# 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

PresenterAbstract #Title

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

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

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

Yano                                    4Effectiveness 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                                5Do Patients with Mental Disorders “Unnecessarily” Use  more Medical Services?  Policy Implications for Mental Health Capitation

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

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

Leslie                                  8Comparing Reimbursement Models for VA Mental Health Services

Rosenheck                          9Impact 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

PresenterAbstract #Title

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

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

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

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

Roselle                              14Hepatitis 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

PresenterAbstract #Title

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

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

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

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

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

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

###### Prostate 

PresenterAbstract #Title

Kim                                   20Prostate 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                                 21Prevalence of Lower Urinary Tract Symptoms and Associated Resource Utilization among VA Primary Care Patients

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

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

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

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

PresenterAbstract #Title

Bradham      25HSR&D Development Center Workshop

Ibrahim      26Internet-Based Education for Epidemiology

Reiber                               27Using 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

PresenterAbstract #Title

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

Burman                             29Patient 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

PresenterAbstract #Title

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

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

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

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

Peck                                 34Measuring 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

PresenterAbstract #Title

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

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

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

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

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

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

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

###### General Health Services Research

PresenterAbstract #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

PresenterAbstract #Title

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

Sipler                                43Variations 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                             44Tailoring Smoking Cessation Treatments Based on Nicotine Dependence Level and Depression Status of Patients.

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

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

Wright                             47 Use of VA Services by Medicare HMO Enrollees.

Wright                             48Validating Ascertainment of Mortality Using Multiple Administrative Data.

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

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

PresenterAbstract #Title

Borowsky                         49Veterans’ 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

PresenterAbstract #Title

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

Dresselhaus 51Determinants of House Staff Time Use in the Inpatient 

Setting

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

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

Thompson                       54The Impact of Involving LPNs in Colorectal Cancer Screening

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

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

PresenterAbstract #Title

Barnett                             56Determining the Cost of VA Health Care

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

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

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

PresenterAbstract #Title

Bauer  59Are Clinical Practice Guidelines Implemented in Clinical Practice?

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

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

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

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

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

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

Czarnowski                      66Family Satisfaction with VA Hospice Care.

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

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

Evans                              69Evaluating Screening Criteria for Adverse Outcomes in Medical Patients

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

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

PresenterAbstract #Title

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

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

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

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

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

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

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

Keane                           78Multi-Site Research:  Overcoming Hurdles.

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

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

Kubal                           81An Overview of the Decision Support System.

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

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

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

Lohr                            85Patient-Centered Alternative to Psychiatric Hospitalization.

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

PresenterAbstract #Title

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

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

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

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

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

Menke                           91Developing Algorithms to Define Episodes of Care.

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

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

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

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

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

Pyne                                97Extending 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

PresenterAbstract #Title

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

Render                          99VISN 10 Automated ICU Severity Adjustment Tool:  SISVISTA

Rosansky                     100Psychogeriatric Interventions Saves Inpatient Costs:  Preliminary Findings.

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

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

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

VanDeusen Lukas        104Integrating VA Medical Centers.

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

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

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

Zalenski                        108ACI-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

PresenterAbstract #Title

Bokhour                          109Improving 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                             111Seeking Care in the VA:  What Differentiates Level of VA use for Women Veterans?

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

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

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

Kemppainen                   115Predictors of Quality of Life in AIDS Patients.

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

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

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

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

###### General Epidemiology

PresenterAbstract #Title

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

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

###### General Epidemiology

PresenterAbstract #Title

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

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

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

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

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

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

###### Quality

PresenterAbstract #Title

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

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

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

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

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

Young                             130Patient-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

PresenterAbstract #Title

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

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

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

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

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

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

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

###### Mental Health

PresenterAbstract #Title

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

Lenert                              138Conflicts in Values for Health Outcomes in Schizophrenia.

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

Mansell                           140Validity 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

PresenterAbstract #Title

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

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

PresenterAbstract #Title

Captain                           143Using Focus Group Methodology in the VA System.

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

Pugh                                145VA 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 TitleAbstract #**

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 Mortality17

A Pilot Study:  Telecare in the Management of Diabetes70

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 Patients55

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

Utility, Validity

Access to Care Among Adults with Diabetes in VA and County Clinics94

Accuracy of Computer Identified Diagnoses in a VA General Medicine Clinic19

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 Scores95

*Ambulatory Care Sensitive Hospitalizations for Veterans in Rural Nebraska      146

An Overview of the Decision Support System81

Antimicrobial Prophylaxis for Urinary Tract Infection in Persons with Spinal Cord41

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 Survey71

*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 Patients35

*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 Services8

**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    133Cost 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?  Policy5

 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 Findings4

**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 Workshop25

*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 

21st 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 Sources48

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 Men36

*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.  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. 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.  Bedford VA Medical Center, Bedford, MA.   D Mansell,MD, MPH.  Assistant Professor, Birmingham, AL  LE Kazis, ScD, 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. 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.  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.  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**

Therese Dawson, BMED.  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.  VA Medical Center, Minneapolis, MN.  N Aronson, J Seidenfeld, D Samson, V Hasselblad, and P Albertsen.Charles Bennett, MD, Chicago, IL.  PhD Alan Garber, MD. PhD.  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.  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, 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.  VA Puget Sound Health Care System, Seattle, WA.  Charles Maynard.Michael Chapko, PhD, 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.  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

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

Bob Peck, MS.  Durham VA Medical Center, Durham, NC.  DA Asch, MD, MBA.  Leonard Davis Institute of Health Economics, Philadelphia, PA.  SD Goold, and D Roter.Peter Ubel, MD.  Philadelphia VA Medical Center.  James Tulsky, MD.  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.  University Hospitals of Cleveland and Cleveland VA Medical Center, Cleveland, OH.  EF CookC. Kent Kwoh, MD and Gary Rosenthal, MD. Cleveland VA Medical Center.  DW Baker.

**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.  Houston VA Medical Center, Houston, TX.   M Johnson.Jennifer Daley, MD.  Brockton, MA.  W Henderson, and SF Khuri.

**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. 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. Center for Health Services Research in Primary Care, Durham, NC.  DL Simel, RP Hall, ME Foy, and KM Stechuchak.Ronnie Horner PhD, 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.  VA Medical Center, West Roxbury, MA.  ES Fisher, R Lamkin, C Cagan, D Hults. 

**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.   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. Center for Chronic Disease Outcomes Research, Minneapolis, MN.  DB Nelson, SM Nugent, PR Hamann, CJ Stolee, and JL Bradley.Hanna Rubins, MD, MPH.  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. Center for the Study of Healthcare Provider Behavior, San Diego, CA.  D Timberlake.Jeff Luck MBA, PhD.  UCLA School of Public Health, Los Angeles, CA.   B Wright and R Spragg.Samuel Bozzette MD, PhD, 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.  San Diego VA Medical Center.  San Diego, CA.  R Collins and D Timberlake.Samuel Bozzette, MD, PhD, Center for the Study of Healthcare Provider Behavior, San Diego, CA.  M Shapiro, M Schuter, and D Kanouse.

**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.  University of Iowa, Iowa City, IA.  Michael Chapko, PhD.  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.  Assistant Professor of Medicine, UCLA, Los Angeles, CA.   Paul Shekelle, MD.  West LA VA Medical Center, Los Angeles, CA.  CD Stevens and RH Brook.

**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 Chang, ScD.  Bedford VA Medical Center, Bedford, MA.  Catherine Comstock, MPH. 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, 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. 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.  Mental Health and Behavioral Sciences Service, Providence, RI.  E Dawson, N Shea, L McBride, and WO Williford.

**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.  Omaha VA Medical Center, Omaha, NE.  EC Rich, RL Recker, PD Turner, and MW Lubeley.

**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. Center for Health Services Research in Primary Care, Durham, NC.  David B. Matchar

**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.  VA Puget Sound Health Care System. Seattle, WA. C Maynard and JL Ritchie

**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. 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.  Bedford VA Medical Center, Bedford, MA.   J Anderson.Carol VanDeusen Lukas, EdD.  Boston VA Medical Center, Boston, MA.  L Leonard

**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.  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.  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.  Boston VA Medical Center, Boston, MA.  BG Fincke.Dan Berlowitz, MD, MPH.  Bedford VA Medical Center, Bedford, MA.  J Clark and J Anderson.

**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.  Pittsburgh VA Medical Center, Pittsburgh, PA. Peter Glassman, MD.  West Los Angeles VA Medical Center. Los Angeles, CA.  M Kelley, M Bradley, M Valentino, J Ogden, and K Kizer.

**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. West Los Angeles VA Medical Center, Los Angeles, CA.  T Makinodan, H Liu, and S Dhanani.

**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. 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.  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.  Bedford VA Medical Center, Bedford, MA.  RI Garcia.

**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.  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.  National Center for PTSD, Boston, MA.  P Miller and V Savarese.   J Wolfe

**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. 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, 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, 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.  Sepulveda VA Medical Center, Sepulveda, CA.  BL Smith, S Leader, and P Westlake.

**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.  Bedford VA Medical Center, Bedford, MA.  A AshCheryl Hankin, PhD, James Rothendler, MD, Dan Berlowitz, MD, MPH, and Jennifer Anderson, PhD. Bedford VA Medical Center, Bedford, MA.   Mark Moskowitz, MD.  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.  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.  VANC Health Care System, Martinez, CA.  JR Lopez, RM Moskowitz, and D Siegel     

**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.  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, 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.  Houston VA Medical Center, Houston, TX.  J Tuchschmidt, G Twedt, and J Bellah. Nelda Wray, MD, MPH.  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 (+ 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 + 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<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.  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.  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.  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.  Boston VA Medical Center, Boston, MA.  B Mittman, PhD J Hernandez, J Macdonald, E Yano, PHD, MSPH, and B Simon, MA.  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.  Hines VA Medical Center, Hines, IL.  D Ippolito, W Cull, B Thakkar, and J Gibbs.

**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,  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.  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, 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.  Iowa City VA Medical Center, Iowa City, IA.  RA Frantz and FL Schmidt

**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.  VA Palo Alto Health Care System, Menlo Park, CA.  B Henson, and J Finney, RH Moos, PhD.  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, 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. 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. Santa Monica, CA.  J Ofman, MD, MSHS.  Director, Pharmacoeconomics and Technology Assessment, Beverly Hills, CA.  Sally Morton, PhD.  RAND Statistics Group, Santa Monica, CA.  Walter Straus  Paul  Shekelle, MD.  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. 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.  VA Puget Sound Health Care System, Seattle, WA.  EJ Boyko.

**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.  Minneapolis VA Medical Center, Minneapolis, MN.   Sheridan and M Lavin.  TJ Wilt, MD, MPH and HB Rubins, MD, MPH.  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.  Assistant Professor, UCLA School of Public Health, Los Angeles, CA. JW Peabody, MD.  West Los Angeles, VA Medical Center, Los Angeles, CA. T Dresselhaus, MD. PA Glassman, MD,. West Los Angeles, VA Medical Center, Los Angeles, CA.  ML Lee, PhD and MM Wang, MPH.  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.  VA Puget Sound Health Care System, Seattle, WA. SK Mirza

**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.  VA Puget Sound Health Care System, Seattle, WA.  O Yu.  M McDonell, MS, and S Fihn, MD, MPH.  VA Puget Sound Health Care System, Seattle, WA.  J Tuchschmidt

**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.  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.  Hines VA Hospital, Hines, IL.  A Giobbie-Hurder. JD Kubal, MA.  Hines VA Hospital, Hines, IL  A Ulasevich and TO Sindowski

**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.  Hines VA Hospital, Hines, IL.  E Oddone, MS, MHS.  Durham VA Medial Center, Durham, NC.  M Weinberger, PhD.  Indianapolis VA Medical Center, Indianapolis, IN.  A Giobbe-Hurder and W Henderson.

**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.  VANCHCS, Martinez, CA.  JR Lopez and D Siegel.

**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.  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.  Ann Arbor VA Medical Center, Ann Arbor, MI. DL Veenstra.  SD Sullivan.

**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.  VA San Diego Healthcare System, San Diego, CA.  J Ziegler, T Le, and R Mahmoud.

**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.  Alvin C. York VA Medical Center, Murfreesboro,TN.  J St. Onge, R Harris-Turner, H Meltzer, R Prakash, and R Levine.

**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. Birmingham, AL.  A Spiro III, PhD, and A Lee, L Kazis, ScD.  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.  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.  Minneapolis VA Medical Center, Minneapolis, MN.  L Fortier

# 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. 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.  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.  Audie L. Murphy Memorial Veterans Hospital, San Antonio, TX and Gayle E. Reiber, PhD, MPH.  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

**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,  Hines VA Hopsital, Hines, IL.  CF Longino. Joseph Kubal, MA.  Hines VA Hospital, Hines, IL.  LM Manheim, SJ Dienstfrey, J Palmer.

**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.  Northport VA Medical Center, Northport, NY.  VE Proctor, DC Tompkins

**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.  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).  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

**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

**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

**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.  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.  Boston VA Hospital, Boston, MA.   KM Skinner, LM Sullivan

**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.  Martinsburg VA Medical Center, Martinsburg, WV.  K Scott, L Perry, A Hargrove, DD Bradham

**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

**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

**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

**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.  VA Medical Center, Iowa City, IA.  JR Flanagan, JP Specht

**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.  VA Medical Center, Iowa City, IA.  RA Frantz, JK Specht, JL Johnson-Mekota, KA Buresh, BJ Wakefield, JR Flanagan

**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.  VA San Diego Healthcare System, San Diego, CA  A Gifford, J Bormann, D Timberlake, S Bozzette

**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

**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.  VANCHCS, Martinez, CA.  JR Lopez, ALM Swislocki, RH Noth, D Siegel

**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.  Hines VA Hospital, Hines, IL.  JM Palmer

**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.  VA Medical Center, Omaha, NE.  EC Rich

**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.  West Los Angeles Veterans Hospital, Los Angeles, CA.  G Sulivan

**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

**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.  VA Greater Los Angeles Healthcare System, Sepulveda, CA.

# I Gonzalez, AB Lanto, B Simon, LV Rubenstein

**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.  North Little Rock VA Medical Center, North Little Rock, AR.  KM Rost

**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

**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.  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

**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

**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.  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

**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

**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.  Hines VA Hospital, Hines, IL.  D Ippolito, W Cull, B Thakkar, J Gibbs

**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.*

Advani152

Bach179

Baldwin42

Barnett56

Bauer59, 60

Baughman153

Bennett10

Berger175

Berlowitz1

Bittner61, 171

Bokhour109

Borowsky49

Bosworth62

Bozzette11

Bradham25

Branch119

Buffum191

Burke154

Burman28, 29

Burton177

Byrne50

Cahill181

Captain143

Chaney63

Chang131

Chapko64

Chun 110

Collins40

Cotton111

Covinsky137

Cowper147

Cronkite65

Curran112

Czarnowski66

Dawson13

Doyle158

Dresselhaus51

Druss67

Dubbert35, 36, 68

Emery184

Evans37, 69

Fihn2

Fink113, 120

Frayne155

Fridsma185

Gaehde70

Gardner114, 162

Garvey44

Geraci15

Gifford52

Good71

Gordon16

Gralnek30

Hammermeister182

Hankin5

Harada72

Hasenberg73

Hechtel74

Hendricks57

Herndon157

Hoff6

Holley149

Hopp151

Huey178

Hughes132

Huizenga165, 183

Humphreys75

Hynes133, 193

Ibrahim, M26

Ibrahim, S38

Jaworski164

Johnson17, 18

Jones76

Kazis77

Keane78

Kemppainen115

Kerr170

Kiefe39

Kim20

King79

Knight174

Krein168

Kressin80

Kubal81

Lam53

Lasfargues188

Lee82, 83, 84, 144

Lenert138

Leslie7, 8

Licht116

Linn139

Liu160

Lohr85

Loveland86

Luck126, 189

Maciejewski87

MacLean121

Mansell140

Mares88

Marottoli173

Mayfield27

McDonell31, 127

Meier89, 134, 169

Menke90, 91

Miller117

Mittman92

Morton41

Muir12

Murdoch125, 142

Nachtigall122

Niakan128

Owen141

Patrick187

Peck34

Penrod93

Petersen186

Phillips135

Piette94

Pietz95

Pogach96

Powell-Cope167

Provenzale123

Pugh145

Pyne97

Reiber            124

Ren98

Render99

Rosansky100

Roselle14

Rosen, C118

Rosen, A58

Rosenheck9

Russell190

Saint24, 136

Sales129, 150, 163

Selim32

Sherman45

Shively166

Sipler43

Souchek101

Spurzem146

Starks33

Steele102

Steinhauser103

Stine156

Szeto19

Tesfa148

Thompson54

VanDeusen Lukas104

Wahby180

Wakefield161

Washington55

Weaver105

Weingardt159

Whited46

Whooley106

Wilkins3

Wilt22

Wright47, 48

Wu107

Yano4, 21, 176

Yeh192

Young, G130

Young, A172

Zalenski108

Zemencuk23

1999 HSR&D Annual Meeting Abstracts1

PAGE  

*1999 HSR&D Annual Meeting Abstracts*194