' Preferences for Transfer of Primary Care to Community
Based Outpatient Clinics (CBOC): Association with Health Status,
Satisfaction with VA Care, and Prior Use of VA Care**

[Steven Borowsky MD, MPH.]{.underline} Center for Chronic Disease
Outcomes Research, Minneapolis, MN. [DB Nelson, SM Nugent, PR Hamann, CJ
Stolee, and JL Bradley.]{.underline} [Hanna Rubins, MD,
MPH.]{.underline} Center for Chronic Disease Outcomes Research,
Minneapolis, MN.

**Objectives:** CBOCs are a national VHA initiative intended to enhance
access to care. This study examines whether veterans\' preferences to
transfer primary care to a CBOC are associated with health status,
satisfaction with VA care, and prior utilization of VA care.

**Methods:** We surveyed 1469 veterans in March 1998. Included with the
first of two survey mailings was an application to transfer primary care
to a contract CBOC. Veterans located in southern Minnesota (n=784) were
offered a consortium of 23 clinics; veterans in northern Minnesota
(n=685) were offered a CBOC consisting of 2 clinics. The sample included
all veterans who lived within 50 miles of either CBOC area and had \>= 1
primary care visit at any of three Network 13 facilities during the
preceding year. The dependent variable was whether or not veterans
requested transfer to a CBOC. We used bivariate analyses and
multivariate logistic regression to evaluate associations between
preference for CBOC and health status (SF36-V), VA Customer Satisfaction
Survey (CSS) scales, inpatient and outpatient VA utilization during the
preceding 12 months (data from Austin Automation Center), demographics,
and service connected status. Variable selection for the multivariate
analysis used a model score criteria.

**Results:** 1246 (85%) responded to the survey. Of these, 53% requested
transfer of primary care to a CBOC. On bivariate analyses, compared to
veterans not requesting CBOC, those who chose CBOC had fewer prior VA
outpatient encounters (19.9 vs. 26.2, p\<.0001), and had higher CSS
scores (lower satisfaction with VA care) on 7 of 8 scales (p values
ranging from \<.0001 to \< .05). CBOC preference was greater in the
north than south (59.5% vs. 47.4%, p\< .001), and a possible association
was seen between CBOC preference and SC status (55.4 % NSC, 52.7% 0-50%
SC, 45.2% 50-100% SC, p=.08). Seven of 8 SF36-V scales did not differ
between veterans who did and did not request CBOC. Multivariate analysis
confirmed that preference for CBOC varied by CBOC area (south vs. north
OR=0.61 95%CI 0.47-0.79) and SC status (50-100% SC vs NSC OR=0.57 95%CI
0.38-0.85). Number of prior VA outpatient encounters was negatively
associated with preference for CBOC (OR 0.98 95%CI 0.97-0.99). Three
satisfaction scales were retained in the final model, each demonstrating
an association between lower satisfaction and preference for CBOC (for
0.1 increase on 0-1 scale, higher=less satisfied: \"access\" OR 1.11
95%CI 1.01-1.23, \"coordination\" OR 1.11 95%CI 1.01-1.22,
\"preferences\" OR 1.19, 95%CI 1.02-1.38). Three SF36V scales were
retained in the model but did not indicate a strong association between
health status and CBOC preference.

**Conclusions:** Preference for contract CBOCs is associated with less
prior VA use, lower satisfaction with VA, and lower SC status but is not
strongly related to self-reported health status.

**Impact:** Contract CBOCs may attract patients who use less VA care and
who are less satisfied with VA care. CBOCs are an alternative that may
improve access and satisfaction for this subpopulation. Comparisons of
CBOC vs. VA-based care may not be confounded by large differences in
patient health status.

**HSR&D Funded:** CDA 98-309

**50. Effect of Facility-Level Characteristics on Primary Care
Enrollment and Bed-days of Care**

## Margaret Byrne, PhD, Carol Ashton, MD, PhD, and Laura Hechtel, PhD. Houston VA Medical Center, Houston, TX.

**Objectives:** Performance standards (e.g. reducing bed days of care
\[BDOC\], increasing enrollment in primary care \[PCE\]) have been
established for all VA network and hospital facility directors. To the
degree that these parameters are determined by facility characteristics,
their use to estimate management performance may be biased. Therefore,
we undertook this study to assess the extent to which PCE and acute BDOC
are determined by station-level characteristics such as facility type
(free-standing outpatient clinics \[FSCs\], hospitals), facility size
(number of beds and users), focus of care (GM&S, psychiatric, long term
care), or hospital complexity (acute, intermediate, tertiary).

**Methods:** The study was conducted on FY 1997 data. Patients\' care
and outcomes are assumed to be the responsibility of the predominant
outpatient care provider. Therefore, using the Outpatient Clinic
database, all patients were assigned to a unique station (5-digit
identifier code) where they received the plurality of visits to primary
care clinics or the plurality of total visits for those veterans without
any primary care stop. Veterans were classified as \"enrolled in PC\" if
they had any PC clinic stop. Acute BDOC rates were determined from the
Patient Treatment File as the total acute VA bed days for veterans
assigned to that station, regardless of which VA hospital was used.

**Results:** Over all stations providing ambulatory care (n=391), 70% of
veterans were enrolled in primary care; 72.8% enrollment for hospitals
(n=158), 68% for FSCs (n=231), 87% for independent outpatient clinics
(n=3), and 99% for mobile clinics (n=4). Larger FSCs (more than 100
assigned users), however, had a 86.2% PCE rate. This was significantly
greater than for hospitals (p\<0.0001). Hospital complexity was
associated with PCE; both acute (p\<0.01) and intermediate (p\<0.001)
hospitals had higher PCE than tertiary hospitals. Hospitals which focus
on psychiatric care had higher PCE than did general hospitals (p\<0.02).
The acute BDOC rate (per 1000 assigned users) over all VHA stations was
2,143. Overall, patients of FSCs had significantly fewer BDOC than
hospitals (p\<0.003), although small FSCs had higher BDOC (3,070) than
did larger FSCs (1,267). Patients of psychiatric hospitals had higher
BDOC (3,563) than other hospitals (2,352) (p\<0.001). Regression
analyses, controlling for characteristics found significant in bivariate
analyses, showed that station size was predictive of BDOC. Patients of
stations with more assigned users (p\<0.003) and hospitals with more
total beds (p\<0.01) had higher BDOC rates.

**Conclusions:** We have shown that station characteristics (type,
complexity, focus of care, and size) are important predictors of PCE and
acute BDOC rates. This finding suggests stations may have structural
characteristics that provide an advantage or disadvantage in meeting
standards, regardless of management effectiveness. This brings into
question the practice of using these indicators, unadjusted for hospital
characteristics, to assess performance.

**Impact:** Currently, unadjusted PCE and BDOC rates are being used to
judge facility managers\' proficiency. Our study suggests that this may
lead to invalid conclusions due to important effects of facility level
characteristics. Future standards should take into account the effect of
these facility characteristics before judgements are made.

**HSR&D Funded:** LFP 98-001

# 51. Determinants of House Staff Time Use in the Inpatient Setting 

[Timothy Dresselhaus MD.]{.underline} Center for the Study of Healthcare
Provider Behavior, San Diego, CA. [D Timberlake.]{.underline} [Jeff Luck
MBA, PhD.]{.underline} UCLA School of Public Health, Los Angeles, CA. [B
Wright and R Spragg.]{.underline} [Samuel Bozzette MD, PhD]{.underline},
Center for the Study of Healthcare Provider Behavior, San Diego, CA.

**Objectives:** As patient care in the VA shifts to the ambulatory
setting, the inpatient time of house staff will be constrained. To
maintain the value of inpatient time, training programs must preserve
activities contributing directly to patient care and education. Data on
time allocation and the determinants of time use are needed to inform
the redesign of inpatient training. We used automated random sampling to
measure house staff inpatient work and developed prediction models to
identify factors influencing house staff time allocation in the
inpatient setting.

**Methods:** We developed and validated a computer assisted self
interview (CASI) survey and assigned house staff rotating on our VA
medical service hand-held computers for periods of five consecutive
weekdays. House staff were prompted randomly within consecutive
intervals to complete the work survey. Fifty-one medical house staff (30
interns, 21 residents) were sampled during 480 weekdays. We analyzed
activities according to three content domains: direct patient care (time
with patient), indirect patient care (time supporting patient care but
not with patient), and education. In predicting the proportion of time
allocated to these domains, the following independent variables were
included in three multivariate models: gender, house staff type (intern
or resident), program director ratings of overall clinical performance,
attending ratings of clinical performance for the concurrent rotation
(rotation rating), type of day in call schedule (long call, post-call,
short call, pre-call), scheduled clinic day, and patient load. Two
separate random-effects linear regression models were used to identify
the significant predictors of the proportions of time that house staff
participated in indirect patient care and education. For direct patient
care, a logistic regression model incorporating robust variance
estimates for clustered data was used to identify the predictors of days
in which sampled activities included direct patient care versus days in
which sampled activities did not include direct patient care.

**Results:** In the 480 days of observation, 3,762 complete responses
were obtained. House staff spent more time in indirect (56%) than direct
patient care (14%) or educational activities (45%). The proportion of
time spent in indirect patient care was negatively associated with
rotation rating (p\<0.01) and long call (vs pre-call, p\<0.01). Time
spent in direct patient care was positively correlated to long call (vs
pre-call, p\<0.001) and short call (vs pre-call, p\<0.01), but
negatively correlated to scheduled clinic day (p\<0.05). Time spent in
education was negatively associated with female gender (p\<0.05), short
call (vs pre-call, p\<0.01), and intern status (vs resident, p\<0.01)
but positively associated with rotation rating (p\<0.05).

**Conclusions:** House staff at our VA spend more of their workday in
activities indirectly supporting patient care than in time with patients
or in educational activities. Elements of program structure correlate to
time spent in direct patient care, while house staff factors, including
ratings of clinical performance, correlate to the amount of time in
educational or indirect patient care activities.

**Impact:** Planners must consider the influence of structural change
upon house staff time allocation to patient care and education when
redesigning house staff inpatient work. Further research is needed to
understand how time use is related to the clinical performance of house
staff.

**52. Effects of Race, Income, and Psychological Well-being on HIV
Patient Decisions about Emergency Department (ED) Use.**

[Allen Gifford, MD.]{.underline} San Diego VA Medical Center. San Diego,
CA. [R Collins and D Timberlake.]{.underline} [Samuel Bozzette, MD,
PhD]{.underline}, Center for the Study of Healthcare Provider Behavior,
San Diego, CA. [M Shapiro, M Schuter, and D Kanouse.]{.underline}

**Objectives:** Veterans with HIV often choose the ED for care of both
non-urgent and urgent symptoms, however ED care is expensive, and
quality of care may suffer due to poor integration of ED care with
primary care. To understand what determines HIV patient decisions to go
to the ED or to their usual source of primary care (USOC), we
interviewed a probability sample of both veteran and non-veteran HIV
patients in the U.S. to determine how they would seek care in response
to several symptom scenarios.

**Methods:** A nationally representative probability sample of all U.S.
HIV+ adults in care underwent detailed structured interviews. Three
brief clinical scenarios describing headache, respiratory, and other
HIV-related symptoms were asked of each subject. Different scenarios
were asked of early stage (non-AIDS) and late stage (AIDS) patients.
Scenario response options included \"I would go to the emergency room\"
and \"I would go to the doctorÆs office the same day.\" Sociodemographic
(SD), access to care, health status, psychological, and
knowledge/attitude/belief (KAB) variables were also assessed. Weights
were used to adjust for the sampling design, and non-response;
linearization methods corrected for weights and multistage sample
design. Proportional logit models to identify independent predictors of
propensity to seek ED care were estimated separately for early and late
stage patients. A hypothesis-driven regression approach was used to
evaluate the relative contributions of SD, access, health, and KAB
variables to propensity to choose ED care (among those who would seek
immediate care).

**Results:** Data were collected from 1245 non-AIDS and 1612 AIDS
patients representing 86,800 and 126,420 HIV patients respectively
nationwide. In a full multivariate model of those with AIDS,
African-American race was the strongest independent predictor of
propensity to use the ED (Adjusted odds ratio \[AOR\] compared with
white 2.87, p\<.0001), even with adjustment for all other SD, access,
health, psychological, and KAB variables. Other independent predictors
were low income (AOR 1.64, p\<.04), low psychological well-being (AOR
1.08, p\<.02), cognitive denial coping (AOR 1.01, p\<.05), and several
access (travel time to USOC, usually see the same person at USOC, length
of time with same USOC provider) and attitude (prefer doctor to make
decisions) variables. Among HIV+ patients without AIDS, African-American
race was again the strongest independent predictor of propensity to use
the ED (AOR 3.73, p\<.0001), again with adjustment for all other
variables; Hispanic ethnicity was also a predictor (AOR 2.17, p\<.005),
as was female gender (AOR 1.45, p\<.03). Other predictors were again low
income (AOR 2.00, p\<.009), low psychological well-being (AOR 1.11,
p\<.02), and access (wait time for appointment date, wait time at
appointment) variables. Health insurance category was not associated
with propensity to use the ED in either model.

**Conclusions:** African-American race is a significant, independent
predictor of propensity to use the ED across stages of disease, even
after adjustment for access, income, insurance, and other variables.
Income, psychological well-being, and access variables are also
important.

**Impact:** Cultural preferences or habits that go beyond socioeconomic
and access issues may influence propensity to use the ED among
African-Americans.

# 

# 53. Cost-effectiveness of the Primary Care Provider Program at the West Los Angeles VAMC 

## Hwai-Tai Lam, PhD. VA Greater Los Angeles Healthcare System, Los Angeles, CA. D Norman, S Cretin, G Sun, M Gee, and M Wong.

**Objectives:** Primary Care Provider Program (PCP) was implemented at
the West Los Angeles VA Medical Center in 1996. This study evaluates the
cost-effectiveness of that program. Patients\' total medical costs and
admission rates for a period of eleven months, from October 1997 through
August 1998, were used as outcome measures to answer the following
questions: (1) Does the coordination of a PCP reduce patients\' overall
medical costs? (2) Does the coordination of a PCP reduce patients\'
admission rates?

**Methods:** This study includes patients who have utilized the West Los
Angeles health care system during the study period, and who had at least
three outpatient visits. Patients referred from other VA facilities and
psychiatric patients who did not utilize surgical or medical clinics
were excluded. Cost data were downloaded from the Decision Support
System (DSS). Patients were categorized into three groups based on their
contact with their primary care provider teams. Group one (N=5,444) was
patients who were seen by their PCP teams in more than 50% of their
primary care clinic visits. Group two (N=5,452) was patients seen by
their PCP team in less than 50% of their primary care visits. Group
three patients (N=15,081) had no primary care clinic visits during the
study period. A linear regression model controlling for risk factors
assessed the effect of contacting with primary care provider teams on
patients\' overall medical costs.

**Results:** Group one patients, who had the most contact with their
PCP, had the lowest average total cost (\$8,298) per patient when
compared to Group two (\$9,470) and Group three (\$9,451). Group one
patients also had the lowest inpatient cost (\$2,731); Group two and
Group three\'s costs were \$4,022 and \$6,341, respectively. It had an
admission rate of 0.27 while Group two and Group three\'s rates were
0.34, and an average length of hospital stay of 5.64 days (Group two:
7.41 days, Group three: 6.69 days). However, Group one patients had the
highest outpatient costs of \$5,567 (Group two: \$5,447, Group three:
\$3,110). Although Group two patients had the highest average total
costs, after controlling for age and principal diagnoses, the linear
regression model showed that Group two\'s costs were lower than Group
three\'s (p=0.0001), and Group one\'s cost were lowest of all.

**Conclusions:** Use of a PCP team had a significant effect on reducing
patients\' total costs and length of hospital stay. The effect would be
greater if patients were seen at the primary care clinics by their
assigned PCPs or by other providers of the same team. The setting of
services provided by PCPs seemed to shift from inpatient to outpatient.

**Impact:** Currently, at the West LA VAMC, the PCP program and the
patient self-coordinated system coexist. Patients can have access to
sub-specialty care for a long period of time without going through the
PCP program. The results of this study attest to the cost-effectiveness
of a PCP program and support its reinforcement.

**54. The Impact of Involving LPNs in Colorectal Cancer Screening**

[Nancy Thompson, PhD.]{.underline} University of Iowa, Iowa City, IA.
[Michael Chapko, PhD.]{.underline} VA Puget Sound Health Care System,
Seattle, WA.

**Objectives:** The objective was to determine if involving nurses in
the delivery of fecal occult blood tests (FOBT) for early detection of
colorectal cancer would improve the utilization of FOBTs without
negatively impacting the patient return rate in a VA primary care
clinic.

**Methods:** The study was conducted between January and March 1998. The
intervention involved having licensed practical nurses (LPNs) assess
need for and order FOBTs during the time they interacted with 50-69 year
old patients scheduled to see primary care providers in the General
Internal Medicine Clinic at the Seattle VAMC. The orders were to be made
on the basis of a predefined protocol. As the clinic is organized as a
firm, it was randomly divided into experimental and control units. In
the experimental unit FOBT orders were placed by the primary care
providers(physicians/nurse practitioners MD/NP)or the LPNs. In the
control unit FOBT orders were placed by only the primary care providers.
Data were collected regarding orders, and returns as well as other
characteristics of both the patients and providers. A 90-day window of
time was allowed to elapse prior to categorizing a test as \"returned\"
or \"not returned.\" Descriptive and regression analyses were conducted.

**Results:** A total of 1109 patients were included in the study (545
experimental, 564 control). The experimental and control units were
found to be comparable in terms of the variables of interest. The
experimental unit ordered significantly more FOBT tests than the control
unit for all patients (52 vs 15%, p\<.000) as well as for FOBT eligible
patients (72 vs 19%, p\<.000).

Within the experimental unit, the LPN orders were returned as frequently
as the MD/NP orders (LPN 42% vs MD/NP 59%, p =.0951)and were less likely
to be placed inappropriately (LPN 6% vs MD/NP 31%, p \<.000. Finally,
the LPNs\' involvement in ordering FOBTs did not decrease their ability
to provide other expected services.

**Conclusions:** The use of LPNs in ordering FOBTs significantly
increased the rates of ordering without compromising the potential for
its return rate or other expected LPN services. Efforts to improve the
delivery of preventive services should consider changes to the system
that support use of nurses in delivering preventive services.

**Impact:** This study has demonstrated that LPNs ordering FOBTs in a VA
medical facility can produce nearly a threefold increase in the number
of veterans receiving and returning the test with minimal cost.

**55. A Standardized Method for Assessing Urgency Among Walk-in VA
Patients**

[Donna Washington, MD, MPH.]{.underline} Assistant Professor of
Medicine, UCLA, Los Angeles, CA. [Paul Shekelle, MD.]{.underline} West
LA VA Medical Center, Los Angeles, CA. [CD Stevens and RH
Brook.]{.underline}

**Objectives:** Faced with the challenge of delivering maximum medical
value within a fixed budget, the Department of Veteran Affairs has begun
adopting managed care principles. Both cost and quality concerns dictate
the need to shift from unscheduled, episodic care in hospital emergency
departments to a strengthened primary care system. However, few
systematic methods exist for identifying walk-in patients who are safe
for triage to primary care settings. We developed, operationalized and
validated a method to direct walk-in VA patients to emergency, urgent,
or deferred (by up to 1 week) care.

**Methods:** Using the scientific literature and expert opinion, a
17-member multidisciplinary physician panel rated the safety of
deferring care for 365 detailed clinical scenarios representing common
complaints (abdominal pain, musculoskeletal pain, and respiratory
infection symptoms) of ambulatory adults presenting to emergency
departments. We converted ratings into explicit, standardized triage
algorithms for use by emergency department nurses. Following training in
their use, nurses at the West Los Angeles VAMC applied the algorithms to
1,187 consecutive walk-in patients who had conditions covered by the
guidelines. Patients meeting deferred care criteria were offered the
option of an appointment within 1 week in the ambulatory care clinic.
All other patients received same day care in the emergency department or
urgent care clinic at the study site. We measured nurse triage times
using our guidelines in comparison to usual implicit judgment methods.
We also assessed non-elective hospitalizations at all southern
California and Nevada VA facilities within 7 days of triage and 30-day
mortality using the VA National Health Exchange and Beneficiary
Identification Records Locator System databases respectively.

**Results:** The mean nurse triage time using the criteria was 9.95
minutes (95% C.I. 8.1 to 11.8) in contrast to 9.52 minutes (95% C.I.,
7.9 to 11.2) without the criteria. 226 (19%) patients met deferred care
criteria, and of this group, 154 (68%) had their care deferred by up to
one week. Transportation difficulties represented the most common reason
for declining a deferred care appointment. Patients meeting deferred
care criteria experienced zero (95% C.I., 0% to 1.2%) related
non-elective VA hospitalizations within 7 days of evaluation, and none
died within 30 days. By contrast, 7% (95% C.I., 5.5 to 8.9%) of patients
who did not meet deferred care criteria were hospitalized non-electively
for related conditions, and five (0.5%) died.

**Conclusions:** We developed standardized, clinically-detailed triage
guidelines for deferring care that apply to a significant proportion of
patients with common ambulatory conditions. Trained nurses applied the
criteria to a large group of patients without adverse impact on triage
time or work flow. No patient classified as safe for deferred care using
the guidelines was hospitalized within a week at a VA facility or died
within 30 days.

**Impact:** This explicit triage approach may allow facilities to manage
their acute care resources more efficiently by safely diverting a
significant proportion of walk-in patients from the emergency department
to primary care settings. The safety and reliability of achieving this
goal with the implicit triage methods currently used at most facilities
is unknown.

# 56. Determining the Cost of VA Health Care

## Paul Barnett, PhD. Center for Healthcare Evaluation, Menlo Park, CA.

**Objectives:** Cost data are needed to conduct cost-effectiveness
analysis and to increase the policy relevance of health services
research. Since VA does not routinely prepare patient bills, it is
difficult to determine the cost of VA provided health care. This
workshop will introduce the data sources and methods needed to determine
the cost of VA health care for use in health services research. Cost
finding will be illustrated from examples drawn from health services
research projects and clinical trials conducted by the Cooperative
Studies Program.

**Target:** The workshop is intended for health services researchers and
VA managers with research problems requiring cost data. Attendees need
not have a health economics background.

**Methods:** Methods for estimating VA costs will be described,
including micro-cost and average-cost methods. Micro-cost methods
include time activity analysis and the use of detailed VA utilization
data and cost estimates from non-VA settings, either by preparing a
pseudo-bill, or by estimating a clinical cost function from non-VA data.
Average cost methods combine VA cost and utilization data, and resource
weights obtained from the non-VA sector. Data sources that are useful
for cost-determination will be described. VA data sources include the
Cost Distribution Report, the Financial Management System, Fee Basis
Files, centralized VA utilization data bases such as the Patient
Treatment File and National Ambulatory Care Database, and decentralized
utilization data from the VISTA clinical data system. The workshop will
also describe extraction of cost data from the VA Decision Support
System. Non-VA data sources, including Medicare DRG weights and
reimbursement schedules, will also be described. Cost determination
methods will be illustrated by example. Examples will include a health
services study of costs incurred by patients treated for substance abuse
disorders, and clinical trials of interventions in cardiology and
primary care. The workshop presenters will lead a discussion of the
advantages and drawbacks of the different methods, along with
suggestions for the methods appropriate to different types of research.

**57. Using VHA Administrative Data to Measure Performance:
Methodological Issues of HEDIS**

# [Ann Hendricks, PhD, Debra Jones, PhD, Cheryl Hankin, PhD, James Rothendler, MD, Bei-Hung]{.underline} [Chang, ScD.]{.underline} Bedford VA Medical Center, Bedford, MA. [Catherine Comstock, MPH]{.underline}. Carlisle, MA. Amy Rosen, PhD and Mark Prashker, MD, MPH. Center for Health Quality, Outcomes, and Economic Research, Bedford, MA.

**Objectives:** The primary goal of this workshop is to explore the
methodological issues faced by managers and researchers trying to
construct standardized VISN-level performance measures. The topic is
timely and consistent with the conference theme (research at the
interface) because it relates to policymakers\' attempts to monitor
performance in the delivery of health care. Activities: The workshop
presenters include researchers and clinicians who will illustrate the
issues using experience with six HEDIS measures applied to VHA and then
lead discussions regarding possible solutions for research and
management. Specific aims are to give a general overview of moving from
theory to practice in applying HEDIS measures in VHA and to discuss five
methodological areas and our methods in resolving issues: 1) definitions
and construction of denominators and numerators using different VA
databases (illustrated by rates of eye exams for people with diabetes),
2) defining levels of severity for psychiatric illnesses (illustrated
for rates of follow-up care and readmissions for people hospitalized for
mental illness), 3) risk adjusting for underlying prevalence of disease
in the denominator population (illustrated for rates of cardiac
procedures), 4) comparisons across providers (Bayesian techniques for
VISN comparisons), and 5) veterans use of VA and Medicare. Materials
based on the project will be disseminated.

**Audience:** Health services researchers with an interest in either
developing or evaluating VA performance measures, and medical and mental
health care managers who use such measures in assessing VISN-level or
facility-level performance.

**58. Implementing Ambulatory Care Case-Mix Measures in the VA: From
Theory to Practice**

[Amy Rosen, PhD, Arlene Ash, PhD, James Rothendler, MD,and Susan
Loveland, MAT]{.underline}, Bedford VA Medical Center, Bedford, MA.

**Objectives:** Ambulatory care case-mix measures are currently being
used by health care organizations to describe the illness burden of
their populations, evaluate the content of ambulatory practice, assess
the costs and quality of care, and predict resource utilization. As the
VA evolves into an integrated health care delivery system, methods that
take account of the unique issues related to ambulatory care and that
can classify patients into clinically homogeneous groupings are critical
for accurately assessing VA\'s effectiveness as a managed care
organization.

**Activities:** This workshop will discuss the theoretical and
operational frameworks useful in constructing population-based
ambulatory care case-mix measures with VA administrative data. We will
lead a series of presentations that will describe: 1) the importance of
using case-mix measures to evaluate health care delivery in VA; 2) the
leading case-mix measurement systems, Ambulatory Care Groups (ACGs) and
Diagnostic Cost Groups (DCGs) that are currently being used; 3) the data
and file requirements necessary for implementing the ACG and DCG
software; and 4) the special considerations in constructing input and
output measures using VA inpatient and outpatient data. Examples of how
specific outcome measures were constructed from VA files will be
presented by the speakers; however, as this is an interactive workshop,
participants are encouraged to bring examples using ambulatory care
case-mix measures from their own research studies.

**Target Audience:** This workshop is intended for researchers
interested in using administrative databases to evaluate changes in
health care delivery using case-mix measurement systems, as well as
managers and clinicians who need to use the results of these analyses
for evaluating health care delivery.

**Audience\'s Assumed Familiarity with the Subject:** Some familiarity
with the subject of risk adjustment as well as the different VA
databases would be helpful but is not required.

**59. Are Clinical Practice Guidelines Implemented in Clinical
Practice?**

[Mark Bauer, MD.]{.underline} Mental Health and Behavioral Sciences
Service, Providence, RI.

**Objectives:** Clinical practice guidelines have been proposed to fill
many roles from improving quality of care to reducing health care costs.
Several major efforts have been undertaken to develop guidelines for
mental health. However, we have little information regarding the extent
to which guidelines are actually implemented in medical, surgical, or
mental health practice. This paper reviews the available evidence
regarding guideline implementation in medical, surgical, and mental
health general clinical practice settings.

**Methods:** All available articles on adherence to guidelines, as
defined by IOM, were located through Medline search supplemented by
review of bibliographies of located articles. Abstracts and articles
were then reviewed and the study categorized as positive or negative
according to the authors\' principle interpretation.

**Results:** This review found 36 articles distributed across three
types of studies: cross-sectional, pre/post, and intervention trials.
33% of cross-sectional and pre/post trials and 67% of intervention
trials demonstrate adherence to practice guidelines, for an overall
adherence rate of approximately 45%. Additional studies indicate that
when intervention trials finish, rates of adherence return to baseline.

**Conclusions:** Thus the substantial expenditure of effort among
leading academics and major professional organizations may actually be
having little effect on \> general clinical practice.

**Impact:** The issue of how to facilitate the adoption of guidelines in
general clinical practice must become a focus of research; otherwise we
run the risk of putting tremendous effort into documents that will have
primarily archival value, and negligible public health impact. In
addition, some data indicate that there may be value in investigating
this issue from the perspective of \"diffusion research.\" This
decades-old multidisciplinary approach has been successfully applied to
understanding the adoption of new technologies in many fields, but has
been applied to health care delivery issues only sporadically.

**HSR&D Funded:** DEV 97-015

60\. VA Cooperative Study #430: Reducing the Efficacy-Effectiveness Gap
in Bipolar Disorder

[Mark Bauer MD.]{.underline} Mental Health and Behavioral Sciences
Service, Providence, RI. [E Dawson, N Shea, L McBride, and WO
Williford]{.underline}.

**Objectives:** The VA Cooperative Study has funded a 12-site randomized
controlled trial of an easy-access program for bipolar disorder from
1997-2003. This study proposes that increased access and provider and
patient education will reduce the \"efficacy-effectiveness gap\" for
bipolar disorder. We specifically hypothesize that compared to usual VA
care (UVAC) the easy-access Bipolar Disorders Program (BDP), will
improve clinical, functional, and economic outcome.

**Methods:** Patients who are admitted to a acute psychiatric ward with
a primary or co-primary admission diagnosis of bipolar disorder type I
or II are screened for the study. One hundred and ninety-one patients
are being randomized to each of the two treatment groups (BDP and UVAC).
All enrolled patients are followed up for three years.

**Results:** All 12 sites have been trained to criterion and are fully
functioning. Statistics regarding training to criterion are presented.
As of October 15, 1998, 996 patients have been screened and 124 patients
have been randomized (67 BDP and 57 UVAC), which is 107% of the current
randomization goal. Follow-up data flow is also presented with quality
of follow-up evaluation.

**Conclusions:** Complex treatment interventions can be implemented
validly across multiple sites. Monitors based on \"CQI\" principles can
provide important process information. Reliability of outcome data can
be assured by training and ongoing monitoring.

**Impact:** In terms of impact, this study will have impact on both the
private and the government healthcare sectors. It is designed to
evaluate the basic principle that augmenting ambulatory access for major
mental illness will improve outcome and reduce overall treatment costs.
If results are positive, this study will provide reason to reconsider
the prevailing trend toward limitation of ambulatory service that is
characteristic of many managed care systems today. Further, the study
will provide specific direction with regard to how to structure such
ambulatory services.

**HSR&D Funded**: CSP #430

61\. Consistent Satisfaction Measured by American Board of Internal
Medicine Patient Satisfaction Questionnaire Following Initial Evaluation
of Inpatients by VA Medical Center Interns

# [MJ Bittner, MD.]{.underline} Omaha VA Medical Center, Omaha, NE. [EC Rich, RL Recker, PD Turner, and MW Lubeley.]{.underline}

**Objectives:** As academic medical centers face more competition and as
inpatient care in VA medical centers evolves, concern heightens about
maintaining patient satisfaction. Among Lexington VA inpatients with
chronic obstructive pulmonary disease studied January-May 1995, greater
intern workloads were associated with diminished patient satisfaction.
(Acad Med 1998;73:427-429) We looked for this finding among patients
with a variety of diagnoses, studying patients shortly after admission.

**Methods:** We studied patients of Creighton medical interns assigned
to non-intensive care unit inpatient floors at the Omaha VA Medical
Center July 6-October 12, using the American Board of Internal
Medicine\'s Patient Satisfaction Questionnaire (PSQ). This ten-item
instrument assesses physicians\' interpersonal skills. Each item has
five responses, from 1 (excellent) to 5 (poor). We analyzed responses
from patients who completed the questionnaire in a face-to-face
interview the morning after admission; however, for patients admitted
after 5 pm, the interview occurred the second day after admission. At
the interview we noted these variables based on the Lexington study:
patient age, intern gender, intern census size, and severity of illness
(modified APACHE II score). Additionally, we noted the number of
admissions to the intern in the previous 24 hours and whether the
admission occurred after inaugurating stricter utilization review
(August 24). Using multiple linear regression, we studied mean PSQ
response as the dependent variable, assessing the effect of intern
workload (census, admissions) and controlling for the effect of patient
factors (age, illness severity), intern gender, and utilization review.

**Results:** Of 254 assigned patients, we excluded those initially
admitted to intensive care (48), unavailable for interview (11), not
competent (12), or not completing all items (59). Because some patients
were excluded for multiple reasons, 182 remained for analysis.
Satisfaction scores obtained shortly after admission (mean 1.79,
standard deviation 0.74) resembled those from Lexington patients just
before discharge (1.7, s.d. 0.9). Fewer of our patients (19.2%) rated
all ten items as excellent (Lexington, 37%). The mean age was 65.8 (s.d.
13.9), modified APACHE II score 7.27 (s.d. 3.53), intern census 3.23
(s.d. 1.84), and intern admissions 0.77 (s.d. 1.03). Of the admissions,
37.4% were to women interns and 42.9% occurred after instituting
stricter review criteria. Only 2.7% of the admissions involved interns
with more than three admissions in the 24-hour period before the
questionnaire administration. In the multiple linear regression model,
neither census, admissions, nor any of the other explanatory variables
were significantly associated with PSQ response.

**Conclusions:** Greater workload adversely affected satisfaction among
Lexington COPD patients, and greater age was associated with more
satisfaction among Lexington patients. In a setting with a limited
number of intern admissions and limited intern census, we observed
neither finding; nor did we find an association between satisfaction and
intern gender, modified APACHE II score, or institution of stricter
utilization review.

**Impact:** An academic VA medical center can achieve a consistently
high level of patient satisfaction with physician interpersonal and
communication skills, even among inexperienced house officers, in an
environment where intern workload is controlled.

**62. The Effect of Depression on Change in Stroke Patients' Physical
and Mental Health**

[Hayden Bosworth PhD and Ronnie Horner PhD.]{.underline} Center for
Health Services Research in Primary Care, Durham, NC. [David B.
Matchar]{.underline}

**Objectives:** This study examined the effect of depressive symptoms on
change in acute ischemic stroke patients\' physical and mental health
using a subset of data from the VA Acute Stroke (VASt) study, a
nationwide prospective cohort of 881 patients admitted for acute stroke
at any of nine VA sites between 4/1/95 and 3/31/97.

**Methods:** Patients were interviewed at 1, 6, and 12 months post
admission via telephone regarding depressive symptoms (short form
CES-D), activities of daily living (ADL), and preference for current
health state (measured by the time-tradeoff method). Analyses were
confined to the 246 patients (M=66 years of age; SD=10 years) who had
three measurements and complete data (28%). Proxies (n=451) were not
included because they cannot provide valid responses regarding
patients\' psychological health. Besides the proxies, there were 184
(21%) had incomplete data at baseline. Patients who were able to
participate were on average younger, had more education, were less
likely to be married, and have less physical problems in contrast to
those patients that required a proxy to compete the questionnaire for
them or had missing data.

**Results:** A repeated ANOVA controlling for age, gender, level of
education, race, and ADL at baseline indicated that increased time was
positively associated with increased patients\' perceptions of their
current health state over the 12-months post hospital admissions (F\[2,
204\]=3.13, p\<.04). After adjusting for related factors, number of
depressive symptoms

(F\[1, 204\]=10.89, p\<.001) was inversely related to patients\'
perception of their current health state at 1, 6, and 12-months
post-stroke (i.e., willingness to trade more years of life to live in
perfect health), despite improvements in physical function. In a similar
model that examined change in physical function, increased number of
depressive symptoms was also associated with worse function (F\[1,
238\]=9.88; p\<.002). There were no significant interactions between
depressive symptoms and any independent variable for either model.

**Conclusions:** It has been suggested that depression may be a reactive
process to the physical limitation effects of stroke. We found that
depressive symptoms continue to be independently related to both short
(1 month) and longer-term (12-months) perceptions of quality of life in
this

sample of veteran stroke patients, despite increased improvement in
physical function. Presence of increased depressive symptoms was also
independently associated with both short and longer- term physical
function. Further studies are necessary to determine if the effect of
depression is even more profound in more debilitated stroke patients.

**Impact:** Depressive symptoms aggravate veterans\' perceptions of
quality of life, thereby possibly reducing the effects of the recovery
process and inhibiting the process and the benefits of rehabilitation.
Health care providers may need to focus more attention on the mental
health needs of stroke patients.

**HSR&D Funded:** SDR 93-003 "Clinical Management of Patients with
Stroke at VAMCs

# 63. Implementing Depression Screening in Primary Care: An Effective Strategy?

## Edmund Chaney PhD, Nicole Hasenberg MPH, and Susan Hedrick, PhD, VA Puget Sound Health Care System, Seattle, WA . 

# 

# Objective: Although increasingly recommended or mandated in quality improvement efforts, the utility of screening for depression in primary care remains controversial. This study addresses one critical issue on which there is little data: what is the actual gain in detection of unrecognized, untreated major depression for which the patient is at least amenable to discussing treatment alternatives? 

# Methods: Preliminary data are drawn from a four-month period in which patients responded to a comprehensive primary care clinic-wide health promotion survey as they checked in for their appointment. Clinical records for patients screening positive on the two survey depression items were examined to determine whether patients were being actively treated for depression in Mental Health Clinic. Those who were not were contacted by telephone and, if willing, were administered a structured computer-assisted interview based on the Prime-MD by a trained evaluator. Those positive for major depression or dysthymia were asked whether they were interested in treatment (and if interested, that information was conveyed to their primary care provider.) 

# Results: The General Internal Medicine primary care clinic of the Seattle Division of the VA Puget Sound Health Care System in which the survey was conducted currently has an enrollment of 9100 patients and averages 850 visits per week. Patients are predominantly male (95%), Caucasian (90%), elderly (mean age 65), and not working (86%). During the four- month period, 837 patients were positive on the depression screen and 508 have been reviewed to date. Chart review found 45% to be in mental health treatment, either in the primary care setting, or in specialty care. After interview we found that 15% met MDD criteria and 2% had a mood disorder secondary to alcohol abuse. Of the rest, 11% could not be contacted, 2% could not be interviewed because of hearing or cognition, 12% declined to be interviewed and 3% we are still attempting to reach. Of those interviewed, 10% did not meet depression criteria. Of these currently untreated patients, almost all of the former group (and some of the latter) were amenable to discussing treatment alternatives. 

# Conclusions: In this population, a high percentage of patients screened were either already in treatment or met depression criteria, suggesting a short screen is an effective method of identifying depression. However, following up on those patients not in treatment requires a significant investment of staff time, even using computer-assisted technology.

#  Impacts: This study provides information on one component of depression treatment guidelines implementation in primary care which can be used by planners in deciding how to distribute available resources.

**64. Coronary Artery Stent Outcomes in Department of Veterans Affairs
Medical Centers**

[Michael Chapko, PhD and Nathan Every, MD, MPH.]{.underline} VA Puget
Sound Health Care System. Seattle, WA. [C Maynard and JL
Ritchie]{.underline}

**Objectives:** Randomized trials of coronary stents versus conventional
balloon percutaneous transluminal coronary angioplasty (PTCA) have
demonstrated improved short and long-term outcomes for selected patients
receiving stents. PTCA caseloads in Department of Veterans Affairs (VA)
medical centers have increased from about 5,000 per year in fiscal year
(FY) 1993 to 6,000 per year in FY 97 In FY 96, the first year the ICD-9
stent code was used, there were 3895 conventional PTCA and 2573 stent
cases (40%). In FY 97, the number of stent cases increased 39% to 3588
and accounted for 58% of all PTCAs. The purpose of this study is to
compare outcomes in patients with stents with outcomes in patients with
conventional PTCA in the VA in FY 97.

**Methods:** Data on the outcomes of conventional PTCA and PTCA with
stents were obtained for all VA medical facilities from the Austin
Automation Center. For patients with more than 1 procedure, only the
index case is considered, and results are reported separately for men
with and without the primary diagnosis of acute miocardial infarction
(AMI).

**Results:** For both AMI and no AMI patients, the stent (N: AMI = 607;
No AMI = 2389) and no stent (N: AMI = 485; No AMI = 1999) groups were
comparable with respect to age, race, and medical histories including
diabetes, hypertension, myocardial infarction, and chronic heart
failure. For both AMI and no AMI patients there was no significant
difference in mortality rates (\< 11 days after admission) between
patients receiving (AMI = 2.8%; No AMI = .8%) and not receiving stents
(AMI = 3.3%; No AMI = 1.2%). However, patients receiving stents (AMI =
0.2%; No AMI = 0.8%) had significantly lower rates of coronary artery
bypass graft surgery (CABG) compared to patients who did not receive
stents (AMI = 2.1%; No AMI = 3.0%). This association did not change
after multivariate adjustment. In VA medical centers, the use of stents
has increased, and the rate of same admission CABG has decreased.

**Conclusions:** The observational data from the VA with regard to the
reduction in CABG rates is consistent with previous clinical trails that
demonstrated the positive outcomes from the use of stents.

**Impact:** This study has the potential to encourage the continued use
of stents and thereby reduce CABG rates within the VA.

**HSR&D Funded:** IIR 94-044

**65. Symptom-Based Predictors of a Ten-Year Course of Treated
Depression**

[Ruth Cronkite, PhD and Rudolf Moos, PhD.]{.underline} Center for Health
Care Evaluation, Menlo Park, CA

**Objectives:** The primary objective of this research is to predict the
likelihood of a long-term chronic course of depression from a set of
risk factors that reflect three symptom domains associated with poor
outcome: severity of specific depressive symptoms, lack of
self-confidence, and a tendency toward social isolation and avoidance
coping. We also examine the intensity of the index episode of treatment
as a moderator of the influence of baseline risk factors on long-term
outcome.

**Methods:** In a sample of 313 unipolar depressed patients, 20
potential symptom-based risk factors were assessed at treatment intake
in the following domains: depressive symptoms, self-concept, and social
functioning and coping. These patients were followed for ten years and
were categorized into two groups: (1) those who were considered to have
followed a chronic course, and (2) those who were considered to have
followed a course of remission or partial remission.Chi-square analyses
were used to select a set of baseline risk factors that were most
strongly associated with a chronic course. Scores reflecting the number
of risk factors present at intake were used to identify the relationship
between the number of risk factors and chronic course. Logistic
regression analysis was used to examine the influence of the amount of
treatment on the association between the number of risk factors and
long-term chronic course.

**Results:** The prototypic chronically depressed patient was an
individual who at baseline experienced more severe symptoms of fatigue,
loss of interest in usual activities, trouble sleeping, and thoughts
about death or suicide; was not calm, successful, or self-confident; did
not socialize with friends outside the home, and frequently coped with
stressors by avoiding other people. A larger number of risk factors was
associated with a higher likelihood of experiencing a chronic course.
High-risk patients who received more psychological treatment during the
index episode were more likely to experience a long-term course of
remission or partial remission.

**Conclusion:** Symptoms that change more slowly during treatment and
that are more closely tied to behavioral concomitants of depressed mood
may be better predictors of outcome than depressed mood itself. Frequent
thoughts of death and suicidal ideation are especially serious symptoms
and are strong predictors of chronicity. Lack of self-confidence and
social withdrawal are also important predictors of long-term chronic
course and point to the heterogeneity of the mechanisms that influence
chronicity.

**Impact:** Information about specific risk factors may help to direct
treatment efforts and point to the need for continuing care. When
patients report ongoing severe symptoms that predict a chronic course, a
longer and more intensive course of treatment may be indicated. When the
patient has a low self-concept, is socially isolated, and tries to
manage stressors by avoiding people, these issues should be specifically
addressed in treatment. By alerting the clinician to the patient\'s need
for additional care, feedback obtained from a risk factor index can help
to address the pervasive under- treatment of depression.

# 66. Family Satisfaction with VA Hospice Care

[Elaine Czarnowski, RN, Elaine Hickey, RN, MSN, Cheryl Hankin,
PhD.]{.underline} Bedford VA Medical Center, Bedford, MA. [J
Anderson.]{.underline} [Carol VanDeusen Lukas, EdD.]{.underline} Boston
VA Medical Center, Boston, MA. [L Leonard]{.underline}

**Objective:** VA\'s emphasis on patient-centered care requires the
evaluation of satisfaction with services. We present data regarding
family satisfaction with hospice care as a component of a
Congressionally mandated study to evaluate VA hospice programs.

**Methods:** As part of The Veterans Hospice Care Study, The National
Hospice Organization (NHO) Family Satisfaction Survey was completed by a
random sample of 528 family members of recently deceased veterans who
received VA hospice care. Family members were asked to rate levels of
satisfaction with eight aspects of hospice care. These aspects were: 1)
satisfaction with the patient\'s pain control after hospice admission;
2) satisfaction with other symptom control; 3) quality of family and
patient education; 4) responsiveness of the interdisciplinary care team
to patient and family needs; 5) staff assistance in managing patient and
family stress and anxiety; 6) staff support of patient and family
spiritual needs; 7) perceived timeliness of patient\'s referral to
hospice; 8) staff efforts to support the patient\'s quality of life.
Levels of satisfaction were measured on a scale of 1 (very dissatisfied)
to 5 (very satisfied), so that higher mean scores (closer to 5.0)
correspond to greater levels of satisfaction. VA survey findings were
compared with responses from 17,510 family members from private (non-VA)
hospices. In addition, family members of veterans were asked to identify
what they believed were the strengths and barriers of VA hospice
programs.

**Results:** Both VA mean satisfaction scores and NHO reported scores
ranged from satisfied (4.0) to very satisfied (5.0). In comparison to
the NHO results, the levels of satisfaction reported by all VA hospice
patients were similar but slightly lower than NHO scores. (VA mean
satisfaction scores ranged from 95% to 100% of the NHO mean scores.) The
most frequently cited strength of VA hospice programs was the commitment
and skill of VA hospice staff. Family members specifically commented on
staff\'s willingness to individualize care to meet the changing needs of
patients and families. The most frequently cited barrier to effective
hospice care was a perceived delay in veterans\' referrals to hospice.
Some family members stated that they believed the veteran would have
benefited from hospice services earlier during his or her disease.

**Conclusions:** Study results show that overall, family members of VA
hospice patients were satisfied to highly satisfied with the care that
veterans received. Levels of satisfaction with VA hospice care were
comparable to those reported in the NHO survey of non-VA hospices. The
average length of stay in hospice for the veterans in this sample was 65
days compared to 58 days for NHO patients. Although veterans\' length of
stay was longer than those reported for non-VA hospice patients, some
family members would have preferred earlier referrals.

**Statements:** Satisfaction with care is an essential part of any
program evaluation. High levels of satisfaction among family members of
veterans who received hospice care are an indicator of the effectiveness
of VA hospice programs. Family comments indicate that care must be taken
to assure timely referral to hospice.

**HSR&D Funded:** MMR 97-004

**67. Mental Health Services Delivery in the Department of Veterans
Affairs: Treatment in Psychiatric, Primary Care, and Specialty Medical
Settings**

[Benjamin Druss, MD, MPH and Robert Rosenheck, MD.]{.underline}
Northwest Program Evaluation Center, West Haven, CT.

**Objectives:** Epidemiological surveys suggest that half of patients
with mental disorders in the US are treated in general medical settings.
This paper examines delivery of mental health services in psychiatric,
primary care, and specialty medical clinics in the Department of
Veterans Affairs (VA), the largest public sector health care system in
the US.

**Methods:** Using national VA encounter files, we examined all
outpatient visits to the VA during an 18-month period: October
1996-March 1998. During this time, VA policy promoted a general shift to
a primary care-based delivery system. Among veterans with any visit for
a primary diagnosis of a mental or substance abuse disorder, we compared
the locus, diagnoses, and procedures performed in each of three settings
\-- specialty mental health clinics, primary care medical clinics, and
medical subspecialty clinics.

**Results:** Of 437,035 veterans treated for a mental disorder during
the final 6 months of the study period, 83.0% were seen for their mental
disorders only in specialty mental health clinics; 5.0% were seen
exclusively in primary care medical clinics; 1.7% in specialty medical
clinics; and 10.3% in multiple settings. Over 90% of individuals with
serious Axis I disorders (Schizophrenia, major depression, bipolar
disorder and PTSD) received mental health care only in specialty mental
health settings. There was no change in the distribution of care between
medical and mental health settings over time, although there was a shift
in mental health services delivery from specialty medical to primary
care settings.

**Conclusions:** A far greater percentage of mental health care in the
VA than in community or HMO populations is provided through specialty
mental health clinics. In contrast to private sector samples, the high
levels of psychiatric morbidity seen in VA patients may make medical
treaters reluctant to assume a large portion of their patients\' mental
health care.

**Impact:** These findings may help inform debates regarding mental
health staffing projections both in the VA and in the larger \"de
facto\" US mental health care system. Estimates of mental health
staffing needs based on \"benchmarking,\" or extrapolation from current
managed care staffing patterns, have generally projected a surplus of
mental health providers in the US. However, mental health\'s two-tiered
public/private system may make such techniques problematic to apply to
mental health services. Developing mental health staffing models that
can be generalized to both the private and public sectors will
ultimately require better methods of adjusting for case-mix and
estimating need in these very different populations.

### 68. Provider Advice and Walking for Exercise in Elderly Primary Care Patients, and Speciality medical Setting

##### Patricia Dubbert, PhD. GU "Sonny" Montgomery VA Medical Center, Jackson, MS. ER Meydrech, KA Kirchner, KM Cooper, and DE Bilbrew.

**Objectives:** Recent studies have confirmed that physical activity is
beneficial for elderly men and women. Epidemiologic studies and health
guidelines suggest that many elders could decrease risk of disability
and premature mortality by increasing moderate intensity activity such
as walking. The purpose of this study was to examine prevalence and
potential predictors of walking for exercise among patients being
screened for the Seniors Telephone Exercise Primary Care Study (STEPS),
an exercise nurse counseling intervention trial.

**Methods:** Methods:Participants were veterans, 60-80 years of age,
enrolled in VA primary care clinics, and whose health status permitted
increased walking. From 352 identified by medical record and PC provider
review, 280 completed a phone prescreening which included questions
about health habits and recall of provider advice to exercise. 182
subsequently completed a screening visit which allowed collection of
demographic and additional health data.

**Results:** 164 (59%) of the 280 phone prescreen participants reported
some walking for exercise. Of those already walking, 56% walked \<= one
day ago, 68% within the past 3 days, and 72% within the past week. 68%
reported walks \>= 20 minutes duration. The frequency distribution of
walking was bimodal, with about 40% of participants walking 2-3 times
per week and 27% reporting daily walking. 58% reported they had been
walking for 6 months or longer. 16% of patients reported doing regular
exercise, but not walking. Information obtained from the 182
participants who completed a screening visit found the mean age was 68.8
(S.D. 4.5) years, 26% were minority, 79% married, 22% employed, 55%
lived in a rural setting, and 47% had \< HS education. Participants had
on average 3 major medical diagnoses. 143 (51%) of the 280 prescreening
participants recalled being given exercise advice by their health care
provider. Estimated in a model that included ethnicity, number of
medical conditions, and urban vs. rural dwelling, recall of provider
advice was significantly related to walking for exercise (O.R. =2.27,
C.I. 1.23-4.17, P\<.01). None of the other covariates was significantly
related to walking**.**

**Conclusions:** More than half of elderly VA primary care patients with
chronic illness whose providers thought they could increase physical
activity were already doing some walking for exercise. Notably, those
who recalled a provider advising them to exercise were more likely to be
walking. Speed/intensity of walking was not assessed, and it is likely
that the health benefits of walking could be improved if some
participants walked faster or for longer periods of time.

**Implications:** Although these data are observational, the results
support previous research with younger, healthier populations which
indicate that provider counseling can increase physical activity in
sedentary patients. At least 1/3 of participants reported no regular
physical activity. Providers should continue to encourage patients to be
active as their health status permits. Future studies should address
barriers to activity and cost-effective methods of preventive counseling
including physical activity

**HSR&D Funded:** NRI 95-022

**69. Evaluating Screening Criteria for Adverse Outcomes in Medical
Patients**

[Ron Evans, MSW.]{.underline} VA Puget Sound health Care System,
Seattle, WA.

**Objectives:** The purpose of the current study was to identify
variables near hospital admission that could effectively discriminate
patients at risk for nursing home placement, lengthy hospital stay, or
readmission. The specific goals were to determine the sensitivity and
specificity of differing screening strategies in predicting adverse
outcomes.

**Methods:** We evaluated the screening criteria, including those
available through hospital billing and resource usage data, to determine
if a subset of generic screens might efficiently identify outcome. Risk
criteria reported in the literature were used to predict discharge
destination and duration of care for 1,332 admissions.

**Results:** Factors that discriminated outcome included: comorbidity,
mental status, living arrangement, transfer to a special care unit,
prior admission within 1 year, iatrogenic trauma, and pending
litigation. Sensitivity and specificity of individual screens varied
widely. Prior hospitalization was the most sensitive \[64%\] but least
specific \[47%\]. Transfer to a special care unit was specific \[91%\]
but not sensitive \[11%\]. Transfer to another hospital was intermediate
\[sensitivity 32%, specificity 71%\]. Combinations of screens were
compared, including some using only resource usage data. The most
sensitive strategy using billing data detected 44% of adverse outcomes
and cost only \$4 per admission \[\$51 per adverse event\], versus \$14
per admission \[\$94 per event\] when all records were reviewed.

**Conclusion**: We concluded that use of cumulative risk scores can
result in accurate prediction of hospital outcome, which may be useful
in targeting patients for intervention.

**Impact:** Using screens available through billing and resource use
data, although insensitive, would be the most cost effective strategy.

**70. A Pilot Study: Telecare in the Management of Diabetes.**

[Stephan Gaehde, MD, MPH.]{.underline} Boston VA Medical Center, Boston,
MA. [BG Fincke.]{.underline} [Dan Berlowitz, MD, MPH.]{.underline}
Bedford VA Medical Center, Bedford, MA. [J Clark and J
Anderson.]{.underline}

**Objectives:** Recent advances in telemedicine may lead to substantial
changes in the outpatient management of chronic illness. Changes in
computer technology and the development of sophisticated disease
management software that is both physician and patient-friendly may lead
to reduced distance between doctors and patients and improved patient
self-management of complex health problems, such a diabetes.Here we
present the results from a pilot study to assess the feasibility of a
telemedicine program that links VA physicians with outpatients with
diabetes, through a system of personal computers in physician offices
and their patients\' homes connected by ISDN lines that enable data
transfer and videoconferencing. Specific study objectives were to: 1)
Characterize how the technology is adopted, accepted and integrated into
the process of care by patients and providers. 2) Determine effect size
of the intervention on satisfaction with care, degree of glycemic
control, health-related quality of life, and utilization of health care
resources.

**Methods:** In this descriptive pilot study using a pre/post
intervention design, we enrolled 20 patients with type 2 diabetes
mellitus requiring insulin from 5 provider panels at the Boston VAMC.
Study outcomes include degree of glycemic control, patient satisfaction
with care, health-related quality of life, and utilization of resources.
Qualitative data regarding acceptability and adoption of the
intervention were collected in structured interviews conducted by a
medical sociologist. Use of the system was characterized by analysis of
descriptive data. Outcomes were assessed using a pre/post intervention
design.

**Results:** Patient interviews prior to having the computers set up in
their homes and at study termination revealed a varied response. Some
patients found the system facile to use and said that the routine of
interacting with the program and reporting the results of glucose and
symptoms served to reinforce their motivation for self-management while
several patients had used the system very little, either because they
could not get the system to work or they lost interest. Glycemic control
improved from a mean value of 9.4% to 8.7% (p=0.24) from the start of
training to 4.5 months. We also report how the intervention was used and
adopted by patients as well as its effect on health-related quality of
life, satisfaction with care, utilization of resources, and outpatient
visits.

**Conclusions:** This project has demonstrated that: 1) elderly veterans
without previous computer experience are able to use a technically
sophisticated telemedicine intervention 2) successful deployment of a
sophisticated telemedicine system in actual clinical care. Telemedicine
may reduce the distance between physicians and their patients, who are
responsible for following a complicated self-management regimens at
home, with patients experiencing the closer attention as supportive.

**Impact:** The findings of this study will provide important insights
into how such interventions are adopted by patients and providers and
how they may be best positioned in the process of clinical care in a VA
setting. These finding will be very useful in designing effective future
interventions. Further, the findings will allow estimation of effect
sizes of several outcomes including glycemic control, health-related
quality of life and patient satisfaction with care.

**HSR&D Funded:** SDR 94-11

**71. Assessing VA's National Formulary Policy by Physician Survey**

[Chester Good, MD, MPH.]{.underline} Pittsburgh VA Medical Center,
Pittsburgh, PA. [Peter Glassman, MD]{.underline}. West Los Angeles VA
Medical Center. Los Angeles, CA. [M Kelley, M Bradley, M Valentino, J
Ogden, and K Kizer.]{.underline}

**Objectives:** The VA National Formulary (VANF) was implemented in June
1997 to improve equity of access to pharmaceuticals across VHA and to
improve accountability of VA\'s 1.6 billion dollar pharmaceutical
program. We surveyed physicians approximately 1 year after
implementation to help assess VANF\'s effects on patient care, access to
drugs, physician workload and VA\'s ability to train resident staff.

**Methods:** Questions, scored on a 5-point Likert scale, addressed
general issues about the VANF and specific effects of choosing selected
drugs within six drug classes. Respondents also provided demographic
information. The sample population (n = 4640), based on the circulation
files of The Veterans Health Journal, included all listed general
internists (n = 2824) and convenience samples of neurologists (n = 238),
psychiatrists (n=997), general surgeons (n = 429), neurologists (n =
238) and urologists (n = 152). Non-responding physicians received a
second survey approximately 1 month after the first. A total of 104
physicians were declared ineligible, leaving a final sample of 4536.
Comparisons across groups were by Chi-squared analysis.

**Results:** Overall response rate was 45% (2041/4536). Physicians were
all attendings, average age 49 years, with 11 years of VA service, and
averaging 5 half-day outpatient clinics per week; 73% were full-time
employees; 20% practiced in other health systems with formularies, and
13% were on VA Pharmacy Committees. Most physicians (63%) agreed that
they could prescribe needed drugs; 66% agreed that patients could obtain
non-formulary drugs, when necessary. About one-third (32%) of physicians
disagreed that access to prescription pharmaceuticals had increased over
the past year. Although 29% stated the VANF impinged on providing
quality care to their patients, fewer physicians (24%) felt that it
impinged on providing quality care to other VA patients. Thirty-eight
percent (38%) felt that the VANF was more restrictive than private
sector formularies but only 16% felt that the VANF diminished the
ability to train residents for managed care. Most physicians (60%) did
not agree that the Formulary added substantially to their workload.
Regarding questions on drug class selections, the overall perception was
that selections had nominal effect on patient care. For example,
choosing lovastatin and simvastatin as formulary drugs was felt to have
a positive effect on patient care by 29% of physicians, no effect by 46%
and a negative effect by 8%. We noted significant differences among
physicians on many issues. For example, VA physicians who worked in
other health care systems with formularies were less likely to agree
that the VANF added substantially to workload (28% vs. 38%, P \< .001).

**Conclusions:** Most participating VA physicians did not perceive that
the VANF negatively affected quality of patient care, access to
pharmaceuticals, physician workload or resident training.

**Impact:** VHA is the first national health care system to assess the
impact of formulary policy by surveying physicians. Survey results are
being used to increase understanding of the VANF and to improve its
functioning, with further policy evaluations now being directed towards
ensuring access to non-formulary products and towards understanding
effects on physician workload. Future surveys are planned.

**72. Does Military Status Influence Use of VA Ambulatory Care**?

[Nancy Harada, PhD, Donna Washington, MD, MPH, and JoAnn
Damron-Rodriguez, PhD.]{.underline} West Los Angeles VA Medical Center,
Los Angeles, CA. [T Makinodan, H Liu, and S Dhanani.]{.underline}

**Objectives:** Military experiences have been documented to influence a
veteran\'s subsequent use of health care services. Specifically, these
military experiences may serve as predisposing, enabling, or need
variables affecting VA ambulatory care utilization. The objectives of
this study were to identify military status factors predictive of VA
ambulatory care use, and to determine whether these factors remain
significant after controlling for race/ethnicity, sociodemographic, and
health status characteristics.

**Methods:** The source of data was the 1992 National Survey of Veterans
(NSV). Since the NSV sample is 97% male, our analyses were limited to
this gender group. Bivariate analyses were conducted to describe the
demographic and military status characteristics of VA ambulatory care
users and non-users. A hierarchical logistic regression analysis was
conducted with use of VA ambulatory care as the dependent variable. The
initial logistic model included several variables descriptive of
military status, followed by 3 additional models controlling for
race/ethnicity, sociodemographic, and health status.

**Results:** Of the total sample (n=7,851, mean age=56 years), 41% had
used VA ambulatory care services in the previous year. Sixty-four
percent of the VA users came exclusively to the VA for ambulatory care,
and the remaining had used the VA in conjunction with non-VA ambulatory
care. The first model explored the contribution of military status
variables to ambulatory care use without controlling for race/ethnicity,
sociodemographic, or health status. Significant military status
variables included retirement from the military for disability (OR=1.6),
combat exposure (OR=1.1), service in the Marines (OR=1.3), Army
(OR=1.3), or during the Korean Conflict (OR=1.3), service-connected
injury (OR=1.6), 6 or more years of military service (OR=1.3), and
retirement from the military after 20 years of service (OR=.58).
Controlling for race/ethnicity in the second model did not alter the
list of significant military status variables. The inclusion of
sociodemographic characteristics in model 3 decreased the list of
significant military status variables to service in the Marines
(OR=1.6), service-connected injury (OR=1.2), and 6 or more years of
service (OR=1.4). After controlling for race/ethnicity,
sociodemographic, and health status in the final model only military
service for 6 or more years remained significant (OR=1.4). However the
final model showed that veterans who are minorities, of lower
socioeconomic status, uninsured, have poor health status and a
service-connected disability have a greater likelihood of being a VA
ambulatory care user.

**Conclusions:** The findings demonstrate that the VA serves as an
important source of health care for veterans with service-connected
disabilities and long term service in the military. In addition,
veterans who are minorities, of low socioeconomic status and poor health
status also use the VA for ambulatory care.

**Impact:** Military status characteristics describing veterans who use
ambulatory care highlight the importance of health care entitlement for
Americans who served their country. The VA serves as an important source
of ambulatory care for veterans with service-connected disabilities and
long term service in the military. As the VA seeks to restructure its
delivery of ambulatory care, it must create policies to benefit this
deserving population.

**HSR&D Funded**: ECV 97-028

73\. How Primary Care Providers Treat Depression: Attitudes, Skills,
Barriers and Personal Experience

[Nicole Hasenberg, MPH, Edmund Chaney, PhD, CE Hansen, and Susan
Hedrick, PhD.]{.underline} VA Puget Sound Health Care System, Seattle,
WA.

**Objectives:** We wanted to learn more about primary care providers
(PCP) attitudes regarding the diagnosis and treatment of depression with
the eventual goal of targeting different educational interventions
toward PCPs and improving medical care for patients who are depressed.

**Methods:** We obtained cross-sectional data from PCPs as part of a
larger study about depression treatment at the General Internal Medicine
Clinic at the VA Puget Sound Health Care System in Seattle. We asked
them to evaluate their attitudes, skills, and barriers to treating their
patients with major depression. We also were interested in whether
having personal experience with depression would influence self-reported
skills and comfort level with treating depression.

**Results:** At the end of two GIMC Journal Clubs and several Resident
Post-Clinic Case Conferences during January, February, July, and August
of 1998, we notified PCPs about the depression study and asked them to
complete an anonymous 5 to 10-minute questionnaire. During that time, 90
Primary Care Providers were on staff, of whom 31(34%) were Attending

Physicians or Medical Fellows, 18(20%) were Nurse Practitioners and
41(46%) were Medical Residents. Of those on staff, 61(68%) PCPs
completed the survey.

Almost all PCPs (91.8%) feel comfortable writing referrals for further
depression treatment. Overall comfort level with skill-based treatment
was good; 40(78.7%) PCPs said they felt somewhat or very skilled at
making a diagnosis; 39(63.9%) felt somewhat or very skilled about
writing a prescription for anti-depressant medication; and 28(45.9%)
believed the same about counseling and education regarding depression.

Many providers reported the following barriers to care limit them a
great deal in treating depression: no time for education and/or
counseling (54%); preferred medication difficult to obtain (43%);
viewing other medical problems as more pressing (36%); perceiving the
patient as reluctant to accept diagnosis or treatment (30%); inadequate
time for follow-up (28%); and lack of availability of mental health
professionals (25%).

In terms of provision of care, 59% think depression usually should be
treated in primary care settings compared with 31% who think those with
depression should be referred to specialty clinics.

In this population 48(79%) providers report that they or a close friend
or family member had personal experiences with depression. We tested
whether there was an association between providers who had personal
experience with depression and all the mentioned skills and barriers to
care. None of the variables were statistically significant, however
small numbers in each cell may influence such results.

**Conclusions:** Primary care provider education may be more effective
if it is tailored toward counseling and educating a person who is
depressed. Individual VAs can focus on particular systems barriers (such
as getting different medications on the formulary or providing more time
for care of depressed patients) to improve the treatment of depression.
Finally, initial analysis suggests that personal experience with
depression does not seem to significantly influence skills and barriers
to treatment.

**Impact:** These results can be used for educating primary care
providers and for planning and delivering depression treatment in
ambulatory care settings.

**HSR&D Funded:** 95-097

**74. The Use of Ambulatory Care Sensitive Hospitalization as a
Qualitative Indicator of Primary Care**

[Laura Hechtel, PhD, Margaret Byrne PhD, and Carol Ashton MD,
MPH]{.underline}. Houston VA Medical Center, Houston, TX.

**Objectives:** Ambulatory care sensitive (ACS) conditions have been
proposed as an indicator of access to, and quality of, primary care. In
this study, we examine the validity of using such an indicator as it
relates to primary care enrollment.

**Methods:** From the Outpatient Clinic file (OPC, FY 1996), users were
considered to be enrolled in primary care if they had at least one
primary care clinic stop. From the Patient Treatment File (FY 1996), ACS
and non-ACS hospitalizations were determined for each OPC user and for
each hospital facility. In addition, the 10 most frequent DRG\'s for
primary care (PC) enrollees and non-primary care (NPC) enrollees were
collected.

**Results:** 31.0% of PC enrollees were hospitalized for any condition
as compared to 21.7 % for NPC enrollees. PC enrollees had a
significantly higher (p=0.0001) hospitalization rate (1130 per 1000
individuals) than NPC enrollees (1068 per 1000 individuals). The
proportion of hospitalizations that were for ACS conditions was
significantly greater (p=0.0001) in PC enrollees (12.8%) than in NPC
enrollees (7.5%). This outcome was consistent across hospital facilities
(n=153). Among 10 most frequent DRG\'s, 4 were ACS conditions while the
other 6 were psychiatric diseases. All 4 ACS conditions were more common
than expected in PC enrollees, while 4 of the 6 psychiatric diseases
were more common than expected in the NPC enrollees.

**Conclusions:** The hospitalization rate for ACS conditions is higher
in VA users enrolled in PC compared with those not enrolled in PC. That
this finding was consistent across all VA facilities makes it highly
unlikely that the ACS hospitalization rate is measuring quality of care.
It is more likely that ACS hospitalization rates are reflecting
systematic differences in the prevalence and severity of certain
diseases between the PC and NPC VA user populations. If hospitalization
rates for ACS conditions are to be used as an indicator of quality of
care, more research is needed into their validity.

**Impact:** Using hospitalization rates for ACS conditions as a quality
of care indicator assumes that the populations under study are
clinically similar and utilize VA hospital facilities in the same
manner. However, this study shows that this may not be true. Health
science research must take into consideration population characteristics
in order to more reliably assess quality of care. Our findings show that
it is inappropriate at the present time to use hospitalization rates for
ACS conditions as a quality indicator with VA system.

### 75. Treatment can Enhance the Effectiveness of Substance Abuse Self-Help Groups

##### Keith Humphreys, PhD. VA Palo Alto Health Care System, Menlo Park, CA. Rudolf Moos, PhD. VA Palo Alto Health Care System, Palo Alto, CA.

**Objectives:** Affiliation with Alcoholics Anonymous (AA) and other
12-step self-help groups is becoming more common at the same time as
professional substance abuse treatment services are becoming less
available and of shorter duration. As a result of these two trends,
patients\' outcomes may be increasingly influenced by the degree to
which professional treatment programs help patients take maximum
advantage of self-help groups. The present study of 3018 treated
veterans examined how the theoretical orientation of a substance abuse
treatment program affects (1) The proportion of its patients that
participate in self- help groups, and, (2) The degree of benefit
patients derive from participation in self-help groups.

**Methods:** A 1-year longitudinal study at 15 VA facilities nationwide.

**Results:** Patients treated in 12-step and eclectic treatment programs
had higher rates of subsequent participation in 12-step self-help groups
than did patients treated in cognitive behavioral programs. Further, the
theoretical orientation of treatment moderated the outcome of self-help
group participation: As the degree of programs\' emphasis on 12-step
approaches increased, the positive relationships of 12-step group
participation to better substance use and psychological outcomes became
stronger.

**Conculsions:** Hence, it appears that 12-step oriented treatment
programs enhance the effectiveness of 12-step self-help groups. Findings
are discussed in terms of implications for clinical practice and for
future evaluations of the combined effects of treatment and self-help
groups.

**Impact:** These findings present a practical way for VA clinicians to
improve outcomes at little additional costs.

**76. Do Oral Health-Related Quality of Life Measures Relate to Use of
Dental Care?**

[Judith Jones, DDS, MPH, Nancy Kressin, PhD, A Spiro III, PhD, Donald
Miller, ScD and Lewis Kazis, ScD.]{.underline} Bedford VA Medical
Center, Bedford, MA. [RI Garcia.]{.underline}

**Objectives:** Valid dental outcome measures should vary with the use
of dental services. The purpose of this analysis is to examine the
relationship of oral health-related quality of life measures to past use
of dental care in two populations.

**Methods:** We examined the retrospective relationships of
self-reported oral health measures to self-reported use of care in two
contrasting samples of veterans, the Veterans Health Study (VHS, N=538,
mean age=62) and the VA Dental Longitudinal Study (DLS, N=278, mean age
=71). Self-reported oral health measures included a single-item
self-report measure of oral health (OH1), the 3-item Oral Health-Related
Quality of Life measure (OHQOL, Kressin, et al, 1996) the 12-item
Geriatric Oral Health Assessment (GOHAI, Atchison & Dolan, 1990), and
the 49-item Oral Health Impact Profile (OHIP, Slade & Spencer, 1994).
Use of care was categorized into \<=1year, \>1year; and \<=2years,
\>2years. Reason for last visit was divided into emergency and routine
care (exam and cleaning, fillings, other).

**Results:** In the VHS sample, better oral health (OH1) was associated
with recency of dental visit, i.e., better oral health was associated
(p\<0.05) with more recent use (in last year and last 2 years). Better
scores on the OH1, OHQOL and OHIP were significantly associated with
reason for last visit, with approximately 0.5 sdev lower scores, on
average, in persons who used emergency as compared to routine care. In
the DLS sample, there were no significant differences in mean
self-reported oral health scores by recency of use or reason for last
visit; however trends were in the expected directions.

**Conclusions:** The validity of these self-report measures of oral
health is suggested by the association with recency of dental care and
reason for last visit in VA health care users. However, no significant
associations were observed in the DLS, most of whom use routine dental
care.

**Impact:** Self-reported oral health measures may be useful to monitor
the effects of dental care on patients\' quality of life in users of VA
health care.

**HSR&D Funded:** IIR 93-025

77\. Health Outcomes of Veterans Using SF-36V: 1998 National Survey of
Ambulatory Care Patients

##### Lewis Kazis, ScD. Bedford VA Medical Center, Bedford, MA. N Wilson, W Rogers, and A Lee. Xinhua Ren, PhD, Katherine Skinner, PhD, Alfredo Selim, MD, MPH, and Donald Miller, ScD. Bedford VA Medical Center, Bedford, MA. 

**Objectives:** The Veterans Health Administration (VHA) is now
implementing patient centered measures of functional status as part of
its performance measurement system to set goals and standards for the 22
VISNs (geographically based groups of hospitals), individual hospitals
and providers. To monitor the changes in health status over time, we
established a cohort of veteran users of the VHA who were administered
the SF-36V in 1996 and again in 1998. These changes may be related to
the processes of care.

**Methods:** The SF-36V (Short Form Health Survey for Veterans) was
mailed to a national probability sample of 25,040 veterans between
January and February 1998 who had been administered the same
questionnaire, 17 months earlier in 1996. For the cohort, the response
rate was 85.2% using a modified Total Design Methodology approach
developed by Dillman. The SF-36V, developed in the Veterans Health Study
is a patient based questionnaire designed specifically for use among
veterans who are in ambulatory care. The SF-36V is a reliable and valid
measure of health status with increased precision over the MOS SF-36.
Eight concepts of health are summarized into physical (PCS) and mental
(MCS) component summaries standardized to the U.S. population with a
mean of 50. Each of the patient scores were computed as the difference
of the 1996 score from the 1998 score for PCS and MCS, respectively. A
negative score denotes worsening. Overall trends in the VA were compared
to the Medical Outcomes Study (MOS), a general population in civilian
managed care for the same duration of follow-up. Comparisons of the
trends over time among VISNs were made with multivariable adjustments
for case mix using age, gender, and diagnoses with a previously
validated approach using ICD-9 codes.

**Results:** Rates of physical decline in the VA were about a third of
that observed in the civilian sector (MOS) (p\<0.01). For PCS, the
17-month physical decline was -0.39. The MOS study showed a much greater
rate of decline equivalent to -1.08 over the same time period. There
were no important differences in the trends among the VISNs for PCS. For
MCS, the rate of mental decline in the VA compared to the MOS study was
comparable (p\>0.20). However, we found considerable variation in mental
health trends across the VISNs. Trends varied from 0.69 to -0.93, an
overall range of 1.62 (p\< 0.05). After discounting sampling errors,
regression to the mean effects and attrition, trends in PCS for the VA
compared to the civilian sector remained significant and clinically
important. For MCS, differences in the trends observed among VISNs, are
larger than case mix explanations would suggest even after taking random
sampling errors into account. The differences in the trends for MCS are
equivalent to treating the psychological impact of two medical
conditions.

**Conclusions:** Substantial variation in MCS trends among VISNs were
observed and for the most part, were not explained by case mix or
methodologic factors. These findings suggest that processes of care are
likely candidates to explain these differences.

**Impact:** These results have important implications for quality
assessment and for setting goals for the VISN performance measures.

**HSR&D Funded**: SDR 91-006

### 78. Multi-site Research: Overcoming Hurdles

[Anne Keane PA-C, JD, Nathan Every MD, MPH, and Anne Sales PhD,
RN.]{.underline} VA Puget Sound Health Care System, Seattle, WA.

**Objectives:** In this paper, we describe the process and costs of
obtaining Institutional Review Board (IRB or Human Subjects Committee)
approval and access to electronic data systems at each of 30 VA Medical
Centers (VAMCs) in five Networks for a study of patient outcomes and
clinical integration in cardiology. We then propose changes to some of
the processes of obtaining necessary approvals that would enable
research to be done at less cost while still preserving adequate reviews
for patient safety at each medical center and facility providing patient
care.

**Methods:** As part of the proposal process, we gained approval from
our local IRB for the protocol. This submission and required revisions
are not included in our estimates of time and cost. Beginning in January
1998, we contacted the IRBs for all of the VAMCs in the five VISNs
included in our study: VISNs 13, 18, 19, 20, and 22. We contacted the
people who had supported the study at each of the medical centers, and
obtained the contacts for the local IRB. We then submitted the
application required for the local IRB, as well as complete copies of
the protocol, human subject submission and approval from our own IRB.
During the same time period, we began to contact Information Resource
Management (IRM) at each medical center to obtain the applications for
gaining access to electronic records. Once we had obtained IRB approval
at each site, we requested IRM access.

**Results:** We found a wide variety of IRB mechanisms in the 35 sites
we initially contacted. We began the process in January 1998, and are
still completing IRB negotiations at one site in November 1998. Most
sites had given us approval by June 1998. We had to drop some sites from
the study because of the difficulties of negotiating IRB approval. The
project manager and secretarial support staff spent the most time
involved in obtaining IRB approval, for a combined total of
approximately 800 hours of effort, at a cost of approximately \$20500.
Several staff members were involved in obtaining IRM access, with a
combined total of 560 hours, for a total cost of \$15600. The two
Principal Investigators were involved to a lesser extent, for about 32
hours, at a cost of approximately \$1100. The total cost of this piece
of the project was approximately \$37200. The final number of VAMCs
participating in the study is 30, for an average cost of \$1240 to
obtain both IRB approval and IRM access to each medical center.

**Conclusions:** Obtaining IRB approval and IRM access for a large,
multi-site study is time-consuming and expensive. The process worked
best when there were dedicated staff, and when we could link medical
centers together in a geographic region, generally the VISN.

**Impact:** These results are likely to be of interest to VA HSRD
Management, researchers in the field, and VISN staff who have a vested
interest in VISN-wide research studies. Obtaining high quality
comparative data at relatively low cost across medical centers is a high
priority for these groups.

**HSR&D Funded:** ACC 97-001

**79. Toward Gender-Aware VA Health Care: Staff Ideology, Sensitivity,
and Knowledge**

[Lynda King, PhD and Daniel King, PhD]{.underline}. National Center for
PTSD, Boston, MA. [P Miller and V Savarese]{.underline}. [J
Wolfe]{.underline}

**Objectives:** Despite VHA efforts to better accommodate the healthcare
needs of a growing number of women veterans, an historical orientation
towards treating male patients may have resulted in a less than optimal
care environment for female patients. Our guiding hypothesis is that
this environment is influenced by three overlapping personal
characteristics of VHA employees: (1) the tendency to work without
gender stereotypes, (2) sensitivity to female patientsÆ special needs,
and (3) knowledge of women veterans and their healthcare. Together these
comprise what we have termed gender awareness. For this three-year
project, we seek to develop a reliable and valid self-report measure of
gender awareness for use with all VHA personnel. The project has four
objectives: (1) to refine the definitions of the gender awareness
components and create the instrument, (2) to establish the instrumentÆs
psychometric properties, (3) to obtain normative data, and (4) to make
the instrument available for large-scale use.

**Methods:** The design is observational and cross-sectional, with
multiple waves of data for reliability and validity analyses.
Participants are VHA employees selected using proportional stratified
random sampling from the VA New England Healthcare System. In the first
year, 621 employees received a preliminary version of the instrument;
371 (60%) were completed. The sampleÆs mean age was 46.01 years (SD =
11.58); 60% were female; and 25% were military veterans. Analyses
included computation of descriptive statistics and frequency
distributions for all questionnaire items, probabilities of endorsement,
item-total correlations, coefficients of internal consistency
reliability (alpha), and interscale correlations.

**Results:** The 18-item scale assessing the ideology component of
gender awareness had a mean of 72.38 (SD = 11.77; range = 39-90); alpha
= .90. The 19-item sensitivity scale had a mean of 75.72 (SD = 8.08;
range = 56-94); alpha = .75. On the 36-item knowledge test, the mean
number of correct responses was 19.60 (SD = 4.92; range = 0-29). The
most-missed knowledge items were related to demographics of women
veterans, eligibility for sexual trauma services, and VHA utilization
rates.

**Conclusions:** The project is ongoing. Year 1 was successful, with the
more affective components of gender awareness, ideology and sensitivity,
having established discriminant validity, correlating .38. Presently,
the instrument is being further refined, as the sensitivity scale is
seeing additional adjustments to improve its consistency.

**Impact:** The gender awareness assessment instrument will provide a
means to identify and measure factors that contribute to the quality of
VA healthcare for women veterans, and will provide a mechanism to
pinpoint training needs for the education and remediation of employees.
Moreover, the instrument will afford a means to monitor organizational
improvements in gender awareness over time. Our long-term goal is to
have a product that has justifiable transportability on a large scale.
At an organizational level, we anticipate that the proposed project will
contribute to the contemporary emphasis on outcomes measurement. The
gender awareness assessment package can fit nicely within a program to
monitor patient satisfaction among the growing number of women veterans,
as that satisfaction relates to features of organizational climate.

**HSR&D Funded:** GEN 97-014

**80. Is Depression Associated with Oral Health-Related Quality of
Life?**

##### Nancy Kressin, PhD, Avron Spiro III, PhD, Katherine Skinner, PhD and Judith Jones, DDS, MPH. Bedford VA Medical Center, Bedford, MA.

**Objectives:** The health-related quality of life (functional status,
emotional well-being) of patients with depression is often as low as, or
lower than, that of patients with chronic medical conditions. However,
we do not know whether depression has a similar effect on oral health-
related quality of life (oral QOL). VA dental policymakers, clinicians
and researchers are increasingly relying on oral QOL ratings to evaluate
dental treatment needs and outcomes of care. Thus, it is important to
understand what factors influence such ratings.

**Methods:** We examined the association between depression (measured by
the CES-D) and oral QOL, using two different indices: the Geriatric Oral
Health Assessment Index (GOHAI) and the Oral Health-Related Quality of
Life measure (OHQOL). Using data from 3 veteran samples: male VA
patients in the Veterans Health Study (VHS), female VA patients in the
VA Women\'s Health Project (WHP), and male community dwelling veterans
who do not use VA care (Normative Aging Study (NAS)), we examined
whether individuals who screened positive for depression (scoring above
the standard cutpoint) had worse oral QOL than those who were not,
controlling for sociodemographics (age, education, marital status), and
self-reported oral health.

**Results:** In bivariate analyses, being depressed was associated with
worse OHQOL scores in both the VHS and WHP veteran patient samples, as
well as in the NAS. Depressed individuals had worse GOHAI scores in the
VHS and WHP, but not in the NAS. After controlling for self-reported
oral health, age, income, marital status and education, depression
remained significantly associated with both oral quality of life
measures in all samples, and the independent and control variables
together explained between 15 and 30% of the variance.

**Conclusions:** These results suggest that there is a strong
association between depression and oral quality of life, suggesting
further negative health impacts of depression in addition to those
already quantified with regard to physical health. However, these
cross-sectional data cannot prove causality. Future research should
further explore the mechanisms of the association of depression and oral
quality of life through the use of longitudinal data.

**Impact:** The understanding of psychosocial and other factors which
influence patients\' ratings of quality of life is crucial to the
accurate interpretation of findings by researchers, clinicians, and
policy makers. Recognizing that depression is a significant correlate of
oral health outcomes improves the measurement of oral quality of life
and provides a potential avenue for interventions to improve oral health
outcomes.

**HSR&D Funded:** 93-05, SD 91-006, SDR 93-101, HFP 91-012

**81. An Overview of the Decision Support System**

[Joseph Kubal, MA, Denise Hynes RN, PhD, Diane Cowper, MA, Michael Kerr,
MS, MA and J Palmer]{.underline}. VA Information Resource Center, Hines
IL.

**Objectives:** The primary objective of this informational poster is to
present summary information on the currently evolving Decision Support
System (DSS). DSS is a database that provides integrated clinical and
financial data to help managers make informed tactical and strategic
decisions. The DSS software was developed and tailored for the VA by
Transition Systems Incorporated (TSI). The information for this poster
was developed by the VHA Chief Information Office and the DSS Program
Office and is being presented by VA Information Resource Center (VIREC)
staff to inform HSR&D researchers of this new VA-wide system which
ultimately has ramifications for health services research.

**Methods:** All the data in the DSS come from existing VA databases
resident at the Austin Automation Center (AAC). These include: 1)
Personnel and Accounting Integrated Data (PAID), 2) Consolidated
Memorandum of Receipt (CMR), 3) Financial Management System, 4) National
Patient Care Database (NPCD), 5) Patient Treatment File (PTF), and 6)
Patient Assessment Instrument (PAI).

**Results:** DSS: 1) Allows budgeting and budget modeling for medical
centers, VISNs and VHA based on case-specific workload, 2) provides for
resource distribution to the medical centers and VISNs based on
performance, 3) Supports implementation of managed care for the VHA
system, 4) Allows equitable comparisons of medical centers, 5) Supports
VHA funding request to OMB and Congress, 6) Supports quality management
and quality improvement initiatives, 7) Supports the development of an
itemized patient bill for the Medical Care Cost Recovery (MCCR) program
and 8) Provides productivity analysis and patient specific costs.

**Conclusions:** The VA is now realizing what private hospitals have
known for some time û becoming and remaining competitive ensures success
and survival. The health care industry is rapidly evolving; the VA must
keep up and compete with other health care organizations to remain
viable. DSS is designed to provide the information that is needed to
make those business decisions that are required in a competitive
marketplace.

**Impact:** DSS will provide the critical tools necessary for VA
hospitals to remain cost effective and efficient in the dynamic U.S.
health care environment. The VA strategy for implementing DSS emphasizes
an interdisciplinary approach, integrating clinical and administrative
cost accounting systems, and now senior leadership. Consistent use of
this approach in DSS will permit VHA to become and remain competitive
now and in the future. Finally, DSS information will prove useful to
HSR&D, CSP, and other VA researchers in their ongoing quest for accurate
clinical and cost data.

**HSR&D Funded:** SDR 98-004

**82. Establishing Clinical Equivalence: An Example from a Study of
Self-Care Center versus Full-Care Hemodialysis**

[Martin Lee PhD, CA Landis, Mingming Wang MPH, Elizabeth Yano PhD, Lisa
Rubenstein MD, MSPH,]{.underline} Center for the Study of Healthcare
Provider Behavior, Sepulveda, CA.

**Objective:** In most studies, the goal of the research is to
demonstrate that one or more of the intervention groups is superior in
some sense to other arms of the study. These comparisons may be dealt
with using standard statistical approaches. However, on some occasions,
the objective may be to demonstrate that an intervention is no worse
than another, since such a finding might be helpful if this new approach
is easier to use, more cost-effective, etc., and could be used if the
clinical effectiveness is basically equivalent to existing
methodologies. A failure to reject the usual statistical null hypothesis
of no difference is not grounds for reaching this conclusion because of
power considerations arising from small sample sizes. Our objective here
is to demonstrate how to reach the conclusion of clinical equivalence
using a proper statistical framework within the context of a study on
two methods for the care of chronic dialysis patients.

**Method:** An observational retrospective cohort study was conducted on
135 patients undergoing hemodialysis patients at the West Los Angeles VA
Medical Center between June 1977 and December 1994. Forty-nine subjects
used a self-care approach (at the center) and 86 received traditional
full-care hemodialysis. Patient mortality was the primary endpoint
insofar as demonstrating clinical equivalence of these two methods for
care delivery. The Cox proportional hazards model was used to generate
the adjusted the 1, 2, and 5-year survival probabilities with respect to
patient age and presence of pulmonary disease (the only significant
baseline covariates). The comparison of these probabilities was based on
the usual two-sample Z-statistic with the hypothesis testing paradigm
modified whereby the null hypothesis was one of inferiority (defined as
a difference in survival probabilities of more than 10%) and the
alternative hypothesis indicating clinical equivalence.

**Results:** The estimates of the survival probabilities were .976 for
self-care and .928 for full-care at 1 year, .891 for self-care and .752
for full-care at 2 years, and .719 and .466 at 5-years. The test of
inferiority was significant in each case (p\<.001), providing
statistical evidence of a lack of inferiority for the self-care
approach.

**Conclusion:** Using an appropriate statistical strategy, it was
possible to demonstrate that a self-care center approach to hemodialysis
is no worse than the traditional method for delivery of this care. Given
the potential for cost-savings and improved patient quality of life,
this approach may be a reasonable alternative.

**Impact:** This study indicates that alternatives to full-service
clinical care at a VA center are reasonable to consider, and may in
fact, be potentially superior. This is particularly relevant as the VA
healthcare system further embarks on the examination of practice
patterns to identify and promulgate best practices through the QUERI
process.

**83. Evaluating the Effect of Primary Care Clinic Visits on Survival
for Hospitalization**

[Martin Lee PhD, Mingming Wang MPH, Elizabeth Yano PhD, and Lisa
Rubenstein MD, MSPH,]{.underline} Center for the Study of Healthcare
Provider Behavior, Sepulveda, CA.

**Objectives:** Objective: From an examination of patients hospitalized
at the Sepulveda and West Los Angeles VA Medical Centers, we evaluated
the possibility that more frequent primary care users had a greater
likelihood of surviving a hospital stay for one of a set of significant
clinical situations.

**Methods:** Method: All patients hospitalized during the 1993 fiscal
year at Sepulveda VA (SVA) and the West Los Angeles VA (WVA) (two
academically-affiliated VA medical centers with active primary care
programs in Southern California) were identified. The subset of
individuals identified as being admitted for major cardiac,
cerebrovascular and respiratory conditions based on ICD-9 codes were
specifically utilized in this study, as these conditions appeared to be
the most likely to be affected by frequent primary care. We classified
each case according to whether the patient survived (survivors), died in
hospital or within thirty days of discharge (early death), or died
between thirty days and one year after discharge (late death). We
obtained demographic information and the mean number of primary care
clinic visits during the twelve months prior to hospitalization for
patients in each of these three categories. We used a polytomous
logistic regression model to determine whether there was a relationship
between primary care visitation and survival after adjustment for key
independent survival indicators such as age. We also utilized a Cox
proportional hazards regression model to examine the same variables as a
function of the actual survival time (potentially censored twelve months
after hospital discharge). Initial univariate analyses were considered
to compare the three study groupings with respect to mean primary care
visitation (using the Kruskal-Wallis test).

**Results:** The SVA sample included 3,459 inpatients (88.8% survived,
5.9% late deaths, 5.3% early deaths) and the WVA sample had 5,344
individuals (87.4% survived, 6.2% late deaths, 6.4% early deaths). On a
univariate basis, both institutions\' survivors had significantly more
primary care visits (average 6.7/yr: SVA, 5.3/yr: WVA) than early death
(5.1/yr:SVA, 2.7/yr:WLA) or late death (4.1/yr:SVA, 2.7/yr:WLA)
patients.This significance held up in both multivariate models.

**Conclusions:** Patients admitted with serious major medical conditions
who had been seen more often in primary care clinics prior to their
hospitalization were more likely to survive their hospital stay. The
significance of the primary care visitation pattern may be to
hospitalize the patient earlier in the course of an illness episode or
result in better peri-hospital management. It is also possible that the
more frequent users had different casemix characteristics than less
frequent users, although we did attempt to adjust for many of these
potential covariates. At the very least, investigators evaluating the
significance of primary care should consider visit patterns into
consideration.

**Impact:** With the emphasis in the VA healthcare system on the
delivery of primary care, this study suggests that such care may have a
direct impact on future hospitalization survival. This provides further
impetus for the continuing efforts to adequately deliver this care.

**84. The Economic Impact of Automated Primary Screening for Cervical
Cancer: Use of a Markov Chain Model**

[Martin Lee, PhD.]{.underline} Sepulveda VA Medical Center, Sepulveda,
CA. [BL Smith, S Leader, and P Westlake.]{.underline}

**Objective:** The Papanicolaou (Pap) smear detects precursor changes to
cervical cancer enabling therapeutic interventions to potentially avert
invasive cervical cancer. Its widespread use has resulted in more than a
70% decline in cervical cancer-related morbidity and mortality in the
United States over the past forty years. Yet, cervical cancer continues
to be prevalent. Newly developed technologies such as automated primary
screening have been introduced to reduce the incidence of false negative
Pap exams. We have examined one such device, the AutoPap« Primary
Screening System (Neopath, Inc., Redmond, WA) with respect to its
economic impact on the healthcare system, since this device has been
previously shown to be more sensitive and specific than manual
examination of Pap smears. This study serves to address the concern as
to whether a clinically effective diagnostic procedure can also be cost
effective.

**Method:** To evaluate the economic impact of AutoPap, we developed a
model of the progression of cervical disease that involves six stages of
pathology from a healthy state through death. This traditional model was
expanded to include substances that allow for treatment (or its absence)
and the success thereof within each stage. During a fixed time interval
(say, one year), patients are allowed to move between stages or remain
in the same stage with certain fixed probabilities. This was represented
by a basic first-order Markov model. The probabilities that populated
this model were determined from the literature or from consultation with
medical practitioners. Ranges (determined by a modified Delphi process)
were use to assess model sensitivity. The model was run on a
hypothetical group of 18 year old women whose mortality pattern
represented that for the general population of women of that age in the
US. The program DATA (TreeAge Software, V3.0.17) was used to run the
simulation.

**Results:** Annual screening with AutoPap produced a meaningful
increase in life expectancy of 32.1 days relative to manual screening at
a marginal savings of \$628 per person (or -\$7,144 per life year
saved). Less frequent screening yielded lower positive savings.

**Conclusion:** Automated screening for cervical cancer has the
potential to significantly improve healthcare outcomes and reduce cost.
The use of appropriate mathematical models for the evaluation of the
economic impact of such new interventions can be of great value in these
determinations.

**Impact:** Given that as of the end of 1996 there were 1.2 million
female veterans, an evaluation such as that reported here may prove to
have a significant economic impact for the VA system.

**85. Patient-Centered Alternative to Psychiatric Hospitalization**

##### James Lohr, MD. VA San Diego Healthcare System. San Diego, CA. W Hawthorne, B Green

**Objectives:** The purpose of this study was to assess the
effectiveness of an alternative to acute psychiatric hospital treatment,
the Short-Term Acute Residential Treatment(START) model.

**Methods:** A total of 376 START program clients participated in the
study, which used a repeated measures design and assessed participants
on multiple standardized measures of symptoms and functioning at
admission, discharge, and at a 4-month follow-up interval. Ex post facto
comparisons were made with data from 186 psychiatric hospital patients
from previously conducted outcome studies utilizing the same instruments
and procedures. Measures included the Brief Symptom Inventory, the
Behavior and Symptom Identification Scale-32, the Medical Outcome Short
Form 36, and the Client Satisfaction Questionnaire-8, as well as
demographic and other data.

**Results:** The results of this study indicate that START facilities
and psychiatric hospital programs admit persons with similar levels of
acute distress, demonstrate comparable levels of improvement by
discharge, and produce an equivalent degree of short-term stability of
treatment gains.

**Conclusions:** This study supports the START program model as a less
costly yet similarly effective alternative to psychiatric
hospitalization for many voluntary adults.

**Impact:** During the 1997 fiscal year, the VHA spent 1.5 billion
dollars on mental health services for veterans, of which inpatient
psychiatric hospital services accounted for 50% of those costs. The
development of START programs could have significant impact on this very
costly aspect of psychiatric care.

**86. VA Utilization by Level of Diagnostic Cost Group (DCG) Predicted
Risk**

[Susan Loveland and Amy Rosen.]{.underline} Bedford VA Medical Center,
Bedford, MA. [A Ash]{.underline} [Cheryl Hankin, PhD, James Rothendler,
MD, Dan Berlowitz, MD, MPH, and Jennifer Anderson, PhD.]{.underline}
Bedford VA Medical Center, Bedford, MA. [Mark Moskowitz,
MD]{.underline}. Boston University School of Medicine, Boston, MA.

**Objectives:** As VHA adopts managed care practices, it needs to
understand the disease burden and resource utilization of its
population. Risk adjustment methods, such as Diagnostic Cost Groups
(DCGs), can be used to profile and predict the health care resource
consumption of population subgroups across VHA facilities. This study
examines the relationship between levels of DCG predicted risk (DPR) and
resource utilization among a sample of VA health care users.

**Methods:** We used VA administrative data, specifically the
outpatient, inpatient, extended care, and census files from FY97. We
selected a random 1% sample of all veterans (N=26,165) with any
utilization during that period, retaining diagnostic information
assigned during "face-to-face" provider encounters and deleting
diagnoses associated with lab, x-ray and telephone stops. We divided the
sample into two patient subgroups based on the setting in which they
received care: outpatient care only (N=21,765), or those with any
inpatient care (N=4,400). Patients with any nursing home care (N=484)
were separately identified as were those who received inpatient care for
substance abuse problems (N=632). The DCG model profiled the disease
burden of the population by summarizing the diagnostic information
(i.e., ICD-9-CM codes) available for each veteran during the study
period and produced a risk score (DPR) to predict utilization during the
same period. We ranked patients into deciles of DPR, where the first
decile contains patients with the lowest DPR, and the 10th, those with
the highest DPR. We examined the composition of the deciles and computed
the mean number of service days (the sum of outpatient visit days and
inpatient days) within each decile.

**Results:** Ten percent of the outpatients fell into the highest two
deciles of DPR, in contrast to 69.4% of the inpatients. Similarly 70.1%
of the outpatients fell into the lowest 6 deciles compared to only 10.1%
of the inpatients. As DPR increased, the mean service days of the
outpatients increased from 3.6 to 27.6. A similar pattern of increasing
utilization with level of DPR was found for inpatients in the highest
risk deciles, with mean service days increasing from 46.5 to 65.8.
Furthermore, while only 1.8% of all patients were identified as nursing
home residents, 60.5% fell into the highest DPR decile. Similarly, 95.9%
of substance abuse patients fell into the two highest risk deciles, with
mean service days in the 9th and 10th deciles of 60.7 and 102.6,
respectively.

**Conclusions:** Higher levels of predicted risk were associated with
increased levels of utilization among specific subgroups of the VA
population. In addition, inpatients and nursing home residents, who
would be expected to have higher utilization were, in fact, classified
in the highest deciles.

**Impact:** This study validates the usefulness of the DCG methodology
in measuring the disease burden of the VA population. Reliable risk
stratification can lead to a better understanding of the factors that
drive resource consumption, an understanding which is critical in
managing health care delivery.

**HSR&D Funded:** MPC 97-009

**87. Mortality and Days of Survival for Medicare Beneficiaries in the
Fee-for-Service and HMO Systems**

##### Matthew Maciejewski, PhD. VA Puget Sound Health Care System, Seattle, WA.

**Objectives:** To compare the mortality rates and days of survival for
elderly Medicare beneficiaries enrolled in fee-for-service (FFS) health
plans with enrollees and disenrollees of health maintenance
organizations (HMOs) under capitation.

**Methods:** Data for this study are based on 1993 and 1994 Medicare
Patient Activity Record and enrollment files, as well as county-level
data on enrollment in Medicare HMOs under capitation (TEFRA-risk HMOs)
and Medicare capitation payments. The sample of Medicare beneficiaries
is based upon FFS and HMO enrollees in the 124 counties with the
greatest enrollment in TEFRA-risk HMOs. The first part of the analysis
compared a cohort of FFS and HMO enrollees, and the second part compared
a cohort of FFS enrollees and HMO disenrollees. The mortality rate for
Medicare beneficiaries in the two delivery systems was estimated using
logistic regression. For beneficiaries that died between April 1, 1993
and April 1, 1994, the number of days of survival in each system was
estimated using ordinary least squares. Selection bias was partially
controlled using variables for age, gender, and institutional status.
The analyses also included several county-specific variables of
interest.

**Results:** HMO enrollees had lower mortality rates and higher days of
survival than FFS enrollees. Conversely, HMO disenrollees had higher
mortality rates and lower days of survival than a comparable group of
FFS enrollees.

**Conclusions:** Movement of elderly Americans into HMOs under
capitation is associated with lower mortality rates and higher survival
times until death. Although this analysis did not completely control for
selection bias, this study provides some evidence that alternative
delivery systems may yield better health outcomes for elderly veterans
than conventional, FFS systems. However, some elderly beneficiaries in
poor health or likely to be in poor health may find HMOs to be
incompatible with their needs and will disenroll. These beneficiaries
may be able to obtain better outcomes by remaining in the FFS system.

**Impact:** The VA may be able to improve patient outcomes by
introducing new organizational structures and financial incentives
applied successfully in other settings. Greater enrollment of veterans
into community-based outpatient clinics is one such alternative delivery
system that contracts with providers under capitation in some sites. The
VA may be able to capitalize on some of the lessons learned from
Medicare\'s experience with TEFRA-risk HMOs in its own efforts to
promote veterans\' health.

88\. Recidivism among Veterans with Schizophrenia Living in Board and
Care: An Outcome Evaluation of the Community Residential Care Program

[Alvin Mares MSPS, MSW, and J McGuire.]{.underline} Alhambra, CA.

**Objectives:** Recidivism-the repeated use of inpatient
services\--among veterans diagnosed with schizophrenia is an important
problem. In FY96, veterans with schizophrenia consumed 21% of all
inpatient bed days while representing only 4% of the total inpatient
population. Health providers are increasingly using intensive
community-based case management interventions such as Assertive
Community Treatment (ACT) and Intensive Psychiatric Community Care to
reduce the risk of recidivism. While much is known about intensive
community interventions (especially ACT), little is known of the
effectiveness of less intensive community interventions, such as the
Community Residential Care (CRC) Program, in reducing the risk of
recidivism. CRC provides schizophrenic veterans and others who live in
privately operated board and care homes with monthly home visits. The
purpose of this study is to estimate the effect of CRC home visits on
the risk of recidivism among patients at West Los Angeles VAMC.

**Methods:** A retrospective cohort study design was used. A group CRC
patients (N=214) was followed from their first CRC home visit until
8/31/98 for first psych/SA and med/surg admission. DHCP Patient File was
queried on 9/17/98 for all patients matching the street address or
facility name of one of the 27 participating board and care homes. A
total of 321 matches were made-214 CRC patients and 107 non-CRC
patients. All 214 CRC patients (52% of the total CRC patient roster)
were included in the study. This method of selecting subjects was chosen
to allow for future comparisons of inpatient lengths of stay among CRC
and matched comparison subjects. Five secondary data sources were used.
DHCP Patient, Outpatient Clinic Visit, and Patient Treatment Files
provided data on socio-demographics, CRC home visits, and
hospitalizations, respectively. The CRC program database provided
additional licensing data on board and care homes. Psychiatric/substance
abuse (psych/SA) and medical/surgical (med/surg) hospitalizations were
defined based on discharge ward. Twenty inpatient wards were designated
psych/SA wards and forty wards as med/surg. All domiciliary and nursing
home admissions were excluded. Cox regression was used, in concert with
the Andersen Behavioral Model, to identify recidivism risk factors.
Twelve dichotomized covariates were included: visit duration, worker
profession, home size, age, marital status, race, income, service
connected percentage, family support, psychiatric diagnosis, symptoms,
and alcohol/substance abuse diagnosis.

**Results:** Psych/SA recidivism risk factors included: home visit
duration fewer than four years (RR=2.86, p=.0002), minority status
(RR=1.94, p=.0273), and schizophrenia diagnosis (RR=1.79, p=.1056).
Med/surg risk factors included: home visit duration fewer than four
years and med/surg (RR=3.88, p=.0055), residence in a facility having
80+ beds (RR=1.97, p=.1103), and limited family contact (RR=1.82,
p=.1126).

**Conclusions:** Minority status, schizophrenia diagnosis, and shorter
time receiving CRC home visits were associated with increased psych/SA
recidivism. Living in a larger board and care, having limited social
contact with family, and shorter time receiving CRC home visits were
associated with increased med/surg recidivism.

**Impact:** Additional efforts may be warranted to reduce recidivism
among minority, those with schizophrenia, residents of larger
facilities, those isolated from family, and recently enrolled CRC
patients.

89\. Patterns of Medical Treatment for Congestive Heart Failure (CHF) in
a Veteran Population

[JL Meier, PharmD.]{.underline} VANC Health Care System, Martinez, CA.
[JR Lopez, RM Moskowitz, and D Siegel]{.underline}

**Objectives:** Evidence of the beneficial effect of angiotensin
converting enzyme (ACE) inhibitors in reducing morbidity and mortality
in patients with CHF has accumulated over the past decade. Although ACE
inhibitor use in patients with CHF has increased, only 36% of patients
studied by Smith et al (Arch Int Med, 1998) in 1994-1995 received
treatment with ACE inhibitors. Hydralazine and isosorbide dinitrate in
combination also reduce morbidity and mortality in patients with CHF,
and angiotensin II antagonists are being studied for this purpose. To
determine the extent of ACE inhibitor and other medication use in
patients with CHF in the VA Northern California Health Care System
(VANCHCS).

**Methods:** ICD-9 codes from patient encounter forms identified
patients with CHF in the VANCHCS database between 4/1/97 and 3/31/98.
Researchers related this data to prescriptions for drugs categorized in
the VA Cardiovascular Series, including ACE inhibitors, angiotensin II
antagonists, hydralazine, isosorbide dinitrate, nitroglycerin patches,
digoxin, loop diuretics, hydrochlorothiazide, and potassium-sparing
diuretics filled over a six month period (1/1/98 to 6/30/98) using
Access=99 and Excel=99.

**Results:** Of 1518 patients with CHF, the percentage receiving a drug
included: diuretic (78%), ACE inhibitor (63%), digoxin (50%), nitrate
(34%) angiotensin II antagonist (10%), and hydralazine (5%).
Seventy-four patients 5%) received prescriptions for both hydralazine
and a nitrate, and 840 (55%) received a diuretic and an ACE inhibitor.
Thirty-two percent of patients received a combination of a diuretic,
digoxin, and either an ACE inhibitor or an angiotensin II antagonist.

**Conclusions:** ACE inhibitor use in this analysis is higher than
published data from other populations that have been studied. Greater
use of ACE inhibitors or hydralazine with nitrates may further improve
patient outcomes.

**Impact:** A higher proportion of patients with CHF are treated with
ACE inhibitors at VANCHCS. However, there is potential to further
increase use and improve CHF management.

**90. Comparison of Health Care Use and Outcomes for HIV-Infected
Patients in VA Versus Non-VA Settings**

##### Terri Menke, PhD, Linda Rabeneck, MD, MPH, and Nelda Wray, MD, MPH. Houston, VA Medical Center, Houston, TX.

**Objectives:** To compare VA and non-VA health care utilization and
outcomes for HIV-infected patients.

**Methods:** For VA users, we collected data on both VA and non-VA
health care obtained during 1994 for 470 patients at five VAMCs: New
York, Miami, Houston, Los Angeles, and San Francisco. Data on VA health
care came from VAÆs HIV Registry, which electronically extracts data on
all HIV-infected patients from VISTA. Information on the sampled
patientsÆ use of non-VA health care and patient characteristics was
obtained from patient interviews. We used the questionnaire from the
AIDS Costs and Service Utilization Survey (ACSUS), a study of non-VA
HIV-infected patients conducted by the Agency for Health Care Policy and
Research. The ACSUS study provided the non-VA sample with which our VA
sample was compared in terms of utilization and outcomes. We estimated
regression equations for seventeen utilization measures. We used
logistic regression to estimate the probabilities of any use for
hospitalizations, physician visits, emergency department visits, nursing
home stays, mental health visits, substance abuse visits, home health
visits, dental visits, and anti-retroviral medication. We used Poisson
regression to estimate equations among users of each type of health care
for the amount of use (e.g., number of hospitalizations among those with
inpatient stays). We used linear regression to estimate an equation for
inpatient length of stay in logarithm form. The covariates included
measures of HIV illness severity, age, ethnicity, HIV transmission
route, education, social support, health insurance, employment status,
income, health status, physical function, role function, social
function, and mental function. Dummy variables were used to estimate
differences in use among three patient categories, controlling for the
covariates: (1) VA only users; (2) dual VA and non-VA users; and (3)
only non-VA. We used Cox proportional hazards modeling to compare
progression from early to late stage HIV disease or death among the
three patient groups.

**Results:** There were no significant differences among VA-only, dual
VA and non-VA, and non-VA only users in the use of inpatient hospital or
nursing home care, or in the number of physician, emergency, mental
health, substance abuse, or home health visits among users. Dual VA and
non-VA users had higher probabilities of physician, mental health,
substance abuse, and dental visits than the other patient groups.
Compared to those who only used non-VA care, both dual users and VA-only
users had lower probabilities of emergency department visits and
anti-retroviral medication use, but obtained more dental visits per
user. VA-only users had a lower probability of home health use than the
other patient groups.

**Conclusions:** Depending on the type of health care, HIV-infected
patients in VA obtained the same or less care compared to patients in
non-VA settings. Outcomes were the same for VA and non-VA patients.
These results imply that VA care for HIV-infected patients is more
efficient than non-VA care.

**Impact:** In this era when VA must compete with non-VA settings in
terms of providing cost-effective care, this study demonstrates that VA
is more efficient at least for HIV-infected patients.

**HSR&D Funded**: IIR 95.107

### 91. Developing Algorithms to Define Episodes of Care 

[Terri Menke PhD, Nelda Wray MD, MPH, Carol Ashton MD, MPH, and Linda
Rabeneck MD, MPH.]{.underline} Houston VA Medical Center, Houston, TX.

**Objectives:** To define episodes of care that include
hospitalizations, including the time frames pre and
post-hospitalization, and the health care to be included.

**Methods:** An expert panel of physicians selected high-volume
diagnoses or surgical procedures to examine, and developed criteria for
defining episodes of care. Among the conditions selected were: coronary
artery bypass, colon cancer procedures, total hip replacement, bleeding
ulcer, and congestive heart failure. For each condition selected,
computer printouts using VA administrative data from FY1997 were
generated of the frequency of: (1) visits by clinic stop, by month, from
6 months prior to admission to 6 months following discharge; (2)
outpatient tests and procedures by CPT code for relevant organ systems,
by month, from 6 months prior to admission to 6 months following
discharge; (3) readmissions by ICD-9 code of the primary diagnosis, by
week, up to 6 months following discharge from the index hospitalization;
and (4) nursing home stays, by week, up to 6 months following discharge.
The expert panel used their clinical knowledge and the computer
printouts to determine how long prior to the hospitalization the episode
began, how long after discharge the episode ended, and which specific
clinic stops, tests, readmissions, and nursing home stays should be
included in the episode.

**Results:** Episodes of care for surgical hospitalizations took the
following general form. Episodes of care for medical diagnoses were
defined analogously. (1) Pre-admission care: (a) started 90 days prior
to admission for most surgeries; (b) included visits to principal
medicine clinics, relevant medical specialty and surgery clinics,
nursing, relevant behavioral counseling, and clinics designated as
pre-operative; and (c) included outpatient tests or procedures specific
to the evaluation of the extent or indication for surgery. (2)
Post-discharge outpatient care: (a) included visits to principal
medicine or nursing clinics within 4-6 weeks after discharge, depending
on the surgery; and (b) included visits to all other clinics specified
in (1) and relevant rehabilitation visits up to 6 months following
discharge. (3) Readmissions: (a) were all included up to 1-6 weeks after
discharge, depending on the surgery; (b) were included in the episode
based on containing a relevant surgical procedure or primary diagnosis
if they occurred between the time specified in (a) and 6 months after
discharge. (4) Nursing home stays were included if they immediately
followed the initial hospitalization, or a readmission that was included
in the episode.

**Conclusions:** A process combining clinical knowledge and relevant
data was developed for defining episodes of care that include a
hospitalization. The algorithms developed can be applied by managers or
researchers who want to examine the costs, efficiency, or outcomes for
episodes of care.

**Impact:** Current organizational features of health care have shifted
the focus of quality and efficiency evaluation from the health care
event (e.g. hospitalization) to the entire package of services required
to treat an episode of illness. This shift is evident in VAÆs adoption
of the VERA system, which allocates funding to VISNs on a capitated
basis.

**HSR&D Funded:** IIR 95-139

**92. Designing Guidelines for Successful Dissemination and
Implementation: The California Guidelines for Alzheimer\'s Disease
Management**

##### Brian Mittman, MD. VA Greater Los Angeles Health Care System, Sepulveda, CA. Saliba, DA Lang, and BG Vickrey.

**Objectives:** Efforts to improve the quality and outcomes of
healthcare through clinical practice guidelines have generally been
disappointing: while hundreds of guidelines are developed and
disseminated yearly, studies continue to show low levels of guideline
use and minimal impact on clinical practice. The Executive Committee of
the California Workgroup on Guidelines for Alzheimer\'s Disease
Management in Primary Care (a broad public-private coalition including
VHA representatives) sought to avoid this problem by commissioning the
Sepulveda Field Program to form a guideline dissemination/implementation
team. Our overall goal was to enhance acceptance and impact of the
guideline, which was then still under development. We sought to
accomplish this goal by (1) collaborating with the guideline development
Workgroup to ensure that the guideline\'s content, format and other
characteristics reflected current thinking regarding attributes
facilitating guideline use and acceptance, and by (2) developing a
comprehensive dissemination and implementation plan containing
recommendations for the Executive Committee and for provider
organizations scheduled to receive the guideline.

**Methods:** Our efforts to influence guideline content and format began
with presentations at Workgroup and subcommittee meetings regarding
dissemination and implementation challenges and solutions. We presented
results of published research and reviews, and detailed examples from
our own work. We illustrated our recommendations by revising specific
guideline sections and by drafting recommended additions (e.g., purpose
and scope statements). Our content/format recommendations addressed
language (e.g., clear, declarative recommendation statements rather than
unstructured text or broad, ambiguous statements), overall guideline
structure (e.g., development of one-page recommendation list and
accompanying narrative summarizing relevant evidence) and other issues.
Our dissemination/implementation report included a brief analysis of the
guideline\'s features relevant to implementation success and strategies,
assessment of the guideline\'s likely impact on quality, cost and other
outcomes, and detailed recommendations for dissemination and
implementation activities, accompanied by reviews of relevant literature
and other evidence. We addressed (1) guideline development (e.g.,
recruitment of key stakeholder groups as collaborators in guideline
development, to ensure buy-in and subsequent dissemination support), (2)
publicity (collaborative press conferences and guideline release
activities), (3) publication (preparation of a manuscript for journal
publication in conjunction with the stand-alone guideline document,
preparation of summaries for inclusion in guideline directories and
compilations), (4) guideline tools (e.g., medical record checklists,
patient brochures), (5) implementation support packages (sample
educational program outlines and resources, detailed plans for provider
organization implementation projects), and (6) funding strategies
(recommendations regarding private foundations, for-profit industry
organizations such as pharmaceutical companies, and government
agencies).

**Results:** The guideline development Workgroup, subcommittees and
Executive Committee accepted nearly all of the
dissemination/implementation team\'s recommendations regarding guideline
content and format, and is currently implementing many of the
dissemination/implementation report\'s recommendations.

**Conclusions:** Guideline dissemination and implementation remain key
challenges to success of clinical practice guidelines as quality
improvement tools. Attending to these challenges during the development
of a guideline, rather than after its release, should help meet many of
these challenges.

**Impact:** Development of the guideline was enhanced by the emphasis
placed on dissemination and implementation needs and the resulting
awareness and attention the guideline development Workgroup devoted to
implementation barriers and challenges. Acceptance and use of the
guideline are likely to be enhanced as well.

**93. Health and Functional Status Differences Between Veterans Admitted
to State Veterans Homes Compared to Community Nursing Homes**

##### Joan Penrod, MSW, PhD. University of Nebraska Medical Center, Omaha, NE. M Vandivort, L Zhao, D Shutzer, and J Potter.

**Objectives:** To examine factors associated with admission of veterans
to state veterans homes (SVHs) compared to community nursing homes
(CNHs) in Nebraska.

**Methods:** The Minimum Data Set (MDS) was obtained for veterans
admitted to SVHs and CNHs in Nebraska over a 12 month period.
Demographic, health, and functional status differences in the two
admission cohorts were examined. Multiple logistic regression was used
to estimate the effects of admission functional and cognitive status,
age, gender, social support, marital status, presence of behavior,
mental health, and incontinence problems, and number of medications used
on the probability of admission to a SVH versus a CNH.

**Results:** Veterans admitted to Nebraska SVHs (N = 188) are
significantly less functionally impaired at admission (p= .003) compared
to those admitted to CNHs (N = 126). However, a history of mental
problems (p\< .001) and use of anti-psychotic medication (p = .001) is
more prevalent in the SVH admission cohort. Moreover, the results of the
multiple logistic regression indicate as functionally disability
increases, veterans\' odds of admission to a SVH as compared to a CNH
decrease (p = .01). Also, veterans with cognitive impairment and mental
health problems are more likely to be admitted to a SVH rather than a
CNH. Finally, veterans living alone, admitted from home rather than a
hospital or nursing home, and those with daily contact with family are
less likely to enter a SVH compared to a CNH. Age, gender, incontinence,
and marital status had no effect of the odds of admission to SVHs.

**Conclusions:** The SVHs in Nebraska appear to admit from a different
population of veterans than the CNHs. In particular, SVHs are more
likely to accept veteran residents with mental health problems compared
to the CNHs. However, Nebraska SVHs attract a less functionally disabled
admission cohort. Nebraska SVHs have a policy of not accepting
ventilator dependent residents. This may account for part of the higher
level of functional disability in the CNH veteran cohort. Furthermore
many CNHs are reluctant to take residents with significant mental health
problems and by rule, can not accept applicants if a psychiatric illness
is the primary diagnosis at admission. Thus, the SVHs may serve veterans
who would otherwise have difficulty with traditional institutional
long-term care arrangements.

**Impact:** Reorganization, consolidation, and closer management of VA
nursing home resources is a major focus at the Federal, VA Network, and
State level. This study provides relevant information to assist in that
effort. Specifically, moves to reduce reliance on SVHs will need to
consider alternative care arrangement for veterans with mental health
problems.

**HSR&D Funded**: DEV 97-019

### 94. Access to Care Among Adults with Diabetes in VA and County Clinics

[John Piette, PhD]{.underline}, Center for health Care Evaluation, Menlo
Park, CA.

**Objectives:** In a prior study, we found that VA patients with
diabetes were substantially more satisfied with their access to care
than similar patients in a nearby county health care system. In this
study, we sought to determine the actual prevalence of access problems
perceived by patients in the two systems.

**Methods:** Data were collected via structured telephone surveys of
patients participating in two randomized trials of automated diabetes
management with nurse follow-up. Participants in the trials were
recruited at the time of visits to general medicine clinics in each
health system. Data for the current study were from follow-up surveys
for 108 patients recruited through 4 VA clinics and 132 patients
recruited through 2 county clinics who all were randomized to the
control groups.

**Results:** Compared to county patients, VA patients were older, more
likely to be married, and had better glucose control. In the six months
prior to their surveys, between 9% and 10% of county patients reported
that they failed to refill a prescription, seek care for an urgent
health problem, or call an ambulance because of cost concerns. However,
less than 2% of VA patients perceived similar barriers (each p \<.01).
Compared to county patients, fewer VA patients failed to seek medical
advice by phone because they did not know the number or thought that
they would be put on hold (14% versus 23%, respectively; p = .07). Fewer
VA patients failed to seek urgent care because they thought that the
clinic would not be helpful (2% versus 11%; p \< .01). Roughly equal
numbers of patients in both systems failed to refill a prescription
because they \"didn\'t know how\" (13% for VA patients and 11% for
county patients, p = .66). None of these differences were substantially
changed when we adjusted for sociodemographic factors that could affect
perceived access (e.g., social support, education, and age).

**Conclusions:** Overall, the proportion of VA patients with diabetes
who perceived financial barriers to accessing medical care was small on
an absolute level and relative to county clinic patients. Relative to
county patients, VA patients perceived the system\'s telephone services
and emergency care services as more accessible. Nevertheless, a
significant minority of VA patients perceived problems accessing
telephone care services and medication refills.

**Impact:** VA policy-makers can be assured that few patients with
diabetes perceive financial barriers to receiving care. The problems
reported by county patients suggest that VA patients\' perceptions might
be worsened if they faced significant co-payments. VA should focus on
improving the perceived accessibility of telephone care and medication
refills.

**HSR&D Funded:** IIR 95-084

**95. Ambulatory Care Groups and SF-36 Mental and Phusical Component
Summary Scores**

[Kenneth Pietz, PhD, and Carol Ashton, MD. MPH.]{.underline} Houston VA
Medical Center, Houston, TX. [J Tuchschmidt, G Twedt, and J
Bellah.]{.underline} [Nelda Wray, MD, MPH.]{.underline} Houston VA
Medical Center, Houston, TX.

**Objectives:** Determine the relationship between Adjusted Clinical
Groups (ACGs) and SF-36 physical and mental component summary scores.
Determine whether these SF-36 summary scores can be used as case-mix
adjustment variables in resource utilization studies, as proxy for
patients' frailty and illness burden. Determine how much of the
variation in per-patient resource utilization is explained by the SF-36
summary scores.

**Methods:** The data consists of 24,726 patients in the Northwest
Network (VISN 20) who voluntarily completed an SF-36, who had inpatient
or outpatient care during the study period from September 1, 1997 to
August 31, 1998 and who had a primary care provider assigned. The amount
of utilization of each of nine resources for the study period was known
for each patient. The resources were: bed days of care, hospital stays,
medical encounters, laboratory tests and cost, radiology tests and cost,
prescriptions, and pharmacy cost. The ACG of each patient was computed
using he/her demographic information and inpatient and outpatient ICD-9
codes. A significant amount of the variation in patients' resource
utilization is explained by the patient's ACG. For each patient the
Kazis physical and mental component summary scores (PCS and MCS,
respectively) were calculated from their SF-36 health self-assessment.
The PCS ranged from a minimum of 3.1 to a maximum of 70.6. The mean and
standard deviation were 33.4 and 11.4, respectively. The MCS ranged from
a minimum of 3.8 to a maximum of 78.9. The mean and standard deviation
were 44.8 and 13.9, respectively. The effect of using PCS and MCS to
explain variation in resource usage was evaluated. Also, these scores
were added as independent variables to the regression models which model
resource utilization as a function of the patient's ACG. Finally,
regression models were generated which evaluated the ability of the ACGs
to explain variation in PCS and MCS.

**Findings:** The amount of variation in the resource utilization
explained by the PCS and MCS was highest for prescriptions. The amounts
of variation explained in the logarithms of prescriptions and pharmacy
cost explained by PCS and MCS combined were 12.3% and 8.9% respectively,
compared with 27.4% and 19.7% explained by ACGs. For the other resources
the amount of variation explained by the PCS and MCS was less than 7%.
The change in \$-squared by adding the summary scores to the ACG models
of resource utilization was negligible except for prescriptions and
pharmacy costs. Finally, ACGs explain 8.1% of the variation in PCS and
5.5% of the variation in MCS.

**Conclusions:** The PCS and MCS summary scores add to the ability of
ACGs to predict prescriptions and pharmacy cost in this population of
veterans. PCS and MCS add little predictive ability to ACGs for the
other utilization outcomes. The summary scores cannot replace ACGs as
case-mix adjustment covariates.

**Impact:** SF-36 physical and mental component summary scores are not
usable as case-mix adjustment covariates as a proxy for frailty and
illness burden in a population of veteran patients.

**96. Development of a Case Mix Adjustment Model for Hemoglobin A1c**

##### Leonard Pogach, MD. Houston VA Medical Center, Houston, TX. QW Zhang, S Dhar, H Cheng, G Hawley,and D Repke.

**Objectives:** The current VA health outcome performance measure for
glycemic control, the proportion of veterans exceeding an unadjusted
glycohemoglobin of 10 percent, was chosen because of the absence of
laboratory standardization and case mix adjustment. The objective of
this study was to validate a case mix model that would permit accurate
cross sectional comparisons of mean Hemoglobin A1c (HbA1c) values among
administrative units.

**Methods:** A cohort of 53,343 patients with documented HbA1c values
was identified from a larger cohort of 203,987 veterans receiving oral
agents, insulin and/or blood glucose monitoring supplies from 130
participating stations in the FY1996 National Center for Cost
Containment Diabetes Cost and Outcomes Report using a previously
validated data extraction program based upon the DHCP pharmacy file. A
hierarchical, mixed effects models was utilized that employed a nested
data structure to estimate random variance and covariance components
among dependent measures to increase the model\'s explanatory value.
High-normal adjusted HbA1c levels (subtracting the upper normative limit
from each individual value) were predicted by linear age (centered at
the median of 66 years), quadratic age, gender, race/ethnicity,
patient\'s financial means classification (temporary surrogate of SES),
treatment modality (insulin, oral agents, insulin and oral agents, and
neither insulin nor oral agents), blood glucose monitoring (yes/no),
total number of VA clinic visits (natural log transformed), and the
interactions of demographic variables with treatment modality and blood
glucose monitoring. The last HbA1c record was utilized. Fixed parameter
estimates (beta) were determined for each predictor.

**Results:** The intercept for the cohort mean adjusted HbA1c was 1.93
\[percent above high normal value\]. No difference in HbA1c level was
found between gender groups or individuals receiving monitoring
supplies. HgbA1c level was higher in younger than in older patients.
Compared to those who used oral medications only, patients treated by
insulin had higher HgbA1c results (beta=.546, p=.0001), while those
treated with both insulin and oral agents during FY96 had even higher
HgbA1c (beta=.96, p=.0001) while patients receiving only monitoring
supplies showed a lower level of HgbA1c (beta=-1.068, p=.0001). There
was a complex interaction between ethnicity and treatment modality, and
Black Hispanic/African American patients had higher HgbA1c (beta=0.28,
p=0.0001) than White patients for those who received oral or oral plus
insulin therapy. The number of outpatient visits to a VA clinic was
associated with a significantly lower level of HgbA1c (beta=.115,
p=.0001). The predictor betas were almost identical whether adjusted or
unadjusted means or threshold proportions were utilized. However, the
modality of reporting HbA1c results determined which facilities were
classified as outliers from the national means. After adjusting for the
upper limit of the normative ranges, a significant (p\<0.05) difference
in mean adjusted HbA1c occurred in 26 of 48 participating facilities.

**Conclusions:** Age, ethnicity, treatment modality and clinic visits,
but not gender, socioeconomic status or blood glucose monitoring were
statistically significant predictors of HbA1c values.

**Impact:** Future diabetes performance measures for HbA1c could utilize
case mix adjustment to compare mean HbA1c values of populations as well
as proportions of individuals exceeding a threshold measure.

97\. Extending the Use of the Self-Administered Quality of Well-Being to
Patients with Depression

##### Jeff Pyne, MD. North Little Rock VA Medical Center, North Little Rock, AR. WJ Sieber, K David, and DK Williams

**Objective:** We examined the sensitivity of the self-administered
Quality of Well-Being (QWB-SA) Scale to changing levels of depression
severity. The original QWB Scale was designed as a generic measure for
use in cost-effectiveness analyses and provided the recommended health
policy effectiveness unit of quality-adjusted life years (QALYs). The
QWB-SA was developed in response to concerns that the original
interviewer version of the QWB took too long and was too costly to
administer. The QWB-SA takes approximately 7 minutes to complete, has
been used to estimate QALYs in migraine and arthritic patients, and has
well-established validity and reliability.

**Methods:** A total of 67 subjects participated in the study: 51 male
(39 inpatient and 12 outpatient) and 16 female (7 inpatient and 9
outpatient). All subjects were diagnosed with a current major depressive
episode using the Structured Clinical Interview for DSM-IV and were
simultaneously administered the QWB-SA, the interview version of the QWB
Scale, 17-item Hamilton Rating Scale for Depression (HRSD), and Beck
Depression Inventory (BDI). The output from both QWB scales is a single
score between 0.0 (death) and 1.0 (perfect health). The study design was
observational. Acute treatment response was determined using weekly QWB
and depression ratings during 4 weeks of medication treatment or until
criteria for a 50% improvement from baseline HRSD was met (defined as
the mean HRSD score from weeks 1 and 2), and longer term response was
determined at 4-months post-treatment.

**Results:** There were no differences found between male and female
subjects on any measure and therefore the data were combined for all
reported analyses. To place the QWB-SA scores in context, the reported
mean score (SD) for migraineurs without headache was .619 (.15), with
headache .484 (.15); patients with rheumatoid arthritis .509 (.14); in
the current sample depressed outpatients .479 (.12), inpatients .382
(.12). Baseline correlations between QWB-SA, HRSD and BDI were -.38
(p\<.01) and -.30 (p\<.05), respectively. Acute change score
correlations between QWB-SA, HRSD and BDI were both -.27 (p\<.05). Four
month change score correlations between QWB-SA, HRSD and BDI were -.51
(p\<.01) and -.57 (p\<.01), respectively. Interviewer QWB change score
correlations with HRSD and BDI were non-significant for acute treatment
response and less robust for the 4-month response.

**Conclusions:** The QWB-SA scores for depressed subjects were similar
or lower than QWB-SA scores for other chronic disorders, namely migraine
and rheumatoid arthritis patients. The baseline QWB-SA correlation with
depression severity is significant and consistent with a medium effect
size. The acute and 4-months post-treatment change score correlations
are significant and consistent with a medium and large effect size,
respectively. The QWB-SA appears to be more sensitive to acute change in
depression severity than the interviewer QWB.

**Impacts:** The QWB-SA is an inexpensive and low staff impact method
for documenting the cost-effectiveness of medical interventions and for
comparing the cost per QALY across specialties. The QWB-SA may be a
valuable measure to inform healthcare resource allocation decisions.

**98. The Relationship between Functional Status and Satisfaction of
Care among Patients Served by the Veterans Health Administration**

##### Xinhua Ren, PhD and Lewis Kazis, ScD. Bedford VA Medical Center, Bedford, MA. A Lee and W Rogers. Susan Pendergrass, DPH. Department of Veterans Affairs, Ridgeland, MS.

**Objectives:** As the Veterans Health Administration (VHA) places high
priority on quality of care, comprehensive frameworks for quality
accountability have been established to manage performance within the
VHA. To address this accountability, there is an increasing need for the
VHA to assess the outcomes of health care. In this presentation, we
assess the relationship between two domains of VHA health care value,
patient satisfaction of care and functional status, in the context of
sociodemographic characteristics such as age, gender, race, marital
status, educational attainment, and periods of service (WWII, Korea,
Vietnam, and Persian Gulf).

**Methods:** We analyzed both the cross-sectional data from the 1996
National Survey of VA Ambulatory Care Patients and the cohort data from
the 1998 National Survey of VA Ambulatory Care Patients. The 1996 Survey
included 32,631 patients, among whom 26,424 patients were followed in
the 1998 Survey. Participants in the study were mailed a health status
(the SF-36V) and a Customer Service Standards (or patient satisfaction)
questionnaire. Using the cross-sectional data, we first conducted
Pearson\'s product moment correlations to examine the relationship
between functional status and patient satisfaction. Then using ordinary
least squares regression (OLS), we examined the effects of
sociodemographics (such as age, gender, race, marital status,,
education, and periods of service) and functional status on domains of
patient satisfaction. Using the cohort data, we conducted \"cross
correlations\" between patient satisfaction and functional status in
wave 1 (1996 Survey) and patient satisfaction and functional status in
wave 2 (1998 Survey) to examine the causal relationship between
functional status and patient satisfaction.

**Results:** In the cross-sectional data analysis, the SF-36V scales had
significant, negative correlation coefficients with the satisfaction
scales (p \< 0.001), indicating that patients with better functional
status were less likely to be dissatisfied with the care they received
within the VHA. Furthermore, compared to physical health (or PCS),
mental health (or MCS) seemed to be more strongly correlated with
patient satisfaction. Patients who were older, white, married, and more
educated had significant, negative regression coefficients on
satisfaction scales (p \< 0.01), indicating that those patients were
less likely to be dissatisfied with the care they received within the
VHA. In the cohort data analysis, the relationship between physical
(PCS) or mental (MCS) health and domains of patient satisfaction was
rather stable over time; however, the effect of PCS or MCS on patient
satisfaction seemed to be more important than that of patient
satisfaction on PCS or MCS.

**Conclusions:** The study results suggest that after adjusting for
sociodemographics such as age, gender, race, marital status, education,
and periods of service, patients with poorer functional status are more
likely to be dissatisfied with the care they received from the VHA than
patients with better functional status.

**Impact:** Results have implications for the use of the SF-36V as an
important adjuster in future work. The physical and mental component
summary scales from the SF-36V are both correlated with the satisfaction
scales, suggesting that comparisons across VISNs should consider both
unadjusted and adjusted satisfaction scale scores.

# 99. VISN 10 Automated ICU Severity Adjustment Tool: SISVISTA

## Marta Render MD. Cincinnati VA Medical Center, Cincinnati, OH. SH Timmons, R Hayward, D Welsh. Timothy Hofer, MD, MSc. Ann Arbor VA Medical Center, Ann Arbor, MI. 

**Objective:** Proprietary intensive care unit (ICU) risk adjustment
tools are costly. We developed an automated ICU risk adjustment tool
using only those variables from APACHE III found in the computerized
database of the Department of Veterans Affairs (VistA).

**Methods:** We included the first admission of each patient to any
intensive care unit in three Ohio Veterans Affairs hospitals from 2/1/98
through 7/31/97. Customized programming in the VistA database at each
facility identified eligible patients and extracted relevant variables:
diagnosis, age, comorbidity, admission source (direct or transfer) and a
modified Acute Physiology score, hematocrit, white blood count, albumin,
sodium, glucose, bilirubin, blood urea nitrogen, creatinine, partial
pressure of oxygen/fraction of inspired oxygen, partial pressure of
carbon dioxide and pH. A window surrounding admission ([+]{.underline}
24 hours) identified variables and applied APACHE III weights. Direct
admissions were those patients admitted to the ICU from the emergency
area or transferred to the ICU within 1 day of surgery; all others were
considered transfers. APACHE III comorbid diagnoses were defined using
ICD.9.CM coding from the inpatient treatment file (PTF). The ICD.9.CM
ICU discharge code from the PTF file was sorted first into APACHE III
diagnostic groups, then into 10 groups of organ system dysfunction.

**Statistics:** Odds ratios for predictor variables, summary statistics
including the C statistic, and goodness of fit testing are reported for
the logistic regression model predicting 30 day mortality.

**Results:** 4626 of 4851 patients (99.5% of the cohort, 477 deaths) had
complete datasets. Of the 4626 patients, 1389 were classified as
post-operative (30%). Patients were 63 [+]{.underline} 12 years and
predominantly male (97.5%). 74% of patients were directly admitted to
ICU from the emergency area, and 26% were transferred into the ICU.
Mortality was increased in patients transferring to the unit (21%)
compared to those directly admitted (6.5%, p = 0.001); and increased as
the length of time from hospital admission to ICU transfer increased
(mortality at 1 day 15.6%, at 2-4 days 19%, and at \> 4 days 25.2%, p =
0.002). The most common diagnoses were cardiovascular diseases (MI,
CHF). In multivariable analysis, age score (OR \[95%C1\] = 1.05 \[1.02,
1.07\]), some diagnostic systems (Hematology, neurology, orthopedics,
respiratory, sepsis and trauma, p[\<]{.underline}0.05), comorbidity
score (OR \[95%C1\]=1.11\[1.08, 1.1\]), direct admission (OR
\[95%C1\]-0.4\[0.3, 0.5\]), and the sum of the laboratory scores (OR
\[95%C1\]=1.07\[1.06,1.08\]) were significant. The model had excellent
discrimination and calibration (C statistic = 0.85, Hosmer -- Lemeshow,
p = 0.07).

**Conclusion:** This relatively economical automated ICU risk adjustment
system has discrimination similar to existing risk adjustment systems
(APACHE II, SAPS II).

**Impact:** An automated risk adjustment system has broad potential
administrative and research applications in the VHA locally, regionally
and nationally, and in community health care systems with advanced
information systems. These results are being validated in a national
database.

HSR&D Funded: DEV 97-032

# 100. Psychogeriatric Interventions Saves Inpatient Costs: Preliminary Findings

[Joel Rosansky, LCSW, R Anderson, R Bastani, R Gould, D Huang, L F
Jarvik, G Kominsk, A E Maxwell, J Sanchez, and S Taylor, UPBEAT Program
Staff.]{.underline} VA Greater Los Angeles Healthcare System, Los
Angeles, CA.

**Objectives:** The Unified Psychogeriatric Biopsychosocial Evaluation
and Treatment (UPBEAT) Program is a multi-center, interdisciplinary,
randomized, six year outcome-based clinical demonstration project
sponsored by the Department of Veterans Affairs to improve health care
and reduce utilization by geriatric veterans. Specifically, UPBEAT Care
is expected to reduce inpatient utilization and unscheduled hospital
visits, and increase consumer satisfaction.

**Methods:** UPBEAT staff at each of the nine participating VA Medical
Centers use the Veterans Health Information System and Technology
Architecture (VISTA) to identify patients 60 years or older, admitted to
acute medical/surgical inpatient services. Patients are invited to
participate in the program evaluation unless they meet exclusion
criteria. Exclusion criteria include: psychiatric appointments during
the preceding or subsequent 6 months, diagnosed with Post Traumatic
Stress Disorder, psychosis, dementia or other cognitive impairment,
spinal cord injury, rehabilitation plan, outside catchment area,
homeless, admission from nursing home, chemotherapy, hospice care, or
previous assignment to UPBEAT or Usual Care. Eligible patients providing
informed consent are interviewed at bedside with the anxiety and
depression subscales from the Mental Health Index (MHI-38), the Alcohol
Use Disorder Identification Test (AUDIT) and the RAND 36-item Health
Survey Short Form (SF-36) for patients meeting cutoff scores for
anxiety, depression, or alcohol misuse symptomatology. Qualified
patients are randomized to UPBEAT or Usual Care. UPBEAT Care patients
receive in-depth diagnostic assessments, including the following scales:
Geriatric Depression, Hamilton Anxiety and Depression, Lubben, Affect
Balance, Activities of Daily Living, Cumulative Illness Rating,
Mini-Mental State Examination, Multi-Axial Diagnostic Assessment. Each
UPBEAT Care patient is assigned to an UPBEAT Care Coordinator from an
interdisciplinary team. UPBEAT Care teams, with expertise in
psychogeriatrics, are staffed from psychiatry, nursing, social work, and
at some sites psychology. Based on the diagnostic assessment, UPBEAT
Care Coordinators provide patients with referrals to community and
hospital services, or if necessary, direct interventions utilizing
educational, psychosocial, psychotherapeutic or psychopharmacologic
approaches. Outcome evaluation includes follow-up interviews of both
UPBEAT and Usual Care patients at 6, 12 and 24 months after enrollment.
In addition, utilization and cost data are obtained for both groups from
VHA databases.

**Results:** Based on preliminary data from the Allocation Resource
Center for 420 UPBEAT Care and 462 Usual Care patients, the net changes
in inpatient utilization between 12 months pre- and 12 months
post-enrollment yielded a first-year savings of 5.4 inpatient
days/patient for UPBEAT Care over Usual Care. This resulted in a savings
of over \$2,184,000 based on the Cost Distribution Report average
inpatient cost of \$963/day.

**Conclusions:** The UPBEAT Program, i.e. skilled clinical assessment
with identification of symptoms of depression, anxiety and alcohol
misuse followed by community-based mental health care management by an
interdisciplinary team with expertise in psychogeriatrics, resulted in
reduced inpatient utilization and thereby, cost savings.

**Impact:** UPBEAT is expected to demonstrate that skilled clinical
assessment and community-based mental health care coordination (primary
and secondary mental health and other health care intervention and
prevention) by an interdisciplinary team with expertise in
psychogeriatrics can yield enhanced delivery of integrated health care
and decreased utilization of expensive acute inpatient services
(medical/surgical/ psychiatric).

**101. One-year Mortality Rates for all Users of the VA Medical Care
System**

[J Souchek, PhD, NJ Petersen, CM Ashton, and TJ Menke, HJ
Yu.]{.underline} Houston VA Medical Center, Houston, TX.

**Objective:** In the face of changes in the VA medical care system, it
is important to monitor outcomes of care. The purpose of this study was
to estimate the one-year mortality rate for all users of the VA medical
care system for three fiscal years, FY95, FY96, and FY97. Unadjusted,
age-specific, and age-adjusted rates were computed for the 22 Networks
and VA-wide.

**Methods:** Users of the VA medical system were identified for each
year from the patient treatment file, the outpatient file, extended care
file and the fee-basis file. Vital status of patients was obtained from
the VA\'s Beneficiary Identification and Records Locator Subsystem death
file. A file prepared by the VA Planning Systems Support Group was used
to assign the county of residence of each patient to the Network
responsible for his care. We used several methods to compute the
mortality estimates: ratio estimates were used initially, but were
replaced by product limit (Kaplan-Meier) estimates because the ratios
underestimated the death rates. All mortality rates (unadjusted,
age-specific, and age-adjusted) were based on the Kaplan-Meier
estimates. Because of the large number of system users (almost 3
million), it was not feasible to use Cox-regression to age-adjust the
Network rates.

**Results:** The number of system users increased by 5.4% from 2,843,534
in FY95 to 2,996,640 in FY97. The VA-wide death rate decreased from 3.05
per 100 VA users in FY95 to 2.78 per 100 in FY97. Age-standardized rates
varied among the networks; in FY97 the range was 2.11% to 3.42%. As
expected, the mortality rates increased with age from 0.42% in the \<45
age group to 10.60% in the 85 or older group.

**Conclusions:** The all-cause mortality rate per year gives a broad
view of the status of users of VA medical care over time and location,
and allows comparison of age-specific rates with those in the private
sector. Of continuing interest are the methodologies for estimating and
comparing mortality rates over time, and within the hierarchical system
of hospitals within networks within the VA system.

**Impact:** These mortality rates allow comparison of the VA with other
health care systems and indicate areas where death rates are high in
order that efforts, medical or social, may be made to lower the rates in
these areas.

**HSR&D Funded:** SDR 98-001

**102. Accelerometer Activity Monitoring in a Sedentary
Population:Methodology, Clinical Utility, Validity**

[Bonnie Steele, PhD.]{.underline} VA Puget Sound Health Care System,
Seattle, WA. B Belza, L Holt, and D Buchner

**Objectives:** Physical immobility is a major risk factor for a
multitude of illnesses. Precise quantification of daily, free-living
activity is desired to more effectively evalate interventions aimed at
reducing physical frailty and improving mobility in sedentary groups.
Current methods for studying daily activity suffer from several
problems, including intrusiveness, imprecision, and cost. The TriTrac
R3D accelerometer, a triaxial motion sensor worn at the waist, is an
appealing alternative. The TriTrac accelerometer (TriTrac R3D Research
Ergometer, Professional Products, a Division of Reining International,
Ltd.), measures movement across three axes which is expressed in energy
expenditure or gross movement (vector magnitude). The purpose of this
poster is to describe accelerometer methodology, including (1)
standardized protocols for at-home measurement, data management, device
maintenance, and subject acceptance and (2) to compare accelerometer
activity outcomes with self-report of activity over the same time
period, level of obstructive disease, and exercise capacity.

**Methods:** A convenience sample of 48 outpatients with stable chronic
obstructive pulmonary disease (COPD) were studied one week prior to
entry into an 8-week pulmonary rehabilitation program. Mean age was 66
years (SD 7.71; range 48-50) and forced expiratory volume in one second
(FEV1)was 37% predicted for age, gender, and height (SD 16%, range
12-83%). Participants wore the accelerometer in a belted pouch for a
consecutive four day period (two weekdays and a weekend) and completed
the Modified Activity Recall Questionnaire (MARQ) for the same period
they wore the accelerometer. Level of obstructive lung disease was
measured using the FEV1 (% predicted) and the longest of three
six-minute walks measured exercise capacity.

**Results:** Using Pearson product-moment correlations (r),
accelerometer measurement of physical activity (vector magnitude) was
strongly associated with the six-minute walk test (r=0.72; p=0.0001) and
moderately associated with pulmonary function (FEV1%) (r=0.45; p=0.002).
Accelerometer measurement (activity calories) for three full days was
associated with MARQ (kilocalories) but only significant for two days
(Friday, r=0.53, p=0.001; Saturday r=0.61, p=01; and Sunday r=0.28,
p=0.08).

**Conclusions:** Compliance with wearing the TriTrac accelerometer for
five consecutive days was excellent and participants reported no
difficulties with wearing the device. Standardized protocols on device,
use and care, programming and data management facilitated its utility in
the study and will be detailed. The TriTrac is a valid measure of
everyday physical activity in a sedentary population. It has excellent
potential for providing precise measurement of free-living activity and
offers an improvement over existing measures.

**Impact:** The study of devices that better quantitate free-living
activity has the potential for improving process and outcome efficacy
measures of restorative and rehabilitative programs of which improved
physical functioning are of intrest. These programs include exercise
classes and cardiac and pulmonary rehabilitation programs, major surgery
(coronary artery bypass grafting, lung volume reduction, and hear and/or
lung transplantation) and assignment of durable medical equipment (home
oxygen, motorized wheelchairs, CPP/BiPAP).

**HSR&D Funded:** NRI 95-082

**103. Defining the Attributes of the Quality of Dying: Perspectives of
Patients, Families and Health Care Providers**.

## K Steinhauser, PhD, EC Clipp, M McNeilly, N Christakis, L McIntyre, PhD, and J Tulsky, MD. Durham VA Medical Center, Durham, NC.

**Objectives:** Health care providers and the public have targeted
considerable resources towards improving the quality of dying through
such interventions as hospice care, education of medical personnel, and
promotion of advance directives. However, despite these efforts, no
well-established standardized tools exist to assess the quality of
dying. In particular, no tools explicitly acknowledge the variability in
patients\' and families\' perspectives. Consequently, attempts to
evaluate the effectiveness of hospice care have suffered. Our primary
objective was to gather definitions of a \"good death\" from the
perspectives of patients, families, and health care professionals. These
data will be used in subsequent research to develop an instrument to
assess the quality of dying.

**Methods:** We convened focus groups to define the key domains of
experience for those involved in the process of dying including
patients, recently bereaved family members, physicians, nurses, social
workers, chaplains, and hospice volunteers. Focus groups were stratified
by participant type and ethnicity. Following each focus group we
conducted in-depth interviews with two group members to clarify our
interpretations and gather a deeper level of specificity about the
issues raised in the group.

**Results:** We conducted twelve focus groups with a total of
seventy-five participants. Participants ranged in age from 26-77 years
with an average age of 46.8. Women comprised 64 percent of our sample,
men 36 percent. Seventy percent of focus group participants were
Caucasian, 28 percent were African-American and 3 percent were
Asian-American. Sixty one percent of the sample were Protestant, 18
percent were Roman Catholic and 8 percent identified as Jewish. Eleven
percent were unaffiliated. The most prominent distinctions in definition
of a \"good death\"occurred between groups of health care professionals.
These professional role distinctions appeared to override differences by
gender or ethnicity. For example, discussions with physicians\' centered
primarily on issues of pain control. Non-physician providers tended to
discuss patients\' and families\' psychosocial and spiritual needs in
addition to the importance of managing physical symptoms. Groups also
identified new domains of the quality of dying including being known by
providers as a \"whole person,\" preparation for dying, the opportunity
to contribute to others\' well-being, and the opportunity to develop a
sense of completion. Finally, participants stressed the very individual
nature of the dying experience. \"Good deaths\" are crafted through a
process of communication about patients\' and families\' values and
preferences regarding care at the end of life.

**Conclusions:** Control of physical symptoms at the end of life is
important but only a point of departure for improving the quality of
dying. Participants suggested a \"good death\" also includes attention
to psychosocial and spiritual issues. Instruments designed to assess the
quality of dying must include these multiple domains.

**Impact:** We hope to use the results of this study to develop an
instrument to measure the quality and effectiveness of interventions to
improve end-of-life care, such as palliative care units or hospice
programs. These data will allow us to create instruments that focus on
aspects of care patients and families consider most important.

**HSR&D Funded:** 96-006

**104. Integrating VA Medical Centers**

[C VanDeusen Lukas, EdD.]{.underline} Boston VA Medical Center, Boston,
MA. [B Mittman, PhD J Hernandez, J Macdonald, E Yano, PHD, MSPH, and B
Simon, MA.]{.underline} VA Greater Los Angeles Healthcare System, Los
Angeles, CA.

**Objectives:** There is a strong trend in the VHA, as in the private
sector, to integrate healthcare facilities. This multi-year study was
designed to analyze 14 VHA integrated systems in order to develop
management lessons for other VHA systems. Drawing from the first phase
of the study, this paper examines: 1) the effects of facility
characteristics on integration structures; 2) the planning and change
processes used by the integrating systems; and 3) the perceived impact
of integration on operations, patient care and staff morale in different
integration settings.

**Methods:** Qualitative and quantitative data for 14 integrating
systems were drawn from four sources: 1) face-to-face interviews with
top leadership, middle managers, and representative staff and
clinicians; 2) a survey of all system department heads and service
chiefs (91% response rate); 3) documents provided by the systems and 4)
VA administrative and research databases. Descriptive analyses
identified patterns in characteristics, processes and structures of
integrating systems. Systems were clustered by patterns and compared to
assess differences in effectiveness on selected variables.

**Results:** 1) Systems with one clearly dominant partner - an
affiliated tertiary facility paired with a smaller community or
specialty facility \-- were more likely than systems with equal partners
to be structurally integrated two years after integration approval -
particularly in clinical departments - and to have consolidated acute
care services to one campus. Equal-partner systems - with facilities
similar in size, complexity and academic affiliation \-- were less
likely consolidate services to one campus and/or combine departments
across campuses. Equal-partner systems on average reported lower impacts
of integration on department operations and lower perceived staff moral.
2) Systems differed in the speed of appointment of new managers and in
the roles management and staff played in the early planning processes.
Systems that appointed the director immediately and used a model of
shared leadership were more effective in terms of a shorter integration
process, higher staff satisfaction with the p rocess and higher
perceived staff morale.

**Conclusions:** 1) The characteristics of the participating facilities
strongly influence the structure of the integrated system. Equal-partner
systems tend to take longer and/or result in less complete clinical
integration. Integration among equal partners is often more difficult
than in dominant partner systems because more issues have to be
negotiated extensively. 2) Effective planning processes balance strong
leadership with early involvement of middle managers. Staff are most
satisfied when they have an opportunity to participate within a clear
structure - after key decisions are made about the organizational
structure, and when they are given clear guidelines for planning. 3)
Clinical integration is a key aspect of VHA integrations. In most of the
systems studied, the majority of clinical services are integrated. These
patterns are consistent with VHA goals of creating integrated delivery
systems, not simply joining hospitals for administrative purposes.

**Impact:** The first phase report has been distributed to all VISNs and
medical centers to inform their efforts in integrating services and
facilities, and more broadly creating integrated delivery systems. Study
investigators have presented their findings in VHA systems beginning the
integration process.

**HSR&D Funded:** MRR96-022

# 105. Characteristics and Outcomes of Women Undergoing Hysterectomies in VA Facilities

[F Weaver, PhD and D Hynes, PhD, RN.]{.underline} Hines VA Medical
Center, Hines, IL. [D Ippolito, W Cull, B Thakkar, and J
Gibbs.]{.underline}

**Objectives:** The objectives of this research are to: describe the
patient sociodemographic, preoperative risk, structure and process
characteristics and outcomes of women undergoing selected procedures at
VAMCs; and examine the relationship between sociodemographic,
preoperative risk, structure and process characteristics and outcomes
for women undergoing select procedures (i.e., hysterectomy, mastectomy,
total joint replacement) using multivariate modeling techniques.

**Methods:** This study is a secondary analysis of the National Surgical
Quality Improvement Program (NSQIP) database. For the present analyses,
all hysterectomy procedures (vaginal, abdominal and
laproscopic-assisted) collected by the NSQIP between FY92 and FY97 were
selected. The NSQIP contains data on 62 preoperative risk and
demographic characteristics, four process, and 23 outcome variables. We
supplemented the NSQIP with data from the VA\'s Patient Treatment File
for readmission data, pathology reports from sites, and facility
characteristic data. Data from these sources were merged on patient
identifiers and procedure date. Any hospitalizations that occurred
within one year of the procedure were captured. Outcomes of interest
include: post-operative length of stay, morbidity within 30 days (i.e.,
one or more of 21 complications monitored by the NSQIP), and any
readmissions that occurred as a result of a complication of the
procedure within one year post surgery. Complications were defined by an
expert panel of surgeons who identified relevant diagnostic codes and
assigned a time period within which the diagnosis would be considered a
complication.

**Results:** Over a six year period, VA performed 1,758 hysterectomies.
The majority were for abdominal hysterectomies (75%), whereas 22% were
vaginal, and less than 4% were laproscopic-assisted. The most frequent
indications for surgery included leioyomas of the uterus (31%), bleeding
problems (16%), and endometriosis (10%). Women were predominately white
(64%), with an average age of 42.8 years, and a minority were married
(37%). Preoperatively, 40% of these women were smokers, 14% had a
history of hypertension requiring medications, and 5% were frequent
alcohol users. The mean length of stay was 4.2 days (sd=3.7) and almost
9% experienced one or more of the 21 complications defined by the NSQIP
within 30 days of the procedure. Logistic regression modeling of 30-day
morbidity identified 6 significant predictors. Preoperative patient
variables, including impaired functional status, current smoker, alcohol
use within two weeks of admission, dyspnea, and infection, as well as,
longer operation times were associated with greater probability of
morbidity (c-index=0.670). Modeling of postoperative length of stay and
readmissions due to complications is in process.

**Conclusions:** Research on hysterectomy outcomes have focused on
single outcomes and limited examination of preoperative characteristics.
This work examining multiple preoperative characteristics and outcomes
indicates that risky health behaviors and poorer health status prior to
surgery were significant predictors of 30-day mortality.

**Impact:** Women veterans account for less than 5% of all VA health
care users. The rate of female-specific procedures at any one facility
is very low. Given these infrequent events, this study will help to
inform the system as to the types of women who undergo procedures within
VA and their outcomes and how this compares to the non-VA health care
sector.

**HSR&D Funded:** GEN 97-016

# 106. Depression, Falls, and Risk of Fracture in Older Women

[Mary Whooley, MD, KE Kip, JA Cauley, KE Ensrud, MC Nevitt, and WS
Browner,]{.underline} San Francisco VA Medical Center, San Francisco,
CA.

**Objective:** Previous studies have suggested that depression is
associated with falls and with low bone density, but it is not known
whether depression leads to an increased risk of fracture.

**Methods:** We conducted a prospective cohort study in elderly white
women who were recruited from population-based listings in the U.S. At
their second visit (1988-90), 7414 participants completed the 15-item
Geriatric Depression Scale (GDS), and were considered depressed if they
reported 6 or more symptoms of depression. We measured bone mineral
density (BMD) in the spine and hip using dual energy x-ray
absorptiometry, and askedparticipants about incident falls (yes/no) at 4
follow-up visits. Nonvertebral fractures were ascertained for an average
of 6 years

following the depression measure, and verified radiologically.
Wedetermined incident vertebral fractures by comparing lateral spine
films obtained at the first visit (1986-88) with repeat films obtained
an average of 3.7 years later (1991-92).

**Results:** The prevalence of depression (GDS \>= 6) was 6.3% (467 of
7414). We found no difference in mean BMD of the hip and lumbar spine in
depressed compared with nondepressed women. Depressed women were more
likely to experience subsequent falls than nondepressed women \[70% vs.
59%; age-adjusted odds ratio (OR) 1.6, 95% CI, 1.3 - 1.9; p\<0.001\], an
association that persisted after adjusting for potential confounding
variables (OR 1.4, 95% CI, 1.1 - 1.8; p=0.004). Women with depression
had a 40% \[age-adjusted hazard ratio (HR) 1.4, 95% CI, 1.2 - 1.7;
p\<0.001\] increased rate of nonvertebral fracture (124 fractures in
3,805woman-years of follow-up) compared with nondepressed women (1367
fractures in 59,503 woman-years of follow-up). This association remained
strong after adjusting for potential confounding variables, including
neuromuscular function and use of antidepressant medication (HR 1.3, 95%
CI, 1.1 - 1.6; p=0.008). Further adjustment for subsequent falls
appeared to explain part of the association between depression and
nonvertebral fracture (HR 1.2, 95% CI, 1.0 - 1.5; p=0.06). Depressed
women were also more likely to suffer vertebral fractures than
nondepressed women, adjusting for history of vertebral fracture, history
of falling, arthritis, diabetes, steroid use, estrogen use, supplemental
calcium use, cognitive function, and hip BMD (OR 2.1, 95% CI, 1.4 - 3.2;
p\<0.001).

**Conclusions:** Depression is a significant risk factor for fracture in
older women. The greater frequency of falls among depressed persons
partially explains this finding.

**Impact:** If treatment for depression were effective in reducing the
associated risk of falls and fracture, then better diagnosis and
treatment of depression could substantially decrease fracture-related
morbidity and mortality.

107\. Comparing Approaches to Predict Decline in Functional Status in
the VA Long-Term Care Population

## J Wu, A Rosen, PhD, B Chang, ScD, D Berlowitz, MD, MPH, Lewis Kazis, ScD. Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA. A Ash Mark Moskowitz, MD. Boston University School of Medicine.

**Objectives:** Outcome measures, such as decline in functional status
(FS), have been shown to be useful when assessing quality in the
Medicare population. To replicate this approach in the VA setting, we
developed a risk-adjustment model to predict decline in FS in VA
long-term care. Decline in FS is operationalized by measuring the change
in the sum of activities of daily living (ADLs) scores between two time
periods. However, there is no consensus on the best method of using
baseline ADLs to distinguish residents at different levels of risk for
decline in FS. This study compares approaches to using initial ADLs to
model decline in FS.

**Methods:** Our sample consisted of 16,998 residents who resided in VA
long-term care facilities between 4/1/96 and 10/1/96. The Patient
Assessment File (PAF) was used to evaluate changes in residents\' FS.
Baseline and outcome FS were measured using 3 ADLs: eating,
transferring, and toileting (each rated on a 1-5 scale). Decline in FS
was defined dichotomously as an increase (worsening) of two or more in
the summed ADL scores (ADLSUM) between baseline and semi-annual
assessments. Patient characteristics related to decline (e.g., age,
medical conditions, and length of stay) were used as risk factors, along
with baseline ADLs, to predict decline in FS. Logistic regression models
were developed using each of the 3 ADLs individually as well as ADLSUM.
ADL variables were modeled continuously (i.e., linearly), categorically
and quadratically. We also developed a classification tree (using CART)
based on ADLSUM, each of the 3 ADLs, and a fourth ADL, mobility.

**Results:** Decline in FS was not linearly associated with baseline
ADLs. The model that regressed decline in FS on baseline ADLSUM
performed least well; chi-square for covariates, p-value and c-statistic
were 608.6 with 5 df, 0.0001 and 0.659, respectively. The regression
model that used the categorical groupings from CART and the one which
included both ADLSUM and (ADLSUM)2 terms had similar, better
performance. For example, the analogous performance figures for the CART
model were 909.7 with 11 df, 0.0001 and 0.685, respectively.

**Conclusions:** Since model performance is affected by the method used
in modeling baseline ADLs, we suggest that to capture the full
complexity of the relationship between baseline ADLs and decline in FS,
models that use baseline ADLs non-linearly, such as CART, are the most
appropriate for predicting decline.

**Impact:** Health services researchers need to use independent
variables which are clinically valid and statistically robust in
modeling in order to make comparisons across facilities on their quality
of care.

**HSR&D Funded:** IIR 96-065

# 108. ACI-TIPI Intervention in the Triage of Urgest Care Patients with Chest Pain

## Robert Zalenski, MD. Wayne State University and John D. Dingle Veteran's Hospital, Detroit, MI. FH Shamsa, D Waselewsky

**Objectives:** Although the ACI-TIPI score has been shown to reduce
unnecessary admissions to CCU, its effect on processes of care outcomes,
such as length of stay and resource utilization has never been examined.

**Methods:** We examined the effect of introducing the ACI-TIPI, which
provides a valid and reliable estimation of the probability of acute
cardiac ischemia (ACI) on process of care outcomes in Urgent Care
setting (UC) of a VA hospital. We used a pre-post study design, where no
ACI-TIPI was used for 8 weeks followed by the providing of instrument to
all UC physicians with the initial ECG. Patients with chest pain were
studied, unless they were unstable. Primary outcomes were hospital
admissions, the use of diagnostic testing, cardiac consultation, length
of stay, admission to CCU, and hospital admission. Outcomes were
analyzed considering patients with and without ACI.

**Results:** The study group of 203 patients has a mean age of 56.6 yrs
with a 96.6% males and a racial distribution: 73.9% blacks, 20.2%
whites, and 5.9% others. In the 181 (89.1%) patients without a final
diagnosis of ACI, there was no difference comparing the control versus
the ACI-TIPI periods in the proportions of hospital admissions, the use
of diagnostic testing (Chest X-ray, Cardiac enzymes, and IV insertion).
But, the rate of cardiac consultation (24.21%)in the control period was
significantly lower than that of the ACI-TIPI period (39.53%) with
p=.02. Study groups were also not different in the mean time to IV or
aspirin, ED length of stay, admission to CCU, and hospital admission.

**Conclusions:** In this study, ACI-TIPI did not appear to reduce
resource utilization or decrease the length of stay but was associated
with increased rate of cardiac consultation

**Impact:** In patients with chest pain, treated in an Urgent Care
setting, the ACI-TIPI was not associated with the decrease of resource
utilization.

**HSR&D Funded:** LIP

**109. Improving the Quality of Interdisciplinary Team Meetings: The use
of In-Depth Qualitative Research to Understand Team Processes**.

## Barbara Bokhour, PhD. Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA.

**Objectives:** JCAHO mandates individualized treatment plans in long
term care. Team meetings are essential to the coordination of
multidisciplinary treatment teams in creating these plans. However, the
manner in which meetings actually produce consensus and coordinate
activities is poorly understood, while professionals often complain that
they are inefficient and ineffective. Through the use of in-depth
qualitative methods, this study sought to describe how team meetings
work, characterize effective and ineffective interactions, and identify
potential targets for improving the process.

**Methods:** Two interdisciplinary teams in a long-term care unit for
patients with Alzheimer's disease were observed. Teams included nurses,
physicians, recreational and occupational therapists, kinesiotherapists,
dentists, pharmacists, and social workers. Qualitative data include
videotapes of seven meetings, in-depth interviews with 16 team members,
and participant observations of the staff and patients on the units. All
data were transcribed and analyzed using sociolinguistic and activity
analysis of the discourse of team meetings and thematic analysis of
interviews. Activities performed in the meeting were analyzed for their
function in relation to the members\' goals of planning and coordinating
patient care, with analyses guided by the members\' own reflections on
their team interaction.

**Results:** In interviews, team members stated that the primary goal of
the meetings was collaborative treatment planning in order to insure
good, coordinated patient care. Team meetings proceeded in a ritualized
fashion with little room for variation. They included three primary
activities: 1) Giving report: team members state each listed problem, a
goal and a plan for intervention, 2) Writing report: the team determines
how this information is to be written on the care plan, and 3)
Discussion: members openly exchange ideas about an individual patient's
particular problem. "Giving report" and "writing report" were found to
be most productive in terms of the administrative goal of \"getting the
paper done\" û that is generating the written treatment plan.
"Discussion" was more productive in creating truly interdisciplinary
decisions and coordinated plans for individual patient care. The process
emphasized "giving report" which imposed limited categories for
discussion discordant with team members' knowledge of patients' social
and personal histories.

**Conclusions:** Although the goal of team meetings is to produce unique
individualized treatment plans for patients, the ritualized quality of
the interactions, oriented towards producing a report, effectively
eliminates dialogue about individuals and their unique qualities. Hence,
much information regarding personal and psychosocial histories are
omitted from the process, and discussions are often cut short in order
to complete the administrative function of the meetings.

**Impact:** Through the use of intensive observation and sociolinguistic
analysis of team meetings, this study was able to produce a detailed
description of the process, and identify specific practices that
contribute to the goal of creating individualized treatment plans.
Interventions to improve the quality of team meetings might include
refocusing the team on current and crucial problems for each individual
at the start of each meeting, encouraging team members to discuss all
psychosocial and background knowledge about patients, and eliminate the
ritualistic presentation of information well known to the team members.

**110. Gender Differences in Addiction Severity, Health Status, and
Psychosocial Functioning in Veterans with Substance Use Disorders**

[C Chun, PhD, P Ouimette, PhD, R Kimerling, and R Moos,
Ph.D.]{.underline} VA Palo Alto Healthcare System, Menlo Park, CA.

**Objectives:** The objectives of the present study were (a) to examine
gender differences in characteristics of VA substance abuse patients and
(b) to assess the impact of gender on the severity of addiction to
alcohol and drugs as well as on physical and mental health problems and
social functioning. This effort is part of the first large-scale study
on veterans that used the Fifth Edition of the Addiction Severity Index
(ASI), which is part of the standard intake assessment battery in many
VA substance abuse programs.

**Methods:** The sample was composed of 23,724 VA patients (97% men and
3% women) with a primary diagnosis of substance abuse who obtained
inpatient or outpatient treatment in one of 150 VA facilities in
September 1997. The ASI assesses problem severity in seven areas:
Alcohol use, drug use, psychiatric symptoms, medical problems, family
and social problems, legal problems, and employment problems.

**Results:** The results identified important gender differences. In
terms of substance use problems, men reported having recently used more
alcohol than women. The men also reported experiencing greater trouble
with alcohol problems and expressed greater need for treatment for their
alcohol problems. However, the opposite was true for drug use problems,
with the women using more drugs, experiencing more drug problems, and
expressing greater need for drug treatment. In terms of physical and
mental health problems, although a large majority of both men and women
reported experiencing many medical and psychiatric symptoms and needing
treatment, overall women reported more medical and psychiatric problems
compared to men. The women also consistently reported experiencing
greater conflict with their spouse, parents, children, and friends and
expressed greater need for treatment for family problems. There were no
significant gender differences in patients\' legal and employment
problems. The results of hierarchical multiple regression analyses show
that gender was a significant predictor of six of the seven ASI
composite scores after controlling for age, education, income, marital
status, and race. The women had less alcohol, legal, and employment
problems than the men but had more psychiatric, medical, and
family/social problems. The gender effect on drug use composite score
disappeared when the sociodemographic variables were controlled, whereas
a gender effect on legal and employment composite scores emerged after
the control variables were entered into the analysis.

**Conclusion:** Most of our findings on veterans are consistent with
past findings on gender and substance abuse. Particularly important are
the findings that suggest that women with substance use disorders,
whether they are veterans or not, tend to have more comorbid medical and
psychiatric conditions compared to men. Furthermore, the women appear to
have fewer social resources than the men.

**Impact:** The clinical implication of our findings is that treatment
for veteran women with substance use disorders will need to be
comprehensive, addressing not only their addiction problems but also
their psychosocial problems and deficits.

**111. Seeking Care in the VA: What Differentiates Level of VA Use for
Women Veterans?**

## Shelia R. Cotton, PhD. Edith Nourse Rogers Veterans Memorial Hospital, Bedford, MA.

**Objectives:** The numbers of women veterans are increasing, but little
is known about factors that influence their use of the VA system for
health care services. The objective of this study is to understand
characteristics of women veterans that account for their decisions to
seek care in the VA.

**Methods:** A national sample of women veterans (n=3632) who had at
least one VA out-patient visit during a one year time period completed
self-administered mailed questionnaires (58.4% response rate). Use of
health care was measured through responses to a question asking which of
the following best described their use of VA health care services: they
use the VA (1) for all their medical care, (2) for most of their medical
care, and (3) for little of their care or as a \"back-up\" for health
care. Based upon this question, three self-identified groups of VA users
were defined and compared on demographic, VA access, resource, and
health status (SF-36) characteristics through the use of ANOVAS and
logistic regression.

**Results:** The respondents were equally divided across the three
groups of users. Bivariate analyses reveal that women who obtained all
their care at the VA were significantly older, less educated, less
likely to be currently married, and less likely to have private health
insurance than were women veterans from the other two user groups
(p\<.05 for each). Average income for the all care at VA group
(\$20,128) was significantly lower than for most care (\$26,107) and
\"back-up\" care (\$35,215) groups. They also had lower levels of social
support and they lived alone more often than their counterparts. The
\"back-up\" group had significantly better health status than the other
two user groups. Logistic regression results indicate that being married
(p\<.01), having higher income (p\<.001), and having private health
insurance (p\<.001) are associated with use of VA for \"back-up\" health
care. Women veterans who have lower levels of social support (p\<.01),
live alone (p\<.05), rate convenience of VA location (p\<.001) and VA
access factors (p\<.001) more favorably, report feeling welcome as a
woman receiving treatment at a VA hospital (p\<.001), and have lower
levels of physical functioning (p\<.01) are more likely to use the VA
for most or all of their health care needs.

**Conclusions:** The results suggest that women veterans who use the VA
for most or all of their health care needs are different from women
veterans who use the VA as a \"back-up\" for care. It is apparent that
economic resources, social resources, and perceptions of the VA
discriminate those who use the VA for most or all of their care from
those who use it only for \"back-up\" care.

**Impact:** These results suggest that the VA should focus attention on
the decision-making processes of women veterans who use the VA as a
\"back-up\" for health care. These women have more economic and social
resources which may lead them to seek care outside the VA. Issues
surrounding access, location, and satisfaction with services may be key
to drawing these women into the VA for more health care services. In
addition, results suggest that the VA should pay particular attention to
the lower levels of social and economic resources of women who use the
VA for substantial amounts of their health care. This may impact how
health care providers develop and implement patient education and
treatment plans.

**HSR&D Funded:** SDR 93-101

**112. Depression Post Alcohol Treatment and Drinking Outcomes:
Implications for Clinical Intervention and Research Design**

[Geoffrey Curran, PhD, Jo Ann Kirchner, MD, and Brenda Booth,
PhD,]{.underline} HSR&D Center for Mental Healthcare and Outcomes
Research, North Little Rock, AR.

**Objectives:** This study examines the association between continued
abstinence and depressive symptomology measured during inpatient
treatment for alcohol disorder and three-months post-treatment.

**Methods:** Data were obtained from 298 males with alcohol use
disorders who completed 21-day inpatient treatment at a Midwestern VA
Alcoholism Treatment Unit. Three-, six-, nine-, and twelve-month
follow-up interviews were conducted, with 271 subjects completing all
phases of the study (91%). Multiple logistic regression was used to
assess the association between continued abstinence and baseline/three
months post-treatment measures of depression (Beck inventory),
controlling for various demographic and other treatment outcome relevant
variables (ASI composite scores during treatment; age, education,
participation in a domiciliary aftercare program, number of previous
alcohol treatments, and baseline social support).

**Results:** Depressive symptomology at baseline was not associated with
abstinence at any follow up, but depression severity at three months
post-treatment was strongly negatively associated with abstinence at
each follow up. Further analysis of three-month depression with dummy
coded variables representing mild-to-moderate (Beck=14-19) and severe
depression (Beck=20+) indicated that 1) the mild-to-moderately depressed
were on average 2.9 times less likely as those not depressed to be
abstinent at each follow-up, and 2) the severely depressed were on
average 4.9 times less likely to be abstinent at each follow-up. In
comparison to those subjects with depressive symtomatology (Beck \>= 14)
at baseline and 3 month follow-up, the never depressed were on average
2.6 times more likely to remain abstinent at each follow-up; subjects
who were depressed at baseline but not at follow-up were on average 4
times more like to remain abstinent across follow-ups.

**Conclusions:** The data support our hypothesis that the presence of
depressive symptomology following a treatment/abstinent period is a
better predictor of abstinence/relapse than depressive symptoms
presenting during the initial phase of treatment. In addition, our data
suggest the presence of depressive symptomology post-alcohol treatment
is a high risk factor for relapse which needs to be identified and
addressed in aftercare planning. Further, our results indicate the need
for more focused research on depressive symptomatology both during and
following treatment for alcohol/drug use disorders.

**Impact:** Our research is important to the development of
interventions for the treatment of comorbid depression in patients
seeking substance use care.

**113. Efficacy and Safety of Medical Interventions for Male Erectile
Dysfunction: a Systematic Review**

## HA Fink, MD. Minneapolis VA Medical Center, Minneapolis, MN. R MacDonald, IR Rutks, and D Schow. TJ Wilt, MD, MPH. Minneapolis VA Medical Center, Minneapolis, MN.

**Objectives:** Erectile dysfunction (ED) is a common condition which
reduces quality of life. We conducted a technology assessment to
evaluate the efficacy and safety of medical treatments for ED in men
with acquired ED of primarily organic etiology, excluding that secondary
to gonadal dysfunction.

**Methods:** To update a 1996 American Urological Association report on
ED treatments, we performed a systematic review of the literature on
treatment for ED published from January 1995-August 1998. We looked at
oral sildenafil, yohimbine, phentolamine and trazodone; intraurethral
alprostadil; and the intracavernosal treatments of alprostadil,
phentolamine/papaverine and alprostadil/phentolamine/papaverine. Studies
were eligible if they were randomized and controlled. Only multiple dose
studies using clinically relevant outcomes (e.g. \"successful
intercourse\" as opposed to penile rigidity) were considered, except for
intracavernous treatments where no studies met these criteria. For
included studies, information on study characteristics and outcomes was
extracted in a standardized fashion. Data was pooled using a fixed
effects model unless there was evidence of heterogeneity. A modified
intention to treat analysis was utilized.

**Results:** Sildenafil produced \"erections sufficient for
intercourse\" in 48% of intercourse attempts (compared with placebo, RR
= 2.7; 95%CI = 2.1, 3.5; NNT = 3.4) and \"successful intercourse during
treatment\" in 84% of subjects (RR = 1.6; 95%CI = 1.4, 1.8; NNT = 3.4).
Adverse events included headaches (20%) and visual disturbances (5%).
Through August 1998, 69 confirmed deaths have been associated with
sildenafil. Yohimbine provided \"response to treatment\" in 48% of
subjects compared to 25% with placebo (RR = 1.9; 95%CI = 1.3, 2.8; NNT =
3.9). Adverse events, including hypertension and anxiety, occurred in
17%. Neither trazodone nor oral phentolamine were superior to placebo,
though clinically important effects could not be ruled out. In studies
limited to responders (66% of subjects screened), intraurethral
alprostadil produced \"erections sufficient for intercourse\" in 51% of
intercourse attempts (compared with placebo, RR = 5.0; 95%CI = 4.6, 5.5;
NNT = 2.5) and \"successful intercourse during treatment\" in 61% of
subjects (RR = 3.6; 95%CI = 3.0, 4.3; NNT = 2.3). Intracavernous
alprostadil produced \"erections adequate for intercourse,\" in 22-56%
of in-clinic administrations. Mean percent successful self-injections
was 61% in unblinded at-home use. Comparative studies suggested that
intracavernous combination therapies may be as effective as alprostadil
with fewer adverse events.

**Conclusions:** Effective medical treatments for male ED include oral
sildenafil and yohimbine; intraurethral alprostadil; and intracavernous
alprostadil/phentolamine/papaverine, phentolamine/papaverine or
alprostadil alone. Randomized trials directly comparing treatments have
not been performed, making evaluation of relative treatment efficacy and
safety difficult. Treatment options have marked differences in costs,
contraindications, side effects, and patient acceptability profiles.

**Impact:** ED is common and the number of men seeking evaluation and
treatment is likely to increase with enhanced awareness and increased
treatment options, especially with the availability of oral medications
like sildenafil. If one fifth of current VA users received sildenafil
drug costs would approach \$100,000,000 per year. Cost estimates for
treatment with intraurethral or intracavernosal therapy are higher, but
these treatments are unlikely to be as widely utilized.

**HSR&D Funded:** MTA 98-016

# 114. The Effect of Electrical Stimulation on Chronic Wound Healing: A Meta-Analysis

[S Gardner, PhD(C), MA, RN.]{.underline} Iowa City VA Medical Center,
Iowa City, IA. [RA Frantz and FL Schmidt]{.underline}

**Objectives:** Electrical Stimulation (ES) is a largely unknown and
poorly understood treatment modality for chronic wounds. The problem is
that the collective body of evidence has not been considered in
examining the merits of ES. The purpose of this meta-analytic review was
to determine if there is sufficient evidence to support ES as an
adjunctive therapy for chronic wound healing. Specific objectives were
to:1) Estimate the rate of healing of chronic wounds treated with ES and
compare this rate to controls using findings of multiple human studies.
2) Estimate the rate of healing of chronic wounds treated with ES
according to type of ES device and type of chronic wound.

**Methods:** Studies of ES and chronic wound healing were identified
from computerized and printed indices. 28 studies were identified with
15 meeting the inclusion criteria. These 15 studies contained 24
independent ES samples and 15 independent control samples. Mean rate of
healing was calculated for both the ES and control samples using percent
healing per week as the measure of healing. The net effectiveness of ES
was determined by subtracting the control rate of healing from the ES
rate. 95% confidence intervals were also calculated and compared for
width and overlap. The studies were then subgrouped and analyzed by type
of ES device (continuous direct, pulsed direct, and TENS) and type of
chronic wound (pressure ulcers, venous ulcers, mixed chronic wounds, and
chronic wounds mixed with acute wounds).

**Results:** There were 591 ulcers in the ES samples and 212 in the
control samples. The mean rate of healing was 22 percent per week for ES
and 9 percent per week for control samples. The net effect was 13
percent per week, an increase of 144% over the control rate. The 95%
confidence intervals of the ES samples (18 to 26 percent per week) and
control samples (3.8 to 14 percent per week) did not overlap. The net
increase in rate of healing was 11 percent per week for TENS, 13 percent
per week for continuous direct, and 16 percent per week for pulsed
direct. However the confidence substantially overlapped. ES was most
effective on pressure ulcers with a net effect of 13 percent healing per
week and no overlap of confidence intervals.

**Conclusions:** ES is an effective adjunctive therapy for chronic
wounds, especially pressure ulcers. However, further research is needed
in order to delineate the most effective ES device and optimal
dose-responses.

**Impact:** Evidence of effectiveness is an appropriate standard from
which to base reimbursement policies. Both the effect and cost of ES
compare favorably with other adjunctive therapies used to manage chronic
wounds. In the absence of the findings of this meta-analysis, the Health
Care Financing Administration has taken action to deny reimbursement of
ES for wound treatment. Without reimbursement, patients will be unable
to access an efficacious treatment and studies needed to ascertain the
most effective utilization of ES will be abandoned.

**115. Predictors of Quality of Life in AIDS Patients**

## JK Kemppainen, PhD, RN. VA Palo Alto Health Care System, Palo Alto, CA.

**Objectives:** While many studies examine quality of life in persons
with HIV/AIDS, these studies tend to focus on assessment and
measurement. Little research attention has been directed toward
identifying factors which influence quality of life. This present study
examined whether variables relating to demographic characteristics,
severity of illness, psychological status, or level of engagement in
nursing care could predict quality of life scores in patients with
advanced or late stage HIV/AIDS.

**Methods:** Questionnaires were administered to a representative sample
of hospitalized patients with AIDS. The total of 162 patients, including
65% males (N=102) and 35% females (n=60), completed the following
assessment measures: 1) HIV symptom checklist, 2) Beck Depression
Inventory (BDI), 3) the HIV/QAM (a measure of physical status), and 4)
two measures of engagement in nursing care, the Patient Participation
Scale and the Patient Anger Scale. The Living with HIV Scale was used as
the measure of quality of life.

**Results:** Stepwise multiple regression analyses were conducted
employing 6 factors: depression, patient demographics, symptoms,
severity of illness, psychological status, and two measures of patient
engagement with nurses. Depression proved to be the strongest predictor
of quality of life, accounting for 23% of the variance of scores in the
quality of life measure. Symptoms accounted for 9.7% and female gender
accounted for 8% of the variance in the quality of life scores. Two
measures of engagement with nursing care providers contributed a total
of 13.44% of the variance in quality of life scores. Demographic
variables did not significantly predict quality of life.

**Conclusions:** Multiple regression analyses revealed that depression,
the presence of symptoms, and female gender predicted quality of life
scores. Study findings also suggest that quality of life for an acutely
ill hospitalized patient with HIV/AIDS is enhanced through more active
involvement in the process of nursing care. The association in this
study between patient level of engagement with nurses and quality of
life adds increased emphasis to the importance of the nurse-patient
relationship in acute care settings. The findings in this study also
emphasize the importance of recognizing and treating depression in
patients with HIV/AIDS. It is noteworthy that at least half of the
patients scored moderate to severe depression on the Beck Depression
Inventory. Findings in this study are consistent with previous work
which suggests that the reporting of symptoms and the frequency have a
profound effect on quality of life.

**Impact:** As care givers learn more about the issues affecting quality
of life for patients with HIV/AIDS, more focused interventions can be
undertaken to improve this important outcome of patient care.

**116. Variations and Conflicts in Clinical Practice Guideline
Recommendations: Sources and Implications**

##### E Licht, MD, B Vickrey, B Simon, MA, and BS Mittman, PhD. VA Greater Los Angeles Healthcare System, Sepulveda, CA.

**Objectives:** Development and dissemination of clinical practice
guidelines represents an important strategy for medical societies,
government agencies and other public and private bodies seeking to
improve the quality of healthcare and to enhance uniformity of clinical
practice. In recent years, the number of published guidelines has
expanded considerably, resulting in the availability of multiple,
overlapping guidelines in many clinical areas. Although redundancy and
duplication are not necessarily harmful, guideline users and others
often note inconsistencies and conflicts in guideline recommendations,
suggesting problems in their development methods, evidence base, or
other features. Such conflicts may lead to inconsistencies and gaps in
healthcare delivery, particularly for patient populations care for by
multiple specialties. We sought to assess and explain conflicting
recommendations and other variations in guidelines for a single chronic
illness in patients often treated by physicians in multiple
specialties\--women with epilepsy of child bearing age\--for whom
consistency of recommendations and coordination of care can be critical.

**Methods:** We identified ten relevant guidelines through Medline
searches and by contacting medical specialty organizations and public
and private agencies involved with issues of reproductive health.
Guidelines were rated and classified on several dimensions related to
(1) guideline content and format (e.g., breadth of clinical issues,
patient populations addressed, specific recommendations included), (2)
guideline development agency characteristics (e.g., public/private,
medical specialty) and (3) guideline development process (e.g., nature
and mode of evidence use, development committee composition, external
review). We used qualitative methods (due to sample size limitations) to
assess guideline conflicts and inconsistencies and to test hypotheses
regarding causal relationships linking guideline development and agency
characteristics with guideline content and format.

**Results:** Marked differences in general areas of coverage and
specific recommendations were common, and areas of direct conflict were
identified. A major area of inconsistency related to dosages of folate
to reduce risk of neural tube defects: suggestions ranged from 0.4- 5
mg/day of folic acid, and one agency failed to recommend any specific
dose. Guidelines from neurology-oriented organizations addressed issues
often excluded from guidelines developed by primary care and obstetric
groups (e.g., risk of neonatal hemorrhage from anticonvulsants);
guidelines created by public agencies (governmental and not-for-profit,
public service agencies) also differed significantly from those
developed by private specialty societies and other organizations.

**Conclusions:** Inconsistencies in clinical practice guidelines may
undermine physician confidence and acceptance. Interactions between
physicians with different knowledge bases and different areas of
clinical emphasis are more likely to produce fragmented care when each
group relies on separate and conflicting practice guidelines. Greater
cooperation between organizations developing guidelines is needed,
particularly when large, shared patient populations are involved, to
produce recommendations more likely to be accepted by physicians and
more likely to unify rather than fragment clinical practices across
disciplines.

**Impact:** Results of this study should facilitate more effective
guideline development, by focusing attention on potential conflicts and
other problems in guideline content and format.

**117. A Population-Based Survey of Tuberculosis Symptoms: Insight into
the Utility of Symptom-Based Screening for Active Disease**

##### LG Miller, EI Yu, and SM Asch

**Objectives:** There have been few population-based case series
published on tuberculosis (TB) symptoms and none from the United States.
Population-based surveys are advantageous because they capture
non-hospitalized cases that would have been omitted in previous case
series. The Centers for Disease Control and Prevention recommends that
screening programs that evaluate persons at risk for TB (such as health
care workers and persons entering long-term communal living facilities)
should include questions about symptoms. However the effectiveness of
such screening has never been evaluated. Finally, we wished to identify
persons who present with less classic symptoms of TB, potentially
delaying their diagnosis.

**Methods:** We prospectively identified 526 consecutive cases of TB
reported between April and September 1993 to Los Angeles County
Tuberculosis Control and administered questionnaires to 313. Persons had
significant symptoms if they had at least 1 of the following: cough \>2
weeks, fever \>2 weeks, hemoptysis, or weight loss. We pre-selected 20
items from the County Registry and our questionnaire which we felt might
be associated with significant symptoms. We also surveyed physicians\'
perceptions of TB symptoms.

**Results:** Our population was predominantly male (64%) and nonwhite
(90%). 73% (48% \> for 2 weeks) had cough and 52% had fever (29% \> for
2 weeks). 60% had fatigue, 45% had weight loss, and 21% had hemoptysis.
71% of patients had significant symptoms. In bivariate analysis using
Chi-squared analysis and t-testing, significant symptoms were associated
with (p\<0.05)= positive smears, negative tuberculin skin tests (TST),=
alcoholism, drug use, HIV co-infection, homelessness, lack of insurance,
not being diagnosed during a screening program, American-born, and
younger age. Additionally, race was significantly associated with
significant symptoms. In a= multiple logistic regression model negative
TST= (OR=3D12.5,p=3D0.02), not being diagnosed in a screening program
(OR=3D6.2,p\<0.0001) and lack of health insurance (OR=3D3.5,p=3D0.002)=
was found to be associated with significant symptoms. Additionally,
Asian race (OR=3D0.16,p\<0.0001) was associated with lacking significant
symptoms of TB. Physicians estimates of the percentage of patients with
\> 2 weeks of cough and fever significantly exceeded measured rates. A
commonly used screening program would have identified 75% of cases, and
99% of cases when used in conjunction with a positive TST. However
missed cases included those with contagious pulmonary disease.

**Conclusions:** Fever and cough were less common symptoms of TB than
expected by physicians and lower than previously reported. Currently
employed symptom screening significantly augments the sensitivity of TST
during screening of high-risk populations. However, our data suggests
that more effective questionnaires can be developed. In a multiple
regression model, persons with TB who lacked insurance or had a negative
TST were more likely to have significant symptoms from TB. Additionally,
persons of Asian descent with TB were less likely to report significant
symptoms.

**Impact:** Rates of prolonged cough and fever may not be as frequent in
TB as commonly believed. Questionnaires used in TB screening appear to
complement skin testing but should be revised to enhance sensitivity.
Clinicians should have a higher degree of suspicion for TB in Asians
when presented with an undiagnosed syndrome compatible with TB.

**118. Consistency of Self-Administered ASI Composites with the
Interview ASI**

[CS Rosen, PhD.]{.underline} VA Palo Alto Health Care System, Menlo
Park, CA. [B Henson, and J Finney, RH Moos, PhD.]{.underline} VA Palo
Alto Health Care System, Menlo Park, CA.

**Objectives:** To determine the viability of using a patient
self-report instrument as an alternative to the clinician-administered
Addiction Severity Index (ASI, McLellan et al., 1980; 1985; 1992) in
monitoring outcomes of addiction treatment programs.

**Methods:** Eighty-five substance abuse patients at the VA Palo Alto
Health Care System completed both the standard semi-structured ASI
interview, a measure previously validated with VA patients, and a
self-report questionnaire including items used to calculate ASI
composite scores. Composite scores (ranging from 0 to 1.0) were
calculated for seven domains of functioning: alcohol use, drug use,
psychological distress, family/social conflict, medical problems,
employment, and legal problems. The consistency of responses between the
self-report and interview formats was assessed with Pearson correlations
and paired t-tests for continuous variables, and kappa coefficients for
dichotomous variables.

**Results:** For six of the seven ASI composites, scores obtained from
the self-report

instrument correlated .60 to .89 with the interview ASI. The most
consistent composite scores were alcohol use (r = .89), employment (r =
.78), legal problems (r = .77), and drug use (r = .73). Family/social
conflict (r = .62) and psychological distress (r = .60) were also highly
correlated across both formats. The least consistent composite score
across the two formats was medical problems (r = .49). Patients endorsed
higher absolute levels of drug use, psychological distress, legal
problems, and family/social conflict by self-report than in the
face-to-face ASI interview. It is unclear whether patients tended to
minimize problems in the face-to-face interview or overstate problems on
the self-report questionnaire. Exclusion of two subjective questions
(perceived distress and desire for treatment) from calculation of the
self-report composite scores did not significantly reduce the
consistency of the self-report alcohol, psychological, and family/social
composites with the corresponding composites in the interview ASI.
Exclusion of these subjective items did reduce the consistency of the
self-reported drug use composite with the interview ASI composite.

**Conclusions:** The self-report instrument provided information on
patient functioning that was generally consistent with information
obtained from the clinician-administered ASI interview. The present
study confirms similar findings by Cacciola, McLellan, Alterman, and
Mulvaney (1998) with substance abuse patients at the Philadelphia VA
Medical Center. Further research is need to determine whether a tendency
to endorse more pathology on a self-report questionnaire than in an
interview, found in the present study but not by Cacciola et al. (1998),
is a generalizeable finding.

**Impact:** Results of the present study and previous research by
Cacciola et al. (1998) support using a patient self-report version of
the ASI to assess substance abuse patients\' functioning. A self-report
administration of the ASI enhances its use for monitoring patient
outcomes and gauging the performance of substance abuse treatment
programs.

### 119. Rediscovering the Patient\'s Role in Receiving Health Promotion Services

[Laurence Branch PhD and D Rabiner,]{.underline} VA National Center for
Health Promotion and Disease Prevention, Durham, NC.

**Objectives:** This study examined differences in the odds of receiving
U.S. Preventive Services Task Force recommended health promotion/disease
prevention services among four subgroups of patients. We tested the
hypotheses that those most uninvolved in their own health (as
exemplified by the lack of knowledge of blood pressure and cholesterol
levels despite having been tested) would receive fewer services, and
those being treated for both high blood pressure and hyperlipidemia
would receive the most.

**Methods:** A mail survey was sent to a random sample of 68,422
veterans who obtained primary care from any of the 153 VA facilities in
1996. The adjusted response rate was 68%. Subgroup analyses were
performed on four subgroups who reported being tested for both
hypertension and hyperlipidemia: 1) those undergoing treatment for both
conditions (TREATED; n=4,944), 2) those with elevated blood levels for
both conditions but not undergoing treatment (HIGH RISK; n=534), those
with normal or low blood levels for both conditions (NORMAL; n=10,147),
and those who did not know their blood levels despite having been tested
for both hypertension and hyperlipidemia (UNINVOLVED; n=1,988). Three
sets of analyses were conducted. First, prevalence rates for each of the
four mutually-exclusive subgroups were reported for 11
USPSTF-recommended health promotion services. Second, multivariate
logistic regression models were conducted to examine the relationship
between blood pressure/cholesterol status and the odds of receiving 11
other USPSTF-recommended services after controlling for age and gender.
Third, patient characteristics and VA system characteristics were
examined for the uninvolved subgroup of veterans indicating that they
did not know their blood pressure and cholesterol levels.

**Results:** The two main hypotheses were supported. Uninvolved patients
were the least likely subgroup to obtain other recommended health
promotion services and the dually treated were most likely. The
uninvolved subgroup was significantly more likely to be female,
physically inactive, current smokers, heavy alcohol drinkers, to report
having a problem with alcohol, and significantly less likely to be 50
years of age or older, overweight, almost always wear seat belts, and
obtain at least 90% of their health care at the VA.

**Conclusions:** Clinicians need to encourage all patients to receive
health promotion services but in particular should be aware that those
who do not know their last hypertension and cholesterol levels despite
having been tested are particularly in need of attention. Fortunately,
busy clinicians can identify this undertreated subgroup very easily;
they just need to ask their patients if they remember whether their last
hypertension and cholesterol tests were high, normal, or low.

**Impact:** The new managed care paradigm requires that health care
providers become more proactive in the education and clinical management
of their patients to ensure that patients both become more motivated to
seek out and obtain all USPSTF-recommended services, and become better
able to understand what the results of these health promotion/disease
prevention services mean for their health status over time. Given the
results reported here, health care providers need to refocus their
health promotion efforts on this important, relatively undertreated
uninvolved subgroup.

# 120. The Accuracy of Physical Examination to Detect Abdominal Aortic Aneurysm

[Howard Fink MD, FA Lederle, CS Roth, CA Bowles, DB Nelson, and MA
Haas]{.underline}. VISN 13, Center for Chronic Disease Outcomes
Research, Minneapolis, MN.

**Objective:** Abdominal palpation to detect abdominal aortic aneurysm
(AAA) has been recommended by some authors for the periodic health
examination of older men, but its accuracy remains uncertain. Previous
studies in which the examiner was unaware of the diagnosis were limited
by low numbers of subjects with AAA. The purpose of the present study
was to better determine the operating characteristics of abdominal
palpation to detect AAA.

**Methods:** 200 subjects with and without AAA, as documented by recent
ultrasound, were invited to participate. 99 had AAA, of which 41 were
3.0-3.9 cm in diameter, 44 were 4.0-4.9 cm, and 14 were \> 5.0 cm. Each
subject was examined by two internists, who were blinded to each other's
findings and to the ultrasound findings. Examiners were to define AAA as
pulsatile mass \>= 3 cm in greatest transverse diameter and were given
brief instruction on AAA palpation prior to the study. For each of their
first 25 exams, after documenting their findings, the examiners were
informed of the ultrasound results as a means of feedback. Examiners
rated each examination as definite or suggestive for AAA (considered
together as 'positive'), or as no AAA. In addition, for each subject,
the first examiner characterized the abdomen as "obese" or " non-obese"
and measured the girth. The examination was used as the unit of analysis
with repeated measures logistic regression used to control for
dependence of exams within each subject.

**Results:** Subject mean age was 73 years (range 51-88). 97 subjects
were rated "obese" and 118 had abdominal girth \>= 100 cm (Kappa for
"obese" vs. girth \>= 100 cm -- 0.78). Agreement between examiners
regarding presence of AAA was 77% (kappa = 0.53). For all examinations,
sensitivity of abdominal palpation for AAA was 67% and specificity was
75% (LR + = 2.7, LR - = 0.43). Sensitivity for the first 10 exams by
each examiner was 76%, higher than overall sensitivity and suggesting
absence of an important training effect. When abdominal girth was \< 100
cm, sensitivity was 91% and specificity was 64% (LR + = 2.5, LR - =
0.14), whereas when girth was \>= 10 cm, sensitivity was 53% and
specificity was 83% (LR + = 3.2, LR - = 0.56). Results for "non-obese"
vs. "obese" were similar to those for girth. Sensitivity also increased
with AAA diameter, ranging from 61% for AAA 3.0-3.9 cm, to 69\^ for AAA
4.0-4.9 cm, and 82% for AAA \>= 5.0 cm. In 12 exams on subjects with
girth \<100 cm and AA \>=5.0 cm sensitivity was 100%.

**Conclusions:** In this study, abdominal palpation demonstrated
moderate sensitivity for detection of AAA and fair-to-good interobserver
agreement. For larger AAA, especially in non-obese subjects, sensitivity
was high. Sensitivity was higher and specificity lower in this study
that in previous studies, presumably reflecting the examiners' increased
vigilance due to the high prevalence of AAA in this series.

**Implications:** These results, considered along with previous
screening and cost-effectiveness studies, suggest that case-finding with
abdominal palpation in non-obese older men may be worthwhile.

**121. The Risk of Gastrointestinal Complications from Nonsteroidal
Antiinflammatory Drugs: a Meta-analysis**

# [Catherine MacLean, MD.]{.underline} Santa Monica, CA. [J Ofman, MD, MSHS.]{.underline} Director, Pharmacoeconomics and Technology Assessment, Beverly Hills, CA. [Sally Morton, PhD.]{.underline} RAND Statistics Group, Santa Monica, CA. [Walter Straus]{.underline} [Paul Shekelle, MD.]{.underline} West Los Angeles VA Medical Center, Los Angeles, CA.

**Objectives:** Nonsteroidal antiinflammatory drugs (NSAIDs) are mong
the most commonly prescribed drugs in the VA. Past reviews of the
gastrointestinal (GI) complications of NSAIDs are limited by their
reliance on only some of the relevant study designs, and/or have
focussed solely on the serious complication of perforations, ulcers, and
bleeds (PUB, and not dealt with the most common complication, dyspepsia.
Our goal with this meta-analysis was to review the evidence from all
relevant study designs published in any language on both PUBs and
dyspepsia.

**Methods:** We searched MEDLINE, EMBASE, HEALTHSTAR, and BIOSIS from
1966-1997 for studies of NSAIDs which reported original data on
gastrointestinal complications, regardless of study design or language.
Potentially relevant abtracts were selected, retrieved and reviewed
against preset criteria for rejection. Each accepted abstract had the
full article retrieved, which was screened for relevancy. Relevant
articles were reviewed for study quality according to criteria developed
by Jadad. All work was done in duplicate by physician reviewers, with
consensus to resolve disagreements. Nonenglish language articles were
reviewed by physicians fluent in the language, with assistance from
members of the study team. After data abstraction, studies were assessed
for clinical heterogeneity, and those deemed sufficiently clinically
homogenous were pooled using the DerSimonian and Laird random effects
model.

**Results:** 4849 titles were identified of which 2145 were potentially
relevant and had abstracts reviewed. This resulted in selecting 1768
articles (514 non-english), of which all but 70 (4%) were retrieved and
reviewed. We identified 54 RCT\'s of an NSAID vs a placebo, of which 35,
comprising 9396 patients, reported data on dyspepsia. We identified an
additional 84 RCT\'s of an NSAID vs.another NSAID (sample size \>49),
and 24 studies reporting GI complications in a population of sample size
\>1000 all taking NSAIDs (large exposure series). Data from these two
types of studies were used to better estimate the rate of dyspepsia in
the NSAID-treated group. We identified 27 case control studies and 8
cohort studies, of which 19 (encompassing 26,103 patients) and 5
(representing 126,902 person-years of NSAID exposure), respectively,
were judged sufficiently clinically similar to pool. The quality of
RCT\'s was generally good, with more than 60% of studies scoring \>3
according the the Jadad criteria. The rate of dyspepsia in persons
receiving NSAIDs increased from 5.5% to 7.5% to 10.9%, respectively, in
the NSAID vs. placebo, the NSAID vs. NSAID, and the large exposure
studies. The rate of dyspepsia in the placebo group was 2.2%. The pooled
odds ratio for PUBs in the case control studies was 2.9. The relative
risk for PUBs in the cohort studies was 2.2, with an absolute magnitude
of 1% in the NSAID group and 0.44% in the no NSAID group.

**Conclusions:** The use of NSAIDs increases the rate of dyspepsia from
2-3% to 6-10%, and increases the rate of GI perforations, ulcers, and
bleeds from 0.5% to 1%.

**Impact:** These data provide the best evidence-based estimates to date
of GI complications and should be helpful to clinicians and policy
makers when weighing the benefits and harms of NSAIDs.

# 122. Depression, Self-Care, and Glycemic Control in Patients with Diabetes Mellitus

## DM Nachtigall, BA and MA Whooley, for the Ambulatory Care Improvement Project. San Francisco VA Medical Center, San Francisco, CA.

**Objectives:** Previous studies have suggested that depression leads to
poor glycemic control in diabetic patients, but the reasons for this
association have not been determined. This study examined whether
depressed patients have reduced self-care, and whether lack of self-care
is responsible for poor glycemic control among patients who have
diabetes mellitus.

**Methods:** We evaluated 24,671 patients who were recruited from 6
Veterans Affairs Medical Centers for the Ambulatory Care Quality
Improvement Project. All participants completed the Mental Health
Inventory (MHI-5) and were considered depressed if they scored at least
17 on a 30-point scale. Those with self-reported diabetes mellitus were
asked to complete an additional questionnaire regarding frequency of
self-care (how often they checked their blood sugar, checked their feet,
and followed a meal plan) and frequency of elevated blood sugar (\>240
mg/dL) within the past 4 weeks. Results are reported as odds ratios (OR)
with 95% confidence intervals (CI) based on logistic regression models.

**Results:** Of the 3184 participants who completed the diabetes
questionnaire, 759 (24%) were depressed (MHI-5 \>= 17). Compared with
nondepressed patients, depressed patients were equally likely to check
their blood sugar (OR 1.0, 95% CI, 0.8 - 1.2; p=0.96), but less likely
to follow a meal plan (OR 0.7, 95% CI, 0.6 - 0.9; p\<0.001), and
somewhat less likely to check their feet on a daily basis (OR 0.9; 95%
CI 0.7-1.0; p=0.12). These results were not affected by adjusting for
age, sex, ethnicity, marital status, education, income, employment,
smoking, alcohol, or comorbid illnesses. Among participants who tested
their blood sugar at least once per week (n=2189), those who were
depressed were more likely to report having a blood sugar \> 240 mg/dL
within the past 4 weeks (OR 1.5, 95% CI, 1.2 - 1.9; p\<0.001) than
nondepressed patients. This association was unchanged by adjusting for
not following a meal plan.

**Conclusions:** Depression is associated with reduced self-care, and
with poorer self reported glycemic control. However, lack of self-care
does not appear to explain why depression leads to poor metabolic
control in patients with diabetes mellitus.

**Impact:** Better recognition and treatment of depression may improve
both self-care and glycemic control in diabetic patients.

**HSR&D Funded:** 96-002

123\. Colorectal Cancer: Risk Factors for Advanced Disease -- Comparison
of Stage at Diagnosis with SEER Cancer Statistics

[Dawn Provenzale, MD, SC Murray, TD Schmidt, CF Martin, CM Rose, and RS
Sandler.]{.underline} Durham VA Medical Center, Durham, NC.

**Objective:** Colorectal cancer is the second leading cause of cancer
death in the United States each year. It has been estimated that
approximately one million veterans aged 50 and older, will develop
colorectal cancer over the remainder of their lives and approximately
433,000 will die from it. The mortality rate of nearly 50% associated
with colorectal cancer is a consequence of most cancers being diagnosed
after local or regional spread. If modifiable risk factors for
presentation at advanced stages of cancer (e.g., physician and patient
delay in diagnosis, or poverty) could be identified, interventions that
should reduce mortality from colorectal cancer could be implemented. Our
study of \"Colorectal Cancer: Risk Factors for Advanced Disease\" among
veterans, (ERIC Study 97-023) will enroll 800 patients aged 40-79 in a
four year period, and will examine demographic and access to care
factors as risks for presentation with advanced disease.

The objectives of this report are:

1\) To summarize the demographic characteristics of the 110 patients for
whom we have complete data in the ERIC study.

2\) To compare the stage at diagnosis with the Surveillance and
Epidemiology End Results (SEER) cancer statistics.

**Methods:** We determined age at diagnosis, race and stage at
presentation. Because most of our patients were white males, we compared
their stage at diagnosis with the SEER data (stage at diagnosis) for
white males. We used original pathology reports (TNM Staging) to
classify our patients as having localized, or non-localized (regional or
distant) cancer, according to SEER notation. The Pearson\'s chi-square
test for independence was used to compare the proportion with localized
cancer in our data to that in the SEER population.

**Results:** The median age of the study population is 68 years (range
45-78 years old), and 96.4% are white. Eighty-five and one-half percent
of study patients are white, 10% are African American and 4.5% are
Hispanic. Thirty-three percent of white males presented with localized
disease (associated with a 92% five-year survival), while 67% presented
with regional or distant spread of disease (5-year survival 9%-66%).
Forty percent of patients reported in SEER cancer statistics have
localized disease and 60% have evidence of regional or distant spread at
the time of diagnosis, which was not significantly different from our
results.

**Conclusions:**

1\) Our preliminary results suggest that most veteran patients present
with evidence of regional or distant spread of their colorectal cancer.

2\) There was no significant difference in stage at presentation among
veterans and the population-based SEER patients.

3\) Fewer VA patients presented with localized disease (33% vs. 40%),
and although not statistically significant, could suggest a trend toward
presentation at a more advanced stage, which might become apparent as
more patients are enrolled.

Impact statement:

Colorectal cancer is curable if diagnosed early. Our results suggest
that most veterans present with evidence of regional or distant spread
of their cancer. If modifiable factors such as physician and patient
delay in diagnosis, or poverty, explain the increased mortality among
veterans, interventions that improve the process of care associated with
screening and diagnosis can be instituted.

**CSP Funded:** EPP 97-023 "Colorectal Cancer: Risk Factors for Advanced
Disease"

**124. Epidemiology Education Preferences of VA Administrators,
Clinicians and Researchers**

# [GE Reiber, PhD, MPH, TD Koepsell.]{.underline} VA Puget Sound Health Care System, Seattle, WA. [EJ Boyko.]{.underline}

**Objective:** To determine epidemiologic and research methods courses
of greatest continuing education interest to VA administrators,
clinicians and researchers.

**Methods:** In 1997 the VA funded three Epidemiology Research and
Information Centers (ERICs), one in Seattle, Durham and Boston. A
collective ERIC goal is to promote the use of epidemiology by
administrators and policy makers, clinicians, and researchers. To learn
the preferences of our target audience, a stratified random sample of
2,346 VA administrators, clinicians and researchers received a
questionnaire requesting information on their educational background,
length of time and primary role with the VA, preferred learning
strategies and interest in 28 potential epidemiology and research
methods courses. For each of the 28 course topics, participants rated
their interest on a scale ranging from no interest to high interest and
indicated whether they already knew the content. Participants completed
either a hardcopy or WWW version of the survey.

**Results:** The survey response rate is 58% with additional surveys
still being received. The primary role of respondents was 17%
administration, 67% clinical care and 16% research. These participants
had been in their present jobs a mean of 8 years and employed by the VA
a mean of 12 years. When asked to select all the educational formats
they found acceptable 41% identified

teleconference courses, 52% preferred travel to ERIC sites or DC, 26%
were interested in Internet courses with no travel involved, and 33%
wanted combined onsite and Internet courses involving travel. The three
content areas of greatest interest to administrators were: use of
epidemiologic data in VA quality improvement programs, epidemiologic
methods for planning and evaluating health services, and quantitative
assessment of guidelines and their implementation. Highest interest
areas for clinicians were: improving clinical decision-making, use and
interpretation of diagnostic and screening tests, and evidence-based
medicine/critical reading of medical literature. Researchers' highest
priorities were: clinical decision making, outcomes and effectiveness
research, and utilizing national VA data in research. Based on these
results the Seattle ERIC will host the first of the VA's Summer
Epidemiology Sessions in Seattle during June 1999.

**Conclusions:** Many administrators, clinicians and researchers have
identified an interest in additional epidemiologic and research methods
training. Onsite, teleconference and distance learning courses are being
designed to address these needs.

**Impact:** VA specific continuing education on epidemiology can provide
methodology that will assist administrators, clinicians and researchers
in their various VA roles.

**125. Impact of a Low-cost Intervention on the Cholesterol Awareness of
Older Veterans Enrolled in an Ambulatory Care Clinic**

# [M Murdoch, MD, MPH.]{.underline} Minneapolis VA Medical Center, Minneapolis, MN. [Sheridan and M Lavin.]{.underline} [TJ Wilt, MD, MPH and HB Rubins, MD, MPH.]{.underline} Minneapolis VA Medical Center, Minneapolis, MN.

**Background:** Improving the public\'s cholesterol awareness is a
cornerstone of the National Cholesterol Education Panel\'s (NCEP)
population-based approach to cholesterol risk-reduction. Both the NCEP
and American College of Physicians agree that measuring individuals\'
serum cholesterol levels may help ensure their subsequent compliance
with Step I diets. However, previous work at our institution showed that
only two-thirds of patients screened by physicians for high cholesterol
knew they had received such screening, only half said they had been told
their test results, and less than one-fifth knew their cholesterol
number.

Objective: 1) Develop a low-cost, sustainable intervention that would
improve veterans\' cholesterol awareness, and 2) Improve resident
physicians\' compliance with the NCEP population-based guidelines.

**Methods:** Quasi-experimental, pre- and post-intervention survey of
patients screened for high cholesterol. Survey results were correlated
to laboratory data.

Setting: A large, Mid-Western, primary care clinic located within a
university-affiliated VA medical center.

**Interventions:** Provision of an automated feedback letter to patients
screened for high cholesterol and an educational program directed at
internal medicine residents assigned to the primary care clinic.

**Results:** Response rates to the pre- and post-intervention surveys
were 89% and 80%, respectively. Respondents were 99% male, and their
mean age was 69 years (SD = 9.4). They reported, on average, 4.5 risk
factors for coronary heart disease (SD = 1.2). Compliance with some of
the NCEP population-based guidelines improved after the intervention.
The percentage of subjects who remembered having their cholesterol level
tested increased from 88% to 94% (p = .04); the percentage who
remembered being told their cholesterol test results increased from 67%
to 76% (p = .04); and the percentage who remembered receiving general
dietary information increased from 60% to 67% (p = .16). However,
subjects\' cholesterol awareness and ability to recall their serum
cholesterol numbers were low at baseline (50% and 23%, respectively) and
did not change significantly after the intervention (to 51% and 17%,
respectively; p = .17 and .86). On logistic regression, cholesterol
awareness was significantly and negatively associated with age \[OR =
.97, 95% CI = (.95, .99)\], and it was positively associated with a
college education \[OR = 2.09, 95% CI = (1.26, 3.45)\], with subjects\'
remembering being told their cholesterol test results \[OR= 3.16, 95% CI
= (1.89, 5.30)\], and with subjects\' remembering being provided general
dietary information \[OR = 1.93, 95% CI = (1.19, 3.14). These 4
parameters accounted for only 4% of the total variance in cholesterol
awareness.

**Conclusions:** The intervention successfully improved compliance with
some of the NCEP population-based guidelines but did not improve
veterans\' cholesterol awareness.

Impact: Other programs successful in improving subjects\' cholesterol
awareness have generally been conducted in younger and healthier
populations, and the subjects who became cholesterol-aware also took
steps to modify other risk factors for coronary heart disease. Older,
male veterans may have unique barriers to becoming cholesterol-aware
that are not yet understood. Before these individuals can enjoy the
potential benefits of cholesterol awareness, barriers to and other,
mutable characteristics associated with cholesterol awareness will need
to be identified.

126\. Measuring the Validity of Chart Abstraction: Should We Use It as a
Quality Improvement Tool?

# [J Luck, MBA, PhD.]{.underline} Assistant Professor, UCLA School of Public Health, Los Angeles, CA. [JW Peabody, MD.]{.underline} West Los Angeles, VA Medical Center, Los Angeles, CA. [T Dresselhaus, MD. PA Glassman, MD,.]{.underline} West Los Angeles, VA Medical Center, Los Angeles, CA. [ML Lee, PhD and MM Wang, MPH.]{.underline} Sepulveda Campus/Southern California System of Clinics, Sepulveda, CA.

**Objectives:** Improvements in clinical practice depend on a reliable
measure of quality. Chart abstraction is the usual method but many feel
that it is subject to biases, varies significantly within a single
provider and has a low generalizability across common conditions. The
objective of this study was to measure the criterion validity of medical
record abstraction in the outpatient setting.

**Methods:** In a prospective study, we compared physician performance
as measured by standardized patients (SPs) to medical records derived
during the same SP visits. We introduced the SPs unannounced into two VA
primary care outpatient clinics. Each randomly selected physician saw 8
SPs with four common conditions-two cases each of coronary artery
disease, diabetes, low back pain and chronic obstructive pulmonary
disease. A total of 160 SP encounters were carried out yielding 320
scores for comparison. The analytic model for comparison was a three way
crossed one way nested ANOVA. The main effect of the model compared the
two measurement methods for overall score and for clinical domain
(history, physical examination, diagnosis and treatment). We also
included site, level of training and clinical case as random effects in
our analysis.

**Results:** Chart abstraction consistently underreports the quality of
care across several dimensions as reported by SPs. Performance, as
defined by national guidelines and local exert panels, showed that
history taking scores were 26% lower and diagnostic accuracy was 17%
lower. Overall scores were 10% lower and this was consistent across
sites, clinical conditions and case complexity. When we measured reports
of unnecessary care, however, charts consistently over reported quality
by about 10%.

**Conclusions:** The criterion validity of charts as a measure of
quality in the outpatient setting may be limited. Underestimation is a
variable problem depending on whether the history, the physical,
diagnostic accuracy or appropriateness of treatment are being measured.
If charts are used to measure case mix in a population they might
seriously underestimate the prevalence, incidence or severity of
disease.

**Impact:** Quality measurement programs that rely on chart abstraction,
such as the External Peer Review Program used by the VA, may severely
underreport the quality of care actually provided to patients. A more
reliable quality measure that is less expensive than standardized
patients would provide a better basis for quality improvement
initiatives.

**HSR&D Funded:** IIR 95-014

**127. Validation of a Computerized Adaption of the Charlson Index Using
the SF-36 among VA Outpatients**

# [MB McDonell, MS, DM Martin, PhD, and SD Fihn, MD, MPH.]{.underline} VA Puget Sound Health Care System, Seattle, WA. [SK Mirza]{.underline}

**Objectives:** When comparing patient outcomes, it is essential that
results be adjusted for severity of illness, including comorbid
conditions. Charlson et al. described a method of classifying and
scoring comorbidities according to prognostic significance. Deyo and
colleagues adapted this index for use with an ICD-9-CM coded
administrative database. Using diagnostic codes extracted from a VA
hospital database, this study examines the effect of comorbid conditions
(as measured by the adapted Charlson Index) on functional status of
patients followed in the Seattle VA General Internal Medicine Clinic.

**Methods:** We conducted a cross-sectional analysis of 4,222 patients
who were mailed the SF-36 as part of the Ambulatory Care Quality
Improvement Project (ACQUIP). All inpatient and outpatient ICD-9-CM
diagnoses for the past two years were extracted from a centralized data
warehouse developed for the VA Northwest Region. These data were then
merged with SF-36 and demographic data collected as part of the ACQUIP
study. Patients were grouped according to their comorbidity scores; 0,
1-3, and \>3. SF-36 domains were correlated to the Charlson score, and
group differences were examined using ANOVA with adjustment for multiple
comparisons and age. To assess the accuracy of computer generated
comorbidity scores, 200 charts were reviewed by physicians and manually
scored.

**Results:** Sixty-three percent (2,460/4,222) of patients (63%)
responded to the SF36. The mean age was 65 years, and 96% were male. The
three comorbidity groups differed in age; those with higher Charlson
scores were older. The mean age was 62, 66, and 69 for patients scoring
0, 1-3 and \>3 respectively (p \< .001). Correlations between the
Charlson score and SF36 scores were significant for 7 of 8 domains;
physical function, general health, vitality, social function, role
physical, emotional, and bodily pain (p \< .001). The Mental Health
domain was not significantly correlated. Similarly, group means differed
for all domains except Mental Health with SF36 scores decreasing as the
comorbidity index increased (p \<.001). These differences persisted
after adjusting for multiple comparisons and age. The domain means for
the three groups (0, 1-3, \>3) were: Physical Function (57.7, 46.6,
36.1); Role Emotional (60.3, 57.7, 48.8); General Health (53.8, 45.6,
36.7); Vitality (46.2, 41.6, 33.3); Bodily Pain (53.6, 51.6, 45.8);
Social Function (64.8, 61.3,52.5); Role Physical (40.7,29.5, 18.2); and
Mental Health (66.2, 67.7, 64.5). The analysis of discrepancies between
computer and manually generated scores showed no overall bias and no
differential bias between high and low scores. A graphical analysis
failed to show any systematic change in variance over the range.

**Conclusions:** Comorbidity, as measured by the Charlson Index, was
significantly related to functional status, as measured by SF-36 scores,
independent of age. The results support the validity of the
computerized, adapted Charlson Index when applied to VA outpatients.

**Impact:** The adapted Charlson index may be a useful tool for severity
adjustment in outcomes research. The ability to compute this index from
an administrative database makes this approach appealing for health
services research and quality improvement efforts

**HSR&D Funded:** SDR 96-002

### 128. Appropriateness of Quinidine use at a Veterans Affairs Medical Center

##### A Niakan, MD. Memphis VA Medical Center, Memphis, TN. LM Humma

**Objectives:** The results of the Cardiac Arrhythmia Suppression Trials
in 1989 heightened our awareness of the potentially dangerous effects of
class I antiarrhythmics. Quinidine is one of the oldest prescribed
agents in this drug class. The manufacturer\'s package insert recommends
quinidine\'s use for several indications including preventing
recurrences of paroxysmal ventricular and supraventricular arrhythmias
and maintaining sinus rhythm after cardioversion of atrial fibrillation
and flutter. However, the results of several studies have raised concern
of increased mortality associated with quinidine\'s use, particularly in
patients with heart failure or a history of myocardial infarction. In
this study we evaluated the appropriateness of quinidine use, dosing,
and follow-up at our medical center and tried to identify patients who
may be at increased risk for mortality with quinidine.

**Methods:** A computer search identified all outpatients receiving
quinidine from the Memphis Veteran Affairs Medical Center (VAMC) as of
February 1998. We retrospectively reviewed the complete medical records
for these patients To determine the indication, dose, and duration of
quinidine therapy, contraindications to quinidine treatment, cardiac
disease history, concomitant drug therapy, ambulatory
electrocardiography results, and laboratory and electrocardiographic
data.

**Results:** Over 30 percent of patients were receiving quinidine
inappropriately or for unspecified reasons such as PVC\'s or
palpitations. In addition, forty percent of patients on quinidine had
left ventricular systolic dysfunction or a history of myocardial
infarction. Although serum chemistries were routinely performed in the
majority of patients, quinidine levels and electrocardiographs were
monitored much less frequently. The most recently checked qunidine
levels were below 2 mg/L in 54% of patients.

**Conclusions:** This study demonstrates that quinidine is frequently
prescribedfor patients inappropriately, often for unspecified or
questionable indications, and with inadequate follow-up. Quinidine is
frequently used in patients with cardiac disease which place them at an
increased risk for mortality.

**Impact:** We hypothesize that other practice sites have similar
patient care issues related to the inappropriate prescribing and patient
follow-up with quinidine therapy. The challenge for practitioners is to
confirm and document the presence of arrhythmias then treat with the
most appropriate therapy available with necessary follow-up and
monitoring.

### 129. Testing the Performance of VHA\'s 1997 Ambulatory Care Survey Instrument

# [AE Sales, PhD, RNC.]{.underline} VA Puget Sound Health Care System, Seattle, WA. [O Yu]{.underline}. [M McDonell, MS, and S Fihn, MD, MPH.]{.underline} VA Puget Sound Health Care System, Seattle, WA. [J Tuchschmidt]{.underline}

**Objectives:** The aim of this project was to determine if items could
be eliminated on the VHA\'s 1997 Ambulatory Care Survey. One of the
corporate aims of VHA is to achieve levels of customer satisfaction
comparable with those in the private sector. Customer satisfaction has
been measured annually by the National Customer Feedback Center (NCFC),
a unit of the Office of Performance and Quality (OPQ) using the
Ambulatory Care Survey. Some items are borrowed from private sector
satisfaction instruments, and have some items tailored to VHA, as well
as incorporating some health status questions. The result is a
relatively long instrument which may constitute a significant patient
burden. Response rates are typically around 50%.

**Methods:** Data from the 1997 Ambulatory Care Survey for VISN 20
(Northwest Network) were received from the NCFC. The number of
respondents, sampled from all eight VISN 20 facilities, was 1216
overall. We recoded variables that included logical skips as
legitimately missing values. We checked for inter-item reliability using
Cronbach\'s alpha on each of the seven domains. We used factor analysis
with varimax rotation to examine which items in each scale were
responsible for the preponderance of the information in each scale,
including only items with eigenvalues greater than 1.00 in the analysis
and restricting the factor analysis to one factor. We then performed
confirmatory regression analyses where possible to check to see if the
results from the factor analysis were confirmed.

**Results:** Cronbach\'s alphas ranged from below .15 (Emotional
Support) to .735 (Courtesy). If Cronbach\'s alpha was below .40, we did
not proceed with factor analysis. We did not conduct further analysis on
the Emotional, Preference and Overall Coordination scales. The Courtesy
scale consisted of only two items, obviating the need for further
analysis. Of the remaining three scales, consisting of 17 items, we were
able to identify two items per scale that explained most of the variance
in the scale, suggesting that these six items could replace the 17
items, shortening the instrument somewhat

**Conclusions:** The 1997 Ambulatory Care Survey demonstrates
questionable reliability on three of its seven scales, based on 1997
VISN 20 data. Of the three scales amenable to factor analysis, dominant
items emerge, allowing the instrument to be shortened. However, focusing
on improving the reliability of the other scales, and determining the
relative importance of including a large number of health status related
questions would have a greater impact in terms of shortening the
instrument in its current state.

**Impact:** The results of this study are likely to be of interest to
Network Directors, facility directors, and national leadership in the
Office of Performance and Quality. Some of the scales in the current
instrument perform very poorly, suggesting the need for further
evaluation. Others can be predicted with fewer items, thus reducing
patient burden and increasing the ability of facilities to add their own
items, relevant to local initiatives more under control of local
managers, which potentially could increase customer satisfaction more
than responses to items not under local

control.

### 130. Patient-Level and Facility-Level Factors Affecting Patient Satisfaction Ratings of VA Care

##### Gary Young, JD, PhD, M Meterko, and Kamal Desai, PhD. Boston VA Medical Center, Boston, MA. 

**Objectives:** To examine whether and to what degree a patient\'s
satisfaction ratings of VA care are related to his/her demographic
characteristics as well as selected characteristics of the facility
where care was received. To assess the relative contribution of
patient-level versus facility-level characteristics to explaining
variation in patient satisfaction ratings. To examine whether a
facility\'s involvement in total quality improvement activities (TQI)
affects patient satisfaction ratings.

**Methods:** We used several sources of data to construct patient-level
data sets for inpatient medicine, inpatient surgery, and outpatient
care. Our primary source of data consisted of the 1997 inpatient and
outpatient patient satisfaction surveys conducted by the VHA National
Customer Feedback Center. This data source provided satisfaction ratings
for inpatient care from approximately 20,000 patients and for outpatient
care from approximately 24,000 patients. This data source also included
the demographic characteristics and self-reported health status of the
patients who provided satisfaction ratings. We used internal VA files to
obtain data on facility-level structural characteristics (e.g. size).
Data on facility- level TQI involvement came from our own 1997 VHA-wide
survey of quality improvement practices. For the dependent variable we
created a composite measure of patient satisfaction that was the average
of a patient\'s satisfaction ratings (i.e., problem scores) across the
subscales comprising the survey questionnaire. Patient-level
characteristics consisted of age (continuous), self-reported health
status (five-point scale), sex, and race (white versus nonwhite).
Facility-level characteristics consisted of size (number of FTE),
whether or not a major teaching hospital (based on membership in the
Council of Teaching Hospitals), urban/rural status, geographic location
(east, west, central, and south), and TQI involvement (five-point
scale). Because of the multi-level nature of the data, we used
random-effects regression models. We conducted separate analyses for
each type of setting (e.g., inpatient medicine).

**Results:** Among patient-level characteristics, advancing age and
better health status were consistently associated with higher
satisfaction ratings. Nonwhite patients were consistently less satisfied
with their care than were white patients. Among the facility-level
characteristics, hospital size was consistently associated with lower
ratings. TQI involvement was associated with higher ratings for both
inpatient medicine and ambulatory surgery. Patient-level characteristics
explained only a small amount of sample Variation (between 8 and 14
percent). Facility level characteristics contributed little additional
explanatory power to the models.

**Conclusions:** Age, health status, and race appear to be important
proxies for patient expectations about service quality. Facility size is
a possibly important marker for processes that affect patient
experiences with satisfaction. Facility involvement in TQI appears to
have potential in improving processes that ultimately result in greater
patient satisfaction.

**Impact:** Comparisons of facilities based on patient satisfaction data
need to take into account differences in the patient population.
Accounting for differences in age, health status, and race is
particularly important. Larger facilities appear to be at a disadvantage
in terms of patient satisfaction. More research is needed to understand
the nature of the size effect. VHA should assess whether opportunities
exist to strengthen TQI training and education for VA managers and
clinicians.

**HSR&D Funded:** 94-085

**131. Comparing Faclities on Functional Status Decline: a Hierarchical
Bayes Linear Modeling Approach**

[BH Chang, ScD, J Wu, and AK Rosen, PhD.]{.underline} Edith Nourse
Rogers memorial Veterans Hospital, Bedford, MA.

**Objectives:** Decline in functional status is considered an important
outcome measure for making comparisons across facilities on quality of
care. Variation among facilities on decline rates can be attributed to
various factors: patient attributes, facility characteristics, and
random error. We compare facilities on decline rates which are case-mix
adjusted using patient attributes. A Hierarchical Bayes Linear Modeling
(HBLM) approach is used for the comparison. Results from HBLM are
compared with a non-Bayesian approach. We also investigate the effect of
a single facility level characteristic, geographic region, on decline
using HBLM.

**Methods:** Administrative inpatient and long-term care databases
(FY\'96) from the Department of Veterans Affairs (VA) were used for
analyses. To have reliable estimates of decline rates, we included only
those long-term care facilities which had at least 50 residents (n=95).
Decline in functional status was measured by a worsening of 2 points in
the activities of daily living (ADLs) summed score between residents\'
baseline and semi-annual assessments. Facility case-mix adjusted decline
rates were estimated by a logistic regression model which included
residents\' medical conditions, diagnoses, and demographic
characteristics. The difference between observed (O) and expected (E) or
case-mix adjusted decline rates was used as the outcome measure. We
modeled this outcome and estimated its posterior distribution using
HBLM. This method compares facilities on the \"true\" outcome which does
not include random error, while a typical non-Bayesian method uses the
observed outcome which generally includes random error. HBLM takes into
account the variance of the random error when estimating the posterior
mean of the true (O-E) rates. The uncertainty about the variance of the
true (O-E) is also incorporated into the estimation of both the mean and
variance of the true (O-E). Another feature of HBLM is that it can
estimate the effects of the facility level characteristics.

**Results:** HBLM estimated the standard deviation (S.D.) of the true
outcome to be .028 which was around half of the S.D. of the observed
outcome (.054) . Two facilities were identified as outliers by HBLM
since they had significant non-zero posterior means of the true \"O-E\"
rates. The non-Bayesian method identified 4 more outliers in addition to
the two identified by HBLM. Geographic region was not significantly
associated with decline.

**Conclusions:** Facility comparison using HBLM, which is based on the
posterior mean and variance of the true (O-E), is more appropriate than
comparison based on the observed (O-E) and its variance. As a result
fewer outliers were identified when HBLM was used compare to the
non-Bayesian approach. Although the facility level characteristic,
geographic region, was not related to decline, future studies should
include additional facility characteristics, such as clinician to
patient ratio, in the model.

**Impact:** With increasing interest in facility comparison in the VA,
it is important to have a sound statistical method for making such
comparisons. HBLM is a promising method because it models random error
appropriately and thus avoids identifying spurious outliers.

**HSR&D Funded:** IIR 96-065

# 132. Cost Effectiveness of Team Managed Home Based Primary Care

[Susan Hughes, DSW and FM Weaver, PhD.]{.underline} Hines VA Hospital,
Hines, IL. [A Giobbie-Hurder. JD Kubal, MA.]{.underline} Hines VA
Hospital, Hines, IL [A Ulasevich and TO Sindowski]{.underline}

**Objectives:** This study examined the cost-effectiveness of a new
ôteam managedö model of Hospital Based Primary Care (TM/HBPC). A
previous test of TM/HBPC at Hines VA Hospital demonstrated a net cost
savings of 10% that was attributable to a 29% reduction in hospital
readmission costs. The TM/HBPC model emphasized targeting patients at
high risk of repeat hospital admission and active participation of the
home care physician in ongoing patient primary care management. The
current study sought to determine whether the model was generalizable
and the cost savings replicable throughout the VA health care system.

**Methods:** We used an RCT with pretest and multiple posttests to
examine cost-effectiveness. Pairs of patients and informal caregivers
were recruited at 16 VA hospitals, stratified by age, disease (2 or more
ADL impairments, terminal illness, CHF, or COPD) and by site and
randomly assigned to TM/HBPC or to customary care. Primary outcomes
tracked over 12 months were total health care costs, including inpatient
and outpatient VA and private sector costs. Secondary outcomes obtained
at baseline, one, six and 12 months included patient functional status,
patient and informal caregiver health-related quality of life,
satisfaction with care and caregiver burden. Results were analyzed using
intent to treat analyses.

**Results:** Study investigators were only recently unblinded to
outcomes. Analyses are still on going but will be finalized by January
in time for a scheduled February 11-12, 1999 close-out meeting. 1,967
patients were randomized to the study over four years. The primary
reason for exclusion among patients screened was residence outside the
area served by HBPC(38%). Of persons who met the inclusion criteria, 40%
refused to participate in the study. Inclusion criteria suceeded in
identifying a high risk patient group. At baseline 75% of study
enrollees had severe disabilities, 20% were terminally ill, and 5% had
CHF or COPD. At baseline, patients had a mean age of 71, 3.2 ADL
impairments on average and a mean SF-36 physical function score of 20.
Close to 90% of patients were recruited to the study during an index
hospital admission and 88% had been hospitalized at least once during
the six months prior to enrollment. No significant differences were
observed between groups on demographics or baseline measures of study
outcomes. Attrition from secondary outcome measurement was low at 6% for
treatment subjects vs. 8 % for controls. Twelve-month mortality rates
were similar at 37% and 36%, respectively. Primary outcome data based on
VA administrative databases, HCFA Medicare charge data, and self reports
confirmed with providers were obtained on close to 100% of study
participants.

**Conclusions:** Preliminary findings based on repeated measures ANOVA
indicate significant treatment group benefits in patient and caregiver
satisfaction with care at one, six, and 12 months and in objective
caregiver burden at 6 months. Cost analyses are still ongoing but
findings will

be available by February and will be presented.

**Impact:** The advisability of adopting this new home care management
model throughout the VA health care **system will be discussed.**

**HSR&D Funded:** CSP-003

## **133. Cost Effectiveness of a Primary Care Intervention: Results from a VA Cooperative Study**

### [DM Hynes, RN, PhD.]{.underline} Hines VA Hospital, Hines, IL. [E Oddone, MS, MHS.]{.underline} Durham VA Medial Center, Durham, NC. [M Weinberger, PhD.]{.underline} Indianapolis VA Medical Center, Indianapolis, IN. [A Giobbe-Hurder and W Henderson.]{.underline}

**Objectives:** We examined the cost effectiveness of a primary care
intervention in VA hospitals in a multi-site randomized clinical trial.
We focused specifically on marginal costs relative to a key patient
centered outcome: improvement in patient satisfaction.

**Methods:** This multi-site RCT was conducted at nine geographically
and academically diverse VA Medical Centers to ascertain whether
enhanced access to a primary care intervention reduced hospital use of
chronically ill veterans over a six month period. Eligible patients with
a diagnosis of diabetes mellitus, chronic obstructive pulmonary disease,
or congestive heart failure at or before the time of their index
admission were enrolled during an admission to the General Medicine
Service. Following enrollment, 1,396 eligible patients were randomized
to receive their usual care or the intervention. The intervention,
delivered by a registered nurse and primary care physicians, contained
an inpatient and outpatient component. The inpatient component included
discharge planning with the nurse and physician, disease education, and
scheduling of a follow-up visit within 7 days to that primary care
physician and nurse. The outpatient component comprised follow-up
telephone contact by the nurse, post-discharge outpatient appointment
within a week after discharge and a monitoring of the treatment plan by
the nurse and physician. Patients were followed for six months and
utilization data were tracked for one year after randomization. Costs
were measured using information from VA (Patient Treatment File,
Outpatient File and Cost Distribution Report) and non-VA sources
(Medicare claims data and validated patient self-report) about the use
and costs of inpatient and outpatient care for the intervention and
usual care group. Patient satisfaction was measured using the Patient
Satisfaction Questionnaire (PSQ) at baseline and at the completion of
the intervention for the intervention and the usual care group.

**Results:** VA hospital and outpatient visit costs were significantly
greater in the intervention group (Mean hospital: \$5,438 \_ 12,356
versus \$4,079 \_ 9,108; p=0.02; Mean outpatient: \$1,036 \_ 832 versus
\$927 \_ 1,269). While use of non-VA inpatient and outpatient care
accounted for less than 10% of health care use, non-VA outpatient costs
for the usual care group were significantly greater than for the
intervention group. Mean level of patient satisfaction for the
intervention group increased by 6% from baseline compared to no change
in the usual care group (p=0.0001). Marginal cost effectiveness ratios
will be forthcoming.

**Conclusions:** With increasing emphasis on managed care principles in
VHA, the impact of patient care interventions must be examined relative
to patient centered outcomes.

**Impact:** As the VHA strives to compete for patient enrollment in an
increasingly competitive health care market, it must consider approaches
for reducing costs while maintaining quality of care. Strategies that
demonstrate cost effectiveness in terms of patient centered outcomes
such as satisfaction with care, will have the most likelihood of proving
successful. This study provides a method that can be used to examine the
cost effectiveness of a wide range of health care interventions in VHA.

**HSR&D Funded**: CSHS #8

**134. Cost-Savings Associated with Limited Academic Detailing to
Promote Hypertension (HTN) Clinical Practice Guidelines**

# [Joy Meier, PharmD.]{.underline} VANCHCS, Martinez, CA. [JR Lopez and D Siegel.]{.underline}

**Objectives:** VA clinical practice guidelines for HTN recommend the
use of beta-blockers and thiazide diuretics as first-line therapy for
hypertension, depending on co-morbidities, but do not recommend calcium
antagonists as first-line therapy with any co-morbidity. Prior analysis
revealed an overuse of calcium antagonists in our system.

To determine: 1) baseline antihypertensive prescribing patterns for
hypertensives with or without co-morbid conditions and 2) changes in
antihypertensive prescribing patterns following initiation of limited
academic detailing.

**Methods:** Researchers used ICD-9 codes from encounter forms to
identify patients with HTN, DM, CHF, coronary artery disease (CAD),
chronic obstructive pulmonary disease (COPD) and asthma between 10/1/96
and 8/1/97, and between 4/1/97 and 3/31/98. Researchers determined
prescribing patterns for HTN with and without co-morbid conditions by
relating the ICD-9 code database to prescriptions for beta-blockers,
alpha-1 blockers, calcium antagonists, thiazide diuretics (alone or in
combination with a potassium sparing diuretic), loop diuretics,
angiotensin converting enzyme (ACE) inhibitors, and angiotensin II
antagonists over a six month period (1/1/97 to 6/30/97 for baseline and
12/1/97 to 5/31/98 for follow-up) using Access (TM) and Excel(TM).
Interventions included lectures, distribution of educational materials,
profiling of provider prescribing patterns, and individualized meetings
with providers to promote the guideline. Researchers calculated cost
savings as the differences in expenditures for The two study periods. In
order to avoid changes in expenditures attributable to increases or
decreases in drug acquisition cost, researchers calculated the average
cost per patient in the follow-up period using the average cost per
patient for each drug class at baseline times the number of patients
receiving drugs in that class.

**Results:** Of 7526 hypertensives at baseline, the percentage receiving
a drug class included: calcium antagonist (55%), ACE inhibitor (50%),
beta-blockers (20%), thiazide +/- potassium sparing diuretic (21%),
alpha-1 blocker (22%), loop diuretic (16%), angiotensin II antagonist
(3%). Of 2426 hypertensives with DM, and of 970 hypertensives with CHF,
65% of both groups received an ACE inhibitor. Of hypertensives with CAD
who did not also have COPD, asthma, DM, or CHF, 38% received a
beta-blocker. At follow-up, of 8901 hypertensives, the percentage
receiving a drug class included: calcium antagonists (49%), ACE
inhibitor (49%), thiazide +/- potassium sparing diuretic (25%), alpha-1
blocker (23%), loop diuretic (16%), angiotensin II antagonist (4%).
There was no change in the proportion of hypertensives with either DM or
CHF who received an ACE inhibitor. Of hypertensives with CAD who did not
also have COPD, asthma, DM, or CHF, 42% received a beta-blocker. Over
the six month follow-up period, \$36,596 was saved.

**Conclusions:** Prescribing patterns following limited academic
detailing more closely followed VA and JNC VI recommendations and
resulted in significant cost savings.

**Impact:** Following VA and JNC VI guidelines for the treatment of HTN
will result in considerable cost savings nationwide.

**135. The Impact of Per-Episode Payment for Medicare Home Health Care
on the Use of Non-Medicare Services: A Randomized Control Trial**

#### [BR Phillips, PhD.]{.underline} VA San Diego Healthcare System, San Diego, CA.

**Objectives:** The use of Medicare home health services has increased
dramatically over the last decade, much of increase involves care to
long-term patients, who might have otherwise been served by Medicaid,
VA, and other public programs. Partly in response to these changes,
Congress has mandated a prospective payment system for Medicare home
health by the turn of the century. The Health Care Financing
Administration (HCFA) has been implementing demonstrations of
prospective payment for Medicare home health care, including a
demonstration of a lump-sum payment for an episode of care. This payment
system creates incentives for providers to reduce their own costs,
perhaps by shifting costs to other payers, such as VA, Medicaid, and
Administration on Aging programs, or shifting burden to relatives and
friends of patients. The objective of this study was to evaluate the
impact of lump-sum payment on the use of non-Medicare services, such as
VA services.

**Methods:** Ninety-one home health agencies in five states enrolled in
the demonstration and were randomly assigned to receive per-episode
payments or to continue under cost-reimbursement. During their second
year of demonstration operations, a random sample of patients was
selected at home health admission. These patients were interviewed by
telephone at the end of the 120-day period covered by the lump-sum
payment about their use of non-Medicare services. Logistic regression
and Tobit models were estimated, adjusting for the design effect of the
clustering of the sampled patients in agencies.

**Results:** Lump-sum payment for Medicare home health care reduced the
likelihood of admission to assisted living facilities by about 25
percent (p = .02) and may have reduced the likelihood of admission to
nursing homes (p - .07). It did not affect the likelihood of receipt of
non-residential services, such as personal care aide and adult day care.
Nor did it affect the likelihood of receipt of care from relatives or
friends.

**Conclusions:** Lump-sum payment for home health care does not increase
the costs borne by payers other than Medicare. Rather, such payment
reduces the use of residential non-Medicare services, perhaps as a
by-product of home health agencies stressing patient self-care and
independence.

**Impact:** This study impacts the VA in two major ways. First, it
indicates that use of VA personal assistance and long term care programs
should not increase as Medicare moves to prospective payment for home
health care. Second, it buttresses other evidence that per-episode
payment is a cost-effective approach to provider payment for home health
care\--one that the VA should consider for its home health programs.

**136. Cost-Effectiveness of Antiseptic-Impregnated Central Venous
Catheters in the Critically Ill**

# [S Saint, MD, MPH.]{.underline} Ann Arbor VA Medical Center, Ann Arbor, MI. [DL Veenstra.]{.underline} [SD Sullivan.]{.underline}

**Objectives:** Central venous vascular catheters, commonly used in
caring for critically ill patients, are associated with significant
infectious complications. Catheter-related bloodstream infection occurs
in over 250,000 patients per year in the United States and is associated
with increased morbidity, mortality, and costs. Central venous catheters
impregnated with chlorhexidine/silver sulfadiazine have recently been
introduced for the prevention of catheter-related bloodstream infection.
A recently completed meta-analysis indicated these catheters are
efficacious in reducing the incidence of catheter-related bloodstream
infection; however, antiseptic-coated catheters cost about \$25 more
than standard catheters and have recently been associated with several
hypersensitivity reactions in Japan. We thus performed a formal economic
analysis to answer the question, \"Compared with standard
non-impregnated central venous catheters, are antiseptic-impregnated
central venous catheters cost-effective?\"

**Methods:** We utilized decision-analytic techniques to evaluate the
incremental medical and economic outcomes associated with short-term use
(approximately 1 week) of antiseptic-impregnated versus standard central
venous catheters in critically ill patients from the perspective of a
healthcare payer. The clinical outcomes evaluated were catheter-related
bloodstream infection and death. The probability of catheter-related
bloodstream infection was based on a meta-analysis of eleven randomized
controlled trials comparing standard central venous catheters to
chlorhexidine/silver sulfadiazine impregnated central venous catheters.
Medical costs were derived from literature review and the University of
Washington Medical Center. In addition to the base-case scenario, we
analyzed scenarios in which all of the model parameters were set to
favor either standard or antiseptic-impregnated catheters.

**Results:** In the base-case analysis, use of an antiseptic-impregnated
catheter compared to a standard catheter resulted in expected cost
savings of

\$233 per catheter used. The expected incidence of catheter-related
bloodstream infection decreased from 5.2% for standard catheters to 3.0%
for antiseptic-impregnated catheters. The expected incidence of death
due to catheter-related bloodstream infection or hypersensitivity
reaction decreased from 1.30% to 0.76%. The scenario with all parameters
set to favor use of the standard catheter still resulted in a slight
cost-savings per catheter used of \$4, a 0.6% absolute decrease in the
incidence of catheter-related bloodstream infection, and a 0.08%
absolute decrease in the incidence of death.

**Conclusions:** The results of our analysis indicate that the use of
antiseptic-impregnated catheters in the critically ill is likely to
result in cost savings, a reduction in the incidence of catheter-related
bloodstream infection, and an overall decrease in the incidence of death
compared to use of standard, non-impregnated catheters. These results
hold true over a wide range of assumptions and variation in outcome and
cost parameters.

**Impact:** The use of antiseptic-impregnated central venous catheters
in patients at high risk for catheter-related bloodstream infection
e.g., the critically ill) should be strongly considered as part of a
comprehensive nosocomial infection control program. Use of these
catheters in high-risk patients should lead to improved patient outcomes
and decreased healthcare costs. The base-case analysis suggests that for
approximately every 200 antiseptic-impregnated catheters used, an
average of \$47,000 will be saved overall and 4 cases of
catheter-related bloodstream infection and 1 death will be avoided.

### 137. Depressive Symptoms and Three-Year Mortality in Hospitalized Elders

##### KE Covinsky, MD, MPH. San Francisco VA Medical, San Francisco, CA. E Kahana, MH Chin, RM Palmer, and RH Fortinsky. CS Landefeld, MD. San Francisco VA Medical Center, San Francisco, CA.

**Objectives:** Depressive symptoms are common in hospitalized elders.
However, their relationship to long-term mortality is unclear because
few studies have rigorously considered potential confounders of the
relationship between depression and mortality such as comorbidity,
functional impairment, and cognitive impairment. Our objective was to
measure the association between depressive symptoms and long-term
mortality after controlling for these potential confounders.

**Methods:** This was a prospective cohort study of 573 hospitalized
elders (age \>= 70) admitted to the general medical service of a
teaching hospital. We measured depressive symptoms with the Geriatric
Depression Scale at the time of admission. We also measured acute
illness severity (APACHE II scores), comorbidity (Charlson scores),
physical function (nurse assessed dependence in 6 activities of daily
living), and cognitive function (modified mini-mental state examination)
on admission. Mortality over the three years following admission was
determined from the National Death Index. We compared mortality rates in
patients with 6 or more depressive symptoms to those with 5 or fewer
symptoms.

**Results:** The mean age of the patients was 80 and 68% were women.
Patients with 6 or more depressive symptoms had greater levels of
comorbid illness, functional impairment, and cognitive impairment at the
time of admission than patients with fewer depressive symptoms. Three
year mortality was higher in patients with six or more depressive
symptoms (56% vs 40%, p\<.001, hazard ratio= 1.56, 95% CI=1.22-2.00).
After adjustment for acute illness severity, comorbidity, functional
impairment, and cognitive impairment at the time of admission, patients
with six or more depressive symptoms continued to have a higher risk of
death during the three years after admission (hazard ratio=1.34,
1.03-1.73).

**Conclusions:** Depressive symptoms are associated with long-term
mortality in older patients hospitalized with medical illnesses. This
association is not fully explained by greater levels of comorbidity,
functional impairment, and cognitive impairment in patients with more
depressive symptoms.

**Impact:** Screening for depressive symptoms will identify a group of
hospitalized elders at high risk for mortality. This study has important
implications for hospitalized Veterans given previous research
demonstrating high rates of depressive illnesses in Veterans
hospitalized on medical services.

**138. Conflicts in Values for Health Outcomes in Schizophrenia**

# [LA Lenert, MD, MS.]{.underline} VA San Diego Healthcare System, San Diego, CA. [J Ziegler, T Le, and R Mahmoud.]{.underline}

**Objectives:** Evaluate the potential for differences in values among
stakeholders groups to confound therapeutic decision making in
schizophrenia.

**Methods:** A convenience sample of 148 Patients, 92 family members,
and 99 clinicians (nurses, psychologists, doctors of pharmacy and
doctors of medicine) drawn from geographically and clinically diverse
environments were interviewed to study their preferences. Participants
viewed multimedia depictions of health states with symptomatic
schizophrenia with and without pseudo-parkinsonism (one of the most
common adverse effects of anti-psychotic drugs) and rated the
desirability of life with these conditions using standard gamble and
visual analog scale methods. Assessments were performed using a computer
program that could detect and help correct many of subjects\' errors in
preference measurements. Results were compared using analysis of
variance methods for multiple observations.

**Results:** Clinicians placed greater importance control of disease
symptoms than patients as shown by a greater difference in standard
gamble utilities (scaled 0 to 1.0) for states with mild and moderate
symptoms (0.097 vs. 0.056, p\<0.001). Patients placed greater importance
on the loss of in quality of life with drug side-effects as shown by
greater differences in utilities between states with an without such
symptoms (0.104 vs. 0.05, P0.016 and 0.07 vs. 0.032, p=0.014). Patients
preferred states with moderate symptoms from schizophrenia to states
with mild symptoms complicated by pseudo-parkinsonism; clinicians had
the opposite preference (p\<0.001). Visual analog scale ratings
supported findings seen with the standard gamble. Family members had
preferences that were intermediate between patients and clinicians.
There are systematic differences in values for health outcomes between
patients and other stakeholders that may underlay patient non-adherence
with anti-psychotic drug regimens.

**Impact:** Schizophrenia is a high resource use area for the VA.
Results of this study illustrate the importance of directing therapy
based on patients\' preferences and illustrate how patients and
clinicians might work together to improve adherence and patients\'
quality of life.

The World Wide Web-based technologies for preference measurement used to
collect data for this study potentially have broad applicability within
the VA. These tools could readily be adapted to conduct nationwide
surveys of veterans\' health preferences for other medical domains for
cost-effectiveness analysis and used as part of systems that facilitate
shared decision making by measurement of patients preferences.

**139. Evaluating the Effectiveness of Telemedicine for Enhancing
Compliance in the Treatment of Schizophrenia**

# [G Linn, PhD.]{.underline} Alvin C. York VA Medical Center, Murfreesboro,TN. [J St. Onge, R Harris-Turner, H Meltzer, R Prakash, and R Levine.]{.underline}

**Objectives:** The purpose of this study is to collect data on
compliance with atypical antipsychotic medications compared to typical
antipsychotics and conduct a randomized, comparison group (i.e. usual
care) study to assess the clinical effectiveness of a Telephone
Medication Management (TMM) for veterans with Schizophrenia.

**Methods:** One hundred and forty patients with schizophrenia and
schizoaffective disorder were recruited at the Alvin C. York Medical
Center over a one-year period. Patients were randomized, in equal
numbers, to either the TMM condition or non-TMM condition. Research
participants assigned to the TMM intervention met with a nurse to
discuss medication attitudes, develop strategies for taking medication
on a consistent basis post-discharge, and provide psychoeducation about
side effects. A nurse had telephone contact with the subject
approximately once per week and conducted a brief psychiatric and
cognitive assessment, inquired about medication use, side effects, and
non-prescription substance use and provided psychoeducation about
medication use. The nurse initiated appropriate interventions (e.g.,
schedule appointment with a physician) to combat increased symptoms and
significant side effects, and to enhance treatment compliance. Controls
went through normal discharge procedures and received traditional
outpatient services. Cognitive and psychopathology measures, the Brief
Psychiatric Rating Scale (BPRS), as well as the Lehman Quality of Life
Scale were administered to all participants, Adherence to the medication
regimen was assessed using self-report measures, pill counts, and
prescription refills. Side effects were examined using the Simpson-Angus
Rating Scale and the Abnormal Involuntary Movement Scale (AIMS). The
Wisconsin Care Sort was administered to assess the patient\'s problem
solving and abstract reasoning skills and the WAIS-III Subtest Letter
Number Span was used to assess working memory capacity. Research
interviews were conducted at baseline (prior to randomization), 6-weeks,
6-months, and 12-months post-discharge. Pill counts were obtained at the
time of the interviews. Prescription refills and utilization data were
obtained from research participants\' medical records at the end of the
study. Regression, hierarchical linear modeling, covariate analyses
(e.g. ANCOVA, MANCOVA), and analysis of variance were used for
hypothesis testing.

**Results:** TMM was found to increase the effectiveness and compliance
of both typical and atypical antipsychotic drugs. Recall memory was
observed to be a predictor of non-compliance. Non-compliance was found
to be inversely related to efficacy and extra pyramidal symptoms.
Compliance with atypical antipsychotic drugs was better than that with
typical neuroleptics due to enhanced cognitive abilities, increased
efficacy, and decreased side effects.

**Conclusions:** Telephone medication management is a valuable
intervention strategy for efficiently and effectively enhancing the
effectiveness of schizophrenia treatment in veterans.

**Statements:** The results from this study are being used to improve
the quality and cost-effectiveness of services offered to veterans with
psychoses at the Alvin C. York VA Medical Center and other medical
centers in the network. We have gained an understanding of the
usefulness of telephone medication management for enhancing clinical
outcomes, quality of life, and compliance, and for decreasing
hospitalization rates.

## **140. Validity of a Alcohol Severity Measure in Ambulatory Patients with Alcohol Disorders** 

# [Darcas Mansell, MD, MPH.]{.underline} Birmingham, AL. [A Spiro III, PhD, and A Lee, L Kazis, ScD]{.underline}. Bedford VA Medical Center, Bedford, MA.

**Objectives:** Existing measures of severity of alcohol disorders were
developed for use in alcohol treatment settings and are labor intensive
to administer. We describe the validation of a patient based assessment
of alcohol severity for patients seen in ambulatory care settings and
describe the effect of the severity of alcohol disorders on summary
measures of health related quality of life.

**Methods:** The Veterans Health Study is a prospective study of
ambulatory patients in the greater Boston area; 286 (12%) of
2425patients were identified as having an alcohol disorder (defined as
answering \"yes\" to two or more CAGE questions and having had a drink
in the past year. Patients completed a self-report measure of health
related quality of life (SF-36) and a short form of the Diagnostic
Interview Survey (QDIS) for alcohol abuse and dependence. They were also
administered a measure of alcohol related severity (TyPEsm
Specification) and a medical history interview. From these latter two,
three scales were developed to assess different aspects of alcohol
severity: Phys-Sum, a measure of medical complications of alcohol,
Phys-With, a measure of alcohol tolerance and withdrawal, and Behavior,
a measure of behavioral consequences of alcohol. Higher scores denote
greater severity. T-tests were used to compare mean scores on the three
scales for those with and without alcohol abuse/dependence, and ordinary
least squares regression was used to examine the association of the
three scales with PCS and MCS from the SF-36. The PCS (physical
component scale) and MCS (mental component scale) are two summary scales
expressed as linear T score transformations with a mean of 50 and a
standard deviation of 10 in a normal population. Higher scores denote
better function.

**Results:** 245(85%) completed the QDIS; of these 80.6% had alcohol
abuse or dependence. Patients with alcohol abuse/dependence had higher
severity on all three severity measures (p\<0.001). Ordinary least
squares regression revealed that age, Phys-Sum, Phys-With and Behavior
explained 14.1% of the variance in PCS and 15.7% of the variance in MCS.
After controlling for age, Phys-Sum was negatively associated with PCS
(p\<0.0001) and Phy-Sum (p\<0.001) and Behavior (p\<0.05)were negatively
associated with MCS.

**Conclusions:** Medical consequences of alcohol are associated with
both poorer physical and mental health status, while behavioral
consequences of alcohol are associated with poorer mental health status.
Although alcohol withdrawal was not associated with health status, it
may predict utilization of alcohol detoxification and treatment
services. Multidimensional patient based assessments of alcohol severity
for ambulatory care patients are associated with health related quality
of life.

**Impact:** We expect that these relatively brief patient based
assessments for alcohol disorders, which are related to well validated
measures of health status, will predict use of health care services by
ambulatory patients with alcohol disorders.

**HSR&D Funded:** SDR 91-006

**141. Guideline-Concordant Antipsychotic Dose and Outcomes of Routine
Care for Schizophrenia**

# [RR Owen, MD, EP Fischer, PhD, CRN Thrush, M Zhang, PhD, and JE Kirchner, MD.]{.underline} North Little Rock VA Medical Center, North Little Rock, AR.

**Objectives:** The publication of clinical practice guidelines for
schizophrenia by VHA and other organizations provides an opportunity to
develop measures to assess guideline concordance and examine their
relationship to patient outcomes. This study examines the association
between guideline-concordant antipsychotic doses and symptom and
functioning outcomes in a sample of patients who were receiving routine
care for schizophrenia.

**Methods:** This study involves a secondary analysis of data collected
during a longitudinal outcomes study of routine care for patients with
schizophrenia. In this study, patients with a diagnosis of schizophrenia
confirmed by structured interview were enrolled during an acute
psychiatric hospitalization. The Brief Psychiatric Rating Scale (BPRS)
and Short-Form 36 were administered at baseline and six-month follow-up
to assess symptom severity and functioning, respectively. Medical
records were abstracted to determine antipsychotic doses at discharge,
which were converted to chlorpromazine equivalent doses (CPZE) for
comparison to the guideline-recommended dose range, 300-1,000 CPZE. For
all patients prescribed oral antipsychotics (n=87), linear regression
models were developed to test the association between patient outcomes
and two methods of classifying guideline on-concordant doses,
dichotomous (\< or \>= 300 CPZE) and trichotomous (below, within and
above the 300-1000 CPZE range). Outcomes of interest included follow-up
BPRS total score and SF-36 social functioning score. Analyses controlled
for the baseline value for outcomes measures, substance abuse,
medication compliance, and the interaction between medication compliance
and dose level.

**Results:** The interaction between medication compliance and the
dichotomous dose range variable was significantly associated with both
BPRS total score at follow-up (F(1 df)=4.1, p\<0.05) and follow-up SF-36
social functioning score (F(1 df)=3.89, p=0.05). Adjusted means for
symptom severity were signifcantly higher for noncompliant patients who
were prescribed doses \< 300 CPZE than for noncomplant patients in the
higher dose category (BPRS totals 45.5 versus 35.7, p\<0.05). Similarly,
the low-dose, noncompliant group had significantly lower social
functioning scores than patients prescribed \>= 300 CPZE (32.9 versus
56.0-62.1, p\<0.05). In contrast, the trichotomous guideline-concordant
dose variable was significantly associated only with follow-up symptom
severity (F(1 df)=4.65, p\<0.05). Patients prescribed
guideline-concordant doses of 300-1,000 CPZE had lower adjusted mean
BPRS scores (36.2) than patients prescribed \>1,000 CPZE (45.1,
p\<0.01), and than patients prescribed \<300 CPZE (42.8, p\<0.07).

**Conclusions:** The interpretation of our findings is limited by
potential differences in unmeasured patient characteristics that could
affect patients\' response to treatment. Nevertheless, our study is
among the first to find dose-outcome relationships for patients with
schizophrenia undergoing outine treatment. These findings suggest that
quality improvement programs could measure guideline-concordance of
antipsychotic doses and use this as an explicit criterion for the
quality of medication management for schizophrenia.

**Impact:** With the planned implementation of clinical practice
guidelines for schizophrenia in VHA, quality managers and administrators
will need to implement straightforward performance measures to monitor
guideline implementation. This research suggests that guideline-derived
explicit criteria for antipsychotic dose are related to patient
outcomes. Because this measure can be readily extracted from
computerized pharmacy data, it can be widely used for quality
improvement and for monitoring clinical practice as part of the Quality
Enhancement Research Initiative.

**HSR&D Funded:** IIR 95-020

**142. Gender Differences in VA Disability Benefits for PTSD after
Controlling for Combat Exposure**

[Maureen Murdoch, MD, MPH.]{.underline} Minneapolis VA Medical Center,
Minneapolis, MN. [L Fortier]{.underline}

# Background: Although standardized protocols exist to determine claimants\' eligibility for Posttraumatic Stress Disorder (PTSD)-related disability benefits, the granting of such benefits has historically varied across regions. More recently, concerns have been raised that PTSD claims for men and women are processed differently, perhaps because men and women cite different causative exposures. OBJECTIVES: Examine gender and regional differences in PTSD claims approval rates after adjusting for combat exposure. 

# Methods: Historical cohort study using the Special Interest Resources System (SIRS) database. SIRS contains data on all veterans who have filed a claim for PTSD since 1980, the first year PTSD was recognized as a separately compensable diagnosis. RESULTS: 191,701 men and 5,249 women have filed disability claims for PTSD since 1980. Among male claimants, 67% served in the Army, 17% in the Marine Corps, 10% in the Navy, and 5% in the Air Force. Of women, 55% served in the Army, 6% in the Marine Corps, 20% in the Navy, and 17% in the Air Force. 19.6% of men and 2.4% of women reported combat-related disabilities, and men were more likely than women to report either the loss of an anatomical part (0.4% v. 0) or the loss of its use (0.5% v. 0.1%). Rating specialists deemed 6% of men and 4% of women unemployable. Since 1980, 55% of male veterans\' claims for PTSD have been approved versus 43% of women\'s claims. Men\'s combined degree of service connection is slightly higher, 46.6% v. 41.6% for women, which translates into an additional annual benefit of \$1,020 for men. Five percent of men and 2% of women appealed denied claims, but men\'s appeals succeeded more often: 63% were ultimately granted versus 42% of the women\'s. Men were older than women when they first filed a claim (49.4 v. 37.1 years) and, from the date of military separation, waited nearly twice as long to file (25.4 v. 11.1 years). Combat exposure was the strongest predictor of an approved disabilityclaim (OR = 6.52) after adjusting for gender, age, service branch, year and VISN in which claim was filed, employability, and either the loss of an anatomical body part or the loss of its use. Unemployability was the second strongest predictor (OR = 2.04). After adjustment, men were 1.15 times more likely than women to be granted service connection for PTSD; regional differences in claims approval rates were also confirmed. Across VISN\'s, the odds of claims approval ranged from 0.74 to 1.52. 

# Conclusions: Small, but important, gender differences in PTSD claims approval rates persisted after adjusting for combat exposure and other covariates. Likewise, important regional differences remained, with the odds of claim approval varying as much as 2-fold across particular VISN\'s. 

# Impact: A welfare loss may exist for women veterans who file disability claims for PTSD and for veterans filing within specific VISN\'s. However, SIRS data has limited clinical information, and unmeasured factors may explain the gender and regional differences found here. Additional research using primary data collection is required to confirm or deny our findings.

**HSR&D Funded:** GEN 97-002

**143. Using Focus Group Methodology in the VA System**

[Constance Captain, PhD and Donna Gladstone, Med, MSHP, RN]{.underline}.
South Texas Veterans Healthcare System, San Antonio, TX.

**Abstract:** \"Prescription for Change\" specifically identified the
use of focus groups to evaluate VHA\'s customer and stakeholder needs
and satisfaction with services. Study findings have helped VA better
understand its customers, their perceptions about healthcare and what
was needed to further improve services. However, there are special
considerations when using focus groups to study customer satisfaction.

**Objectives:** This workshop will explore several of these issues and
present an overview of focus groups for those unfamiliar with this
approach. Specific objectives are to enable participants to
understand: 1) the value and use of focus groups to improve customer
satisfaction, 2) key concepts of focus group methodology as a
qualitative research tool, 3) strategies and techniques for conducting
effective focus groups, and 5) how to analyze and use focus group data.

**Target:** Researchers interested in using focus groups to evaluate
customer satisfaction as well as, managers and clinicians who need to
use the data from focus groups to improve services. Participants with
little to no experience with focus groups will obtain overview-level
knowledge.

**Activities:** The two presenters will share their experiences in
conducting focus groups with a variety of \'customer\' groups to
highlight the workshop content; a \'lessons learned\' format. Key
concepts and techniques will be demonstrated and discussed.

**144. Evaluating Health Care Organizational Change: Benefits and
Limitations** **of Hierarchical and Structural Equation Modeling**

[Martin Lee, PhD.]{.underline} Center for the Study of Healthcare
Provider Behavior, Sepulveda, CA.

**Abstract:** To review the strengths and limitations of statistical
approaches for controlling the effects of hierarchical relationships
embedded in models evaluating health care organizational change,
including hierarchical (nested) analysis of variance, multiple
regression, non and semi-parametric corrections such as those suggested
by Huber, and other multivariate adjustment techniques, including
structural equation modeling. Activities: A multidisciplinary panel of
methodologists (statistician, epidemiologist, organizational theorist,
and clinician-health services researcher) will present the basic tenets
of evaluating health care organizational change through statistical
models, followed by presentation of the approaches and basic issues
faced by users of each approach. Organizational case studies will be
used to characterize particular strengths and limitations based on
previous and current studies evaluating the effects of VA integrations
and the economic and clinical performance of alternative VA primary care
delivery systems.

**Target:** Health services researchers interested in adding
hierarchical and structural equation modeling to their methodologic
toolkits and those generally interested in the issues involved in
evaluating the effects of organizational change.

**Familiarity:** The workshop is designed for the broad health services
research audience, with low to moderate levels of statistical and
modeling understanding and familiarity needed.

**145. VA National Guidelines, Strategies for Implementation, Local
Modifications, and Ways to Quantitatively Assess Guidelines Impact**

# [Jacqueline A. Pugh, MD.]{.underline} Audie L. Murphy Memorial Veterans Hospital, San Antonio, TX and [Gayle E. Reiber, PhD, MPH.]{.underline} VA Puget Sound Healthcare System, Seattle, WA.

# Ojective: To discuss VA national guidelines, strategies for implementation, local modifications, and ways to quantitatively assess guideline impact. 

**Activities:** Practice guidelines attempt to summarize the available
scientific data regarding diagnosis of treatment of a particular medical
disorder and to suggest a course of action for the provider. Evidence
suggests guidelines offer potential for improved quality of care,
reduced practice variation, improved outcomes and better cost
containment at an organizational level. The VA has supported development
of national guidelines for many conditions that are prevalent among
veterans. This workshop will discuss strategies to target and reach
users, recommendations for adapting guidelines to local facilities, and
focus on strategies in three areas that are important in guideline
implementation:

1\) Strategies for individual providers

2\) Strategies for individual patients

3\) Strategies for organizational changes

Limitations of guidelines will also be discussed, including
appropriateness, infrastructure and fiscal realities, and ceiling and
floor effects. Existing VA guidelines will be used as examples.

**Target:** Clinicians and health services researchers interested in
guidelines and quality of care initiatives.

### \*146. Ambulatory Care Sensitive Hospitalizations for Veterans in Rural Nebraska

# [JR Spurzem, AM Bowman, KJ Mueller, DM Olsen]{.underline}

**Objectives:** Veterans living in rural areas face several potential
barriers to ambulatory health care including long distances they travel
for care. In order to evaluate barriers to care, we examined rates of
inpatient discharges for potentially preventable hospitalizations,
ambulatory care sensitive conditions (ACSC), among selected Nebraska
veterans compared to discharges for non-VA hospitals. Hospitalization
for an ACSC is thought to suggest the presence of barriers to ambulatory
care outside a hospital setting. The specific objectives are: 1) compare
rates of ACSC hospitalization among subsets of veterans served by the
Omaha VAMC; and 2) compare rates of ACSC hospitalization of the veterans
with others in the same counties.

**Methods:** ACSCs have been defined by the Institute of Medicine (1993)
in Access to Health Care in America. Data for two years (Oct. 94 --
Sept. 96) from the Nebraska Association of Hospitals and health Systems
(NAHHS) were used for evaluating discharges for persons 21 and older
residing in the 18 counties included in the Omaha VAMC area. Omaha VA
discharge data for Oct. 94 -- Sept. 97 were used. Population data were
obtained from the US Census and the VA Planning Systems Support Group.
Distances from the hospital of admission were measured as distance from
county population centers to the Omaha VAMC. Chi-square tests are used
to compare discharge rates among different population groups.

**Results:** The results confirmed expectations that there were higher
rates of discharged for ACSCs among veterans than in the community
dataset. Among veterans there were 22.8 discharges per 1000 versus 14.5
NAHHS discharges (p\<0.010. Also as expected, civilian ACSC rates
increased as distance from the Omaha area increased. Specifically, there
were 17.7 ACSC discharges per 1000 among those living more than 50 miles
away verses 13.7 for those within 50 miles of Omaha (p\<0.01). For
veterans, the rate of discharge dropped as distance from the VAMC
increased. Among those veterans living greater than 50 miles away, the
ACSC rate was 6.7 per 1000 population verses 27.3 for those living
within 50 miles of the facility (p\<0.01).

**Conclusions:** Because ACSC hospitalization rates are higher in
counties closest to the VAMC raises the possibility that veterans
farther away are not using VA services at all. If veterans are admitted
to non-VA facilities and rely on Medicare or other means to pay for
care, they are not included in the VA data used in this study. Having
little reason to suspect a hospitalization rate lower among veterans
than others, a plausible explanation for the rate in counties more than
50 miles from the facility is that these veterans are getting care by
means other than the VA.

**Impact:** High rates of ACSC hospitalization suggest a potential to
both save expenditures and improve quality of life for veterans by
improving access to primary care in ambulatory sites. The Omaha VAMC
should consider the implications of the finding for veterans residing
within 50 miles of the facility. Future research should focus on
specific conditions, and analyze data describing general use of health
care services by veterans.

**HSR&D Funded:** DEV 97-019

**\*147. Are U.S. Veterans Still the Forerunners of Retirement
Migration**

[Diane Cowper, MA,]{.underline} Hines VA Hopsital, Hines, IL. [CF
Longino.]{.underline} [Joseph Kubal, MA.]{.underline} Hines VA Hospital,
Hines, IL. [LM Manheim, SJ Dienstfrey, J Palmer.]{.underline}

**Objectives:** This research extends and reconfirms our previous work,
which found that U.S. Veterans appear in the vanguard of retirement-age
migrants entering popular destination states. Analyses update migration
patterns for the veteran and non-veteran sub-populations in include the
1985-90 migration period.

**Methods:** The data are from the 1990 Census Public Use Microdata
Sample (PUMS), a 5% sample of the U.S. population. All records of
persons 60 years of age and older were extracted, as well as a number of
demographic, socio-economic, and disability variables. Comparisons
primarily focus on interstate migrants of the veteran and non-veteran
groups. In the 1985-1990 migration period, there were approximately 1.5
million elderly non-veteran migrants and 558,000 older veteran migrants.
T-tests, chi-squares, and analysis of variance were used to assess the
differences between groups. The identification of salient migration
streams was determined using transaction flow analysis.

**Results:** Results show that veteran retirees have been fore-runners
of the western regional Migration pattern featuring out-migration from
California to its neighboring states of Arizona, Nevada, Oregon, and
Washington. With minor exceptions, the top ten destinations for veterans
in the past two censuses are states in the Sunbelt and Pacific Northwest
that are well-known for the attraction of their amenities. The
non-veteran migrants show a much wider geographic range, including the
Sunbelt states, but also states in the Northeast and Midwest. We found
that the differences are due, in part, to the socio-demographic profile
of, and the types of moves made by, these two sub-populations.

**Conclusions:** The primary relevance of veteran residential mobility
to applied gerontology is found in its implications for health service
use. The forerunner hypothesis lends relevance to the notion that
veteran migrants disproportionately fit the model of the amenity-seeking
migrant who is relatively young, recently retired, and married.

**Impact :** Veteran migrants may use health services less than others
of retirement age. If they remain in their new retirement location,
however, they will use health services more frequently as they age
collectively. The increase in health care demand will impact all
services provided to veterans, including government health services. The
retirement of World War II veterans sets the stage for future increases
in health services demand, a topic of great interest to the department
of Veteran Affairs.

**HSR&D Funded:** 95-065

**\*148. Barriers to Adherence to Highly Active Antiretroviral Therapy
as Expressed by People Living with HIV/AIDS**

# [Asrat Tesfa, PhD.]{.underline} Northport VA Medical Center, Northport, NY. [VE Proctor, DC Tompkins]{.underline}

**Objectives:** The use of highly active antiretroviral therapy (HAART)
has shown great promise in treating people living with human
immunodeficiency virus/acquired immune deficiency syndrome
(PLWHIV/AIDS). The treatment with HAART requires complex combinations of
antiretroviral agents and prophylactic medications to prevent viral
replication, damage to the immune system and development of
opportunistic infections. In some patients, this means rigid adherence
to over 20 medications a day. Non-adherence to HAART has presented new
challenges to PLWHIV/AIDS. We conducted a study to address the problem
of non-adherence to HAART. The primary objective of this study was to
gain a clearer understanding of barriers to adherence to HAART as
expressed by PLWHIV/AIDS. The secondary objective was to develop a
survey questionnaire based on data collected. This abstract focuses on
the primary objective.

**Methods:** A qualitative research method, focus group, was conducted
to study barriers to adherence to HAART in PLWHIV/AIDS. The study was
conducted in 1998 on Long Island, New York, at five institutions which
provide services to 1,700 PLWHIV/AIDS. Two institutions were located in
Nassau County, a state and private institution; three institutions were
located in Suffolk County, a federal (VAMC) and two state institutions.
Three of the institutions were affiliated with medical centers and two
with State Public Health Clinics. Prior to initiation the Internal
Review Board of the VA Medical Center approved the study. Patients on
HAART, willing to participate in a one-time focus group discussion, were
recruited from five infectious disease clinics. Five focus groups were
conducted with 6 to 13 PLWHIV/AIDS in each group, a total of 39
subjects.

**Results:** Of the 39 patients, there were 10 men classified as men who
have sex with men, 9 heterosexual men, 9 heterosexual women, 8 men and 3
women who were injecting drug users. No distinguishing barriers or
characteristics were identified among the four exposure categories.
PLWHIV/AIDS identified eight common barriers to adherence to HAART. In
descending order, the barriers included: 1) frequency & severity of side
effects, 2) conflicts with daily routines, 3) dietary requirements, 4)
frequency of taking medications, 5) number and dosage of medications, 6)
psychosocial factors, 7) pharmacy refills, and 8) physiological needs.

**Conclusions:** Unlike patients with other chronic illnesses, who
require treatment with medications, PLWHIV/AIDS taking HAART must not
only endure a very rigid regimen but one that changes frequently.
Clinicians sensitive to barriers to adherence to HAART identified by
PLWHIV/AIDS may play a more proactive role in supporting adherence to
the medication regimen, thus increasing the durability of effective
viral suppression, decreasing the morbidity, mortality as well as the
selection and transmission of resistant strains of HIV.

**Impact:** Clinicians rsponsible for the care of PLWHIV/AIDS may have a
better understanding of barriers to adherence to HAART. This knowledge
may assist them in planning interventional strategies which may improve
adherence to HAART.

\***149. Cancer Related Fatigue: Traversing the Edge**

# [Sandra Holley, PhDc.]{.underline} JAH VA Hospital, Tampa, FL.

**Objectives:** Patients with cancer identify fatigue as the number one
cause of distress in their lives as they deal with their cancer and its
various forms of treatment. Cancer related fatigue (CRF) is a
significant issue for nursing because nurses are the major health care
providers who are responsible for assisting persons with cancer in
managing and adapting to the fatigue that is a part of the cancer
experience. The purpose of this study was to understand the experiences
and the common meanings of CRF and to generate a grounded substantive
theory for understanding the experience of fatigue in persons with
cancer.

**Methods:** The grounded theory method was used. The transcribed
interviews were coded and categorized using the constant comparative
method of analysis. The patterns and basic properties of categories and
constructs were identified. Theoretical memoing, an analytic technique
used to capture hypothetical ideas, was used to elevate the descriptive
data to a conceptual level. SAMPLE: The sample consisted of 20 in-depth
interviews with 16 participants who were adult individuals with cancer
and who agreed to audio-taped interviews. Participants included
inpatients and outpatients from a dedicated cancer center and a VA
Hospital.

**Results:** CRF as suffering a different fatigue was identified as the
basic social psychological problem. Participants reported they expected
CRF and typical fatigue to be similar. CRF was not what participants
expected. CRF was different. When it was compared to typical fatigue,
CRF was more rapid in onset, more intense, more energy draining, longer
lasting, often unexpected, and frequently unrelenting. The basic social
psychological and structural processes of the CRF experience were found
to be transitional and dynamic, thus, the metaphor of traversing, which
implies movement. Participants experienced CRF as a passage that was
sometimes precarious, thus, the edge. The edge and edgy are grounded in
the participant data. Six phases of the process of traversing the edge
were identified. The phases were sensing the edge, measuring the edge,
balancing on the edge, recovering the edge, approaching the edge and
going over the edge. All of the phases of traversing the edge had an
impact on physical, cognitive, spiritual, social and psychological
domains of the participants lives. The grounded theory, \"Cancer Related
Fatigue: Traversing the Edge.\" portrays the impact of the morbidity and
suffering that CRF produced in the lives of persons with cancer
experiencing fatigue.

Conclusions: This theory illustrates the morbidity and suffering that
persons with cancer experience with CRF. It can be used to educate
clinicians to the devastating consequences of CRF on quality of life.

**Impact:** This theory will also provide the framework for the
development of an assessment and intervention teaching guide for
clinicians o use with patients with CRF to minimize sub-optimal and
variations in care.

## **\*150. Creating an Operational Definition of Degree of Clinical Integration**

# [Ann Sales, PhD, RN, Nathan Every, MD, MPH and Ann Keane, PA-C, Esq (JD).]{.underline} VA Puget Sound Health Care System, Seattle, WA

**Objectives:** The primary aim of this paper is to describe methods of
operationalizing degree of clinical integration. This is one component
of a study in which we test the hypothesis that higher levels of
clinical integration in cardiology lead to better patient outcomes. It
has been suggested that more integrated organizations are likely to
produce better outcomes than those that are less integrated, both in
terms of cost and patient health outcomes. A hierarchy of integration
has been outlined in which clinical integration (integration among
clinical providers) occurs as the ultimate type of integration. However,
clinical integration is not directly observable, but can be inferred. We
attempt in this paper to describe a set of variables, both directly
observed and constructed, to measure degree of clinical integration.

**Methods:** We visited the ten VA Medical Centers in the five Networks
(VISNs 13, 18, 19. 20, 22) included in this study that have cardiac
catheterization labs. At each site, we interviewed the Chief of
Cardiology, Chief of Staff, and Director. The structured interviews
obtained detailed information describing the arrangements for referral
and consultation between the tertiary centers and referring facilities.
Interviews were conducted by one of the two Principal Investigators for
the study, and followed the same areas of inquiry, with flexibility to
explore the details of a particular site. We then used exploratory
factor analysis to examine the relationships between the variables
describing the degree of clinical integration. The results described
here are still preliminary, with analysis continuing.

**Results:** Each of these tertiary VAMCs has between four and seven
units referring patients for tertiary cardiology services. The units
referring range from non-tertiary VAMCs to the primary care clinics in
their own medical centers to free-standing outpatient clinics. The
methods and arrangements for consultation and patient referral vary
across the sites, ranging from staff cardiologists visiting remote sites
to contracting extensively with community cardiology services, to
telephone and written contact only with patient referral for complex
problems. Preliminary factor analysis scores range from -.94 to 2.10,
with mean 0 and standard deviation 1. Median score is -.41. In this
analysis, the factor explaining most of the variance in the score is
whether or not a staff cardiologist visited the referring site; this
explained 34% of the variance in the score.

**Conclusions:** There is wide variation among VAMCs in the way that
cardiology consultation and referral services are arranged. Underlying
the different arrangements are differing degrees of clinical integration
among the facilities that interact to provide a full range of cardiology
services to VA patients. It is possible to construct one or more
variables to describe degree of clinical integration among these
facilities.

**Impact:** These results are likely to be of interest to clinicians,
managers, and researchers studying organizational integration.
Successful measurement of degree of clinical integration, coupled with
patient outcome measurement, will assist in making decisions about how
best to organize services provision.

**HSR&D Funded:** ACC 97-001

**\*151. Current Smoking Among Veterans and Nonveterans Age 70 and
Older: Results from the Survey of Asset and Health Dynamics Among the
Oldest-Old (AHEAD**)

# [RP Hopp, SA Duffy]{.underline}

**Objectives:** The objectives of this study are to (1) examine the
difference in current smoking between older veterans and older
nonveterans; and, (2) determine whether there are=differences in the
predictors of current smoking between older veterans and older
nonveterans.

**Methods:** Data are based on the Survey of Asset and Health Dynamics
Among the Oldest-Old (AHEAD),a nationally representative sample
(N=3D7441) of persons age 70 and older. = Logistic regression models are
used to assess the predictors of current smoking including age, gender,
socioeconomic status (educational level) and depression among three
respondent groups: 1) the full sample of persons age 70 and older
(n=3D7441); 2) U.S. veterans (n=3D1624); and, 3) nonveterans (n=3D5817).

**Results:** Among all persons age 70 and over, a significantly greater
proportion of veterans are current smokers (14%) compared with
nonveterans (9%), and these differences remain even after controlling
for age, gender and educational attainment (p\<.01). Among both veterans
and nonveterans, current smoking is significantly higher among the
youngest age group (age 70-74) compared with the oldest age group (age
80+) (p\<.05) and among those with higher levels of depression compared
with those with lower levels of depression (p\<.05). Among veterans,
females are more likely to be current smokers than males (p \<=.01),
while among nonveterans, males are more likely to be current smokers
than females (p \<.01). Furthermore, veterans without a high school
education are significantly more likely to be current smokers than are
high school and college educated veterans (p\<.05), however, educational
level does not predict current smoking in the nonveteran population.

**Conclusions:** These results build on previous research by suggesting
that the higher rate of current smoking among veterans compared with
nonveterans is true even among those age=70 and older. Veterans who
appear to be at particular risk for current smoking include females,
those with less than a high school education, and those with high levels
of depression.

**Impact:** Those most at risk for current smoking among older veterans
include females, those who are less educated, and those with higher
levels of depression. Elderly, female, less educated and depressed
smokers are often those who are least likely to attend formal smoking
cessation groups commonly offered through the VHA system. Creative
smoking cessation interventions to target these hard to reach smokers
will be necessary for the VHA to reach the goals of improving both
access to care and patient outcomes. Smoking is the number one cause of
preventable death in this country, accounting for nearly half a million
deaths and \$50=billion in medical expenditures each year. These high
medical expenditures place an even greater relative burden upon veterans
and the VHA due to the higher rate of smoking among veterans compared to
nonveterans. Successful smoking cessation appears to halt the
progressive increase in the use of health care services associated with
continued smoking even among elderly populations. Among the growing
number of older U.S. veterans, effective smoking cessation programs have
the potential to decrease subsequent health care use and costs.

**\*152. Decision Support and Quality Assessment of Chronic Hypertension
Care Based on a Computerized System for Implementing Clinical Practice
Guidelines: Report on System Development**

# [A Advani, BB Hoffman, MK Goldstein]{.underline}

**Objectives:** The 1993 National Survey of Veterans identified
hypertension as the most common outpatient diagnosis. Also common is
clinician non-adherence to VA Guidelines on Hypertension, including
over-prescription of expensive Ca-Channel antagonists, and
under-prescription of thiazide diuretics and beta adrenergic receptor
antagonists, contributing to health-care costs. Physician compliance has
been shown to improve with immediate, patient-specific, accurate
feedback. The Assessment and Treatment of Hypertension: Evidence-based
Automation (ATHENA) project at VA Palo Alto is being developed to
address these goals using an automated decision support system (DSS) to
improve compliance with guidelines for managing primary hypertension in
VA clinics. A collateral objective is expanding ATHENA into a system for
implementing clinical practice guidelines for other diseases in VA
nationally.

**Methods:** This is a report of preliminary work on system development.
The system design plans include an interface to patient information
available through VISTA/DHCP medical record data. These data will be fed
into a data interpretation module that will prepare the data for
reasoning using the DSS. We are designing the DSS for reuse in other
medical domains by creating a guideline concept model with
hypertension-specific knowledge, such as diuretics", separated from the
more abstract concepts applicable to all guideline-based care such as
"start a drug prescription" or "guideline-eligibility criteria." This
guideline concept model is then passed to a knowledge acquisition tool
that generates forms on the computer screen for expert physicians to
enter detailed guideline knowledge representing best practices in
hypertension management. Lastly, this knowledge is used to drive a
domain-independent problem-solver, given data about a specific patient,
or critiquing and assessing the quality of care already administered to
a group of patients.

**Results:** Using our guideline model, we have incorporated the drug
information and co-morbidities in Table 9 of the JNC6 Hypertension
Guideline. We plan to add detailed evidence-based extensions covering
drug use exceptions and multiple drug-disease combinations and
assessment of lab values. The algorithm as currently implemented first
determines whether current therapy is consistent with the
guideline-recommended therapy. Next, the algorithm reconciles current
and recommended therapy in a conflict-resolution phase. The system then
generates an advisory that the therapy remain the same, gives warnings
about the current therapy, or recommends therapy modifications. We are
preparing to test the system, which now accepts data in VISTA format,
with live medical data from primary care clinics processed from the
VISTA patient record. Case examples will be presented.

**Conclusions:** The ATHENA system is designed to provide a mechanism
for immediate, direct feedback to clinicians at the time of the therapy
decision. When completed, it will support retrospective analyses of
guideline compliance to analyze prescribing patterns in quality
improvement initiatives. The system for automated guideline-based care
could be used in multiple domains, since the system design separates
domain-specific guideline knowledge from the domain-independent general
guideline model and algorithm.

**Impact:** This system, still under development, has the potential to
improve upon the traditional diffusion model of practice guideline
implementations by incorporating an automated expert system that
provides immediate patient-specific point of care advisories.

**HSR&D Funded:** CPG 97-006

**\*153. Development of a Longitudinal Database for Monitoring Quality
of Care Provided to Patients with Spinal Cord Dysfunction Receiving Long
Term Care under VHA Auspices**

# [WA Baughman, V Litvak, T Nguyen]{.underline}

**Objective:** To create a database for investigating health status and
outcomes related to care in a nursing home setting. Individuals with
spinal cord dysfunction have a high risk of developing preventable
comorbidity. The Patient Assessment File (PAF) contains information as
to which VHA parent facility granted auspice. The Patient Treatment File
(PTF) contains information for inpatient encounters describing admission
and discharge characteristics. Combining the PAF and PTF provides unique
information useful to longitudinal epidemiological and health services
research.

**Methods:** Veteran Health Administration PAF records of individuals
Identified as having a Spinal Cord Dysfunction are retained into a data
set for fiscal years 1995 to 1997. PTF records of these individuals over
the same time Period are then concatenated with PAF records. Using
admission and discharge information from the PTF can be used to create
new data fields identifying the most likely facility type where the
Patient Assessment Instrument was administered. This process documents
the continuum of care under VHA auspices provided by VA and non-VA
facilities.

**Results:** Inspection of patient\'s records with respect to time
series Sequence appears to be informational and may provide a reasonable
assessment as to where and when co-morbidity conditions originate.

**Conclusion:** Reliable inferences can be made regarding quality of
care from health status information recorded in the PAF and PTF for VA
and non-VA facilities.

**Impacts:** Quality of care monitoring strategies can be developed
using this Data set including recidivism and specific comorbid
conditions.

\*154. Diabetes Quality Improvement Project Initial Measure Set: Can We
Measure the Measures?

#### [John Burke, MA, RPh.]{.underline} Chief, Pharmacy Service, Louisville, KY.

# Objectives: 1. Apply the DQIP Initial Measure Set to a diabetic population at the Louisville Department of Veterans Affairs medical center (DVAMC).2. Apply the DQIP Initial Measure Set to a diabetic population in a Veterans Integrated Service Network (VISN 9).3. Develop VISN, medical center, provider and patient profiles to compare diabetic care based on the data extracted. 

**Methods:** A class III software tool developed at the Louisville DVAMC
was used to extract hemoglobin A1c data, patient name, personal
identification number, age and primary care provider for diabetic
patients. Data were extracted from the Louisville VISTA databases
maintained by the medical center. Data using this same software were
extracted from all seven medical centers in VISN 9. The DQIP measure set
was applied across this data to develop a VISN profile of diabetic
patients. Data were analyzed using both Microsoft Exel 97 and Access 97

**Results:** Hemoglobin A1c profiles were developed four times over a
two year period for patients, providers, and the Louisville DVAMC.
Hemoglobin A1c laboratory tests were ordered on 79%, 82%, 85%, and 84%
of approximately 3,000 diabetic patients in the 12 months prior to each
data extracton. Patients in the database had average hemoglobin A1c
levels of 7.86%, 7.22% and 6.86% over three successive periods where
data were available. Provider profiles were developed over the three
data extraction periods and improvement was assessed by lower average
hemoglobin A1c levels in the patient population they followed. Baseline
data on 18,572 diabetic patients in VISN 9 was extracted in September
and October 1998. Of these 18,572 patients 12,747 (69%) had a hemoglobin
A1c ordered in the previous 12 months.

**Conclusions:** The hemoglobin A1c measures part of the Diabetes
Quality Improvement Program Initial Measures Set can be utilized to
assess the level of care provided within a system of care to populations
with diabetics. The hemoglobin A1c measures part of the DQIP measures
can be applied consistently over large systems of care. Profiles can be
developed to tract patient outcome and provider performance over time.
Provider performance may be enhanced because of the feedback of
information about their own performance and the status of diabetic
patients under their care. Louisville DVAMC\'s current profile of
diabetic patients is better than VISN 9\'s profile.

**Impact:** The hemoglobin A1c measures part of the Diabetes Quality
Improvement Program Initial Measures Set can be utilized to assess the
level of care provided within a system of care to populations with
diabetics. The hemoglobin A1c measures part of the DQIP measures can be
applied consistently over large systems of care

**\*155. Do Women VA Patients With a History of Military-Related Sexual
Assault Participate in Cancer Screening**

[Susan Frayne, MD, MPH.]{.underline} Boston VA Hospital, Boston, MA. [KM
Skinner, LM Sullivan]{.underline}

**Objectives:** For women who have sustained sexual assault (SA),
medical procedures like mammograms and pap smears can be disturbing;
little is known about how this translates into health-related behaviors.
We sought to determine whether women with a self-reported history of SA
while in the military were less likely to have been screened for breast
and cervical cancer than were women who did not report such a history.

**Methods:** A nationally representative sample of women veteran
patients with at least one outpatient visit to a VA facility between
7/1/94 and 6/30/95 were mailed a survey. The survey included a question
about SA: \"Did you ever have an experience where someone used force or
the threat of force to have sexual relations with you against your will
while you were in the military?\"

**Results:** Of the 3632 repondents (58.4% response rate), 23% reported
they had experienced SA while they were in the military. Among women 40
years or older, those with a SA history were less likely than those with
no such history to have had a mammogram within the past 2 years in
unadjusted analyses (83.9% vs. 88.4%, p=.009); however, after adjusting
for age, women with a SA history were more likely to have had a
mammogram (odds ratio 1.3, 95% CI 1.1-1.6). Excluding women with prior
hysterectomy left 2377 presumed eligible for cervical cancer screening;
of them, women with a SA history were as likely as those reporting no
such history to have had a pap smear within the past 2 years (93.0%
versus 91.6%, p=.32; age-adjusted odds ratio 1.1, 95% CI 0.8-1.5).

**Conclusions:** Women VA users report high adherence rates for breast
and cervical cancer screening, irrespective of a history of SA while in
the military.

**Impact:** The Department of Veterans Affairs can be reassured that its
efforts to achieve high rates of gender-specific cancer screening in
women VA users appear to be having promising results, even among women
with a self-reported SA history. However, while SA survivors may comply
with cancer screening procedures, future studies should explore the
possibility that they experience these procedures differently.

**HSR&D Funded:** SDR 93-101

## **\*156. Factors Predicting Completion of DCHV Program**

#  [Oscar Stine, MD, DrPH.]{.underline} Martinsburg VA Medical Center, Martinsburg, WV. [K Scott, L Perry, A Hargrove, DD Bradham]{.underline}

**Objectives:** Multiple factors influence the completion of the VA\'s
treatment program for homeless veterans (DCHV). Rosenheck, et al. (1990)
showed that interaction between mental illness and chemical abuse
resulted in far fewer days of hospital care than in mentally ill
non-chemical abusers. Kessler (1994), in a national probability sample,
found that half of persons with lifetime disorders occurred in 14% of
the population with 3 or more comorbid conditions. We found that half of
the 449 discharges from the Martinsburg DCHV had four major diagnoses.
This led us to exam how diagnoses among other factors might interact to
influence early departure from the four-month DCHV program. We examined
the diagnoses and premature departure from rehabilitation for the 449
homeless veterans admitted to the residential treatment program, DCHV. A
conceptual model of patient diagnoses, patient characteristics,
isolationfactors and treatment history was developed and operationalized
using these data. Overall, a larger number of diagnoses were expected to
contribute to completion because of recognized need for clinical care.
Isolation factors (e.g., non-white ethnicity, never married and POW
status) were expected to predict early departure. Experience in
residential treatment for alcohol, drug abuse or prior VA domicilliary
stays were anticipated to predict completion of DCHV. Patient
characteristics of age at admission, homelessness in past two years and
employment in the last month were considered to have unpredictable
influence on completion.

**Methods:** Frequencies for orthopedic and PTSD diagnoses were higher
than clinically expected in univariate examination. This pattern led us
to suspect an interaction might influence completion. A multivariate,
logistics regression model tested these hypotheses.

**Results:** Findings are: (a) the logistics model consistently predicts
the DCHV completion for 379 cases (mean of 60.50%, range of 56.46% to
62.53%); (b) only days worked and number of diagnoses are significant
throughout most of the stepwise backward elimination procedure; (c)
orthopedic diagnosis is never independently influential; and is removed
in step 4 while the interactive term leaves in step 5; (d) PTSD remains
in the model and becomes significant in the 10th and final step. The
most complete and yet parsimonious predictive model presented in stage
10 is composed of four independent measures: homeless days in the past
two years (coeff. = -0.0006, p=0.15), days employed in the past 30
(coeff. = -0.20, p=0.02), PTSD diagnosis (coeff. = -0.52, p=0.08) and
number of diagnoses (coeff. = +0.11, p=0.05).

**Conclusions:** This model indicates that in these 379 cases, history
of increased homelessness in the past two years increased early
departure, as did both increased employment in the most recent month and
the presence of PTSD. Larger numbers of diagnoses increased the
likelihood of completion. Thus, increased dependency on formal medical
care increased the probability of completing the four-month DCHV
program. Other factors in our conceptual model are less important.

**Impact:** Increased medical and psychiatric diagnoses probably
influence completion through increased dependence on clinical
caregivers, while psychiatric diagnoses of PTSD, recent employment and
history of homelessness contribute to early departure. These findings
suggest changes in the program structure.

**\*157. HIV Risk Behaviors and Patterns of HIV Testing Among a
Probability Sample of Homeless Women**

##### B Herndon, A Kilbourne, S Wenzel, R Andersen, L Gelberg

**Objectives:** HIV is a QUERI target diagnosis that disproportionately
affects poor and minority women. The primary aim of this study is to
investigate the prevalence and predictors of HIV risk behaviors and HIV
testing among homeless women in Los Angeles County in order to devise
intervention strategies that might be applied to other populations of
women, including female veterans.

**Methods:** We performed a secondary data analysis of the UCLA-RAND
survey \"Access to Care for Homeless Women of Reproductive Age\", in
which a probability sample of 974 homeless women, ages 15-44, were
interviewed in 78 shelters and meal programs in Los Angeles County in
1997. Outcome measures included three HIV risk behaviors and HIV testing
status in the past 12 months. Predictors included demographic
characteristics, homelessness history, competing needs, whether children
lived with respondent, general health, functional status, obstetric
history, psychiatric symptoms, substance use, sexual trauma history,
health insurance status, other income or benefits, case manager
assignment, and type of outpatient medical care received. Each outcome
measure was analyzed with a separate multiple logistic regression
analysis to produce odds ratios with confidence intervals.

**Results:** Approximately 8% of respondents reported injection drug use
during the past year; 66% reported having had vaginal sex with a male
without using a condom; and 20% reported trading sex. Common predictors
of risk behaviors include alcohol and drug abuse/dependence, history of
rape, competing needs, and a history of multiple lifetime pregnancies.
The rate of HIV testing in the past year, approximately 70%, was
surprisingly high. Significant predictors included: Latina ethnicity,
low educational status, good physical health, pregnancy in the past
year, not living with children, receipt of benefits or insurance, having
a regular source of care with more frequent visits, and trading sex.

**Conclusions:** The high prevalence of HIV risk behaviors among
homeless women in Los Angeles County places them at substantial risk for
contracting HIV. Although conditions that are indications for HIV
testing (risk behaviors and pregnancy) are prevalent in this population,
only those who reported trading sex or pregnancy in the past year were
more likely to actually have been tested. Social resources, such as
income, insurance, and having a primary care provider with relatively
more frequent visits, all appear to increase the likelihood that a
homeless woman will receive an HIV test. However, access to health and
social services does not appear to be having an impact on HIV risk
behaviors. Research is needed to determine ways in which primary care
sites can help women to decrease their exposure to HIV.

**Impacts:** Based on the results of this study, we can begin to
identify target populations among female veterans that may benefit from
more intensive intervention efforts. Educational programs aimed at
reducing HIV risk behaviors may be ineffective unless they also address
the issues of substance abuse, victimization and competing needs.

**\*158. Identifying Informal Caregivers of Elderly Veterans with
Dementia Using Multiple VA Databases: Process, Results and
Implications**

# [ME Doyle, KM Stechuchak, R Sloane, EC Clipp]{.underline}

**Objectives:** The objective of this study was to identify a national
sample of informal caregivers using multiple VA databases. The caregiver
identification process was implemented as part of the National Caregiver
Study (NCS), a four-year, longitudinal study of informal caregivers of
elderly veterans with dementia funded by the VA Nurses Research
Initiative (NRI) through HSR&D. The overall goal of the NCS is to
identify the key cost and QOL variables associated with service use and
institutionalization.

**Methods:** Caregiver identification involved a three-phase process
that permitted the final baseline sample to be carefully tracked and
their care recipients compared to the

larger Veteran pool identified in Phase One. Phase One consisted of
reviewing all older Veterans (age 60+) with diagnoses of Alzheimer\'s
disease (331.00) or Vascular/Multi-infarct Dementia (290.40) in the
Outpatient Diagnosis File at the Austin Automation Center, who were not
found in the BIRLS Death File and were not among those Veterans admitted
to but not discharged from VA long-term care facilities. An algorithm
was implemented in SAS to remove from the pool those Veterans whose
addresses indicated that they resided in community long-term care
settings, who did not have next-of-kin or emergency contacts, or whose
contacts had unusable addresses. Phase Two involved sending a
\"Caregiver Identification Letter (CIL)\" with an attached return form
to next-of-kin or alternatives. The CIL requested assistance in
identifying the person \"most responsible for the day-to-day care of the
older Veteran with health or memory problems\". In Phase Three, eligible
caregivers identified in Phase Two were sent baseline surveys.

**Results:** A total of 11,294 elderly Veterans with Alzheimer\'s
disease or Vascular Dementia, for whom data was available from a
distributed search of all DHCP Patient Files, entered Phase One. The
First Phase narrowed this number to 9,452 Veterans whose next-of-kin or
alternatives had viable addresses to which CILs could be sent. A total
of 6,571 responses to the CIL were received, identifying 3,845
caregivers who met eligibility criteria for entry into the study. During
the summer of 1998, the first of four questionnaires was sent to these
3,845 eligible caregivers. By November 1998, 2,304 caregivers completed
and returned the baseline survey. Comparisons were made among Veterans
identified in Phases One, Two, and Three on geographic, demographic,
service, diagnosis and caregiver-Veteran relationship variables.

**Conclusions:** A national sample of informal caregivers can be
identified using multiple VA databases and a systematic, multi-stepped,
and vigilant approach. Details of the three-phase process and
comparisons of the three subject pools on key factors related to the
older Veterans, their informal caregivers, and the nature of these
informal relationships provide clues, on a national level, to the
informal care network of non-institutionalized elderly Veterans with
dementia.

**Impact:** The process of moving elderly demented Veterans from the
community to long-term care institutions can never be fully understood
without knowledge of the key decision-makers in this process - informal
caregivers. The methodology for this three-phase caregiver
identification process can be applied to various patient populations for
whom targeted home care interventions may decrease the risk of permanent
institutional placement.

**HSR&D Funded:** NRI 95-218

\*159. Identifying the \"Active Ingredients\" of Substance Abuse
Treatment: Using Structural Equation Modeling to Test Mediation
Hypotheses

# [KR Weingardt]{.underline}

**Objectives:** This study sought to identify the \"active ingredients\"
of substance abuse treatment by analyzing how the quantity and target of
problem-specific services received early in treatment might mediate the
relationship between pre- and post-treatment indicators of problems in
the domains of alcohol use, drug use, psychiatric health, employment and
family functioning.

**Methods:** Addiction Severity Index (ASI) data collected at admission
to treatment and six months after discharge, along with Treatment
Services Review (TSR) data on a sample of 407 outpatients was employed
to build and test a series of structural equation models.

**Results:** Comparison of these models suggested (a) that clients who
enter treatment with more severe problems in a specific domain are more
likely to receive specific treatment services targeting problems in that
domain than their peers, and (b) that problem-specific treatment
services targeting alcohol problems and psychiatric health function as
partial mediators of the relationship between pre- and post-treatment
measures of problems in those areas.

**Conclusions:** The results of a variety of supplementary analyses
indicated that (a) there is significant mean change between baseline and
follow-up for all five problem areas, and this change is in the
predicted direction of decreased problems over time, and (b)that the
provision of targeted treatment services can influence the level of mean
change over time, more so for some domains than for others.

**Impact:** The present study tests mediational hypotheses as a means of
understanding how or why substance abuse treatment works or does not
work.. This attempt to identify the causal mechanisms of substance abuse
treatment has far-reaching implications for the structure, process and
outcomes of substance abuse treatment in the VA Health Care System.

**\*160.** **Impact of Post-Operative Complications on Hospital Patient
Care Costs for Coronary Artery Bypass Surgery**

# [C-F Liu, S Subramanian]{.underline}

**Objectives:** The object of the study is to examine the impact of
post-operative complications to the hospital patient care of coronary
artery bypass surgery (CABG).

**Methods:** This study used micro-cost and clinical data from three
hospitals participating in Health Care Financing Administration\'s
Medicare Heart Bypass Demonstration during the period of 1991 to 1993.
The study sample included 2,849 Medicare patients who underwent CABG
with and without catheterization, i.e., those who discharged in DRGs 106
(1,143 cases) and 107 (1,706 cases). Hospital patient care costs were
measured by direct variable costs, which accounted for 40% to 55% of
total hospital cost for CABG. Professional fees were excluded. The costs
were adjusted to 1993 dollars using hospital input price factors.
Post-operative complications included bleeding, infection, neurological
complications, pulmonary complications, renal failure, vascular
complications, and reoperation.

**Results:** More than one-third of CABG patients (34%) experienced
post-operative complications, including 41% of DRG 106 patients and 29%
of DRG 107 patients. Post-operative complications were significantly
associated with higher direct variable costs for both DRG 106 and DRG
107 patients. For DRG 106 patients, the mean direct variable cost was
\$10,305 for those without complications, while the mean cost raised to
\$14,134 for those with complications. For DRG 107 patients, the mean
direct variable costs were \$7,782 for those without complications and
\$12,458 for those with complications. In addition, the hospital care
cost significantly increased with the number of complications.

**Conclusions:** These results suggest that post-operative complications
associated with CABG are frequent, and their presence significantly
increases hospital patient care costs. In addition, the hospital
patients\' care cost increases witih the number of complications.
Reducing the frequency of post-operative complications is one avenue to
achieve significant cost reduction in heart bypass surgery.

**Impact:** The results indicate that the VA may reduce the cost of
heart bypass surgery by reducing post-operative complications and
improving post-operative outcomes.

**\*161. Implementation and Evaluation of Telemedicine to Improve Health
Care**

[Bonnie Wakefield, PhD.]{.underline} VA Medical Center, Iowa City, IA.
[JR Flanagan, JP Specht]{.underline}

**Objectives:** Telehealth has the potential to enhance patient care by
increasing access to specialized and primary health care and decreasing
costs. However, much attention has focused on selecting and obtaining
equipment with little attention paid to issues surrounding integration
of the technology into the existing organizational and professional
culture and evaluating it\'s effectiveness in improving outcomes and
decreasing costs. For this project, telehealth is defined as use of
real-time interactive video applications to provide health care. The
goal of this program is implementation and evaluation of specific
applications: 1) Triage of patients in the Iowa Veteran\'s Home (IVH) by
primary care staff in the Urgent Care Clinic of the Iowa City VA Medical
Center (ICVAMC); and 2) follow up evaluation of patients in subspecialty
clinics.

**Methods:** Using a prospective design with historical controls,
current practice is compared to use of telehealth. Subjects include
patients and providers at the IVH and providers at the ICVAMC. The
outcome of the consultation (admission, clinic appointment, change in
treatment), length of the consult, equipment used, and qualifications of
the health care provider will provide data for cost analyses. Patient
and provider satisfaction is also being evaluated.

**Results:** For the Urgent Care study, we developed procedures and
pilot-tested the consultation process. We have subsequently encountered
difficulties in getting IVH providers to actually use the system for
referrals to and consultation with ICVAMC physicians. In contrast,
patients at the IVH have requested to be seen by ICVAMC physicians for
their follow-up clinic visits using telehealth. Data are being collected
on Urgent Care use by the IVH before and after availability of
telehealth consultations. Physicians at the IVH will be interviewed
using a semi-structured format to determine perceptions of telehealth
consultations. The sub specialty clinic study is currently in planning
phase, with the first test planned for October 1998. For the
sub-specialty study, we have identified the following clinics for
implementation:\> urology, neurology, and vascular.

**Conclusions:** Veterans at the IVH see the potential advantages of
telehealth care. Anecdotal evidence suggests a high level of patient
satisfaction with the consultation process using telehealth technology.
Primarily, these veterans prefer to avoid the 4-hour round trip to the
ICVAMC for clinic visits. Furthermore, anecdotal evidence suggests the
potential for improved processes of care. However, physician resistance
to use of telehealth care is a barrier to implementation.

**Impact:** For the VA health care system, and the public at large,
telehealth has the potential to increase access to specialized care
provided by physicians and other health professionals, enhance training
of health professions students, and provide patient and staff education.
Telehealth care can be provided through a local clinic or in the
patient\'s home in rural and urban settings. However, telehealth is not
a panacea for all access issues. Therefore, research such as this
project will help determine under what conditions and for which types of
patients telehealth will be most applicable and cost-effective.

**HSR&D Funded**: DEV 97-012

**\*162. Implementation of a Telehealth Nurse Consultation Wound
Clinic**

# [Sue Gardner, PhD(c), MA, RN.]{.underline} VA Medical Center, Iowa City, IA. [RA Frantz, JK Specht, JL Johnson-Mekota, KA Buresh, BJ Wakefield, JR Flanagan]{.underline}

**Objectives:** Telehealth has the potential to enhance patient care by
increasing access to specialized and primary health care and decreasing
costs. However, attention has focused on selecting and obtaining
equipment with little attention paid to users of the equipment. Consumer
and provider satisfaction is key to the continued use and expansion of
telehealth technology. For this project, telehealth is defined as use of
real-time interactive video applications to provide health care. The
objective of this program is implementation and evaluation of specific
telehealth applications between the Iowa Veterans Home (IVH) and the
Iowa City VA Medical Center (ICVAMC). This abstract describes
implementation of a Skin/Wound Nurse Consultation clinic.

**Methods:** The evaluation of the Skin/Wound Nurse Consultation Clinic
pilot-tested the equipment, procedures and evaluation instruments on 11
subjects. Immediately preceding an in-person consultation for patients
at the IVH, a second nurse expert at the ICVAMC conducted and taped a
chronic wound consultation via telehealth interaction. Data were also
collected on patient and provider satisfaction with the technology.

**Results:** The referring nurses at the IVH were satisfied (100%) with
both the telehealth and in-person consultations. Half of the patients
expressed satisfaction with the telehealth consultation and 40% were
satisfied with the in person consultation. Difficulty in hearing for the
patients was equal in both groups, which resulted in changes in the
consultation process. The patients\' difficulty in seeing the telehealth
consultant was addressed through larger screen monitors and strategic
positioning to provided easier viewing for the patient and provider.
Data on the concordance of the telehealth wound assessments between
in-person assessments and assessments completed from tapes of chronic
wounds are currently being analyzed.

**Conclusions:** Veterans at the IVH see the potential advantages of
telehealth care. Evidence suggests the potential for improved care via
this technology through increased access to care by nurse specialists,
enhanced training of staff and health professions students, and
provision of patient and staff education.

**Impact:** The ICVAMC implemented a monthly telehealth skin/wound
clinic based on what we learned from this pilot study. A very successful
public demonstration was held in June 1998 involving the Governor of
Iowa and other local officials, highlighting cooperative telehealth
efforts between state and federal agencies.

**HSR&D Funded:** DEV 97-012

# \*163. Implementation of Primary Care Principles in VISN 20

## Ann Sales, PhD, RN. VA Puget Sound Health Care System, Seattle, WA. J Tuchschmidt, F Mambourg

**Objectives:** The aim of this study was to examine the extent to which
facilities in VISN 20 have implemented principles of care management in
their primary medical and mental health care operations. All eight
facilities in VISN 20 submitted plans aligned with VA Care principles
which outlined steps for implementing principles of care management to
improve care coordination, increase efficiency, and increase primary
care providers\' accountability for care management.

**Methods:** Site visits were conducted at each of the eight facilities
in VISN 20. Site visitors represented VISN staff and management and
practicing clinicians in both primary medical and mental health care.
Structured interview protocols were used which allowed probing but
ensured comparability of information across facilities. Respondents
included senior level management in each facility, senior product line
or service managers for Medicine and Mental Health, practice managers
for both areas, and a clinical care team in primary medical care, and a
clinical care team in primary mental health care. The clinical teams
included providers and ancillary staff for each team. Extensive written
notes were taken during each set of interviews, and reports were
generated using a common format.

**Results:** Facilities in VISN 20 include a free-standing domiciliary,
a free-standing outpatient clinic, small and medium-sized facilities,
and two large tertiary medical centers. Number of veterans served range
from 6000 to 45000. Despite the diversity of facility types, common
themes emerged across the eight facilities, primary among them the
difficulty of organizing information and accounting systems to achieve
sufficient knowledge on the part of clinicians providing care to allow
them to take full responsibility for managing the care of their patients
across the continuum of care settings. Facilities varied widely in the
degree to which coordination of care between primary medical care
providers and primary mental health has been achieved, with some
facilities showing no evidence of coordination while others have
employed innovative means of integrating between the two areas of care.
There is a wide range among facilities in the number of patients
included in a full time primary medical provider\'s panel of patients,
ranging from about 350 to over 1100, with less variation in primary
mental health provider panel sizes.

**Conclusions:** The wide variation among VISN 20 facilities reflects
differing degrees of complexity, and differing areas of organizational
emphasis. A need for more infrastructure to support decision-making and
accountability at the level of individual providers and care teams, as
well as mid-level managers, emerges from the results of this study, but
also a need for shifts in attitudes and expectations of accountability
for care management.

**Impact:** Managers in Networks and facilities are likely to find the
themes discovered through these site visits useful in implementing VA
Care principles. The issues being faced by VISN 20 facilities are
analogous to those being faced throughout VHA as we make the transition
from more centralized control of resources to managing care at more
local levels.

**\*164. Integrating Primary Care into Mental Health Services: An
Assessment of Feasibility and Barriers to Implementation**

##### BA Jaworski, BS Mittman, JA Pyne, EP Schten, JB Lohr, SA Bozzette

**Objectives:** The ongoing reengineering of the Veterans Health
administration has produced a broad range of innovative proposals and
approaches to delivering healthcare services in an effective, efficient
manner. An important group of innovations comprises programs designed to
improve access and care delivery for traditionally under-served groups,
including the homeless and mentally disabled. We assessed barriers to
acceptance and implementation of a pilot VHA healthcare delivery program
in which psychiatrists provide both general medical (primary care)
services and psychiatric care to seriously mentally ill patients in
outpatient mental health clinics. Development of the pilot program was
motivated by the large number of community-based seriously mentally ill
patients who successfully access VHA mental health clinics on a
recurring basis, but for whom efforts to encourage primary care visits
to the VHA general medical clinics have failed.

**Methods:** Physician and support staff views toward the integrated
delivery model before and during its implementation were assessed
through focus groups, semi-structured interviews and written surveys.
The focus groups and approximately one-half of the interviews were
audiotaped; detailed notes were taken via laptop computer during the
remaining interviews. Audiotape transcripts and computer notes were
coded and analyzed qualitatively to (1) identify and classify positive
and negative views toward the general concept of integrated primary
care/mental health delivery, and (2) document attitudes and reactions to
the specific implementation of this concept represented by the pilot
program.

**Results:** Reactions to the general concept of integrated
primary/mental health care and the pilot implementation effort varied.
Views regarding the general concept were more favorable than reactions
to the specific pilot implementation. Attending and resident
psychiatrists expressing favorable views toward the general concept and
the pilot project tended to be younger and with more recent medical
training than those expressing unfavorable views. Specific barriers to
acceptance and implementation of the pilot integrated model included:
(1) resource limitations (e.g., professional and support staff time,
clinic space needs), (2) psychiatrist acceptance and comfort with the
integrated model (particularly in regard to its implications for their
patient care roles and responsibilities and their training and technical
proficiency in primary care), (3) professional and support staff
training, (4) logistical issues (patient scheduling) and (5) patient
acceptance.

**Conclusions:** Barriers to implementation of integrated primary
care/mental health delivery programs within VHA are significant but
appear to be surmountable with adequate resources, a careful
restructuring of day-to-day clinic operations, and thoughtfully designed
interventions and tools to facilitate and support psychiatrist
acceptance and preparation for expanded clinical responsibilities.
Barriers associated with psychiatrist comfort and acceptance may be the
most difficult to overcome, although the magnitude of these barriers is
greater for some psychiatrists than others. Implementation of an
integrated model of care constitutes a significant organizational and
professional change, requiring extensive planning, broad support by
clinical and administrative leaders, and a thorough understanding of-and
attention to\--a broad range of issues and potential barriers.

Impact: VHA efforts to reorganize healthcare delivery for seriously
mentally ill patients should take account of these findings and approach
subsequent implementation efforts accordingly.

**HSR&D Funded:** Yes (no number given)

**\*165. Lung Volume Reduction Surgery for Emphysema: Initial Results
from the Veterans Affairs Puget Sound Health Care System - Seattle**

## HF Huizenga, E Vallieres, RB Goodman, S Lakshminarayan, T Torey, KA Kierland

# Objectives: Lung volume reduction surgery is currently being evaluated as a treatment for chronic obstructive pulmonary disease. We report our experience to date in performing lung volume reduction surgery at the Veterans Affairs Puget Sound Health Care System- Seattle. 

**Methods:** Single center case series of patients undergoing lung
volume reduction surgery. pre-operative and post-operative pulmoanry
function test comparisons were made using paired t tests.

**Results:** 52 patients with severe emphysema have undergone lung
volume reduction surgery since May 1995. The mean age of the patients
was 65 and they ranged from age 49 to age 75. All were male.
Pre-operative forced expiratory volume at 1 second (FEV1), a commonly
used measure of lung function, ranged from 0.44 to 1.86 liters (mean
0.88) or from 13 to 46% (mean 25%) of predicted norms. 55% of patients
were dependent on supplemental oxygen prior to surgery. Overall 30 day
mortality has been five percent. Length of stay has ranged from 4 to 87
days with a mean of 17.8 and a median of 11 days. Complete three month
follow-up pulmonary function testing results are available for 31
patients. These test results demonstrated statistically significant
improvements in FEV1 (mean 0.88 pre-operatively to 1.13 liters
post-operatively) , forced vital capacity (2.8 liters pre-operatively to
3.1 liters post-operatively) , residual volume (6.1 liters
pre-operatively to 4.5 liters post-operatively), and total lung capacity
(9.5 liters pre-operatively to 8.0 liters post-operatively).

**Conclusions:** The experience to date with lung volume reduction
surgery at the VAPSHCS-Seattle demonstrates that the results of the
surgery in the VA population are comparable to previously published
series of non-veterans undergoing the procedure at non-VA institutions.
Further studies are ongoing to identify whether these improvements in
pulmonary function test results translate into improved exercise
performance and health-related quality of life, and to determine the
costs of the procedure and associated care in the VA hospital setting.

**Impact:** Veterans undergoing lung volume reduction surgery have
outcomes comparable to non-veterans with respect to peri-operative
mortality, length of stay, and improvements in pulmonary function test
results.

**HSR&D Funded:** II 96-024

**\*166. Measuring Self-Efficacy for an HIV Disease Management
Intervention**

# [Marty Shively, PhD, RN.]{.underline} VA San Diego Healthcare System, San Diego, CA [A Gifford, J Bormann, D Timberlake, S Bozzette]{.underline}

**Objectives:** Self-efficacy is an important determinant of health
behavior change/outcomes in veterans and non-veterans with chronic
illness, but little is known about how to measure self-efficacy in
persons with chronic HIV. This study evaluated the psychometric
properties of an HIV self-efficacy instrument in 144 persons who are
HIV+ and symptomatic.

**Methods:** The HIV Self-Efficacy instrument is self-administered and
based on the work of Lorig et al. (1996). The instrument has 37 items.
Conceptual domains are communicating with health care provider (4
items), managing HIV illness in general (3 items), managing symptoms (5
items), managing depression/mood (9 items), managing fatigue (4 items),
getting support (5 items) and managing medications (7 items).
Self-efficacy items are scored on a 10-point Likert scale. Items are
summed for 7 subscale scores and a total score; the higher the score the
greater the self-efficacy. Internal consistency reliabilities
(CronbachÆs alpha) were calculated for each subscale and the total
score. Factor analysis was also done to evaluate construct validity.
Bivariate analyses were done between the self-efficacy subscales, health
behaviors, and illness impact to assess construct validity.

**Results:** The majority of subjects were male (85%), Caucasian (61%),
unemployed (73%), completed at least some college (61%), and reported
HIV exposure to be sex with an HIV-infected man (67%). Construct
validity was assessed using principal components factor analysis with
the 37 items. Four factors were retained; these factors had eigenvalues
greater than one and accounted for at least 5% of the variance. The
first factor accounted for 40% of the variance and had items with
loadings \> .48 (managing HIV illness in general, managing symptoms,
managing depression/mood, managing fatigue, and getting support). The
second factor accounted for 12% of the variance (communicating with
healthcare provider). Significant bivariate correlations were found
between each subscale score and appropriate health behaviors, e.g.,
self-efficacy to manage fatigue and number of days spent in bed (r = -.
42, p\<.01) and self-efficacy to manage in general and illness impact (r
= -.30, p\<.01).

**Conclusions:** Subjects report moderate to high self-efficacy in all
domains. This instrument shows good preliminary psychometric properties.
It is being tested with a total of 200 HIV+ persons who are
participating in a randomized clinical trial of an HIV disease
self-management program.

**Impact:** This HIV Self-Efficacy instrument should be used in future
studies to evaluate patient education interventions and outcomes. It may
also be useful in clinical settings to evaluate patientsÆ confidence to
manage their own symptoms and their medication regimens.

# \*167. Methodological Issues in Meta-Synthesis of Qualitative Research

## Gail Powell-Cope, PhD, ARNP. James A. Holey VA Medical Center, Tampa, FL. J Barroso

**Objectives:** The purpose of this paper is to discuss the process of
meta-synthesis and issues that arise when conducting a meta-synthesis of
qualitative studies, in this case, about adults living with HIV
infection. Little discussion is evident in the literature about the
processes for conducting meta-syntheses. Therefore, based on few models
in literature, we developed a method to synthesize a body of qualitative
research.

**Methods:** The first step in beginning this project was to build a
team with expertise and experience in conducting qualitative research
and in the subject matter of interest. The next step was to run
extensive computer searches to identify as many published qualitative
studies as possible. Searches were run using a wide range of descriptors
and using multiple data bases. Any research that was qualitative and
dealt with HIV infection or AIDS was retrieved. At this point decisions
were made to define boundaries that would reflect the specific purpose
of the meta-synthesis. For example, studies conducted outside of the
U.S. were excluded. The purpose of the meta-synthesis became focused on
understanding the experience of adults living with HIV infection. To
further determine the acceptability of studies we used a group of
standards for critique of qualitative research (Burns, 1989) to develop
a four-page check-list reflecting essential elements of qualitative
studies. Each article was reviewed to determine its quality and those
that did not meet a majority of the standards were excluded. The next
step was to list the major findings for each study along with critical
methodologic information, for example, characteristics of the sample.
The final challenge was to develop overarching metaphors that would
account for similarities and dissimilarities across study findings. The
goal was to integrate the entire set of findings into a parsimonious,
cogent, powerful, and credible whole.

**Results:** Findings from 21 studies were categorized into six
overarching metaphors: The Meaning of Living with HIV, Human
Connectedness, Focusing on the Self, Negotiating Health Care, Protection
from Stigma, and The Dark Side of HIV.

**Conclusions:** Major challenges in conducting this meta-synthesis
were: 1) developing effective strategies to make sense of a specified
body of literature, in this case, of studies about adults living with
HIV infection, and 2) remaining focused on the interpretative process of
qualitative research without becoming lost in procedural requirements.
Further methodological work is needed to refine this process.

**Impact:** As increasing numbers of qualitative studies of interest to
health services researchers are conducted, researchers are challenged to
develop sound methods to synthesize findings to provide direction for
further research and for clinical practice. Meta-analysis of
quantitative studies is considered by many the gold standard for what
counts as evidence for evidence-based practice. However, qualitative
researchers are beginning to debate this assertion. Findings from
qualitative research provide useful evidence for clinical practice
recommendations because they provide the patient perspective.

\***168. Michigan Diabetes Outreach Networks (MDONs): A Public Health
Approach to Improve Diabetes Care and Outcomes**

# [SL Krein, ML Klamerus, L Schwartz, E Watt, A Scott]{.underline}

**Objectives:** Michigan Diabetes Outreach Networks (MDONs) are part of
a statewide effort to reduce morbidity and mortality related to diabetes
by establishing collaborative partnerships between individuals with
diabetes, health care providers (including the VHA), and the public
health community. Each of the regional networks is a unique example of a
public health approach to improve diabetes care through patient and
professional education, improvements in care delivery and the
implementation of a continuous quality improvement (CQI) system. Using
both qualitative and quantitative data we examine and discuss several
issues associated with developing an outreach system to improve care for
individuals with diabetes.

**Methods:** Data were collected through semi-structured interviews with
the DON directors, key informants, and program officials at the Michigan
Department of Community Health. Process and outcome data are from client
baseline and six month follow-up forms, which are a key part of the CQI
system.

**Results:** Although the six networks have a common blueprint, each has
many unique features including the strategies used for developing a
regional network for diabetes care, the types of participating agencies,
and the enrolled population. Some of these characteristics are related
to the diverse geographic composition of each region, while others seem
to reflect the philosophy of the network staff and the regional advisory
council. Key aspects in developing DONs include: 1) establishing the
network as an independent entity; 2) having a committed, well-connected
network director; and, 3) demonstrating that the network is a valuable
educational and quality improvement resource. As part of the quality
improvement component, baseline data have been collected on over 10,500
persons. Six month follow-up data are available for over + of those
enrolled. Preliminary analyses based on those with both intake and
follow-up data show that 14% of those without a hemoglobin A1c
measurement at baseline had one at follow-up; 62% without a diet and/or
exercise plan at baseline had one at follow-up; and, 42% of those
referred for a dilated eye exam reported having an exam in the months
between baseline and follow-up.

**Conclusions:** The MDON model may be a promising population-based
approach for improving the care of many individuals with diabetes and/or
other chronic conditions. Through the experiences and insight of those
involved in developing MDONs there are many valuable lessons that can be
used to inform similar efforts. Moreover, it is encouraging to note that
with a minimal amount of resources, productive partnerships and
networking can be achieved to improve care for persons with diabetes.

**Impact:** Diabetes is a costly chronic condition that is prevalent in
the veteran population. Identifying effective ways to improve care and
outcomes for individuals with diabetes is important. The MDON model
demonstrates how partnerships, which include both private and public
health care providers, can be developed and how a quality improvement
data system can be implemented to try to improve any chronic disease
care, as has been demonstrated with diabetes care. Participating in
programs such as MDONs may provide the VHA with an effective and
efficient outreach strategy to improve care for many veterans with
diabetes.

\***169. Modification of Self-Monitoring of Blood Glucose (SMBG) Testing
Frequency in Stable Type II Diabetics on Oral Agents or Diet Therapy**

# [Joy Meier, PharmD.]{.underline} VANCHCS, Martinez, CA. [JR Lopez, ALM Swislocki, RH Noth, D Siegel]{.underline}

**Objectives:** VA Medical Advisory Panel Guidelines for Pharmacologic
Management of Diabetes Mellitus (DM) recommend that stable diabetic
patients controlled on oral agents perform SMBG twice-weekly. More
frequent testing is allowed in patients with hypoglycemia unawareness,
for a limited time period in newly diagnosed diabetics and during
initiation or active adjustment of oral medications. Twice-weekly SMBG
represents a= change in usual testing frequency in our patients.

**Objectives:** To 1) determine baseline frequency of SMBG in diabetic
patients on oral agents or diet therapy alone, 2) modify SMBG frequency
in this patient population to reflect current recommendations, and 3)
determine the cost-savings associated with this change.

**Methods:** To determine SMBG testing frequency by type of drug therapy
(insulin, oral hypoglycemic, oral hypoglycemic with insulin, or no drug
therapy), researchers analyzed prescriptions for blood glucose
monitoring strips filled over a six-month period (7/1/97 to 12/31/97)
and related this data to both oral hypoglycemics and insulin filled over
an 11 month period (4/1/97 to 2/28/98) using Access(TM) and Excel(TM). A
letter sent to all patients on oral hypoglycemic therapy or diet therapy
only outlined instructions to reduce SMBG testing frequency to two or
three times weekly and prn for symptoms of hyper- or hypoglycemia.
Between April and May 1998, pharmacists changed these patients\' BG
strip prescriptions to 50 strips for 90 days, but contacted the
patient\'s provider prior to making these changes for diabetic patients
testing more than once daily and for those with recent adjustments in
drug therapy. Researchers calculated average monthly cost savings as the
difference in the average monthly expenditures for the three months
prior to conversion vs. three months after conversion. Researchers will
compare study patient\'s baseline average Hgb A1c to average Hgb A1c
obtained during the six months following the conversion.

**Results:** 2532 Type II diabetics received SMBG strips during the
study period. The average SMBG testing frequency was 1.33
strips/patient/day for diabetics on oral hypoglycemic agents only
(n=1213), and 1.06 strips/patient/day for patients controlled on diet
alone (n=255). Hemoglobin A1c was obtained on 1067 study patients during
the six-month period prior to the conversion. Average baseline Hgb A1c
was 7.82% for patients on oral hypoglycemic agents (n=913) and 6.85% for
patients controlled on diet therapy (n=154). Patients (n=1460) received
a letter with instructions on the current testing frequency, and were
successfully switched resulting in an average monthly cost savings of
\$9400.

**Conclusions:** We successfully decreased the frequency of SMBG in Type
II diabetics resulting in substantial cost savings. The impact of these
changes on diabetic control will be determined.

**Impact:** The VA could realize considerable cost-savings if this
program were followed nation-wide.

**\*170. National Patient Care Database: Uses for Outcomes Research**

# [Mike Kerr, BS, MA, Diane Cowper, MA, Denise Hynes, RN, PhD, and Joseph Kubal, MA.]{.underline} Hines VA Hospital, Hines, IL. [JM Palmer]{.underline}

**Objectives:** The primary objective of this informational poster is to
document the objectives and processes involved in creating the national
patient care database, NPCD.

**Methods:** Resource materials were gathered from the Austin Automated
Center (AAC), which is the VA\'s corporate data warehouse, the National
Patient Care Database internet web page and through attendance at the
VA\'s Information Technology Conference (ITC98). Personal meetings,
phone and e-mail conversations provided fuller explanation of the
history and design objectives for NPCD. Individuals spoken to included
Gregg Seppala, a major architect of the NPCD, Sam Georgeson, Director of
the VHA-CIO Liaison Office and the principal manager of NPCD, Catherine
Pfeil, Program Manager OCIO and Dave Brown, Database Administrator for
NPCD.

**Results:** NPCD has developed a patient centered database which allows
for analysis across health care services or programs. The processes
involved included mandating the electronic capture of full diagnostic
and procedural data for outpatients and combining the best elements of,
and then eliminating the data flow to, 4 existing VHA national patient
databases: Patient Treatment File (PTF), Outpatient Clinic File (OPC),
Event Driven Reporting (EDR), and the Integrated Patient Data Base
(IPDB). The traditional formats for PTF and OPC remain, but they are fed
data from the NPCD tables creating a single data source and removing the
inconsistencies which had existed among these other databases.

**Conclusions:** In NPCD, VA has developed a patient centered database
which links diagnoses to procedures across inpatient and outpatient
programs. This represents a much needed broader scope to outcomes
analysis. However, Health Services researchers need to link diagnosis
with laboratory results and pharmacy dosages for a great deal of
outcomes analysis. The incorporation of these two treatment parameters
within NPCD remains to be developed. Because the NPCD is not currently
at production level, that is, it is not an on-line system with complete
data, analysis of system performance (data processing speed) is
incomplete. Further, the specifics of the Graphical User Interface (GUI)
are not, as yet developed.

**Impact:** Diagnosis provides for identifying a patient population.
Treatments and results data provide for the outcomes analysis of
identified populations. The incorporation of other treatment parameters
such as lab and pharmacy will determine the extent of usefulness of NPCD
to the Health Services Research community.

**HSR&D Funded:** SDR 98-004

\*171. Non-equivalent Control Group Study Using Soap and Towel
Consumption Measurements to Detect a Transient Increase in Handwashing
Associated with Simple Feedback in an Adult Intensive Care Unit

# [Marvin Bittner, MD.]{.underline} VA Medical Center, Omaha, NE. [EC Rich]{.underline}

**Objectives:** Despite handwashing\'s importance, compliance is poor.
Limitations of improvement efforts include complexity of interventions
and monitoring. We sought to improve handwashing with simple feedback
and to monitor its impact by measuring changes in soap and paper towel
consumption.

**Methods:** During a baseline period (May 12-June 26), we randomly
scheduled 4-hour weekday daytime observation sessions in an 8-bed,
5-sink Medical Intensive Care Unit (MICU, 31 sessions) open room and a
9-bed, 3-sink Surgical Intensive Care Unit (SICU, 33). Observers counted
handwashing episodes (1461 in MICU, 1545 SICU) and measured soap and
paper towel consumption. We performed linear regression through the
origin (dependent variable, handwashing episodes (HE); independent, soap
and towel measurements). Using regression coefficients, we estimated
each day\'s HE from weekday daytime soap and towel use May 12-October 6
(102 observation days). Starting June 29 (feedback period, 69
observation days), we provided weekly handwashing feedback to the SICU
but not the MICU. Feedback involved a bar chart showing the most recent
5 weeks\' handwashing, posted at the central desk and placed in nurses\'
mailboxes.

**Results:** Regression models (MICU r-squared 0.977, SICU 0.972)
retained changes in grams of soap (MICU coefficient 0.08617, SICU 0.218)
and towels (MICU coefficient 0.110, SICU 0.05456), with p \< 0.001 (all
parameters). Compared to baseline period (MICU mean 2.20 HE/occupied
bed-hour, SICU 1.96), feedback period handwashing dropped in the control
unit (MICU -0.59 HE/occupied bed-hour) but rose over 10% in the
intervention unit (SICU +0.28). The 95% confidence interval for the
difference in changes was 0.59 to 1.14 (p \< 0.001). MICU handwashing
was less than baseline in the first third of the feedback period (1.65
HE/occupied bed-hour; p=0.01; 95% confidence limits for the difference
0.23, 0.88), the middle third (1.53;p\< 0.001; 0.35, 0.98), and the last
third (1.66; p = 0.007; 0.16, 0.94). SICU handwashing trended down in
the first third (1.67; p = 0.08; -0.04, 0.63), exceeded baseline in the
middle third (2.92; p \< 0.001; 0.47, 1.45), and approached baseline in
the last third (2.13; p = 0.398; -0.54, 0.22). Handwashing was
negatively correlated with average bed occupancy in both the MICU
(Spearman r = -0.289, p = 0.01) and SICU (Spearman r = -0.392, p =
0.01).

**Conclusions:** Simple feedback, based on handwashing estimated from
soap and towel consumption, was associated with increased estimated
handwashing, compared to a control unit. However, the effect was
transient. In the control unit, withdrawal of handwashing observers
after the baseline period was associated with a drop in handwashing.
Despite the proximity of the units, evaluation of the feedback
intervention was not obscured by \"contamination\" of the control unit.
Soap and towel handwashing monitoring could be sustained over four
months. A higher workload was associated with less handwashing.

**Impact:** Soap and towel consumption can monitor handwashing for
sustained periods, evaluating improvement programs and detecting
problems. Simple feedback can improve handwashing for a limited time.
Additional interventions might produce more sustained effects.
Controlling workload might increase handwashing. By improving
handwashing, these measures can reduce nosocomial infections.

\*172. Patient Factors Associated With Poor Quality Medication
Management for Schizophrenia

# [Alexander Young, MD, MSHS.]{.underline} West Los Angeles Veterans Hospital, Los Angeles, CA. [G Sulivan]{.underline}

**Objectives:** Schizophrenia is a severe, chronic disorder that
accounts for 10% of permanently disabled people and 2.5% of all US
health care expenditures. Ongoing changes in the organization and
financing of mental health care have renewed concerns about the quality
of care being provided for schizophrenia. Using Donabedian\'s model and
established guidelines for best practice, researchers have developed
methods that measure the quality of care for this disorder. These
methods have revealed that treatment quality for schizophrenia is often
poor, and that quality improvement interventions are needed. There is,
however, limited research that can inform the design of these
interventions. In particular, it would be helpful to know which patients
are at increased risk for poor quality care. Understanding which patient
factors are associated with poor quality care can help identify aspects
of treatment process that become the focus of quality improvement
interventions.

**Methods:** We randomly sampled 224 patient in treatment for
schizophrenia at one VA mental health clinic and one non-VA public
mental health clinic. Appropriate medication management was defined
according to criteria derived from national treatment recommendations.
Quality of medication management of symptoms and side-effects was
evaluated using an established method, and based on data from patient
interviews and medical record abstractions. A literature review
identified patient factors to be studied. Multivariate logistic
regression was used to study the effect of each patient factor on poor
quality care, controlling for clinic site and treating physician.

**Results:** Patient, physician and clinic factors each had a
significant effect on the odds that a patient would receive poor quality
care. Physicians were more likely to provide poor quality care if they
had fewer patients with schizophrenia in their practice, or were not
currently in residency training. Patients were more likely to receive
poor quality symptom management if they were male, hostile, or poorly
compliant with treatment recommendations. Patients were more likely to
receive poor quality side-effect management if they were minority, had
been ill longer, or were hostile.

**Conclusions:** Patients, providers and treatment organizations are all
reasonable targets for quality improvement interventions in
schizophrenia. Research is needed to determine whether outcomes can be
enhanced by (1) improving the management of hostile, chronically ill,
and poorly compliant patients; (2) increasing physician use of
appropriate prescribing practices; and (3) directing patient to
high-volume providers. However, improving care can be quite challenging,
and quality improvement interventions may be more effective if we can
better understand problems in the process of care for this disorder.

**Impact:** Managers and researchers who wish to enhance outcomes in
schizophrenia should study the role of patient factors in the provider -
patient interaction, and use this information as they develop
interventions to improve the process of care.

**HSR&D Funded:** Yes (no number given)

**\*173. Patient Preferences For Recovery of Activities after Hip
Fracture**

## Richard Marottoli, MD, MPH. VA Conecticut, West Haven, CT. P Peduzzi, J Concato, T Fried, S Bogardus, M Tinetti

# Objectives: To deterrmine the extent of recovery at 6 months after hip fracture, a patient-generated list of activities they would \"most like to be able to do\" again was compared with standard scales of instrumental and basic activities of daily living (IADL/ADL). 

**Methods:** The study included 304 non-demented subjects age 65 years
and older who had surgical repair of a hip fracture at 2 New Haven area
hospitals between May 1, 1993 and September 30, 1995 and returned home
within 3 months. During the hospitalization, subjects were asked to list
up to 5 activities they would most like to be able to do again after
their rehabilitation, as well as standard scales of IADL and ADL. Extent
of recovery (using both methods) was assessed at 6 months.

**Results:** IADL and ADL items accounted for 54% of patient-generated
preferences, whereas other higher level activities accounted for the
remaining 46%. Recovery in preference items was modestly correlated with
change in ADL (r = .45) and IADL (r = .54) scores.

**Conclusions**: Patient-generated preferences identified a substantial
number of activities not captured by standard activity scales.

**Impact:** Direct assessment of patient preference offers an
alternative or adjunct to standard activity scales as a measure of
functional recovery. Although the ability to compare individuals
directly or to pool results across studies is limited, potential
advantages include improved efficiency and the ability to focus
rehabilitation efforts, as well as the assessment of their
effectiveness, on what is important to each patient.

\*174. Patient Satisfaction, Quality of Life, and Reasons for Seeking
Care in Veterans Affairs Medical Centers among Lower Socioeconomic
Status Men with Prostate Cancer

##### SJ Knight, PR Yarnold, S Kim, D Falcone, T Kuzel, CL Bennett

**Objectives:** Because currently there is no evidence that any medical
treatment provides optimal survival benefit in metastatic prostate
cancer, a manÆs satisfaction with treatment is an important outcome
indicator. The purpose of this research is to examine patient
satisfaction, its relationship to quality of life (QOL), and reasons for
seeking VA health care among men with metastatic prostate cancer of low
socioeconomic status cared for in Veterans Affairs (VA) medical centers.

**Methods:** In the first study, participants were 103 men with stage D2
prostate cancer cared for in four VA medical centers. Inclusion criteria
required that the men had received an orchiectomy or hormonal therapy at
least 28 days before the study interview. The satisfaction measure
included twelve items adapted from the Medical Outcomes Study. QOL
instruments included the European Organization for Research and
Treatment of Cancer Quality of Life Questionnaire and the Functional
Assessment of Cancer Therapy Scale. In a second study, an independent
sample of 105 men diagnosed with prostate cancer at any stage and cared
for in two VA clinics completed a brief survey of reasons for seeking
care in the VA health care system.

**Results:** In the first study, participants had an average age of 71
years and a majority (62%) was African American. The men were highly
satisfied with their VA care overall and with their doctorsÆ
interpersonal qualities, but were least satisfied with the time spent
waiting in clinic to see the doctor. Higher scores on satisfaction with
convenience of doctorÆs hours and access and the doctorÆs courtesy, and
lower scores on thoroughness of care, were associated with better scores
for physical and functional well-being and satisfaction with doctor
relationship and lower scores for social functioning. In the second
study, participants, similar to the first sample in sociodemographic and
medical characteristics, attributed their transfer to VA medical care to
concerns about the cost of treatment, particularly the expense of
hormonal therapies.

**Conclusions:** The results suggest that, while men were highly
satisfied with VA care, they were least satisfied with their wait in
clinic for their doctor. Some aspects of satisfaction were more
important than others, however, depending on QOL. Patients with good
physical and functional status, but with cancer-related disruption to
social activities, are satisfied with the doctor relationship when
access to care is convenient, doctors are courteous, the diagnostic
tests are thorough, and routine treatments are less thorough. Because
hormone therapy cost is a frequent reason for seeking VA medical care
for prostate cancer, these results may be especially relevant to the VA
where visits can last a half-day for a single injection of hormonal
treatment. For men with metastatic prostate cancer, good physical and
functional status, and disruption in social activities, less time in the
clinic for routine treatment may yield greater satisfaction.

**Impact:** This study provides important information on prostate cancer
patient satisfaction in the VA and has implications for outcomes
assessment, particularly that QOL should be considered in satisfaction
measurement.

## **\*175. Pilot Study of the Effectiveness of Telepsychiatry Treatment in the Upper Mid-west**

# [BD Berger, SE Kerr, D Cory, SO Kidd, J Lehrmann]{.underline}

**Objectives:** A number of studies have been reported which show the
increasing use of telemedicine in the treatment and assessment of a
variety of medical problems including mental illness. Anecdotal studies
of mentally ill patients suggest that providing treatment via video
conferencing is better than providing no or delayed treatment for
remote, under served populations. However, there are no studies to date
that have evaluated telepsychiatric treatment using a comparison group.
The following study is designed to evaluate differences between subjects
treated face-to-face (FTF) for mental illness as compared to
long-distance treatment of mental illness using a tele-video-audio
conference (TVAC) system \[telepsychatry\].

**Methods:** A total of 60 subjects are being selected into 2 groups who
are referred for outpatient psychiatric medication evaluations and
ongoing treatment. Group 1 will include 30 veterans living in the
Milwaukee, WI area receiving psychiatric treatment at the Zablocki VAMC.
Group 1 will be matched by diagnosis (equal percentages of diagnoses per
group) to Group 2 who will consist of 30 subjects who live in the Iron
Mountain, MI area receiving psychiatric treatment via TVAC at the Iron
Mountain, Michigan VAMC. TVAC equipment is utilized which provides full
motion sound and video via a 384k bps phone connection. The same
psychiatrist will treat both groups to avoid provider differences. Group
2 are accompanied in each session by a psychiatric RN. Subjects are
administered a satisfaction survey, a quality of life inventory, and the
Behavior Symptom Inventory at the time of the initial assessment and at
the next 2 follow-up visits. Difference scores from the baseline
assessment and at each follow-up visit will be compared between the
groups. Data analysis will involve comparisons between the groups over
time on all of the questionnaires administered using a repeated measures
2 X 2 (group by time) MANOVA statistic.

**Results:** It is hypothesized there will be no significant differences
between groups over time of treatment. Data collection began in the
spring of 1998 with a total of approximately 20 subjects collected by
October 1, 1998. It is anticipated that for the poster presentation
there will be data for 15 to 20 subjects per group. Issues related to
statistical power with a small sample will be addressed.

**Conclusions:** Anecdotal evidence has suggested that using TVAC may be
more viable approach to providing treatment to patients in rural under
served populations. The current study will provide some initial data to
investigate symptom changes, quality of life, and patient satisfaction
between psychiatric treatment administered via traditional FTF versus
TVAC technology. If the results are consistent with hypotheses and
telepsychiatric treatment is equivalent to FTF on these measures it
would hopefully stimulate further investigation and expansion of the use
of this technology.

**Impact:** It is expected that if TVAC is shown to be effective and as
the cost of this technology decreases, it will be expanded and improved
providing even better access for under served populations. Improved
access and continuity of treatment would be expected to reduce the
incidence of crisis treatment and inpatient hospitalization in a
psychiatric population.

\***176. Primary Care Delivery in VHA Satellite Outpatient Clinics
(1993-96)**

# [Elizabeth Yano, PhD, MSPH.]{.underline} VA Greater Los Angeles Healthcare System, Sepulveda, CA.

# [I Gonzalez, AB Lanto, B Simon, LV Rubenstein]{.underline}

**Objectives:** VHA has supported local VA healthcare systems\' efforts
to facilitate access to VA healthcare services for current users by
opening new community-based outpatient clinics to bring the point of
service within closer proximity to veterans and to enhance their primary
care capacity. We evaluated the changes in primary care delivery in
satellite outpatient clinics (SOCs) from 1993 to 1996 to gauge the
effects of policy and practice initiatives to enhance accessible primary
care delivery in the community.

**Methods:** We surveyed all SOCs using the 1993 VHA Managed Care Survey
(n=50) and the 1996 VHA Survey of Delivery Models for Primary Care
(n=67) regarding their location, infrastructure, reporting arrangements,
team composition and referral practices. SOCs were defined as
community-based outpatient clinics with over 25,000 patient visits/year.
Survey data were linked to VA administrative data to extract numbers of
unique patients. We compared changes within existing SOCs using paired
sample t-tests and among all SOCs using independent samples t-tests.

**Results:** SOCs were primarily located in large urban (40%) and small
city (53%) areas. The number of SOCs increased from 50 in 1993 to 67 in
1996 (34% gain). By 1996, the increase in the number of SOCs realized an
average gain in the number of veterans served, although early SOCs lost
an average of 234 patients (p\<.05), with large variations incurred at
individual sites. Staffing patterns remaining relatively stable, with
increases in dietitians (p\<.05), slight increases in numbers of
generalist and specialist physicians, physicians\' assistants and nurses
(NS), declines in local primary care leadership among existing SOCs
(p\<.05), as well as in social work (p\<.05) and pharmacy (p\<.01)
positions. By 1996, subspecialists were more likely to be providing
primary care (p\<.05), more nurse practitioners (p\<.001) and
physicians\' assistants (p\<.05) were used, with SOC providers assuming
more responsibility for the overall health of their patients (p\<.05)
and being more likely to report to the primary care program than their
professional discipline (p\<.01). SOCs were also more likely to have
written procedures for notifying their providers of admissions (p\<.05),
but less so for managing specialty referrals (41.9% vs. 30.3%).

**Conclusions:** These larger community-based clinics have become more
primary care-oriented, increasing the proportion of resources devoted to
primary care and the local management and accountability of staff by
realigning staff to the primary care practice, rather than distant
departments. They have increased the patient base seen by VA
practitioners. Not all SOCs have been equally successful in carrying out
their primary care mission. More research is needed to assure that this
diffusion of existing resources across increasingly remote sites
demonstrates the same performance standards as larger care centers,
maximizing lessons learned at high-quality sites, so the investment in
access pays off for veterans and their providers.

**Impact:** This research will provide a basis for VA facilities to
enhance their planning, design and management of larger community-based
outpatient clinics.

**HSR&D Funded:** MPC 97-012

\***177. Private and Public Sectors Purchase of Behavioral Healthcare
Benefits: A Comparison of Quality Based Behavioral Healthcare Purchases
in the VA and in the Private Sector**

[Russell Burton, PhD.]{.underline} North Little Rock VA Medical Center,
North Little Rock, AR. [KM Rost]{.underline}

**Objectives:** Recent research is beginning to suggest that quality
behavioral healthcare influences the use, cost, and outcomes of
behavioral healthcare, including worker productivity. However, the
process by which the VA and other large corporations use quality
indicators in their purchase of a behavioral healthcare product is
relatively unknown. Thus, the purpose of our current paper is to
describe and compare the decision-making processes regarding the
provision of behavioral health insurance benefits in the VA with those
in other large scale private sector organizations.

**Methods:** From the Dun and Bradstreet's Business Directory of U.S.
Businesses we drew a sample representative of this country's 2,895
corporations with 5,000 or more employees (excluding educational
services û schools; public administration û state, local and federal
governments; and the U.S. postal service). Between the first of June and
the last day of October 1998, 70 percent of the samples 44 corporations
participated in the study (N = 31). Although a 70 percent response rate
initially appears low, this response rate is 8 to 20 percentage points
above response rates in corporate behavioral health benefits research,
and only 4 percentage points below the Bureau of Labor Statistics annual
Employee Benefits Survey. In order to make a comparison of the VA's
purchase of behavioral healthcare with this nationally representative
sample of corporations, we administered the same instrument to a top
federal government executive who directs the federal governments
purchase and provision of healthcare. Our main variables of interest
are 1) the corporate use and value of quality indicators in their
purchase of their most popular behavioral health care plan, and 2) an
ideal \"wish list\" of quality indicators corporations would like to use
in their next purchase of behavioral health care.

**Results:** Results show that the quality indicators used by the
federal government in their purchase of their most popular behavioral
health plan differ from those of large private corporations in the
consideration of plan reputation, the ability to process claims, the
geographic fit of the network, accreditation, projected costs, and
evidence that the plan does not reduce quality to save costs. Results
also show that the \"wish list\" of quality indicators used by the VA
differ from those of large private corporations in the consideration of
plan reputation, the number and type of customers, accreditation, and
evidence that the plan reduces behavioral health symptoms and improve
work functioning.

**Conclusions:** Taken together these data indicate to us that the
federal government relies on a \"free market\" approach, while private
corporations tend to use more of a \"managed competition\" approach.
These two approaches seem to be associated with the types (and value) of
quality indicators that are being used in the behavioral health care
purchasing decision.

**Impact:** These data have allowed us to identify key indicators of
quality which are used in the behavioral healthcare decision-making
process, and how these uses differ from the VA to the private sector.
Future research needs to determine how these key elements predict the
purchase of cost effective care.

\***178. Reducing Inpatient Length of Stay in the PRIME
Multidisciplinary Education Program**

# [JM Huey, J Lekson, Q Guo, M Thrun]{.underline}

**Objective:** Hospitalization is a high cost alternative in patient
care when other modalities cannot provide sufficient monitoring. Length
of stay is a measurement frequently utilized to provide information
about effectiveness and efficiency of care. It may be influenced by a
number of circumstances relating to patient and family socioeconomic
issues, continuum of care, and availability of suitable alternative
modalities of treatment.

The PRIME service is a multidisciplinary educational program which
provides inpatient medical and outpatient care to a cohort of primary
care patients. The continuity of care in the PRIME service provided an
opportunity for a concerted interdisciplinary effort to reduce inpatient
length of stay. With an objective to improve patient care efficiency,
the PRIME team worked collaboratively to reduce cost in cutting
unnecessary hospital stay of acute care admissions.

**Methods:** The PRIME case manager initiated discharge planning
activities at the time of admission in conjunction with the PRIME social
worker. In daily attending rounds, the interdisciplinary team reviewed
the patient's status, plan of care, and readiness for discharge.
Alternative treatment sites were considered and follow-up visits to
appropriate team members which could expedite discharge were arranged.
Data monitoring was based on a monthly computer report of a list of
PRIME inpatients which provided information on patient's admission time,
discharge time, discharge specialty, and discharge provider. Length of
stay of each inpatient episode with a PRIME provider was recorded.
Average Length of stay was obtained by dividing the total hospital days
of patients by the number of inpatients within that time period.

**Results:** The average inpatient length of stay for the PRIME service
was 5.0 days during the eight month period (Sep 97 -- Apr 98) of data
collection. The result compares favorably with the reported 8.2 days VHA
national (1996), and the 6.6 days national average length of stay for
Medicare (1997). During the period of data collection there was a trend
of progressive reduction of length of inpatient stay within the PRIME
service. Length of stay decreased from 8.6 days in Sept 97 to 4.1 days
in April 98. The initial average of stay for the last four months of 97
was 5.7 days compared with the 4.3 days average for the first four
months of 98.

**Conclusion:** Hospitalization provides high cost patient care. The
results of this study demonstrate that hospital stay can be reduced by
an interdisciplinary team providing inpatient and outpatient continuity
of care. Length of stay data have been integrated into the PRIME service
quality measurement program along with trainee, staff and patient
satisfaction data.

# \*179. Rehabilitation Issues of Concern to Women with Spinal Cord Injuries

### [Carole Bach, PhD, RN, CRRN.]{.underline} VA Medical Center, Nashville, TN.

**Objectives:** The goal of this project is to explore the
rehabilitation needs of female veterans with spinal cord injuries (SCI).
Few injuries are as encompassing to the individual\'s well being and
quality of life as a spinal cord injury. Therefore, it is important to
explore, from the individual\'s own perspective, the experience of
managing life following an SCI and the factors that contribute to and
detract from the individual\'s quality of life. The research questions
are: 1: How do female veterans with SCI describe their rehabilitation
experiences? 2. Are there common themes that arise in female veterans\'
descriptions of their lives after injury? 3. What strategies do female
veterans with SCI use to manage their lives after injury? 4. What
recommendations do female veterans with SCI have for interventions
designed to meet their post injury rehabilitation needs?

**Methods:** A grounded theory qualitative research design using three
focused interviews will be used to answer the research questions, with
the goal of developing a theory about females undergoing rehabilitation
for SCI and what needs to be changed to better equip them for being as
productive and independent as possible. The constant comparative
technique will be used to analyze the data.

**Results:** Twenty-five participants have been interviewed once. The
participants were all from the Southeast and their rehabilitation took
place at a variety of VA and private rehabilitation facilities. The mean
age of the participants was 40 with an age range of 25-75. They had a
mean income of \$3680/month with an income range from
\$530-\$7000/month. The levels of injury were classified as cervical
(10), thoracic (11), and lumbar (4) with 7 classified as complete and 18
classified as incomplete.

**Conclusions:** Preliminary themes are: 1. What to expect when they
went home; 2. Network of other women with SCI to talk to about what is
happening with them; 3. Bladder issues as a source of concern; 4. Need
to be organized in order to be as independent as possible; 5. The
importance of exercise and the VA games. The tapes of the interviews
have been transcribed and checked for accuracy. The data are being
analyzed in order to develop a theory of how women veterans adjust to
SCI.

**Impact:** Information gleaned from this study should provide health
care personnel with ways to focus the rehabilitation programs for women
veterans with SCI in the future. Finding out the most important issued
concerning women veterans with SCI will enable health care providers to
focus educational materials and group discussions to meet the needs of
this population.

**HSR&D Funded:** NRI 95-145

## **\*180. Sharing Lessons Learned: Improving Healthcare Cost, Quality and Outcomes**

# [VS Wahby, NA Thompson]{.underline}

**Objectives:** VHA LESSONS LEARNED is an effort to enhance
organizational learning in the Veterans Health Administration (VHA), to
be expanded to a One-VA project. VHA may be the only national healthcare
system possessing a highly sophisticated lessons learned mechanism.
Goal: collect, evaluate and disseminate lessons learned from successes
or errors. Paradigm: systematic and non-punitive analysis of past
experience to improve future performance.

**Methods:** A component of the VHA LESSONS LEARNED project is the
Virtual Learning Center (VLC) on the VA Intranet. Designed with user
input and benchmarking, the VLC is a \"one stop\" resource for
just-in-time learning, a repository for easily searchable information, a
gateway to other information sources, and a \"place\" where for
dialogue. Users may submit, browse, search, and discuss innovations,
award-winning programs, and raw ideas. The Patient Safety component
contains lessons learned from adverse events, advisories and alerts. The
Ask Colleagues function allows asynchronous consultations. Personal
Profiling allows VLC users to automatically receive lessons in their
areas of interest promptly whenever these are posted. A second component
of VHA LESSONS LEARNED is the Lesson of the Month (LOM), an innovation
by a VA medical center that is broadcast on the VHA nationwide
conference calls. A written summary of the call is distributed
electronically and the lesson is posted in the Virtual Learning Center.

**Results:** The VLC (http://vaww.va.gov/vlc.htm), activated in December
1997 now carries 154 lessons. Total hits on lessons are 16,217. Average
hits/lesson = 105. There are 40 Ask Colleagues Questions and 16
comments, and 89 Personal Profile users registered. Most of the VLC is
now available on the Internet (http://www.va.gov/vlc). The first LOM was
shared in September 1997. Follow up inquiries average 13 per lesson,
with 50% implemented. To date 15 Lessons have been broadcast. Lesson of
the Year awards are given to the author(s) of the best lesson(s) entered
in the VLC in various area of specialization.

**Conclusions:** VHA had no systematic mechanism for the sharing of best
practices and lessons learned until the Lessons Learned project was
implemented. VLC Lessons have been accessed over 16,000 times, allowing
others to adapt/adopt the best practices in the VA, extending the
resources of the system.

**Impact:** The Lessons Learned project impacts are:- Rapid sharing of
innovations, successes, and solutions to problems.- Sharing of lessons
learned from errors leading to system improvement.- Sharing of problems
as they are identified, such that solutions generated at other sites can
be applied promptly.- Matching of problems to experts, to speed and
enhance the solutions to those problems.

**\*181. Simulation Modeling of Access to the ICU**

# [W Cahill, J Tsevat, ML Render]{.underline}

**Objectives:** Continuous access to the intensive care unit (ICU) is
required for health care systems, but excess capacity wastes limited
resources. Presently, no ICU beds at our facility are available for new
admissions about one-third of the time. Phased planned construction will
increase telemetry (Tele) beds on a ward and then add ICU beds in a new
heart emergency room (Heart ER). In this study, we apply industrial
modeling software to a health care system to assess the expected impact
of additional telemetry and ICU beds on access to the ICU

## **Methods:** We analyzed ICU bed availability using dynamic simulation software (Arena). Three models were constructed using data on admissions, length of stay(LOS), and transfer rates collected over one year. We varied bed number, average LOS in hours (minimum, average, maximum) in ICU and Tele and did not change characteristics of floor beds (70 beds; LOS mean of 36 hours, maximum of 144). We modeled 1) current medical beds (ICU - 10 beds\[18 minimum, 71 average, 228 maximum hrs\], Tele - 15 \[18,36,120\]. 2) New telemetry beds (ICU - 10 \[18, 71,192 hrs}, Tele - 24 \[18,48,240) and 3) New Heart ER beds (ICU - 13 \[18,71,228 hrs\], telemetry - 24 \[18,48,240\]. We defined ICU FILLED when all ICU beds were filled and 2 patients were waiting for ICU beds in the ER. Each model was run for 12 simulated months. Queue, bed utilization, and patient flow data was collected. Simple statistics (mean, standard deviation, CI) were performed on each model. 

**Results:** Using the existing bed configuration, ICU FILLED occurred
30.1% of each month, and 23 patients were diverted to other hospitals.
This compares well with historical data. Additional Tele predicted a
decrease in ICU FILLED to 22.8%, and diverted patients to 15. Adding
Heart ER beds reduced ICU FILLED to 5%, diverting 3 patients per month.
This is associated with increased mean utilization of telemetry (99% of
capacity) and maximal utilization of floor beds (92% from 89%).
Unexpectedly, average length of stay on the medicine service increased
by 1.2 days with the addition of these ICU patients to the system.

**Conclusions:** ICU access improved with additional telemetry beds, but
Heart ER beds were needed to resolve ICU access problems. The improved
access results in additional ICU patients who cause an increase in
telemetry and floor bed usage downstream. Length of stay on the medical
service increased as the proportion of post-ICU patients on the floors
increased.

**Impact:** Dynamic simulation modeling may be useful in strategic
planning to evaluate patient care access problems at a medical center.
Changes in ICU patient flow require careful management of telemetry
resources. Results can be tested as construction is completed. Changes
in veteran eligibility and access may affect the results. Use of dynamic
simulation modeling may assist the VA in the distribution of limited
resources by identifying potential effects of changes in bed capacity.
Modeling may identify unexpected consequences of changes in the services
available (e.g., increase in floor bed utilization).

**HSR&D Funded:** DEV 97-032

\*182. The Care Guide (Care Aided and Refined with GUIDElines) Program,
A Guideline-Based Conceptual Model for Continuous Quality Improvement in
the 21st Century

## Karl Hammermeister, Denver VA Medical Center. Denver, CO. S Ludwig, C VillaNueva

**Objectives:** Despite the recent emphasis on clinical practice
guidelines, there remains abundant evidence of marked variation in
processes of care, which have been shown to result in inferior patient
outcomes. These findings suggest that guideline implementation has been
ineffective. We believe that a major reason is the failure to provide
the care provider with the right information in the right amount, and at
the right time û e.g., patient-specific guidelines and predicted
outcomes at the point-of-care and credible feedback of guideline
compliance and risk-adjusted outcomes. Although the VA Computer-Based
Patient Record System (CPRS) currently being implemented is the most
advanced computer-based patient record in the world, it primarily
supports documentation of care in a narrative format of unspecified
content. Such a format still requires manual abstraction to get
information into databases to be used for decision support and
performance measurement. A solution is to document care using
pre-specified, encoded data elements. However, there are few such
computer-based patient records, probably because of the difficulty to
get consensus on a core set of data elements.

**Methods:** The solution to this conundrum is clinical practice
guidelines in an algorithmic format, such as the VA CARE GUIDE (Care
Aided and REfined with GUIDElines) for Ischemic Heart Disease. The CARE
GUIDE tables of clinical decision criteria are the minimum data set
required to describe the patient and illness characteristics for an
episode of care. Similarly, the CARE GUIDE tables of recommended
processes of care define the minimum data set for describing the care
delivered. Finally, this same set of data elements is the data set
required for the assessment of guideline compliance and risk-adjusted
outcomes.

**Results:** We will describe the CARE GUIDE Information Model, which
makes these linkages explicit. The other components of the CARE GUIDE
Program Model are a computer-based patient record incorporating
automated, patient-specific, point-of-care, clinical decision support,
CARE GUIDE RT (RT = Real Time); a system of automated audit and
feedback, CARE GUIDE: PM (PM = Performance Measurement); and a data
dictionary for storing the data elements, the CARE GUIDE Data
Dictionary. The key activity in the CARE GUIDE Program Model is care
provider documentation of care using a core set of data elements
specified by the guidelines. The database thus generated makes possible
the electronic automation of both clinical decision support and audit
with feedback.

**Conclusions:** Greater use of standardized, encoded data (data that
can be expressed as a number and readily retrieved from a relational
database) is essential to the automation of clinical decision support
and audit with feedback. National consensus clinical practice guidelines
in an algorithmic format define the minimum information content required
to document an episode of care, to drive real-time clinical decision
support algorithms, and to support automated performance measurement.

**Impact:** Given its commitment to clinical practice guidelines,
performance measurement, and a clinical information system (VISTA)
second to none, the VA is ideally positioned to lead the world in
innovative information management to enhance patient outcomes and reduce
the costs of health care.

\*183. The Prevalence of Veterans Meeting Selection Criteria for Lung
Volume Reduction Surgery

## HF Huizenga, KF Kierland, NB Charan

**Objectives:** Lung volume reduction surgery is currently being
advocated as a treatment for severe chronic obstructive pulmonary
disease. To date, no population-based studies have been published to
identify how many patients with chronic obstructive pulmonary disease
would be candidates for lung volume reduction surgery. We sought to
estimate the percentage of all veterans and of veterans with chronic
obstructive pulmonary disease at the Veterans Affairs Puget Sound Health
Care System -Seattle and the Boise Veterans Affairs Medical Center who
would meet current selection criteria for lung volume reduction surgery.

**Methods:** We reviewed all pulmonary function test results from the
past five years at the VAPSHCS- Seattle and the Boise Veterans Affairs
Medical Center to identify patients who meet currently accepted age and
pulmonary function test criteria for lung volume reduction surgery. The
medical records of these individuals were then carefully reviewed to
identify additional exclusion criteria that might be applicable.
Patients referred to the Veterans Affairs Puget Sound Health Care
System - Seattle from outside of the medical center\'s service area were
excluded from the analysis

**Results:** Pulmonary function tests on 10,024 patients were reviewed.
546 individuals met pulmonary function test and age criteria for lung
volume reduction surgery. Upon chart review, 125 patients continued to
meet criteria for selection for lung volume reduction surgery. Of the
421 patients excluded based upon chart review, the leading reasons
were 1) continued smoking (42%), 2) congestive heart failure (18%), 3)
obesity (10%), 4) prior lung surgery, (7%), and 5) hypercapnia (7%). The
remaining 16% of the patients were determined to be poor surgical
candidates for varying reasons including malignancy, severe coronary
artery disease, debilitating stroke, ongoing alcohol abuse, or being
confined to a nursing home.

**Conclusions:** The total number of veterans cared for annually by
these two medical centers is approximately 56,000. An estimated 18 % of
these individuals or approximately 10,080 have a diagnosis of chronic
obstructive pulmonary disease. Therefore, we estimate that approximately
0.2 % of all veterans and 1.2% of veterans with a diagnosis of chronic
obstructive pulmonary disease would meet current selection criteria for
lung volume reduction surgery. Our experience at the VAPSHCS -Seattle
suggests that 30% of patients referred for lung volume reduction surgery
evaluation are determined to not be candidates for surgery based upon
further evaluation. This evaluation consists of high resolution CT
scanning, exercise testing, repeat pulmonary function testing, and
detailed history and examination by a pulmonologist. Therefore, we
estimate that less than 1% of veterans with chronic obstructive
pulmonary disease would meet selection criteria for lung volume
reduction surgery.

**Impact:** Based upon current selection criteria, less than 1% of
veterans with chronic obstructive pulmonary disease would be appropriate
candidates for lung volume reduction surgery.

**HSR&D Funded:** IIR 96-024

# \*184. The Psychodynamics of Traumatic Memories

## PE Emery

**Objectives:** The psychoanalytic theoretical system is in a state of
transition as is the VA Health Care System itself. The current
psychoanalytic paradigm shift is best described as a movement from the
propositions of ego-psychology to those of trauma-psychology. This shift
represents a development that theoretically organizes the findings of
our clinical work with patients suffering from traumatic conditions -
the prototype of which is posttraumatic stress disorder. The shift is
necessitated by the imperviousness of trauma reactions to yield, so far,
in any substantial way, to clinical interventions. The objective of this
presentation is to propose a multiaxial, dynamic, diagnostic system that
supplements the multiaxial, descriptive system of DSM-IV in the case of
the entity - posttraumatic stress disorder. In doing so, new clinical
therapeutic tools can be utilized to analyze the narratives that reflect
traumatic memories.

**Methods:** The notion of the structural dynamics of the psyche as a
supplement to the cathectic, emotional, dynamics of the psyche was
proposed some fifty years ago. The evolution of the psychodynamic
inquiry of the organization and pathology of thinking is resulting in
the propositions of trauma-psychology and in the development of six
axes, which together, form an explanatory model for a dynamic
understanding of four basic modalities of psychic structure: imagery,
perception, memory and knowledge. These dynamic axes are: (1) The
psychic location or milieu where the content lies; (2) the nature of the
psychic conflict; (3) the impact of the perceptual system that regulates
and reactivates the psychic conflict; (4) psychic work, which in the
case of traumatic memories is referred to as trauma work, and which
utilizes four mechanisms of consciousness; (5) the impact of cathectic
dynamics, in this instance, the vicissitudes of narcissistic interests,
on the construction of psychic structures; and (6) the transformation of
the psychic structures into the modality of knowledge.

**Results:** The notion of the structural dynamics of the psyche as a
supplement to the cathectic, emotional, dynamics of the psyche was
proposed some fifty years ago. The evolution of the psychodynamic
inquiry of the organization and pathology of thinking is resulting in
the propositions of trauma-psychology and in the development of six
axes, which together, form an explanatory model for a dynamic
understanding of four basic modalities of psychic structure: imagery,
perception, memory and knowledge. These dynamic axes are: (1) The
psychic location or milieu where the content lies; (2) the nature of the
psychic conflict; (3) the impact of the perceptual system that regulates
and reactivates the psychic conflict; (4) psychic work, which in the
case of traumatic memories is referred to as trauma work, and which
utilizes four mechanisms of consciousness; (5) the impact of cathectic
dynamics, in this instance, the vicissitudes of narcissistic interests,
on the construction of psychic structures; and (6) the transformation of
the psychic structures into the modality of knowledge.

**Conclusions:** The propositions of trauma-psychology provides a
useful, multiaxial, dynamic framework in the psychotherapeutic treatment
of patients suffering from traumatic memories. Much clinical work needs
to follow.

**Impact:** The abstract best fits the subject area of \"Special
Populations.\" In this case, the population of patients suffering from
post-traumatic stress disorder. The theoretical paradigm shift suggested
correlates with the nature of the current changes in the organization
and delivery of healthcare services. The content of the paper is
relevant to the discussion of the delivery of services along the mental
health product line.

**\*185. The Simulation of Medical Work using Information-Processing
Theory: Anticipating Outcomes by Understanding the Process of Medical
Care**

## DB Fridsma

Modern medical care is a collaborative activity among health care
providers who work in complex, interconnected organizations. Although
outcome measures help researchers identify problems in medical care
delivery, improving outcomes measures requires knowledge of the
organizational processes that lead to those outcomes. Ideally,
health-care administrators would like to proactively design
high-quality, efficient organizations to implement patient care
protocols, rather that fix problems after they have occurred. However,
to design efficient organizations, health-care administrators must
understand organizational work processes, organizational structure, and
the way in which people do their work. An unforeseen mismatch between
organizational work processes and structure -- particularly when using
novel ways of delivery health care -- can result in inefficiencies in
medical care delivery and poor patient outcomes.

Simulation systems, based on an information-processing theory of
organizations, have provided valuable insight into business and
engineering organizations and have predicted bottlenecks and quality
problems before problems developed. Unfortunately, similar simulation
systems in medical organizations do not exist because existing
information-processing simulation tools have models of work processes
that are inadequate for the dynamic organizational structures and
uncertain clinical work processes found in medical organizations.

In my talk, I will describe extensions to organization theory and to a
simulation tool that will make it possible to test medical organization
or protocol design in a simulation environment, and use the simulation
results to guide organizational change and protocol implementation. As a
first step, I have developed a more flexible information-processing
model of organizations, based on a review of medical protocols, patient
activities, and VA clinics. This work will lead to development of a
simulation system capable of identifying organizational bottlenecks that
might impair the efficiency and efficacy of medical protocols.

Understanding the link between guidelines, clinical processes, and
patient using a simulation tool should help administrators improve
clinical efficiency and patient outcomes proactively through systematic
protocol and organization design.

\*186. The Use of Risk-Adjusted Mortality Rates to Monitor Performance
in the Department of Veterans Affairs

# [MJ Petersen, Carol Ashton, MD, MPH, J Souchek, PhD, and Terri Menke.]{.underline} Houston VA Medical Center, Houston, TX. 

**Objectives:** Monitoring the performance of the VA system is essential
as it undergoes major changes in the way medical care is provided. The
objective of this study was to analyze one measure of performance, the
short-term risk-adjusted mortality rate from all causes, for patients
with 3 conditions for which poor care might be associated with poor
outcomes acute myocardial infarction (MI), acute stroke, and surgical
repair of hip fracture.

**Methods:** Patients hospitalized in FY95-FY97 for the 3 conditions
were identified from the VA Patient Treatment File. Vital status was
obtained from VA\'s Beneficiary Identification and Records Locator
Subsystem death file. Admission date was used as the starting point for
counting days until death for MI and stroke patients, while date of
surgery was used for hip fracture patients. Kaplan-Meier estimates were
used to compute unadjusted 30- and 90-day mortality rates for MI and
stroke and 180-day rates for hip fracture repair. Cox regression models
provided proportional hazards estimates of age-adjusted rates. Outliers
were identified by comparing each Network with the median mortality
rate. For each VA hospital with 10 or more patients in the
disease-specific cohort, we computed unadjusted and age-adjusted rates.

**Results:** Overall, adjusted 30-day and 90-day mortality rates in FY97
for acute MI were 11.5% and 14.5%. There were significant differences by
age, with 30-day and 90-day rates of 6.2% and 7.8% in patients under 65,
14.5% and 18.5% in patients 65-74, and 24.9% and 31.0% in patients 75
and older. Across the VISNs, age-adjusted 30-day rates ranged from 7.8%
in VISN 13 to 14.6% in VISNs 14 and 18. Variation also existed among VA
medical centers, with 30-day mortality rates ranging from 0% at Battle
Creek and Saginaw to 24.9% at Bath. For acute stroke, the FY97 30-day
and 90-day age-adjusted rates were 10.8% and 15.2%. As with MI, there
were significant differences by age (30-day mortality of 7.6% for under
65, 10.6% for 65-74, and 16.3% for 75 and older; 90-day mortality of
9.8% for under 65, 15.5% for 65-74, and 24.4% for 75 and older). The
lowest 30-day rate was in VISN 22 (5.3%) while VISN 14 had the highest
at 14.5%. Three VAMCs (Castle Point, Lebanon, Grand Junction) had 0%
30-day mortality whereas Grand Island had the highest rate (28.2%) among
facilities hospitalizing at least 10 stroke patients. System-wide, the
180-day adjusted mortality rate in FY97 for hip fracture repair was
14.3%. Mortality for patients 75 and older (21.9%) differed
significantly from that of patients under 65 (7.1%). The lowest rate was
in VISN 13 (5.3%); the highest rate was in VISN 2 (21.3%). Seven VAMCs
had 0% mortality while Albuquerque had the highest adjusted rate at
33.2%.

**Conclusions:** Wide variations exist across Networks and across VAMCs
in mortality rates for patients hospitalized for the 3 conditions. This
may be due to process-of-care or to additional differences in case mix.

**Impact:** These data, available on the VA Intranet, are used as a
screening tool to help identify hospitals with effective practices as
well as hospitals with possible problems.

**HSR&D Funded:** SDR 98-001

## **\*187. Trends in Primary Care and Subspecialty Residents in Network 7 compared to VHA**

# [CH Patrick, CL Pillinger]{.underline}

**Objectives:** The objectives of this study are:

a\) to examine trends in resident positions at affiliated medical
centers in Network 7 and system-wide, and b) to analyze shifts in the
allocation of these positions among primary care and subspecialty care
from 1991 to 1999. From these objectives, we can determine the impacts
brought about by the implementation of the VA Residency Realignment
Committee (RRC) Report and how these shifts correlate with the medical
conditions of the VA patient population.

**Methods:** The methodology employed is both descriptive and
analytical. Trend analysis will be used to determine the absolute and
percent change in resident positions by discipline at the affiliated
VISN 7 medical centers. These will be done in comparison to the VA
system. Chi-square will be used to assess significance of the changes in
resident positions in VISN 7 relative to VHA before and after the RRC
Report. Data for this study are derived from residency position files
maintained by the VHA Office of Academic Affiliations.

**Results:** The growth of residency positions underwent a clear shift
in Network 7 as a result of the implementation of the Residency Review
Committee. The proportion of resident positions in fields defined as
primary care is now almost half of all residents in the VISN, compared
to 38% less than 4 years previously. The shift in VISN 7 exceeded that
occurring in VA as a whole. Significant decreases have occurred in a
number of subspecialty areas which had previously been growing
nationally. Both medical and surgical subspecialties were affected,
though at quite different rates. Psychiatric subspecialties were also
affected. The decline in the growth of residency positions in the
psychiatric subspecialties in the Network at a time when many VA
patients have a multiple array of conditions including substance abuse
and major depression would appear to be counterintuitive.

**Conclusions:** These trends indicate that major shifts have occurred
in residency positions which reflect the national move of VA patient
services delivery to primary care. The subspecialties that were affected
most reflect a trend which began two decades ago with the GMENAC Report
and brought to fruition in the VA by the RRC. Not addressed in this
study, but increasing raised as an issue in graduate medical education,
are the role of residents in delivery of high quality care in different
settings, and the role played by VA residency programs in recruiting
staff physicians to the VA system.

**Impact:** What long-term impacts this shift in emphasis in VA
residency training may have on VA patient care is not clear, but needs
to be addressed by VA. While the shift away from subspecialty positions
has not been as large proportionally in VISN 7 as it has in the VA as a
whole, this shift nonetheless may also have impacts which need to be
monitored closely to prevent the loss of ACGME accreditation in those VA
programs which are small. Long-term planning alsoshould be done to
determine if the VA patient population in 10 years will have access to
the types of subspecialists trained to treat their particular array of
conditions.

**HSR&D Funded:** DEV 97-009

**\*188. Use of Geographic Information Systems to Assess the Effect of
Travel Distance on Utilization of Specialized SCI Services**

# [JE Lasfargues, W Baughman, V Litvak]{.underline}

**Objectiv**e**:** To determine how demand for specialized SCI program
services is effected by the distance a patient must travel to obtain
services.

**Methods:** All patients with Spinal Cord Injury who used VHA services
in 1997 were identified and geocoded according to their residential ZIP
code by using a geographic information system (Atlas GIS). The distance
of each patient to the nearest regional VA SCI center was calculated
using a straight-line method. Distance to the nearest SCI clinic was
similarly calculated. Patients were grouped according to the distance
they lived from the closest VHA facility offering specialized SCI
services and use rates were compared.

**Results:** Distance thresholds are significantly greater for inpatient
services than for clinic services. The 50% threshold (i.e. fifty percent
of patients use the service) for outpatient services occurs between 26
and 50 miles while for inpatient services it is beyond 200 miles. More
than 85 percent of the patients with SCI needing inpatient services and
who live within 100 miles of a regional SCI center use the service.

**Conclusions:** Proximity to services does effect utilization of
specialized SCI services, particularly outpatient services. SCI support
clinics serve to extend the distance patients will travel to obtain
specialized inpatient services.

**Impacts:** Decisions regarding the location of SCI support clinics can
take into consideration the geographic distribution of the patients who
will use them to maximize utilization and optimize use of resources.

**\*189. Using Clinical Vignettes to Compare Quality in Disparate Health
Care Systems**

##### Jeff Luck, MBA, PhD. UCLA School of Public Health, Los Angeles, CA. John Peabody, MD, PhD. RAND, Santa Monica, CA. C Roth, MM Wang, J Stone

**Objectives:** Comparisons of quality between health care systems are
complicated by many factors including differences in economic welfare,
patient population,organization of services and financing. Regardless of
how care is organized, financed or made available, physicians are
expected to provide the highest quality care. Simultaneously,
policymakers want to know how much the variation in health outcomes is
attributable to differences in quality. We used clinical vignettes,
which controlled for case mix variation and differences in health care
organization, to compare the quality of primary care in the United
States and in a developing countryùthe Former Yugoslav Republic of
Macedonia. We hypothesized that quality would be higher in the US but we
also expected the highest scores to be similar.

**Methods:** We prospectively administered identical clinical vignettes
to primary care providers in two VAMCs West Los Angeles and San Diego
and four Municipalities in Macedonia. The vignettes, which described an
uncomplicated post myocardial infarction (MI) and a post MI complicated
by mild heart failure, were randomly administered simultaneously to
40-50 providers in each country. To ensure comparability, the vignettes
were translated and back translated and then pretested. These vignettes
had been previously validated for content and criterion validity in
another study. Performance criteria for the quality scores were defined
by international guidelines and reviewed by local exert panels in both
countries. Providers were asked to indicate how they would proceed in
five domains: taking the history, performing a physical examination,
ordering laboratory or imaging studies, making the diagnosis and
prescribing treatment. Scores were calculated as the percentage of
scoring categories correct for each domain. Minimum and maximum scores
were calculated and differences in means were calculated and compared
using a t-test.

**Results:** The average score of Macedonian doctors was lower than in
the U.S. Means were 25 and 17% lower for the two cases, respectively.
Comparisons of specific skills showed that history taking by the
Macedonian physicians was 21% and 25% lower. Test ordering, however, was
comparable in both countries (differences were not statistically
significant). When we examined the range of scores, the better doctors
in both countries performed at a similar level. However, in Macedonia,
the lowest scores were much lower than their US counterparts.

**Conclusions:** Clinically validated vignettes, which describe the
essential elements of clinical care for post MI patients, reflect
substantial variation in practice both in the U.S. and Macedonia. The
level of information asked for in the vignettes is appropriate across
vastly different health care systems and US and Macedonian providers do
not have problems using the vignettes or identifying what the critical
information is when they knew the correct answer.

**Impact:** Vignettes show promise as a method for comparing the quality
of primary care in different health care systemsùeven systems as
disparate as an academic VA practice and a developing country.
Quantifying these variation in the quality of care provides policymakers
useful information to design interventions that improve the quality of
care in their respective health care systems.

**HSR&D Funded:** IIR 95-014

\*190. Using Patients\' Perspectives to Develop an Intervention to
Improve Outpatient-Clinician Communication

##### CK Russell, C Drumwright, S Harrison, J Holt, L Madlock, M Graney

**Objectives:** Survey results of outpatients reveal that our facility
was rated below the VHA benchmarks in timeliness/access, preferences,
and courtesy. Since aggregated numerical responses to the general survey
questions offered no specific direction for understanding and addressing
patient concerns, we undertook a two-step process to elicit and address
particular concerns of our outpatient population.

**Methods:** First, we conducted separate focus groups for patients in
each of our outpatient firm clinics (general medicine \[n=2\],
psychiatric, SCI, geriatrics, women). A total of 52 patients and 5
spouses participated in the 6 focus groups that lasted an average of 2
hours each. An experienced focus group leader moderated the audiotaped
groups and consistent procedures were used among the groups. Verbatim
transcripts from the groups were analyzed (in general and by firm) for
themes related to each question. Second, clinician-focused communication
training will be completed. This training consists of a videotape
(\"Through the PatientÆs Eyes\" by the Picker Institute) and slide
presentation of general and specific outpatient communication issues.
The effects of this training will be determined by changes in the scores
on the \"Provider Humanistic Attitudes and Behavior Instrument\" which
is administered pre and post intervention.

**Results:** Focus group participants related positive and negative
experiences of receiving care in the outpatient area; described positive
and negative interactions with clinicians; noted situations of
partnership in health care and feeling known as unique individuals by
clinicians; and offered advice to clinicians on the topic of
communicating with outpatients. We are in the process of completing the
clinician communication training and anticipate that this process will
be completed shortly.

**Conclusions:** Focus group participants were able to offer specific
and detailed commentary on the topic of communication with clinicians
and staff. While, overall, participants felt as if they were respected
and well-cared for by their specific clinicians in their assigned firms,
this feeling did not extend to their experiences in most sub-specialty
clinics or with other services in the outpatient area. Conclusions
related to the clinician communication training will be presented at the
meeting and we will offer direction for how similar projects could be
conducted in other facilities.

**Impact:** Improved clinician-patient communication has been reported
to positively effect patients' satisfaction with health care services
and outcomes. However, research consistently demonstrates the challenges
associated with enhancing communication between patients and their
clinicians. Health care quality improvement projects such as this are
vital in VA efforts to improve services to the patients who have been
noted to have the most difficulty in communicating with clinicians
(those being older adults, men, and persons with chronic diseases)
precisely the types of patients for which VA clinicians routinely
provide care.

**\*191. VA Participation in a Statewide Nursing Quality Indicator
Database Project**

##### MD Buffum, S Parkes, G Wike

**Objectives:** The California Nursing Outcomes Coalition (CalNOC)
Project is a collaborative quality indicator database development effort
evolving from the American Nurses Association Report Card Initiative in
1995. Six states (CA, AZ, MN, ND, VA, TX) are participating in projects,
piloting various methods of collecting data from diverse sites. The
purposes of the CalNOC project are to establish valid and reliable
indicators, determine whether comparable data collection is feasible,
and benchmark within and between health care organizations to
continuously improve care. The current study describes three diverse VA
Medical Centers\' experiences with participation in the CalNOC project
among the forty-four non-VA sites. This qualitative study seeks to
understand participating VA sites\' experiences with data collection in
the development of a statewide nursing quality report card.

**Methods:** Data are collected quarterly and include patient falls,
staff mix, census, pressure ulcers, restraint prevalence and tracking,
patient satisfaction with pain management and with patient education,
and nurse education. VA sites\' experiences with the first nine months
of data collection have been content analyzed for themes from anecdotal
data, written responses and conference calls. The themes include
professional benefits, strategic issues, and clinical improvements.

**Results:** Professional benefits of participating in the CalNOC
project include: 1) VA and non-VA collaboration throughout California;
2) awareness in all levels of nursing staff about measuring
effectiveness of their practice; 3) lessons about pressure ulcer
prevalence study method; 4) opportunities to review literature and
engage in statewide dialogue about indicator selection, instrument
selection, and measurement methods; 5) knowledge development about
managing VA and non-VA site differences in developing a meaningful
database; 6) discoveries about similarities in data and collection
methods within VA; 7) opportunity to have interdisciplinary dialogue
intra-facility to obtain data; 8) opportunity to utilize unique VA data
collection methods (One-Staff); 9) involvement with a visionary project
that can demonstrate linkages between nursing care and patient outcomes.
Strategic issues are the organizational costs, risks, and benefits
involved in project participation. Costs are: 1) numbers of personnel
and their time devoted to data collection; 2) technological requirements
for data collection and sharing. Risks are: 1) uncertainty about sharing
data externally; 2) concerns about confidentiality; 3) validity
challenges with varying data collection methods. Benefits include: 1)
capacity for internal and external benchmarking to advance performance
improvement; 2) demonstrating linkages between nursing care and patient
outcomes for strategic planning and accreditation reviews. Clinical
improvements attributed to CalNOC participation are: 1) practice changes
-use of valid and reliable instruments; 2) patient involvement in
satisfaction surveys; 3) staff nurse participation in data collection.

**Conclusions:** Feasibility of VA quality indicator data collection has
been established and VA has existing untapped electronic methodologies.
Statewide database building offers unique professional, clinical, and
organizational gains for VA.

**Impact:** VA involvement with CalNOC is expected to contribute to
effective recruitment and retention of more VA sites in the development
of a nation-wide nursing quality database.

# 

# \*192. Variation in Discharge Destination of VA Ischemic Stroke Patients 

##### SJ Yeh, DM Reker, AK Rosen

**Objectives:** This study explores variation in discharge destination
among VA patients hospitalized for ischemic stroke. We also identify
some factors that predict discharge destination for this group of
patients.

**Methods:** This is a retrospective, cross-sectional study of 7,765
ischemic stroke patients who were discharged alive from VA acute care
facilities in FY\'97. We defined ischemic stroke as cerebral infarction
(and not hemorrhagic stroke), since the two groups vary dramatically in
both costs and outcome. Based on the definition used by Mitchell et al.
(1996), ischemic stroke patients were identified using the following
primary ICD-9-CM diagnosis (DXPRIME) codes: 434 and 436. Data were
extracted from the Patient Treatment File (PTF). Discharge destination
following hospitalization was the outcome measure. This included
discharge to community and discharge to other facilities (for example,
VA hospital, military hospital, and VA nursing home). Patients\'
demographic information, clinical characteristics, and comorbid
illnesses were included as covariates. Logistic regression analysis was
used to identify the predictors of discharge destination for ischemic
stroke patients.

**Results:** We had complete data on 6,505 patients or 84% of the
original sample. Approximately 82% of patients were discharged to the
community; 17% went to other facilities. Mean age of the sample was 68
years; average length of stay was 19 days. Approximately 67% of patients
were white; 98% were male; and 48% were married. Almost 57% were
admitted from the community. Patients who were married (Odds Ratio (OR)
= 1.86; 95% confidence interval (CI) = 1.64-2.11), who were admitted
from the community (OR = 2.78; 95% CI = 2.17-3.56), and who came from
outpatient clinics (OR = 2.44; 95% CI =1.89-3.15) were more likely to be
discharged to the community.

On the other hand, patients who were older (OR = 0.98; 95% CI =
0.97-0.98), who had longer lengths of stay (OR = 0.98; 95% CI =
0.982-0.987), and who were admitted from nursing homes (OR = 0.08; 95%
CI = 0.04-0.14) were less likely to be discharged to the community.
Other clinical or comorbid factors were not statistically significant.
The model R-squared was .111 and the c-statistic was 0.72.

**Conclusions:** This study suggests that patient demographic factors
and social support (e.g. marital status) variables are important in
predicting discharge destination. Development of risk-adjusted outcomes
that predict discharge destination of stroke patients should be useful
in comparing differences across hospitals and VISNs in quality of care.
However, future research should obtain severity of illness and
functional status as risk factors from other data sources since
administrative data lack sufficient clinical information.

**Impact:** The findings from this study will enhance our understanding
of the predictors of discharge destination for ischemic stroke patients.
These predictors should be considered when creating or validating a
risk-adjusted model for stroke patients.

**HSR&D Funded:** Yes (no number given)

\***193. Women Undergoing Mastectomies in VA Facilities: Characteristics
and Outcomes**

# [Denise Hynes, RN, PhD, and Fran Weaver, PhD.]{.underline} Hines VA Hospital, Hines, IL. [D Ippolito, W Cull, B Thakkar, J Gibbs]{.underline}

**Objectives:** The objectives of this research are to: describe the
patient sociodemographic, preoperative risk, structure and process
characteristics and surgical outcomes of women undergoing mastectomies
at VAMCs; and to examine the relationship between these characteristics
and specific outcomes for women undergoing mastectomies using
hierarchical multivariate modeling techniques.

**Methods:** This study is a secondary analysis of the National Surgical
Quality Improvement Program (NSQIP) data base. For the present analyses,
all mastectomy procedures collected by the NSQIP between FY92 and FY97
were selected. The NSQIP contains data on 62 preoperative risk and
demographic characteristics, four process, and 23 outcome variables. We
supplemented the NSQIP data base with tumor registry/pathology reports
from sites, hospital data from the VA\'s Patient Treatment File (PTF) to
capture readmission data, and facility characteristic data. Data from
these sources were merged based on patient identifiers and the date of
the surgical procedure. Any hospitalizations that occurred within one
year of the procedure were captured. Outcomes of interest include:
length of stay following the procedure, mortality within 30 days,
morbidity within 30 days (defined as one or more of 21 complications
monitored by the NSQIP), and any readmissions that occurred as a result
of a complication or adverse event of the procedure within one year post
surgery. Complications/adverse events were defined by an expert panel of
surgeons we assembled who identified relevant diagnostic codes and
assigned a time period within which the diagnosis would be considered a
complication. Descriptive analyses have been completed and modeling of
outcomes is in process.

**Results:** Over a six year period, VA performed 886 mastectomies (55%
female; 45% male). For women, the leading indication for surgery was
malignant neoplasm of breast (75%). Women were predominately white
(84%), average age was 58.3 years, and only 28% were married.
Preoperatively, 35% were smokers, 35% had a history of hypertension
requiring medications, and 4% were frequent alcohol users. Surgical
procedures for mastectomy included 6% radical, 77% modified radical and
17% partial mastectomy/lumpectomy or other. The mean length of stay was
5.4 days (sd=5.5). Within 30 days of the procedure, 10% experienced one
or more of the 21 complications defined by the NSQIP. Only one woman
(0.2%) died within 30 days of the procedure. Mastectomy practice
variations in VHA will be examined in relation to cancer stage and other
clinical factors.

**Conclusions:** Women undergoing mastectomy in VA are slightly younger
than mastectomy patients in general. This research has important
implications for mastectomy practice patterns in VHA.

**Impact:** Women veterans account for less than 5% of all VA health
care users. The rate of female-specific surgical procedures (e.g.,
mastectomy) at any one facility is very low. Given these infrequent
events, this study will help to inform the system as to the types of
women who undergo procedures within VA and their outcomes and how this
compares to the non-VA health care sector.

**HSR&D Funded:** GEN 97-016

**AUTHOR INDEX**

**Plenary Presentation, Concurrent Papers, Workshops and Posters**

**Author Name & Abstract Number**

*Note: This index includes only the authors presenting and first author
of abstracts not selected.*

Advani 152

Bach 179

Baldwin 42

Barnett 56

Bauer 59, 60

Baughman 153

Bennett 10

Berger 175

Berlowitz 1

Bittner 61, 171

Bokhour 109

Borowsky 49

Bosworth 62

Bozzette 11

Bradham 25

Branch 119

Buffum 191

Burke 154

Burman 28, 29

Burton 177

Byrne 50

Cahill 181

Captain 143

Chaney 63

Chang 131

Chapko 64

Chun 110

Collins 40

Cotton 111

Covinsky 137

Cowper 147

Cronkite 65

Curran 112

Czarnowski 66

Dawson 13

Doyle 158

Dresselhaus 51

Druss 67

Dubbert 35, 36, 68

Emery 184

Evans 37, 69

Fihn 2

Fink 113, 120

Frayne 155

Fridsma 185

Gaehde 70

Gardner 114, 162

Garvey 44

Geraci 15

Gifford 52

Good 71

Gordon 16

Gralnek 30

Hammermeister 182

Hankin 5

Harada 72

Hasenberg 73

Hechtel 74

Hendricks 57

Herndon 157

Hoff 6

Holley 149

Hopp 151

Huey 178

Hughes 132

Huizenga 165, 183

Humphreys 75

Hynes 133, 193

Ibrahim, M 26

Ibrahim, S 38

Jaworski 164

Johnson 17, 18

Jones 76

Kazis 77

Keane 78

Kemppainen 115

Kerr 170

Kiefe 39

Kim 20

King 79

Knight 174

Krein 168

Kressin 80

Kubal 81

Lam 53

Lasfargues 188

Lee 82, 83, 84, 144

Lenert 138

Leslie 7, 8

Licht 116

Linn 139

Liu 160

Lohr 85

Loveland 86

Luck 126, 189

Maciejewski 87

MacLean 121

Mansell 140

Mares 88

Marottoli 173

Mayfield 27

McDonell 31, 127

Meier 89, 134, 169

Menke 90, 91

Miller 117

Mittman 92

Morton 41

Muir 12

Murdoch 125, 142

Nachtigall 122

Niakan 128

Owen 141

Patrick 187

Peck 34

Penrod 93

Petersen 186

Phillips 135

Piette 94

Pietz 95

Pogach 96

Powell-Cope 167

Provenzale 123

Pugh 145

Pyne 97

Reiber 124

Ren 98

Render 99

Rosansky 100

Roselle 14

Rosen, C 118

Rosen, A 58

Rosenheck 9

Russell 190

Saint 24, 136

Sales 129, 150, 163

Selim 32

Sherman 45

Shively 166

Sipler 43

Souchek 101

Spurzem 146

Starks 33

Steele 102

Steinhauser 103

Stine 156

Szeto 19

Tesfa 148

Thompson 54

VanDeusen Lukas 104

Wahby 180

Wakefield 161

Washington 55

Weaver 105

Weingardt 159

Whited 46

Whooley 106

Wilkins 3

Wilt 22

Wright 47, 48

Wu 107

Yano 4, 21, 176

Yeh 192

Young, G 130

Young, A 172

Zalenski 108

Zemencuk 23